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Objective: To investigate the relationship between hearing difficulty and measures of mobility for US adults. Study Design: Cross‐sectional study. Setting: 2021 National Health Interview Survey. Methods: The survey asked US adults about hearing difficulty and mobility measures, including difficulty walking 100 yards, difficulty climbing 12 steps, and injury from falling within the past 3 months. Multivariable logistic regressions examined the associations between hearing and mobility outcomes, controlling for visual difficulty, medical comorbidities, and various demographic characteristics (age [18‐39, 40‐64, 65+], race/ethnicity, sex, socioeconomic status). Results: The 2021 NHIS surveyed 29,467 adults, representing 253 million people in weighted responses (52% female; mean age 48.3, standard deviation = 18.6). Controlling for covariates, hearing difficulty was associated with increased odds of difficulty walking 100 yards (odds ratio, OR = 1.47, P <.001), difficulty climbing stairs (OR = 1.62, P <.001), and injury from falling in the past 3 months (OR = 1.51, P <.001). There was a significant interaction between age and hearing difficulty for injurious falls; stratifying by age revealed that younger adults (ages 18‐39) with hearing difficulty were more likely to report recent harmful falls than their normal hearing peers; this increased risk was greater in magnitude than that observed comparing older adults with and without hearing difficulty. Conclusion: The hearing difficulty is associated with worsened mobility for US adults and may be a stronger independent predictor of injury from falls for younger adults as compared to older adults. These findings can inform interventions to reduce the burden of declining mobility in adults with hearing difficulty. [ABSTRACT FROM AUTHOR]

The evolution of innate behaviours is ultimately due to genetic variation likely acting in the nervous system. Gene regulation may be particularly important because it can evolve in a modular brain‐region specific fashion through the concerted action of cis‐ and trans‐regulatory changes. Here, to investigate transcriptional variation and its regulatory basis across the brain, we perform RNA sequencing (RNA‐Seq) on ten brain subregions in two sister species of deer mice (Peromyscus maniculatus and P. polionotus)—which differ in a range of innate behaviours, including their social system—and their F1 hybrids. We find that most of the variation in gene expression distinguishes subregions, followed by species. Interspecific differential expression (DE) is pervasive (52–59% of expressed genes), whereas the number of DE genes between sexes is modest overall (~3%). Interestingly, the identity of DE genes varies considerably across brain regions. Much of this modularity is due to cis‐regulatory divergence, and while 43% of genes were consistently assigned to the same gene regulatory class across subregions (e.g. conserved, cis‐ or trans‐regulatory divergence), a similar number were assigned to two or more different gene regulatory classes. Together, these results highlight the modularity of gene expression differences and divergence in the brain, which may be key to explain how the evolution of brain gene expression can contribute to the astonishing diversity of animal behaviours. [ABSTRACT FROM AUTHOR]

Objective: Competency‐based surgical education requires practical assessments and meaningful benchmarks. In otolaryngology, key indicator procedure (KIP) minima are indicators of surgical exposure during training, yet it remains unknown how many times trainees must be evaluated on KIPs to ensure operative competence. Herein, we used Bayesian mixed effects models to compute predicted performance expectations for KIPs. Methods: From November 2017 to September 2021, a smartphone application (SIMPL OR) was used by attendings at five otolaryngology training programs to rate resident operative performance after each case on a five‐level scale. Bayesian mixed effects models were used to estimate the probability that postgraduate year (PGY) 3, 4, or 5 trainees would earn a "practice‐ready" (PR) rating on a subsequent evaluation based on their previously earned PR ratings for each KIP. Probabilities of earning a subsequent PR rating were examined for interpretability, and cross‐validation was used to assess predictive validity. Results: A total of 842 assessments of KIPs were submitted by 72 attendings for 92 residents PGY 2–5. The predictive model had an average Area Under the Receiver Operating Curve of 0.77. The number of prior PR ratings that senior residents needed to attain a 95% probability of earning a PR rating on a subsequent evaluation was estimated for each KIP. For example, for mastoidectomies, PGY4 residents needed to earn 10 PR ratings whereas PGY5 residents needed 4 PR ratings on average to have a 95% probability of attaining a PR rating on a subsequent evaluation. Conclusion: Predictive modeling can inform assessment benchmarks for competency‐based surgical education. Level of Evidence: NA Laryngoscope, 133:3341–3345, 2023 [ABSTRACT FROM AUTHOR]

Individuals with hearing loss are at increased risk of having poor access to health care compared with hearing peers. The impact of the COVID‐19 pandemic on health care access for adults with hearing loss in the United States was investigated through weighted analyses of the 2021 National Health Interview Survey. The association of hearing loss and disruptions to health care use during the pandemic was examined using multivariable logistic regression controlling for demographic characteristics including sex, race/ethnicity, education, socioeconomic status, insurance status, and medical comorbidities. Adults with hearing loss had significantly higher odds of reporting receiving no medical care (odds ratio [OR] = 1.63, 95% confidence interval [CI]: 1.46‐1.82, p <.001) or delayed medical care (OR = 1.57, 95% CI: 1.43‐1.71, p <.001) due to the pandemic. Individuals with hearing loss did not have higher odds of COVID‐19 diagnosis or vaccination. Strategies should be developed to support adults with hearing loss to improve their access to care during public health emergencies. [ABSTRACT FROM AUTHOR]

Summary: Mantle cell lymphoma (MCL) after relapse is associated with poor prognosis. No standard of care exists and available evidence for treatments is limited, particularly in patients who fail Bruton tyrosine kinase inhibitor (BTKi) therapy. This multicentre retrospective chart review study, SCHOLAR‐2, addresses this knowledge gap and reports on data collected from 240 patients with relapsed/refractory MCL in Europe who were treated with BTKi‐based therapy between July 2012 and July 2018, and had experienced disease progression while on BTKi therapy or discontinued BTKi therapy due to intolerance. The median overall survival (OS) from initiation of first BTKi therapy was 14.6 months (95% confidence interval [CI] 11.6–20.0) in the overall cohort, 5.5 months (95% CI 3.9–8.2) in 91 patients without post‐BTKi therapy, and 23.8 months (95% CI 18.9–30.1) in 149 patients who received post‐BTKi therapy (excluding chimeric antigen receptor T‐cell treatment). In the latter group, patients received a median of one (range, one to seven) line of post‐BTKi therapy, with lenalidomide‐containing regimens and bendamustine plus rituximab being the most frequently administered; the median OS from initiation of first post‐BTKi therapy was 9.7 months (95% CI 6.3–12.7). These results provide a benchmark for survival in patients with R/R MCL receiving salvage therapy after BTKi failure. [ABSTRACT FROM AUTHOR]

Competency‐based medical education (CBME) is an outcomes‐focused approach to educating medical professionals that will be central to future efforts to improve resident training in otolaryngology. The transition to CBME for otolaryngology in the United States will require the development of specialty‐specific assessments and benchmarks, the financial and administrative support for implementation, the professional development of faculty and learners, and the cooperation of all major stakeholders in graduate medical education. In this article, we describe the need for evidence‐based innovation in surgical training, the history of CBME in the United States, and the progress towards defining "entrustable professional activities" as the building blocks of assessments for CBME. We explore what such a paradigm shift in surgical education could mean for academic otolaryngologists by examining innovative educational practices in other surgical specialties and discussing foreseeable challenges in implementation for the American healthcare system. [ABSTRACT FROM AUTHOR]

Objective: To determine how augmented reality (AR) has been applied to the field of otology/neurotology, examine trends and gaps in research, and provide an assessment of the future potential of this technology within surgical practice and education. Data Sources: PubMed, EMBASE, and Cochrane Library were assessed from their inceptions through October 2022. A manual bibliography search was also conducted. Review Methods: A scoping review was conducted and reported according to PRISMA‐ScR guidelines. Data from studies describing the application of AR to the field of otology/neurotology were evaluated, according to a priori inclusion/exclusion criteria. Exclusion criteria included non‐English language articles, abstracts, letters/commentaries, conference papers, and review articles. Results: Eighteen articles covering a diverse range of AR platforms were included. Publication dates spanned from 2007 to 2022 and the rate of publication increased over this time. Six of 18 studies were case series in human patients although the remaining were proof of concepts in cadaveric/artificial/animal models. The most common application of AR was for surgical navigation (14 of 18 studies). Computed tomography was the most common source of input data. Few studies noted potential applications to surgical training. Conclusion: Interest in the application of AR to otology/neurotology is growing based on the number of recent publications that use a broad range of hardware, software, and AR platforms. Large gaps in research such as the need for submillimeter registration error must be addressed prior to adoption in the operating room and for educational purposes. Level of Evidence: N/A Laryngoscope, 133:1786–1795, 2023 [ABSTRACT FROM AUTHOR]

A paired surgical educator curriculum on adult learning was designed for residents and faculty at a large otolaryngology residency program. In its first year of implementation, 12 core faculty and 20 residents attending the workshops, with positive feedback from all participants and measurable improvements in their understanding of basic terms in adult cognitive learning theory. The curriculum enabled faculty and residents to practice applying educational theories to their every day clinical teaching activities and is adaptable for use in other surgical training programs. Level of Evidence: IV. [ABSTRACT FROM AUTHOR]

Objective: There is concern that current otolaryngology residents may not receive adequate surgical training. We aimed to characterize residents' surgical experiences at 5 academic centers performing the 14 key indicator procedures (KIPs) outlined by the Accreditation Council for Graduate Medical Education. Study Design: Prospective study. Setting: Five otolaryngology training programs. Methods: Data were gathered from December 2019 to December 2020 with a smartphone application from the Society for Improving Medical Professional Learning. After each operation, residents and faculty rated trainee autonomy on a 4-level Zwisch scale and performance on a 5-level modified Dreyfus scale. Results: Residents and attendings (n = 92 and 78, respectively) logged 2984 evaluations. Attending ratings of resident autonomy and performance increased with training level (P <.001). Resident self-assessments of autonomy and performance were lower than paired attending assessments (P <.001). Among attending evaluations of KIPs performed by senior residents (postgraduate year 4 or 5), 55% of cases were performed with meaningful autonomy (passive help or supervision only). Similarly, attendings rated 55% of these cases as a practice-ready or exceptional performance. Senior residents had meaningful autonomy for ≥50% of cases for most KIPs, with the exception of flaps and grafts (40%), pediatric/adult airway (39%), and stapedectomy/ossiculoplasty (33%). Similarly, senior residents received practice-ready or exceptional performance ratings for ≥50% of cases across all KIPs other than pediatric/adult airway (42%) and stapedectomy/ossiculoplasty (33%). Conclusion: In this multicenter study, resident surgical autonomy and performance varied across otolaryngology KIPs. The development of nationwide benchmarks will help programs and residents set educational goals. Level of evidence: 2. [ABSTRACT FROM AUTHOR]

Dialysis withdrawal has become an accepted treatment option for patients with kidney failure and is one of the leading causes of death in patients receiving dialysis in high‐income countries. Despite its increasing acceptance, dialysis withdrawal currently lacks a clear, consistent definition. The processes and outcomes of dialysis withdrawal have wide temporal and geographical variability, attributed to dialysis patient selection, influence from cultural, religious and spiritual beliefs, and availability of kidney replacement therapy and conservative kidney management. As a complex, evolving process, dialysis withdrawal poses an enormous challenge for clinicians and healthcare teams with various limitations precluding a peaceful and smooth transition between active dialysis and end‐of‐life care. In this review, we examine the current definitions of dialysis withdrawal, the temporal and geographical patterns of dialysis withdrawal, international barriers in the decision‐making process (including dialysis withdrawal during the COVID‐19 pandemic), and gaps in the current dialysis withdrawal recommendations for clinical consideration and future studies. SUMMARY AT A GLANCE: This review consolidates some of data around the definitions and challenges of withdrawing dialysis. It explores differences in global interpretation of the concepts and practice, and touches upon how COVID‐19 has influenced this subject. [ABSTRACT FROM AUTHOR]

Objective: Surgical education is changing in an era of new regulations and evolving training cultures. We sought to understand the factors that affect operative experiences during otolaryngology residency. Methods: From December 2019 to December 2020, five otolaryngology training programs used the SIMPL OR smartphone application to evaluate residents after each operation. Residents and attendings rated the trainee's autonomy on a 4‐level Zwisch scale, performance on a 5‐level scale, and case complexity on a 3‐level scale. We examined associations between ratings of autonomy and performance with variables including postgraduate year (PGY), case complexity, gender, week of the academic year (AY), and whether multiple procedures were logged. Results: 78 attendings and 92 residents logged 2984 evaluations. PGY level and week of the AY were positively associated with attending ratings of autonomy and performance (PGY3 vs. PGY2: B = 0.63, p <.001 for autonomy and B = 1.05, p <.001 for performance; week of the AY: B = 0.013, p =.002 for autonomy; B = 0.025, p <.001 for performance). Multiple procedures logged and increasing case complexity were negatively associated with attending ratings (multiple procedures: B = −0.19, p =.04 for autonomy and B = −0.48, p <.001 for performance; hardest vs. easiest 1/3 of cases: B = −1.01, p <.001 for autonomy and B = −0.59, p <.001 for performance). Attending and trainee genders were not associated with attending ratings of autonomy or performance. Conclusion: Resident autonomy and performance were positively associated with PGY level and week of the academic year, and negatively associated with case complexity and multiple procedures. These findings highlight the need to align training level with case complexity to promote quality operative experiences. Level of Evidence: 2. [ABSTRACT FROM AUTHOR]

Background: Antineutrophil cytoplasmic autoantibodies (ANCA)‐associated vasculitis (AAV) is more prevalent in rural Australia compared with metropolitan areas, suggesting a role of environment in disease pathogenesis. However, the prevalence of environmental risk factors in Australian AAV patients has not been described. Aims: To compare the incidence of AAV between two health districts (Illawarra Shoalhaven Local Health District (ISLHD), a mixed rural/metropolitan region, and South Eastern Sydney Local Health District (SESLHD), a metropolitan region) in Australia and its relationship to environmental exposures. Methods: Cases of AAV from 2002 to 2017 were retrospectively identified from ISLHD and SESLHD using electronic medical records. Eligible participants were invited to complete a standardised questionnaire examining their exposure to silica, solvents, metal, dust, farming, gardening and sunlight. Results: One hundred and fifty‐six cases of AAV were identified from 2002 to 2017. A higher cumulative incidence of AAV was observed in the ISLHD (184.2 (95% confidence interval (CI) 143.6–232.7) per million) compared with SESLHD (102.6 (95% CI 82.1–126.8) per million). Over 50% of the cohort had high levels of silica and solvents exposure, based on self‐reported questionnaires. There was no significant relationship between region and exposure to silica (P = 0.96), solvents (P = 0.44), metal (P = 0.33), dust (P = 0.25), farming (P = 0.90), gardening (P = 0.93) or sunlight (P = 0.55). Conclusions: We found a higher incidence of AAV in ISLHD compared with SESLHD with high levels of exposure to silica and solvents in both regions based on self‐reported questionnaires. Prospective systematic collection of data, such as a registry of AAV, is warranted to further explore the relationship between environmental exposures and AAV. [ABSTRACT FROM AUTHOR]

Objective: We surveyed otolaryngology program directors (PDs) and recent otolaryngology residency graduates on the operative autonomy of graduating residents and their comfort with independent practice. Methods: An anonymous survey was sent to otolaryngology PDs and recent graduates of training programs (members of the Young Physicians Section [YPS] of the American Academy of Otolaryngology‐Head and Neck Surgery Foundation). Questions were developed around the 14 key indicator procedures (KIPs) defined by the Accreditation Council for Graduate Medical Education. Results: Fifty PDs (43% of PDs) and 152 recent graduates (6% of YPS members) responded. Over 90% of participating PDs felt their graduating residents were either somewhat or extremely comfortable performing 12 out of 14 KIPs. Among the 12 procedures PDs felt their graduating residents were comfortable performing, 57% to 95% of recent graduates also felt either somewhat or extremely comfortable performing them by graduation. Similarly, at least 90% of responding PDs felt their residents achieved meaningful autonomy in the last 2 months of residency prior to graduation for 11 of 14 KIPs. For these same 11 procedures, 74% to 95% of recent graduates indicated they achieved meaningful autonomy. The procedures that PDs and recent graduates felt required the most surgical assistance were ossiculoplasty/stapedectomy, rhinoplasty, and mastoidectomy. All PDs agreed or strongly agreed that graduating residents are comfortable operating and taking call as general otolaryngologists, compared to 86% and 93% of recent graduates. Conclusion: Most PDs and recent graduates agree that residents are well‐prepared for general otolaryngology practice with the exception of select KIPs. Level of evidence: 4. [ABSTRACT FROM AUTHOR]

Objective: To investigate small-particle aerosolization from mastoidectomy relevant to potential viral transmission and to test source-control mitigation strategies. Study Design: Cadaveric simulation. Setting: Surgical simulation laboratory. Methods: An optical particle size spectrometer was used to quantify 1- to 10-µm aerosols 30 cm from mastoid cortex drilling. Two barrier drapes were evaluated: OtoTent1, a drape sheet affixed to the microscope; OtoTent2, a custom-structured drape that enclosed the surgical field with specialized ports. Results: Mastoid drilling without a barrier drape, with or without an aerosol-scavenging second suction, generated large amounts of 1- to 10-µm particulate. Drilling under OtoTent1 generated a high density of particles when compared with baseline environmental levels (P <.001, U = 107). By contrast, when drilling was conducted under OtoTent2, mean particle density remained at baseline. Adding a second suction inside OtoTent1 or OtoTent2 kept particle density at baseline levels. Significant aerosols were released upon removal of OtoTent1 or OtoTent2 despite a 60-second pause before drape removal after drilling (P <.001, U = 0, n = 10, 12; P <.001, U = 2, n = 12, 12, respectively). However, particle density did not increase above baseline when a second suction and a pause before removal were both employed. Conclusions: Mastoidectomy without a barrier, even when a second suction was added, generated substantial 1- to 10-µm aerosols. During drilling, large amounts of aerosols above baseline levels were detected with OtoTent1 but not OtoTent2. For both drapes, a second suction was an effective mitigation strategy during drilling. Last, the combination of a second suction and a pause before removal prevented aerosol escape during the removal of either drape. [ABSTRACT FROM AUTHOR]

Background: Tau PET offers the potential of in vivo imaging neurofibrillary tangles (NFT) in the brain to assess Alzheimer's disease (AD) progression and help guide the development of disease‐modifying treatments. In this study, we evaluate visualization and quantification of NFT using simultaneous acquisition of MRI and PET using [18F]‐MK‐6240 [1]. To overcome limitations in PET spatial resolution resulting in partial volume effects (PVE), MRI‐guided PET reconstruction using an asymmetrical Bowsher prior [2,3] was tested. Method: Cognitively normal volunteers from the NYU Center Sleep and Brain Health Center (n=18, 15 female, age=65.4±5.6) underwent examination on a 3‐T integrated PET‐MRI system (Biograph mMR (Siemens Healthcare, Erlangen, Germany). MRI and PET were performed simultaneously; MRI contrasts included MPRAGE (1‐mm isotropic) for anatomy and ultrashort echo‐time (UTE) (1.6‐mm isotropic) for attenuation correction. [18F]‐MK‐6240 was injected intravenously and PET data was reconstructed 70‐90 min post‐injection. Standard iterative reconstruction (OSEM) (2‐mm isotropic) was compared to asymmetrical Bowsher [2,3] reconstruction with MPRAGE prior regularization weight β=30 (1x1x2mm3). PET standard uptake value (SUV) maps were co‐registered to respective MPRAGE, and (cerebellum or pons normalized) SUVR values were extracted from FreeSurfer‐derived regions of interest (ROIs). Results: Example SUVR maps of standard PET and MR‐guided PET (Fig.1) reveal the Bowsher reconstruction to have more localized and increased focal uptake in the amygdala and cortical regions including the entorhinal, posterior cingulate and precuneus, with regional SUVR‐increases of 39%, 53%, 32%, and 16% respectively. Over all subjects (Fig.2), Bowsher reconstruction results in 30% or 48% higher SUVR, and an 64% or 84%‐increase of dynamic SUVR‐range (Fig.3) when normalized versus cerebellum or pons, respectively. These trends are emphasized for entorhinal cortex (Fig.4). Conclusions: These initial results demonstrate that MR‐guided PET reconstruction of tau data may improve NFT localization and quantification. Study limitations include small number of high uptake tau‐cases and lack of standard such as histology for comparison. Future work will compare against CSF tau‐markers, cognition and comparison to other PVE correction methods. References: [1] Betthauser et al, JNM 2018;60(1):93–99; [2] Bowsher et al, Proc. IEEE Nucl. Sci. Symp., 2004(4):2488–2492; [3] Vunckx & Nuyts, Proc. IEEE Nucl. Sci. Symp., 2010:3262–3266. [ABSTRACT FROM AUTHOR]

Objective: Microvascular decompression (MVD) may be employed in the management of hemifacial spasm (HFS), wherein a pledget of polytetrafluoroethylene (i.e., Teflon, Chemours, Wilmington DE) is sometimes introduced to separate an offending vessel from the cisternal segment of facial nerve. Rarely, Teflon may cause a granulomatous reaction resulting in nerve palsy. We here present the first case series of facial palsy thought to be secondary to Teflon granuloma following MVD for HFS.Methods: A data repository of 1,312 patients with facial palsy was reviewed to identify individuals who had previously undergone MVD for HFS. Data collected include age at time of MVD, age at onset of facial weakness and at presentation, House-Brackmann scores, clinician-graded facial function using the Electronic Facial Paralysis Assessment scale, imaging findings, and therapeutic interventions and outcomes.Results: Six patients meeting criteria were identified. Average time between MVD with Teflon placement and onset of facial weakness was 16.1 (±4.9) years (range 9.3-23.3 years). Initial House-Brackmann scores were as follows: four patients with V/VI and one each with III/VI and IV/VI. Interventions included eyelid weight placement (n = 3), chemodenervation (n = 2), static suspension with tensor fascia latae (n = 2), dynamic reanimation with cranial nerves V to VII transfer (n = 1), and temporalis muscle transfer (n = 1).Conclusion: Teflon granuloma should be considered in the differential diagnosis for patients presenting with new onset facial weakness with a previous history of MVD for HFS. It remains unknown whether early granuloma extirpation is effective. Prompt diagnosis allows consideration of time-sensitive nerve transfer procedures to reanimate facial function.Level Of Evidence: 4 Laryngoscope, 130:1422-1427, 2020. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Few studies have specifically addressed auditory complaints in patients with nonblast mild traumatic brain injury (mTBI). Herein, we aimed to investigate auditory symptoms in patients following mTBI using patient-reported outcome measures.Study Design: Retrospective analysis of prospectively collected data in a tertiary-care hospital.Methods: The patients included those with mTBI (cases) and those without mTBI (controls). Individuals (≥18 years old) with and without mTBI were screened. Exclusion criteria included history of otologic disorders, blast injury, or occupational noise exposure. Primary outcomes included the Hearing Handicap Inventory for Adults (HHIA), Tinnitus Handicap Inventory (THI), and Hyperacusis Questionnaire (HQ). Secondary outcomes included subjective auditory complaints.Results: From September 2017 to September 2018, 52 patients with mTBI and 55 controls met inclusion and exclusion criteria. The mean time between mTBI and survey intake was 70.6 months. The mean age and gender were 51.5 years old and 73% female in the mTBI group, and 46.1 years old and 56.3% female in the control group (P = .112 and P = .105, respectively). Patients with mTBI reported hyperacusis (67.3% of all mTBI patients), hearing loss (61.5%), and tinnitus (61.5%), compared to 8.3%, 12.7%, and 16.4%, respectively, for control subjects (P < .0001). The mean HHIA score in the mTBI group was 38.3 versus 8.5 in controls (P = .002). The mean THI score was 27.4 in the mTBI group and 3.1 in controls (P < .0001). The mean HQ score was 26.5 in mTBI group and 7.3 in controls (P = .001).Conclusions: Auditory symptoms and associated handicap were common in patients with nonblast mTBI compared to age-matched controls. Findings have implications for the pathophysiology and management of symptoms in this patient population.Level Of Evidence: 3 Laryngoscope, 130:761-767, 2020. [ABSTRACT FROM AUTHOR]

Graduate medical education (GME) is funded by the Centers for Medicare and Medicaid Services through both direct and indirect payments. In recent years, stakeholders have raised concerns about the growth of spending on GME and distribution of payment among hospitals. Key stakeholders have proposed reforms to reduce GME funding such as adjustments to statutory payment formulas and absolute caps on annual payments per resident. Otolaryngology departmental leadership should understand the potential effects of proposed reforms, which could have significant implications for the short-term financial performance and the long-term specialty workforce. Although some hospitals and departments may elect to reduce resident salaries or eliminate positions in the face of GME funding cuts, this approach overlooks the substantial Medicare revenue contributed by resident care and high cost of alternative labor sources. Commitment to resident training is necessary to align both the margin and mission of otolaryngology departments and their sponsoring hospitals. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the response in patients undergoing SBRT using dynamic contrast-enhanced (DCE) integrated magnetic resonance positron emission tomography (MR-PET). Stereotactic body radiation therapy (SBRT) is efficacious as a front-line local treatment for non-small cell lung cancer (NSCLC).Materials and Methods: We prospectively enrolled 19 lung tumors in 17 nonmetastatic NSCLC patients who were receiving SBRT as a primary treatment. They underwent DCE-integrated 3T MR-PET before and 6 weeks after SBRT. The following image parameters were analyzed: tumor size, standardized uptake value (SUV), apparent diffusion coefficient, Ktrans , kep , ve , vp , and iAUC60 . Chest computed tomography (CT) was performed at 3 months after SBRT.Results: SBRT treatment led to tumor changes including significant decreases in the SUVmax (-61%, P < 0.001), Ktrans mean (-72%, P = 0.005), Ktrans standard deviation (SD; -85%, P = 0.046), kep mean (-53%, P = 0.014), kep SD (-63%, P = 0.001), and vp SD (-58%, P = 0.002). The PET SUVmax was correlated with the MR kep mean (P = 0.002) and kep SD (P < 0.001). The percentage reduction in Ktrans mean (P < 0.001) and kep mean (P = 0.034) at 6 weeks post-SBRT were significantly correlated with the percentage reduction in tumor size, as measured using CT at 3 months after SBRT. Univariate analyses revealed a trend toward disease progression when the initial SUVmax > 10 (P = 0.083).Conclusion: In patients with NSCLC who are receiving SBRT, DCE-integrated MR-PET can be used to evaluate the response after SBRT and to predict the local treatment outcome.Level Of Evidence: 2 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2018;47:191-199. [ABSTRACT FROM AUTHOR]

The field of otolaryngology–head and neck surgery is rapidly changing, and surgical education must keep pace. In the face of recent advances in medical knowledge, surgical technique, and novel technology, educators may find it increasingly difficult to identify the evolving educational needs of otolaryngology residents. To better align training activities with modern practice patterns, we propose conducting a longitudinal needs assessment by designing a standardized specialty‐specific survey for practicing otolaryngologists. This recurring survey could be implemented alongside accreditation or other continuing medical education activities. The outcomes would report what contemporary otolaryngologists see and do in everyday practice to guide educational reforms to better prepare trainees for future practice. [ABSTRACT FROM AUTHOR]

Postmortem temporal bone computed tomography (CT) and histopathologic findings in an infant with CHARGE syndrome revealed bilateral cochleovestibular hypoplasia, including cochlear pathology relevant to cochlear implant candidacy. Both ears had absence of the superior semicircular canals (SCCs), severely hypoplastic posterior SCCs, and hypoplastic (right ear) or absent (left ear) lateral SCCs seen on CT and histopathology. Histopathology further revealed the absence of all SCC ampullae except the right lateral SCC ampulla and atrophic vestibular neuroepithelium in the saccule and utricle bilaterally. The right cochlea consisted of a basal turn with patent round window, and malformed middle turn (type IV cochlear hypoplasia), with a small internal auditory canal (IAC) but near normal cochlear nerve aperture (fossette). Quantification of spiral ganglion neurons (SGNs) on histologic sections revealed a reduced SGN population (35% of normal for age), but this ear would still have likely achieved benefit from a cochlear implant based on this population. The left cochlea consisted of only a basal turn with patent round window (type III cochlear hypoplasia) with a small IAC and very small cochlear nerve aperture. Notably, histology revealed that there were no SGNs in the cochlea, and therefore, this ear would not have been a good candidate for cochlear implantation. Level of evidence: IV. [ABSTRACT FROM AUTHOR]

Background: In the era of duty hour restrictions, otolaryngology residents may not gain the operative experience necessary to function autonomously by the end of training. This study quantifies residents' autonomy during key indicator cases, defined by the Accreditation Council for Graduate Medical Education. Study Design: Prospective cohort study. Methods: Faculty and residents at a large academic institution were surveyed on the surgical autonomy trainees should achieve for otolaryngology key indicator surgeries at each training level. Residents and faculty used the mobile application "System for Improving and Measuring Procedural Learning" (SIMPL) between December 2017 and July 2018 to log trainees' operative autonomy during cases on a validated four‐level Zwisch scale, from "show and tell" to "supervision only." Results: The study included 40 participants (23 residents and 17 attendings). The survey response rate was 83%. In surveys, residents overestimated the autonomy PGY5 residents should achieve for parotidectomy, rhinoplasty, thyroid/parathyroidectomy, and airway procedures compared with faculty (P <.05). Using SIMPL, 833 evaluations were logged of which 253 were paired evaluations for key indicator cases. Comparing survey predictions with actual cases logged in SIMPL, residents and faculty overestimated the autonomy achieved by senior trainees performing mastoidectomy (PGY5, P <.05) and ethmoidectomy (PGY4/5, P <.05); both felt that senior residents should operate with between "passive help" and "supervision only" whereas residents actually had "passive help." Residents overestimated their autonomy during rhinoplasty (PGY5, P =.017) and parotidectomy (PGY5, P =.007) while attendings accurately expected chief residents to have "passive help." Conclusions: Resident surgical autonomy varies across otolaryngology procedures. Multicenter studies are needed to elucidate national trends. Level of Evidence: 2 [ABSTRACT FROM AUTHOR]

Objectives: Surgical education has shifted from the Halstedian model of "see one, do one, teach one" to a competency-based model of training. Otolaryngology residency programs can benefit from a fast and simple system to assess residents' surgical skills. In this quality initiative, we hypothesize that a novel smartphone application called System for Improving and Measuring Procedural Learning (SIMPL) could be applied in an otolaryngology residency to facilitate the assessment of resident operative experiences.Methods: The Plan Do Study Act method of quality improvement was used. After researching tools of surgical assessment and trialing SIMPL in a resident-attending pair, we piloted SIMPL across an otolaryngology residency program. Faculty and residents were trained to use SIMPL to rate resident operative performance and autonomy with a previously validated Zwisch Scale.Results: Residents (n = 23) and faculty (n = 17) were trained to use SIMPL using a standardized curriculum. A total of 833 assessments were completed from December 1, 2017, to June 30, 2018. Attendings completed a median 20 assessments, and residents completed a median 14 self-assessments. All evaluations were resident initiated, and attendings had a 78% median response rate. Evaluations took residents a median 22 seconds to complete; 126 unique procedures were logged, representing all 14 key indicator cases for otolaryngology.Discussion: This is the first residency-wide application of a mobile platform to track the operative experiences of otolaryngology residents.Implications For Practice: We adapted and implemented a novel assessment tool in a large otolaryngology program. Future multicenter studies will benchmark resident operative experiences nationwide. [ABSTRACT FROM AUTHOR]

Background: We hypothesized that patients with head and neck squamous cell carcinoma (HNSCC) with smoking cessation during curative chemoradiotherapy (CRT) had fewer complications and lower tumor progression risks. Methods: Sixty‐three patients with nonmetastatic HNSCC who were smokers at diagnosis (carbon monoxide [CO] breath concentrations ≥3 ppm) and underwent curative CRT were prospectively enrolled. Successful smoking cessation throughout CRT was confirmed by CO breath concentrations <3 ppm at CRT completion. Results: Forty‐one patients (65%) successfully discontinued smoking throughout CRT. With a median 33‐month follow‐up, patients with successful smoking cessation during CRT had significantly fewer, greater, and lower probabilities of grade ≥3 acute toxicities (P = .01), progression‐free survival (P = .03), and permanent gastrostomy or tracheostomy (P = .04), respectively, than those continuing smoking throughout CRT. In multivariate analysis, successful smoking cessation during CRT significantly reduced tumor progression risks (hazard ratio: 0.4, P = .05). Conclusion: Smoking cessation during curative CRT reduced treatment‐related toxicities and tumor progression risks in patients with HNSCC. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Investigate the otopathology of angiosarcoma of the temporal bone, which has not been previously described in the literature.Study Design: Postmortem evaluation and literature review.Methods: Postmortem histological evaluation of the temporal bones and review of the literature for the treatment and prognosis of this rare disease were performed.Results: A 50-year-old male with right chronic otitis media presented with progressive hearing loss, disequilibrium, otalgia, and acute facial paresis. Biopsy of the external auditory canal was unrevealing, but specimens from a canal wall down tympanomastoidectomy later showed high-grade angiosarcoma. Magnetic resonance imaging demonstrated an unresectable middle ear and mastoid mass extending superiorly into the temporal lobe. The patient received induction chemotherapy followed by proton beam radiation therapy and concurrent paclitaxel and bevacizumab. His course was complicated by a cerebrospinal fluid leak and cauda equina syndrome from leptomeningeal sarcomatosis. The patient died after developing meningitis and a temporal lobe abscess. Postmortem otopathology revealed persistent angiosarcoma in the internal auditory canal, although none was found in the middle ear or mastoid. There was inflammatory infiltrate throughout the mastoid, with direct extension of neutrophils and bacteria into the cochlea and through the tegmen into the middle cranial fossa.Conclusions: Angiosarcoma of the temporal bone can arise in the setting of chronic otitis media. In this case, postmortem temporal bone sections demonstrated viable cancer despite chemoradiation. Inflammatory infiltrates crossing from the middle ear/mastoid into the labyrinth and central nervous system illustrate pathways for the development of otogenic meningitis.Level Of Evidence: 4 Laryngoscope, 129:737-742, 2019. [ABSTRACT FROM AUTHOR]

Objective: Vestibular symptoms such as dizziness and vertigo are common after head injury and may be due to trauma to the peripheral vestibular system. The pathophysiology of peripheral vestibular symptoms following head injury without temporal bone (TB) fracture, however, is not well understood. Herein, we investigate the histopathology of the peripheral vestibular system of patients who sustained head injury without a TB fracture.Study Design: Otopathology study.Setting: Otopathology laboratory.Subjects and Methods: TB of subjects with a history of head injury without TB fractures were included and evaluated by light microscopy. Specimens were assessed for qualitative and quantitative characteristics, such as number of Scarpa's ganglion cells in the superior and inferior vestibular nerves, vestibular hair cell and/or dendrite degeneration in vestibular end organs, presence of vestibular hydrops, and obstruction of the endolymphatic duct.Results: Five cases (n = 5 TBs) had evidence of vestibular pathology. There was a decrease of 48.6% (range, 40%-59%) in the mean count of Scarpa's ganglion cells as compared with that of normative historical age-matched controls. Moderate to severe degeneration of the vestibular membranous labyrinth was identified in the posterior, superior, and lateral canals in several cases (50%, n = 4 TBs). The maculae utriculi and sacculi showed mild to severe degeneration in 2 cases. Additional findings include vestibular hydrops (25%, n = 2 TBs) and blockage of the endolymphatic duct (n = 1 TB).Conclusions: Otopathologic analysis of patients with a history of head injury without TB fracture demonstrated peripheral vestibular otopathology. Future studies are necessary to determine if otopathology findings are directly attributable to head injury. [ABSTRACT FROM AUTHOR]

Objective Hearing loss following temporal bone (TB) fracture may result from direct transection of the middle and inner ear. The pathophysiology of hearing loss due to head injury without TB fracture, however, is not well understood. Few reports describe otopathologic findings. Herein, we investigate the pathologic findings of patients who sustained a head injury without evidence of a TB fracture. Study Design Otopathology study. Setting Otopathology laboratory. Subjects Subjects with a history of head injury without TB fracture. Methods The TBs of patients with head injury were evaluated by light microscopy. Inner ear anatomy was evaluated, including counts of spiral ganglion cells (SGCs), hair cells, pillar cells, atrophy of the stria vascularis, and the presence of endolymphatic hydrops. SGC counts were compared with those of historical age-matched controls. Results All cases (N = 6 TBs) had evidence of inner ear pathology. Of the 6 cases, 2 (33%) had severe loss of hair cells in all 3 turns of the cochlea, and 4 (67%) cases demonstrated moderate to severe loss at the basal turn of the cochlea. Four cases had scattered atrophy of the stria vascularis, and 3 (50%) had cochlear hydrops. The number of total SGCs was decreased, with an average 53% loss (range, 25%-79%) as compared with controls. The SGC count loss was evenly distributed along Rosenthal's canal. Conclusions Patients with a history of head injury without TB fracture demonstrate inner ear pathology. Further studies are necessary to determine if otopathology findings are directly attributable to trauma. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the potential association of macrolide antibiotics with sensorineural hearing loss (SNHL) and which agents and dosage may be related. To evaluate whether an optimal treatment exists for reversing SNHL that occurs after macrolide therapy.Study Design: Systematic review of the literature.Methods: Computerized (PubMed, EMBASE, Cochrane Library) and manual searches were performed to identify human studies of all ages (patients) who received macrolides (intervention, with or without control) and documented SNHL (outcome). All study designs were assessed. Extracted data included macrolide regimen details, as well as the timing, severity, and reversibility of SNHL with drug cessation alone or with additional medical intervention. Study designs and the associated risk of bias were assessed.Results: The 44 publications (3 prospective, 41 retrospective) that met these criteria described 78 cases of audiometrically confirmed SNHL. SNHL was associated with oral and intravenous macrolide administration at standard and elevated doses. SNHL was irreversible in six cases, despite macrolide cessation (n = 5) and oral steroid treatment (n = 1). Irreversible SNHL was observed following 2 to 3 days of exposure. SNHL was reversible with macrolide cessation alone in 70 cases. In two cases, macrolide cessation coupled with oral steroid administration restored hearing. Reversible cases improved within hours to days. Nine studies also described 42 cases of subjective patient-reported hearing loss. Limitations in the data arose from study design, related comorbidities, and concomitant drug administration.Conclusion: SNHL may follow macrolide exposure, even at standard oral doses. Further research is needed to understand the incidence, prevalence, and biological mechanism of its ototoxicity. Laryngoscope, 128:228-236, 2018. [ABSTRACT FROM AUTHOR]

Resistance of cancer stem cells to radiotherapy remains a major obstacle to successful cancer management. Prominin-1 (PROM1) is a cancer stem cell marker. Nanoparticle (NP) chemotherapeutics preferentially accumulate in tumors and are able to target cancer and cancer stem-like cells through cancer cell-specific ligands, making them uniquely suited as radiosensitizers for chemoradiation therapy. Using a biocompatible apoferritin NP, a PROM1-targeted NP carrying irinotecan (PROM1-NP) is engineered. The synergistic effect of the NP and irradiation is evaluated in PROM1-overexpressing HCT-116 colorectal cancer cell lines in vitro and in vivo. PROM1-NP has a size of 17.2 ± 0.2 nm and surface charge of −13.5 ± 0.2 mV. It demonstrates higher intracellular uptake than nontargeted NP or irinotecan alone. Treatment with PROM1-NPs decreases HCT-116 cell proliferation in a dose- and time-dependent manner. In vitro radiosensitization reveals that PROM1-NP is significantly more effective as a radiosensitizer than nontargeted NP or irinotecan. HCT-116 tumor xenograft growth is markedly slower following treatment with PROM1-NP plus irradiation, suggesting that PROM1-NP is more effective as a radiosensitizer than irinotecan and nontargeted NP in vivo. This study provides the first preclinical evidence of the effectiveness of PROM1-targeted NP formulation of irinotecan as a radiosensitizer. [ABSTRACT FROM AUTHOR]

Objectives: Avoiding oral steroids for otitis media with effusion (OME) is endorsed as a performance measure by the National Quality Foundation, but data regarding current gaps and practice patterns are lacking. Our objectives were to evaluate oral steroid use for OME and the related diagnoses of eustachian tube dysfunction (ETD) and tympanic membrane retraction (TMR), to assess variations by visit setting, and to identify opportunities for measurable performance improvement.Study Design: Cross-sectional analysis of a national database.Setting: Ambulatory visits in the United States.Subjects: Children and adults in the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey (2005-2010).Methods: Data were coded for patient demographic information, potential confounders (eg, concurrent conditions managed by oral steroids), and diagnosis of OME, ETD, or TMR (OME/ETD/TMR). The latter 2 diagnoses were included to meet minimum numbers for reliability of weighted estimates, but OME constituted the majority of cases. Multivariate regression was used to determine the variables associated with oral steroid use.Results: Among 590,772 observations representing 7,191,711,480 visits for OME/ETD/TMR, 3.2% resulted in a new prescription for oral steroid medication (2.3% for children, 7.0% for adults). Adults were more likely to receive steroids (odds ratio = 3.50, P < .001) than those with other diagnoses, but a similar association was not found for children. Patients seen by an otolaryngologist or in the emergency department were less likely to receive steroids than those seen in other settings.Conclusions: OME/ETD/TMR is infrequently treated with oral steroids, particularly in children. Opportunities for performance improvement are limited. [ABSTRACT FROM AUTHOR]

The article presents a study which described the technical aspects of microsurgical instrument-assisted facial nerve dissection for deep lobe parotid tumors and examined the benefits of this approach. Topics discussed include an overview of the surgical technique, an underlying principle of microsurgical technique, and recommendation by several authors for full microsurgical dissection under the operative microscope for the entirety of a parotidectomy.

An introduction to articles published within the issue is presented, including a 2020 survey which examined nephrology training experience and workforce perspectives in Australia and New Zealand, another on a survey of 105 consultant nephrologists which suggested that the pattern of nephrology training has not changed significantly over the past two decades, and one on a study which highlighted the gaps in current nephrology training and subsequent career choices.

Background: Diffusion MRI (dMRI) allows non‐invasive mapping of microstructural changes in the brain. In this study, we assess the relationship between amyloid and tau deposition and grey matter microstructure as detected with diffusion kurtosis imaging (DKI) [1,2]. We hypothesize that inflammation associated with amyloid deposits might result in more restricted diffusion and neuronal death associated with tau pathology might result in less restricted diffusion. Method: 38 cognitively healthy subjects received 3‐T PET‐MR imaging, each including anatomical MPRAGE, DKI and static PET scans either with 18F‐Florbetaben (n=20, 12 females, age = 67.20±5.75 years) or 18F‐MK‐6240 tracer (n=18, 14 females, age = 66.56±5.23 years) to probe amyloid or tau deposition, respectively. For each subject, regions of interest (ROIs) were automatically segmented on MPRAGE using Freesurfer, combined and narrowed down to 4 regions of interest: primary motor cortex as a control, anterior/posterior cingulate cortex as high amyloid regions, and entorhinal cortex as a high tau region. The standardized uptake values in these ROIs normalized to grey matter cerebellum yielded cortical relative SUV (SUVR). DKI processing provided parametric maps of the mean diffusivity (MD), kurtosis (MK) and fractional anisotropy (FA). Pearson correlation between tau PET SUVR/amyloid PET SUVR and MD, FA, and MK was calculated with significance testing. Result: Correlation analysis (Tables 1, 2) showed positive correlations between amyloid PET SUVR and MD in posterior cingulate cortex, tau PET SUVR and MD in anterior cingulate cortex and posterior cingulate cortex, and tau PET SUVR and MK in primary motor cortex. Negative correlation was observed between PET SUVR and FA in entorhinal cortex. Conclusion: Increased amyloid and tau burden on PET correlated with less restricted diffusion as indicated by higher MD and lower FA, suggesting sensitivity of dMRI to cortical atrophy and late‐stage neuronal death, as previously observed in cortex and white matter tracts [2, 3]. The current study of healthy controls is limited by the narrow range of amyloid and tau burden. Future work will extend to subjects with mild cognitive impairment. References: [1] Jensen & Helpern, NMR Biomed., 2010(23):698‐710; [2] Dong et al, Neurobiol. Aging 2020(89):118‐128; [3] Montal et al, Alzheimer’s Dement., 2017(14):340‐351. [ABSTRACT FROM AUTHOR]

Objectives (1) To evaluate changes in the resident publications over time, including before and after duty hour restrictions, and (2) to identify factors statistically associated with publications during residency. Study Design Retrospective review of bibliometric data. Subjects and Methods Residents who graduated from an otolaryngology residency program from 1996 to 2013 were evaluated. Thomson Reuters Web of Science was searched to determine the number of indexed peer-reviewed publications before and after implementation of resident duty hour restrictions in 2003. Resident demographics, PhD degrees, training tracks, and postgraduation plans were collected to determine factors associated with publication rate using multivariable regression analysis. Results During the studied period, 75 residents completed otolaryngology residency training and published a total of 294 papers, averaging 3.92 publications per resident during training. After work hour restrictions were implemented, the mean number of publications increased from 1.21 to 5.10 (P < .0001). First author publications, clinical publications, and basic science publications all increased (P < .001). In regression analysis, T32 grants (β = 6.98, standard error [SE] = 1.87, P = .0004) and the time period after duty hour restrictions were introduced (β = 4.72, SE = 1.73, P = .0083) were positively associated with resident publications. Gender, PhD degree, and pursuit of fellowship training were not associated with increased publications (P > .05). Conclusion There has been a significant increase in resident publications over time, coinciding with the implementation of work hour restrictions. T32 grants were most predictive of increased resident publications, while PhD degrees were not significantly associated. [ABSTRACT FROM AUTHOR]

Lateral osteotomies are essential to rhinoplasty and are performed through percutaneous or intranasal approaches. Both techniques are difficult to teach as they rely on tactile feedback. Thus, it is critical to understand trainee learning curves to minimize complications. Herein, we aim to (1) demonstrate an educational module for teaching lateral osteotomies and (2) examine potential differences in outcomes between the 2 surgical approaches when performed by trainees. After a hands-on cadaveric laboratory, trainees (n = 24) reported increased confidence in performing both types of osteotomies ( P < .0001). Completion of the bony cut was similar between intranasal and percutaneous osteotomies (96% vs 75%, P = .097), as was correct placement of the osteotomy (75% vs 67%, P = .53). Intranasal osteotomies were more likely to cause periosteal disruption ( P = .02). This pilot study demonstrates that cadaveric laboratories are an effective way to teach lateral osteotomies and that percutaneous osteotomies may be less likely to cause periosteal disruption in trainees' hands. [ABSTRACT FROM AUTHOR]

Objective To compare tumor characteristics and clinical outcome of patients with cervical locally advanced adenocarcinoma ( AC)/adenosquamous carcinoma ( ASC) and squamous cell carcinoma ( SCC). Design Retrospective study. Setting National Taiwan University Hospital, Taipei, Taiwan. Population All patients with cervical SCC ( n = 35), AC or ASC ( n = 194) with FIGO stage ≥IIB who received definitive radiotherapy or concurrent chemoradiotherapy ( CCRT) from January 1995 to December 2009. Method Medical and histopathological record review. Main outcome measures Progression-free survival ( PFS), local recurrence-free survival, distant metastasis-free survival, and overall survival ( OS). Results Compared with the SCC subgroup, patients with AC/ ASC were significantly younger ( p = 0.007), more of them without clinical symptoms were diagnosed by abnormal Pap smear findings ( p = 0.043), and less responded to treatment ( p = 0.018). After a median follow-up of 59.3 months, patients with AC/ ASC had worse 5-year PFS (30.0% vs. 47.6%, p = 0.044), worse 5-year distant metastasis-free survival (41.5% vs. 69.9%, p = 0.005), and trends toward worse 5-year local recurrence-free survival (64.4% vs. 76.2%, p = 0.165) and worse 5-year OS (41.3% vs. 58.1%, p = 0.090) than patients with SCC. In univariate analysis, early FIGO stage and complete treatment response were significantly associated with PFS and OS. Histology of non- AC/ ASC and Point A biologically equivalent doses in 2-Gy fractions >85 Gy were significantly associated with better PFS, and CCRT was significantly associated with better OS. In multivariate analysis, complete treatment response and early FIGO stage remained significant factors for predicting better PFS and OS. Conclusions Cervical AC/ ASC may be more aggressive than is SCC. For cervical AC/ ASC, more comprehensively effective treatments are warranted. [ABSTRACT FROM AUTHOR]

Objective. To compare survival between patients with cervical adenocarcinoma (AC) and adenosquamous carcinoma (ASC). Design. Retrospective study. Setting. National Taiwan University Hospital, Taipei, Taiwan. Population. All patients with cervical AC or ASC who received definitive treatment from January 1995 to December 2009. Methods. Medical and histopathological record review. Main outcome measures. Overall and recurrence-free survival. Results. A total of 170 women received a histological diagnosis of AC and 42 of ASC. The median follow-up was 56.7 months. There were no significant differences in age, International Federation of Gynecology and Obstetrics (FIGO) stage, gravidity or treatment modality between women with AC and ASC. Patients with ASC had a higher percentage of poorly differentiated tumors than those with AC (33.3 vs. 15.3%, respectively; p= 0.014). Five year overall and recurrence-free survival was 66.8 and 58.9%, respectively, for women with AC and 69.5 and 61.9%, respectively, for those with ASC ( p= 0.795 and p= 0.892, respectively). Survival outcomes in patients with early or advanced stage disease did not differ between the histological groups. No differences in failure patterns were found between the two groups. The FIGO stage and treatment modality were factors which affected overall and recurrence-free survival. Conclusions. We did not find evidence to suggest that ASC subtypes indicate worse outcome. Cervical ASC could be categorized as one subtype of AC. The FIGO stage and treatment modalities have greater influence on outcomes than histological subtype. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "The Only Girl in the Room: How Paradigmatic Trajectories Deter Female Students From Surgical Careers" by E. Hill and S. Vaughan.