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BACKGROUND Logging and landscape work are among the most hazardous occupations, and one of the most dangerous tasks in these occupations is tree felling. While much research has been conducted to examine fatalities from logging and landscape services, there is a dearth of research looking specifically at tree felling. There is a need to focus on hazards associated with tree felling activities so that proactive prevention strategies can be developed. METHODS An Occupational Safety and Health Administration (OSHA) database was used to identify occupational tree-felling fatalities in the United States during the period from 2010 through the first half of 2020. We compared data for the two industry segments of logging and landscaping services. RESULTS There were 314 fatalities over the period. The victims were overwhelmingly male with the median age being 43. Struck-by was the number one event type causing fatalities, with the head being the number one body part involved in fatalities. Falls from elevation was the only event type significantly different between the logging and landscaping industries. Poor decision-making is noted as a key component of fatal incidents, but bystanders were fatally injured due to the actions of others. CONCLUSIONS Tree felling is one of the most hazardous activities for both loggers and commercial landscapers and is a common cause of fatalities; significant differences in events and source are encountered in those two occupations. Loggers should continue efforts to adopt mechanized harvesting methods. Landscape services tree fellers should receive training related to fall prevention.

Utilizing emergency department admissions to estimate and describe agricultural injuries in the United States (U.S.) provides a unique view of one of the country's most dangerous occupations. This study characterizes and provides nationally representative estimates of persons with non-fatal agricultural-related injuries treated in emergency departments in the U.S.We conducted a cross-sectional study using U.S. Consumer Product Safety Commission, National Electronic Injury Surveillance System (NEISS) data for patients treated in emergency departments from January 1, 2015 to December 31, 2019. We queried all cases in the NEISS database using the location code "farm" and with a narrative search using relevant key words.An estimated 62,079 people were treated in an emergency department for agricultural related injuries. The mean age estimate in this population was 39 years-old, with ages ranging from 1 to 95. Almost two-thirds of patients were male, and almost 80% were white. Approximately 30% and 22% of those injured were youth and elderly patients, respectively. The majority of injuries occurred from April through September. The most common injury was fracture, followed by open wound or amputation. There were significant differences between the body parts injured in youth versus adult patients. The primary source of injury was in the vehicles category, with tractors being the dominant vehicle type.Agricultural vehicles remain a major source of injuries that require treatment in emergency departments. Previous methods of quantifying severe ag-related injuries were limited; our research utilized NEISS data to portray injury statistics more accurately.

Objectives Pain and analgesic requirements after functional endoscopic sinus surgery (FESS) vary widely. This study aims to quantify pain after routine FESS and determine the most commonly used pain management regimen. Methods Retrospective chart review of 100 patients who underwent FESS from Oct 2017 to May 2019. Patients prospectively completed a daily pain diary and reported pain levels that were categorized into no pain (0), mild (1‐3), moderate (4‐7), or severe (8‐10). Patients were categorized into narcotics, non‐narcotics, combination, or none based on type of analgesic used. Results Sixty‐nine patients were included. Majority of patients reported either mild (39%) or no pain (28%) during the first 5 PODs. Mean POD1 pain score was 3.98, which decreased with each subsequent POD. On POD1, 37% used opioids (n = 37), 32% used non‐opioids (n = 32), 22% used a combination (n = 22), and 9% used no pain meds (n = 9). Mean number of narcotic pills used within the first 5 PODs was 2 pills on any given day. Age was inversely associated with reported POD1 pain scores (P = .003) and use of preoperative steroids in patients with sinonasal polyposis was associated with lower POD1 pain scores (P = .03). Conclusions Even on POD1, majority of patients experienced either mild or no pain, and this decreases with each POD. Narcotics are grossly overprescribed and underutilized by patients postoperatively after FESS. We advocate for more judicious prescribing habits of narcotics by Otolaryngologists after FESS, and emphasize relying on non‐narcotic alternatives like Acetaminophen or NSAIDS to diminish narcotic use and abuse in the postoperative period. Level of Evidence 4.

Many millions of bags of mulch are sold at retail in the United States each year. Most mulch products claim to be of a certain species, with cypress being perhaps the most widely marketed. Unfortunately, it is practically impossible for the average consumer to know with certainty whether a product is indeed the species listed on the packaging. Claims of misleading behavior by some producers raise the question of whether species mix should be more closely monitored. Regulators charged with ensuring fair competition and consumer welfare, however, do not have an accurate means to determine species content. It would be difficult, if not impossible, to determine the species mix for 100% of the wood particles in a package of mulch because of the inability to identify species of the smallest particles, and the impracticality of 100% sampling in the intended use. We propose and develop a new method to allow analysts to estimate the percentage of a given species in samples of mulch, with a focus on cypress. This case study illustrates our methods and highlights the challenges in accurately determining species mix in the type of wood product. We purchased and tested 10 bags of cypress mulch obtained from six different states. Results indicate that one producer was filling some bags with only 50% cypress and others with no cypress. Consumers may therefore suffer as they receive a lower valued species, whereas honest competitors are also harmed. The wood science community could help regulators and consumers by developing a method by which small particles of wood could be positively identified as to species. Improved methods for species identification are relevant for a wide variety of purposes ranging from identifying consumer products to upholding the U.S. Lacey Act.

BACKGROUND Endoscopic transsphenoidal surgery (ETS) for the resection of pituitary adenoma has become more common throughout the past decade. Although most patients have a short postoperative hospitalization, others require a more prolonged stay. We aimed to identify predictors for prolonged hospitalization in the setting of ETS for pituitary adenomas. METHODS A retrospective chart review as performed on 658 patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from 2005 to 2019. Length of stay (LoS) was defined as date of surgery to date of discharge. Patients with LoS in the top 10th percentile (prolonged LoS [PLS] >4 days, N = 72) were compared with the remainder (standard LoS [SLS], N = 586). RESULTS The average age was 54 years and 52.5% were male. The mean LoS was 2.1 days vs 7.5 days (SLS vs PLS). On univariate analysis, atrial fibrillation (p = 0.002), hypertension (p = 0.033), partial tumor resection (p < 0.001), apoplexy (p = 0.020), intraoperative cerebrospinal fluid (ioCSF) leak (p = 0.001), nasoseptal flap (p = 0.049), postoperative diabetes insipidus (DI) (p = 0.010), and readmission within 30 days (p = 0.025) were significantly associated with PLS. Preoperative continuous positive airway pressure (CPAP) (odds ratio, 15.144; 95% confidence interval, 2.596-88.346; p = 0.003) and presence of an ioCSF leak (OR, 10.362; 95% CI, 2.143-50.104; p = 0.004) remained significant on multivariable analysis. CONCLUSION For patients undergoing ETS for pituitary adenomas, an ioCSF leak or preoperative use of CPAP predicted PLS. Additional common reasons for PLS included postoperative CSF leak (10 of 72), management of DI or hypopituitarism (15 of 72), or reoperation due to surgical or medical complications (14 of 72).

Efforts aimed at minimizing the spread of COVID-19 and "flattening the curve" may be affecting clinical care delivery for non-COVID-19 cases that include otolaryngologic and orbital conditions. We are witnessing changes in the manner that patients present, as well as modifications in clinical management strategies. An improved understanding of these phenomena and the contributing factors is essential for otolaryngologists to provide sound clinical care during this unprecedented pandemic.

Background Sinonasal malignancies are a rare, heterogeneous group of tumors that often present at an advanced stage and require multimodal therapy. The presence of high-grade toxicity and sinonasal complications after treatment can negatively impact quality of life. In this study we aim to describe posttreatment morbidity in patients with sinonasal malignancy. Methods A retrospective analysis of all patients treated for sinonasal malignancy was conducted from 2005 to 2018 at a tertiary referral institution. A total of 129 patients met the inclusion criteria. Primary outcomes were treatment details, pathology, posttreatment complications, and radiation toxicity. Fisher's exact test, chi-square test, and Student t test were used for statistical analysis. Results Mean age was 58.4 (median, 61; range, 19-94) years. After diagnosis, 24 patients had surgery alone, 46 had surgery with radiation alone, 47 had surgery with chemoradiation, and 14 received definitive chemoradiation. Overall, 10.4% (n = 12) of patients had postoperative complications, and 21.0% (n = 22) had high-grade (grade 3-5) radiation toxicity. After radiation, 20% (n = 21) of patients had chronic sinusitis requiring functional endoscopic sinus surgery and 20% (n = 21) had symptomatic nasal obstruction requiring operative debridement. Conclusion Sinonasal complications, including nasal obstruction and chronic sinusitis, occur frequently after definitive treatment of sinonasal malignancy and should be addressed when considering quality of life in survivors. These complications occur more frequently in patients who undergo chemoradiation as opposed to surgery alone.

Objective A variety of endonasal sellar repair techniques have been described; many of which are complex, expensive, and carry potential morbidity but are felt to be necessary to prevent postoperative cerebrospinal fluid (CSF) leaks. We propose an effective, technically simple repair for select sellar defects utilizing an onlay of regenerated oxidized cellulose. Design Retrospective review of patients from a single neurosurgeon who underwent endoscopic transsphenoidal surgery for pituitary adenoma and sellar reconstruction with only an onlay of regenerated oxidized cellulose. Patients were selected for this repair technique based on the absence of: (1) intraoperative identification of a CSF leak, (2) patulous diaphragm (expanded diaphragm sella herniating to or through sellar floor defect), and (3) other prohibiting comorbidities. Setting The present study was conducted at a tertiary care center. Participants In this study, pituitary adenoma patients were the participants. Outcome Measures Main outcome measure of the study is postoperative CSF leak. Results A total of 172 patients were identified. Of these, 153 were initial resections of pituitary adenomas. Gross total resection was achieved in 142 (82.6%) cases. Average tumor size was 2.2 ± 1.1 cm. Average tumor volume was 10.4 ± 19.8 cm3. No patients had intraoperative CSF leaks. All cases were repaired with only an onlay of regenerated oxidized cellulose. There were two postoperative CSF leaks (1.16%). Pre and postoperative SNOT-22 scores were 12.9 ± 11.9 and 14.3 ± 14.9 (p = 0.796), respectively. Conclusion The use of an onlay of regenerated oxidized cellulose alone is an effective repair technique for select sellar defects. This technique does not result in increased postoperative CSF leak rates and avoids the higher relative cost and potential morbidity associated with more complex, multilayered closures.

Background Due to the diverse histopathologic features and variable survival rates seen in sinonasal undifferentiated carcinoma (SNUC), it is likely that this diagnostic entity is comprised of a heterogonous group of morphologically undifferentiated tumors. As advancements in molecular testing have led to a better understanding of tumor biology, it has become increasingly evident that SNUC may actually encompass several tumor subtypes with different clinical behavior. As a result, it is also likely that all SNUC patients cannot be treated in the same fashion. Recent investigations have identified loss of the tumor suppressor SMARCB1 (INI1) expression in a subset of undifferentiated sinonasal tumors and extrasinonasal tumors and, studies have suggested that this genetic aberration may be a poor prognostic marker. The objective of this study was to identify differential expression of SMARCB1 in SNUC and to analyze and compare the survival outcomes in SNUC patients with and without SMARCB1 expression. Methods All cases of undifferentiated or poorly differentiated neoplasms of the sinonasal tract treated between 2007 and 2018 at a single tertiary care institution were selected. All cases of SNUC were tested for SMARCB1 status by immunohistochemistry (IHC). Clinical parameters were analyzed using Student's t-test and Fischer's test. Kaplan–Meier methods were used to estimate survival durations, while comparison between both the subgroups was done using the log-rank test. Statistical analysis was performed with the use of SPSS software, Version 25 (IBM, New York, NY, United States). Results Fourteen cases of SNUC were identified. Approximately two-thirds (64%; n = 9) of patients were male and the majority (79%; n = 11) were between fifth to seventh decade. Skull base and orbital invasion were seen in 79% (n = 11) and 93% (n = 13) of cases, respectively. Fifty-seven percent of tumors (n = 8) retained SMARCB1 expression by IHC (SR-SNUC), while the remaining 43% (n = 6) showed loss of SMARCB1 expression and, thus, were considered as SMARCB1-deficient (SD-SNUC). Although clinicopathological features and treatment modalities were similar, SD-SNUC showed poorer (OS: p = 0.07; disease free survival [DFS]: p = 0.02) overall survival (OS) and DFS on Kaplan–Meier curves. Additionally, SD-SNUC showed higher recurrence (75 vs. 17%) and mortality (67 vs. 14%) (hazard rate = 8.562; p = 0.05) rates. Both OS (28.82 ± 31.15 vs. 53.24 ± 37.50) and DFS durations (10.62 ± 10.26 vs. 43.79 ± 40.97) were consistently worse for SD-SNUC. Five-year survival probabilities were lower for SD-SNUC (0.33 vs. 0.85). Conclusion SNUC represents a heterogeneous group of undifferentiated sinonasal malignancies. Based on the status of SMARCB1 expression, the two subgroups SD-SNUC and SR-SNUC appear to represent distinct clinical entities, with loss of SMARCB1 expression conferring an overall worse prognosis.

Anterior skull base surgery requires intimate knowledge of a highly complex anatomic region containing critical neurovascular structures. A wide array of pathologies can occur along the anterior cranial base, including meningiomas, esthesioneuroblastomas, pituitary adenomas, craniopharyngiomas, chondrosarcomas, and chordomas. Advancements in endoscopic sinus surgery have allowed many of these tumors to be effectively treated via an endoscopic endonasal technique. This approach obviates the need for large incisions causing cosmetic deformity, improves magnification of the surgical field, and offers a direct path to lesions thus avoiding retraction of structures such as the brain and nerves. Surgeons must understand the limitations of endoscopic techniques and consider open or combined open and endoscopic approaches when appropriate. Reconstructive anterior skull base techniques vary depending on the size and location of defects, along with factors such as intracranial pressure and patient co-morbidities. Large skull base defects require multilayer reconstruction that include a watertight primary dural repair with either synthetic or autologous tissue, followed by local vascularized tissue flaps. This review contains 8 figures, 2 videos, 4 tables and 33 references Key words: Anterior skull base, meningioma, esthesioneuroblastoma, chordoma, pituitary, CSF leak, nasosptal flap, dural repair, expanded endonasal approaches, endoscopic surgery