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Objective Methods Results Discussion Letters of recommendation (LORs) are an important part of pain medicine fellowship applications that may be subject to implicit bias by the letter's author. This study evaluated letters of recommendation for applications to pain medicine fellowships in the United States to characterize biases and differences among applicants over four application cycles.This was a retrospective single‐site cohort study. De‐identified LORs were collected from 2020 to 2023 from one institution. The Valence Aware Dictionary and sEntiment Reasoner (VADER) natural language processing package scored positive LOR sentiment. In addition, the deep learning tool, Empath, scored LORs for 15 sentiments. Wilcoxon rank‐sum and one‐way ANOVA tests compared scores between applicant demographics: gender, race, medical school type, residency specialty, and chief resident status, as well as letter writers' academic position.Nine hundred and sixty‐four applications were studied over four application cycles. Program directors wrote fewer words (p = 0.020) and less positively (p < 0.001) compared to department chairs and letter writers with neither position. Department chairs wrote with less “negative emotion” compared to both program directors and writers with neither position (p < 0.001). Anesthesiologist applicants received more letters highlighting “achievement” (p < 0.001) while PM&R applicants submitted letters with less “negative emotion” (p < 0.001) compared to other specialties. Chief residents' letters scored higher in “leader” sentiment (p < 0.001) and lower in “negative emotion” (p < 0.001).Linguistic content did not favor certain genders or races over others. However, disparities in LORs do exist depending on an applicant's specialty and chief resident status, as well as the academic status of the letter writer. [ABSTRACT FROM AUTHOR]

Introduction: Microbiome research has predominantly focused on the oral cavity and oropharynx's role in disease, while the upper airway, specifically the larynx and trachea, has been relatively overlooked. Examining the microbial communities in these regions can shed light on how dysbiosis influences diseases and their management. This review evaluates laryngotracheal microbial compositions in both healthy and diseased patients. Methods: We conducted a systematic review in EMBASE, MEDLINE, and Cochrane Central databases, yielding 1383 studies in the initial search. Inclusion criteria involved participants aged over 18 years and the use of next‐generation 16s ribosomal sequencing methods. Results: We included 10 studies—seven focused on larynx sequencing and four on trachea sequencing (one investigated both sites). In a healthy larynx, diverse species such as Streptococcus, Cloacibacterium, Prevotella, and Helicobacter were found. Benign laryngeal diseases exhibited reduced microbial diversity, mainly dominated by Streptococcus. Subglottic stenosis patients showed diminished diversity in both idiopathic and iatrogenic scars. Laryngeal squamous cell carcinoma displayed increased diversity, primarily featuring Fusobacterium. Among non‐respiratory‐compromised surgery patients, the tracheal microbiome was more diverse in diabetics and those later developing lower respiratory infections. Pneumonia patients exhibited an abundance of Prevotella and Streptococcus, linked to an increased 28‐day survival rate, while Streptococcus and Haemophilus abundance correlated with successful extubation. Conclusions: The laryngotracheal region hosts a unique microbial community influenced by both benign and malignant conditions. Many lesions remain unexplored, underscoring the need for future studies encompassing diverse laryngotracheal conditions. Clinical trials assessing microbiome modifications may unveil novel therapeutic avenues. Level of Evidence: NA Laryngoscope, 134:4167–4175, 2024 [ABSTRACT FROM AUTHOR]

Background We explored the clinical significance of the residual hematoma cavity 1 year after minimally invasive intracerebral hemorrhage (ICH) evacuation. Methods Patients presenting with spontaneous supratentorial ICH were evaluated for minimally invasive surgical evacuation. Inclusion criteria included age ≥18 years, preoperative hematoma volume (Hv) ≥15 mL, presenting National Institutes of Health Stroke Scale score ≥6, and premorbid modified Rankin Scale (mRS) score ≤3. Patients with longitudinal CT scans at least 3 months after evacuation were included in the study. Remnant cavity volumes (Cv) after evacuation were computed using semi-automatic volumetric segmentation software. Relative cavity volume (rCv) was defined as the ratio of the preoperative Hv to the remnant Cv. Results 108 patients with a total of 484 head CT scans were included in the study. The median postoperative Cv was 2.4 (IQR 0.0-11) mL, or just 6% (0-33%) of the preoperative Hv. The median residual Cv on the final head CT scan a median of 13 months (range 11-27 months) after surgery had increased to 9.4 (IQR 3.1-18) mL, or 25% (10-60%) of the preoperative Hv. rCv on the final head CT scan was negatively associated with measures of operative success including evacuation percentage, postoperative Hv ≤ 15 mL, and decreased time from ictus to evacuation. rCv on the final head CT scan was also associated with a worse 6-month functional outcome (β per mRS point 17.6%, P<0.0001; area under the receiver operating characteristic curve 0.91). Conclusion After minimally invasive ICH evacuation the hematoma lesion decompresses significantly, with a residual Cv just 6% of the original lesion, but then gradually increases in size over time. Early and high percentage ICH evacuation may reduce the remnant Cv over time which, in turn, is associated with improved functional outcomes. [ABSTRACT FROM AUTHOR]

Background Diffusion-weighted imaging (DWI) lesions have been linked to poor outcomes after intracerebral hemorrhage (ICH). We aimed to assess the impact of cerebral digital subtraction angiography (DSA) on the presence of DWI lesions in patients who underwent minimally invasive surgery (MIS) for ICH. Methods Retrospective chart review was performed on ICH patients treated with MIS in a single health system from 2015 to 2021. One hundred and seventy consecutive patients who underwent postoperative MRIS were reviewed. Univariate analyses were conducted to determine associations. Variables with p<0.05 were included in multivariate analyses. Results DWI lesions were present in 88 (52%) patients who underwent MIS for ICH. Of the 83 patients who underwent preoperative DSA, 56 (67%) patients demonstrated DWI lesions. In this DSA cohort, older age, severe leukoaraiosis, larger preoperative hematoma volume, and increased presenting National Institutes of Health Stroke Score (NIHSS) were independently associated with DWI lesion identification (p<0.05). In contrast, of 87 patients who did not undergo DSA, 32 (37%) patients demonstrated DWI lesions on MRI. In the non-DSA cohort, presenting systolic blood pressure, intraventricular hemorrhage, and NIHSS were independently associated with DWI lesions (p<0.05). Higher DWI lesion burden was independently associated with poor modified Rankin Scale (mRS) at 6 months on a univariate (p=0.02) and multivariate level (p=0.02). Conclusions In this cohort of ICH patients who underwent minimally invasive evacuation, preprocedural angiography was associated with the presence of DWI lesions on post-ICH evacuation MRI. Furthermore, the burden of DWI lesions portends a worse prognosis after ICH. [ABSTRACT FROM AUTHOR]

Introduction: Letters of recommendation (LORs) are a highly influential yet subjective and often enigmatic aspect of the residency application process. This study hypothesizes that LORs do contain valuable insights into applicants and can be used to predict outcomes. This pilot study utilizes natural language processing and machine learning (ML) models using LOR text to predict interview invitations for otolaryngology residency applicants. Methods: A total of 1642 LORs from the 2022–2023 application cycle were retrospectively retrieved from a single institution. LORs were preprocessed and vectorized using three different techniques to represent the text in a way that an ML model can understand written prose: CountVectorizer (CV), Term Frequency‐Inverse Document Frequency (TF‐IDF), and Word2Vec (WV). Then, the LORs were trained and tested on five ML models: Logistic Regression (LR), Naive Bayes (NB), Decision Tree (DT), Random Forest (RF), and Support Vector Machine (SVM). Results: Of the 337 applicants, 67 were interviewed and 270 were not interviewed. In total, 1642 LORs (26.7% interviewed) were analyzed. The two best‐performing ML models in predicting interview invitations were the TF‐IDF vectorized DT and CV vectorized DT models. Conclusion: This preliminary study revealed that ML models and vectorization combinations can provide better‐than‐chance predictions for interview invitations for otolaryngology residency applicants. The high‐performing ML models were able to classify meaningful information from the LORs to predict applicant interview invitation. The potential of an automated process to help predict an applicant's likelihood of obtaining an interview invitation could be a valuable tool for training programs in the future. Level of Evidence: N/A Laryngoscope, 134:4016–4022, 2024 [ABSTRACT FROM AUTHOR]

Key points This follow‐up dual‐institutional and longitudinal study further evaluated for underlying gender biases in LORs for rhinology fellowship. Explicit and implicit linguistic gender bias was found, heavily favoring male applicants [ABSTRACT FROM AUTHOR]

Background Patients with vein of Galen malformations (VOGMs) can develop fine angiogenic networks with fistulous connections to the precursor of the vein of Galen. In these cases, transarterial embolization (TAE) with liquid embolic agents (LEAs) is challenging due to reflux in the pedicle leading to the network, causing poor penetration. Transvenous approaches carry a risk of hemorrhage from pathologic vasculature. Dual-lumen balloon microcatheters like the Scepter Mini (Microvention, Aliso Viejo, CA) improve distal pedicle access, preventing reflux. Objective Here, we report on the use of the Scepter Mini for TAE of angiogenic VOGM. Methods A single-institution retrospective chart review identified all VOGMs treated with Scepter Mini microcatheters. Clinical data, angioarchitecture, and technical parameters were reviewed. Results 17 Scepter Mini catheters were used in 12 embolization procedures of 7 patients with VOGM at a median age of 2.1 years. Patients presented with hydrocephalus (100%) and gross motor and speech delays (57.1%). Networks developed extra-axially into the subependymal zone fed by posterior choroidal, posterior cerebral, and thalamoperforator arteries. Posterior choroidal branches (n=7/17, 41.2%) were most frequently catheterized to achieve distal access to the network. Embolization with Onyx-18 and significant network penetration occurred in 17/17 uses. Near tip entrapment with LEA cast displacement occurred in 1/17 uses. Another patient experienced postprocedural intraventricular hemorrhage requiring a third ventriculostomy without permanent neurologic deficit. Conclusion The Scepter Mini provided excellent distal access with penetration to the fistula and extra-axial network reduction with few complications. The Scepter Mini provides a means for successful treatment of technically challenging angiogenic VOGM. [ABSTRACT FROM AUTHOR]

Introduction: Major disparities in outcomes by race are present throughout vascular surgery, yet little has been published on iliac vein stent outcomes by race. This retrospective study assessed iliac vein stent outcomes by patient race. Methods: Patients who underwent iliac vein stenting at a single institution for chronic venous insufficiency (CVI) from 2011 to 2021 were reviewed. Demographic, preoperative, perioperative, and postoperative data were collected. Self-reported race groups included Asian, Black, Hispanic, and White. Univariate differences were analyzed using χ2 tests for categorical variables and 1-way ANOVA for continuous variables. Outcomes included change in Venous Clinical Severity Score (VCSS) at interval timepoints relative to a preoperative baseline and reinterventions. Logistic regression models were used to determine the unadjusted and adjusted odds ratio (OR) of any minor and major reintervention. Multivariate regression models controlled for demographic and comorbidity characteristics. Results: A total of 827 patients were included. Asian patients were younger and had a greater proportion of male patients, lower Body mass index (BMI), less smoking history, and fewer comorbidities. White patients were more likely to have a history of deep vein thrombosis (DVT). White patients presented with the most severe CVI symptoms as defined by both Clinical-Etiological-Anatomical-Pathophysiological (CEAP) classification and preoperative VCSS composite scores. There were no differences in acute DVT, number of stents deployed, and bilateral versus unilateral stent placement. Black patients had the longest average days of follow-up, followed sequentially by Hispanic, White, and Asian. Black patients had the most reinterventions, while Asian patients had the fewest. Asian patients were less likely to have a major reintervention. No differences in VCSS composite or change in VCSS were observed. Conclusions: In patients with CVI, Asian patients presented younger and healthier, while White patients presented with the most severe symptoms. No differences were observed in VCSS outcomes, though Black patients had the most reinterventions. [ABSTRACT FROM AUTHOR]

Simple Summary: Papillary thyroid cancer diagnosis is a significant source of worry to patients, despite its relatively good prognosis. Such significant distress may prompt patients to receive surgical treatment, even when active surveillance may be a safer alternative. Patients with pre-existing anxiety and depression may be particularly prone to opting for surgical treatment. We collected data on the time between fine-needle aspiration (FNA) diagnosis and surgical treatment of a cohort of patients seen at a large tertiary center in New York in 2018–2020 and investigated mental health status as potential predictors. We found that pre-existing anxiety and depression may lead to shorter times for surgical intervention for thyroid cancer. Our study adds to the limited literature on mental health predictors of thyroid cancer decision making. (1) Background: A pre-existing psychiatric condition may impact decision making by patients and/or physicians following a thyroid cancer diagnosis, such as potentially electing surgery over active surveillance, thus shortening the time to cancer removal. This is the first study to investigate the association between pre-existing anxiety and/or depression and time to receive surgical treatment for thyroid cancer. (2) Methods: Retrospective data were collected from 652 surgical thyroid cancer patients at our institution from 2018 to 2020. We investigated the time between thyroid cancer diagnosis and surgery, comparing patients with pre-existing anxiety and/or depression to those without. (3) Results: Patients with anxiety, depression, and both anxiety and depression had a significantly shorter time between diagnosis and surgery (51.6, 57, and 57.4 days, respectively) compared to patients without (111.9 days) (p = 0.002, p = 0.004, p = 0.003, respectively). (4) Conclusions: Although little is known about the impact of pre-existing psychiatric conditions in the decision-making process for thyroid cancer surgery, this present study showed that anxiety and/or depression may lead to more immediate surgical interventions. Thus, psychiatric history may be an important factor for physicians to consider when counseling patients with thyroid cancer. [ABSTRACT FROM AUTHOR]

This article, published in the Journal of Neurological Surgery, explores the risk factors for cerebrospinal fluid (CSF) leaks in patients undergoing surgical treatment for idiopathic intracranial hypertension (IIH). The study, based on a retrospective analysis of the National Inpatient Survey dataset, included 11,070 patients diagnosed with IIH who received either optic nerve sheath fenestration or cerebrospinal fluid shunt placement. The findings indicate that patients over the age of 80 and those with diabetes mellitus had a higher risk of experiencing CSF leaks. The study suggests that careful patient selection is necessary for surgical intervention in refractory IIH cases. [Extracted from the article]

This article, published in the Journal of Neurological Surgery, explores the predictors of venous thromboembolism (VTE) in patients undergoing endoscopic pituitary adenoma resection. The study, based on a large cohort from the National Inpatient Survey dataset, found that race, geographical location, coagulopathy, emergent surgery, diabetes mellitus, and fluid and electrolyte disorders were associated with an increased risk of VTE. However, obesity was not found to be a significant predictor. The authors suggest that further prospective studies are needed to better understand the risk factors and to assess the need for standardized anticoagulation protocols in pituitary adenoma resection. [Extracted from the article]

This article, titled "Benign Meningiomas Develop Through a Four-Hit Mechanism," explores the pathogenesis of benign meningiomas, which are central nervous system tumors that become more common with age. The study investigates the number of rate-limiting steps required for the development of benign meningiomas in American patients and high-risk subpopulations. The researchers analyzed incidence data from the Surveillance, Epidemiology and End Results Program (SEER) and found a linear relationship between the incidence of benign meningiomas and age, suggesting that four mutations are necessary for their development. The study also suggests that the tumor microenvironment may play a role in affecting the number of mutations. Further research is needed to understand the effect of driver mutations and identify the specific steps involved in the development of benign meningiomas. [Extracted from the article]

Background Minimally invasive evacuation may help ameliorate outcomes after intracerebral hemorrhage (ICH). However, hospital length of stay (LOS) postevacuation is often long and costly. Objective To examine factors associated with LOS in a large cohort of patients who underwent minimally invasive endoscopic evacuation. Methods Patients presenting to a large health system with spontaneous supratentorial ICH qualified for minimally invasive endoscopic evacuation if they met the following inclusion criteria: age ≥18, premorbid modified Rankin Scale (mRS) score ≤3, hematoma volume ≥15 mL, and presenting National Institutes of Health Stroke Scale (NIHSS) score ≥6. Demographic, clinical, radiographic, and operative characteristics were included in a multivariate logistic regression for hospital and ICU LOS dichotomized into short and prolonged stay at 14 and 7 days, respectively. Results Among 226 patients who underwent minimally invasive endoscopic evacuation, the median intensive care unit and hospital LOS were 8 (4-15) days and 16 (9-27) days, respectively. A greater extent of functional impairment on presentation (OR per NIHSS point 1.10 (95% CI 1.04 to 1.17), P=0.007), concurrent intraventricular hemorrhage (OR=2.46 (1.25 to 4.86), P=0.02), and deep origin (OR=per point 2.42 (1.21 to 4.83), P=0.01) were associated with prolonged hospital LOS. A longer delay from ictus to evacuation (OR per hour 1.02 (1.01 to 1.04), P=0.007) and longer procedure time (OR per hour 1.91 (1.26 to 2.89), P=0.002) were associated with prolonged ICU LOS. Prolonged hospital and ICU LOS were in turn longitudinally associated with a lower rate of discharge to acute rehabilitation (40% vs 70%, P<0.0001) and worse 6- month mRS outcomes (5 (4-6) vs 3 (2-4), P<0.0001). Conclusions We present factors associated with prolonged LOS, which in turn was associated with poor long-term outcomes. Factors associated with LOS may help to inform patient and clinician expectations of recovery, guide protocols for clinical trials, and select suitable populations for minimally invasive endoscopic evacuation. [ABSTRACT FROM AUTHOR]

Concussions are the leading cause of injury among youth athletes, and antibiotics are the most prescribed pediatric medication in the United States. Antibiotics have shown to exert neuroprotective effects in animal models of traumatic brain injury, but to date, no human studies exist. Between 2009 and 2019, 6,343 adolescent athletes with differential antibiotic use at baseline were administered Immediate Post-concussion Assessment and Cognitive Testing at baseline and twice postinjury. Chronic antibiotic use was associated with a reduced risk for concussion (odds ratio 0.54), increased postconcussive symptomology and neurocognitive burden, and improved recovery by follow-up, a median of 7 days after concussion. This preliminary retrospective analysis suggests antibiotic use may impart neuroprotection up to a certain severity threshold, leading to fewer, yet more severe concussions that tend to recover faster. [ABSTRACT FROM AUTHOR]