Publications by authors named "Alyson Kaplan"

30 Publications

  • Page 1 of 1

Identification of Quantifiable Predictors of Relapse in Patients with Alcohol-Associated Liver Disease.

Hepatol Commun 2021 Jul 13;5(7):1156-1164. Epub 2021 Mar 13.

Division of Gastroenterology and Hepatology Weill Cornell Medicine New York NY USA.

Abstinence in patients with alcohol-associated liver disease (ALD) reduces mortality. Most predictors of relapse are not quantifiable, preventing objective analysis of relapse risk and targeted intervention to improve clinical outcomes. We prospectively enrolled patients with ALD from November 2016 to December 2019 and administered a survey with two previously published scales to assess insight into alcohol-use disorder (Hanil Alcohol Insight Scale [HAIS]) and social support (Community Assessment Inventory Scale [CAIS]). Relapse was assessed using surveys and metabolite testing. Unadjusted and prespecified adjusted regression analyses identified predictors of relapse. We enrolled 81% of eligible patients (n = 136), of whom 58 had follow-up data available at the time of analysis. Over a median follow-up of 1 year (interquartile range: 0.5-1.4), 10 patients relapsed (17%). Patients who relapsed were more likely to continue drinking despite either a diagnosis of liver disease or a decompensating event, and were less likely to have been transplanted (all < 0.05). In unadjusted regression, the HAIS and the "support inside the home" subcategory of the CAIS were predictive of relapse, with odds ratio (OR) = 0.84 (95% confidence interval 0.72-0.97) and 0.85 (0.74-0.97). In adjusted regression, the HAIS was no longer significant, with adjusted OR = 0.70 (0.49-1.00, = 0.05), whereas the "support inside the home' subcategory of CAIS remained significant, with adjusted OR = 0.69 (0.51-0.92, = 0.01). : Risk factors for relapse in patients with ALD were identified and quantified prospectively, suggesting opportunities to objectively identify patients at risk for relapse as well as to intervene to prevent relapse.
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http://dx.doi.org/10.1002/hep4.1704DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8279469PMC
July 2021

Can Living Donor Liver Transplantation in the United States Reach Its Potential?

Liver Transpl 2021 Jun 26. Epub 2021 Jun 26.

Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell School of Medicine, New York Presbyterian, New York, NY.

Living donor liver transplantation (LDLT) is a vital tool to address the growing organ shortage in the United States caused by increasing numbers of patients diagnosed with end-stage liver disease. LDLT still only makes up a very small proportion of all liver transplantations performed each year, but there are many innovations taking place in the field that may increase its acceptance among both transplant programs and patients. These innovations include ways to improve access to LDLT, such as through nondirected donation, paired exchange, transplant chains, transplant of ABO-incompatible donors, and transplants in patients with high Model for End-Stage Liver Disease scores. Surgical innovations, such as laparoscopic donor hepatectomy, robotic hepatectomy, and portal flow modulation, are also increasingly being implemented. Policy changes, including decreasing the financial burden associated with LDLT, may make it a more feasible option for a wider range of patients. Lastly, center-level behavior, such as ensuring surgical expertise and providing culturally competent education, will help toward LDLT expansion. Although it is challenging to know which of these innovations will take hold, we are already seeing LDLT numbers improve within the past 2 years.
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http://dx.doi.org/10.1002/lt.26220DOI Listing
June 2021

Medicaid Expansion Association With End-Stage Liver Disease Mortality Depends on Leniency of Medicaid Hepatitis C Virus Coverage.

Liver Transpl 2021 Jun 12. Epub 2021 Jun 12.

Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY.

The Affordable Care Act expanded Medicaid around the same time that direct-acting antivirals became widely available for the treatment of hepatitis C virus (HCV). However, there is significant variation in Medicaid HCV treatment eligibility criteria between states. We explored the combined effects of Medicaid expansion and leniency of HCV coverage under Medicaid on liver outcomes. We assessed state-level end-stage liver disease (ESLD) mortality rates, listings for liver transplantation (LT), and listing-to-death ratios (LDRs) for adults aged 25 to 64 years using data from United Network for Organ Sharing and Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research. States were divided into 4 nonoverlapping groups based on expansion status on January 1, 2014 (expansion versus nonexpansion) and leniency of Medicaid HCV coverage (lenient versus restrictive coverage). Joinpoint regression analysis evaluated the significant changes in slope over time (joinpoints) during the pre-expansion (2009-2013) and postexpansion (2014-2018) time periods. We found significant changes in the annual percent change for population-adjusted ESLD deaths between 2014 and 2015 in all cohorts except for the nonexpansion/restrictive cohort, in which deaths increased at the same annual percent change from 2009 to 2018 (annual percent change of +2.5%; 95% confidence interval [CI], 1.8-3.3]). In the expansion/lenient coverage cohort, deaths increased at an annual percent change of +2.6% (95% CI, 1.8-3.5) until 2014 and then tended to decrease at an annual percent change of -0.4% (95% CI, -1.5 to 0.8). LT listings tended to decrease over time for all cohorts. For LDRs, only the expansion/lenient and expansion/restrictive cohorts had statistically significant joinpoints. Improvements in ESLD mortality and LDRs were associated with both Medicaid expansion and leniency of HCV coverage under Medicaid. These findings suggest the importance of implementing more lenient and widespread public health insurance to improve liver disease outcomes, including mortality.
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http://dx.doi.org/10.1002/lt.26209DOI Listing
June 2021

Gender Prevalence and Trends in Otology and Neurotology Publications.

Otol Neurotol 2021 06;42(5):659-665

Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.

Objective: To assess otology and neurotology authorship by gender, subject, and country of origin from 2000 to 2019.

Study Design: Retrospective review of otology and neurotology publications in 2000, 2005, 2010, 2015, and 2019 from 10 prominent journals within otolaryngology.

Main Outcome Measures: Demographics for first through third and final authors, including gender, degree, coauthorship, as well as number of authors, subject matter, and region of origin for each publication.

Results: A total of 4,411 neurotology articles published in 2000, 2005, 2010, 2015, and 2019 were analyzed. During the study period, the proportion of female authors increased from 22.3% in 2000 to 33.9% in 2019 (p < 0.0001). However, authorship position analysis demonstrated no increase in final female authorship (22.5% in 2019, from 19.4% in 2000, p = 0.112). Geographic region analysis demonstrated a similar overall global trend toward an increase in female authors. When considering author gender by position, North America, the Middle East, and Africa failed to demonstrate significant increasing trends for female final authors. Female final authors were also significantly less likely to have medical degrees than final male authors, (37.4% versus 78.6%, respectfully, p =  < 0.0001). Finally, women published more often within the subjects of pediatrics and audiology (46.5% and 37.3% of final authors, p < 0.0001).

Conclusions: Female authorship in otology and neurotology has increased globally. With the predominant number of articles originating from North America, and articles originating from North America failing to demonstrate an increase in female final authorship, overall, final female authorship did not change during the study period.

Professional Practice Gap And Educational Need: There is no comprehensive study exploring gender distribution within only the specialty of otology and neurotology. While it is known that more women are becoming otolaryngologists, it is unknown if this increase is reflected in otology and neurotology publications, domestically and internationally.

Learning Objective: To understand if gender biases and/or differences exist within otology and neurotology publications.

Desired Result: Identify trends in otology and neurotology publications to address particular barriers to female publication within the field.
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http://dx.doi.org/10.1097/MAO.0000000000003067DOI Listing
June 2021

Black Patients Have Unequal Access to Listing for Liver Transplantation in the United States.

Hepatology 2021 Mar 29. Epub 2021 Mar 29.

Weill Cornell Medicin, New York, USA.

The Model for End-Stage Liver Disease score may have eliminated racial disparities on the waitlist for liver transplantation (LT), but disparities prior to waitlist placement have not been adequately quantified. We aimed to analyze differences in patients who are listed for LT, undergo transplantation, and die from end-stage liver disease (ESLD), stratified by state and race/ethnicity. We analyzed two databases retrospectively - the Center for Disease Control Wide-ranging OnLine Data for Epidemiologic Research (CDC WONDER) and the United Network for Organ Sharing (UNOS) databases from 2014-2018. We included patients aged 25-64 years who had a primary cause of death of ESLD and listed for transplant in the CDC WONDER and UNOS databases, respectively. Our primary outcome was the ratio of listing for LT to death from ESLD - listing to death ratio (LDR). Our secondary outcome was the transplant to listing and transplant to death ratios. Chi-squared and multivariable linear regression evaluated for differences between race/ethnicity. 135,367 patients died of ESLD, 54,734 patients were listed for transplant, and 26,571 underwent transplant. Patients were mostly male and White. The national LDR was 0.40, significantly lowest in Black patients (0.30), p<0.001. The national transplant to listing ratio was 0.48, highest in Black patients (0.53), p<0.01. The national transplant to death ratio was 0.20, lowest in Black patients (0.16), p<0.001. States that had an above-mean LDR had a lower transplant to listing ratio, but higher transplant to death ratio. Multivariable analysis confirmed Black race is significantly associated with a lower LDR and transplant to death ratio. Conclusion: Black patients face a disparity in access to LT due to low listing rates for transplant relative to deaths from ESLD.
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http://dx.doi.org/10.1002/hep.31837DOI Listing
March 2021

Reply.

Liver Transpl 2021 04 18;27(4):606. Epub 2021 Feb 18.

Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY.

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http://dx.doi.org/10.1002/lt.25997DOI Listing
April 2021

National Trends in Location of Death in Patients With End-Stage Liver Disease.

Liver Transpl 2021 02;27(2):165-176

Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY.

Despite improvement in the care of patients with end-stage liver disease (ESLD), mortality is rising. In the United States, patients are increasingly choosing to die at hospice and home, but data in patients with ESLD are lacking. Therefore, this study aimed to describe the trends in location of death in patients with ESLD. We conducted a retrospective cross-sectional analysis using the Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research from 2003 to 2018. Death location was categorized as hospice, home, inpatient facility, nursing home, or other. Comparisons were made between sex, age, ethnicity, race, region, and other causes of death. Comparisons were also made between rates of change (calculated as annual percent change), proportion of deaths in 2018, and multivariable logistic regression. A total of 535,261 deaths were attributed to ESLD-most were male, non-Hispanic, and White. The proportion of deaths at hospice and home increased during the study period from 0.2% to 10.6% and 20.3% to 25.7%, respectively. Whites had the highest proportion of deaths in hospice and home. In multivariable analysis, elderly patients were more likely to die in hospice or home (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.07-1.35), whereas Black patients were less likely (OR, 0.58; 95% CI, 0.46-0.73). Compared with other causes of death, ESLD had the second highest proportion of deaths in hospice but lagged behind non-hepatocellular carcinoma malignancy. Deaths in patients with ESLD are increasingly common at hospice and home overall, and although the rates have been increasing among Black patients, they are still less likely to die at hospice or home. Efforts to improve this disparity, promote end-of-life care planning, and enhance access to death at hospice and home are needed.
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http://dx.doi.org/10.1002/lt.25952DOI Listing
February 2021

Clinical Characteristics, Diagnosis, and Outcomes of 6 Patients With COVID-19 Infection and Rhabdomyolysis.

Mayo Clin Proc 2020 11 8;95(11):2557-2559. Epub 2020 Sep 8.

NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY.

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http://dx.doi.org/10.1016/j.mayocp.2020.09.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7831467PMC
November 2020

Gastrointestinal Bleeding in Patients With Coronavirus Disease 2019: A Matched Case-Control Study.

Am J Gastroenterol 2020 10;115(10):1609-1616

Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York.

Introduction: Although current literature has addressed gastrointestinal presentations including nausea, vomiting, diarrhea, abnormal liver chemistries, and hyperlipasemia as possible coronavirus disease 2019 (COVID-19) manifestations, the risk and type of gastrointestinal bleeding (GIB) in this population is not well characterized.

Methods: This is a matched case-control (1:2) study with 41 cases of GIB (31 upper and 10 lower) in patients with COVID-19 and 82 matched controls of patients with COVID-19 without GIB. The primary objective was to characterize bleeding etiologies, and our secondary aim was to discuss outcomes and therapeutic approaches.

Results: There was no difference in the presenting symptoms of the cases and controls, and no difference in severity of COVID-19 manifestations (P > 0.05) was observed. Ten (32%) patients with upper GIB underwent esophagogastroduodenoscopy and 5 (50%) patients with lower GIBs underwent flexible sigmoidoscopy or colonoscopy. The most common upper and lower GIB etiologies were gastric or duodenal ulcers (80%) and rectal ulcers related to rectal tubes (60%), respectively. Four of the esophagogastroduodenoscopies resulted in therapeutic interventions, and the 3 patients with rectal ulcers were referred to colorectal surgery for rectal packing. Successful hemostasis was achieved in all 7 cases that required interventions. Transfusion requirements between patients who underwent endoscopic therapy and those who were conservatively managed were not significantly different. Anticoagulation and rectal tube usage trended toward being a risk factor for GIB, although it did not reach statistical significance.

Discussion: In COVID-19 patients with GIB, compared with matched controls of COVID-19 patients without GIB, there seemed to be no difference in initial presenting symptoms. Of those with upper and lower GIB, the most common etiology was peptic ulcer disease and rectal ulcers from rectal tubes, respectively. Conservative management seems to be a reasonable initial approach in managing these complex cases, but larger studies are needed to guide management.
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http://dx.doi.org/10.14309/ajg.0000000000000805DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7446989PMC
October 2020

Microthrombosis associated with GI bleeding in COVID-19.

Gastrointest Endosc 2021 01 17;93(1):263-264. Epub 2020 Jul 17.

Division of Gastroenterology and Hepatology, New York-Presbyterian/Weill Cornell Medical Center, New York, New York, USA.

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http://dx.doi.org/10.1016/j.gie.2020.07.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7366093PMC
January 2021

Brief Report: Relationship Between Nonalcoholic Fatty Liver Disease and Cardiovascular Disease in Persons With HIV.

J Acquir Immune Defic Syndr 2020 08;84(4):400-404

Department of Medicine, Liver Center, Massachusetts General Hospital, Boston, MA.

Background: Nonalcoholic fatty liver disease (NAFLD) and HIV are independently associated with cardiovascular disease (CVD). However, the factors associated with NAFLD in persons living with HIV (PWH) and whether CVD is more frequent in PWH with NAFLD are currently unknown.

Methods: From the Partners HealthCare Research Patient Data Registry, we identified PWH with and without NAFLD between 2010 and 2017. NAFLD was defined using validated histological or radiographic criteria. CVD was defined by an ICD-9 diagnosis of coronary artery disease, myocardial infarction, coronary revascularization, peripheral vascular disease, heart failure, transient ischemic attack, or stroke and was confirmed by clinician review. Multivariable logistic regression was performed to examine the relationship between NAFLD and CVD.

Results: Compared with PWH without NAFLD (n = 135), PWH with NAFLD (n = 97) had higher body mass index and more frequently had hypertension, obstructive sleep apnea, diabetes mellitus, dyslipidemia, coronary artery disease, and CVD (P < 0.01 for all). PWH with NAFLD were also more likely to have CD4 T-cell counts (CD4) <200 cells/mm. In multivariable models, the presence of NAFLD was significantly associated with CVD (adjusted odds ratio 3.08, 95% confidence interval: 1.37 to 6.94) and CD4 <200 cells/mm (adjusted odds ratio 4.49, 95% confidence interval: 1.74 to 11.55).

Conclusion: In PWH, CVD was independently associated with prevalent NAFLD after controlling for traditional CVD risk factors. NAFLD was also associated with CD4 <200 cells/mm, suggesting that immune dysfunction may be related to NAFLD. Both CVD and low CD4 count as risk factors for NAFLD require prospective evaluation.
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http://dx.doi.org/10.1097/QAI.0000000000002359DOI Listing
August 2020

Advanced fibrosis is associated with incident cardiovascular disease in patients with non-alcoholic fatty liver disease.

Aliment Pharmacol Ther 2020 04 11;51(7):728-736. Epub 2020 Feb 11.

Liver Center, Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.

Background: Non-alcoholic fatty liver disease (NAFLD) is associated with an increased risk of cardiovascular disease. It is not well understood, however, which individuals with NAFLD are at highest risk for cardiovascular disease.

Aims: To determine the factors associated with incident cardiovascular events in a prospective cohort of individuals with biopsy-proven NAFLD without pre-existing cardiovascular disease.

Methods: From 2011 to 2018, adults with biopsy-proven NAFLD without cardiovascular disease were enrolled in a tissue repository and were followed prospectively to the first recorded date of incident cardiovascular disease, death or the end of follow-up (11/1/2018). Competing risks analysis was performed to identify predictors of incident cardiovascular disease.

Results: After a median follow-up time of 5.2 years, 26/285 (9.1%) individuals experienced an incident cardiovascular event. Advanced fibrosis (stage 3-4) on biopsy was a significant predictor of incident cardiovascular disease, and this persisted on multivariable analysis (SHR 2.86, 95% CI 1.36-6.04) after considering relevant covariates, including cardiovascular risk scores, which were not independent predictors. Of the non-invasive indicators of fibrosis, the NAFLD fibrosis score was the only independent predictor of cardiovascular disease. Other histologic features, including steatohepatitis, were not associated with incident cardiovascular disease.

Conclusions: In adults with biopsy-proven NAFLD, advanced fibrosis on biopsy and higher NAFLD fibrosis score were significant and independent predictors of incident cardiovascular disease, even after considering traditional risk factors and cardiovascular risk scores. These findings should be considered when evaluating NAFLD patients for primary prevention of cardiovascular disease, and further evaluation into the link between advanced fibrosis and cardiovascular disease is needed.
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http://dx.doi.org/10.1111/apt.15660DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7069774PMC
April 2020

Gastrointestinal Mucormycosis Presenting as Emphysematous Gastritis After Stem Cell Transplant for Myeloma.

Mayo Clin Proc 2020 01;95(1):33-34

Department of Internal Medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY.

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http://dx.doi.org/10.1016/j.mayocp.2019.10.037DOI Listing
January 2020

Household Diversion of Prescription Stimulants: Medication Misuse by Parents of Children with Attention-Deficit/Hyperactivity Disorder.

J Child Adolesc Psychopharmacol 2017 Oct 7;27(8):741-746. Epub 2017 Jul 7.

Division of Developmental and Behavioral Pediatrics, Steven and Alexandra Cohen Children's Medical Center of New York , Lake Success, New York.

Objectives: The primary objective of this study is to investigate household diversion of stimulant medication. Secondary objectives are to examine clinical/demographic predictors of diversion, types of formulations diverted, exposure to household diversion in the media, and storage of prescription stimulants within households.

Methods: Questionnaires were completed by 180 parents of youth who were currently taking stimulant medication for treatment of attention-deficit/hyperactivity disorder (ADHD). Parents were asked whether they or another adult in the home had ever taken their child's stimulant medication or given one child's stimulant medication to another child in the home. Additionally, data regarding demographics, parental ADHD (diagnosed or suspected), past suspicions of missing medication, and medication storage were also collected. Responses were compared using Pearson's chi-squared test with Yates' continuity correction.

Results: Sixteen percent of parents reported diversion of stimulant medication to another household member, with the majority admitting to taking the medication themselves. Another 13% had been tempted to illicitly self-administer their child's medication. Parents with suspected or diagnosed ADHD showed greater risk of self-administration or temptation to do so, compared to parents without (33% vs. 17%, p = 0.01). The majority of parents (71%) stored prescription stimulants "in plain sight," or "out of sight but available to all."

Conclusion: Although previous research has focused on peer diversion among adolescents and young adults, clinicians must be vigilant for the possibility of diversion by parents of children treated with stimulant medication.
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http://dx.doi.org/10.1089/cap.2016.0058DOI Listing
October 2017

Pediatric Auditory Brainstem Implant Surgery: A New Option for Auditory Habilitation in Congenital Deafness?

J Am Board Fam Med 2016 Mar-Apr;29(2):286-8

From the Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA.

Introduction: The auditory brainstem implant (ABI) is a neuroprosthetic device that provides sound sensations to individuals with profound hearing loss who are not candidates for a cochlear implant (CI) because of anatomic constraints. Herein we describe the ABI for family physicians.

Methods: PubMed was searched to identify articles relevant to the ABI, as well as articles that contain outcomes data for pediatric patients (age <18 years) who have undergone ABI surgery.

Results: The ABI was originally developed for patients with neurofibromatosis type 2 (NF2) who become deaf from bilateral vestibular schwannomas. Over the past decade, indications for an ABI have expanded to adult patients without tumors (without NF2) who cannot receive a CI and children with no cochlea or cochlear nerve. Outcomes among NF2 ABI users are modest compared to cochlear implant patients, but recent studies from Europe suggest that some non-tumor adult and pediatric ABI users achieve speech perception.

Conclusion: The ABI is a reasonable surgical option for children with profound hearing loss due to severe cochlear or cochlear nerve deformities. Continued prospective data collection from several clinical trials in the U.S. will provide greater understanding on long term outcomes that focus on speech intelligibility.
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http://dx.doi.org/10.3122/jabfm.2016.02.150258DOI Listing
December 2016

Amblyaudia: Review of Pathophysiology, Clinical Presentation, and Treatment of a New Diagnosis.

Otolaryngol Head Neck Surg 2016 Feb 10;154(2):247-55. Epub 2015 Nov 10.

Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.

Objective: Similar to amblyopia in the visual system, "amblyaudia" is a term used to describe persistent hearing difficulty experienced by individuals with a history of asymmetric hearing loss (AHL) during a critical window of brain development. Few clinical reports have described this phenomenon and its consequent effects on central auditory processing. We aim to (1) define the concept of amblyaudia and (2) review contemporary research on its pathophysiology and emerging clinical relevance.

Data Sources: PubMed, Embase, and Cochrane databases.

Review Methods: A systematic literature search was performed with combinations of search terms: "amblyaudia," "conductive hearing loss," "sensorineural hearing loss," "asymmetric," "pediatric," "auditory deprivation," and "auditory development." Relevant articles were considered for inclusion, including basic and clinical studies, case series, and major reviews.

Conclusions: During critical periods of infant brain development, imbalanced auditory input associated with AHL may lead to abnormalities in binaural processing. Patients with amblyaudia can demonstrate long-term deficits in auditory perception even with correction or resolution of AHL. The greatest impact is in sound localization and hearing in noisy environments, both of which rely on bilateral auditory cues. Diagnosis and quantification of amblyaudia remain controversial and poorly defined. Prevention of amblyaudia may be possible through early identification and timely management of reversible causes of AHL.

Implications For Practice: Otolaryngologists, audiologists, and pediatricians should be aware of emerging data supporting amblyaudia as a diagnostic entity and be cognizant of the potential for lasting consequences of AHL. Prevention of long-term auditory deficits may be possible through rapid identification and correction.
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http://dx.doi.org/10.1177/0194599815615871DOI Listing
February 2016

Systematic Review of Nontumor Pediatric Auditory Brainstem Implant Outcomes.

Otolaryngol Head Neck Surg 2015 Nov 30;153(5):739-50. Epub 2015 Jul 30.

Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA

Objective: The auditory brainstem implant (ABI) was initially developed for patients with deafness as a result of neurofibromatosis type 2. ABI indications have recently extended to children with congenital deafness who are not cochlear implant candidates. Few multi-institutional outcome data exist. Herein, we aim to provide a systematic review of outcomes following implantation of the ABI in pediatric patients with nontumor diagnosis, with a focus on audiometric outcomes.

Data Sources: PubMed, Embase, and Cochrane.

Review Methods: A systematic review of literature was performed using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) recommendations. Variables assessed included age at implantation, diagnosis, medical history, cochlear implant history, radiographic findings, ABI device implanted, surgical approach, complications, side effects, and auditory outcomes.

Results: The initial search identified 304 articles; 21 met inclusion criteria for a total of 162 children. The majority of these patients had cochlear nerve aplasia (63.6%, 103 of 162). Cerebrospinal fluid leak occurred in up to 8.5% of cases. Audiometric outcomes improved over time. After 5 years, almost 50% of patients reached Categories of Auditory Performance scores >4; however, patients with nonauditory disabilities did not demonstrate a similar increase in scores.

Conclusion: ABI surgery is a reasonable option for the habilitation of deaf children who are not cochlear implant candidates. Although improvement in Categories of Auditory Performance scores was seen across studies, pediatric ABI users with nonauditory disabilities have inferior audiometric outcomes.
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http://dx.doi.org/10.1177/0194599815596929DOI Listing
November 2015

Increasing Competitiveness for an Otolaryngology Residency: Where We Are and Concerns about the Future.

Otolaryngol Head Neck Surg 2015 Nov 17;153(5):699-701. Epub 2015 Jul 17.

Department of Otolaryngology, Boston University School of Medicine, Boston, Massachusetts, USA Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, Massachusetts, USA

For graduating medical students, securing a residency in otolaryngology-head and neck surgery has become exceedingly difficult. This commentary explores the ways that applicants and residency programs are reacting to the increasing competitiveness in applying to, interviewing for, and matching to an otolaryngology residency. The commonly held perceptions of applicants are compared to perspectives held by residency program directors and resident selection committees. Unintended consequences of the growing trend for medical students to add a research year to their curriculum are presented. Some cautions and suggestions about how to improve the application and selection process are offered.
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http://dx.doi.org/10.1177/0194599815593734DOI Listing
November 2015

Epidemiology of otologic diagnoses in United States emergency departments.

Laryngoscope 2015 Aug 20;125(8):1926-33. Epub 2015 Feb 20.

Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts.

Objectives/hypothesis: Otologic complaints may place a significant burden on emergency departments (EDs) in the United States; however, few studies have comprehensively examined this discrete patient population. We aimed to identify utilization of EDs by patients with primary otologic complaints.

Study Design: Retrospective analysis of the Nationwide Emergency Department Sample (NEDS) from 2009 through 2011.

Methods: The NEDS database was queried for patient encounters with a primary otologic diagnosis based on International Classification of Diseases, Ninth Revision codes (380-389). Weighted estimates for demographics, diagnostic characteristics, socioeconomic status, and trends over time were extracted. Predictors of mortality and admission were determined by multivariable logistic regression.

Results: A weighted total of 8,611,282 visits between 2009 and 2011 were attributed to otologic diagnoses, representing 2.21% of all ED visits. Stratified by patient age, otologic diagnoses encompassed 1.01% and 6.79% of all adult and pediatric ED visits, respectively. The majority of patients were treated and released (98.17%). The average age of patients presenting with an otologic complaint was 17.9 years (standard error = 0.23). Overall, 62.7% of patients who presented with an otologic complaint were 0 to 17 years old. The most common diagnoses among all age groups included otitis media not otherwise specified (NOS) (60.6%), infected otitis externa NOS (11.8%), and otalgia NOS (6.8%).

Conclusions: We provide a comprehensive overview of otologic complaints that are an overlooked diagnostic category in public health research. NEDS data demonstrate a significant number of visits related to otologic complaints, especially in the pediatric population, that are nonemergent.

Level Of Evidence: 4
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http://dx.doi.org/10.1002/lary.25197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4512842PMC
August 2015

Direct visualization of the murine dorsal cochlear nucleus for optogenetic stimulation of the auditory pathway.

J Vis Exp 2015 Jan 20(95):52426. Epub 2015 Jan 20.

Department of Otology and Laryngology, Harvard Medical School.

Investigation into the use of virus-mediated gene transfer to arrest or reverse hearing loss has largely been relegated to the peripheral auditory system. Few studies have examined gene transfer to the central auditory system. The dorsal cochlear nucleus (DCN) of the brainstem, which contains second order neurons of the auditory pathway, is a potential site for gene transfer. In this protocol, a technique for direct and maximal exposure of the murine DCN via a posterior fossa approach is demonstrated. This approach allows for either acute or survival surgery. Following direct visualization of the DCN, a host of experiments are possible, including injection of opsins into the cochlear nucleus and subsequent stimulation by an optical fiber coupled to a blue light laser. Other neurophysiology experiments, such as electrical stimulation and neural injector tracings are also feasible. The level of visualization and the duration of stimulation achievable make this approach applicable to a wide range of experiments.
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http://dx.doi.org/10.3791/52426DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4354549PMC
January 2015

Auditory brainstem implant candidacy in the United States in children 0-17 years old.

Int J Pediatr Otorhinolaryngol 2015 Mar 15;79(3):310-315. Epub 2014 Dec 15.

Department of Otology and Laryngology, Harvard Medical School, Boston, MA; Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA.

Objectives: The auditory brainstem implant (ABI) is an option for hearing rehabilitation in profoundly deaf patients ineligible for cochlear implantation. Over the past decade, surgeons have begun implanting ABIs in pediatric patients who are unable to receive cochlear implants due to congenital or acquired malformations of the inner ear. No study has examined the potential population-level demand for ABIs in the United States (US). Herein, we aim to quantify the potential need for pediatric ABIs.

Methods: A systematic literature review was conducted to identify studies detailing the rates of congenital cochlear and/or cochlear nerve (CN) anomalies. Absolute indications for ABI include bilateral cochlea or CN aplasia (Group A), and relative indications for ABI include bilateral cochlea or CN hypoplasia (Group B). Data was subsequently correlated to the US Census Bureau, the National Health Interview Survey, and the Gallaudet Research Institute to provide an estimation of pediatric ABI candidates.

Results: Eleven studies documented rates of bilateral findings. Bilateral cochlea aplasia was identified in 0-8.7% of patients and bilateral CN aplasia in 0-4.8% of patients (Group A). Bilateral cochlea hypoplasia was identified in 0-8.7% of patients and bilateral CN hypoplasia in 0-5.4% of patients (Group B). Using population-level sensorineural hearing loss data, we roughly estimate 2.1% of potential implant candidates meet absolute indications for an ABI in the United States.

Conclusion: Congenital cochlear and cochlear nerve anomalies are exceedingly rare. This study provides the first preliminary estimate of cochlea and CN aplasia/hypoplasia at the population level albeit with limitations based on available data. These data suggest the need for dedicated ABI centers to focus expertise and management.
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http://dx.doi.org/10.1016/j.ijporl.2014.11.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4477282PMC
March 2015

Systematic review of outcomes following observational and operative endoscopic middle ear surgery.

Laryngoscope 2015 May 24;125(5):1205-14. Epub 2014 Nov 24.

Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, Boston, Massachusetts, U.S.A; Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A.

Objectives: Middle ear surgery increasingly employs endoscopes as an adjunct to or replacement for the operative microscope. We provide a systematic review of endoscope applications in middle ear surgery with an emphasis on outcomes, including the need for conversion to microscope, audiometric findings, length of follow-up, as well as disease-specific outcomes.

Data Sources: PubMed, Embase, and Cochrane CENTRAL database.

Methods: A literature review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. Articles were categorized based on study design, indication, and use of an endoscope either as an adjunct to or as a replacement for a microscope. Qualitative and descriptive analyses of studies and outcomes data were performed.

Results: One-hundred three articles met inclusion and exclusion criteria. Of the identified articles, 38 provided outcomes data. The majority of these studies were moderate quality, retrospective, case-series reports. The indications for use of the endoscope were broad, with the most common being resection of cholesteatoma. In cholesteatoma surgery, endoscope approaches routinely identified residual cholesteatoma in primary and second-look cases. Other outcomes, including robust audiometric data, operating room times, wound healing, and quality of life surveys were not well described.

Conclusions: Endoscopes have consistently been used as an adjunct to the microscope to improve visualization of the tympanic cavity. Recent reports utilize the endoscope exclusively during surgical dissection; however, data comparing patient outcomes following the use of an endoscope to a microscope are lacking. Areas in need of additional research are highlighted.

Level Of Evidence: NA
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http://dx.doi.org/10.1002/lary.25048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4467784PMC
May 2015

Clinical diagnosis and management of attention deficit hyperactivity disorder in preschool children.

Curr Opin Pediatr 2011 Dec;23(6):684-92

Psychology Department, Princeton University, Princeton, New Jersey, USA.

Purpose Of Review: To provide an overview of clinical advances and research findings related to attention deficit hyperactivity disorder (ADHD) in preschool children, with an emphasis on assessment and management.

Recent Findings: The American Academy of Pediatrics has just released new clinical practice guidelines for the diagnosis and management of ADHD. These guidelines are broader in scope, now extending down to preschool children (ages 4 and 5 years). With respect to diagnosis, the American Psychiatric Association has recently proposed modifications to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); the current draft version of DSM-V includes changes to the diagnosis criteria for ADHD. With respect to treatment of preschool children with ADHD, studies continue to support the efficacy of behavioral interventions. Regarding pharmacotherapy, a large, recently completed, placebo-controlled study of methylphenidate for preschool ADHD identified some age-related medication differences.

Summary: ADHD can be reliably diagnosed in preschool children. Behavior therapy remains the recommended first-line treatment approach; pharmacotherapy is sometimes indicated as a treatment adjunct, or, less commonly, a treatment alternative.
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http://dx.doi.org/10.1097/MOP.0b013e32834cbbbaDOI Listing
December 2011

Cannabis use disorders in schizophrenia: effects on cognition and symptoms.

Schizophr Res 2010 Jul 18;120(1-3):95-100. Epub 2010 May 18.

Center for Translational Psychiatry, The Feinstein Institute for Medical Research, Manhasset, NY, USA.

Objective: Despite the controversy surrounding the possible causal link between cannabis use and the onset of schizophrenia (SZ), data seeking to elucidate the effect of cannabis use disorders (CUDs) on the clinical presentation of SZ have produced mixed results. Although several studies have suggested that CUD in patients with SZ may be associated with variation in cognitive function, clinical presentation and course of illness, the effects have been inconsistent.

Methods: We retrospectively ascertained a large cohort (N=455) of SZ patients with either no history of a CUD (CUD-; N=280) or a history of CUD (CUD+; N=175). The groups were initially compared on key demographic variables including sex, race, age, age at onset of SZ, parental socioeconomic status, premorbid IQ, education level and global assessment of functioning. Covarying for any observed differences in demographic variables, we then compared groups on lifetime measures of psychotic symptoms as well as a brief battery of neurocognitive tests.

Results: Compared to the CUD- group the CUD+ group demonstrated significantly better performance on measures of processing speed (Trail Making Tests A and B), verbal fluency (animal naming) and verbal learning and memory (California Verbal Learning Test). Moreover, the CUD+ group had better GAF scores than the CUD group.

Conclusions: Collectively, these findings suggest that SZ patients with comorbid CUD may represent a higher functioning subgroup of SZ. Future prospective studies are needed to elucidate the nature of this relationship.
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http://dx.doi.org/10.1016/j.schres.2010.04.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2902262PMC
July 2010
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