Objective: To determine the impact of patient demographics and social determinants of health on treatment pathways for unilateral vocal fold paralysis (UVFP) at a tertiary laryngology clinic.Study design: Retrospective medical record review.Methods: Patient demographics (age, gender, race, ethnicity, and insurance status) were extracted for adults diagnosed with UVFP between 2009 and 2019. Odds ratios for the associations between sociodemographic factors and UVFP treatment pathways were determined by chi-square analyses.Results: A total of 1490 UVFP diagnoses were identified during the study period with the majority being female (58%), White (85%), non-Hispanic (97%), and publicly insured (54%). Five treatment pathways were identified: observation, injection laryngoplasty, voice therapy, laryngeal framework surgery/thyroplasty, and reinnervation surgery. There were 538 patients who underwent observation, 512 injection laryngoplasty, 366 voice therapy, 136 thyroplasty, and 26 laryngeal reinnervation surgery.Males were more likely to undergo injection laryngoplasty than females (OR 1.32; CI 1.08-1.61), whereas females were more likely to undergo voice therapy (OR 1.39; CI 1.09-1.76). Patients with public insurance (OR 1.48; CI 1.03-2.14) and Hispanics (OR 2.60; CI 1.18-5.72) were more likely to undergo thyroplasty. Patients who underwent reinnervation surgery were younger than those in other treatment pathways (median: 39.1 years vs. 50.7-56.1 years).Conclusions: Gender, ethnicity, and insurance status were significantly associated with specific UVFP treatment pathways. Patients with public insurance were more likely to undergo surgical intervention than voice therapy. This data overall supports differences in care pathway utilization for UVFP based on social determinants of health.
Placenta percreta is the most severe form of placenta accreta and is characterized by placental invasion through the entirety of the myometrium and possibly into extrauterine tissues. It is associated with prior cesarean deliveries and placenta previa. Herein, we present the case of a patient who developed placenta percreta and experienced massive blood loss of 27 liters. She developed many complications over the next 11 months, including deep vein thrombosis, pulmonary embolism, preeclampsia after pregnancy, hematoma, blood clots in the bladder, lactation failure, ileus, vesicovaginal fistula, excessive scar tissue requiring surgery, loss of an ovary, and recurrent bladder perforation. We analyze the mechanisms of these complications and the most common complications associated with placenta percreta.
Erosion of metal surgical staples is a rare but described surgical complication. Staple erosion in a bladder may present with hematuria, urinary tract infection (UTI), bladder pain, or fistula. We present a 64-year-old male with a history of urothelial carcinoma treated by cystoprostatectomy with neobladder reconstruction. Over the next two to three years, he developed hematuria and had multiple urine cytologies suspicious for cancer. The cystoscopic evaluation revealed staple line erosion but no cancer. We believe this to be the first published case of symptomatic staple erosion in a neobladder. Clinicians should be aware that staple line erosion in a neobladder can occur and mimic malignancy recurrence.
Diffuse brucellar spondylodiscitis is the most severe subtype of osteoarticular brucellosis and is defined as a brucellar infection involving an entire vertebral body, typically a lumbar vertebra, with spread to the adjacent disc space, vertebra, and even extravertebral spaces, including epidural, paraspinal, or intramuscular locations. Although it is a relatively rare diagnosis in the US healthcare system, it should be considered in all patients with severe back pain, radicular symptoms, and a history of extensive exposure to an endemic area. Any delays in treatment can be associated with an increased risk of permanent neurological deficits or death. Here, we present a case of diffuse brucellar spondylodiscitis in a patient who presented to our facility with a history of extensive exposure to an endemic area. While an MRI can reveal pathognomonic findings in brucellar spondylodiscitis, for our case, it was nonspecific. The MRI provided early evidence of an infectious etiology which prompted immediate broad-spectrum antimicrobial coverage until causal organisms were identified and culture sensitivities directed targeted antibiotic therapy. The patient was able to recover over the course of four months without surgical intervention. At her final clinical follow-up, she had no neurological deficits and had complete resolution of her radicular symptoms.
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