The Impact of Socioeconomic Status on Voice Outcomes in Patients With Spasmodic Dysphonia Treated With Botulinum Toxin Injections

Factors associated with the use of botulinum toxin injections for adult strabismus in the IRIS Registry

This cross-sectional study used data from a large nationwide registry to describe the factors associated with use of botulinum toxin injections for adults with strabismus in the United States. Botulinum toxin injections were performed on 3.1% of adults undergoing an intervention for strabismus between 2013 and 2020. Adults treated with botulinum toxin injections were more likely to be older and female. Compared to non-Hispanic White patients, non-Hispanic Black patients were three times less likely to receive treatment with botulinum toxin after adjusting for age, sex, geographic region, and type of insurance. Efforts to understand the factors contributing to disparities in the use of botulinum toxin for strabismus may lead to opportunities for more equitable access to this intervention.

Association of Sociodemographic Factors on the Presentation and Management of Unilateral Vocal Fold Immobility

OBJECTIVE

To determine the association of social determinants of health (SDOH) on the presentation and management of unilateral vocal fold immobility (UVFI).

METHODS

Retrospective chart review of 207 adult UVFI patients evaluated at a tertiary-care hospital between 2018 and 2019 was performed. Sociodemographic factors including gender, median household income, preferred language, and insurance type were recorded. Confounding clinical factors including etiology of UVFI, Voice Handicap Index-10 (VHI-10) score, laryngoscopic findings, and intervention history were extracted from medical records. Multivariable logistic regression was performed using sociodemographic and clinical factors.

RESULTS

Patient demographics and socioeconomic status were not associated with time to presentation. Patients presenting with glottic insufficiency and UVFI due to malignancy or recurrent laryngeal nerve (RLN) sacrifice had a shorter time to presentation. Higher household income was associated with greater number of interventions (p = 0.02), but neither income nor insurance type affected intervention type or timing. Female patients were less likely to undergo injection medialization laryngoplasty (odds ratio [OR] 0.25, p = 0.005). Older patients were more likely to undergo injection (OR 1.04, p = 0.027). Patients with large glottic gaps (OR 21.2, p = 0.014) and higher VHI-10 scores (OR 1.06, p = 0.047) were more likely to undergo surgery.

CONCLUSION

Higher household income was associated with greater number of interventions and longer duration of care at a private tertiary-care hospital. RLN sacrifice, known malignancy, and glottic insufficiency significantly reduced the time to presentation. Type of intervention received was a complex interplay of both demographic and clinical factors. Large prospective studies should examine the role of SDOH in the presentation and management of UVFI.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:297-304, 2024.

Assessment of Factors Associated With Parental Perceptions of Voluntary Decisions About Child Participation in Leukemia Clinical Trials

IMPORTANCE

Obtaining voluntary informed consent prior to enrollment in clinical trials is a fundamental ethical requirement.

OBJECTIVE

To assess whether health literacy, contextual factors, or sociodemographic characteristics are associated with perception of voluntariness among parents who had consented for their child's participation in a leukemia therapeutic clinical trial.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study prospectively enrolled 97 parents of children diagnosed as having leukemia at Rady Children's Hospital San Diego, a large tertiary academic center in California, from 2014 to 2017. Health literacy, contextual factors (acculturation, decisional regret, and satisfaction with informed consent), sociodemographic characteristics, and perception of voluntariness after consenting for a therapeutic clinical trial were measured. Univariable and multivariable regression were used to determine significant associations. The analyses for the present study were conducted from May 2019 to May 2020.

EXPOSURES

Informed consent for a therapeutic leukemia clinical trial.

MAIN OUTCOMES AND MEASURES

The primary outcome of interest was perception of voluntariness and its associations with health literacy and other contextual factors (acculturation, decisional regret, and satisfaction with informed consent) and sociodemographic characteristics, including age, race/ethnicity, parental language, educational level, insurance type, marital status, and socioeconomic status.

RESULTS

Of 97 parents included, the majority were women (65 [67%]), married (71 [73%]), and of self-reported Hispanic ethnicity (50 [52%]). Lower perception of voluntariness was significantly associated with lower health literacy (r = 0.30; 95% CI, 0.11-0.47; P = .004), Spanish language (x̅ = -4.50, P = .05), lower acculturation if of Hispanic ethnicity (r = 0.30; 95% CI, 0.02-0.54; P = .05), greater decisional regret (r = -0.54; 95% CI, -0.67 to -0.38; P < .001), and lower satisfaction with informed consent (r = 0.39; 95% CI, 0.21-0.54; P < .001) in univariable analysis. Lower health literacy remained significantly associated with lower perception of voluntariness in multivariable analysis after adjustment for contextual factors and sociodemographic characteristics (β = 4.06; 95% CI, 1.60-6.53; P = .001). Lower health literacy was significantly associated with Hispanic ethnicity (mean, 4.16; 95% CI, 3.75-4.57; P < .001), Spanish language spoken at home (mean, 3.17; 95% CI, 1.94-4.40; P < .001), high school or less educational level (mean, 3.41; 95% CI, 2.83-3.99; P < .001), public insurance (mean, 4.00; 95% CI, 3.55-4.45; P < .001), and unmarried status (mean, 3.71; 95% CI, 2.91-4.51; P = .03).

CONCLUSIONS AND RELEVANCE

Among parents of children with newly diagnosed leukemia who had consented for their child's participation in a therapeutic clinical trial, lower perception of voluntariness was significantly associated with lower health literacy. These results suggest that parents with low health literacy may perceive external influences in their decision for their child's participation in clinical trials. This finding highlights the potential role of recruitment interventions tailored to the participant's health literacy level to improve voluntary informed consent in underserved populations.

Laryngeal Electromyography-Guided Hyaluronic Acid Vocal Fold Injections for Glottic Insufficiency

OBJECTIVES

To assess voice outcomes using the novel technique of in-office laryngeal electromyography-guided vocal fold injections (LEVFI) with hyaluronic acid to treat glottal insufficiency. Secondary objectives included determining the complication/completion rates and if any factors were associated with improved voice outcomes.

METHODS

Retrospective review of patients who received their first LEVFI from August 2017 to December 2018. Three- and six-month voice outcomes were assessed. Outcomes included voice handicap index-10 (VHI-10), maximum phonation time (MPT), perceptual analysis of voice (GRBAS), fundamental frequency, and stroboscopy.

RESULTS

Of the 121 eligible patients (55.4% male, age 63.7 years), 94 (77.7%) had complete 3-month data and 59 (48.8%) had complete 6-month data. VHI-10 was significantly improved from 25.7 ± 7.5 to 20.9 ± 10.9 at 3 months (P < .001) and to 19.1 ± 11.5 at 6 months (P < .001). MPT improved from 6.2 ± 5.4 seconds to 9.4 ± 7.1 seconds at 3 months (P < .001) and to 11.3 ± 8.2 seconds at 6 months (P < .001). GRBAS was improved in 74.8% of patients ([65.2, 82.8] 95% CI) at 3 months and 80.8% ([69.9, 89.1]) 95% CI) at 6 months. Stroboscopy showed a glottic gap improvement in 74.8% of patients ([65.8, 82.4] 95% CI) at 3 months and in 80.3% ([65.9, 88.5] 95% CI) at 6 months. Fundamental frequency was unchanged, as expected. Multivariate analysis reported that no factors were associated with better voice outcomes. Overall, 177/181 (97.8%) injections were completed. There were no complications.

CONCLUSION

In-office LEVFI is an effective, novel technique to treat glottic insufficiency with improved voice outcomes, high completion rate, and no significant complications.

Prenatal socioeconomic status and social support are associated with neonatal brain morphology, toddler language and psychiatric symptoms

Few studies have assessed the association of parental socioeconomic status (SES) with brain measures in neonates, at a time when exposure to the postnatal environment is minimal. Social support may buffer the adverse consequences of SES, and has been associated with better cognitive - emotional development in children. We studied the association of prenatal SES and social support with neonatal brain structure, and toddler cognition, and psychiatric symptoms. In a sample of 37 healthy neonates, we correlated a measure of SES and marital/partner status (an index of social support) with morphological features of the cerebral surface measured on high-resolution MRI scans between the 1^st - 6^th weeks of postnatal life. We then assessed how SES relates to cognitive and behavioral outcomes at age 24-months. We found that neonates born to mothers with lower SES had greater local volumes at the surface of the right occipital lobe, left temporal pole, and left inferior frontal and anterior cingulate regions. Partner status moderated the associations of SES on neonatal brain morphology. Lower SES was associated with poorer language scores and less severe ADHD and ODD symptoms. In summary, SES was associated with neonatal brain structure and language and behavioral outcomes at toddler age. Future studies with a greater sample size and longitudinal MRI scans will help to determine whether prenatal SES continues to relate to early brain development in the same or different brain regions.