Astrocyte ensheathment of calyx-forming axons of the auditory brainstem precedes accelerated expression of myelin genes and myelination by oligodendrocytes

Early postnatal brain development involves complex interactions among maturing neurons and glial cells that drive tissue organization. We previously analyzed gene expression in tissue from the mouse medial nucleus of the trapezoid body (MNTB) during the first postnatal week to study changes that surround rapid growth of the large calyx of Held (CH) nerve terminal. Here, we present genes that show significant changes in gene expression level during the second postnatal week, a developmental timeframe that brackets the onset of airborne sound stimulation and the early stages of myelination. Gene Ontology analysis revealed that many of these genes are related to the myelination process. Further investigation of these genes using a previously published cell type-specific bulk RNA-Seq data set in cortex and our own single-cell RNA-Seq data set in the MNTB revealed enrichment of these genes in the oligodendrocyte lineage (OL) cells. Combining the postnatal day (P)6-P14 microarray gene expression data with the previously published P0-P6 data provided fine temporal resolution to investigate the initiation and subsequent waves of gene expression related to OL cell maturation and the process of myelination. Many genes showed increasing expression levels between P2 and P6 in patterns that reflect OL cell maturation. Correspondingly, the first myelin proteins were detected by P4. Using a complementary, developmental series of electron microscopy 3D image volumes, we analyzed the temporal progression of axon wrapping and myelination in the MNTB. By employing a combination of established ultrastructural criteria to classify reconstructed early postnatal glial cells in the 3D volumes, we demonstrated for the first time that astrocytes within the mouse MNTB extensively wrap the axons of the growing CH terminal prior to OL cell wrapping and compaction of myelin. Our data revealed significant expression of several myelin genes and enrichment of multiple genes associated with lipid metabolism in astrocytes, which may subserve axon wrapping in addition to myelin formation. The transition from axon wrapping by astrocytes to OL cells occurs rapidly between P4 and P9 and identifies a potential new role of astrocytes in priming calyceal axons for subsequent myelination.

Identifying biomarkers of drug use recurrence using wearable device technologies and phone applications

BACKGROUND

Identifying predictors of drug use recurrence (DUR) is critical to combat the addiction epidemic. Wearable devices and phone-based applications for obtaining self-reported assessments in the patient's natural environment (e.g., ecological momentary assessment; EMA) have been used in various healthcare settings. However, the utility of combining these technologies to predict DUR in substance use disorder (SUD) has not yet been explored. This study investigates the combined use of wearable technologies and EMA as a potential mechanism for identifying physiological/behavioral biomarkers of DUR.

METHODS

Participants, recruited from an SUD treatment program, were provided with a commercially available wearable device that continuously monitors biometric signals (e.g., heart rate/variability [HR/HRV], sleep characteristics). They were also prompted daily to complete an EMA via phone-based application (EMA-APP) that included questionnaires regarding mood, pain, and craving.

RESULTS

Seventy-seven participants are included in this pilot study (34 participants experienced a DUR during enrollment). Wearable technologies revealed that physiological markers were significantly elevated in the week prior to DUR relative to periods of sustained abstinence (p<0.001). Results from the EMA-APP revealed that those who experienced a DUR reported greater difficulty concentrating, exposure to triggers associated with substance use, and increased isolation the day prior to DUR (p<0.001). Compliance with study procedures during the DUR week was lower than any other period of measurement (p<0.001).

CONCLUSIONS

These results suggest that data acquired via wearable technologies and the EMA-APP may serve as a method of predicting near-term DUR, thereby potentially prompting intervention before drug use occurs.

Whole-body photobiomodulation improves post-exercise recovery but does not affect performance or physiological response during maximal anaerobic cycling

This study aims to examine the effects of acute whole-body photobiomodulation (wbPBM), applied pre-exercise, on bouts of anaerobic cycling (Wingate) performances. Forty-eight healthy, active males and females participated in this single-blind, randomized, crossover study. Participants visited the laboratory three times to complete repeat (4 ×) Wingate testing, with one week between each visit. All participants completed baseline testing during their first visit and randomly received either the wbPBM or placebo condition before testing on the second visit, followed by the opposite condition on the third visit. There were no significant condition × time interactions for any variable (peak power, average power, power decrement, lactate, heart rate, ratings of perceived exertion, heart rate variability (HRV), root-mean square of differences between R-R intervals (rMSSD), power in the high-frequency range (HF) average, power in the low-frequency range (LF) average, total power, LF/HF, or power in the very-low-frequency range average). A main condition effect was only noted for heart rate, where peak heart rate was significantly higher for wbPBM (145, 141-148 bpm) than placebo (143, 139-146 bpm; p = 0.006) and baseline testing (143, 140-146; p = 0.049) throughout the entire testing session (i.e., collapsed across all timepoints). Furthermore, HRV (rMSSD) the following morning after testing was significantly higher for the wbPBM session compared to placebo (p = 0.043). There were no differences in perceived recovery (p = 0.713) or stress (p = 0.978) scores between wbPBM and placebo. Implementing 20 min of wbPBM immediately prior to maximal bouts of anaerobic cycling did not improve performance (i.e., power output) or physiological responses (e.g., lactate). However, wbPBM elicited the ability to work at a higher heart rate throughout testing and seemed to enhance recovery through improved HRV the following morning.

Transcriptional profiling reveals roles of intercellular Fgf9 signaling in astrocyte maturation and synaptic refinement during brainstem development

Neural tissue maturation is a coordinated process under tight transcriptional control. We previously analyzed the kinetics of gene expression in the medial nucleus of the trapezoid body (MNTB) in the brainstem during the critical postnatal phase of its development. While this work revealed timed execution of transcriptional programs, it was blind to the specific cells where gene expression changes occurred. Here, we utilized single-cell RNA-Seq to determine transcriptional profiles of each major MNTB cell type. We discerned directional signaling patterns between neuronal, glial, and vascular-associated cells for VEGF, TGFβ, and Delta-Notch pathways during a robust period of vascular remodeling in the MNTB. Furthermore, we describe functional outcomes of the disruption of neuron-astrocyte fibroblast growth factor 9 (Fgf9) signaling. We used a conditional KO (cKO) approach to genetically delete Fgf9 from principal neurons in the MNTB, which led to an early onset of glial fibrillary acidic protein (Gfap) expression in astrocytes. In turn, Fgf9 cKO mice show increased levels of astrocyte-enriched brevican (Bcan), a component of the perineuronal net matrix that ensheaths principal neurons in the MNTB and the large calyx of Held terminal, while levels of the neuron-enriched hyaluronan and proteoglycan link protein 1 (Hapln1) were unchanged. Finally, volumetric analysis of vesicular glutamate transporters 1 and 2 (Vglut1/2), which serves as a proxy for terminal size, revealed an increase in calyx of Held volume in the Fgf9 cKO. Overall, we demonstrate a coordinated neuron-astrocyte Fgf9 signaling network that functions to regulate astrocyte maturation, perineuronal net structure, and synaptic refinement.

Full-Body Photobiomodulation Therapy Is Associated with Reduced Sleep Durations and Augmented Cardiorespiratory Indicators of Recovery

Research is emerging on the use of Photobiomodulation therapy (PBMT) and its potential for augmenting human performance, however, relatively little research exists utilizing full-body administration methods. As such, further research supporting the efficacy of whole-body applications of PBMT for behavioral and physiological modifications in applicable, real-world settings are warranted. The purpose of this analysis was to observe cardiorespiratory and sleep patterns surrounding the use of full-body PBMT in an elite cohort of female soccer players. Members of a women’s soccer team in a “Power 5 conference” of the National Collegiate Athletic Association (NCAA) were observed across one competitive season while wearing an OURA Ring nightly and a global positioning system (GPS) sensor during training. Within-subject comparisons of cardiorespiratory physiology, sleep duration, and sleep composition were evaluated the night before and after PBMT sessions completed as a standard of care for team recovery. Compared to pre-intervention, mean heart rate (HR) was significantly lower the night after a PBMT session (p = 0.0055). Sleep durations were also reduced following PBMT, with total sleep time (TST) averaging 40 min less the night after a session (p = 0.0006), as well as significant reductions in light sleep (p = 0.0307) and rapid eye movement (REM) sleep durations (p = 0.0019). Sleep durations were still lower following PBMT, even when controlling for daily and accumulated training loads. Enhanced cardiorespiratory indicators of recovery following PBMT, despite significant reductions in sleep duration, suggest that it may be an effective modality for maintaining adequate recovery from the high stress loads experienced by elite athletes.

Simplifying External Load Data in NCAA Division-I Men's Basketball Competitions: A Principal Component Analysis

The primary purpose was to simplify external load data obtained during Division-I (DI) basketball competitions via principal component analysis (PCA). A secondary purpose was to determine if the PCA results were sensitive to load demands of different positional groups (POS). Data comprised 229 observations obtained from 10 men's basketball athletes participating in NCAA DI competitions. Each athlete donned an inertial measurement unit that was affixed to the same location on their shorts prior to competition. The PCA revealed two factors that possessed eigenvalues >1.0 and explained 81.42% of the total variance. The first factor comprised total decelerations (totDEC, 0.94), average speed (avgSPD, 0.90), total accelerations (totACC, 0.85), total mechanical load (totMECH, 0.84), and total jump load (totJUMP, 0.78). Maximum speed (maxSPD, 0.94) was the lone contributor to the second factor. Based on the PCA, external load variables were included in a multinomial logistic regression that predicted POS (Overall model, p < 0.0001; AUC_centers = 0.93, AUC_guards = 0.88, AUC_forwards = 0.80), but only maxSPD, totDEC, totJUMP, and totMECH were significant contributors to the model's success (p < 0.0001 for each). Even with the high significance, the model still had some issues differentiating between guards and forwards, as in-game demands often overlap between the two positions. Nevertheless, the PCA was effective at simplifying a large external load dataset collected on NCAA DI men's basketball athletes. These data revealed that maxSPD, totDEC, totJUMP, and totMECH were the most sensitive to positional differences during competitions. To best characterize competition demands, such variables may be used to individualize training and recovery regimens most effectively.

The Nasoseptal Flap for Reconstruction of Lateral Oropharyngectomy Defects: A Clinical Series

OBJECTIVES/HYPOTHESIS

To study use of the nasoseptal flap (NSF) to reconstruct lateral transoral robotic surgery (TORS) oropharyngectomy defects.

STUDY DESIGN

Retrospective case series.

METHODS

A clinical series of six patients undergoing NSF reconstruction of lateral TORS oropharyngectomy defects was retrospectively studied. All patients underwent TORS for the treatment of intermediate-risk human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma of the lateral pharyngeal wall between January and June 2017. All patients underwent NSF reconstruction of lateral TORS defects with retrospective analysis of outcomes and complications.

RESULTS

Six patients underwent NSF reconstruction of lateral TORS defects. Operative times decreased from 180 minutes to 90 minutes over the study period. There were two cases of partial flap dehiscence and partial necrosis. There were no major donor site complications. All patients had temporary nasal obstruction and crusting. Two experienced temporary aural fullness. In all patients, the lateral wall was mucosalized in 1-3 weeks. Cephalometric analysis of preoperative imaging revealed that patients with high-arched palates (>3 cm) and defect lengths that are longer than NSF flap lengths are poor candidates for this technique.

CONCLUSIONS

This NSF is a vascularized, locoregional rotational flap that can reconstruct lateral TORS defects in salvages cases or those where the parapharyngeal carotid or mandibular bone are exposed. Postoperative morbidity is limited to temporary nasal dyspnea, aural fullness, and crusting. Preoperative imaging can determine which patient will have successful defect coverage.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:53-60, 2022.

Using Random Forest Regression to Determine Influential Force-Time Metrics for Countermovement Jump Height: A Technical Report

ABSTRACT

Merrigan, JJ, Stone, JD, Wagle, JP, Hornsby, WG, Ramadan, J, Joseph, M, and Hagen, JA. Using random forest regression to determine influential force-time metrics for countermovement jump height: a technical report. J Strength Cond Res 36(1): 277-283, 2022-The purpose of this study was to indicate the most influential force-time metrics on countermovement jump (CMJ) height using multiple statistical procedures. Eighty-two National Collegiate Athletic Association Division I American football players performed 2 maximal-effort, no arm-swing, CMJs on force plates. The average absolute and relative (i.e., power/body mass) metrics were included as predictor variables, whereas jump height was the dependent variable within regression models (p < 0.05). Best subsets regression (8 metrics, R2 = 0.95) included less metrics compared with stepwise regression (18 metrics, R2 = 0.96), while explaining similar overall variance in jump height (p = 0.083). Random forest regression (RFR) models included 8 metrics, explained ∼93% of jump height variance, and were not significantly different than best subsets regression models (p > 0.05). Players achieved higher CMJs by attaining a deeper, faster, and more forceful countermovement with lower eccentric-to-concentric force ratios. An additional RFR was conducted on metrics scaled to body mass and revealed relative mean and peak concentric power to be the most influential. For exploratory purposes, additional RFR were run for each positional group and suggested that the most influential variables may differ across positions. Thus, developing power output capabilities and providing coaching to improve technique during the countermovement may maximize jump height capabilities. Scientists and practitioners may use best subsets or RFR analyses to help identify which force-time metrics are of interest to reduce the selectable number of multicollinear force-time metrics to monitor. These results may inform their training programs to maximize individual performance capabilities.

Contextual Variation in External and Internal Workloads across the Competitive Season of a Collegiate Women's Soccer Team

As sports technology has continued to develop, monitoring athlete workloads, performance, and recovery has demonstrated boundless benefits for athlete and team success. Specifically, technologies such as global positioning systems (GPS) and heart rate (HR) monitors have granted the opportunity to delve deeper into performance contributors, and how variations may exist based upon context. A team of NCAA Division I women’s soccer athletes were monitored during games throughout one competitive season. Individual athlete, positional groups, and team external and internal workloads were explored for differences based upon game location, opponent ranking, game result, and the final score differential. Game location and opponent ranking were found to have no effect on team-wide absolute or relative external workloads, whereas game result and score differential did. Internal workloads across the team tended to only vary by game half, independent of game context; however, the HR of defenders was determined to be higher during losses as compared to wins (p = 0.0256). Notably, the games that resulted in losses also represented the games with the fewest number of substitutions. These findings suggest high value in monitoring performance and workloads that are characteristic of varying, often multifaceted, contexts. It is hoped that this information can lead to more informed approaches to vital game-time and coaching decisions.

Airway foreign bodies in pediatric patients: An analysis of composition and age via HCUP KID

OBJECTIVE

To compare outcomes for children food and non-food airway foreign body (AFB) diagnoses and to compare outcomes for patients age <2 versus ≥2 years with an AFB diagnosis.

METHODS

Data from 2016 HCUP KID was used to compare outcomes for food and non-food AFB diagnoses based on location in the larynx, trachea, bronchus, and whole group (including these three specified locations and location unspecified). Outcomes were also compared for children aged <2 versus ≥2 years. Demographic data included age, race, gender, primary payer, location and teaching status of the hospital. Available co-morbidity data included APR-DRG mortality and APR-DRG severity. Outcomes were length of stay (LOS), total charge, mortality, and performance of a tracheotomy.

RESULTS

2973 patients were included. 49.1% were less than 2 years old, the remainder (50.9%) were between 2 and 20 years old. Food AFBs made up 26.0% and 74.0% were other specified non-food AFBs. Overall mortality was 3.7%, and 3.8% underwent tracheotomy. Children with non-food AFBs were significantly older, had significantly longer median LOS, and higher median total charges, when compared to food AFBs. Non-food AFBs had a significantly higher likelihood of tracheotomy. Patients aged 2 or more years with bronchial AFBs had significantly higher total charges, LOS, and APR-DRG risk mortality and severity than <2 year old patients with bronchial AFBs.

CONCLUSION

AFBs remain a serious health concern, especially non-food objects in older children which have elevated risks.

Thrombocytosis Predicts Surgical Site Infection in Head and Neck Microvascular Surgery- A Pilot Study

OBJECTIVE/HYPOTHESIS

Early and objective prediction of complications in head and neck reconstructive surgery could decrease morbidity and prolonged hospital stays but unfortunately most complications are not identified until their effect is fully realized. There are limited data regarding the association of platelet levels and post-operative complications. Post-operative thrombocytosis (POTCT) is proposed as a possible indicator for complications following free-flap reconstruction.

STUDY DESIGN

Retrospective review.

METHODS

A multisite retrospective chart review of patients undergoing free tissue transfer between 2013 and 2018 was undertaken. POTCT was recorded and data normalized between institutions. Data were compared between groups using t-tests and logistic regression (P < .05). A lag-1 difference was used to compare the rate of change in platelet values.

RESULTS

A total of 398 patients were included. POTCT and a rate of change of 30 K between POD5 and POD6 was significantly associated with the presence of post-operative complication (P = .007). Additionally, lag-1 difference demonstrated a significant association of change in daily platelet counts and complication rates.

CONCLUSIONS

Isolated POTCT may be an early predictor of complications in HNC patients undergoing free-flap reconstruction.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1542-1547, 2021.

Assessment of Pediatric Middle Ear Effusions With Wideband Tympanometry

OBJECTIVE

To determine if wideband tympanometry (WBT) can differentiate types of middle ear effusion (MEE): serous, mucoid, and purulent.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary care children's hospital.

METHODS

Children who met American Academy of Otolaryngology-Head and Neck Surgery's guidelines for ventilation tube insertion had WBT after anesthesia induction but before tympanotomy. MEE was categorized into 1 of 4 comparison groups: serous effusion, mucoid effusion, purulent effusion, or no effusion. WBT measurements were averaged to 16 one-third octave frequency bands, and comparison of the absorbance patterns for each MEE type was performed through a linear mixed effects model.

RESULTS

A total of 118 children (211 ears) were included: 47 females (39.8%) and 71 males (60.2%). The mean age was 2.73 years (95% CI, 2.25-3.22); mean weight, 14.35 kg (95% CI, 12.85-15.85); and mean Z score, 1.13 (95% CI, -0.64 to 2.33). Effusions included 61 mucoid (28.9%), 30 purulent (14.2%), and 14 serous (6.6%), with 106 (50.2%) having no effusion. No significant differences were found for sex, race, age, weight, or Z score among the 4 types of effusion (P < .05). WBT showed a significant difference in median absorption among the effusion groups (P < .001), with a medium effect size of 0.35.

CONCLUSIONS

WBT has potential use to differentiate types of MEE and should be studied further as a tool for investigating how the natural history and management of serous and mucoid effusions may differ.

Evaluations of Commercial Sleep Technologies for Objective Monitoring During Routine Sleeping Conditions

PURPOSE

The commercial market is saturated with technologies that claim to collect proficient, free-living sleep measurements despite a severe lack of independent third-party evaluations. Therefore, the present study evaluated the accuracy of various commercial sleep technologies during in-home sleeping conditions.

MATERIALS AND METHODS

Data collection spanned 98 separate nights of ad libitum sleep from five healthy adults. Prior to bedtime, participants utilized nine popular sleep devices while concurrently wearing a previously validated electroencephalography (EEG)-based device. Data collected from the commercial devices were extracted for later comparison against EEG to determine degrees of accuracy. Sleep and wake summary outcomes as well as sleep staging metrics were evaluated, where available, for each device.

RESULTS

Total sleep time (TST), total wake time (TWT), and sleep efficiency (SE) were measured with greater accuracy (lower percent errors) and limited bias by Fitbit Ionic [mean absolute percent error, bias (95% confidence interval); TST: 9.90%, 0.25 (-0.11, 0.61); TWT: 25.64%, -0.17 (-0.28, -0.06); SE: 3.49%, 0.65 (-0.82, 2.12)] and Oura smart ring [TST: 7.39%, 0.19 (0.04, 0.35); TWT: 36.29%, -0.18 (-0.31, -0.04); SE: 5.42%, 1.66 (0.17, 3.15)], whereas all other devices demonstrated a propensity to over or underestimate at least one if not all of the aforementioned sleep metrics. No commercial sleep technology appeared to accurately quantify sleep stages.

CONCLUSION

Generally speaking, commercial sleep technologies displayed lower error and bias values when quantifying sleep/wake states as compared to sleep staging durations. Still, these findings revealed that there is a remarkably high degree of variability in the accuracy of commercial sleep technologies, which further emphasizes that continuous evaluations of newly developed sleep technologies are vital. End-users may then be able to determine more accurately which sleep device is most suited for their desired application(s).

Test and Evaluation of Heart Rate Derived Core Temperature Algorithms for Use in NCAA Division I Football Athletes

The purpose of this study was to assess the validity of utilizing heart rate to derive an estimate of core body temperature in American Football athletes. This was evaluated by combining commercially available Zephyr Bioharness devices, which includes an embedded estimated core temperature (ECT) algorithm, and an ingestible radio frequency core temperature pill during the highest heat injury risk timepoint of the season, summer training camp. Results showed a concordance of 0.643 and 78% of all data points fell within +/-1.0 °F. When the athletes were split into Upper (>/=6.0%) and Lower (<6.0%) body composition groups, there was a statistical improvement in accuracy with the Upper Body Fat% reaching 0.834 concordance and 93% of all values falling within +/-1.0 °F of the Gold Standard. Results suggest that heart rate derived core temperature assessments are a viable tool for heat stress monitoring in American football, but more work is required to improve on accuracy based on body composition.

Endoscopic endonasal CSF rhinorrhea repair in children: Systematic review with meta-analysis

OBJECTIVES

Cerebrospinal fluid (CSF) rhinorrhea in children is relatively uncommon. Endoscopic repair techniques in adults have become first line for nasal-based CSF leaks, and this meta-analysis looks at the success rates of CSF leak cessation following endoscopic repair in children.

METHODS

Three researchers extracted information involving patient population, surgical technique, outcomes of interest, and study design. A computerized search of MEDLINE, EMBASE and the Cochrane library (January 1990-September 2019) looked for several papers on the subject of CSF leak repair in children using endoscopic technique.

RESULTS

A total of 15 studies met inclusion criteria. Endoscopic repair of CSF rhinorrhea in children shows a pooled weighted success rate of 94% after first attempt. The most common etiology was traumatic followed by congenital. Iatrogenic defects secondary to tumor resection are becoming more common. The high success rate was irrespective of the techniques using.

CONCLUSION

Endoscopic repair techniques have a highly successful closure rate for children presenting with CSF rhinorrhea.

Adult Palatopharyngoplasty: Trends in Morbidity and Mortality from the NSQIP Database

OBJECTIVES

Describe the postop morbidity of adults undergoing palatopharyngoplasty (PPP).

METHOD

Adults who underwent PPP were studied using ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database (2016-2017) via CPT code 42145. Analyzed outcomes included length of stay (LOS), readmission, reoperation, and postop complications. Predictive variables were age, gender, BMI, comorbidities.

RESULTS

A total of 1081 patients (73.7% male, mean age 42.0 years, range 18-79 years) were included. 95 (8.8%) were diabetic, 183 (16.9%) were smokers, 30 (2.8%) had preoperative dyspnea. 328 (30.3%) took medicine for hypertension. Concurrent procedures occurred in 646 (59.76%), 357 (33.02%) had nasal procedures, 320 (29.60%) had tonsil procedures, 66 (6.11%) had tongue procedures. Within 30 days postop, there were two (0.19%) mortalities. Complications included six wound infections, two dehiscences, four with pneumonia, two pulmonary embolisms, three myocardial infarctions, one DVT, three sepsis, one UTI, one who required CPR, and two who were ventilated for >48 hours. Five required reintubation. A total of 41 (3.79%) returned to OR for a related reason, at least 27 (65.90%) for bleeding. LOS ranged from 0 to 15 days, median 1 day. Overall 38 (3.52%) were readmitted for a related reason, 12 (31.58%) for bleeding and three (7.89%) for pain. Using a significance level of 0.002 (Bonferroni correction), LOS varied with presence of any concurrent procedure, BMI, and estimated probability of mortality and morbidity indices; readmission and reoperation had no significantly associated variables.

CONCLUSION

PPP is associated with low frequency but significant morbidity and mortality.

Laryngomalacia in Neonates Versus Older Infants: HCUP-KID Perspective

This study evaluated the hospital course for neonates and older infants with a diagnosis of laryngomalacia (LM). Data came from the 2016 Kids' Inpatient Database of the Healthcare Cost Utilization Project. A total of 6537 children aged <1 year with a diagnosis of LM (International Classification of Diseases, 10th Revision, code Q31.5) were identified: 2212 neonates and 4325 non-neonates. Neonates had a higher mortality rate, 1.31% versus 0.72% in older infants, had more diagnoses (median 9 vs 7) and procedures (mean 85.24 vs 21.83), longer length of stay (median 10 vs 4 days), and higher total charges (median US$65 722 vs US$25 582). A total of 23.3% of neonates born during the admission and diagnosed with LM had undergone laryngoscopy. Second airway lesions were present in 12.33% of neonates and 15.77% of older infants. It appears that neonates are being discharged with a diagnosis of LM without laryngoscopy. Neonatal intensive care unit and newborn nursery policies should require visualization of the larynx prior to diagnosis of LM.

Surgical Intervention for Laryngomalacia: Age-Related Differences in Postoperative Sequelae

OBJECTIVE

Identify risk factors and determine perioperative morbidity of children undergoing surgery for laryngomalacia (LM).

METHODS

A retrospective analysis of the multi-institutional American College of Surgeons National Surgical Quality Improvement Program-Pediatric Database (ACS-NSQIP-P) was performed to abstract patients aged <18 years with LM (ICD-10 code Q31.5) who underwent laryngeal surgery (CPT code 31541) from 2015 to 2017. Analyzed clinical variables include patient demographics, hospital setting, length of stay, medical comorbidities, postoperative complications, readmission, and reoperation.

RESULTS

A total of 491 patients were identified, 283 were male (57.6%) and 208 were female (42.4%). The mean age at time of surgery was 1.07 years (range .01-17 years). Younger patients were more likely to undergo surgery in the inpatient setting compared to their counterparts (P < .001). Infants were more likely to have prolonged duration of days from admission to surgery (P < .001), days from surgery to discharge (P < .001), and total length of stay (P<.0010). Finally, there was no significant difference between age groups with respect to 30-day general surgical complications (P = .189), with an overall low incidence of reintubation (1.2%), readmission (3.1%), and reoperation (1.6%).

CONCLUSION

This analysis supports laryngeal surgery as a safe surgical procedure for LM. However, younger children are more likely to undergo operative intervention in the inpatient setting, endure delays from hospital admission to surgical intervention, and experience a prolonged length of stay due to their overall medical complexity. Recognition of key factors may assist in optimizing perioperative risk assessment and promote timely procedural planning in this unique pediatric patient subpopulation.

Balloon Catheter Dilation in Pediatric Chronic Rhinosinusitis: A Meta-analysis

BACKGROUND

Paranasal sinus balloon catheter dilation (BCD) represents a tool that has been shown to be safe in the management of pediatric chronic rhinosinusitis (pCRS); however, its efficacy compared to standard treatment regimens has not been well established.

OBJECTIVE

The purpose of this meta-analysis was to evaluate the clinical utility of BCD in pCRS.

METHODS

Articles reporting BCD for pCRS in patients under 18 years of age were identified via the following search terms: sinusitis OR rhinosinusitis AND balloon dilatation OR balloon dilation OR balloon sinuplasty OR sinuplasty AND adolescent OR children OR infant OR pediatric OR toddler. The primary outcome analyzed includes quality of life improvement as measured via Sinus and Nasal Quality of Life Survey (SN-5) or Sino-nasal Outcome Test (SNOT-22) scores.

RESULTS

Eighty studies were abstracted; 10 studies were included for final qualitative analysis after dual investigator screening. Three studies described BCD with surgical controls, including adenoidectomy, saline irrigation, or maxillary antrostomy. Noninferiority was not demonstrated (ie, BCD is inferior) in 2 of 3 studies. Pooled analysis utilizing a random effects model revealed a decreased effect size yet no statistically significant difference between BCD and standard operative techniques as measured by quality of life measures (g = -0.04, I² = 41%).

CONCLUSION

This work highlights a lack of published evidence regarding the role of BCD in pCRS. Two of the 3 included studies demonstrated the inferiority of BCD when compared to other standard surgical interventions, whereas meta-analysis was unable to detect any statistically significant difference between standard treatment regimens. Future scientific investigations are necessary to assess the comparative effectiveness of BCD in pCRS.

Lateral cervical abscesses: NSQIP-P perspective on length of stay, readmission, and reoperation

OBJECTIVES

Identify risk factors and determine perioperative sequelae of children undergoing lateral cervical abscess incision and drainage.

METHODS

Pediatric patients who underwent lateral cervical abscess incision and drainage aged 1-18 years were retrospectively queried via ACS-NSQIP-P (2012-2016) utilizing CPT code 21501. Analyzed outcomes include age, time to surgery, operative time, total length of stay, readmission, and reoperation.

RESULTS

A total of 1917 children were identified, with a mean age at time of surgery of 4.05 years (95% CI 3.86-4.25). The mean number of days from hospital admission to operative intervention was 1.24 days (95% CI 1.16-1.31), with a mean total length of stay of 3.64 days (95% CI 3.46-3.82). The mean number of days from hospital admission to surgery was significantly lengthened in younger children (P = .0001) and pediatric patients of non-Caucasian origin (P < 0.001). Children with positive septic parameters not only had a prolonged time to surgery but also a significantly prolonged total length of stay (P < 0.001). Finally, a persistent requirement for postoperative mechanical ventilation and prolonged operative time (P = 0.003) was found to be related to reoperation.

CONCLUSION

Younger children are more likely to have delays from hospital admission to definitive surgical intervention, but this does not appear to affect total length of stay. Recognition of pertinent clinical factors may assist in optimizing perioperative risk assessment and promote timely procedural planning in the pediatric subpopulation.

Decision Quality Among Parents Who Are Offered Ventilation Tube Insertion for Their Children

Objective:

To develop a Decision Quality (DQ) tool to measure parents’ DQ concerning ventilation tube (VT) insertion in their children.

Method:

Parental survey during 2017 to 2018 in a tertiary care pediatric otolaryngology clinic comparing a validated Decisional Conflict (DC) scale with a DQ instrument including Shared Decision-Making (SDM) scale, parental treatment goals, and knowledge about VT.

Results:

Of 100 parent participants, 83% were mothers and 14% were fathers. 94% elected VT insertion, 6% elected monitoring or deferred the decision. 44% of the patients were <18 months, 42% were 19 months to 3 years, and the rest were older. The mean DC score was 8.26 out of 100 (95% CI 4.82-11.69), indicating low DC. Mean DQ score was 82.45 out of 100 (95% CI 80.18-84.72), including mean SDM of 87.71 (95% CI 83.53-91.88,), mean knowledge score of 87.5% (95% CI 84.56-91.59) and mean values score of 7.16 (95% CI 6.90-7.41). Comparisons between those who elected VT and those who did not showed that electors had lower DC scores (7.15 vs 24.74, P < .001), higher DQ scores (83.00 vs 72.61, P = .028) with higher SDM scores (88.70 vs 70.22, P = .044) and higher values score (7.20 vs 6.36, P = .034). Cronbach alpha for the DQ scale was 0.76. Spearman’s rho for DQ score versus DC score was −0.458, P < .001.

Conclusions:

DQ, as measured with this tool, was higher when parents chose to place tubes. Our DQ instrument has potential use for study of why parents may decline VT when their child meets criteria for them.

Bleeding Complications After Transoral Robotic Surgery: A Meta-Analysis and Systematic Review

OBJECTIVE

Postoperative hemorrhage is the most common complication of transoral robotic surgery (TORS), the severity of which can range from minor bleeding treated with observation to catastrophic hemorrhage leading to death. To date, little is known about the incidence, risk factors, and management of post-TORS hemorrhage.

STUDY DESIGN

Systematic Review and Metanlysis.

METHODS

A systematic review of the published literature using the Cochrane Handbook for Systematic Reviews of Interventions was performed and examined TORS, postoperative hemorrhage, and the use of prophylactic transcervical arterial ligation (TAL).

RESULTS

A total of 13 articles were included in the analysis. To date, there have been 332 cases of hemorrhage following a total of 5748 TORS. The pooled median post-TORS hemorrhage rate was 6.47%. The overall incidence of minor and major hemorrhage was 5.29% and 2.90%. Patients with prior radiation (relative risk [RR] = 1.46, 95% confidence interval [CI] = 1.00-2.12), large tumors (RR = 2.11, 95% CI = 1.48-2.99), and those requiring perioperative coagulation (RR = 2.25, 95% CI = 1.54-3.28) had significantly higher relative risks of hemorrhage. There was no significant difference in the relative risk of overall hemorrhage with TAL. Looking at major hemorrhage, patients undergoing TAL had a large but insignificant relative risk reduction in post-TORS hemorrhage (RR = 0.40, 95% CI = 0.15-1.07).

CONCLUSION

The incidence of post-TORS hemorrhage is low (5.78%), and for major hemorrhage requiring emergent embolization, TAL, or tracheotomy to control hemorrhage it is even lower (2.90%). Large tumors, perioperative anticoagulation, and prior radiation were associated with significantly increased risk of post-TORS hemorrhage. TAL does not reduce the overall incidence of post-TORS hemorrhage but may lead to fewer severe hemorrhages.

LEVEL OF EVIDENCE

III Laryngoscope, 131:95-105, 2021.

Congenital Choanal Atresia Repair: An Analysis of Adverse Perioperative Events

Objectives

To identify risk factors and determine the perioperative morbidity of infants undergoing congenital choanal atresia (CCA) repair.

Study Design

Retrospective analysis of the ACS-NSQIP-P database (American College of Surgeons National Surgical Quality Improvement–Pediatric).

Setting

Tertiary medical center.

Subjects and Methods

Patients who underwent CCA repair at age ≤365 days at the time of surgery were queried via the ACS-NSQIP-P database (2013-2016) via Current Procedural Terminology code 30540. Analyzed outcomes include age, length of stay, medical comorbidities, operative time, readmission, reoperation, and postoperative complications.

Results

A total of 168 patients were identified, 70 of which were within the neonatal period. Preoperatively, gastrointestinal disease ( P < .0001), mechanical ventilation ( P < .0001), and oxygen supplementation ( P = .0040) were significantly greater in frequency among neonates. For all children preoperatively, ASA class ( P < .0001), chronic lung disease ( P = .0019), oxygen supplementation ( P < .0001), and prematurity ( P = .0016) had a significant impact on prolonged length of stay. Neonates had a persistent requirement for postoperative mechanical ventilation ( P < .0001) and a prolonged length of stay ( P < .00001).

Conclusion

Neonates undergoing CCA repair are more likely to have a persistent requirement for postoperative mechanical ventilation and a prolonged length of stay. Recognition of key clinical factors may aid in optimizing perioperative risk assessment, patient counseling, and procedural planning.

Malaysian Cardiothoracic Surgery Registry--a patient registry to evaluate the health outcomes of patients undergoing surgery for cardiothoracic diseases in Malaysia

The formulation of the Cardiothoracic Registry. Cardiothoracic surgery is the field of medicine involved in surgical treatment of diseases affecting organs inside the thorax (the chest). It is a general treatment of conditions of the heart (heart disease) and lungs (lung disease). In Malaysia, due to lack of data collection we do not have estimates of number and outcome of such procedure in the country. Western figures are often used as our reference values and this may not accurately reflect our Malaysian population. The Malaysian Cardiothoracic Surgery Registry (MyCARE) by the Ministry of Health will be a valuable tool to provide timely and robust data of cardiology practice, its safety and cost effectiveness and most importantly the outcome of these patients in the Malaysian setting.

Pulmonary ventilatory functions and obesity in Kuwait

OBJECTIVE

To study the relationship between obesity and pulmonary ventilatory functions in Kuwaiti adults.

SUBJECTS AND METHODS

A total of 200 male and 180 female Kuwaiti adults aged 20-65 years were investigated in six medical centers from April 2004 to March 2006. Parameters measured included forced expiratory volume in 1 s (FEV(1)), forced vital capacity (FVC), FEV(1) as a percentage of FVC (FEV%); body mass index (BMI in kg/m(2)) and waist-to-hip ratio (W/H).

RESULTS

For the whole group, males or females, BMI (kg x m(2)) and W/H were poor individual predictors of pulmonary ventilatory functions. However, central adiposity (W/H) was associated with restrictive respiratory impairment (10.6-13.9% decrease in FEV(1) and 10-12.3% decrease in FVC), independent of sex, age or height. In obese females and males (BMI >30), increasing severity of obesity was significantly (p < 0.05, R(2) >0.6) [corrected] associated with increasing restrictive respiratory impairment (8.7-14.4% decrease in FEV(1) and 8-11.7% decrease in FVC), with no evidence of obstructive disease (FEV(1)/FVC >0.8).

CONCLUSION

In adult Kuwaiti males and females, increase in body fat at BMI >30 or W/H >1 was associated with a restrictive effect on pulmonary ventilation.

Anthropometric profiles of elite Asian female handball players

AIM

Handball has increased in status as a sport since its introduction in 1972 into the Summer Olympic Games. Whereas anthropometric profiles of female athletes have been reported for certain sports, data for elite handball players are limited. The current study was based on anthropometric measurements of 60 female Asian handball players competing in the continental championship, the aim being to identify any differences between countries and between playing positions.

METHODS

The setting was the 12(th) Asian Games in Hiroshima, Japan. Anthropometric data were obtained from 60 players including teams from China, Japan, Kazakhstan and South Korea. Measurements included height, mass, skinfold thicknesses: from these measures percent body fat and muscle mass were estimated. Profiles were compared between 4 nations and 4 positional roles by means of ANOVA.

RESULTS

Overall, mean (SD) values were 1.708 (0.068) m, 64.6 (7.7) kg, 20.8% (4.4%), 39.6% (5.2%) for stature, mass, percent body fat and percent muscle mass, respectively. There were small differences between players from different countries but no significant (P>0.05) influence of playing position. Players from Japan were shortest, lightest and lowest in adiposity. The Chinese players were tallest and had the greatest muscle mass.

CONCLUSION

These female international handball players differed in some respects in anthropometric characteristics according to their country of origin. The Asian players were found to be relatively homogeneous across the different positions.

Reported frequency of physical activity, fitness, and fatness in Kuwait

We studied reported frequency of physical activity (PA), body composition, and fitness in Kuwaiti females (n = 84) and males (n = 72), urban office government employees, or students. A sedentary (SED) group reported no or occasional participation in self-directed PA of 30 minutes or more during the week for the last 6 months; group LOF (low frequency) participated in 1-2 sessions/week (walking, jogging, sports such as volleyball, soccer, or gym); group HIF (higher frequency) reported three or more sessions/week. Aerobic fitness was measured using Bruce's treadmill protocol. Body fat and fat-free mass (FFM) were estimated from seven skinfolds and body weight (BW). Grip strength and trunk flexibility were also measured. Maximal O(2) consumption (VO(2)max)/BW was proportional to reported frequency of PA in males and females, indicating reliability of the reported PA frequencies. SED males (%fat > 25), SED and LOF females (%fat > 30) were overweight. In males, LOF PA was associated with lower %fat and higher flexibility than SED, and in females with higher VO(2)max/FFM than SED. LOF females, in contrast to males, were resilient to or exercised at levels insufficient for fat loss but sufficient for aerobic conditioning of the FFM, likely related to the low VO(2)max of females in which PA would have the most effect. HIF PA (>/=3/week) was associated in females with significantly lower %fat and higher flexibility than SED females and no further aerobic conditioning of the FFM, and in males with no further differences in study variables compared with LOF males. Grip strength was higher in males than females but was unrelated to frequency of PA, likely reflecting lack of strength training in the activities of most participants. Thus, low-frequency PA was associated with health benefits both in males (lower %fat) and females (higher VO(2)max/FFM). Probably due to the generally low fitness level of females and, hence, the high aerobic effort (%VO(2)max) required for exercise sufficient to impinge on fat stores, this was only achieved in females participating in higher weekly frequency (>/=3) of PA.

Does fasting during Ramadan alter body composition, blood constituents and physical performance?

OBJECTIVE

To study the effect of Ramadan fast (RF) on body composition, plasma constituents, hematology, and cardiorespiratory responses to constant submaximal exercise.

SUBJECTS AND METHODS

Sixteen sedentary healthy Kuwaiti adult males were included in the study. The subjects were tested under thermo-neutral conditions during a spring-like month of Ramadan and 2 months thereafter. They were tested during the week before RF (Pre1); the last 3 days of RF (End1); the week before a non-Ramadan month (Pre2), and the last 3 days of the non-Ramadan month (End2). The following measurements were made: body composition, cellular and biochemical constituents of blood, heart rate, ventilatory responses and blood pressure.

RESULTS

No significant changes were observed in body composition, cellular and biochemical constituents of blood. The heart rate and ventilatory responses to the moderately intense bouts of submaximal aerobic exercise ( approximately 70% of VO(2max)) were significantly reduced (p < 0.04) while systolic blood pressure increased (p < 0.05) by the end of RF.

CONCLUSIONS

Ramadan fasting had no adverse effect on the subjects when performing aerobic exercise at submaximal level. The mild changes in cardiorespiratory responses could be due to dehydration, abstention from consumption of substances with negative inotropy and circadian rhythms.

Low-frequency physical activity insufficient for aerobic conditioning is associated with lower body fat than sedentary conditions

We aimed to show the relationships between reported physical activity, fitness level, and body composition in healthy adult office-working Kuwaiti males (n = 45). Reported level of physical activity (group 0 = no routine exercise, n = 10; group 1 = routine exercise once per wk, n = 19; group 2 = routine exercise two or more times per wk, n = 16) was determined from recall questionnaires. Aerobic fitness levels were assessed from resting exercise heart rates and measurement of maximal oxygen uptake (treadmill exercise, Bruce protocol). Body composition was estimated from measurements of body weight, body height, and seven skin-folds. None of the subjects reported dieting to reduce or maintain their body weight. Despite minimal and not statistically significant differences in resting heart rates, VO(2)max, VO(2)max/kg body weight, and VO(2)max/kg lean body mass, the sedentary group (group 0) had a much higher (12--14 kg) average body weight, higher (12--13 kg) body fat, and thicker skin folds than the more physically active groups 1 and 2. Groups 1 and 2 did not differ significantly from each other with regard to fitness and body composition parameters. Thus, routine physical activities insufficient to result in aerobic conditioning were found to be associated with lower body weight and lower body fat compared to those present in subjects reporting the total absence of any routine physical activity. These data are consistent with the hypothesis that even mild levels of routine physical activity are associated with levels of energy turnover that allow less intense and/or frequent periods of positive energy balance, resulting in maintenance of lower body fat than in totally sedentary people. Frequency of participation in routine physical activities may also reflect the level of non-exercise related physical activities and thus relate to the ability to minimize weight gain.

Responses to exercise, fluid, and energy balances during Ramadan in sedentary and active males

This study compares the effects of the Ramadan fast (RF) on body and plasma compositions, hematology, and responses to steady state submaximal exercise in six physically active (A, 35.5+/-1.6 y) and seven sedentary (S, 37.6+/-2.3 y) Kuwaiti men. Subjects were evaluated: 1) 1 wk before RF (pre-RF); 2) 2 wk after the start of RF (mid-RF); 3) at the 4th wk of RF (end-RF). Total body weight and body fat decreased insignificantly (<1.5%, P>0.3) in both groups. At the end of Ramadan, significant increases in osmolarity (P<0.05), Na (P<0.05) and bicarbonate (P<0.05), and a decrease in serum iron were noted in sedentary but not in active subjects. Platelet count was lower in both groups by the end of RF (P<0.05). Body weight and percent fat changed little (<1.5%) in either group. During RF, submaximal exercise heart rate declined insignificantly in group S but significantly (P<0.05) in group A. The respiratory exchange ratio R during steady state submaximal exercise decreased markedly (P<0.001) by the end of RF in both groups. It is concluded that energy balance is well maintained during RF both in S and in A subjects. Metabolic adaptations during RF result in lower exercise R due to increased lipid usage. Deficits or redistribution of specific micronutrients (iron, vitamins) may account for reductions in serum iron and platelet counts, particularly in sedentary subjects that need to limit intake to maintain body weight. The decrease in submaximal exercise heart rate indicates that during RF, cardiovascular adaptation to conditioning is adequate in the more physically active group. Body fluid balance was better maintained in active than in sedentary subjects.

Exercise time relationship to coronary risk factors in Kuwaiti adult males 1985-1986

Two hundred and sixty-nine apparently healthy Kuwaiti men, aged 20-49, from 800 randomly selected Kuwaiti families, were examined for cardiovascular fitness and risk factors for coronary heart diseases (CHD). The risk factors were examined by exercise stress test on Quinton-2000 ECG monitor and treadmill Q-model 24-26, Bruce protocol, along with Ergo-oxyscreen, by laboratory tests of fasting blood lipid levels, and by interview using a questionnaire. The sample was stratified into three age groups, 20-29, 30-39, and 40-49. For the entire sample, the results showed that a number of the investigated factors were significantly correlated with the duration of treadmill exercise time. Univariate analysis indicated that performance was inversely correlated with age, cholesterol levels, cholesterol:HDL ratio, triglycerides and uric acid, weight, body-build indexes, body density, resting heart rate, blood pressure (BP), personal history of CHD, and smoking habits. Most of the observed significant correlations were particularly pronounced in the younger age groups, 20-39 years. In this group, significant results in the analysis of variance were found between the treadmill performance time and a number of risk factors, including: cholesterol levels, age, cholesterol:HDL ratios, triglycerides, uric acid, heart rate, elevated systolic blood pressure, and obesity.