Harnessing In Situ Simulation to Identify Human Errors and Latent Safety Threats in Adult Tracheostomy Care

BACKGROUND

Tracheostomies are associated with high rates of complications and preventable harm. Safe tracheostomy management requires highly functioning teams and systems, but health care providers are poorly equipped with tracheostomy knowledge and resources. In situ simulation has been used as a quality improvement tool to audit multidisciplinary team emergency response in the actual clinical environment where care is delivered but has been underexplored for tracheostomy care.

METHODS

From July 2021 to May 2022, the study team conducted in situ simulations of a tracheostomy emergency scenario at Montefiore Medical Center to identify human errors and latent safety threats (LSTs). Simulations included structured debriefs as well as audiovisual recording that allowed for blind rating of these human errors and LSTs. Provider knowledge deficits were further characterized using pre-simulation quizzes.

RESULTS

Twelve human errors and 15 LSTs were identified over 20 simulations with 88 participants overall. LSTs were divided into the following categories: communication, equipment, and infection control. Only 50.0% of teams successfully replaced the tracheostomy tube within the scenario's five-minute time limit. In addition, knowledge gaps were highly prevalent, with a median pre-simulation quiz score of 46% (interquartile range 36-64) among participants.

CONCLUSION

An in situ simulation-based quality improvement approach shed light on human errors and LSTs associated with tracheostomy care across multiple settings in one health system. This method of engaging frontline health care provider key stakeholders will inform the development, adaptation, and implementation of interventions.

Factors associated with eosinophilic esophagitis in an urban, tertiary care pediatric aerodigestive population undergoing triple endoscopy

BACKGROUND

Children with aerodigestive dysfunction often undergo triple endoscopy (flexible bronchoscopy, rigid direct laryngoscopy and bronchoscopy, and esophagogastroduodenoscopy) for diagnostic evaluation as well as screening prior to airway reconstruction. Prevalence and risk factors for eosinophilic esophagitis (EoE) in this population are poorly understood.

METHODS

A retrospective chart review was performed for pediatric patients, aged 0-21 years, who received a triple endoscopy with biopsy from January 1, 2015, to December 31, 2019, at the Children's Hospital at Montefiore (CHAM). Bivariate and multivariable analyses were used to compare the baseline characteristics between patients with and without EoE to assess for potential predictors of EoE.

RESULTS

Of the 119 cases included in the analysis, 16.0 % (19) received a histopathologic diagnosis of EoE following triple endoscopy. Patients with EoE were more likely to have a family history of eczema (p = 0.02) and a dairy-free diet (p = 0.02). Age, sex, history of environmental allergies, and recency of initiating oral diet were not significantly associated with increased odds of an EoE diagnosis.

CONCLUSIONS

A family history of eczema and a diet lacking allergenic foods, such as milk, may be associated with an increased risk of a future diagnosis of EoE in patients with aerodigestive dysfunction. Larger, multi-institutional studies are needed to identify early predictors of EoE.

Association and risk factors of pediatric pulmonary hypertension with obstructive sleep apnea: A national study utilizing the Kids' Inpatient Database (KID)

STUDY OBJECTIVE

Assess the prevalence of and risk factors for pediatric pulmonary hypertension (PH) in the 2016 Kids' Inpatient Database (KID), including obstructive sleep apnea (OSA) and obesity.

METHODS

Retrospective cross-sectional cohort study utilizing 6,081,132 weighted pediatric discharges from the 2016 KID. Study variables included age, length of stay, mortality, gender, hospital region, primary payer, race, median household income for patient's ZIP code, OSA, central sleep apnea (CSA), obesity, Down syndrome, sickle cell disease (SCD), thalassemia, congenital heart disease (CHD), hypertension, asthma and chronic lung disease of prematurity (CLDP). PH was the primary outcome of interest. Bivariate and multivariable logistic regression models were utilized with odds ratios and 95 % confidence intervals.

RESULTS

The mean age was 3.76 years, the mean hospital length of stay was 3.85 days, 48.9 % were male, 52.6 % had government health insurance, 51.0 % were White, 16.1 % were Black, 21.1 % were Hispanic, 5.0 % were Asian or Pacific Islander, 0.80 % were Native American and 6.1 % identified as "other". The prevalence of PH was 0.21 % (12,777 patients). There were 37,631 patients with OSA and the prevalence of PH among this cohort was 3.3 %, over 10x greater than the overall prevalence of PH in the 2016 KID (0.21 %). Risk factors associated with PH included CLDP, CHD, Down syndrome, asthma, OSA, CSA, hypertension, SCD, obesity, race/ethnicity, government insurance, age, male gender (p < 0.0001), and hospital region (p = 0.0002).

CONCLUSIONS

Several risk factors were independently associated with PH, such as OSA, CSA, obesity, asthma, and insurance status. Prospective multi-institutional studies are needed to assess the relationships between these risk factors, severity metrics, and causative links in the development of PH; in addition to identifying children with OSA who are most likely to benefit from cardiopulmonary screening prior to adenotonsillectomy.

LEVEL OF EVIDENCE

Level III.

Pediatric Tracheostomy Emergency Readiness Assessment Tool: International Consensus Recommendations

OBJECTIVE

To achieve consensus on critical steps and create an assessment tool for actual and simulated pediatric tracheostomy emergencies that incorporates human and systems factors along with tracheostomy-specific steps.

METHODS

A modified Delphi method was used. Using REDCap software, an instrument comprising 29 potential items was circulated to 171 tracheostomy and simulation experts. Consensus criteria were determined a priori with a goal of consolidating and ordering 15 to 25 final items. In the first round, items were rated as "keep" or "remove". In the second and third rounds, experts were asked to rate the importance of each item on a 9-point Likert scale. Items were refined in subsequent iterations based on analysis of results and respondents' comments.

RESULTS

The response rates were 125/171 (73.1%) for the first round, 111/125 (88.8%) for the second round, and 109/125 (87.2%) for the third round. 133 comments were incorporated. Consensus (>60% participants scoring ≥8, or mean score >7.5) was reached on 22 items distributed across three domains. There were 12, 4, and 6 items in the domains of tracheostomy-specific steps, team and personnel factors, and equipment respectively.

CONCLUSIONS

The resultant assessment tool can be used to assess both tracheostomy-specific steps as well as systems factors affecting hospital team response to simulated and clinical pediatric tracheostomy emergencies. The tool can also be used to guide debriefing discussions of both simulated and clinical emergencies, and to spur quality improvement initiatives.

LEVEL OF EVIDENCE

5 Laryngoscope, 133:3588-3601, 2023.

Teaching Tracheostomy Tube Changes: Comparison of Operant Learning Versus Traditional Demonstration

Objective

Tracheostomy tube change is a multistep skill that must be performed rapidly and precisely. Despite the critical importance of this skill, there is wide variation in teaching protocols.

Methods

An innovative operant conditioning teaching methodology was employed and compared to traditional educational techniques. Medical student volunteers at a tertiary care academic institution (Albert Einstein College of Medicine) were recruited and randomly distributed into 2 groups: operant vs traditional (control). Following the educational session, each group was provided with practice time and then asked to perform 10 tracheostomy tube changes. Performance was recorded and scored by blinded raters using deidentified video recordings.

Results

The operant learning group (OLG) demonstrated greater accuracy in performing a tracheostomy tube change than the traditional demonstration group. Twelve of 13 operant learners performed the skill accurately each time compared to 3 of 13 in the traditional group (P = 0.002). The median lesson time was longer for the OLG (535 seconds) than for the traditional group, (200 seconds P < 0.001). The average time per tracheostomy change was not significantly different between the 2 groups (operant learners mean 7.1 seconds, traditional learners mean 7.5 seconds, P = 0.427).

Discussion

Although the operant conditioning methodology necessarily requires a greater time to teach, the results support this methodology over traditional learning modalities as it enhances accuracy in the acquired skill. Operant learning methodology is under consideration for other skills and education sessions in our program. Future steps include the application and adaptation of this education model to students and residents in other settings and fields.

Implications for Practice

Operant learning is effective for teaching multistep skills such as tracheostomy tube changes with decreased error rates.

The Efficacy of Human Papillomavirus Vaccination as an Adjuvant Therapy in Recurrent Respiratory Papillomatosis

OBJECTIVE

To characterize the efficacy of human papillomavirus (HPV) vaccination as an adjuvant therapy in recurrent respiratory papillomatosis (RRP).

DATA SOURCES

PubMed, Embase, Cochrane, Google Scholar, ClinicalTrials.gov, and Web of Science databases were queried for articles published before April 2021.

REVIEW METHODS

All retrieved studies (n = 870) were independently analyzed by two reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement using predefined inclusion and exclusion criteria. 13 studies met inclusion criteria. A random-effects meta-analysis was performed to study intersurgical interval (ISI) and number of surgical procedures per year before and after vaccination.

RESULTS

The systematic review included 13 studies, comprising 243 patients. All studies utilized the Gardasil® quadrivalent vaccine, and one study (Yiu et al. 2019) utilized both the quadrivalent and Gardasil® 9-valent vaccines. Our meta-analysis included 62 patients with ISI data across 4 studies, and 111 patients with data on the number of surgical procedures per month across 7 studies. The mean number of surgical procedures decreased by 4.43 per year after vaccination (95% CI, -7.48 to -1.37). Mean ISI increased after vaccination, with a mean difference of 15.73 months (95% CI, 1.46-29.99). Two studies reported on HPV sero-conversion, with HPV seropositivity of 100% prior to vaccination and 25.93% after vaccination.

CONCLUSION

The addition of HPV vaccination was associated with an increase in time between surgeries and reduction in the number of surgical procedures required. HPV vaccination may be a beneficial adjuvant treatment for RRP.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:2046-2054, 2023.

In Situ Simulation as a Quality Improvement Tool to Identify and Mitigate Latent Safety Threats for Emergency Department SARS-CoV-2 Airway Management: A Multi-Institutional Initiative

BACKGROUND

In situ simulation has emerged as a powerful quality improvement (QI) tool in the identification of latent safety threats (LSTs). Following the first wave of SARS-CoV-2 at an urban epicenter of the disease, a multi-institutional collaborative was formed to integrate an in situ simulation protocol across five emergency departments (EDs) for systems improvement of acute airway management.

METHODS

A prospective, multi-institutional QI initiative using two Plan-Do-Study-Act (PDSA) cycles was implemented across five EDs. Each institution conducted simulations involving mannequins in acute respiratory failure requiring definitive airways. Simulations and systems-based debriefs were standardized. LSTs were collected in an online database, focused on (1) equipment availability, (2) infection control, and (3) communication.

RESULTS

From June 2020 through May 2021, 58 of 70 (82.9%) planned simulations were completed across five sites with 328 unique individual participants. Overall LSTs per simulation (7.00-4.69, p < 0.001) and equipment LSTs (3.00-1.46, p < 0.001) decreased from cycle 1 to cycle 2. Changes in mean LSTs for infection control and communication categories varied among sites. There was no correlation between total LSTs or any of the categories and team size. Number of beds occupied was significantly negatively correlated with total and infection control LSTs.

CONCLUSION

This study was unique in simultaneously running a structured in situ protocol across numerous diverse institutions during a global pandemic. This initiative found similar categories of threats across sites, and the protocol developed empowered participants to implement changes to mitigate identified threats.

Development and Interrater Agreement of a Novel Classification System Combining Medical and Surgical Adverse Event Reporting

Importance

Categorization systems for adverse events are not standardized across care settings and specialties and do not always include near miss events (events where there was potential for patient harm, but where no actual harm occurred), making it difficult to effectively assess patient safety for quality improvement.

Objective

To develop and assess interrater agreement on a classification system for adverse events reporting that incorporates events in both inpatient and outpatient settings across medical and surgical subspecialties including near miss events.

Design, Setting, and Participants

A cross-sectional study in a tertiary care center including 174 patient cases occurring from 2018 to 2020 was carried out. Data were abstracted from a Department of Otorhinolaryngology-Head and Neck Surgery Quality Assurance database. The cases were comprised of near miss and adverse events occurring in adult and pediatric patients in inpatient, outpatient, and emergency department settings. The ratings took place in March and April of 2022.

Exposures

Four raters (2 attending physicians and 2 senior resident physicians) were recruited to classify these cases according to 3 classification systems: the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP), Clavien-Dindo, and our novel Quality Improvement Classification System (QICS).

Main Outcomes and Measures

The primary outcome was overall interrater agreements using Fleiss κ.

Results

Across all 4 raters grading 174 cases, the NCC-MERP, Clavien-Dindo, and QICS received a κ score. Fair-to-moderate interrater reliability was observed between the resident and attending physician groups across the 3 classification systems: NCC-MERP (κ = 0.33; 95% CI, 0.30-0.35), Clavien-Dindo (κ = 0.47; 95% CI, 0.43-0.50), and QICS (κ = 0.42; 95% CI, 0.39-0.44). Strong interrater concordance was observed for complications across all scenarios.

Conclusion and Relevance

This cross-sectional study found that the new QICS classification scheme was applicable to wide-ranging clinical scenarios with a focus on patient-centered outcomes including near miss events. In addition, QICS allowed for the comparison of patient outcome data in a multitude of settings.

In Situ Simulation as a Tool to Longitudinally Identify and Track Latent Safety Threats in a Structured Quality Improvement Initiative for SARS-CoV-2 Airway Management: A Single-Center Study

BACKGROUND

In situ simulation has emerged as a powerful tool for identifying latent safety threats (LSTs). After the first wave of the SARS-CoV-2 pandemic, an urban community emergency department (ED) identified opportunities for improvement surrounding acute airway management and particularly focused on infection control precautions, equipment availability, and interprofessional communication during acute resuscitation. Using the Model for Improvement, a hybrid in situ/quality improvement initiative was implemented using Plan-Do-Study-Act (PDSA) cycles to enhance systems for intubating patients with SARS-CoV-2.

METHODS

Three PDSA cycles consisting of 10 simulations each were conducted from June 2020 through February 2021. Latent safety threats (LST) were identified through an in situ simulation scenario involving a patient with SARS-CoV-2 in acute respiratory failure. LSTs were collected through structured debriefs focused on (1) infection control, (2) equipment availability, and (3) communication. The SAFER-Matrix was used to score LSTs according to frequency and likelihood of harm by members of the ED QI team (SAFER score). The research team worked with the same QI leaders to implement action plans based on scored threats using cause-and-effect and driver diagrams. The Donabedian model was used to conceptually evaluate the quality of interventions upon conclusion of the third PDSA cycle.

RESULTS

The median SAFER score decreased from 10.94 in PDSA cycle 1 to 6.77 in PDSA cycle 2 to 4.71 in PDSA cycle 3. Across all identified LSTs, the SAFER score decreased by 3.114 for every additional PDSA cycle ( P = 0.0167). When evaluating for threats identified as being primarily structure based, there was a decrease in SAFER score of 1.28 per every additional PDSA cycle ( P = 0.001). There was a decrease in total count of LST of 0.20 per additional simulation run ( P = 0.02) after controlling for shift type, census, perceived workload, team size, and prior attendance in simulations across all PDSA cycles.

CONCLUSIONS

This study presents a blueprint for the utilization of in situ simulation through multiple waves of the SARS-CoV-2 pandemic to identify LSTs and use the SAFER score as a surrogate marker to monitor the impact of interventions for a safer environment for both medical staff and patients.

[Clinical study on application of 3D Slicer software assisted domestic frameless stereotactic robot in biopsy of intracranial lesions]

Objective: To examine the application value of 3D Slicer software assisted domestic frameless stereotactic robot in biopsy of intracranial lesions. Methods: A retrospective analysis was performed on 80 patients who admitted consecutively and underwent intracerebral lesions biopsy with the domestic frameless stereotactic robot at Department of Neurosurgery, Aerospace Central Hospital from January 2019 to December 2021. There were 36 males and 44 females, with a mean age of (38.5±18.0) years (range: 6 to 71 years). Before surgery only enhanced T1-weighted three-dimensional magnetization prepared gradient echo sequences and diffusion tensor imaging scans were performed. Self-reconstruction of intracranial lesions, cerebral cortex and blood vessels was carried out using 3D Slicer software system after the DICOM format imaging data of 80 patients were collected. These imaging data were merged to the workstation of the domestic frameless stereotactic robot for preoperative surgical planning and the surgical puncture path was designed to avoid blood vessels in the brain functional area, cerebral cortex and sulcus. Results: All frameless stereotactic biopsy were successfully performed. Postoperative pathological diagnosis included 50 cases of diffuse astrocytic and oligodendroglioma, 15 cases of lymphoma, 5 cases of metastatic tumors, 5 cases of inflammatory demyelinating disease, 2 cases of inflammatory granuloma, 1 case of hemangioma, 1 case of acute lymphoblastic leukemia intracranial invasion and 1 case of seminoma. The positive diagnosis rate was 100% (80/80). Postoperative imaging confirmed that the puncture path and target were accurately implemented according to the preoperative planning, and the target error was (1.32±0.44) mm (range: 0.55 to 1.99 mm). One case of puncture-related bleeding occurred at the target after surgery and improved after treatment. Conclusion: The three-dimensional multimodal images reconstructed by the 3D Slicer software before operation could help the surgeons make the preoperative planning and reduce the risk of stereotactic brain biopsy.

Admission practices following pediatric tonsillectomy: A survey of ASPO members

OBJECTIVES

Although evidence-based Clinical Practice Guidelines (CPGs) have specified postoperative admission criteria for pediatric tonsillectomy, there is substantial variation in guideline implementation and adherence among otolaryngologists in practice. We aimed to assess pediatric otolaryngologists' post-tonsillectomy admission practices and to examine patient and surgeon factors associated with differences in admission practices.

METHODS

An electronic cross-sectional survey was distributed to members of the American Society of Pediatric Otolaryngology (ASPO) to determine current practices regarding admission practices following pediatric tonsillectomy. Chi-square and Fisher's exact tests were performed to compare differences in adherence to tonsillectomy CPGs by respondent characteristics.

RESULTS

The survey was sent to 644 pediatric otolaryngologists with a response rate of 19.1%. 37% of respondents reported "always" and 60% "often" using the Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) CPG to guide decision for admission. Years in practice was the factor most strongly associated with admission practices, with 10 or fewer years in practice significantly correlated with stricter adherence to the AAO-HNS CPG of overnight observation when Apnea-Hypopnea Index (AHI) ≥10, age <3 years, or O2 nadir <80%) (OR 4.2, p <0.001), as well as specific individual criteria such as an AHI ≥10 (OR 4.1, p = 0.03). Respondents in an academic practice setting were more likely to admit children <3 years of age than those in private practice (OR 5.0, p = 0.01).

CONCLUSION

Admission practices varied among pediatric otolaryngologist survey respondents, and strict AAO-HNS CPG adherence was associated with fewer years in practice and academic practice setting. These results suggest that further study investigating factors influencing guideline adherence and post-tonsillectomy admission practices is warranted.

Assessing Impact: Implementing an Opioid Prescription Protocol in Otolaryngology

OBJECTIVE

A lack of guidance for pain control after otolaryngology surgery can lead to overprescription of opioids. We implemented a postoperative site-specific opioid prescription protocol and analyzed the impact on opioid prescriptions.

METHODS

This is a retrospective cohort study. A postoperative opioid prescription protocol was implemented within our otolaryngology department at a tertiary academic medical center on January 1, 2020. Retrospective chart review was completed for all patients undergoing otolaryngology surgery from November 1, 2019, to February 29, 2020 (2 months before and after initiation of intervention; n = 1070). The primary outcome was change in the amount of opioid prescribed for the preintervention and postintervention cohorts. Unplanned contact related to pain and opioid refills were tracked to assess pain control.

RESULTS

A total of 940 cases were included; adult and pediatric data were analyzed separately. There were 489 pediatric cases, 250 preintervention and 239 postintervention. There was a significant decrease in the amount of opioid prescribed per pediatric patient in the postintervention cohort (2.7 versus 0.32 morphine milligram equivalents, P = 0.02), and 99% of patients were not prescribed opioids at all. There was no significant change in unplanned contact, and no refills were required. There were 451 adult cases, 200 preintervention and 251 postintervention. There was no statistically significant decrease in the amount of opioid prescribed per adult patient (56.8 versus 51.7 morphine milligram equivalents, P = 0.23). There was no significant increase in unplanned contact or refills.

CONCLUSIONS

A postoperative opioid prescribing protocol can reduce the amount of opioid prescribed without increasing unplanned contact or opioid refills.

Amplifying patient voices amid pandemic: Perspectives on tracheostomy care, communication, and connection

OBJECTIVE

To investigate perspectives of patients, family members, caregivers (PFC), and healthcare professionals (HCP) on tracheostomy care during the COVID-19 pandemic.

METHODS

The cross-sectional survey investigating barriers and facilitators to tracheostomy care was collaboratively developed by patients, family members, nurses, speech-language pathologists, respiratory care practitioners, physicians, and surgeons. The survey was distributed to the Global Tracheostomy Collaborative's learning community, and responses were analyzed.

RESULTS

Survey respondents (n = 191) from 17 countries included individuals with a tracheostomy (85 [45 %]), families/caregivers (43 [22 %]), and diverse HCP (63 [33.0 %]). Overall, 94 % of respondents reported concern that patients with tracheostomy were at increased risk of critical illness from SARS-CoV-2 infection and COVID-19; 93 % reported fear or anxiety. With respect to prioritization of care, 38 % of PFC versus 16 % of HCP reported concern that patients with tracheostomies might not be valued or prioritized (p = 0.002). Respondents also differed in fear of contracting COVID-19 (69 % PFC vs. 49 % HCP group, p = 0.009); concern for hospitalization (55.5 % PFC vs. 27 % HCP, p < 0.001); access to medical personnel (34 % PFC vs. 14 % HCP, p = 0.005); and concern about canceled appointments (62 % PFC vs. 41 % HCP, p = 0.01). Respondents from both groups reported severe stress and fatigue, sleep deprivation, lack of breaks, and lack of support (70 % PFC vs. 65 % HCP, p = 0.54). Virtual telecare seldom met perceived needs.

CONCLUSION

PFC with a tracheostomy perceived most risks more acutely than HCP in this global sample. Broad stakeholder engagement is necessary to achieve creative, patient-driven solutions to maintain connection, communication, and access for patients with a tracheostomy.

Impact of a postgraduate year one (PGY-1) otolaryngology bootcamp on procedural skill development

Background: To measure the impact of an intensive eight-week postgraduate year one (PGY-1) otolaryngology bootcamp on the acquisition and retention of otolaryngology residents’ procedural skills compared to the traditional method of skill acquisition through clinical exposure.

Methods: Residents at our institution were evaluated on their performance of flexible laryngoscopy, suture ligature, and rigid bronchoscopy setup at three time points: pre-bootcamp, one-week post-bootcamp, and one-year post-bootcamp. Video recordings were scored by two blinded faculty reviewers using a multipoint rating system. A control group of rising postgraduate year two (PGY-2) residents who did not participate in bootcamp were recorded performing these same skills. Scores in the three skills were compared between groups via t-tests. The eight-week bootcamp curriculum for PGY-1s was held at the Montefiore Einstein Center for Innovation in Simulation at Albert Einstein College of Medicine/Montefiore Medical Center. The participants were two classes of PGY-1 residents (n=8) at our institution who participated in a bootcamp at the beginning of residency, and one class of rising PGY-2 residents (n=3) who did not participate in a bootcamp (control group).

Results: A comparison of pre-bootcamp scores to one-week post-bootcamp scores showed significant improvement in suture ligature ( P<0.05) and rigid bronchoscopy ( P<0.05), but no difference in flexible laryngoscopy ( P=0.54). Suture ligature ( P=0.09) and rigid bronchoscopy ( P=0.25) skills were not significantly different from one-week post-bootcamp to one-year post-bootcamp; however, a significant skill improvement was observed in flexible laryngoscopy ( P<0.05). By June of PGY1 year, the two bootcamp cohorts were similar to controls in all three skills: flexible laryngoscopy ( P=0.05), rigid bronchoscopy ( P=0.26), and suture ligature ( P=0.10).

Conclusions: Participation in PGY-1 bootcamp was associated with improved acquisition and short-term retention of basic procedural skills, suggesting that bootcamps can be an effective arena to teach basic skills in otolaryngology. PGY-1 bootcamp is a promising arena for multi-institutional development.

Using a Logic Model to Enable and Evaluate Long-Term Outcomes of a Mass Casualty Training Program: A Single Center Case Study

PURPOSE

Global health disasters are on the rise and can occur at any time with little advance warning, necessitating preparation. The authors created a comprehensive evidence-based Emergency Preparedness Training Program focused on long-term retention and sustained learner engagement.

METHOD

A prospective observational study was conducted of a simulation-based mass casualty event training program designed using an outcomes-based logic model. A total of 25 frontline healthcare workers from multiple hospital sites in the New York metropolitan area participated in an 8-hour immersive workshop. Data was collected from assessments, and surveys provided to participants 3 weeks prior to the workshop, immediately following the workshop, and 3 months after completion of the workshop.

RESULTS

The mean percentage of total knowledge scores improved across pre-workshop, post-workshop and retention (3 months post-workshop) assessments (53.2% vs. 64.8% vs. 67.6%, P < 0.05). Average comfort scores in the core MCI competencies increased across pre-workshop, post-workshop and retention self-assessments (P < 0.01). Of the participants assessed at 3 months retention (n = 14, 56%), 50.0% (n = 7) assisted in updating their hospital's emergency operations plan and 50.0% (n = 7) pursued further self-directed learning in disaster preparedness medicine.

CONCLUSIONS

The use of the logic model provided a transparent framework for the design, implementation, and evaluation of a competency-based EPT program at a single academic center.

Safety Considerations for In Situ Simulation in Closed SARS-CoV-2 Units

SUMMARY STATEMENT

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic placed a tremendous strain on the healthcare system, which led to the deployment of new personnel into acute care settings, early graduation of medical students, and development of new treatment spaces. Education teams at the Montefiore Health System and New York Health and Hospitals/Jacobi Medical Center found simulation, both laboratory-based and in situ, critical to the training of medical staff and investigation of latent safety threats. Through our experience, we encountered unique infection control concerns based on in situ sessions, which prompted us to redesign our programs for the treatment of SARS-CoV-2. Using this experience, we outline our rationale for the use of in situ simulation for newly developed SARS-CoV-2 spaces along with recommendations on safety checks to consider before starting.

[Analysis of pathogen monitoring results of infectious diarrhea in Beijing Traditional Chinese Medicine Hospital Affiliated to Capital Medical University from 2016 to 2019]

Objective: to analyze the distribution characteristics of major enteropathogens in infectious diarrhea cases attending the intestinal outpatient clinic of Beijing Traditional Chinese medicine hospital, Capital Medical University. Methods: From 2016 to 2019, 588 fecal samples of patients with infectious diarrhea in Beijing Hospital of traditional Chinese Medicine Affiliated to Capital Medical University were collected for microbial isolation, culture, identification and pathogen gene detection. Using VITEK 2 compact full-automatic microbial identification/drug sensitivity analysis system to identify the bacteria isolated from the culture; using serum agglutination test to classify the pure colonies; using multiple fluorescence quantitative PCR amplification technology to detect the gene amplification of the samples. Results: In 2016-2019, the total physical examination rate of pathogen was 39.796%. The top three pathogen were diarrhea Escherichia coli (21.769%, n=128), Salmonella (5.782%, n=34), Vibrio (4.762%, n=28). The difference of positive rates of different pathogens in four years was statistically significant (P=0.021), and the peak of incidence was from July to September. The positive rate of norovirus was 5.612% (n=33), and the highest incidence occurred in May. Conclusion: The pathogen of infectious diarrhea patients in Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University from April to October 2016-2019 is mainly diarrhea Escherichia coli, and the pathogen type of norovirus is GⅡ genome.

Improving the Pediatric Floor Discharge Process Following Tonsillectomy

OBJECTIVES/HYPOTHESIS

Over 300,000 tonsillectomies are performed nationwide every year. In 2017, half of children undergoing tonsillectomy at our institution were admitted to the pediatric floor, with only 10.4% being discharged before 11 AM on postoperative day 1 (POD1). Our primary objective was to increase the percentage of patients discharged before 11 AM on POD1 to at least 50% within 1 year.

STUDY DESIGN

Prospective observational (quality improvement).

METHODS

A multidisciplinary quality improvement (QI) team was assembled. The primary outcome was "timely discharges," defined as percentage of patients discharged before 11 AM on POD1; secondary outcomes were percentage of patients discharged before 1 PM and mean length of stay (hours). Seven-day readmission rate served as our balancing measure. Prior year data served as baseline. A process map, Ishikawa diagram, and Pareto chart were utilized to identify specific target areas for improvement. Key interventions included announcement of our initiative, an electronic health record-based handoff text prompt, discharge checklist, automated discharge instructions, encouragement to place discharge orders by 9 AM and implementation of early POD1 rounds. Data were collected on a biweekly basis and the primary and secondary outcomes were plotted on control charts and analyzed using rules for special cause variation.

RESULTS

Within 12 months, POD1 discharges before 11 AM and before 1 PM increased to 44.9% and 83.8%, respectively, with sustained improvement for the first 6 months of the subsequent year. Mean length of stay decreased, and 7-day readmission rates were unchanged.

CONCLUSIONS

By understanding the factors influencing timely POD1 discharges after tonsillectomy, key interventions were implemented to achieve an increase in timely discharges.

LEVEL OF EVIDENCE

III Laryngoscope, 2021.

Prevalence of elevated right ventricular pressure in children with obstructive sleep apnea syndrome undergoing pulmonary hypertension screening

STUDY OBJECTIVES

Our objective was to determine the prevalence of elevated right ventricular pressure (RVP) as a surrogate marker for pulmonary hypertension (PH) in children with obstructive sleep apnea syndrome (OSAS) undergoing echocardiography.

METHODS

Retrospective chart review of children age 2-21 years diagnosed with OSAS by an overnight polysomnogram (PSG) who underwent cardiac echocardiogram to screen for PH within 6 months of PSG in a tertiary inner-city pediatric hospital. The primary outcome was elevated RVP defined by estimated RVP ≥ 25 mm Hg above right atrial pressure or ventricular septal configuration consistent with elevated RVP.

RESULTS

A total of 174 children were included. The median (interquartile range [IQR]) age was 8.9 (5.5-13.1) years with 59.2% male, 41.4% Hispanic, and 25.9% non-Hispanic Black. The prevalence of obesity was 72.0% and severe or very severe OSAS was present in 93.1%. The median (IQR) apnea-hypopnea index was 28.3 events/h (18.8-52.7 events/h). Seven children (4.0%) had elevated RVP. There was no association between elevated RVP and age, sex, race, BMI percentile, apnea-hypopnea index (AHI), oxygen nadir, or severe (AHI ≥ 10) OSAS.

CONCLUSIONS

Elevated RVP was rare and was not associated with OSAS severity. The prevalence in this cohort is higher than the prevalence of PH noted in similar studies (0-1.8%), which may be related to differences in methodology or unassessed cohort characteristics. Further effort to determine the optimal role for PH screening in pediatric OSAS is needed.

Implementation of an Online Multimedia Pediatric Tracheostomy Care Module for Healthcare Providers

OBJECTIVES/HYPOTHESIS

To investigate the effect of a multimedia educational module on provider attitudes toward pediatric tracheostomy care. We also describe the process of module development and dissemination at an academic children's hospital.

STUDY DESIGN

Prospective observational study.

METHODS

The pediatric airway committee at an urban tertiary care center developed a multimedia pediatric tracheostomy care module. Nurses, respiratory therapists, as well as resident, fellow, and attending physicians caring for pediatric patients with tracheostomies were eligible. Managers and clinical supervisors from various units recruited participants to complete the pediatric tracheostomy care electronic module and pre- and postassessment knowledge quizzes and surveys. Provider confidence was analyzed using Kruskal-Wallis H-test and Mann-Whitney U-test, and paired t-test was used to compare pre- and postmodule quiz scores.

RESULTS

A total of 422 participants completed the module. A total of 275 participants completed the premodule survey, 385 completed the premodule quiz, 253 completed the postmodule survey, and 233 completed the postmodule quiz. Participants included providers in the neonatal intensive care unit, pediatric intensive care unit, pediatric emergency department, and pediatric wards. Postmodule surveys demonstrated a significant reduction in the average percentage of participants indicating lack of confidence with regards to changing an established tracheostomy, responding to accidental decannulation of established tracheostomy, and responding to accidental decannulation of fresh tracheostomy (P < .001). Average quiz scores increased by 5.6 points from 83.0% to 88.6% (P < .00001).

CONCLUSIONS

A multimedia educational module can improve provider perception of their knowledge and confidence surrounding pediatric tracheostomy management.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1893-1901, 2021.

Systemic Bevacizumab for Treatment of Respiratory Papillomatosis: International Consensus Statement

OBJECTIVES/HYPOTHESIS

The purpose of this study is to develop consensus on key points that would support the use of systemic bevacizumab for the treatment of recurrent respiratory papillomatosis (RRP), and to provide preliminary guidance surrounding the use of this treatment modality.

STUDY DESIGN

Delphi method-based survey series.

METHODS

A multidisciplinary, multi-institutional panel of physicians with experience using systemic bevacizumab for the treatment of RRP was established. The Delphi method was used to identify and obtain consensus on characteristics associated with systemic bevacizumab use across five domains: 1) patient characteristics; 2) disease characteristics; 3) treating center characteristics; 4) prior treatment characteristics; and 5) prior work-up.

RESULTS

The international panel was composed of 70 experts from 12 countries, representing pediatric and adult otolaryngology, hematology/oncology, infectious diseases, pediatric surgery, family medicine, and epidemiology. A total of 189 items were identified, of which consensus was achieved on Patient Characteristics (9), Disease Characteristics (10), Treatment Center Characteristics (22), and Prior Workup Characteristics (18).

CONCLUSION

This consensus statement provides a useful starting point for clinicians and centers hoping to offer systemic bevacizumab for RRP and may serve as a framework to assess the components of practices and centers currently using this therapy. We hope to provide a strategy to offer the treatment and also to provide a springboard for bevacizumab's use in combination with other RRP treatment protocols. Standardized delivery systems may facilitate research efforts and provide dosing regimens to help shape best-practice applications of systemic bevacizumab for patients with early-onset or less-severe disease phenotypes.

LEVEL OF EVIDENCE

5 Laryngoscope, 131:E1941-E1949, 2021.

[Characteristics of HIV-1 genotype and drug resistance among men who have sex with men in Kunming, 2018]

Objective: To understand the characteristics of HIV-1 genotypes and drug resistance among men who have sex with men in Kunming in 2018. Methods: A total of 193 plasma samples were collected from the newly reported HIV-1 infected MSM in Kunming from January to December 2018. Viral RNA was extracted, and the gag, pol, env gene segments were amplified by nested PCR. HIV-1 genotypes and drug resistance were also analyzed. Subsequently, the evolutionary characteristics of CRF55_01B and CRF68_01B among MSM in Kunming were analyzed by Bayesian Markov Chain Monte Carlo method. Results: Multiple HIV-1 genotypes were identified among these 193 samples, including CRF07_BC (39.4%, 76/193), CRF01_AE (34.2%, 66/193), unique recombinant forms (URFs) (20.2%, 39/193), CRF08_BC (3.1%, 6/193), CRF55_01B (1.6%, 3/193), subtype B (1.0%, 2/193) and CRF68_01B (0.5%, 1/193). Results from the Bayesian evolutionary analysis showed that CRF55_01B started to spread locally after being imported from other provinces, while CRF68_01B was likely to have been brought in from the eastern provinces of China. Prevalence of HIV-1 drug resistant strains was 2.6%(5/190) before antiviral treatment, with mutation rates resistant to non-nucleoside reverse transcriptase inhibitors being the highest (2.1%, 4/190) among MSM in Kunming, 2018. Conclusion: The diversity of HIV-1 was increasing among MSM in Kunming. Although the resistance rate on pretreatment drug was relatively low, the emergence of multiple resistant strains to first-line antiviral drugs posed a challenge to antiretroviral therapy, in Kunming.

Bridging bronchus (pseudocarina) and left pulmonary artery sling: A case report and literature review

Congenital airway malformations can present with respiratory distress, cyanosis, and difficulty feeding in the neonate or infant. Clinical presentation may vary from asymptomatic to fatal airway obstruction. They may exist in isolation or in association with vascular rings and slings, bronchopulmonary malformations, and/or syndromes. We present an unusual case of bridging bronchus, complete bronchial rings, and left pulmonary artery sling presenting with recurrent croup, highlighting the importance of bronchoscopy and CT imaging to achieve an accurate diagnosis in patients with recurrent croup and/or respiratory failure not responding to usual treatment measures and a multidisciplinary treatment approach.

In Situ Simulation to Assess Pediatric Tracheostomy Care Safety: A Novel Multicenter Quality Improvement Program

OBJECTIVES

Our objectives were (1) to use in situ simulation to assess the clinical environment and identify latent safety threats (LSTs) related to the management of pediatric tracheostomy patients and (2) to analyze the effects of systems interventions and team factors on LSTs and simulation performance.

METHODS

A multicenter, prospective study to assess LSTs related to pediatric tracheostomy care management was conducted in emergency departments (EDs) and intensive care units (ICUs). LSTs were identified through equipment checklists and in situ simulations via structured debriefs and blinded ratings of team performance. The research team and unit champions developed action plans with interventions to address each LST. Reassessment by equipment checklists and in situ simulations was repeated after 6 to 9 months.

RESULTS

Forty-one LSTs were identified over 21 simulations, 24 in the preintervention group and 17 in the postintervention group. These included LSTs in access to equipment (ie, availability of suction catheters, lack of awareness of the location of tracheostomy tubes) and clinical knowledge gaps. Mean equipment checklist scores improved from 76% to 87%. Twenty-one unique teams (65 participants) participated in the simulations. The average simulation score was 6.19 out of 16 points.

DISCUSSION

In situ simulation is feasible and effective as an assessment tool to identify latent safety threats and thus measure the system-level performance of a clinical care environment.

IMPLICATIONS FOR PRACTICE

In situ simulation can be used to identify and reassess latent safety threats related to pediatric tracheostomy management and thereby support quality improvement and educational initiatives.

The relationship of hypertension with obesity and obstructive sleep apnea in adolescents

OBJECTIVES

To assess the independent relationships of obesity and obstructive sleep apnea (OSA) with hypertension/elevated blood pressure (EBP) in adolescent patients.

STUDY DESIGN

A retrospective cohort analysis was performed on 501 patients (age 13-21 years) with three separate blood pressure measurements within 6 months of polysomnography. EBP was defined as average systolic blood pressure (SBP) ≤120 mm Hg; obesity as body mass index Z-score ≤1.65; and OSA as obstructive apnea-hypopnea index <1. Pearson correlations and multivariable analyses were performed to assess the independent effects of the apnea-hypopnea index and body mass index Z-score on SBP.

RESULTS

Of 501 patients (mean age 16 ± 2 years), 246 (49%) were male. OSA was present in 329 (66%) patients, obesity in 337 (67%), and EBP in 262 (52%). EBP was present in 70% of obese adolescents and 60% of adolescents with OSA. Univariable correlation showed a significant relationship between SBP, body mass index Z-score, and apnea-hypopnea index. Multivariable linear regression analysis showed blood pressure was significantly associated with body mass index Z-score (β = .46; P < .01), age (β = .25; P < .01), and height Z-score (β = .14; P < .01), but not apnea-hypopnea index (β = .01; P = .72).

CONCLUSIONS

The relationship between OSA and EBP in adolescents is most closely associated with the degree of obesity. Further studies are needed to assess the effect of the treatment of obesity and OSA on blood pressure in adolescents.

Resection of the irradiated esophagus: the impact of lymph node yield on survival

There is debate surrounding the appropriate threshold for lymph node harvest during esophagectomy in patients with esophageal cancer, specifically for those receiving preoperative radiation. The purpose of this study was to determine the impact of lymph node yield on survival in patients receiving preoperative chemoradiation for esophageal cancer. The National Cancer Database (NCDB) was utilized to identify patients with esophageal cancer that received preoperative radiation. The cohort was divided into patients undergoing minimal (<9) or extensive (≥9) lymph node yield. Demographic, operative, and postoperative outcomes were compared between the groups. Kaplan-Meier analysis with the log rank test was used to compare survival between the yield groups. Cox proportional hazards model was used to determine the association between lymph node yield and survival. In total, 886 cases were included: 349 (39%) belonging to the minimal node group and 537 (61%) to the extensive group. Unadjusted 5-year survival was similar between the minimal and extensive groups, respectively (37.3% vs. 38.8%; P > 0.05). After adjustment using Cox regression, extensive lymph node yield was associated with survival (hazard ratio 0.80, confidence interval 0.66-0.98, P = 0.03). This study suggests that extensive lymph node yield is advantageous for patients with esophageal cancer undergoing esophagectomy following induction therapy. This most likely reflects improved diagnosis and staging with extensive yield.

Ex utero intrapartum treatment (EXIT) for fetal neck masses: A tertiary center experience and literature review

OBJECTIVE

Currently no established criteria exist to guide use of ex utero intrapartum treatment (EXIT) for fetal neck mass management. This study aims to correlate prenatal radiographic findings with incidence of ex utero intrapartum treatment and necessity of airway intervention at delivery.

METHODS

We reviewed our EXIT experience between 2012 and 17. Furthermore, we performed a literature review of articles reporting incidences of fetal neck masses considered for EXIT. Articles that were included (1) discussed prenatal radiographic findings such as size, features, and evidence of compression and (2) reported extractable data on delivery outcomes and airway status.

RESULTS

Ten cases at our institution were reviewed. Another 137 cases across 81 studies met inclusion criteria. These studies showed aerodigestive tract compression to be significantly associated with neck masses undergoing EXIT. Additionally, there was significantly higher incidence of airway intervention in cases where polyhydramnios, anatomic compression, and solid masses were seen on prenatal diagnostic imaging, while mass location and size did not correlate with airway intervention.

CONCLUSION

With this data, we propose that any neck mass with anatomic compression on fetal imaging in the 3rd trimester should be considered for EXIT. When radiographic findings do not show compression but do display polyhydramnios or a solid neck mass (regardless of polyhydramnios), an airway surgeon should be available for perinatal airway assistance.

[HIV-1 gene subtypes among newly reported HIV/AIDS cases in two border areas of Yunnan province]

Objective: To explore the features of distribution on HIV-1 gene subtypes among newly reported HIV/AIDS cases in the border areas of Yunnan province. Methods: A total of 233 newly reported HIV/AIDS cases aged 18 or more were consecutively included in the border counties of Dehong Dai and Jingpo autonomous prefecture (Dehong prefecture), Honghe Hani and Yi autonomous prefecture (Honghe prefecture) of Yunnan province from November 2015 to October 2016. HIV-1 RNA was extracted with pol and env genes amplified. HIV-1 gene subtypes were determined through phylogenetic analysis. Results: A total of 146 out of 233 specimens were genotyped successfully. HIV-1 was found to have had 8 gene subtypes in Dehong prefecture, with the unique recombinant forms (URFs) as the predominant (52.8%, 57/108) type, including 56.8% (21/37) of the cases with Chinese ethnicity and another 50.7% (36/71) were Myanmar citizens. Four HIV-1 gene subtypes were detected in Honghe prefecture, with CRF01_AE as predominant (71.1%, 27/38), including 81.0% (17/21) Vietnamese and 58.8% (10/17) Chinese. Differences on the distribution of HIV-1 gene subtypes were seen statistically significant between Dehong prefecture and Honghe prefecture (χ(2)=61.072, P<0.001). Conclusions: The distribution of HIV-1 gene subtypes showed big difference in the two border areas of Yunnan province, suggesting that both Chinese or non- Chinese citizens living in the area should be taken good care of, in terms of HIV/AIDS prevention and control.

An Innovative Otolaryngology Resident Boot Camp

This article was migrated. The article was not marked as recommended. Simulation provides the opportunity for residency programs to introduce core skills and principles to residents in a low risk environment. We designed a four-week "boot camp" for junior otolaryngology residents aimed at providing the foundation necessary for effective management of commonly encountered clinical scenarios. Sessions emphasized learning through adult and pediatric simulation exercises, technical skills training and didactics. Feedback on resident performance was provided at the completion of simulation exercises.

Bioinformatic analyses of GRAS genes in Betula kirghisorum based on transcriptome data

The transcriptomes of salt-stressed and unstressed Betula kirghisorum plants were analyzed using high throughput sequencing technology. A total of 52,239,804 and 51,772,998 clean reads were obtained from the two libraries, respectively, and de novo assembled into 60,545 all-unigenes. A total of 39,997 unigenes were annotated using public databases. Overall, 7206 genes were differentially expressed in unigenes and were involved in 127 pathways. Thirteen transcription factor families were identified in B. kirghisorum, including GRAS proteins, which are plant-specific transcription factors. By using bioinformatic methods to predict and analyze physicochemical properties, structural data were obtained on the 19 potential GRAS proteins. The results revealed that these proteins are hydrophilic, with significant differences in their length and molecular weight. The main secondary structures were alpha helices and random coils. BkGRAS proteins possess typical GRAS domains: LHR I; VHIID motif; LHR II; PFYRE motif; and SAW motif. In the majority of BkGRAS proteins, AGG, AGA, UCU, GCU, GGG, CCA, GUU, GUG, AUU, GAU, and AAG codons were used preferentially. Aside from the BkGRAS17 gene (relative synonymous codon usage (RSCU) = 1.20), usage of the UUA codon by other BkGRAS genes was low (RSCU < 1.0). The effective number of codons showed that BkGRAS genes have low codon bias. Subcellular localization analysis that predicted these proteins are found in the nucleus, cytoplasm, or chloroplast. BkGRAS proteins were divided into six subfamilies: SCR, LISCL, SCL3, DELLA, HAM, and PAT1. These results provide important information for the further functional study of GRAS genes in B. kirghisorum.

Dietary methionine requirement of Jing Brown layer hens from 9 to 17 weeks of age

This study was conducted to evaluate the effect of dietary methionine (Met) supplementation in growth performance and reproductive performance of Jing Brown layer hens. A total of 375 9-week-old Jing Brown layer hens were allocated equally to five treatments consisting of 5 replicates with 15 hens. Hens were fed with a diet of corn and soya bean meal supplemented with 0.23%, 0.27%, 0.31%, 0.35% and 0.39% Met respectively. Different Met levels did not significantly affect average daily feed intake (ADFI), average daily gain (ADG) and feed/gain ratio (F/G) (p > 0.05), whereas flock uniformity (FU) and jejunum index were significantly different (p < 0.05), and the largest FU was observed in 0.31% Met. Dietary supplementation of Met significantly affected reproductive system development (p < 0.05), and 0.27-0.31% Met obtained optimal reproductive system development. Different Met levels significantly affected serum uric acid and alkaline phosphatase. Moreover, the relatively higher reproductive hormones in serum were observed in 0.27% Met. Analysis of quadratic curve estimation of flock uniformity, the total number of follicles, the primary follicles and the secondary follicles showed that the optimal Met levels were 0.293%, 0.286%, 0.286% and 0.288%, which could be averaged to 0.288%. These results suggested that the optimal Met requirement for Jing Brown layer hens from 9 to 17 weeks old is 0.29%.

Vestibular pathology in children with enlarged vestibular aqueduct

OBJECTIVES/HYPOTHESIS

To establish the prevalence of abnormal vestibular test findings in children with enlarged vestibular aqueduct (EVA) and determine if these findings correlate with clinical symptoms, radiographic findings (EVA size and laterality), audiometric findings, and genetic testing in these patients.

STUDY DESIGN

Prospective cohort.

METHODS

Patients 3 to 12 years of age with hearing loss and imaging findings consistent with EVA treated at our tertiary care institution were sequentially enrolled from 2009 to 2011. The following six outcome measurements were analyzed: audiometric findings, EVA laterality, temporal bone measurements, genetic testing, vestibular testing (cervical-evoked myogenic potentials, posturography, rotational chair, and calorics), and vestibular symptoms.

RESULTS

Twenty-seven patients with EVA (mean age 9.2 years, 48% female) were enrolled in and completed the study. Vertigo was reported in six patients. Twenty-four of 27 (89%) had at least one abnormal vestibular test result. Midpoint and operculum size correlated with directional preponderance (P = .042 and P = .032, respectively). Also, high-frequency pure tone average (HFPTA) correlated with unilateral weakness (P = .002). Walking at a later age correlated with abnormal posturography results. There was no correlation between EVA laterality and vestibular test findings.

CONCLUSION

We found a high rate of vestibular pathology in children with EVA; however, the prevalence of abnormal vestibular test findings in this patient population was not correlated with vestibular symptoms. Enlarged vestibular aqueduct size, HFPTA, and walking at a later age were correlated with abnormal vestibular test findings. In view of these results, it may be prudent to consider vestibular testing in children with these clinical characteristics.

LEVEL OF EVIDENCE

2b. Laryngoscope, 126:2344-2350, 2016.

Quantitative analysis of gains and catch-up saccades of video-head-impulse testing by age in normal subjects

OBJECTIVES

To evaluate video-head-impulse test (vHIT) results in normal subjects, to determine the normative values of vHIT for the vestibulo-ocular reflex (VOR) and to characterise the catch-up saccades (CSs).

DESIGN

Prospective cohort study.

SETTING

Tertiary care academic referral centre.

PARTICIPANTS

Fifty healthy subjects with no history of vestibular impairment, ten each in their 20's, 30's, 40's, 50's and 60's, underwent vHITs in the lateral semicircular canal plane.

MAIN OUTCOME MEASURES

vHIT gains and the incidence and amplitudes of covert and overt CSs.

RESULTS

The mean vHIT gain was 1.02 ± 0.07, and the mean gain asymmetry was 2.39 ± 1.96%, with no significant differences among age groups. CSs were observed during 22.6% of the trials and in 49% of the ears. The incidence of CSs was not associated with age. The mean velocity of CSs was 55.5 ± 16.9°/s, and its mean interaural difference was 11.8 ± 10.7°/s.

CONCLUSIONS

vHIT gains were consistently equal to 1.0 in all age groups (20's to 60's), suggesting that abnormal criteria for vHIT gain (e.g. 0.8) and gain asymmetry (e.g. 8%) can be used, regardless of age. CSs were observed in about half of normal ears, suggesting that VOR is a hypometric system. The amplitudes and interaural difference of CSs were also similar in all age groups, suggesting that abnormal criteria for CS amplitude (e.g. 100°/s) and interaural difference (e.g. 40°/s) can be used, regardless of age.

Cloning and expression pattern analysis of BkGRAS2 from Betula kirghisorum

GRAS proteins are plant-specific transcription factors that are involved in the regulation of root and shoot growth. Here, we cloned BkGRAS2 from Betula kirghisorum (abbreviated to Bk) and analyzed the physicochemical properties and expression pattern of the encoded protein. BkGRAS2 had an open reading frame of 1614 bp encoding 537 amino acid residues. The deduced BkGRAS2 protein was hydrophilic, and it contained highly conserved VHIID and SAW motifs. BkGRAS1 and BkGRAS2 showed considerable sequence similarities. An expression analysis indicated that BkGRAS2 was expressed in root, stem, and leaf, with the highest level in the leaf. Expression of BkGRAS2 was increased following stress treatment with 0.6% NaHCO3. Transient expression analysis of GFP-BkGRAS2 in onion epidermal cells revealed that the BkGRAS2 protein was localized in the cytoplasm, but could also be detected in the nucleus. Our study provides the basis for future research on the role of the GRAS gene family in B. kirghisorum.

Is the OSA-18 predictive of obstructive sleep apnea: comparison to polysomnography

OBJECTIVES/HYPOTHESIS

To examine the ability of the OSA-18 to predict Obstructive Sleep Apnea (OSA) in a racially diverse population when compared to overnight polysomnography (PSG).

STUDY DESIGN

Cross-sectional retrospective.

METHODS

Children 2 to 12 years of age diagnosed with OSA who were treated at a tertiary care institution between 2008 and 2013 and had complete PSG and OSA-18 data were included. We performed logistic regression with OSA as the dependent variable and the OSA-18 total symptom score (TSS), age, gender, race, asthma, and body mass index (BMI) as independent variables.

RESULTS

Seventy-nine children (32 females) were included (mean age 5.2 ± 2.4 years). The positive predictive value (PPV) was greater than 90 for an obstructive apnea-hypopnea index (oAHI) ≥ 1. The PPV and specificity were higher for white than for nonwhite children; however, sensitivity and negative predictive value (NPV) of OSA-18 TSS were low for mild, moderate, and severe OSA regardless of race. Age, race, and BMI were not significantly associated with oAHI.

CONCLUSIONS

This study, conducted in a racially diverse cohort, examined the ability of the OSA-18 to predict OSA when compared to PSG-the gold standard-and found that sensitivity and NPV were extremely low for both white and nonwhite children. This suggests that the OSA-18 is not sufficiently sensitive to detect OSA nor sufficiently specific to determine the absence of OSA. The OSA-18 should be used as a quality-of-life indicator and is not a reliable substitute for PSG.

LEVEL OF EVIDENCE

4.

Discrimination and characterization of different intensities of goaty flavor in goat milk by means of an electronic nose

An electronic nose based on metal oxide sensors was used to measure goaty flavor in goat milk samples. To study the relationships between electronic nose data, sensory data, and levels of free fatty acids (FFA), multivariate partial least square regression (PLS) was carried out. The electronic nose system evaluation correlated well with sensory evaluation. The coefficients of determination (R(2)) of the PLS models reached 90.0%. The electronic nose, combined with principal component analysis and linear discriminant analysis, can discern among goat milk samples with different goaty flavor intensities. In addition, Fisher discriminant analysis and back-propagation neural network were carried out to evaluate goaty flavor intensity, and the prediction accuracies were 98.2 and 100.0%, respectively. The electronic nose is a potentially useful tool to evaluate goaty flavor intensity in goat milk samples.

Effect of Sea Tangle (Laminaria japonica) and Charcoal Supplementation as Alternatives to Antibiotics on Growth Performance and Meat Quality of Ducks

A total of 150 growing ducks were assigned to five dietary treatments to study the effect of sea tangle and charcoal (STC) supplementation on growth performance and meat characteristics in a completely randomized design. There were six replicates and five ducklings in each replication. The five dietary treatments were control, antibiotic, and 0.1%, 0.5%, and 1% STC supplemented diets. No significant differences were found on ADG, ADFI, and gain:feed among treatments in different weeks. The overall (0 to 3 weeks) ADFI decreased in antibiotic treatment (p<0.05) whereas the gain:feed increased significantly upon 1.0% STC supplementation compared to control (p<0.05). No significant variation was found in meat chemical composition except crude fat content which was high in 1.0% STC dietary group (p<0.05). Meat cholesterol was reduced in 0.1% STC group (p<0.05) compared to other dose levels while serum cholesterol was unaffected. High density lipoprotein (HDL) content was high in 1.0% STC (p<0.05) and low density lipoprotein (LDL) was low in 0.1% and 1.0% STC dietary groups (p = 0.06). No significant effect was found on the thiobarbituric acid reactive substances (TBARS) of fresh meat, whereas the TBARS value of meat preserved for 1 week was reduced significantly in STC dietary groups (p<0.05). The 0.1% STC dietary group showed an increased myristic acid (p = 0.07) content whereas, the content of eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids increased in STC supplementation than antibiotic group (p<0.05). An increased concentration of omega-3 fatty acids and a reduced ratio of n-6/n-3 PUFA ratio was found upon 1.0% STC supplementation compared to antibiotic dietary group (p<0.05). Therefore, 1.0% STC dietary supplementation can be used as alternatives to antibiotics in duck production.

Effects of resveratrol and essential oils on growth performance, immunity, digestibility and fecal microbial shedding in challenged piglets

A study was conducted to evaluate the effects of resveratrol and essential oils from medicinal plants on the growth performance, immunity, digestibility, and fecal microbial shedding of weaned piglets. A total of 48 weaned piglets (8 kg initial weight, 28-d-old) were randomly allotted to four dietary treatments with 3 replications of 4 piglets each. The dietary treatments were NC (negative control; basal diet), PC (positive control; basal diet+0.002% apramycin), T1 (basal diet+0.2% resveratrol), and T2 (basal diet+0.0125% essential oil blend). All piglets were orally challenged with 5 ml culture fluid containing 2.3×10⁸ cfu/ml of Escherichia coli KCTC 2571 and 5.9×10⁸ cfu/ml Salmonella enterica serover Typhimurium. The PC group (p<0.05) showed the highest average daily gain (ADG) and average daily feed intake (ADFI) throughout the experimental period, although feed conversion ratio (FCR) was improved in the T1 group (p>0.05). Serum IgG level was increased in the T1 group, whereas TNF-α levels was reduced in the supplemented groups compared to control (p<0.05). The PC diet improved the dry matter (DM) digestibility, whereas PC and T2 diets improved nitrogen (N) digestibility compared to NC and T1 diets (p<0.05). Fecal Salmonella and E. coli counts were reduced in all treatment groups compared to control (p<0.05). Fecal Lactobacillus spp. count was increased in the T2 group compared to others (p<0.05). Dietary treatments had no significant effect on fecal Bacillus spp. count throughout the entire experimental period. Based on these results, resveratrol showed strong potential as antibiotic alternatives for reversing the adverse effects of weaning stress on growth performance, immunity and microbial environment in E. coli and Salmonella-challenged piglets.

Comparison of single and blend acidifiers as alternative to antibiotics on growth performance, fecal microflora, and humoral immunity in weaned piglets

The banning of the use of antibiotics as feed additive has accelerated investigations of alternative feed additives in animal production. This experiment investigated the effect of pure citric acid or acidifier blend supplementation as substitute for antibiotic growth promoters on growth performance, fecal microbial count, and humoral immunity in weaned piglets challenged with Salmonella enterica serover Typhimurium and Escherichia coli KCTC 2571. A total of 60 newly weaned piglets (crossbred, 28-d-old; average 8 kg initial weight) were randomly assigned to four dietary treatments in a completely randomized design. Dietary treatments included NC (negative control; basal diet), PC (positive control; basal diet+0.002% apramycin), T1 (basal diet+0.5% pure citric acid), and T2 (basal diet+0.4% acidifier blend). All piglets were orally challenged with 5 mL of culture fluid containing 2.3×10⁸ cfu/mL of E. coli KCTC 2571 and 5.9×10⁸ cfu/mL of S. typhimurium at the beginning of the experiment. The PC group showed the highest ADG and ADFI, whereas gain:feed was improved in the PC and T1 group (p<0.05). All dietary treatments showed significant reduction in fecal counts of Salmonella and E. coli, compared to NC (p<0.05), with PC being better than T1 and T2. Significant elevation in fecal Lactobacillus spp. counts was shown by treatments with T1, T2, and PC, whereas Bacillus spp. counts were increased by treatment with T1 and T2 compared to NC and PC diet (p<0.05). Serum IgG concentration was increased by T1 diet (p<0.05), whereas IgM and IgA were not significantly affected by any of the dietary treatments (p>0.05). From these above results, it can be concluded that, as alternatives to antibiotics dietary acidification with pure citric acid or acidifiers blend did not fully ameliorate the negative effects of microbial challenges in respect of growth performance and microbial environment, however improved immunity suggested further research with different dose levels.

Balloon dilation in the management of severe airway stenosis in children and adolescents

BACKGROUND/PURPOSE

Children and adolescents with airway stenosis pose a clinical challenge. Recently, balloon dilation has been described, primarily for the treatment of early, immature, less severe airway stenosis. We describe our experience with 8 children and adolescents managed with balloon dilation, including severe, mature subglottic and tracheal stenosis.

METHODS

This is a case series of 8 children and adolescents with acquired subglottic and tracheal stenosis treated by the primary author with balloon dilation between August 2006 and April 2010 at an academic tertiary care center. In the four patients who were tracheotomy-dependent at the time of presentation, suprastomal stents or Montgomery T-tubes were used. In 1 patient with 99% subglottic stenosis (SGS), balloon dilation and stenting were used to create a lumen prior to laryngotracheal reconstruction (LTR).

RESULTS

All 4 patients with tracheotomy were decannulated. The remaining 4 patients were successfully managed without tracheotomy.

CONCLUSIONS

Mature, severe laryngeal and tracheal stenosis in pediatric patients can be successfully managed with balloon dilation. In the most severe cases with prior tracheotomy, stenting is necessary. Balloon dilation with stenting can also facilitate LTR. In patients without prior tracheotomy, tracheotomy and stenting can often be safely avoided with appropriate postoperative management.

Twist2 contributes to breast cancer progression by promoting an epithelial-mesenchymal transition and cancer stem-like cell self-renewal

The epithelial to mesenchymal transition (EMT) is a highly conserved cellular programme that has an important role in normal embryogenesis and in cancer invasion and metastasis. We report here that Twist2, a tissue-specific basic helix-loop-helix transcription factor, is overexpressed in human breast cancers and lymph node metastases. In mammary epithelial cells and breast cancer cells, ectopic overexpression of Twist2 results in morphological transformation, downregulation of epithelial markers and upregulation of mesenchymal markers. Moreover, Twist2 enhances the cell migration and colony-forming abilities of mammary epithelial cells and breast cancer cells in vitro and promotes tumour growth in vivo. Ectopic expression of Twist2 in mammary epithelial cells and breast cancer cells increases the size and number of their CD44(high)/CD24(low) stem-like cell sub-populations, promotes the expression of stem cell markers and enhances the self-renewal capabilities of stem-like cells. In addition, exogenous expression of Twist2 leads to constitutive activation of STAT3 (signal transducer and activator of transcription 3) and downregulation of E-cadherin. Thus, the overexpression of Twist2 may contribute to breast cancer progression by activating the EMT programme and enhancing the self-renewal of cancer stem-like cells.