Postoperative respiratory complications and disposition in patients with type 1 laryngeal clefts undergoing injection or repair - A single institution experience.

OBJECTIVE: Identify incidence and factors associated with respiratory complications after type 1 cleft repair. METHODS: Retrospective chart review of patients who underwent cleft repair over a 5-year period performed by a single surgeon. Primary endpoint was respiratory complications (oxygen desaturation <90%). Fisher's exact test was used to identify differences between repair types (endoscopic carbon dioxide laser-assisted repair and injection laryngoplasty). Logistic regression was used to identify predictors of respiratory events. RESULTS: Fifty-five patients were included. Thirty-four (62%) patients underwent endoscopic carbon dioxide laser-assisted repair and 21 (38%) underwent injection laryngoplasty. Average hospital stay for each group was 1.6 days (SD = 3.1) and 0.6 days (SD = 0.9), respectively. Desaturations occurred in three patients (9%) in the laser-assisted repair group and one patient (4%) in the injection group. All occurred within 3 h after surgery and resolved with supplemental oxygen, oral airway placement, and/or mask ventilation. Two affected patients had comorbid diagnosis of asthma (one had poor medication compliance), and one had a history of developmental delay and hypotonia. In the injection group, desaturations occurred in one patient with a history of tracheal stenosis and double aortic arch. No correlation existed between repair type and desaturation (p = 0.57). No variables were significant predictors of events. CONCLUSIONS: In this cohort, respiratory events after type 1 laryngeal cleft repair occurred early in the postoperative period, in children with cardiac and pulmonary comorbidities. This suggests postoperative admission may only be necessary for a select group of patients undergoing type 1 cleft repair. However, further research is needed to determine criteria for same-day discharge.

Follow-up and Time to Treatment in an Urban Cohort of Children with Sleep-Disordered Breathing.

Objective To evaluate follow-up and timing of sleep-disordered breathing diagnosis and treatment in urban children referred from primary care. Study Design Retrospective longitudinal cohort analysis. Setting Tertiary health system. Subjects and Methods Pediatric outpatients with sleep-disordered breathing, referred from primary care for subspecialty appointment or polysomnography in 2014, followed for 2 years. Timing of polysomnography or subspecialty appointments, loss to follow-up, and sleep-disordered breathing severity were main outcomes. Chi-square and t-test identified differences in children referred for polysomnography, surgery, and loss to follow-up. Logistic regression identified predictors of loss to follow-up. Days to polysomnography or surgery were evaluated using the Kaplan-Meier estimator, with Cox regression comparing estimates by polysomnography receipt and disease severity. Results Of 216 children, 188 (87%) had public insurance. Half (109 [50%]) were lost to follow-up after primary care referral. More children were lost to follow-up when referred for polysomnography (50 [76%]) compared with subspecialty evaluation (35 [32%]; P < .001). Children referred to both polysomnography and subspecialty were more likely to be lost to follow-up (odds ratio = 2.73, 95% confidence interval = 1.29-5.78; P = .009). For children who obtained polysomnography, an asymmetric distribution of obstructive sleep apnea severity was not observed ( P = .152). Median time to polysomnography and surgery was 75 and 226 days, respectively. Obstructive sleep apnea severity did not influence time to surgery ( P = .410). Conclusion In this urban population, half of the children referred for sleep-disordered breathing evaluation are lost to follow-up from primary care. Obstructive sleep apnea severity did not predict follow-up or timeliness of treatment. These findings suggest social determinants may pose barriers to care in addition to the clinical burden of sleep-disordered breathing.

A Systematic Review of Race/Ethnicity and Parental Treatment Decision-Making.

Patient race/ethnicity affects health care utilization, provider trust, and treatment choice. It is uncertain how these influences affect pediatric care. We performed a systematic review (PubMed, Scopus, Web of Science, PsycINFO, Cochrane, and Embase) for articles examining race/ethnicity and parental treatment decision-making, adhering to PRISMA methodology. A total of 9200 studies were identified, and 17 met inclusion criteria. Studies focused on treatment decisions concerning end-of-life care, human papillomavirus vaccination, urological surgery, medication regimens, and dental care. Findings were not uniform between studies; however, pooled results showed (1) racial/ethnic minorities tended to prefer more aggressive end-of-life care; (2) familial tradition of neonatal circumcision influenced the decision to circumcise; and (3) non-Hispanic Whites were less likely to pursue human papillomavirus vaccination but more likely to complete the vaccine series if initiated. The paucity of studies precluded overarching findings regarding the influence of race/ethnicity on parental treatment decisions. Further investigation may improve family-centered communication, parent engagement, and shared decision-making.

Consulting Dr. Google: Quality of Online Resources About Tympanostomy Tube Placement.

OBJECTIVE: Tympanostomy tube (TT) placement is common in children; however, family-centeredness and utility of online information used for decision making and understanding is unknown. We evaluate the quality of leading Internet resources describing TT placement. STUDY DESIGN: Cross-sectional descriptive design. METHODS: We performed a Google (Menlo Park, CA) search for terms related to TTs. We defined quality using scaled readability measures (Flesch Reading Ease and Flesch-Kincaid Grade-Level), understandability and actionability (Patient Education Materials Assessment Tool), shared decision-making centrality (Center for Medicare and Medicaid Services informed consent guidelines), and clinical practice guideline (CPG) compatibility. Three reviewers coded each measure. Fleiss κ interrater reliability analysis was performed. RESULTS: Ten most frequently encountered websites were analyzed. One of 10 met national health literacy standards (mean 10th-grade level reading, median 9th, range 6-15th). All sites were understandable (mean understandability 81.9%, range 73%-92%). Most had low actionability scores (7 of 10, median 47%, mean 44.6%, range 0-80). Shared decision-making centrality was high (mean 5, range 4-6), but most did not list alternative treatment options. Although CPG compatibility was high (mean 3.4, range 1-4), many websites contained inconsistent recommendations about tube duration, follow-up, and water precautions. There was inter-rater agreement for understandability scoring (κ = 0.20; P = 0.02). CONCLUSION: Internet resources about TT placement vary in quality pertaining to health literacy, principles of shared decision making, and consistency with practice guidelines. With growing emphasis on patient-/family-centered engagement in healthcare decision making, standardization of content and improved usability of educational materials for common surgical procedures in children such as tympanostomy tube placement should be a public health priority. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:496-501, 2018.