Identifying barriers and considerations for cochlear implantation in Amish children.

OBJECTIVE: To determine if barriers to cochlear implantation (CI) exist with respect to Amish children and to describe unique considerations associated with CI and subsequent otologic care in the Amish population. METHODS: Out of all patients who underwent CI at a tertiary care pediatric hospital from 2008 to 2019, Amish children were age-matched to the remainder of the cohort to compare demographics and care-related metrics including etiology of hearing loss, age at time of initial hearing-related appointment and at CI, total number of pre- and post-operative audiologic and otologic appointments, and post-operative complications. Social considerations that may pose barriers to care were collected for descriptive analysis. RESULTS: Since 2008, 232 children underwent CI, of which 8 implants were performed on Amish children. Six (75%) Amish children underwent newborn hearing screening and 3(38%) were found to have syndromic etiology for hearing loss. While Amish patients had a lower number of both audiologic (15 vs 33.5, p<.001) and otologic (4.5 vs 8.5, p=.028) appointments when compared to age-matched controls, median age at the time of implantation for the whole sample was not different between groups (2.5 vs 2.0 years, p=.211). From a social standpoint, limitations in transportation, telephone communication, and ability to recharge processor batteries must be considered in the Amish population. CONCLUSION: Amish children undergoing CI face unique barriers to care including transportation and technologic limitations, leading to overall fewer hearing-related appointments when compared to an age-matched cohort. Understanding societal differences is important to facilitate optimal care for Amish children with hearing loss.

Staying out or Going in? The Interplay between Type 3 and Type 5 Secretion Systems in Adhesion and Invasion of Enterobacterial Pathogens.

Enteric pathogens rely on a variety of toxins, adhesins and other virulence factors to cause infections. Some of the best studied pathogens belong to the Enterobacterales order; these include enteropathogenic and enterohemorrhagic Escherichia coli, Shigella spp., and the enteropathogenic Yersiniae. The pathogenesis of these organisms involves two different secretion systems, a type 3 secretion system (T3SS) and type 5 secretion systems (T5SSs). The T3SS forms a syringe-like structure spanning both bacterial membranes and the host cell plasma membrane that translocates toxic effector proteins into the cytoplasm of the host cell. T5SSs are also known as autotransporters, and they export part of their own polypeptide to the bacterial cell surface where it exerts its function, such as adhesion to host cell receptors. During infection with these enteropathogens, the T3SS and T5SS act in concert to bring about rearrangements of the host cell cytoskeleton, either to invade the cell, confer intracellular motility, evade phagocytosis or produce novel structures to shelter the bacteria. Thus, in these bacteria, not only the T3SS effectors but also T5SS proteins could be considered "cytoskeletoxins" that bring about profound alterations in host cell cytoskeletal dynamics and lead to pathogenic outcomes.

Development and evaluation of a mobile application for case management of small and sick newborns in Bangladesh.

BACKGROUND: In low-income settings, community health workers (CHWs) are frequently the first point of contact for newborns. Mobile technology may aid health workers in classifying illness and providing referral and management guidance for newborn care. This study evaluates the potential for mobile health technology to improve diagnosis and case management of newborns in Bangladesh. METHODS: A mobile application based on Bangladesh's Comprehensive Newborn Care Package national guidelines (mCNCP) was developed to aid CHWs in identifying and managing small and sick infants. After a 2-day training, CHWs assessed newborns at Sylhet Osmani Medical College Hospital and in the Projahnmo research site (Sylhet, Bangladesh) using either mCNCP or a comparable paper form (pCNCP), similar to standard IMCI-formatted paper forms. CHWs were randomized to conduct a block of ~ 6 newborn assessments starting with either mCNCP or pCNCP, then switched to the alternate method. Physicians using mCNCP served as gold standard assessors. CHW performance with mCNCP and pCNCP were compared using chi-squared tests of independence for equality of proportions, and logistic regressions clustered by CHW. RESULTS: Two hundred seven total CHW assessments were completed on 101 enrolled infants. mCNCP assessments were more often fully completed and completed faster than pCNCP assessments (100% vs 23.8%, p < 0.001; 17.5 vs 23.6 min; p < 0.001). mCNCP facilitated calculations of respiratory rate, temperature, and gestational age. CHWs using mCNCP were more likely to identify small newborns (Odds Ratio (OR): 20.8, Confidence Interval (CI): (7.1, 60.8), p < 0.001), and to correctly classify 7 out of 16 newborn conditions evaluated, including severe weight loss (OR: 13.1, CI: (4.6, 37.5), p < 0.001), poor movement (OR: 6.6, CI: (2.3, 19.3), p = 0.001), hypothermia (OR: 14.9, CI: (2.7, 82.2), p = 0.002), and feeding intolerance (OR: 2.1, CI: (1.3, 3.3), p = 0.003). CHWs with mCNCP were more likely to provide counseling as needed on 4 out of 7 case management recommendations evaluated, including kangaroo mother care. CONCLUSIONS: CHWs in rural Bangladesh with limited experience using tablets successfully used a mobile application for neonatal assessment after a two-day training. mCNCP may aid frontline health workers in Bangladesh to improve completion of neonatal assessment, classification of illnesses, and adherence to neonatal management guidelines.

Creating a locally driven research agenda for the ethnic minorities of Eastern Myanmar.

BACKGROUND: Research funding and production is inequitably distributed internationally, with emphasis placed on the priorities of funders and international partners. Research capacity development, along with agenda-setting for research priorities can create agency and self-sufficiency and should be inclusive of all relevant stakeholders. Myanmar is a fragile state, where decades of conflict have created a weakened healthcare system and health research sector. The population of Eastern Myanmar have long had their healthcare needs met by community-based organisations and ethnic health organisations operating within Eastern Myanmar and the adjoining Thai-Myanmar border. Despite a transition to civilian rule, the current context does not allow for a truly participatory health research capacity development and agenda-setting exercise between the health leaders of Eastern Myanmar and the government in Yangon. In this context, and with a desire to enhance the capacity, legitimacy and agency of their organisations, the health leaders of Eastern Myanmar are seeking to develop their own health research capacity and to take control of their own research agenda. METHODS: Approximately 60 participants from 15 organisations attended a 3-day forum with the goals of (1) developing research capacity and interest through a research conference and methods workshop; (2) using a nominal group technique (NGT) to develop a locally driven research agenda; and (3) supporting the development of local research projects through ongoing funding and mentorship. RESULTS: Participants were actively engaged in the workshops and NGT. Participants identified a broad range of health issues as priorities and were able to develop consensus around a list of 15 top priorities for the populations they serve. Despite availability of ongoing support, participants did not pursue the opportunity to engage in their own research projects emerging from this forum. CONCLUSIONS: The NGT was an effective way to achieve engagement and consensus around research priorities between a group of healthcare providers, researchers and policy-makers from a variety of ethnic groups. More active involvement of senior leadership must happen before the energy harnessed at such a forum can be implemented in ongoing research capacity development.

Elderly age as a prognostic marker of 1-year poor outcome for subarachnoid hemorrhage patients through its interaction with admission hydrocephalus.

BACKGROUND: An increasing number of elderly patients are treated for aneurysmal subarachnoid hemorrhage. Given that elderly age is associated with both poor outcome and an increased risk of hydrocephalus, we sought to investigate the interaction between age and hydrocephalus in outcome prediction. METHODS: We enrolled 933 consecutive patients treated for subarachnoid hemorrhage between 2002 and 2010 and followed them for 1 yr after intensive care unit discharge. We first performed stepwise analyses to determine the relationship among neurologic events, elderly age (60 or more yr old), and 1-yr poor outcome (defined as Rankin 4-6). Within the most parsimonious model, we then tested for interaction between admission hydrocephalus and elderly age. Finally, we tested the association between age as a stratified variable and 1-yr poor outcome for each subgroup of patients with neurologic events. RESULTS: 24.1% (n=225) of subarachnoid hemorrhage patients were 60 yr old or more and 19.3% (n=180) had 1-yr poor outcomes. In the most parsimonious model (area under the receiver operating characteristic curve, 0.84; 95% CI: 0.82 to 0.88; P<0.001), elderly age and admission hydrocephalus were two independent predictors for 1-yr outcome (P<0.001 and P=0.004, respectively). Including the significant interaction between age and hydrocephalus (P=0.04) improved the model's outcome prediction (P=0.03), but elderly age was no longer a significant predictor. Finally, stratified age was associated with 1-yr poor outcome for hydrocephalus patients (P=0.007), but not for patients without hydrocephalus (P=0.87). CONCLUSION: In this observational study, elderly age and admission hydrocephalus predicted poor outcome, but elderly age without hydrocephalus did not. An external validation, however, will be needed to generalize this finding.

Family Involvement in the Routine Care of Hospitalized Preterm or Low Birth Weight Infants: A Systematic Review and Meta-analysis.

BACKGROUND AND OBJECTIVES: Preterm and low birth weight (LBW) infants are often separated from parents during hospitalization. Our objective was to assess effects of interventions to increase family involvement in the routine newborn care of preterm or LBW infants compared with standard NICU care on infant and parental outcomes. METHODS: Data sources include Medline, Embase, CINAHL, and World Health Organization Global Index Medicus to August 2021. The study selection included randomized controlled trials (RCTs) of family involvement intervention packages. Data were extracted and pooled with random-effects models. RESULTS: We included 15 RCTs with 5240 participants. All interventions included direct parental bedside care; packages varied with respect to additional components. Family involvement interventions decreased retinopathy of prematurity (odds ratio 0.52, 95% confidence interval [CI]: 0.34, 0.80; 8 RCTs), length of hospital stay (mean difference [MD] -2.91 days; 95% CI: -5.15,-0.82; 11 RCTs), and parental stress and anxiety (Parental Stress Scale: MD -0.29 points, 95% CI: -0.56,-0.01, 2 RCTs; Anxiety State-Trait scale: MD -1.79, 95% CI: -3.11,-0.48; 2 RCTs). Family involvement increased weight gain velocity (MD 2.09 g/day; 95% CI: 1.27, 2.91; 3 RCTs), neurobehavioral exam scores (MD: 1.11; 95% CI: 0.21, 2.01; 2 RCTs) and predominant or exclusive breastmilk intake (odds ratio 1.34; 95% CI: 1.01, 1.65; 3 RCTs). It may decrease rates of bronchopulmonary dysplasia, infection, and intraventricular hemorrhage. There were no effects on mortality or necrotizing enterocolitis. Certainty of evidence ranged from low to moderate. CONCLUSIONS: Family involvement has a beneficial role on several infant and parental outcomes.

Measurement of symphysis fundal height for gestational age estimation in low-to-middle-income countries: A systematic review and meta-analysis.

In low- and middle-income countries (LMIC), measurement of symphysis fundal height (SFH) is often the only available method of estimating gestational age (GA) in pregnancy. This systematic review aims to summarize methods of SFH measurement and assess the accuracy of SFH for the purpose of GA estimation. We searched PubMed, EMBASE, Cochrane, Web of Science, POPLINE, and WHO Global Health Libraries from January 1980 through November 2021. For SFH accuracy, we pooled the variance of the mean difference between GA confirmed by ultrasound versus SFH. Of 1,003 studies identified, 37 studies were included. Nineteen different SFH measurement techniques and 13 SFH-to-GA conversion methods were identified. In pooled analysis of five studies (n = 5838 pregnancies), 71% (95% CI: 66-77%) of pregnancies dated by SFH were within ±14 days of ultrasound confirmed dating. Using the 1 cm SFH = 1wk assumption, SFH underestimated GA compared with ultrasound-confirmed GA (mean bias: -14.0 days) with poor accuracy (95% limits of agreement [LOA]: ±42.8 days; n = 3 studies, 2447 pregnancies). Statistical modeling of three serial SFH measurements performed better, but accuracy was still poor (95% LOA ±33 days; n = 4 studies, 4391 pregnancies). In conclusion, there is wide variation in SFH measurement and SFH-to-GA conversion techniques. SFH is inaccurate for estimating GA and should not be used for GA dating. Increasing access to quality ultrasonography early in pregnancy should be prioritized to improve gestational age assessment in LMIC.

Efficacy of inferior turbinate reduction in pediatric patients: a prospective analysis.

BACKGROUND: Chronic nasal congestion is a common presentation in the pediatric setting. For patients who fail to respond to maximal medical therapy and adenoidectomy, inferior turbinate reduction (ITR) may be a reasonable adjuvant surgical approach. Our objective was to prospectively evaluate nasal congestion symptoms and daily medication use in the year following ITR in children with and without allergic rhinitis (AR). METHODS: Patients younger than 18 years undergoing ITR alone or in combination with nonsinonasal procedures were enrolled. Scores from the Nasal Obstruction Symptom Evaluation (NOSE) survey were collected preoperatively and at 3, 6, and 12 months postoperatively from 96 patients. Number and type of pertinent daily medications utilized were also analyzed using Wilcoxon signed-rank and McNemar's tests. Patients with and without comorbid AR were then compared using Wilcoxon rank-sum tests. RESULTS: Median (range) NOSE sum scores significantly improved from preoperative median of 65 out of 100 points (0-100) to 20 (0-100), (z = 7.12, p < 0.001) at 12 months postoperatively. The median number of daily medications was significantly reduced from 1 (range, 0-4) preoperatively to 0 (range, 0-5) postoperatively (z = 2.38, p = 0.017). Fifty-six (58.3%) patients had AR. AR patients received more medications preoperatively and postoperatively compared with those without AR (z = -2.96, p = 0.003; z = -2.23, p = 0.024). At 12 months, NOSE scores remained significantly greater in patients with AR compared with those without AR (ß = 11.6; 95% confidence interval [CI], 0.676-22.5; p = 0.038). CONCLUSION: Our data highlight the need for a multimodal approach to chronic nasal congestion, particularly in children with AR.

Aerosol and Droplet Risk of Common Otolaryngology Clinic Procedures.

OBJECTIVES: Define aerosol and droplet risks associated with routine otolaryngology clinic procedures during the COVID-19 era. METHODS: Clinical procedures were simulated in cadaveric heads whose oral and nasal cavities were coated with fluorescent tracer (vitamin B2) and breathing was manually simulated through retrograde intubation. A cascade impactor placed adjacent to the nares collected generated particles with aerodynamic diameters ≤14.1 µm. The 3D printed models and syringes were used to simulate middle and external ear suctioning as well as open suctioning, respectively. Provider's personal protective equipment (PPE) and procedural field contamination were also recorded for all trials using vitamin B2 fluorescent tracer. RESULTS: The positive controls of nebulized vitamin B2 produced aerosol particles ≤3.30 µm and endonasal drilling of a 3D model generated particles ≤14.1 µm. As compared with positive controls, aerosols and small droplets with aerodynamic diameter ≤14.1 µm were not detected during rigid nasal endoscopy, flexible fiberoptic laryngoscopy, and rigid nasal suction of cadavers with simulated breathing. There was minimal to no field contamination in all 3 scenarios. Middle and external ear suctioning and open container suctioning did not result in any detectable droplet contamination. The clinic suction unit contained all fluorescent material without surrounding environmental contamination. CONCLUSION: While patients' coughing and sneezing may create a baseline risk for providers, this study demonstrates that nasal endoscopy, flexible laryngoscopy, and suctioning inherently do not pose an additional risk in terms of aerosol and small droplet generation. An overarching generalization cannot be made about endoscopy or suctioning being an aerosol generating procedure. LEVEL OF EVIDENCE: 3.

Novel Use of Vitamin B2 as a Fluorescent Tracer in Aerosol and Droplet Contamination Models in Otolaryngology.

OBJECTIVE: During the COVID-19 era, a reliable method for tracing aerosols and droplets generated during otolaryngology procedures is needed to accurately assess contamination risk and to develop mitigation measures. Prior studies have not investigated the reliability of different fluorescent tracers for the purpose of studying aerosols and small droplets. Objectives include (1) comparing vitamin B2, fluorescein, and a commercial fluorescent green dye in terms of particle dispersion pattern, suspension into aerosols and small droplets, and fluorescence in aerosolized form and (2) determining the utility of vitamin B2 as a fluorescent tracer coating the aerodigestive tract mucosa in otolaryngology contamination models. METHODS: Vitamin B2, fluorescein, and a commercial fluorescent dye were aerosolized using a nebulizer and passed through the nasal cavity from the trachea in a retrograde-intubated cadaveric head. In another scenario, vitamin B2 was irrigated to coat the nasal cavity and nasopharyngeal mucosa of a cadaveric head for assessment of aerosol and droplet generation from endonasal drilling. A cascade impactor was used to collect aerosols and small droplets ≤14.1 µm based on average aerodynamic diameter, and the collection chambers were visualized under UV light. RESULTS: When vitamin B2 was nebulized, aerosols ≤5.4 µm were generated and the collected particles were fluorescent. When fluorescein and the commercial water tracer dye were nebulized, aerosols ≤8.61 µm and ≤2.08 µm respectively were generated, but the collected aerosols did not appear visibly fluorescent. Endonasal drilling in the nasopharynx coated with vitamin B2 irrigation yielded aerosols ≤3.30 µm that were fluorescent under UV light. CONCLUSION: Vitamin B2's reliability as a fluorescent tracer when suspended in aerosols and small droplets ≤14.1 µm and known mucosal safety profile make it an ideal compound compared to fluorescein and commercial water-based fluorescent dyes for use as a safe fluorescent tracer in healthcare contamination models especially with human subjects.

Can Ophthalmologic Examination Predict Abducens Nerve Recovery After Endoscopic Skull Base Surgery?

OBJECTIVES: While abducens nerve palsy (ANP) is a known risk in the setting of some endoscopic endonasal skull base surgery (ESBS), frequency and prognosis of post-operative palsy remain unknown. Our goals were to determine the frequency and prognosis of ANP after high-risk ESBS, and identify factors associated with recovery. METHODS: Retrospective case series of all patients with pathology at highest risk for abducens nerve injury (pituitary adenoma, chordoma, meningioma, chondrosarcoma, cholesterol granuloma) generated a list of patients with abducens nerve palsy after ESBS performed from 2011-2016. A validated ophthalmologic clinical grading scale measuring lateral rectus duction from 0 to -5 (full motion to inability to reach midline) was measured at multiple time points to assess recovery of ANP. RESULTS: Of 655 patients who underwent ESBS with increased risk of abducens injury, 40 (6.1%) post-operative palsies were identified and 39 patients with dedicated examination at multiple time points were included in subsequent analysis. Complete resolution was noted in 25 patients (64%) within 12 months. While 19 of 23 (83%) with a partial palsy had complete resolution, only six of 16 (38%) with a complete palsy resolved entirely (P = .005; Fisher's exact test). All six patients with delayed onset of palsy resolved (P = .070; Fisher's exact test). Meningioma and chordoma had higher rates of both temporary and permanent post-operative ANP (P < .0001; Fisher's exact). CONCLUSIONS: The frequency of post-operative ANP following ESBS is low, even in high-risk tumors. While only a minority of complete abducens nerve palsies recover, patients with partial or delayed palsy post-operatively are likely to recover function without intervention. LEVEL OF EVIDENCE: IV Laryngoscope, 131:513-517, 2021.

Implantable Neurostimulation for Treatment of Sleep Apnea: Present and Future.

Hypoglossal nerve stimulation (HNS) therapy represents a novel approach and a paradigm shift in the evolution of obstructive sleep apnea (OSA) treatment as a hybrid surgically implanted, medically titratable device. Unlike traditional sleep apnea surgical procedures, HNS augments the neuromuscular activity of the pharynx, preserves upper airway structure and function, and has the potential to provide multilevel upper airway improvement with one procedure. The early success of HNS sets the stage for new technology development, further investigation into optimal patient selection and therapy titration, and application to other subsets of the OSA population.

Tympanostomy Tube Innovation: Advances in Device Material, Design, and Office-Based Technology.

OBJECTIVES: With tympanostomy tube insertion remaining the most common procedure performed in children to date, growing interests in minimizing both procedural costs and anesthetic exposure in the pediatric population have inspired innovation with respect to tympanostomy tubes. As such, we aim to discuss the current state of tympanostomy tube innovation including insertion devices, tube material, and design. METHODS: Computerized literature review. RESULTS: (1) Numerous single-use devices consisting of a myringotomy knife and preloaded tympanostomy tube offer potential advantages of decreasing or eliminating operating room time and may be performed under moderate instead of a general anesthetic. (2) Innovation with respect to tympanostomy tube material and design may offer enhanced ototopical drug delivery, decreased rates of tube occlusion, and/or the ability to dissolve "on-command" with application of a novel ototopical material. (3) These technologies currently remain in various phases of preclinical and clinical testing. CONCLUSIONS: While clinical testing for a number of new technologies is preliminary and ongoing, tympanostomy tube-related innovations hold exciting promise to supplement or potentially replace the present-day armamentarium of tympanostomy tube design and insertion moving forward.

Natural history matters: Plastics in estuarine fish and sediments at the mouth of an urban watershed.

The extent to which small plastics and potentially associated compounds are entering coastal food webs, especially in estuarine systems, is only beginning to be realized. This study examined an estuarine reach at the mouth of urbanized Chollas Creek in San Diego, California to determine: 1) the extent and magnitude of microplastics pollution in estuarine sediments and fish, 2) the extent and magnitude of SVOC contamination in estuarine fish, and 3) whether fish preferentially ingested certain types of microplastics, when compared with the microplastic composition of creekbed sediments. Surface sediments (0-5 cm depth) contained about 10,000 small plastic pieces per m2, consisting mostly (90%) of fibers, and hard and soft pieces. Nearly 25% of fish contained small plastics, but prevalence varied with size and between species. Of the 25 types of small plastics found in sediment, fish preferred about 10 types (distinct colors and forms). Several SVOCs, both water soluble and sediment-associated compounds, were found in the two species of fish tested. This study revealed that a species' natural history may influence contamination levels, and warrants further study to better understand the pathways of plastics and associated contaminants into and throughout coastal food webs, and the potential health risks for small and/or low-trophic level organisms.

Diagnostic accuracy of neonatal foot length to identify preterm and low birthweight infants: a systematic review and meta-analysis.

INTRODUCTION: Eighty percent of neonatal deaths occur among babies born preterm and/or small for gestational age (SGA). In sub-Saharan Africa and South Asia, approximately 40% of births occur outside of health facilities, and gestational age (GA) and birth weight are commonly unknown. Foot length (FL) has been proposed as a simple, surrogate measurement to identify and triage small babies born in the community. We conducted a systematic review and meta-analysis of the diagnostic accuracy of newborn FL to classify preterm and low birthweight infants. METHODS: PubMed, EMBASE, Cochrane, Web of Science, POPLINE and WHO Global Health Library databases were searched. Studies of live-born infants that compared FL with GA and/or birth weight were included. Data on diagnostic accuracy were summarised, described, and pooled, as appropriate. RESULTS: Six hundred and two studies were identified and 41 included. Techniques for measuring FL included use of a firm plastic ruler, callipers, footprint or a measuring board. Twelve studies assessed the diagnostic accuracy of FL to identify preterm births; however, data were not pooled given heterogeneity and low quality of GA. 19 studies used FL to identify low birthweight infants (<2500 g, <2000 g). Among studies in Asia (n=3), FL <7.7 cm had pooled sensitivity and specificity of 87.6% (95% CI 61.1% to 99.0%) and 70.9% (95% CI 23.5% to 95.1%), respectively, to identify <2500 g infants. FL <7.3 cm had 82.1% (95% CI 63.7% to 92.2%) sensitivity and 82.1% (95% CI 59.2% to 90.8%) specificity for identifying <2000 g infants (n=3). In the African studies (n=3), FL <7.9 cm had pooled sensitivity and specificity of 92.0% (95% CI 85.6% to 95.7%) and 71.9% (95% CI 44.5% to 89.1%), respectively, to identify <2500 g neonates. CONCLUSIONS: FL is a simple proxy measure that can identify babies of low birthweight with high sensitivity, though somewhat lower specificity. Additional research is needed to determine the validity of FL to identify preterm infants, and understand the programmatic impact of screening on healthcare seeking and outcomes. PROSPERO REGISTRATION NUMBER: CRD42015020499.

Prediction of gestational age with symphysis-fundal height and estimated uterine volume in a pregnancy cohort in Sylhet, Bangladesh.

OBJECTIVE: To improve the accuracy of the prediction of gestational age (GA) before birth with the standardised measurement of symphysis-fundal height (SFH), estimation of uterine volume, and statistical modelling including maternal anthropometrics and other factors. DESIGN: Prospective pregnancy cohort study. SETTING: Rural communities in Sylhet, Bangladesh. PARTICIPANTS: 1516 women with singleton pregnancies with early pregnancy ultrasound dating (<20 weeks); 1486 completed follow-up. METHODS: SFH and abdominal girth were measured at subsequent antenatal care (ANC) visits by community health workers at 24 to 28, 32 to 36, and/or >37 weeks gestation. An estimated uterine volume (EUV) was calculated from these measures. Data on pregnancy characteristics and other maternal anthropometrics were also collected. PRIMARY OUTCOME MEASURE: GA at subsequent ANC visits, as defined by early ultrasound dating. RESULTS: 1486 (98%) women had at least one subsequent ANC visit, 1102 (74%) women had two subsequent ANC visits, and 748 (50%) had three visits. Using the common clinical practice of approximating the GA (in weeks) with the SFH measurement (cm), SFH systematically underestimated GA in late pregnancy (mean difference -4.4 weeks, 95% limits of agreement -12.5 to 3.7). For the classification of GA <28 weeks, SFH <26 cm had 85% sensitivity and 81% specificity; and for GA <34 weeks, SFH <29 cm had 83% sensitivity and 71% specificity. EUV had similar diagnostic accuracy. Despite rigorous statistical modelling of SFH, accounting for repeated longitudinal measurements and additional predictors, the best model without including a known last menstrual period predicted 95% of pregnancy dates within ±7.4 weeks of early ultrasound dating. CONCLUSIONS: We were unable to predict GA with a high degree of accuracy before birth using maternal anthropometric measures and other available maternal characteristics. Efforts to improve GA dating in low- and middle-income countries before birth should focus on increasing coverage and training of ultrasonography. TRIAL REGISTRATION NUMBER: NCT01572532.

Button battery versus stacked coin ingestion: A conundrum for radiographic diagnosis.

OBJECTIVES: Given the potential for devastating complications associated with esophageal impaction of a button battery, there is a need to distinguish between a button battery and look-alike stacked coins at the time of presentation. Given there have been no studies analyzing differences in radiographic density between these two entities, the study objective was to determine if a difference exists between esophageal coin and button battery radiographic density on plain radiograph and to describe the operative and treatment course following these two distinct entities of ingestion. METHODS: Retrospective case series following button battery or stacked coin ingestion in a tertiary care pediatric hospital from 2003 to present. Radiographic density of each button battery and stacked coin was calculated by dividing the foreign body radiographic density by the mean density of two background radiographic sections. Radiographic density of coins versus batteries was compared using t-tests. RESULTS: There were 22 patients identified with button battery ingestion and 47 with stacked coins. Median (range) radiographic density of button batteries on anteroposterior view was 1.16 (0.37-2.19) x background compared to 1.13 (0.09-2.65) x background of stacked coins, p = 0.198. There was similarly no statistically significant difference in lateral views, p = 0.622. CONCLUSION: Our study suggests that radiographic density measured on diagnostic x-ray does not prove a reliable adjunctive measure to distinguish an innocuous stacked coin ingestion from the far more ominous button battery and highlights the need for prompt operative evaluation for any suspected button battery ingestion.

Opioid prescription and postoperative outcomes in pediatric patients.

OBJECTIVES/HYPOTHESIS: To determine if the amount of opioid prescribed and postoperative outcomes after adenotonsillectomy changed following implementation of mandated opioid consent forms. STUDY DESIGN: Retrospective cohort study. METHODS: Patients undergoing adenotonsillectomy 6 months before and after implementation of mandated opioid consent forms at a tertiary-care pediatric hospital were studied. Demographics, operative data, weight-based opioid dosage, and postoperative outcome measures, including nursing calls, emergency department (ED) visits, hospital readmission, and bleed rates, were collected and analyzed. RESULTS: Of 300 patients, opioid prescription was provided for 211 patients (70.3%), 112 preconsent (74.7%) and 99 postconsent (66.0%). Mean (standard deviation) total opioid prescribed (milligrams/kilogram) was significantly higher preconsent 4.8 (5.6) than postconsent 3.2 (4.7), (P = .003). There were no differences between number of nursing calls (P = .134) or ED visits (P = .083). Interestingly, preconsent patients had more hospital readmission for pain/dehydration (odds ratio OR: 368, P = .016) and bleeding concerns (OR: 244, P = .003). CONCLUSIONS: A mandated consent form prior to opioid prescription was associated with decreased overall opioid prescription without resultant increase in postoperative complications in pediatric patients. These data provide support for minimizing opioid prescription on a systems-based level. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1477-1481, 2019.

A Novel Icterometer for Hyperbilirubinemia Screening in Low-Resource Settings.

BACKGROUND: Severe neonatal hyperbilirubinemia (>20 mg/dL) affects ∼1 million infants annually. Improved jaundice screening in low-income countries is needed to prevent bilirubin encephalopathy and mortality. METHODS: The Bili-ruler is an icterometer for the assessment of neonatal jaundice that was designed by using advanced digital color processing. A total of 790 newborns were enrolled in a validation study at Brigham and Women's Hospital (Boston) and Sylhet Osmani Medical College Hospital (Sylhet, Bangladesh). Independent Bili-ruler measurements were made and compared with reference standard transcutaneous bilirubin (TcB) and total serum bilirubin (TSB) concentrations. RESULTS: Bili-ruler scores on the nose were correlated with TcB and TSB levels (r = 0.76 and 0.78, respectively). The Bili-ruler distinguished different clinical thresholds of hyperbilirubinemia, defined by TcB, with high sensitivity and specificity (score ≥3.5: 90.1% [95% confidence interval (CI): 84.8%-95.4%] and 85.9% [95% CI: 83.2%-88.6%], respectively, for TcB ≥13 mg/dL). The Bili-ruler also performed reasonably well compared to TSB (score ≥3.5: sensitivity 84.5% [95% CI: 79.1%-90.3%] and specificity 83.2% [95% CI: 76.1%-90.3%] for TSB ≥11 mg/dL). Areas under the receiver operating characteristic curve for identifying TcB ≥11, ≥13, and ≥15 were 0.92, 0.93, and 0.94, respectively, and 0.90, 0.87, and 0.86 for identifying TSB ≥11, ≥13, and ≥15. Interrater reliability was high; 97% of scores by independent readers fell within 1 score of one another (N = 88). CONCLUSIONS: The Bili-ruler is a low-cost, noninvasive tool with high diagnostic accuracy for neonatal jaundice screening. This device may be used to improve referrals from community or peripheral health centers to higher-level facilities with capacity for bilirubin testing and/or phototherapy.

Reducing rates of operative intervention for pediatric post-tonsillectomy hemorrhage.

OBJECTIVES/HYPOTHESIS: The aims of this study were to determine the frequency of rebleeding in patients admitted for observation after presentation for nonactive hemorrhage in the post-tonsillectomy period, compare rebleeding rates between patients managed with observation versus initial operative control, and describe the complication profile associated with observation as a management strategy for post-tonsillectomy bleeding. STUDY DESIGN: Case series with retrospective review of patients. METHODS: Patients presenting from September 1, 2013 to August 31, 2015 for post-tonsillectomy hemorrhage to a tertiary pediatric care center were evaluated for inclusion in the study. Inclusion criteria included patients ≤18 years of age without active bleeding at the time of the initial examination. Proportions were compared using χ2 and Fisher exact tests, whereas continuous data were compared using the Wilcoxon rank sum test. RESULTS: Of 3,866 tonsillectomy patients, 285 (7.4%) presented with concern for oropharyngeal bleeding in the postoperative period, of whom 224 were admitted for nonactive bleeding. Of patients with nonactive bleeding, 203 (90.6%) were managed with observation and 21 (9.4%) with operative intervention. Rate of rebleeding was 26/203 (12.8%) after inpatient observation and 3/21 (14.3%) after operative intervention (P = 1.000). Frequency of rebleeding requiring operative control in patients undergoing initial observation was 14/203 (6.9%). CONCLUSIONS: In our pilot study, rates of rebleeding in patients observed for nonactive post-tonsillectomy hemorrhage was not statistically different than those managed with initial operative exploration. Although preliminary in nature, our data suggest observation may have comparable safety and efficacy when compared to operative management for pediatric patients presenting with nonactive post-tonsillectomy bleeding. Further data collection to establish an optimal management algorithm is ongoing. LEVEL OF EVIDENCE: 4 Laryngoscope, 1958-1962, 2018.