Evaluation of Pain in the Pediatric Emergency Department and the Request of Analgesia.

OBJECTIVES: To determine the acute pain level associated with request for analgesia by children and their parents in the pediatric emergency department (ED) when pain was assessed by verbal numeric scale (VNS), visual analog scale (VAS), and verbal rating scale (VRS). METHODS: A secondary analysis of a prospective cohort study using a sample of children aged 8 to 17 presenting to the ED with acute pain. Patients and their parents were asked to quantify the child's pain on the VNS, VAS, and VRS. Scores for patients and parents who answered "yes" to the request of analgesia were compared with those responding "no." RESULTS: A total of 202 patients aged 12.2 ± 2.6 years were enrolled. The median levels of pain associated with a request of analgesia and no request for analgesia by the patient were: 6.0 (4.0-7.4) and 5.0 (3.0-6.0) (Δ 1.0; 95% confidence interval [CI], 0.5-2.0) for the VNS; 5.7 (3.9-7.2) and 4.3 (2.6-5.8) (Δ 1.3; 95% CI, 0.6-1.9) for the VAS; and 2.0 (2.0-2.0) and 2.0 (1.0-2.0) (Δ 0.0; 95% CI, 0.0-0.0) for the VRS. CONCLUSIONS: Children who requested analgesia had higher pain scores on the VNS and the VAS, than those who did not request analgesia. No difference was demonstrated with the VRS. The pain scores between the analgesia request categories could overlap. This suggests that children seen in the ED should be asked if they want analgesia to decrease their acute pain.

Transcript decay mediated by RNase III in Borrelia burgdorferi.

The causative agent of Lyme disease, Borrelia burgdorferi, requires shifts in gene expression to undergo its natural enzootic cycle between tick and vertebrate hosts. mRNA decay mechanisms play significant roles in governing gene expression in other bacteria, but are not yet characterized in B. burgdorferi. RNase III is an important enzyme in processing ribosomal RNA, but it also plays a role in mRNA decay in many bacteria. We compared RNA decay profiles and steady-state abundances of transcripts in wild-type Borrelia burgdorferi strain B31 and in an RNase III null (rnc-) mutant. Transcripts encoding RNA polymerase subunits (rpoA and rpoS), ribosomal proteins (rpsD, rpsK, rpsM, rplQ, and rpsO), a nuclease (pnp), a flagellar protein (flaB), and a translational regulator (bpuR) decayed more rapidly in the wild-type strain than in the slow growing rnc- mutant indicating that RNA turnover is mediated by RNase III in the bacterium that causes Lyme disease. Additionally, in wild type bacteria, RNA decay rates of rpoS, rpoN, ospA, ospC, bpuR and dbpA transcripts are only modestly affected by changes in the osmolarity.

Phonomicrosurgery simulation: A low-cost teaching model using easily accessible materials.

OBJECTIVES/HYPOTHESIS: To introduce the use of a new phonomicrosurgical trainer using easily accessible materials, and to establish the effectiveness of the model. STUDY DESIGN: The model uses a grape imbedded in gelatin, a microscope, and microlaryngeal instruments. The study was designed to test baseline differences in training levels, as well as improvement in performance after training with the simulation model. METHODS: Thirty subjects enrolled in the Stanford University School of Medicine otolaryngology training program performed microlaryngeal surgery tasks on a grape. Tasks were designed to model both excision of a vocal fold lesion and vocal fold injection. Anonymized video recordings comparing presimulation and postsimulation training were collected and graded by an expert laryngologist. Both objective comparison of skills and subjective participant surveys were analyzed. RESULTS: Objectively, trainees in all groups made statistically significant improvements across all tested variables, including microscope positioning, creation of a linear incision, elevation of epithelial flaps, excision of a crescent of tissue, vocal fold injection, preservation of remaining tissue, and time to complete all tasks. Subjectively, 100% of participants felt that they had increased comfort with microlaryngeal instruments and decreased intimidation of microlaryngeal surgery after completing the simulation training. This appreciation of skills was most notable and statistically significant in the intern trainees. CONCLUSION: Microlaryngeal surgical simulation is a tool that can be used to train residents to prepare them for phonomicrosurgical procedures at all levels of training. Our low-cost model with accessible materials can be easily duplicated and used to introduce trainees to microlaryngeal surgery or improve skills of more senior trainees. LEVEL OF EVIDENCE: NA Laryngoscope, 126:2528-2533, 2016.

Endoscopic suture retriever for endolaryngeal keel placement in treatment of anterior glottic webs.

INTRODUCTION: Endoscopic placement of a laryngeal keel has traditionally required the use of a Lichtenberger endo-extralaryngeal needle passer, which is not universally available. We discuss a safe and technically simple alternate technique using an endoscopic suture retriever through a percutaneously placed angiocatheter that obviates the need for the Lichtenberger instrument. STUDY DESIGN: Case series. MATERIALS AND METHODS: Two 14-gauge angiocatheters were passed through the anterior neck under telescopic visualization of the larynx. The suture retriever was inserted through the catheter and deployed within the larynx to withdraw a Prolene suture that was threaded through a Silastic keel. The keel was then tied in position over a sterile button on the anterior neck. RESULTS: This procedure was performed on 2 patients with excellent outcomes in both cases. CONCLUSION: Endoscopic keel placement is a widely used procedure for treating anterior glottic webs and requires suture passage from within the larynx to the anterior neck to secure the keel into position. This is the first report of an exo-endolaryngeal suture retriever for placement of a laryngeal keel. This technique provides a safe, reliable, and efficient alternative to endo-extralaryngeal needle puncture and uses materials that are available in many operating room settings.

Effects of implant stiffness, shape, and medialization depth on the acoustic outcomes of medialization laryngoplasty.

OBJECTIVE: Medialization laryngoplasty is commonly used to treat glottic insufficiency. In this study, we investigated the effects of implant stiffness (Young modulus), medialization depth, and implant medial surface shape on acoustic outcomes. STUDY DESIGN: Basic science study using ex vivo laryngeal phonation model. METHODS: In an ex vivo human larynx phonation model, bilateral medialization laryngoplasties were performed with implants of varying stiffness, medial surface shape (rectangular, divergent, and convergent), and varying depths of medialization. The subglottal pressure, the flow rate, and the outside sound were measured as the implant parameters were varied. RESULTS: Medialization through the use of implants generally improved the harmonic-to-noise ratio (HNR) and the number of harmonics excited in the outside sound spectra. The degree of acoustic improvement depended on the implant insertion depth, stiffness, and to a lesser degree implant shape. Varying implant insertion depth led to large variations in phonation for stiff implants, but had much smaller effects for soft implants. CONCLUSIONS: Implants with stiffness comparable to vocal folds provided more consistent improvement in acoustic outcomes across different implant conditions. Further investigations are required to better understand the underlying mechanisms.

Office-based tracheoesophageal puncture: updates in techniques and outcomes.

PURPOSE: Tracheoesophageal puncture (TEP) is an effective rehabilitation method for postlaryngectomy speech and has already been described as a procedure that is safely performed in the office. We review our long-term experience with office-based TEP over the past 7 years in the largest cohort published to date. MATERIALS AND METHODS: A retrospective chart review was performed of all patients who underwent TEP by a single surgeon from 2005 through 2012, including office-based and operating room procedures. Indications for the chosen technique (office versus operating room) and surgical outcomes were evaluated. RESULTS: Fifty-nine patients underwent 72 TEP procedures, with 55 performed in the outpatient setting and 17 performed in the operating room, all without complication. The indications for performing TEPs in the operating room included 2 primary TEPs, 14 due to concomitant procedures requiring general anesthesia, and 1 due to failed attempt at office-based TEP. Nineteen patients with prior rotational or free flap reconstruction successfully underwent office-based TEP. CONCLUSIONS: TEP in an office-based setting with immediate voice prosthesis placement continues to be a safe method of voice rehabilitation for postlaryngectomy patients, including those who have previously undergone free flap or rotational flap reconstruction. Office-based TEP is now our primary approach for postlaryngectomy voice rehabilitation.

Indications and outcomes of endoscopic CO2 laser cricopharyngeal myotomy.

OBJECTIVES/HYPOTHESIS: To describe indications, management, and outcomes of endoscopic CO2 laser cricopharyngeal myotomy (CPM). STUDY DESIGN: Case series with chart review. METHODS: All patients treated with endoscopic CO2 laser CPM over a 6-year period were identified. A retrospective chart review was performed for surgical indication, history and physical examinations, and swallow evaluations. Swallowing outcomes were assessed using the Functional Outcome Swallowing Scale (FOSS); findings were compared across groups. RESULTS: Eighty-seven patients underwent endoscopic CO2 laser CPM during the study period for cricopharyngeal dysfunction. Indications included Zenker's diverticulum (ZD) (39), DiGeorge syndrome (two), stroke (five), nerve injury (two), radiation for head and neck cancer (15), idiopathic (16), hyperfunctional tracheoesophageal speech (five) and dysphagia from cricopharyngeus stricture after laryngectomy (three). Mean, median, and mode time to feeding postoperatively were 1.4, 1, and 0 days respectively. Mean, median, and mode hospital stays were 1.8, 1, and 1 day respectively. Overall, FOSS scores improved from 2.6 to 1.6 (P < .001). Improvement was greatest for patients with ZD (2.4 to 1.0) and cricopharyngeal dysfunction from nerve injury (3.3 to 1.8) and least for those with prior radiation (3.9 to 3.2). All patients undergoing CPM for poor tracheoesophageal speech regained speech postoperatively. No patients developed mediastinitis, abscess, or fistula. CONCLUSIONS: Endoscopic CO2 laser CPM is a safe treatment for cricopharyngeal dysfunction of various causes, though swallowing outcomes may vary depending on the surgical indication. Early feeding postoperatively after CPM is safe and facilitates early hospital discharge. LEVEL OF EVIDENCE: 4.

Measurements of mRNA degradation in Borrelia burgdorferi.

The importance of gene regulation in the enzootic cycle of Borrelia burgdorferi, the spirochete that causes Lyme disease, is well established. B. burgdorferi regulates gene expression in response to changes in environmental stimuli associated with changing hosts. In this study, we monitored mRNA decay in B. burgdorferi following transcriptional arrest with actinomycin D. The time-dependent decay of transcripts encoding RNA polymerase subunits (rpoA and rpoS), ribosomal proteins (rpsD, rpsK, rpsM, rplQ, and rpsO), a nuclease (pnp), outer surface lipoproteins (ospA and ospC), and a flagellar protein (flaB) have different profiles and indicate half-lives ranging from approximately 1 min to more than 45 min in cells cultured at 35°C. Our results provide a first step in characterizing mRNA decay in B. burgdorferi and in investigating its role in gene expression and regulation.

Effects of asymmetric superior laryngeal nerve stimulation on glottic posture, acoustics, vibration.

OBJECTIVES/HYPOTHESIS: Evaluate the effects of asymmetric superior laryngeal nerve stimulation on the vibratory phase, laryngeal posture, and acoustics. STUDY DESIGN: Basic science study using an in vivo canine model. METHODS: The superior laryngeal nerves were symmetrically and asymmetrically stimulated over eight activation levels to mimic laryngeal asymmetries representing various levels of superior laryngeal nerve paresis and paralysis conditions. Glottal posture change, vocal fold speed, and vibration of these 64 distinct laryngeal-activation conditions were evaluated by high speed video and concurrent acoustic and aerodynamic recordings. Assessments were made at phonation onset. RESULTS: Vibratory phase was symmetric in all symmetric activation conditions, but consistent phase asymmetry toward the vocal fold with higher superior laryngeal-nerve activation was observed. Superior laryngeal nerve paresis and paralysis conditions had reduced vocal fold strain and fundamental frequency. Superior laryngeal nerve activation increased vocal fold closure speed, but this effect was more pronounced for the ipsilateral vocal fold. Increasing asymmetry led to aperiodic and chaotic vibration. CONCLUSIONS: This study directly links vocal-fold tension asymmetry with vibratory phase asymmetry, in particular the side with greater tension leads in the opening phase. The clinical observations of vocal fold lag, reduced vocal range, and aperiodic voice in superior laryngeal paresis and paralysis is also supported.

Dysphagia characteristics in Zenker's diverticulum.

OBJECTIVES: To evaluate dysphagia characteristics in patients with Zenker's diverticulum (ZD). STUDY DESIGN: Case series with chart review. SETTING: Outpatient tertiary care dysphagia clinic. SUBJECTS AND METHODS: All ZD cases surgically treated over a 6-year period were identified and reviewed for dysphagia history and dysphagia characteristics on initial presentation using fiber-optic endoscopic evaluation of swallowing (FEES). Dysphagia symptoms and swallowing abnormalities were compared across groups based on diverticulum size (small <1 cm, medium 1-3 cm, and large >3 cm). RESULTS: Forty-six patients underwent a total of 52 procedures during the study period. ZD size was available in 49 cases (6 small, 26 medium, 17 large). Regurgitation symptoms were less frequent in patients with small (17%) compared with medium (68%) or large diverticula (76%; P = .03). Postswallow hypopharyngeal reflux (PSHR) was less frequent in patients with small (17%) compared with medium (91%) and large diverticula (87%; P < .01). PSHR was present on all FEES available for patients who presented with a recurrent or residual ZD (n = 7). In all cases, PSHR resolved after successful treatment of ZD. Pharyngeal residue indicating possible weakness was present in 24% of all patients at initial presentation. CONCLUSIONS: Preoperative assessment of dysphagia characteristics in ZD patients reveals that PSHR is predictive of a ZD larger than 1 cm and may be useful in surgical planning. PSHR is also helpful in identifying patients with recurrent or residual symptomatic ZD following surgical treatment. Pharyngeal weakness is present in a subset of ZD patients.

Measurable progress in female authorship in otolaryngology.

OBJECTIVE: To identify contemporary trends in female authorship in the otolaryngology literature. STUDY DESIGN: Analysis of 4 otolaryngology journals. SETTING: All articles published in Annals of Otology, Rhinology and Laryngology, Archives of Otolaryngology-Head and Neck Surgery, Laryngoscope, and Otolaryngology-Head and Neck Surgery in 2008 were reviewed and compared with prior data from 1978, 1988, and 1998. SUBJECTS AND METHODS: Each published article's authorship panel was examined for the number of authors and each author's sex, degree, and the subspecialty area of publication. Year-to-year comparisons were conducted for the rates and characteristics of female authorship. RESULTS: A total of 544, 629, 713, and 785 articles from 1978, 1988, 1998, and 2008, respectively, were analyzed. From 1998 to 2008, the overall percentage of female authors increased from 14.5% to 22.5% (P < .001). Similarly, the percentage of articles with a female first author increased from 12.9% to 21.3% (P < .001). Whereas previously pediatric otolaryngology had the highest female first author percentage (range, 6.9%-19.4%), in 2008 all other subspecialties demonstrated significant increases in female first author percentages: otology (18.6%), general (22.3%), head and neck (22.2%), plastics (18.9%), and pediatrics (19.4%) (P = .885). A significant number of female first authors continue to be nonphysicians (19.2% in 2008, P < .001). CONCLUSIONS: Female authorship has shown significant and steady increases in the otolaryngology literature, particularly in the past decade. Increased rates of publication from female otolaryngologists within most subspecialties have resulted in similar rates of publication across the subspecialties.

Partition-variant desferrithiocin analogues: organ targeting and increased iron clearance.

Altering the lipophilicity (log P(app)) of desferrithiocin analogues can change the organ distribution of the chelators and lead to enhanced iron clearance. For example, alkylation of (S)-2-(2,4-dihydroxyphenyl)-4,5-dihydro-4-methyl-4-thiazolecarboxylic acid [(S)-4'-(HO)-DADFT] and its analogues to more lipophilic compounds, such as (S)-4,5-dihydro-2-(2-hydroxy-4-methoxyphenyl)-4-methyl-4-thiazolecarboxylic acid [(S)-4'-(CH3O)-DADFT], provides ligands that achieved between a 3- and 8-fold increase in chelator concentrations in the heart, liver, and pancreas (the organs most at risk in iron-overload disease) of treated rodents. The 4'-O-methylated compounds are demethylated to their hydroxylated counterparts in rodents; furthermore, this O-demethylation takes place in both rodent and human liver microsomes. The relationship between chelator lipophilicity and iron-clearing efficacy in the iron-overloaded Cebus apella primate is further underscored by a comparison of the iron-clearing efficiency of (S)-2-(2,3-dihydroxyphenyl)-4,5-dihydro-4-methyl-4-thiazolecarboxylic acid [(S)-3'-(HO)-DADFT] and its 3'-(CH3O) counterpart. Finally, these DFT analogues are shown to be both inhibitors of the iron-mediated oxidation of ascorbate as well as effective radical scavengers.