Surgical management of vocal cord nodules in children: Trends and outcomes.

OBJECTIVES: Vocal cord nodules (VCNs) are the most common cause of dysphonia in school-aged children, with potential negative impacts on quality of life including diminished self-esteem and academic performance. The standard of care for VCNs is conservative management which ranges from voice hygiene to speech therapy with a focus on voice otherwise known as voice therapy, with surgical excision reserved for refractory cases. Thus, few studies have analyzed outcomes of surgical management of VCNs. The purpose of this study is to assess the prevalence and efficacy of surgical excision of VCNs when compared to speech therapy. METHODS: Children with VCNs seen at a single tertiary care institution between 2015 and 2020 were identified by ICD-9 code 478.5 and ICD-10 code J38.2. Demographics, objective voice assessment, intervention, and follow-up assessment data were reviewed. Frequencies, medians, and interquartile ranges were calculated. Time to resolution and improvement were assessed by Cox proportional hazards model. Univariate logistic regression was performed. A P value of <0.05 was considered statistically significant. RESULTS: Three hundred sixty-eight patients diagnosed with VCNs were identified. 169 patients received intervention for VCNs, with 159 (43.2 %) receiving speech therapy alone and 5 (1.4 %) receiving surgery alone. On bivariate analysis, there was no significant difference in demographic features between treatment groups, however speech therapy patients did have a longer follow-up time. 154 patients underwent objective voice assessment at the time of VCN diagnosis. Among these patients, 95 (61.7 %) received speech therapy and 59 (40.3 %) received no intervention. Speech therapy patients had significantly higher pVHI scores, however there was no significant difference in CAPE-V Overall Severity scores or computerized voice assessment analysis. On Cox proportional hazards analysis, surgical intervention was associated with faster resolution and faster improvement of dysphonic symptoms. On binary logistic regression, surgery was associated with a significantly greater proportion of patients reporting resolution of dysphonic symptoms, however there was no significant difference in proportion of patients reporting improvement of dysphonia. CONCLUSION: For most patients with VCNs, conservative measures such as voice hygiene and speech therapy remain first line, however certain patients may benefit from the rapid improvement and resolution of symptoms that surgical intervention may provide.

LID study: Plasma lidocaine levels following airway topicalisation for paediatric microlaryngobronchoscopy (MLB).

OBJECTIVES: A dose of 5 mg/kg lidocaine is considered appropriate for paediatric airway topicalisation. Existing literature suggests that younger children are susceptible to toxic lidocaine plasma levels and achieve this at a faster rate. MAIN OUTCOME MEASURES: The primary outcome of this study was to ascertain peak plasma lidocaine levels after topicalisation for airway endoscopy. Secondary endpoints included: time to peak lidocaine plasma levels, signs of lidocaine toxicity (restricted to ECG changes or seizures when under anaesthesia) and clinical adverse events of laryngospasm, coughing or desaturation during the procedure. SETTING: Data were collected prospectively over 18 months at Royal Manchester Children's Hospital. PARTICIPANTS: Children aged 0-8 years undergoing elective diagnostic or therapeutic airway endoscopy were included within the study. DESIGN: Standardised 2% lidocaine was used for airway topicalisation. Dose varied depending upon the practitioner's usual practice. Venous bloodsampling occurred at 5, 10, 15 and 20 min post-administration and plasma lidocaine levels (ng/ml) were analysed. RESULTS: A significant relationship exists between higher peak plasma levels and ages <18 months (p = .00973). Strong linear correlation exists between body weight and age for our cohort (r = .88). Higher peak plasma lidocaine levels occur with total dose volumes between 2 and 3 mls of 2% lidocaine local anaesthetic (p = .03) compared with <2 ml total dose volumes. Data suggest a potential relationship of lower body weights achieving higher peak plasma levels (p = .0516). Reduced interquartile variation of peak plasma lidocaine levels exists when lidocaine dosing is <5 mg/kg. CONCLUSIONS: Age and total dose volume of topicalised lidocaine have a significant relationship with plasma lidocaine levels. A dose of 5 mg/kg topicalised lidocaine for paediatric airway endoscopy is safe and provides good operating conditions. Lower patient body weights trend towards higher peak lidocaine plasma concentrations and require further investigation.

Global multidimensional poverty and COVID-19: A decade of progress at risk?

According to the global Multidimensional Poverty Index (MPI), an internationally comparable measure, poverty in developing countries has fallen substantially over the last 15 years. The COVID-19 pandemic and associated economic contraction are negatively impacting multiple dimensions of poverty and jeopardising this progress. This paper uses recent assessments of food insecurity and school closures made by UN agencies to inform microsimulations of potential short-term impacts of the pandemic under alternative scenarios. These simulations use the nationally representative datasets underlying the 2020 update of the global MPI. Because these datasets were collected in various years before the pandemic, we develop models to translate the simulated impacts to 2020. Our approach accounts for the country-specific joint distribution of deprivations in the simulations, recent poverty reduction trends, and resulting differences in the responsiveness of the global MPI to the scenarios. Aggregating results across 70 countries that account for 89% of the global poor according to the 2020 global MPI, we find that the potential setback to multidimensional poverty reduction is between 3.6 and 9.9 years under the alternative scenarios. We argue that the extent to which such disruptions result in persistent increases of poverty and deprivations may be attenuated by appropriate policy responses.