Assessing silvopasture management as a strategy to reduce fuel loads and mitigate wildfire risk.

Managing private forests for wildfire resilience is challenging due to conflicting social, economic, and ecological decisions that may result in an increase of surface fuel loads leading to greater fire risk. Due to fire suppression and a changing climate, land managers in fire-prone regions face an increasing threat of high severity fires. Thus, land managers need fuel treatment options that match their forest types and management objectives. One potential option for producers that graze livestock is silvopasture management, where livestock, forages, and overstory vegetation are carefully managed for co-benefits on the same unit of land. This study compared forest composition and structure, fuel types, and vegetative biomass between silvopasture and non-grazed managed forests in Washington, U.S. We show that silvopasture management results in reductions in grass biomass, litter, and duff depth when compared to non-grazed managed forest. These findings point to the integrated nature of silvopasture, where management of overstory composition and structure, understory vegetation, and grazing can reduce fuel loads and potential wildfire risk.

Provider moral distress in caring for tracheostomy and ventilator dependent children: A single institution cross-sectional evaluation.

OBJECTIVE: To determine levels of moral distress in a pediatric unit caring for patients with tracheostomy/ventilator dependence. HYPOTHESIS: Moral distress will be significant in a dedicated pediatric trach/vent unit. METHODS: The Moral Distress Survey-Revised (MDS-R) is a 21-question survey measuring moral distress in pediatrics. The MDS-R was anonymously distributed to medical degree/doctor of osteopathy (MD/DOs), advanced practice practitioners (APPs), registered nurses (RNs), and respiratory therapists (RTs) in a unit caring for tracheostomy/ventilator dependent patients. Descriptive statistics, bivariate and multivariate analysis were performed. RESULTS: Response rate was 48% (61/127). Mean MDS-R score was 83 (range 43-119), which is comparable to reported levels in the pediatric intensive care unit (ICU). APPs had the highest median rate of moral distress (112, interquartile range [IQR], 72-138), while MD/DOs had the lowest median score (49, IQR, 43-77). RNs and RTs had MDS-R scores between these two groups (medians of 91 and 84, respectively). CONCLUSIONS: Moral distress levels in a unit caring for long term tracheostomy and ventilator dependent patients are high, comparable to levels in pediatric ICUs. APPs. APPs had higher levels of distress compared to other groups. This may be attributable to the constant stressors of being the primary provider for complex patients, especially in a high-volume inpatient setting.

Reciprocated competition between two forest carnivores drives dietary specialization.

Competition shapes animal communities, but the strength of the interaction varies spatially depending on the availability and aggregation of resources and competitors. Among carnivores, competition is particularly pronounced with the strongest interactions between similar species with intermediate differences in body size. While ecologists have emphasized interference competition among carnivores based on dominance hierarchies from body size (smaller = subordinate; larger = dominant), the reciprocity of exploitative competition from subordinate species has been overlooked even though efficient exploitation can limit resource availability and influence foraging. Across North America, fishers Pekania pennanti and martens (Martes spp.) are two phylogenetically related forest carnivores that exhibit a high degree of overlap in habitat use and diet and differ in body size by a factor of 2-5×, eliciting particularly strong interspecific competition. In the Great Lakes region, fishers and martens occur both allopatrically and sympatrically; where they co-occur, the numerically dominant species varies spatially. This natural variation in competitors and environmental conditions enables comparisons to understand how interference and exploitative competition alter dietary niche overlap and foraging strategies. We analysed stable isotopes (δ13 C and δ15 N) from 317 martens and 132 fishers, as well as dietary items (n = 629) from 20 different genera, to compare niche size and overlap. We then quantified individual diet specialization and modelled the response to environmental conditions that were hypothesized to influence individual foraging. Martens and fishers exhibited high overlap in both available and core isotopic δ-space, but no overlap of core dietary proportions. When the competitor was absent or rare, both martens and fishers consumed more smaller-bodied prey. Notably, the dominant fisher switched from being a specialist of larger to smaller prey in the absence of the subordinate marten. Environmental context also influenced dietary specialization: increasing land cover diversity and prey abundance reduced specialization in martens whereas vegetation productivity increased specialization for both martens and fishers. Despite an important dominance hierarchy, fishers adjusted their niche in the face of a subordinate, but superior, exploitative competitor. These findings highlight the underappreciated role of the subordinate competitor in shaping the dietary niche of a dominant competitor.

Revision Endoscopic Posterior Costal Cartilage Grafting: Is It Feasible?

The objective of this work is to examine the feasibility of revision endoscopic posterior costal cartilage graft (EPCCG) placement for posterior glottic stenosis (PGS) and bilateral vocal fold immobility (BVFI). Revision and primary cases were compared with respect to decannulation rates, and it was hypothesized that there would be no difference in outcomes. Twenty-one patients met inclusion criteria (14 primary, 7 revision). Thirteen (62%) had a primary indication of PGS, and 8 (42%) were for BVFI. There were no differences between revision and primary groups with respect to age, gender, or comorbidities (p > .05). There was no difference between groups with respect to decannulation rate (85% primary vs 100% revision, p = .32). Thus, revision EPCCG appears to have comparable results to primary EPCCG with respect to decannulation rate and time to decannulation. EPCCG may be a feasible alternative to open airway reconstruction for PGS and BVFI in selected patients.

Does the History of Tracheoesophageal Fistula Repair Alter Outcomes of Laryngeal Cleft Repair?

OBJECTIVE: Tracheoesophageal fistula and esophageal atresia (TEA) and laryngeal cleft (LC) can coexist in some patients. The surgery-specific success rate of LC repair in children with associated TEA has not been well described. The aim of the study is to determine if the history of TEA alters the LC repair outcomes. STUDY DESIGN: Case series with chart review. SETTING: Single-institution academic medical center. METHOD: A retrospective review was conducted of patients with LC with and without TEA repair between January 2001 and November 2020. Data collected and analyzed included demographics and clinical characteristics, LC type, and LC with TEA timing of repairs. RESULTS: An overall 282 patients met the inclusion criteria of LC repair: LC (n = 242, 85.8%) and LC + TEA (n = 40, 14.2%). Revision repair was required in 43 patients (15.2%) with 8 (2.8%) needing a second revision repair. The first LC revision rate in the LC group was 36/242 (14.9%) as compared with 7/40 (17.5%) in the LC + TEA group (P = .67). The second LC revision rate in the LC and LC + TEA groups was 7 (2.9%) and 1 (2.4%), respectively. The median time to revision was 5.1 months (interquartile range, 3.45-10.6) in the LC group as compared with 29.2 months (interquartile range, 4.8-44.2) in the LC + TEA group (P = .06). CONCLUSION: The incidence of TEA and LC was 14.2% in our study. Based on our findings, history of TEA repair is not associated with a higher revision rate vs LC alone. The history of TEA repair did not alter the outcomes of LC repair.

The follow up of complex infants in an aerodigestive clinic.

The current available literature evaluating pediatric multidisciplinary aerodigestive programs for the management of aerodigestive disorders in infants was reviewed. Multidisciplinary aerodigestive programs have emerged to provide coordinated and comprehensive care for the growing population of children with aerodigestive conditions, including complex airway, pulmonary, gastrointestinal, and feeding disorders, which are prevalent among infants discharged from the neonatal intensive care unit (NICU). The team approach central to aerodigestive clinics offers a comprehensive diagnostic workup and unified management plan through consolidated interdisciplinary clinics, combined endoscopic procedures, and regular team discussions, leading to improved resource utilization and health care outcomes. We review common conditions presenting in the NICU that benefit from the aerodigestive model of care, including esophageal atresia, prematurity, bronchopulmonary dysplasia with or without tracheostomy or ventilator dependence, and dysphagia.

Update on the diagnosis and management of pediatric laryngotracheal stenosis.

INTRODUCTION: Laryngotracheal stenosis comprises a broad spectrum of congenital and acquired conditions that commonly cause pediatric airway obstruction. With the introduction and popularization of operative procedures such as laryngotracheoplasty, cricotracheal resection, and slide tracheoplasty more patients are presenting with airway issues at multiple anatomic levels. A combination of endoscopic and open techniques continues to be utilized for these complex issues. Additionally, there are specific long-term considerations for the post reconstruction patient. AREAS COVERED: This review highlights important aspects of the diagnosis, work up, and surgical treatment of pediatric laryngotracheal stenosis with updates for revision airway surgery and the post reconstruction patient. Important research articles and techniques within pediatric airway reconstruction are summarized and included in the review, in addition to recent articles from the last five years on pediatric laryngotracheal stenosis which were identified through a search of the PubMed database. EXPERT OPINION: The multidisciplinary concept of evaluation and treatment of laryngotracheal stenosis continues to be essential. Revision airway surgery presents unique challenges to improve the quality of life of patients as they age after reconstruction. Tracheal transplantation remains an important research area in the treatment of laryngotracheal stenosis.

A SEROLOGIC SURVEY OF FRANCISELLA TULARENSIS EXPOSURE IN WILDLIFE ON THE ARCTIC COASTAL PLAIN OF ALASKA, USA.

Tularemia is an infectious zoonotic disease caused by one of several subspecies of Francisella tularensis bacteria. Infections by F. tularensis are common throughout the northern hemisphere and have been detected in more than 250 wildlife species. In Alaska, US, where the pathogen was first identified in 1938, studies have identified F. tularensis antibodies in a diverse suite of taxa, including insects, birds, and mammals. However, few such investigations have been conducted recently and knowledge about the current distribution and disease ecology of F. tularensis is limited, particularly in Arctic Alaska, an area undergoing rapid environmental changes from climate warming. To help address these information gaps and provide insights about patterns of exposure among wildlife, we assessed the seroprevalence of F. tularensis antibodies in mammals and tundra-nesting geese from the Arctic Coastal Plain of Alaska, 2014-17. With a commercially available slide agglutination test, we detected antibodies in 14.7% of all individuals sampled (n=722), with titers ranging from 1:20 to 1:320. We detected significant differences in seroprevalence between family groups, with Canidae (foxes, Vulpes spp.) and Sciuridae (Arctic ground squirrel, Spermophilus parryii) having the highest seroprevalence at 21.5% and 33.3%, respectively. Mean seroprevalence for Ursidae (polar bears, Ursus maritimus) was 13.3%, whereas Cervidae (caribou, Rangifer tarandus) had comparatively low seroprevalence at 6.5%. Antibodies were detected in all Anatidae species sampled, with Black Brant (Branta bernicla nigricans) having the highest seroprevalence at 13.6%. The detection of F. tularensis antibodies across multiple taxa from the Arctic Coastal Plain and its nearshore marine region provides evidence of exposure to this pathogen throughout the region and highlights the need for renewed surveillance in Alaska.

Paralytic shellfish toxins associated with Arctic Tern mortalities in Alaska.

Harmful algal blooms produce biotoxins that can injure or kill fish, wildlife, and humans. These blooms occur naturally but have intensified in many locations globally due to recent climatic changes, including ocean warming. Such changes are especially pronounced in northern regions, where the effects of paralytic shellfish toxins (PSTs) on marine wildlife are of growing concern. In Alaska, seabird mortality events have increased in frequency, magnitude, and duration since 2015 alongside anomalously high ocean temperatures. Although starvation has been implicated as the apparent cause of death in many of these die-offs, saxitoxin (STX) and other PSTs have been identified as possible contributing factors. Here, we describe a mortality event at a nesting colony of Arctic Terns (Sterna paradisaea) near Juneau, Alaska in 2019 and report elevated concentrations of PSTs in bird, forage fish, and mussel samples. Concentrations of STX and other PSTs in tern tissues (2.5-51.2 µg 100g-1 STX-equivalents [STX-eq]) were of similar magnitude to those reported from other PST-induced bird die-offs. We documented high PST concentrations in blue mussels (>11,000 µg 100g-1 STX-eq; Mytilus edulis spp.) collected from nearby beaches, as well as in forage fish (up to 494 µg 100g-1 STX-eq) retrieved from Arctic Tern nests, thereby providing direct evidence of PST exposure via the terns' prey. At maximum concentrations measured in this study, a single 5 g Pacific Sand Lance (Ammodytes personatus) could exceed the median lethal STX dose (LD50) currently estimated for birds, offering strong support for PSTs as a likely source of tern mortality. In addition to describing this localized bird mortality event, we used existing energetics data from adult and nestling Arctic Terns to calculate estimated cumulative daily PST exposure based on ecologically relevant concentrations in forage fish. Our estimates revealed potentially lethal levels of PST exposure even at relatively low (≤30 ug 100g-1 STX-eq) toxin concentrations in prey. These findings suggest that PSTs present a significant hazard to Arctic Terns and other northern seabirds and should be included in future investigations of avian mortality events as well as assessments of population health.

Seasonality drives the survival landscape of a recovering forest carnivore in a changing world.

Ecological heterogeneity promotes species persistence and diversity. Environmental change has, however, eroded patterns of heterogeneity globally, stifling species recovery. To test the effects of seasonal heterogeneity on a reintroduced carnivore, American martens (Martes americana), we compared metrics of local and season-specific heterogeneity to traditional forest metrics on the survival of 242 individuals across 8 years and predicted a survival landscape for 13 reintroduction sites. We found that heterogeneity-created by forest structure in the growing season and snow in the winter-improved survival and outperformed traditional forest metrics. Spatial variation in heterogeneity created a distinct survival landscape, but seasonal change in heterogeneity generated temporal discordance. All translocation sites possessed high forest heterogeneity but there were greater differences in winter heterogeneity; recovery sites with the poorest snow conditions had the lowest viability. Our work links heterogeneity across seasons to fitness and suggests that management strategies that increase seasonal aspects of heterogeneity may help to recover other sensitive species to continuing environmental change.

Facilitative interaction promotes occupancy of a desert amphibian across a climate gradient.

Biotic interactions and environmental factors influence a species' occurrence. Facilitative interactions have the potential to expand species occupancy and mitigate abiotic stress, but are often not considered. The Great Basin clade of the Columbia spotted frog (Rana luteiventris) is an aquatic amphibian found in the arid and semi-arid Great Basin, USA. Aquatic resources in this system are limited and likely to change under future climate scenarios. American beavers (Castor canadensis) are ecosystem engineers that impact the surrounding landscape by increasing water availability. Consequently, beaver-created habitat can facilitate the presence of other species by providing the aquatic resources required by many aquatic and riparian animals. Our objective was to understand patterns of co-occurrence between Columbia spotted frogs and beavers across environmental gradients in the Great Basin, USA. We used environmental DNA detections to quantify the co-occurrence of Columbia spotted frog and beaver using a two-species occupancy framework. At the lowest annual precipitation (202 mm), Columbia spotted frogs were 3× (95% CI 2.35, 3.96) more likely to occur with beavers than without; however, they were less likely to occur with beavers once precipitation was > 380 mm. Thus, beaver activity may increase aquatic resources for Columbia spotted frogs in the Great Basin that may mitigate changing precipitation patterns under climate change. Facilitative interactions likely extend to other aquatic species in arid systems and highlight an important consideration for ecologists when evaluating a species' response to climate change, and may promote the formation of refugia for species with strict abiotic tolerances and dispersal limitations.

Establishing an Endoscopic Chronic Subglottic Stenosis Rabbit Model.

OBJECTIVES/HYPOTHESIS: To develop a reproducible and consistent chronic subglottic stenosis (SGS) in an endoscopic animal model. STUDY DESIGN: Prospective study. METHODS: We conducted a prospective study using New Zealand white rabbits. Chronic SGS was induced endoscopically by Bugbee electrocautery to 50% to 75% of the subglottic area's circumference, followed by 4-hour endotracheal intubation. The rabbit airways were endoscopically assessed and sized with uncuffed endotracheal tubes (ETTs) before the injury, during follow-up, and at the endpoints. There were four endpoints: 2, 4, 6, and 8 weeks post SGS induction. Animals were humanely euthanized for histopathological examination of the subglottic injury site and microscopic measurement of the cricoid lumen. RESULTS: Twenty-two rabbits reached the endpoints, and 18 rabbits developed chronic SGS. ETT size significantly decreased by 0.5 from preinjury to the endpoint in all groups, P < .001. Control median cricoid lumen measurements were 20.48 mm2 , the median cricoid lumen measurement for the 2 weeks endpoint was 14.3 mm2 , 4 weeks 11.69 mm2 , 6 weeks 16.03 mm2 , and 8 weeks endpoint median was 16.33 mm2 . Histopathological examination showed chronic scar tissue and new cartilage formation at the cricoid level, mainly at the posterior subglottic injury site starting from 4 weeks postinjury. Collagen staining revealed substantial amounts of organized collagen and different collagen orientation starting 4 weeks postinjury lasting until 8 weeks postinjury. CONCLUSION: We developed an animal model to study chronic SGS. This model will be utilized to compare different endoscopic treatment interventions in acute SGS versus chronic SGS and further define the molecular basis of SGS. LEVEL OF EVIDENCE: NA Laryngoscope, 132:1909-1915, 2022.

Surgical Treatment of Type III Laryngotracheoesophageal Clefts: Techniques and Outcomes.

OBJECTIVES/HYPOTHESIS: Determine surgical and swallowing outcomes after surgery for type III laryngotracheoesophageal cleft (LTEC). STUDY DESIGN: Case series with chart review. METHODS: Chart review was performed on patients with type III LTEC between 2000 and 2019. Demographics, surgical outcomes, and swallowing outcomes were collected and analyzed. RESULTS: Thirty-three patients met inclusion criteria (28 open and 5 endoscopic repairs). Mean age was 3.4 years for the open group and 0.9 years for the endoscopic group. Seventeen (51.5%) patients had a syndromic diagnosis, most commonly Opitz syndrome and Trisomy 21. Mean follow-up was 33.6 months. Thirteen (39.4%) patients had a previous repair attempt prior to repair at our institution. Twenty-four (70.6%) patients had a tracheostomy prior to or at the time of surgical repair and 13 (38.2%) remain tracheostomy-dependent. Nine patients (27.3%) required a revision cleft repair and four (12.1%) required two revisions. Thirty-one patients had an intact repair at last follow-up (93.9). Two patients died outside the hospital over a year after surgery. Preoperatively 13 of 17 patients with swallowing evaluations aspirated. After repair, 11 of 20 patients were deemed safe for all consistencies and seven were safe for thickened. Endoscopic approaches were performed during the last 2 years of the study and had significantly lower operative time (354.4 minutes vs. 171.5 minutes). CONCLUSIONS: Endoscopic and open approaches are effective for treatment of type III LTEC with 27.3% requiring revision and 93.9% of repairs intact at last follow-up. Overall swallowing outcomes were good in patients who underwent postoperative instrumental swallow evaluation. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:1112-1117, 2022.

Acute oral toxicity and tissue residues of saxitoxin in the mallard (Anas platyrhynchos).

Since 2014, widespread, annual mortality events involving multiple species of seabirds have occurred in the Gulf of Alaska, Bering Sea, and Chukchi Sea. Among these die-offs, emaciation was a common finding with starvation often identified as the cause of death. However, saxitoxin (STX) was detected in many carcasses, indicating exposure of these seabirds to STX in the marine environment. Few data are available that describe the effects of STX in birds, thus presenting challenges for determining its contributions to specific mortality events. To address these knowledge gaps, we conducted an acute oral toxicity trial in mallards (Anas platyrhynchos), a common laboratory avian model, using an up-and-down method to estimate the median lethal dose (LD50) for STX. Using an enzyme-linked immunosorbent assay (ELISA), we tested select tissues from all birds and feces from those individuals that survived initial dosing. Samples with an ELISA result that exceeded approximately 10 µg 100 g-1 STX and randomly selected ELISA negative samples were further tested by high-performance liquid chromatography (HPLC). Tissues collected from mallards were also examined grossly at necropsy and then later by microscopy to identify lesions attributable to STX. The estimated LD50 was 167 µg kg-1 (95% CI = 69-275 µg kg-1). Saxitoxin was detected in fecal samples of all mallards tested for up to 48 h after dosing and at the end of the sampling period (7 d) in three birds. In those individuals that died or were euthanized <2 h after dosing, STX was readily detected throughout the gastrointestinal tract but only infrequently in heart, kidney, liver, lung, and breast muscle. No gross or microscopic lesions were observed that could be attributable to STX exposure. Given its acute toxicity, limited detectability, and frequent occurrence in the Alaska marine environment, additional research on STX in seabirds is warranted.

A recovery network leads to the natural recolonization of an archipelago and a potential trailing edge refuge.

Rapid environmental change is reshaping ecosystems and driving species loss globally. Carnivore populations have declined and retracted rapidly and have been the target of numerous translocation projects. Success, however, is complicated when these efforts occur in novel ecosystems. Identifying refuges, locations that are resistant to environmental change, within a translocation framework should improve population recovery and persistence. American martens (Martes americana) are the most frequently translocated carnivore in North America. As elsewhere, martens were extirpated across much of the Great Lakes region by the 1930s and, despite multiple translocations beginning in the 1950s, martens remain of regional conservation concern. Surprisingly, martens were rediscovered in 2014 on the Apostle Islands of Lake Superior after a putative absence of >40 yr. To identify the source of martens to the islands and understand connectivity of the reintroduction network, we collected genetic data on martens from the archipelago and from all regional reintroduction sites. In total, we genotyped 483 individual martens, 43 of which inhabited the Apostle Islands (densities 0.42-1.46 km-2 ). Coalescent analyses supported the contemporary recolonization of the Apostle Islands with progenitors likely originating from Michigan, which were sourced from Ontario. We also identified movements by a first-order relative between the Apostle Islands and the recovery network. We detected some regional gene flow, but in an unexpected direction: individuals moving from the islands to the mainland. Our findings suggest that the Apostle Islands were naturally recolonized by progeny of translocated individuals and now act as a source back to the reintroduction sites on the mainland. We suggest that the Apostle Islands, given its protection from disturbance, complex forest structure, and reduced carnivore competition, will act as a potential refuge for marten along their trailing range boundary and a central node for regional recovery. Our work reveals that translocations, even those occurring along southern range boundaries, can create recovery networks that function like natural metapopulations. Identifying refuges, locations that are resistant to environmental change, within these recovery networks can further improve species recovery, even within novel environments. Future translocation planning should a priori identify potential refuges and sources to improve short-term recovery and long-term persistence.

Demographic Characteristics of Children Diagnosed with Bacterial Tracheitis.

OBJECTIVES: Examine the presentation and clinical course of patients with bacterial tracheitis (BT). Identify if socioeconomic differences exist among children who present with BT. METHODS: This was a retrospective case series from a tertiary care pediatric medical center. The study group included patients less than 18 years old who were diagnosed with BT from January 2011 to March 2019. Patients with a tracheostomy and those who developed BT after prolonged hospitalization were excluded. Patient demographics were compared with the demographics of the counties surrounding the hospital. RESULTS: 33 patients with BT met inclusion criteria. The most common presenting symptoms were difficulty breathing, stridor, and sore throat (81.8% each), followed by cough (78.8%). Median length of stay was 3 days [interquartile range (IQR):2-4]. 19 patients (57.5%) were admitted to the intensive care unit. Intubation was required for 13 patients (39.4%), for a median length of 2 days [IQR:2-2]. Methicillin sensitive staphylococcus aureus was the most common bacterial etiology (33%). Mean presenting age was 8.58 years [95% confidence interval:7.3-9.9] and 14 patients were female (42.4%). 31 patients were white (93.9%), 1 was black (3%), and 1 was Hispanic (3%). BT patients were more likely to have private insurance compared to comparison (81.8% vs 63.4%, P < .001). CONCLUSION: Children who presented with BT were more likely to be privately insured than a comparison population.

Investigation of Algal Toxins in a Multispecies Seabird Die-Off in the Bering and Chukchi Seas.

Between 2014 and 2017, widespread seabird mortality events were documented annually in the Bering and Chukchi seas, concurrent with dramatic reductions of sea ice, warmer than average ocean temperatures, and rapid shifts in marine ecosystems. Among other changes in the marine environment, harmful algal blooms (HABs) that produce the neurotoxins saxitoxin (STX) and domoic acid (DA) have been identified as a growing concern in this region. Although STX and DA have been documented in Alaska (US) for decades, current projections suggest that the incidence of HABs is likely to increase with climate warming and may pose a threat to marine birds and other wildlife. In 2017, a multispecies die-off consisting of primarily Northern Fulmars (Fulmarus glacialis) and Short-tailed Shearwaters (Ardenna tenuirostris) occurred in the Bering and Chukchi seas. To evaluate whether algal toxins may have contributed to bird mortality, we tested carcasses collected from multiple locations in western and northern Alaska for STX and DA. We did not detect DA in any samples, but STX was present in 60% of all individuals tested and in 88% of Northern Fulmars. Toxin concentrations in Northern Fulmars were within the range of those reported from other STX-induced bird die-offs, suggesting that STX may have contributed to mortalities. However, direct neurotoxic action by STX could not be confirmed and starvation appeared to be the proximate cause of death among birds examined in this study.

The Impact of Socioeconomic Status on Time to Decannulation Among Children With Tracheostomies.

OBJECTIVE: To determine if time to tracheostomy decannulation differs among children by socioeconomic status. STUDY DESIGN: Case series with chart review. SETTING: Tertiary pediatric medical center. METHODS: Patients (≤21 years old) who underwent tracheostomy from January 1, 2011, to December 31, 2016. Patients were divided into 2 groups based on their socioeconomic status (SES), low SES and high SES. Principal components analysis was used to create an index for SES using census data obtained by the US Census Bureau's American Community Survey 5 year data profile from 2013 to 2017. Statistical analysis was performed using a χ2 for categorical variables and Wilcoxon rank-sum test for continuous variables. A general linear model was constructed to control for clinical factors to understand the independent effect of SES on time to decannulation. RESULTS: In total, 215 patients were included; of these patients, 111 patients (52%) were included in the high-SES group and 104 patients (48%) were included in the low-SES group. There was a significant difference in the time to decannulation for children based on SES status, with those children in the low-SES group taking on average 10 months longer to decannulate (38.7 vs 28.0 months, P = .0007). Median follow-up was 44.1 months (interquartile range, 29.6-61.3 months). CONCLUSION: Health care disparities appear to exist among children undergoing decannulation of their tracheostomy tube. Patients with lower SES had a significantly longer time to decannulation than those with higher SES.

Congenital Absence of Tracheal or Bronchial Rings.

OBJECTIVE: Congenital airway stenosis secondary to absent tracheal or bronchial rings is a rare congenital anomaly that is difficult to manage both clinically and surgically. This typically manifests as severe segmental tracheomalacia, and only isolated cases with short-term follow-up have been previously described. We aim to describe a series of children with absent tracheal or bronchial rings who underwent surgical management and had long-term follow-up. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care pediatric hospital. METHODS: Patients with absent tracheal or bronchial rings from 2002 to 2016. Electronic and paper medical records were queried to obtain demographics, age at diagnosis and surgery, pre- and postoperative symptoms, location of absent rings, procedure performed, length of follow-up, and adjunctive procedures performed. RESULTS: Nine subjects were identified who underwent slide tracheoplasty for correction of congenital absent tracheal or bronchial rings. Age at diagnosis ranged from 10 days to 5 years of age (median, 4 weeks). Age at surgery ranged from 3 weeks to 5 years of age (median, 5 weeks). Six out of 9 subjects were extubated on postoperative day 1. Only 1 subject required additional intervention, which included balloon dilation, tracheobronchial stenting, and aortopexy to alleviate the obstruction. Mean follow-up time was 5.89 years. CONCLUSIONS: This is the largest series of children with absent tracheal rings who underwent slide tracheoplasty with long-term follow-up presented to date. Slide tracheoplasty is an effective surgical intervention for the treatment of absent tracheal or bronchial rings in infants and young children.