Dynamic flow for efficient partial decellularization of tracheal grafts: A preliminary rabbit study.

Objective: Bioengineered tracheal grafts are a potential solution for the repair of long-segment tracheal defects. A recent advancement is partially decellularized tracheal grafts (PDTGs) which enable regeneration of host epithelium and retain viable donor chondrocytes for hypothesized benefits to mechanical properties. We propose a novel and tunable 3D-printed bioreactor for creating large animal PDTG that brings this technology closer to the bedside. Methods: Conventional agitated immersion with surfactant and enzymatic activity was used to partially decellularize New Zealand white rabbit (Oryctolagus cuniculus) tracheal segments (n = 3). In parallel, tracheal segments (n = 3) were decellularized in the bioreactor with continuous extraluminal flow of medium and alternating intraluminal flow of surfactant and medium. Unprocessed tracheal segments (n = 3) were also collected as a control. The grafts were assessed using the H&E stain, tissue DNA content, live/dead assay, Masson's trichrome stain, and mechanical testing. Results: Conventional processing required 10 h to achieve decellularization of the epithelium and submucosa with poor chondrocyte viability and mechanical strength. Using the bioreactor reduced processing time by 6 h and resulted in chondrocyte viability and mechanical strength similar to that of native trachea. Conclusion: Large animal PDTG created using our novel 3D printed bioreactor is a promising approach to efficiently produce tracheal grafts. The bioreactor offers flexibility and adjustability favorable to creating PDTG for clinical research and use. Future research includes optimizing flow conditions and transplantation to assess post-implant regeneration and mechanical properties. Level of Evidence: NA.

Tracheostomy in Severe Bronchopulmonary Dysplasia-How to Decide in the Absence of Evidence.

Infants with the most severe forms of bronchopulmonary dysplasia (BPD) may require long-term invasive positive pressure ventilation for survival, therefore necessitating tracheostomy. Although life-saving, tracheostomy has also been associated with high mortality, postoperative complications, high readmission rates, neurodevelopmental impairment, and significant caregiver burden, making it a highly complex and challenging decision. However, for some infants tracheostomy may be necessary for survival and the only way to facilitate a timely and safe transition home. The specific indications for tracheostomy and the timing of the procedure in infants with severe BPD are currently unknown. Hence, centers and clinicians display broad variations in practice with regard to tracheostomy, which presents barriers to designing evidence-generating studies and establishing a consensus approach. As the incidence of severe BPD continues to rise, the question remains, how do we decide on tracheostomy to provide optimal outcomes for these patients?

Partial decellularization eliminates immunogenicity in tracheal allografts.

There is currently no suitable autologous tissue to bridge large tracheal defects. As a result, no standard of care exists for long-segment tracheal reconstruction. Tissue engineering has the potential to create a scaffold from allografts or xenografts that can support neotissue regeneration identical to the native trachea. Recent advances in tissue engineering have led to the idea of partial decellularization that allows for the creation of tracheal scaffolds that supports tracheal epithelial formation while preserving mechanical properties. However, the ability of partial decellularization to eliminate graft immunogenicity remains unknown, and understanding the immunogenic properties of partially decellularized tracheal grafts (PDTG) is a critical step toward clinical translation. Here, we determined that tracheal allograft immunogenicity results in epithelial cell sloughing and replacement with dysplastic columnar epithelium and that partial decellularization creates grafts that are able to support an epithelium without histologic signs of rejection. Moreover, allograft implantation elicits CD8+ T-cell infiltration, a mediator of rejection, while PDTG did not. Hence, we establish that partial decellularization eliminates allograft immunogenicity while creating a scaffold for implantation that can support spatially appropriate airway regeneration.

Biobanked tracheal basal cells retain the capacity to differentiate.

Objective: While airway epithelial biorepositories have established roles in the study of bronchial progenitor stem (basal) cells, the utility of a bank of tracheal basal cells from pediatric patients, who have or are suspected of having an airway disease, has not been established. In vitro study of these cells can enhance options for tracheal restoration, graft design, and disease modeling. Development of a functional epithelium in these settings is a key measure. The aim of this study was the creation a tracheal basal cell biorepository and assessment of recovered cells. Methods: Pediatric patients undergoing bronchoscopy were identified and endotracheal brush (N = 29) biopsies were collected. Cells were cultured using the modified conditional reprogramming culture (mCRC) method. Samples producing colonies by day 14 were passaged and cryopreserved. To explore differentiation potential, cells were thawed and differentiated using the air-liquid interface (ALI) method. Results: No adverse events were associated with biopsy collection. Of 29 brush biopsies, 16 (55%) were successfully cultured to passage 1/cryopreserved. Samples with higher initial cell yields were more likely to achieve this benchmark. Ten unique donors were then thawed for analysis of differentiation. The average age was 2.2 ± 2.2 years with five donors (50%) having laryngotracheal pathology. Nine donors (90%) demonstrated differentiation capacity at 21 days of culture, as indicated by detection of ciliated cells (ACT+) and mucous cells (MUC5B+). Conclusion: Pediatric tracheal basal cells can be successfully collected and cryopreserved. Recovered cells retain the ability to differentiate into epithelial cell types in vitro. Level of Evidence: Level 3.

Tissue-engineered composite tracheal grafts create mechanically stable and biocompatible airway replacements.

We tested composite tracheal grafts (CTG) composed of a partially decellularized tracheal graft (PDTG) combined with a 3-dimensional (3D)-printed airway splint for use in long-segment airway reconstruction. CTG is designed to recapitulate the 3D extracellular matrix of the trachea with stable mechanical properties imparted from the extraluminal airway splint. We performed segmental orthotopic tracheal replacement in a mouse microsurgical model. MicroCT was used to measure graft patency. Tracheal neotissue formation was quantified histologically. Airflow dynamic properties were analyzed using computational fluid dynamics. We found that CTG are easily implanted and did not result in vascular erosion, tracheal injury, or inflammation. Graft epithelialization and endothelialization were comparable with CTG to control. Tracheal collapse was absent with CTG. Composite tracheal scaffolds combine biocompatible synthetic support with PDTG, supporting the regeneration of host epithelium while maintaining graft structure.

Cannabis Adaptation During and After Alcohol Ignition Interlock Device Installation: A Longitudinal Study.

OBJECTIVE: A common intervention to prevent alcohol-impaired driving are alcohol ignition interlock devices (IIDs), which prevent drivers with a blood alcohol concentration greater than .025% from starting the car. These devices force drivers to adapt their drinking to accommodate the device. Prior studies indicated a transfer of risk as some drivers with an IID may increase cannabis use as they decrease alcohol use. This study examines whether this increase in cannabis use persists after IID removal when alcohol use reverts to pre-IID levels. METHOD: The data are from the Managing Heavy Drinking (MHD) study of drivers in New York State. The MHD is a comprehensive three-wave study of drivers convicted of driving under the influence from 2015 to 2020. Participants (N = 189) completed all waves, and provided oral fluid/blood and hair samples to measure cannabis and alcohol use, respectively. Mixed between-within analysis of variance was conducted to assess cannabis use at IID installation (Time 1), removal (Time 2), and at 6-month follow-up (Time 3). RESULTS: In aggregate, participants increased their cannabis use over the course of the study. Drivers who decreased their alcohol use while the IID was installed on their car significantly increased their cannabis use while the IID was in place and further increased cannabis use after the device's removal. CONCLUSIONS: IIDs are efficacious in preventing alcohol-impaired driving. However, in some cases, they may have the unintended effect of increasing other substance use. The current study outlines the need for supplemental treatment interventions while on IID to prevent a transfer of risk to other substances, or polysubstance use after the device is removed.

Type IA Oromandibular-Limb Hypogenesis Syndrome: A Case Report and A Case Update.

Hypoglossia is a rare congenital anomaly resulting in a small rudimentary tongue. It is classified under the oromandibular-limb hypogenesis syndrome and can be found in isolation (Type IA) but is more often associated with other congenital disorders, such as limb defects. Isolated hypoglossia cases are rare, and while feeding disorders are common, in some cases, neonatal airway obstruction is the most problematic. In the present report, we discuss two cases of newborns presenting with hypoglossia without limb deformities or visceral anomalies: one new case and a 10-year update of a previously reported case. These two cases highlight the variability in presenting symptoms and the challenges in diagnosis and management of a rare clinical entity. We focus on the discussion of early diagnosis, multidisciplinary management, and shared decision-making, with emphasis on the current therapeutic strategies available to the clinician and their limitations during the neonatal period. Early surgical multivector mandibular distraction osteogenesis can be proposed with minimal short- and long-term morbidity, pending a consistent follow-up. This clinical entity will require multidisciplinary team care into adult years.

Endoscopic Repair of Type 1 Laryngeal Clefts and Deep Interarytenoid Notches: Cold Steel Versus Laser.

OBJECTIVES/HYPOTHESIS: Endoscopic repair is the preferred surgical treatment for type 1 laryngeal clefts (T1LCs) and deep interarytenoid notches (DINs). No studies exist showing differences in repair rates using laser and cold steel. Our objective is to assess overall success and revision rate for endoscopic cleft repair and determine whether there is any difference in surgical outcomes between cold steel and laser techniques. STUDY DESIGN: Retrospective chart review, cohort study. METHODS: Retrospective review at a quaternary care pediatric hospital. Included all patients who underwent endoscopic repair for T1LCs and DINs between January 2010 and December 2019. Demographics, comorbidities, surgical data, outcomes, and revision status were collected and analyzed. We excluded patients who did not have a follow-up at our institution. RESULTS: A total of 194 patients were identified, 14 were excluded for lack of follow-up data so 180 were analyzed. Of these, 127 had cold steel repair and 53 had laser repair. There is no significant difference in demographics or comorbidities. In the cold steel group, 4 of 127 (3.1%) had breakdown and in the laser group, 10 of 53 (18.9%) had breakdown. Patients who failed after a cold steel repair tended to break down later (median 12.7 months) when compared to laser repairs (median 2.1 months). Nine of the 10 patients with breakdown after laser repair were noted on initial postoperative evaluation. CONCLUSIONS: Endoscopic cleft repair is a well-described and effective method for repair of T1LCs and DINs. Both cold steel and laser have high success rates; however, higher failure rates were noted in the laser repair group. Failure after laser repair may occur earlier than failure after cold steel repair. But this did not reach significance. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:2805-2810, 2021.

Regeneration of partially decellularized tracheal scaffolds in a mouse model of orthotopic tracheal replacement.

Decellularized tracheal scaffolds offer a potential solution for the repair of long-segment tracheal defects. However, complete decellularization of trachea is complicated by tracheal collapse. We created a partially decellularized tracheal scaffold (DTS) and characterized regeneration in a mouse model of tracheal transplantation. All cell populations except chondrocytes were eliminated from DTS. DTS maintained graft integrity as well as its predominant extracellular matrix (ECM) proteins. We then assessed the performance of DTS in vivo. Grafts formed a functional epithelium by study endpoint (28 days). While initial chondrocyte viability was low, this was found to improve in vivo. We then used atomic force microscopy to quantify micromechanical properties of DTS, demonstrating that orthotopic implantation and graft regeneration lead to the restoration of native tracheal rigidity. We conclude that DTS preserves the cartilage ECM, supports neo-epithelialization, endothelialization and chondrocyte viability, and can serve as a potential solution for long-segment tracheal defects.

Convicted drinking and driving offenders: Comparing alcohol use before and after the pandemic outbreak.

BACKGROUND: Before the COVID-19 pandemic, very little was known about the impact of social isolation on individuals' alcohol use and misuse. This study examines how socially isolated individuals with a history of heavy drinking used alcohol during the pandemic. METHODS: Data for this study came from an add-on to the Managing Heavy Drinking (MHD) longitudinal study of drivers convicted of DWI that was conducted in Erie County, New York. Pre-COVID information (October 2019-March 2020) was augmented with a COVID-19 questionnaire collected between July and August 2020. A total of 92 participants completed the COVID-19 survey. RESULTS: The sample of problem drinkers showed a significant increase after the pandemic outbreak in the average number of drinking days from 1.99 to 2.49 per week (p = 0.047), but a significant decrease in the average number of drinks per drinking day, from 3.74 to 2.74 (p = 0.003). The proportion of individuals who drank more frequently was greater among those who, before the outbreak had an Alcohol Use Disorders Identification Test (AUDIT) score <8 (26% increase) compared with those with an AUDIT score of >8 (13%). Alcohol treatment was also associated with the frequency of drinking, with individuals who were not in alcohol treatment showing a 16% increase in frequency compared with a 10% increase among those in treatment. Further, individuals who, after the outbreak worried about their health (30%) or finances (37%) reported greater increases in the frequency of drinking than those who did not worry about their health (17%) or finances (10%). CONCLUSIONS: Overall, the individuals in our sample showed small changes in the frequency andheaviness of drinking after the outbreak of COVID-19, effects that opposite in direction from one another and thus resulted in no overall change in drinks consumed. Nonetheless, we identified factors that influenced the effects of the pandemic on drinking behavior among individuals convicted of DWI, which emphasizes the need to individualize these individuals' treatment, particularly in the context of dramatic environmental change.

Understanding non-installers of the ignition interlock device: A qualitative analysis.

INTRODUCTION: Literature notes the efficacious use of alcohol ignition interlock devices (IID) in reducing rates of drinking and driving while installed on the vehicle. Some drivers who are convicted of driving while intoxicated (DWI) elect to have their license suspended/revoked instead of installing the device. These individuals represent a high-risk subsample of drivers, yet limited literature has addressed this concern. The current study seeks to fill this gap using qualitative interviews addressing: (i) why do non-installers make the choice to not install a mandated IID; and (ii) how are non-installers managing without the IID? METHODS: The study utilises the Managing Heavy Drinkers study of drivers in Erie County, New York, USA. Participants were purposively sampled from a group of non-installers (n = 6; four females, two males) who completed semi-structured interviews. Constructed grounded theory was used to develop a theoretical understanding of participant's experiences. RESULTS: To understand why participants elect not to install the IID, thematic analysis revealed: alleviating constraints, predominantly the financial burdens associated with an IID, and institutional mistrust. Additionally, data revealed that participants are managing without the IID by mitigating apprehension. This included driving cautiously to avoid detection and utilising alternative transportation. DISCUSSION AND CONCLUSIONS: This study furthers understanding of why drivers convicted of a DWI elect not to install an IID. Future research should seek to identify barriers to IID installation. This work provides evidence for establishing institutional protocols that ensure drivers convicted of a DWI receive consistent and correct information about the IID process.

Changes in Alcohol Use and Drinking and Driving Outcomes From Before Arrest for Driving Under the Influence to After Interlock Removal.

BACKGROUND: Half of the offenders convicted of impaired driving in the United States are sentenced to install alcohol ignition interlock devices (IIDs), which prevent them from starting their vehicles if they have been drinking. No research has yet explored offenders' patterns of alcohol consumption and driving under the influence of alcohol (DUI) from the time before the arrest to the time period after the IID is installed. This study aims to fill that gap in knowledge. METHODS: Using the Timeline Follow-back interview procedure, we assessed the daily drinking of 153 convicted DUI offenders' self-reported total alcohol consumption and rates of self-reported driving after drinking over 4 phases: before DUI arrest, between arrest and IID installation, during the phase on the interlock, and after the interlock is removed. Because information about behaviors in each period was not available for every participant, comparisons were made using paired-sample contrasts. RESULTS: Compared with before the arrest, total alcohol use decreased by 50% in the 4-month phase following arrest and before IID installation, though it did not change much afterward. The frequency of drinking and driving decreased sharply after the arrest (-82%), with further decrease upon installation of the interlock (-58%, p = 0.05). The frequency of drinking and driving after the IID was removed returned to preinstallation drinking and driving status (+58%, p = 0.01). CONCLUSIONS: Participants made significant adjustments to their drinking behavior by adhering to the traditional DUI driving restrictions in the postarrest phase. Although installation of an IID was not associated with a significant change in drinking, it further reduced the frequency of drinking and driving. Evaluations of the IID experience should take into account information on an individual's drinking and DUI behaviors not only before the IID was installed, but before the individual was arrested.

Typologies of Drivers Convicted of Driving Under the Influence of Alcohol as Predictors of Alcohol Ignition Interlock Performance.

Background: Alcohol ignition interlock devices (IIDs) reduce rates of drinking and driving when installed on the vehicles of offenders. While the IID is installed on their vehicle, some drivers adapt their drinking behaviors, while others cannot. Heavy alcohol use and mental health concerns reduce treatment adherence in clinical settings, but it has not yet known how they pertain to behavioral adaptation to IIDs. Objectives: This study focuses on identifying driver typologies as predictors of performance while on alcohol IIDs. Methods: The study utilizes the Managing Heavy Drinking study of drivers in New York state. Participants (N = 101; 59 males, 42 females) completed questionnaires assessing demographic information, drinking behaviors, driving history and mental health measures. All participants had been convicted of a DUI, and installed an IID. Latent class analysis was used to establish typologies and predict lockout ratios. Results: Four typologies emerged and drivers with elevations in mental health concerns had significantly worse lockout ratios than those in other classes. Conclusions: The current study may provide support for interventions designed to identify drivers with comorbid mental health concerns and tailor appropriate interventions to administer while the IID is installed with the aim of improving behavioral adaptation to the device.

The impact of interlock installation on driving behavior and drinking behavior related to driving.

OBJECTIVE: There is a substantial body of evidence that the recidivism of impaired-driving offenders is reduced while an ignition interlock device (IID) is on their vehicles. This study examines changes in driving behaviors and drinking behaviors used by DWI offenders to manage driving with the IID. METHODS: A total of 166 IID participants who completed two surveys covering the period from arrest to IID installation (T1) and during IID use (T2) were examined. Four domains were covered: demographics, driving environments and transportation needs, reported driving activity, and reported drinking activities. Participants were on average 38 years old, 43% were female, 35% completed college, 34% had an income of more than $50,000, and 83% were employed. For those who provided it, the mean blood alcohol content (BAC) at arrest was .184 g/dL, with only 8 (5%) individuals below .08 g/dL, and 93 (56%) at over .18 g/dL. About 45% were repeat DWI offenders. RESULTS: Between T1 and T2 there was a slight increase in acknowledging public transportation was available (p=.001), an increase in other individuals driving the interlock-equipped vehicle (p=.002), an increase in the number of vehicles in the household not registered to the DWI offender (p< .001), and an increase in the number of participants who reported that driving was important to their lifestyle (p=.008). Initial (T1) expectations about whether the interlock would be a problem were significantly different from actual experiences reported in T2 (p<.001). With respect to alcohol consumption, 14% reported abstinence at T2 compared to 2% at T1 (p=.001) and the number of drinks per drinking occasion decreased from a mean of 4.90 at T1 to 3.14 at T2 (p=.001), but the number of drinking occasions increased by a third (p=.003). The number of drinking locations (p=.001), the frequency of stopping after work for a drink (p=.001), and drinking at a bar all decreased (p<.001). CONCLUSIONS: Interlock users make some adjustments in how they drink, the amount they drink, and where they drink. This finding suggests that there may be methods that can be used to extend the benefits of the IID beyond the sanction period.

Potential for cannabis adaptation among participants in a drunk driving intervention.

BACKGROUND: Some alcohol interventions have been found to have the adverse outcome of increasing non-alcohol-related substance use. It is unknown, however, how changes in alcohol use over the course of alcohol ignition interlocks - a common DUI intervention - may impact other substance use. METHODS: Alcohol and cannabis use were measured using hair ethylglucuronide and Delta-9-Tetrahydrocannabinol concentrations in blood, respectively. Participants (N = 69) were measured at the interlock installation period and again 6-months later while the interlock was installed. A mixed ANOVA was conducted to examine changes in levels of ethanol and THC over time. RESULTS: On measures of marijuana use, there was a significant interaction effect between the group that increased alcohol use and time F(2, 66) = 7.863, p =.001; partial η 2 =.192; as well as a main effect for time F(2, 66) = 21.106, p <.001; partial η 2 =.242. CONCLUSIONS: Installing interlocks may inadvertently increase cannabis use among those who decrease alcohol use. Crash risk associated with cannabis use is notably less than that of alcohol use, however, continued cannabis use may be problematic when the device is removed and alcohol use is expected to return to the higher pre-interlock levels.

Innovations in Airway Surgery.

The management of pediatric airway stenosis has evolved considerably over time. At the outset, dilation was the mainstay of management. In the 1900s, open surgery in the form of cricoid expansion procedures or resection procedures was the primary treatment with subsequent development of the slide tracheoplasty. Now in the twenty-first century, advances in endoscopic management, balloon dilation, and stenting, along with the advent of external scaffolds and tissue replacement continue to advance pediatric airway surgery.

Cervical slide tracheoplasty in adults with laryngotracheal stenosis.

OBJECTIVES: 1) Evaluate success rates for adults undergoing cervical slide tracheoplasty. 2) Examine complication rates of slide tracheoplasty in adults. METHODS: A retrospective cohort of adults > 21 years of age undergoing cervical slide tracheoplasty for tracheal stenosis between October 2011 and August 2017 was reviewed. Comorbidities, stenosis grade, etiology of stenosis, primary versus revision surgery, complications, and number of adjunct endoscopic procedures required postoperatively were evaluated. RESULTS: Nineteen patients (63% female) underwent cervical slide tracheoplasty during the study period (median age 30 years, range 21-70). The most common etiology of stenosis was iatrogenic (68%), followed by congenital etiologies (26%). Fifty-eight percent of patients had undergone a previous open airway procedure. Thirty-nine percent were tracheostomy-dependent prior to surgery, and the remainder had severe exercise intolerance. Sixty-three percent were successfully extubated on the operating room table at the end of the procedure. Six (32%) patients experienced surgical complications, including one anastomotic dehiscence, three neck abscesses requiring incision and drainage (I&D), and replacement of adjunctive airway device in two patients. Seventy percent of the patients required ≥ 1 endoscopic dilation in the first 12 months following surgery, with a median of one (range 1-8) procedure. At most recent follow-up (median 8 months, range 4-64 months), 18 of 19 (95%) of patients had minimal airway symptoms without need for tracheostomy. The one patient who was not decannulated expired of a presumed cardiac event prior to decannulation. CONCLUSION: Cervical slide tracheoplasty is an excellent reconstructive option for adult patients with tracheal stenosis, including those with history of previous airway reconstruction. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:818-822, 2019.

Can Predictive Modeling Identify Head and Neck Oncology Patients at Risk for Readmission?

Objective Unplanned readmission within 30 days is a contributor to health care costs in the United States. The use of predictive modeling during hospitalization to identify patients at risk for readmission offers a novel approach to quality improvement and cost reduction. Study Design Two-phase study including retrospective analysis of prospectively collected data followed by prospective longitudinal study. Setting Tertiary academic medical center. Subjects and Methods Prospectively collected data for patients undergoing surgical treatment for head and neck cancer from January 2013 to January 2015 were used to build predictive models for readmission within 30 days of discharge using logistic regression, classification and regression tree (CART) analysis, and random forests. One model (logistic regression) was then placed prospectively into the discharge workflow from March 2016 to May 2016 to determine the model's ability to predict which patients would be readmitted within 30 days. Results In total, 174 admissions had descriptive data. Thirty-two were excluded due to incomplete data. Logistic regression, CART, and random forest predictive models were constructed using the remaining 142 admissions. When applied to 106 consecutive prospective head and neck oncology patients at the time of discharge, the logistic regression model predicted readmissions with a specificity of 94%, a sensitivity of 47%, a negative predictive value of 90%, and a positive predictive value of 62% (odds ratio, 14.9; 95% confidence interval, 4.02-55.45). Conclusion Prospectively collected head and neck cancer databases can be used to develop predictive models that can accurately predict which patients will be readmitted. This offers valuable support for quality improvement initiatives and readmission-related cost reduction in head and neck cancer care.

Characterizing Decisional Conflict for Caregivers of Children With Obstructive Sleep Apnea Without Tonsillar Hypertrophy.

STUDY OBJECTIVES: The goals of this study were to (1) evaluate the degree of decisional conflict (DC) experienced by caregivers of children with obstructive sleep apnea (OSA) without tonsillar hypertrophy; and (2) describe the association between DC, quality of life (QOL), and OSA severity. METHODS: This study comprised children evaluated in the multidisciplinary upper airway center at the Cincinnati Children's Hospital Medical Center from December 2014 to May 2016. Caregivers were asked to complete surveys (Pediatric Quality of Life Inventory 4.0 [PedsQL], OSA-18, Epworth Sleepiness Scale, Family Impact Questionnaire, Decisional Conflict Scale, CollaboRATE scale, and SURE questionnaire) during a clinic visit. Polysomnography data were collected. Analysis included Kruskal-Wallis, Wilcoxon rank-sum, and regression testing. RESULTS: Caregivers of 76 children participated; 16 (21.1%) had high DC. There were no significant differences in demographics between those with low and high DC; the low DC group had a higher obstructive apnea-hypopnea index (13.2 versus 12.3 events/h; P = .013). Overall and disease-specific QOL, sleepiness, family impact scores, and DC did not differ by OSA severity except for the PedsQL physical subcategory (P = .02). DC was associated with the total PedsQL (P = .043) on univariate regression; however, this did not persist (P = .61) after controlling for demographic variables. DC scores correlated well with CollaboRATE and SURE throughout the analysis (P < .001). CONCLUSIONS: The proportion of caregivers of children with OSA without tonsillar hypertrophy who experienced a high level of DC regarding their child's treatment was 21.1%. Neither DC nor OSA severity was related to QOL in children with OSA. The briefer SURE or CollaboRATE scales were adequate tools to measure DC in these children.