Reasons for Crown Failures in Primary Teeth: Protocol for a Systematic Review and Meta-Analysis.

BACKGROUND: There is a tendency nowadays to restore large defects in primary dentition with pediatric crowns instead of conventional restorations. Thus, understanding the factors contributing to the survival or failure of dental crowns in pediatric dentistry is essential for optimizing treatment outcomes. OBJECTIVE: The primary objective of this protocol is to outline the methodological approach for analyzing data from observational studies and randomized controlled trials to investigate reasons for the failure of dental crowns in primary teeth and to compute their survival and failure rates. METHODS: A comprehensive literature review will be performed in electronic databases, including PubMed (MEDLINE), Cochrane, Embase, and Web of Science. As per predefined inclusion criteria, we will include observational studies (prospective clinical studies) and randomized clinical trials that have an English abstract and involve children aged 1-10 years undergoing crown restorations. Two independent reviewers will independently screen all retrieved records and full-text articles and extract data. The study's methodological quality will be appraised using suitable tools. Assessments of publication bias will be performed using funnel plots. The findings will be described qualitatively for the systematic review. If possible, a meta-analysis will be performed to estimate failure rates by dividing the number of failures by the total exposure time. A Poisson regression model, assuming constant event rates, will be used to compute 3-year and 5-year survival proportions. The Pearson goodness-of-fit statistics will be used to assess the heterogeneity of the model. A P value <.05 will be considered significant. All analyses will be performed using R Statistical software (version 4.1.2; R Core Team). RESULTS: This systematic review and synthesis aim to assess the survival and failure rates of dental crowns in pediatric dentistry. By following this rigorous methodology, we seek to provide valuable insights into the factors contributing to the success or failure of these restorations. The results of our full review will have implications for pediatric dentists, researchers, and policy makers, helping to improve dental care for children. CONCLUSIONS: This systematic review protocol helps in establishing a thorough approach for reviewing failures in pediatric crowns. By following this methodology, standardization and transparency of the process as well as accountability for the stated methods and outcomes will be ensured. The findings of this review and analysis will provide useful data on the survival of crowns to pediatric dentists and researchers. TRIAL REGISTRATION: PROSPERO CRD42023442266; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=442266. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/51505.

Reasons for Failure of CAD/CAM Restorations in Clinical Studies: A Systematic Review and Meta-analysis.

AIM: The systematic review presented herein was performed to descriptively analyze the causes for the failure of computer-aided design/computer-aided manufacture (CAD/CAM) restorations. The meta-analysis reported herein was performed to estimate long-term survival and success rates of CAD-CAM fabrications. MATERIALS AND METHODS: Using the PICOS paradigm, a systematic search was carried out in the PubMed and Cochrane databases to identify randomized controlled trials (RCTs) and prospective observational studies reporting survival data for CAD/CAM restorations. After selecting studies with a predefined set of selection criteria, data from included prospective clinical studies and RCTs were used for a systematic review aimed at a descriptive analysis of factors associated with failure of CAD-CAM restorations. Data from the included prospective clinical studies were used for meta-analysis, wherein 5-year and 10-year survival and success rates were estimated using Poisson regression models. RESULTS: The systematic review included data from 9 RCTs and 6 observational studies, which had a median follow-up of 36 months and 60 months, respectively. About 58 failures and 118 technical/ biological complications were noted in the included RCTs and 9 failures along with 58 technical/biological complications were noted in the prospective clinical studies. Poisson regression indicated an estimated 5-year and 10-year survival rates of 85.55-100 and 71-100, respectively. The estimated 5-year and 10-year success rates were 74.2-92.75 and 33.3-85.5, respectively. CONCLUSION: Several technical and biological complications contribute to failure of CAD/CAM restorations. However, CAD/CAM restorations with routine chairside materials might have clinically meaningful success rates in the long term. CLINICAL SIGNIFICANCE: The results presented herein indicate that optimal strategies for mitigation of biological and technical complications may augment the success of CAD/CAM fabrications in restorative dentistry. Studies aimed at identification of such strategies are needed to further enhance the long-term success rates of CAD/CAM restorations.

Type 2 diabetes alters the viscoelastic behavior and macromolecular composition of vertebra.

Type 2 diabetes (T2D) affects the functional behavior of vertebra bone by altering its structural and mechanical properties. The vertebral bones are responsible to carry the body weight and it remains under prolonged constant load which results to viscoelastic deformation. The effect of T2D on the viscoelastic behavior of vertebral bone is not well explored yet. In this study, the effects of T2D on the creep and stress relaxation behavior of vertebral bone are investigated. Also, this study established a correlation between T2D associated alteration in macromolecular structure and viscoelastic behavior of vertebra. In this study T2D female rat SD model was used. The obtained results demonstrated a significant reduction in the amount of creep strain (p ≤ 0.05) and stress relaxation (p ≤ 0.01) in T2D specimens than the control. Also, the creep rate was found significantly lower in T2D specimens. On the other hand, molecular structural parameters such as mineral-to-matrix ratio (control vs T2D: 2.93 ± 0.78 vs 3.72 ± 0.53; p = 0.02), and non-enzymatic cross link ratio (NE-xL) (control vs T2D: 1.53 ± 0.07 vs 3.84 ± 0.20; p = 0.01) were found significantly altered in T2D specimens. Pearson linear correlation tests show a significant correlation; between creep rate and NE-xL (r = -0.94, p < 0.01), and between stress relaxation and NE-xL (r = -0.946, p < 0.01). Overall this study explored the understanding about the disease associated alteration in viscoelastic response of vertebra and its correlation with macromolecular composition which can help to understand the disease related impaired functioning of the vertebrae body.

Documentation in Pediatric Microlaryngoscopy/Bronchoscopy: International Modified Delphi Consensus.

BACKGROUND: Complete and accurate documentation of surgical procedures is essential for optimizing patient care, yet significant variation in operative notes persists within and across institutions. We sought to reach consensus on the most important components of an operative note for pediatric microlaryngoscopy and bronchoscopy. METHODS: A modified Delphi consensus process was used. A checklist for operative documentation, created by fellowship-trained pediatric otolaryngologists-head and neck surgeons, was sent to surgeons identified as experts in pediatric laryngoscopy and bronchoscopy. In the first round, items were rated as "keep" or "remove". In the second round, each item was rated on a 7-point Likert scale for importance. The mean score of each item was calculated to determine if consensus was reached. RESULTS: Overall, 43/74 (58.1%) surgeons responded to our survey. After two rounds of editing, 28 components reached consensus, 24 were near consensus, and 26 did not reach consensus. Items that reached final consensus had mean (SD) ratings of 6.12 (0.94) (range, 5.31-6.72). CONCLUSION: Pediatric otolaryngologists identified as bronchoscopy experts were able to create a checklist of essential components of an operative note for pediatric laryngoscopy and bronchoscopy using a Delphi method. Items reaching consensus included procedure name, description of breathing, grade of airway view, description of normal anatomic structures, grade of subglottic stenosis if present, presence and description of tracheobronchomalacia, presence of fistulae, cleft and rings, and several special cases including foreign body and tracheostomy management, as well as end of procedure disposition and complications. LEVEL OF EVIDENCE: 5 Laryngoscope, 133:1234-1238, 2023.

Fetoscopic Balloon Dilation and Stent Placement of Congenital High Airway Obstruction Syndrome Leading to Successful Cesarean Delivery.

INTRODUCTION: Without fetal or perinatal intervention, congenital high airway obstruction syndrome (CHAOS) is a fatal anomaly. The ex utero intrapartum treatment (EXIT) procedure has been used to secure the fetal airway and minimize neonatal hypoxia but is associated with increased maternal morbidity. CASE PRESENTATION: A 16-year-old woman (gravida 1, para 0) was referred to our hospital at 31 weeks gestation with fetal anomalies, including echogenic lungs, tracheobronchial dilation, and flattened diaphragms. At 32 weeks, fetoscopic evaluation identified laryngeal stenosis, which was subsequently treated with balloon dilation and stent placement. The patient developed symptomatic and regular preterm contractions at postoperative day 7 with persistent sonographic signs of CHAOS, which prompted a repeat fetoscopy with confirmation of a patent fetal airway followed by Cesarean delivery under neuraxial anesthesia. Attempts to intubate through the tracheal stent were limited and resulted in removal of the stent. A neonatal airway was successfully established with rigid bronchoscopy. Direct laryngoscopy and bronchoscopy confirmed laryngeal stenosis with a small tracheoesophageal fistula immediately inferior to the laryngeal stenosis and significant tracheomalacia. A tracheostomy was then immediately performed for anticipated long-term airway and pulmonary management. The procedures were well tolerated by both mom and baby. The baby demonstrated spontaneous healing of the tracheoesophageal fistula by day of life 7 with discharge home with ventilator support at 3 months of life. CONCLUSION: Use of repeated fetoscopy in order to relieve fetal upper airway obstruction offers the potential to minimize neonatal hypoxia, while concurrently decreasing maternal morbidity by avoiding an EXIT procedure. Use of the tracheal stent in CHAOS requires further investigation. The long-term reconstruction and respiratory support of children with CHAOS remain challenging.

Surgical Techniques for Tonsillectomy and Perioperative Respiratory Complications in Children.

OBJECTIVES: The aim of this study was to determine the incidence of perioperative respiratory complications in children following tonsillectomy with cold and hot dissection surgical techniques. STUDY DESIGN: The study was a retrospective cohort study. SETTING: Retrospective chart review was performed for all children presenting for a tonsillectomy at Texas Children's Hospital from November 2015 to December 2017. METHODS: Pre- and intraoperative patient factors, including surgical technique with cold or hot dissection (electrocautery or radiofrequency ablation), and perioperative anesthetic factors were collected to determine the incidence of perioperative respiratory complications. RESULTS: A total of 2437 patients underwent a tonsillectomy at Texas Children's Hospital from November 2015 to December 2017. The incidence of perioperative respiratory complications was 20.0% (n = 487). Sickle cell disease, cardiac disease, reactive airway disease, pulmonary disease, age >2 and <3 years, and obesity, defined as a body mass index >95th percentile for age, were significant for overall perioperative respiratory complications. There was no difference in the incidence of perioperative respiratory complications in children undergoing tonsillectomy by cold or hot dissection. CONCLUSION: Perioperative respiratory complications following tonsillectomy are more affected by patient factors than surgical technique.

Successful Repair of Non-facing Sinus ALCAPA Associated With Left-Sided Cardiomegaly Using Takeuchi Technique.

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital heart disease that may present isolated or may be associated with other cardiac malformations. Most of the patients develop symptoms during infancy but some may remain asymptomatic up to adulthood. Symptoms range from mild distress to severe irritability and feed intolerance. We report a case of a five-month-old male child who presented with congestive heart failure and was diagnosed as a case of ALCAPA with left atrial and left ventricular dilation based on two-dimensional echocardiography and computed tomography (CT) coronary angiogram. Left main coronary artery was shown to be arising from the posteroinferior wall of main pulmonary artery. Various surgical approaches have been suggested in the repair but the Takeuchi technique was preferred owing to its origin from the non-facing sinus of the pulmonary artery and co-existing dilatation of left atria and ventricle. The surgery was uneventful and there were no postoperative complications. A cardiac CT dynamic study was also done on the follow-up visit five months later and no signs of abnormality or complications were reported. Early intervention is necessary to prevent irreversible cardiac complications and early mortality.

Genetic Polymorphisms of NLRP3 (rs4612666) and CARD8 (rs2043211) in Periodontitis and Cardiovascular Diseases.

BACKGROUND: The existing data show that inflammasomes play a role in periodontal disease pathogenesis. However, their role in the pathogenesis of periodontitis and coronary heart disease remains unclear. This study had the objective of assessing NLRP3 (rs4612666) and CARD8 (rs2043211) gene polymorphisms in dental plaque and blood of generalized chronic periodontitis (CP) patients in the presence and absence of coronary heart disease (CHD). METHODS: A total of 70 subjects were divided into two groups, including CP and CP + CHD subjects. Demographic variables, periodontal, and cardiac parameters were recorded from both groups. Subgingival plaque and blood samples were obtained from both groups and were subjected to further molecular analysis for NLRP3 (rs4612666) and CARD8 (rs2043211) expression and allele change using conventional polymerase chain reaction (PCR) and gene sequencing (Sanger's method). RESULTS: Amongst the demographic variables, age, and monthly income were statistically significant between the two groups. Plaque index (PI), clinical attachment level (CAL), high-density lipoprotein (HDL), and low density-lipoprotein (LDL) exhibited statistically significant levels between the two groups. NLRP3 (rs4612666) and CARD8 (rs2043211) genes showed a statistically significant association of allele change (frequency) among the groups. In general, when all of the parameters were compared to the allele change of the genes, statistically significant relationships were found between the two groups. CONCLUSIONS: The present study expressed an allele change of the investigated genes which could profoundly affect the pathobiology of the two diseases under investigation.

Influence of Filler Composition on the Refractive Index of Four Different Enamel Shades of Composite Resins.

AIM AND OBJECTIVE: The purpose of this study was to measure the refractive index of four commercially available enamel resin composites, using optical coherence tomography (OCT) and their relationship with the atomic composition of the composite resin fillers utilizing an energy-dispersive X-ray fluorescence spectrometer (EDX). MATERIALS AND METHODS: Four different enamel composites, namely Enamel HRi color UE3, Enamel HFO color GE3, Vit-l-escence color Pearl Frost, and Amelogen Plus color Enamel White were tested. For each composite, disks with different thicknesses were fabricated and then light-cured according to the manufacturer's instructions. The disks were then stored in deionized water under 36.5 °C for at least 7 days. Each of the samples from the four different groups was measured in five distinctive points to analyze the optical and physical length using optical coherence tomography (OCT). Elemental analysis of all four different enamel shades of the composite was done using an EDX. RESULTS: The filler contents showed interesting differences in elemental composition and concentration; however, Si seemed to be a common filler component. The HRi composite presented a distinctive composition compared to other materials and was the only composite that showed a smaller percentage of SiO2, and also was the only composite that contained compounds, such as P2O5, ZnO, CaO, La2O3, and V2O5. The optical coherence tomography analysis showed the refractive index values of all tested enamel composites. Among the four different enamel composite resins tested, the enamel HRi composite demonstrated the most ideal refractive index to mimic natural enamel. CONCLUSION: The enamel HRi composite demonstrated a distinctive filler composition and this could be the main reason behind its higher refractive index. Nonetheless, it remains unclear how much of an impact this feature has in the final esthetic outcome of anterior composite restorations, where many other optical phenomena are also important. CLINICAL SIGNIFICANCE: The clinical success of any esthetic restorative procedure depends on diagnosing the proper treatment plan and also on executing this treatment with the right materials. On direct esthetic restorations, knowing the optical properties of such materials is fundamental, as they should be able to replicate both natural enamel and dentin. How to cite this article: Beolchi RS, Mehta D, Pelissier B, et al. Influence of Filler Composition on the Refractive Index of Four Different Enamel Shades of Composite Resins. J Contemp Dent Pract 2021;22(5):557-561.

Viability of Quercetin-Induced Dental Pulp Stem Cells in Forming Living Cellular Constructs for Soft Tissue Augmentation.

Autogenous gingival grafts used for root coverage or gingival augmentation procedures often result in donor site morbidity. Living cellular constructs as an exogenous alternative have been proven to be associated with lower morbidity. With the available background information, the present study aims to assess if quercetin-induced living cell constructs, derived from dental pulp stem cells, have the potential to be applied as a tool for soft tissue augmentation. The characterized dental pulp stem cells (positive for CD73, CD90, and negative for CD34, HLA-DR) were expanded in Dulbecco's Modified Eagle's medium (DMEM) supplemented with 10 mM quercetin. The handling properties of the quercetin-induced dental pulp stem cell constructs were assessed by visual, and tactile sensation. A microscopic characterization using hematoxylin and eosin staining, and qRT-PCR-based analysis for stemness-associated genes (OCT4, NANOG, SOX2, and cMyc) was also performed. Dental pulp stem cells without quercetin administration were used as the control. Dental pulp stem cell constructs induced by quercetin easily detached from the surface of the plate, whereas there was no formation in the control cells. It was also simple to transfer the induced cellular construct on the flattened surface. Microscopic characterization of the constructs showed cells embedded in a tissue matrix. Quercetin also increased the expression of stemness-related genes. The use of quercetin-induced DPSC living constructs for soft tissue augmentation could provide an alternative to autogenous soft tissue grafts to lower patient morbidity and improve esthetic outcomes.

Parathyroid Hormone Secretion and Receptor Expression Determine the Age-Related Degree of Osteogenic Differentiation in Dental Pulp Stem Cells.

OBJECTIVE: To demonstrate the levels of parathyroid hormone secretion and genetic expressions of parathyroid hormone (PTH) and PTH1 receptor (PTH1R) genes in the dental pulp stem cells (DPSCs) from different age groups before and after induction of osteogenic differentiation. In addition, we also wanted to check their correlation with the degree of osteogenic differentiation. METHODS: Human primary DPSCs from three age groups (milk tooth (SHEDs), 7-12 years old; young DPSCs (yDPSCs), 20-40 years old; old DPSCs (oDPSCs), 60+ years old) were characterized for mesenchymal stem cell (MSC) markers. DPSCs were subjected to osteogenic differentiation and functional staining. Gene expression levels were analyzed by qRT-PCR. Surface receptor analysis was done by flow cytometry. Comparative protein levels were evaluated by ELISA. RESULTS: All SHEDs, yDPSCs, and oDPSCs were found to be expressing mesenchymal stem cell markers. SHEDs showed more mineralization than yDPSCs and oDPSCs after osteogenic induction. SHEDs exhibited higher expression of PTH and PTH1R before and after osteogenic induction, and after osteogenic induction, SHEDs showed more expression for RUNX2, ALPL, and OCN. Higher levels of PTH were observed in SHEDs and yDPSCs, and the number of PTH1R positive cells was relatively lower in yDPSCs and oDPSCs than in SHEDs. After osteogenic induction, SHEDs were superior in the secretion of OPG, and the secretions of ALPL and PTH and the number of PTH1R positive cells were relatively low in the oDPSCs. CONCLUSIONS: The therapeutic quality of dental pulp stem cells is largely based on their ability to retain their stemness characteristics. This study emphasizes the criterion of aging, which affects the secretion of PTH by these cells, which in turn attenuates their osteogenic potential.

Assessing the Potential Association Between Microbes and Corrosion of Intra-Oral Metallic Alloy-Based Dental Appliances Through a Systematic Review of the Literature.

Objective: Systematic review assessing the association between oral microorganisms and corrosion of intra-oral metallic alloy-based dental appliances. Design: PubMed, Scopus, and Web of Science were searched using keyword combinations such as microbes and oral and corrosion; microbes and dental and corrosion; microorganisms and oral and corrosion; microorganisms and dental and corrosion. Results: Out of 141 articles, only 25 satisfied the selection criteria. Lactobacillus reuteri, Streptococcus mutans, Streptococcus sanguis, Streptococcus mitis, Streptococcus sobrinus, Streptococcus salivarius, sulfate-reducing bacteria, sulfate oxidizing bacteria, Veilonella, Actinomyces, Candida albicans were found to have a potential association with corrosion of intraoral metallic alloys such as stainless steel, titanium, nickel, cobalt-chromium, neodymium-iron-boron magnets, zirconia, amalgam, copper aluminum, and precious metal alloys. Conclusion: The included studies inferred an association between oral microorganisms and intra-oral metallic alloys-based dental appliances, although, it is vital to acknowledge that most studies in the review employed an in-vitro simulation of the intra-oral condition.

Modulation of the Dental Pulp Stem Cell Secretory Profile by Hypoxia Induction Using Cobalt Chloride.

The action of stem cells is mediated by their paracrine secretions which comprise the secretory profile. Various approaches can be used to modify the secretory profile of stem cells. Creating a hypoxic environment is one method. The present study aims to demonstrate the influence of CoCl2 in generating hypoxic conditions in a dental pulp stem cell (DPSCs) culture, and the effect of this environment on their secretory profile. DPSCs that were isolated from human permanent teeth were characterized and treated with different concentrations of CoCl2 to assess their viability by an 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay and proliferation by a cell counting kit (CCK)-8 assay. The gene expression level of hypoxia-inducible factor 1-alpha (HIF-1α) was analyzed by quantitative real time polymerase chain reaction (qRT-PCR) to demonstrate a hypoxic environment. Comparative evaluation of the growth factors and cytokines were done by cytometric bead array. Gene expression levels of transcription factors OCT4 and SOX2 were analyzed by qRT-PCR to understand the effect of CoCl2 on stemness in DPSCs. DPSCs were positive for MSC-specific markers. Doses of CoCl2, up to 20 µM, did not negatively affect cell viability; in low doses (5 µM), it promoted cell survival. Treatment with 10 µM of CoCl2 significantly augmented the genetic expression of HIF-1α. Cells treated with 10 µM of CoCl2 showed changes in the levels of growth factors and cytokines produced. It was very evident that CoCl2 also increased the expression of OCT4 and SOX2, which is the modulation of stemness of DPSCs. A CoCl2 treatment-induced hypoxic environment modulates the secretory profile of DPSCs.

Antimicrobial Efficacy of Silver Nanoparticles as Root Canal Irrigant's: A Systematic Review.

Removal of microbes is imperative during endodontic therapy. Due to their antimicrobial property, silver nanoparticles have been used for endodontic irrigation of the root canals. The objective of the present study was to provide a qualitative analysis of the published literature assessing silver nanoparticles as root canal irrigants. A search of PubMed, SCOPUS, Web of Science, and Embase databases was done without any time restriction. Articles published in English were included. Data were extracted and the risk of bias was assessed. Of the 154 studies identified, after screening according to the inclusion criteria, five in vitro studies were included. The results indicate that silver nanoparticles have an anti-microbial effect to varying degrees depending on certain factors. Within the limitations of the present studies that have a moderate to low risk of bias, an antimicrobial effect of silver nanoparticles is observed. Silver nanoparticles have the potential to be used as endodontic irrigants, although their efficacy depends on particle size and the duration of contact which require further investigation.

Perinatal characteristics and early childhood follow up after ex-utero intrapartum treatment for head and neck teratomas by prenatal diagnosis.

BACKGROUND: Ex utero intrapartum treatment (EXIT) is utilized for safe delivery when a baby has a compromised airway. The purpose of this retrospective study was to examine the indications and outcomes of 11 children presenting with airway occluding oropharyngeal and cervical teratomas. METHODS: Study of all children with an airway occluding teratoma delivered via EXIT (2001-2018) in our unit. Primary outcomes included survival and tracheostomy at discharge. Data are reported using descriptive statistics as median (range) and rate (%). RESULTS: We performed 45 EXIT procedure performed between January 2001 and April 2018. Of these, eleven were for cervical and/or upper airway teratoma. Ten (91%) cases had associated polyhydramnios, two (18%) developed nonimmune hydrops, and eight (72%) delivered preterm. Six (45.5%) were performed as an emergency. Estimated blood loss was 1000 ml (500, 1000). The neonatal mortality rate was 18% (2/11) and 33% (3/9) of the survivors were discharged with a tracheostomy. CONCLUSION: EXIT is a reasonable option for delivery of babies with an occlusive upper airway mass. Neonatal survival depends on individualized factors but may be as high as 82% in those with teratoma.

Outcomes Using a Postoperative Protocol in Pediatric Single-Stage Laryngotracheal Reconstruction.

OBJECTIVES: The aim of this study was to evaluate single-stage laryngotracheal reconstruction (ssLTR) outcomes before and after the implementation of a postoperative care protocol in pediatric patients. METHODS: A case-control study with chart review was conducted at 2 tertiary academic centers from 2010 to 2016. Pediatric patients who underwent ssLTR with a postoperative care protocol were compared with those who did not receive care under this protocol. Data regarding perioperative management were collected and compared using χ2 and Wilcoxon rank tests. Planned extubation, length of intubation in the intensive care unit, and complications were examined. RESULTS: Nineteen patients completed ssLTR after the protocol was initiated, and 26 prior patients were used as control subjects. Planned extubation failed in 9 patients (35%) in the control group compared with 1 patient (5%) in the protocol group (P < .05). Using a structured protocol demonstrated a decrease in delayed extubation and intensive care unit stay (P < .05). Despite more postprotocol patients' requiring posterior graft placement, preprotocol patients were less likely to be extubated within 7 days (P < .05). CONCLUSIONS: The authors propose an intensive care unit protocol that uses a combination of pharmacologic agents to optimally reduce the risk for adverse events that delay time to extubation and thus decannulation. Timely extubation was more likely with the use of this postoperative care protocol using a multidisciplinary approach involving otolaryngologists, pharmacists, intensivists, and anesthesiologists.

Predictive Factors for Perinatal Outcomes of Infants Diagnosed With Micrognathia Antenatally.

INTRODUCTION: Advances in fetal imaging have allowed us to identify abnormalities previously not appreciated. With this study, we hope to identify factors predicting a difficult airway at birth and review the perinatal outcomes of these patients. METHODS: Sixteen patients with antenatally diagnosed micrognathia were reviewed from a tertiary care hospital database from 2011 to 2016. Jaw index (JI), amniotic fluid index (AFI), glossoptosis, gastric size, and oropharynx obliteration were assessed. The airway support required at birth, specialist team involvement, and outcomes were evaluated. RESULTS: Nine (56.3%) of 16 patients had JI <5th percentile, 3 (33.3%) of 9 had difficult intubation, 2 (22.2%) of 9 needed an emergency tracheostomy, and 1 (11.1%) of 9 died. Seven patients had polyhydramnios, 2 (28.6%) of 7 had difficult intubation, 2 (28.6%) of 7 required tracheostomy, and 1 (14.3%) of 7 died. Twelve patients had either JI <5th percentile or abnormal AFI, 5 (41.7%) of 12 had difficult intubation, 2 (16.7%) of 12 required tracheostomy, and 1 (8.33%) of 12 died. For the group without otolaryngology consultation, 8 (50%) of 16, 1 (12.5%) of 8 had difficult intubation and 1 (12.5%) of 8 died because airway was not secured after 45 minutes of resuscitation. CONCLUSION: Jaw index <5th percentile or abnormal AFI predicts a difficult airway. A multidisciplinary approach with otolaryngology involvement for airway intervention may be required at birth.

Competency-Based Assessment Tool for Pediatric Esophagoscopy: International Modified Delphi Consensus.

OBJECTIVES/HYPOTHESIS: Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal. STUDY DESIGN: Blinded modified Delphi consensus process. SETTING: Tertiary care center. METHODS: A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items. RESULTS: The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus. CONCLUSIONS: It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated. LEVEL OF EVIDENCE: 5. Laryngoscope, 131:1168-1174, 2021.

EXIT (ex utero Intrapartum Treatment) to Airway Procedure for Twin Fetuses With Oropharyngeal Teratomas: Lessons Learned.

Ex utero intrapartum treatment (EXIT) to airway has been described as a safe method to secure challenging fetal airways while on placental support. Herein, we present a unique case of a monochorionic-diamniotic twin pregnancy where both fetuses presented with oropharyngeal tumors requiring airway securement on placental bypass. A multidisciplinary tabletop simulation was convened to allow for personnel coordination between multiple services, OR equipment allocation, and preparation for a range of possible clinical scenarios. A tabletop simulation was chosen for planning since this is a simulation methodology commonly used for preparation in acute, high intensity multidisciplinary situations such as disaster preparation, and allows for exploration of multiple potential scenarios when outcomes are uncertain. The twins were urgently delivered for decreased fetal movement and decelerations in Twin B at 28 weeks 6 days. Twin A was delivered via EXIT to airway while Twin B had debulking of the tumor on placental support, with subsequent airway securement through a tracheostomy. In conclusion, for complex fetal procedures, detailed pre-operative planning with tabletop simulation may be a useful tool in achieving successful patient outcomes.

Pediatric obstructive sleep apnea revisited: Perioperative considerations for the pediatric Anesthesiologist.

Pediatric obstructive sleep apnea presents in up to 7% of children and represents a constellation from nasal turbulence to cessation in gas exchange. There are numerous end organ sequelae including neurocognitive morbidity associated with persistent OSA. Adenotonsillectomy (AT), the first line therapy for pediatric OSA, has not been demonstrated to reduce all end organ morbidity, specifically neurological and behavioral morbidity. Furthermore, certain at-risk populations are at higher risk from neurocognitive morbidity. Precise knowledge and perioperative planning is required to ensure optimal evidence-based practices in children with OSA. This comprehensive review covers the seminal perioperative implications of OSA, including preoperative polysomnography, pharmacotherapeutics, and postoperative risk stratification.