Probability-Based Estimates of Severe Acute Respiratory Syndrome Coronavirus 2 Seroprevalence and Detection Fraction, Utah, USA.

We aimed to generate an unbiased estimate of the incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in 4 urban counties in Utah, USA. We used a multistage sampling design to randomly select community-representative participants >12 years of age. During May 4-June 30, 2020, we collected serum samples and survey responses from 8,108 persons belonging to 5,125 households. We used a qualitative chemiluminescent microparticle immunoassay to detect SARS-CoV-2 IgG in serum samples. We estimated the overall seroprevalence to be 0.8%. The estimated seroprevalence-to-case count ratio was 2.5, corresponding to a detection fraction of 40%. Only 0.2% of participants from whom we collected nasopharyngeal swab samples had SARS-CoV-2-positive reverse transcription PCR results. SARS-CoV-2 antibody prevalence during the study was low, and prevalence of PCR-positive cases was even lower. The comparatively high SARS-CoV-2 detection rate (40%) demonstrates the effectiveness of Utah's testing strategy and public health response.

Obesity-Preventive Behaviors and Improvements in Depression among Diverse Utah Women Receiving Coaching from Community Health Workers.

OBJECTIVES: This study evaluated how high versus low-intensity community wellness coaching and health behaviors were associated with changes in depression screen results over one year. METHODS: This was an analysis of secondary data collected in a 12-month obesity-related community health worker (CHW) program for 485 Utah women of color. Depression screen (Patient Health Questionnaire-2 score ³3) and self-reported fruit/vegetable consumption and physical activity (FV/PA) were recorded quarterly. Associations between FV/PA and changes in depression screen over time were evaluated in multivariable models. RESULTS: Positive depression screen prevalence declined over 12 months (21.7% to 9.5%) with no difference between study arms. Overall, FV ³5 times/day (AOR=1.5; 95% CI 1.0-2.2), any PA (AOR=3.1; 95% CI 1.5-6.4), and muscle strengthening activities (AOR=1.13; 95% CI 1.01-1.26) were associated with improved depression screen results over time. CONCLUSION: These results indicate value in addressing and evaluating depression in obesity-related interventions in underserved communities.

Development and validation of the Indian Adolescent Health Questionnaire.

The period of adolescence is a critical time of development. There is an urgent need to better assess adolescent health worldwide, particularly in India, a country with the world's largest adolescent population. Validated screening tools are needed to evaluate health-related risks and behaviors in this growing demographic. We developed, validated and administered a school-based health assessment, the Indian Adolescent Health Questionnaire, which can be used as a comprehensive health-screening tool among Indian adolescents in secondary school.

Sex difference in the discordance between Abbott Architect and EuroImmun serological assays.

Background: This study evaluated the discordance between Abbott Architect SARS-CoV-2 IgG and EUROIMMUN SARS-COV-2 ELISA in a seroprevalence study. Methods: From June 10 to August 15, 2020, 8,246 specimens were dually evaluated by the Abbott Architect SARS-CoV-2 IgG (Abbott) and the EUROIMMUN SARS-CoV-2 ELISA (EI) assays. Sex-stratified phi correlation coefficients were calculated to evaluate the concordance between Abbott and EI assay's quantitative results. Multivariable mixed-effect logistic models were implemented to evaluate the association between assay positivity and sex on a low prevalence sample while controlling for age, race, ethnicity, diabetes, cardiovascular disease, hypertension, immunosuppressive therapy, and autoimmune disease. Results: EI positivity among males was 2.1-fold that of females; however, no significant differences in Abbott positivity were observed between sexes. At the manufacturer-recommended threshold, the phi correlation coefficient for the Abbott and EI qualitative results among females (Φ = 0.47) was 34% greater than males (Φ = 0.35). The unadjusted and fully adjusted models yielded a strong association between sex and positive EI result for the low prevalence subgroup (unadjusted OR: 2.24, CI: 1.63, 3.11, adjusted OR: 3.40, CI: 2.15, 5.39). A similar analysis of Abbott positivity in the low prevalence subgroup did not find an association with any of the covariates examined. Significant quantitative and qualitative discordance was observed between Abbott and EI throughout the seroprevalence study. Our results suggest the presence of sex-associated specificity limitations with the EI assay. As these findings may extend to other anti-S assays utilized for SARS-CoV-2 seroprevalence investigations, further investigation is needed to evaluate the generalizability of these findings.

Differences in perceptions and acceptance of COVID-19 vaccination between vaccine hesitant and non-hesitant persons.

Acceptance of the COVID-19 vaccination becomes more critical as new variants continue to evolve and the United States (US) attempts to move from pandemic response to management and control. COVID-19 stands out in the unique way it has polarized patients and generated sustained vaccine hesitancy over time. We sought to understand differences in perceptions and acceptance of COVID-19 vaccination between vaccine hesitant and non-hesitant patients, with the goal of informing communication and implementation strategies to increase uptake of COVID-19 vaccines in Veteran and non-Veteran communities. This qualitative study used interview data from focus groups conducted by the Department of Veterans Affairs (VA) and the University of Utah; all focus groups were conducted using the same script March-July 2021. Groups included forty-six United States Veterans receiving care at 28 VA facilities across the country and 166 non-Veterans across Utah for a total of 36 one-hour focus groups. We identified perceptions and attitudes toward COVID-19 vaccination through qualitative analysis of focus group participant remarks, grouping connections with identified themes within domains developed based on the questions asked in the focus group guide. Responses suggest participant attitudes toward the COVID-19 vaccine were shaped primarily by vaccine attitude changes over time, impacted by perceived vaccine benefits, risks, differing sources of vaccine information and political ideology. Veterans appeared more polarized, being either largely non-hesitant, or hesitant, whereas non-Veterans had a wider range of hesitancy, with more participants identifying minor doubts and concerns about receiving the vaccine, or simply being altogether unsure about receiving it. Development of COVID-19 vaccine communication strategies in Veteran and non-Veteran communities should anticipate incongruous sources of information and explicitly target community differences in perceptions of risks and benefits associated with the vaccine to generate candid discussions and repair individuals' trust. We believe this could accelerate vaccine acceptance over time.

High dose brachytherapy as monotherapy for intermediate risk prostate cancer.

PURPOSE: We evaluated our retrospective, single institution experience with high dose rate brachytherapy as monotherapy for intermediate risk prostate cancer. MATERIALS AND METHODS: Our cohort included 284 patients with intermediate risk prostate cancer, defined as clinical stage T2b/T2c, Gleason score 7 and/or prostate specific antigen 10 to 20 ng/ml, and 1-year minimum followup. Treatment was 2 high dose rate brachytherapy sessions at 3 fractions of 6.5 Gy each for a mean of 19 days. Prostate specific antigen failure was defined as nadir +2 ng/ml. RESULTS: Mean followup was 35.1 months (median 31.9). Actuarial 5-year cause specific survival and clinical local control were 100%, distant-metastasis-free survival 98.8% and biochemical disease-free survival 94.4%. Clinical stage predicted biochemical disease-free survival. For stage T2a or less 5-year biochemical disease-free survival was 95.1% vs 100% for stage T2b and 77.4% for T2c (p = 0.012). Percent positive biopsy cores and prostate specific antigen nadir were also predictive. International Prostate Symptom Score results remained stable and potency was maintained in 82.6% of patients at 2 years. Pads were used for the first time after brachytherapy in 22 patients (7.7%), mostly for grade 1 incontinence (occasionally or less per week). Excluding patients with prior transurethral prostatectomy, stroke or tremor 2.5% used pads for the first time after treatment. No patient had urethral stricture. Radiation Therapy Oncology Group grade 1 rectal toxicity developed in 12 patients (4.2%) but not beyond grade 1. CONCLUSIONS: High dose rate brachytherapy as monotherapy is safe and effective for patients with intermediate risk prostate cancer. We recommend caution for percent positive biopsy cores exceeding 75% or clinical stage T2c. Excluding such patients the 5-year biochemical disease-free survival rate was 97.5%.

Strategies to increase rural maternal utilization of skilled health personnel for childbirth delivery in low- and middle-income countries: a narrative review.

BACKGROUND: Skilled attendance at birth is considered key to accomplishing Sustainable Development Goal (SDG) 3.1 aimed at reducing maternal mortality. Many maternal deaths can be prevented if a woman receives care by skilled health personnel. Maternal utilization of skilled health delivery services in rural areas in low- and middle-income countries is 70% compared to 90% in urban areas. Previous studies have found community-based interventions may increase rural maternal uptake of skilled health delivery services, but evidence is lacking on which strategies are most effective. OBJECTIVE: To review the effectiveness of community-based strategies to increase rural maternal utilization of skilled health personnel for childbirth delivery in low-and middle-income countries. METHODS: We conducted a narrative review. PubMed, CINAHL, Cochrane Library, and PsycINFO databases were searched for articles from database inception through 13 November 2019. Key search terms were pre-determined. Information was extracted on studies meeting our inclusion criteria: cluster and randomized trials, rural setting, reproductive aged women, community engagement, low- and middle-income countries. Studies were considered effective if statistically significant (p < 0.05). A narrative synthesis was conducted. RESULTS: Ten cluster randomized trials out of 5,895 candidate citations met the inclusion criteria. Strategies included home-based visits, women's groups, and combined approaches. Out of the ten articles, only three studies were found to significantly increase maternal uptake of skilled health personnel for delivery, and each used a different strategy. The results are inconclusive as to which strategies are most effective. Limitations of this review include heterogeneity and generalizability of studies. CONCLUSIONS: This research suggests that different strategies may be effective at improving maternal utilization of skilled health personnel for delivery in certain rural settings while ineffective in others. More research is warranted to better understand the context in which strategies may be effective and under what conditions.

Clinical risk factors for fracture among postmenopausal patients at risk for fracture: a historical cohort study using electronic medical record data.

Osteoporosis represents a growing health burden, but recognition and screening rates are low. Electronic reminders for osteoporosis have been beneficial but are not based on clinical risk factors. Available risk screening tools may contain useful constructs for creating risk-based electronic medical record (EMR) reminders. Using a cohort study design among women ≥50 years with osteoporosis or osteoporosis risk, we searched the EMR for five World Health Organization (WHO) clinical risk factors including older age, lower body mass index (BMI), low bone mineral density (BMD), history of fracture since age 50, and maternal history of osteoporosis or fracture. Rates of reporting were lower than expected for BMD (6.8%), personal history of fracture (3.5%), and maternal history of fracture (0.3%). Despite the limitations, the EMR data were useful for identifying women at highest risk for fracture. Some evidence of bias in reporting rates was present. EMR data can be useful for identifying high fracture risk patients.

Impact of early and concurrent stunting on cognition.

Undernutrition is associated with poor cognitive development, late entry into school, decreased years of schooling, reduced productivity and smaller adult stature. We use longitudinal data from 1674 Peruvian children participating in the Young Lives study to assess the relative impact of early stunting (stunted at 6-18 months of age) and concurrent stunting (stunted at 4.5-6 years of age) on cognitive ability. Anthropometric data were longitudinally collected for children at 6-18 months of age and 4.5-6 years of age at which time verbal and quantitative ability were also assessed. We estimate that an increase in concurrent height-for-age z-scores (HAZ) by one standard deviation was associated with an increase in a child's score on the Peabody Picture Vocabulary Test (PPVT) by 2.35 points [confidence interval (CI): 1.55-3.15] and a 0.16 point increase on the cognitive development assessment (CDA) (CI: 0.05-0.27). Furthermore, we report that the estimate for concurrent HAZ and PPVT is significantly higher than the estimate for early stunting and PPVT. We found no significant difference between early and concurrent estimates for HAZ and CDA. Children from older mothers, children whose mothers had higher education levels, children living in urban areas, children who attended pre-school, children with fewer siblings and children from wealthier backgrounds scored higher on both assessments. Cognitive skills of children entering school were associated with early stunting but the strongest association was found with concurrent stunting suggesting that interventions preventing linear growth faltering should not only focus on the under 2s but include children up to 5 years of age.

High variability in transmission of SARS-CoV-2 within households and implications for control.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) poses a high risk of transmission in close-contact indoor settings, which may include households. Prior studies have found a wide range of household secondary attack rates and may contain biases due to simplifying assumptions about transmission variability and test accuracy. METHODS: We compiled serological SARS-CoV-2 antibody test data and prior SARS-CoV-2 test reporting from members of 9,224 Utah households. We paired these data with a probabilistic model of household importation and transmission. We calculated a maximum likelihood estimate of the importation probability, mean and variability of household transmission probability, and sensitivity and specificity of test data. Given our household transmission estimates, we estimated the threshold of non-household transmission required for epidemic growth in the population. RESULTS: We estimated that individuals in our study households had a 0.41% (95% CI 0.32%- 0.51%) chance of acquiring SARS-CoV-2 infection outside their household. Our household secondary attack rate estimate was 36% (27%- 48%), substantially higher than the crude estimate of 16% unadjusted for imperfect serological test specificity and other factors. We found evidence for high variability in individual transmissibility, with higher probability of no transmissions or many transmissions compared to standard models. With household transmission at our estimates, the average number of non-household transmissions per case must be kept below 0.41 (0.33-0.52) to avoid continued growth of the pandemic in Utah. CONCLUSIONS: Our findings suggest that crude estimates of household secondary attack rate based on serology data without accounting for false positive tests may underestimate the true average transmissibility, even when test specificity is high. Our finding of potential high variability (overdispersion) in transmissibility of infected individuals is consistent with characterizing SARS-CoV-2 transmission being largely driven by superspreading from a minority of infected individuals. Mitigation efforts targeting large households and other locations where many people congregate indoors might curb continued spread of the virus.

Children who recover from early stunting and children who are not stunted demonstrate similar levels of cognition.

Stunting is associated with adverse cognitive development in childhood and adolescence, fewer years of schooling, decreased productivity, and reduced adult stature. Recovery from early stunting is possible; however, few studies explore whether those who demonstrate linear catch-up growth experience long-term cognitive deficits. Using longitudinal data on 1674 Peruvian children from the Young Lives study, we identified factors associated with catch-up growth and assessed whether children who displayed catch-up growth have significantly lower cognition than children who were not stunted during infancy and childhood. Based on anthropometric data for children 6-18 mo of age and again for the same children when they were 4.5-6 y of age, we categorized participants as not stunted, stunted in infancy but not childhood (catch-up), stunted in childhood, and stunted in infancy and childhood. Children who had grandparents in the home, had less severe stunting in infancy, and had taller mothers were more likely to demonstrate catch-up growth by round 2. Children who experienced catch-up growth had verbal vocabulary and quantitative test scores that did not differ from children who were not stunted (P = 0.6 and P = 0.7, respectively). Those stunted in childhood as well as those stunted in infancy and childhood scored significantly lower on both assessments than children who were not stunted. Based on findings from this study, policy makers and program planners should consider redoubling efforts to prevent stunting and promote catch-up growth over the first few years of life as a way of improving children's physical and intellectual development.

Exploring the relationship between chronic undernutrition and asymptomatic malaria in Ghanaian children.

BACKGROUND: A moderate association has been found between asymptomatic parasitaemia and undernutrition. However, additional investigation using the gold standard for asymptomatic parasitaemia confirmation, polymerase chain reaction (PCR), is needed to validate this association. Anthropometric measurements and blood samples from children less than five years of age in a rural Ghanaian community were used to determine if an association exists between chronic undernutrition and PCR-confirmed cases of asymptomatic malaria. METHODS: This was a descriptive cross-sectional study of 214 children less than five years of age from a community near Kumasi, Ghana. Blood samples and anthropometric measurements from these children were collected during physical examinations conducted in January 2007 by partners of the Barekuma Collaborative Community Development Programme. RESULTS: Findings from the logistic model predicting the odds of asymptomatic malaria indicate that children who experienced mild, moderate or severe stunting were not more likely to have asymptomatic malaria than children who were not stunted. Children experiencing anaemia had an increased likelihood (OR = 4.15; 95% CI: 1.92, 8.98) of asymptomatic malaria. Similarly, increased spleen size, which was measured by ultrasound, was also associated with asymptomatic malaria (OR = 2.17; 95% CI: 1.44, 3.28). Fast breathing, sex of the child, and age of the child were not significantly associated with the asymptomatic malaria. CONCLUSIONS: No significant association between chronic undernutrition and presence of asymptomatic malaria was found. Children who experience anaemia and children who have splenomegaly are more likely to present asymptomatic malaria. Programmes aimed at addressing malaria should continue to include nutritional components, especially components that address anaemia.

Improving quality of life of children with oral clefts: perspectives of parents.

Quality of life is increasingly recognized as an important health outcome in people with surgically treatable conditions. However, few data are available on children with oral clefts. Focus groups provide a rich exploratory approach to understanding health-related quality of life issues. We report findings from 2 focus groups of parents of children with oral clefts (cleft lip, cleft palate, and cleft lip and palate) in Utah and Idaho. Participants were guided into a discussion of issues and drivers of quality of life, from diagnosis through treatment to school entry. Parents identified crucial factors including the early need for support (including parent support groups), for credible information, and for advice for daily life. Surgery was a major factor affecting satisfaction and quality of life, and satisfaction depended not only on surgical results but importantly on communication, empathy, expectations, postsurgical care, and discharge management. Many parents underscored as critically important the preparation and the postsurgery experience, rather than the surgery itself. Parents also identified crucial milestones, including birth, diagnosis, the first surgery, and school entry. Combining these crucial issues with a life-stage approach provides a framework for intervention that focuses on drivers of quality of life at selected milestones in the life of children with oral clefts.

Court compliance as a predictor of postadjudication recidivism for domestic violence offenders.

This study evaluated pre- and postadjudication behavior of 220 male defendants convicted of a domestic violence-related offense using court records and police department data. Our goal was the identification of possible predictors for continued criminal behavior that could pose a risk of further harm to victims. Factors identified as significant predictors of defendant recidivism were having two or more court reports of noncompliance with domestic violence treatment, two or more warrants issued by the court for noncompliance, and two or more reports to law enforcement of new criminal activity involving the defendant. Law enforcement reports were the strongest predictor of recidivism, with an odds ratio of 7.7 and confidence interval of 3.0-19.7. These results illustrate the importance of monitoring multiple dimensions of defendant behavior while under court supervision and of communicating information on noncompliance with victims and advocates to assist in safety planning efforts.

The Community Faces Model: Community, University and Health Department Partners Thriving Together for Effective Health Education.

We use a community based participatory research approach to examine the processes of collaboration and communication, as well as the relational interactions of one community focused health promotion coalition, the Community Faces of Utah (CFU). We assess the evolution, structure, successes, and challenges of the coalition, comprised of five distinct cultural communities, a state health department, and a university. Researchers from the university collaborated with the coalition to find that CFU is an equitable, collaborative partnership of diverse leaders that functions successfully. Shared values and trusting relationships emerged over time, forming the basis for group interaction. A community liaison to facilitate interaction and collaboration was an essential element of the success of this partnership. The experience of CFU can guide other multi-sectoral partnerships in developing functionality consistent with achieving community driven objectives.

A case control population-based study investigating smoking as a risk factor for gastroschisis in Utah, 1997-2005.

BACKGROUND: Smoking in pregnancy increases the risk for many different adverse pregnancy outcomes, including birth defects. Gastroschisis, a birth defect most commonly associated with young maternal age has been associated with smoking, but findings are inconsistent. We assessed whether smoking increases the risk for gastroschisis using population-based data from Utah. METHODS: Gastroschisis cases (n = 189) were identified from the Utah Birth Defect Network and all live births without birth defects (n = 423,499) occurring in Utah from January 1, 1997 through December 31, 2005 served as controls. Exposure data were derived from birth certificates and fetal death certificates and, for terminated pregnancies, the Utah Birth Defect Network. RESULTS: Women who smoked during the first trimester of pregnancy had an increased risk of gastroschisis (OR 1.6; 95% CI: 1.1, 2.3) after adjusting for maternal age and preconception BMI. Discordance between birth certificate data and data from structured interviews increased exposure prevalence from 16.9 to 22.2% for case mothers and 7.4 to 13.2% for control mothers. Accounting for this misclassification, the crude OR decreased by 24%, 1.9 (1.3, 2.7). CONCLUSIONS: Though first trimester cigarette smoking was reported on birth certificates by more mothers of gastroschisis cases than controls, adjustment for confounders (maternal age and preconception BMI) and smoking misclassification suggests the association is weak. Despite a decrease in smoking prevalence among all women of childbearing years in Utah between 1997 and 2005, the prevalence of gastroschisis has not followed a similar trend.

Perioral burns after adenotonsillectomy: a potentially serious complication.

OBJECTIVES: To evaluate an institutional experience with perioral burns after adenotonsillectomy and to survey the national experience of other pediatric otolaryngologists regarding this complication. DESIGN: A retrospective review of adenotonsillectomy cases from January 1, 1997, to December 31, 2005, was performed to determine the incidence, etiology, severity, and treatment of perioral burns. An online national survey of pediatric otolaryngologists was conducted in May 2006 to identify their experience with perioral burns. SETTING: A tertiary pediatric medical center. PARTICIPANTS: We evaluated cases with patients younger than 18 years who developed a perioral burn during an adenotonsillectomy or tonsillectomy at Primary Children's Medical Center, Salt Lake City, Utah. MAIN OUTCOME MEASURES: Institutional and national incidence, number of injuries per physician, technique used, severity of injury, and outcomes. Comparisons were made with respect to respondent experience and techniques used. RESULTS: Seven cases of perioral burn from a single institution were identified from 4327 procedures, with 1 injury requiring reconstructive surgery. The survey response rate was 101 of 298 invitations (33.9%). Sixty-one respondents reported a total of 124 perioral burns after adenotonsillectomy. Monopolar cautery was the most common technique associated with this injury (n = 84). Coblation was the second most common technique associated with perioral burns and represented 15 (12.1%) of the reported complications. A defective electrocautery device tip was the most commonly identified cause of burn (n = 25), followed by operator error (n = 13), conduction through a metal instrument (n = 8), and lack of insulation in a cautery device (n = 7). Coblation injury was attributed to direct heat transfer from the device shaft. No significant association with operator experience was noted. A total of 14 (11.3%) of the reported injuries were severe, resulting in the need for additional treatment. CONCLUSION: Perioral burns are an underreported complication of adenotonsillectomy that can result in severe long-term morbidity.

Reproducibility of bladder pressure measurements in critically ill patients.

OBJECTIVE: Intra-abdominal hypertension is an independent cause of multiorgan failure and directly effects other physiological measurements, making it an important factor in the management of critically ill patients, but no clinical studies have investigated the reproducibility of intra-abdominal pressure (IAP) measurement to ensure diagnostic accuracy. This study evaluated the intraobserver and interobserver variability of bladder pressure measurements. DESIGN AND SETTING: Prospective, observational study in a university-based adult surgical intensive care unit. PATIENTS: Critically ill patients undergoing intra-abdominal pressure readings, measured by nursing staff. MEASUREMENTS AND RESULTS: The study compared patient IAP measurements obtained by the same nurse (intraobserver variation) and between two different nurses (interobserver variation) in critical care patients with clinical indications for IAP monitoring. Data related to the nursing technique and performance were observed and collected for each IAP measurement obtained. Good correlation of bladder pressure measurements between the same and different individuals was found. Intraobserver and interobserver Pearson's correlations for measured IAP were 0.934 and 0.950, respectively. A unit protocol for IAP measurement standardization was modified based on observational data collected. CONCLUSIONS: Intra-abdominal pressure can be accurately and reliably measured in critically ill patients by utilizing a standardized measurement device combined with a standardized clinical protocol.

Subtotal bipolar tonsillectomy does not decrease postoperative pain compared to total monopolar tonsillectomy.

OBJECTIVE: To determine whether a subtotal bovie tonsillectomy decreases postoperative pain following adenotonsillectomy. METHODS: A prospective, randomized, double-blinded clinical trial was undertaken at a University Pediatric Children's Hospital and included 39 otherwise healthy children, aged 2-12 years, undergoing adenotonsillectomy. Patients were randomized to receive either a subtotal or total removal of the tonsils utilizing an electrocautery technique. The main outcome measures included a visual analog scale (VAS) at rest and while eating, time to take 100 cm(3) of fluid, throat, neck, and ear pain, quantity of liquids, activity level and incidence of emesis and retching. RESULTS: A repeated measures analysis using a repeated measures ANOVA failed to demonstrate a statistically significant impact with either treatment for VAS at rest or while eating (p=0.52 and 0.48, respectively). A repeated measures analysis did not show either procedure significantly affecting throat, neck or ear pain, or liquid quantity. Time to take 100 cm(3) liquids and the incidence of emesis or retching were found not to be statistically significantly different between the treatment groups. CONCLUSION: Subtotal tonsillectomy via an electrocautery technique does not reduce postoperative pain or improve outcome parameters. Subtotal tonsillectomy with this technique is not recommended for this patient population.