Decision aid prototype for treatment of pediatric sleep disordered breathing: A randomized pilot study.

OBJECTIVES: 1) To examine the feasibility and usability of a decision aid prototype (DA) for pediatric obstructive sleep apnea (OSA). 2) to estimate parameters for a future randomized controlled trial. STUDY DESIGN: Multicenter randomized pilot trial. METHODS: Ninety-nine parents of children ( < 6 years of age) undergoing consultation for adenotonsillectomy for sleep-disordered breathing were prospectively enrolled. Families were randomly assigned to receive the DA or to follow standard care procedures. All consultations were video-recorded and coded with the observing patient involvement in decision making (OPTION) instrument. Following the consultation, parents completed the Decisional Conflict Scale (DCS) and Shared Decision-Making Questionnaire (SDM-Q-9), whereas otolaryngologists completed the physician version (SDM-Q-Doc). A subset of parents and surgeons were interviewed to assess the usability of the DA. RESULTS: Overall, a significantly negative correlation between DCS and SDM-Q-9 was observed (P < 0.001). Interviews showed that parents found the DA helpful but wanted more time to read and contemplate the information. Both parents and surgeons indicated that instructions on how to use the DA would be beneficial. For parents receiving the DA, the mean total OPTION score was 13.83 out of 40 (standard deviation 5.24), compared to 11.95 (standard deviation 5.21) in those not receiving the DA (P = 0.11). There were no significant differences in the decisional conflict or shared decision making when using the DA. CONCLUSION: The DA was feasible but used differently among surgeons. The need to improve SDM techniques was suggested by both surgeons and parents. Future studies training otolaryngologists on effective SDM techniques and how to appropriately utilize decision aids may improve SDM for pediatric OSA. LEVEL OF EVIDENCE: 1b Laryngoscope, 129:229-234, 2019.

Preoperative Distress Factors Predicting Postoperative Pain in Adolescents Undergoing Surgery: A Preliminary Study.

The purpose of this study was to determine if preoperative distress factors could be used as predictors of postoperative pain in adolescents scheduled for spinal fusion surgery. Patients reporting the presence of pain before surgery reported greater pain intensity at postoperative day (POD) 1 (p = .033), POD 2 (p = .008) and at follow-up 6 weeks after surgery (p = .0001). Preoperative trait anxiety was associated with pain intensity before surgery (p = .002) but not with postoperative pain intensity (p > .05). Salivary cortisol concentrations did not differentiate between anxious and nonanxious patients based on anxiety trait (p = .21) and was not associated with postoperative pain intensity (p > .05). These findings suggest that preoperative distress factors do not predict postoperative pain intensity in the acute and intermediate period. The presence of preoperative pain was the best predictor of postoperative pain intensity, suggesting that preoperative pain assessment will identify patients at an elevated risk for intense postoperative pain.

Women's Experiences With Flap Failure After Autologous Breast Reconstruction: A Qualitative Analysis.

Clinical experience suggests that flap failure after autologous breast reconstruction can be a devastating experience for women. Previous research has examined women's experiences with autologous breast reconstruction with and without complications, and patients' experiences with suboptimal outcomes from other medical procedures. The authors aimed to examine the psychosocial experience of flap failure from the patient's perspective. Seven women who had experienced unilateral flap failure after deep inferior epigastric perforator flap surgery in the past 12 years completed semistructured interviews about their breast cancer treatments, their experiences with flap failure, the impact of flap failure on their lives, and the coping strategies they used. Interpretive phenomenological analysis, a type of qualitative analysis that provides an in-depth account of participant's experiences and their meanings, was used to analyze the interview data. From these data, patient-derived recommendations were developed for surgeons caring for women who have experienced flap failure. Three main themes (6 subthemes) emerged: coming to terms with flap failure (coping with emotions, body dissatisfaction); making meaning of flap failure experience (questioning, relationship with surgeon); and care providers acknowledging the emotional experience of flap failure (experience of being treated "mechanically," suggestions for improvement). In conclusion, flap failure in breast reconstruction is an emotionally difficult experience for women. Although there are similarities to other populations of patients experiencing suboptimal outcomes from medical procedures, there are also unique aspects of the flap failure experience. A better understanding of women's experiences with flap failure will assist in providing more appropriate supports.

Measuring attentional bias in children with prominent ears: A prospective eye-tracking study.

BACKGROUND AND AIM: When observing new faces, most people focus their attention on the central triangle of the face containing the eyes, nose and mouth. When viewing faces with prominent ears, observers may divert their attention from the central triangle. The objective of this study was to determine whether there was an objective attentional bias to prominent ears in comparison to non-prominent ears. METHODS: A total of 24 naïve participants (13 female; mean age 22.88 years) viewed 15 photographs of children with bilateral prominent ears, unilateral prominent ears and non-prominent ears. Both pre- and post-otoplasty photographs of two patients were included. The eye movements of participants were recorded using the EyeLink 1000, a table-mounted eye-tracking device. RESULTS: Overall, the participants spent more time looking at the ear regions for faces with prominent ears in comparison to faces without prominent ears (p = 0.007, Z = -2.688). The attentional bias to the ear region of the patient who underwent bilateral otoplasty was significantly reduced in the post-operative photograph (p = 0.011, Z = -2.534). The patient who underwent unilateral otoplasty had no significant change in fixation times towards the ear region (p = 0.594, Z = -0.533). CONCLUSIONS: This study presents objective data to support the notion that observers show attentional bias to the ear region when viewing faces of children with prominent ears. The scope of this finding requires further research in both extent and impact.

Children's Immediate Postoperative Distress and Mothers' and Fathers' Touch Behaviors.

OBJECTIVE: This study examined mothers' and fathers' use of child-directed touch in the postanesthesia care unit. METHODS: In all, 142 mothers and 112 fathers of 143 children aged 2-11 years undergoing outpatient surgery participated. Parent touch (instrumental, empathic) and child distress were coded. Mothers' and fathers' rates of touch were compared, and interrelations between touch and child distress were examined (overall and sequentially). RESULTS: The proportion of mothers and fathers who used touch did not differ, but mothers' rates of touch were higher than fathers'. Parental instrumental touch and mothers embracing touch were positively correlated with children's distress. Mothers were more likely to use embracing touch in response to children's distress than at any other time. CONCLUSIONS: Results point to potential differences in mothers' and fathers' roles in the postoperative setting, and potentially different functions of touch. Results suggest that mothers may provide embracing touch to soothe or prevent children's distress.

Pediatric otoplasty and informed consent: do information handouts improve parental risk recall?

BACKGROUND: The elective nature of pediatric otoplasty requires that parents are well educated regarding the risks involved. Simple educational tools have been found to enhance risk recall in some surgical procedures. OBJECTIVE: To assess the effectiveness of information handouts in improving parental risk recall. METHODS: Fifty caregivers were randomly assigned to receive traditional oral dialog of the surgical risks, or to receive oral discussion and a written handout outlining the risks of otoplasty. Twelve to 14 days after the consultation, parents were contacted for assessment of risk recall. RESULTS: Overall risk recall was 48% (3.4 of 7 risks recalled). Bleeding (82%) was the most commonly recalled risk, while cartilage necrosis/deformation (14%) was the least recalled risk. Mean risk recall was higher in the group that received written information (3.9 of 7 risks) compared to the group that received only oral discussion (2.8 of 7 risks) (p=0.003). No child or parental variables were significantly related to higher risk recall on multivariable analysis. CONCLUSION: Caregiver risk recall in pediatric otoplasty was improved with the addition of written information provided during the informed consent process. As the consent process serves a vital role in pediatric otolaryngology, the use of supplementary educational materials should be further studied.

Analysis of health-related quality-of-life outcomes and their predictive factors in pediatric patients who undergo otoplasty.

BACKGROUND: There are limited data on the effect of otoplasty on health-related quality of life in children with prominent ears. Predictors of health-related quality-of-life outcomes in otoplasty have not been well studied. METHODS: In this retrospective cohort study, 79 patients aged 18 years and younger who underwent otoplasty, and their parents, were asked to complete a survey, which included the Glasgow Children's Benefit Inventory and the Pediatric Quality of Life Inventory, to assess the parent-reported health-related quality-of-life changes and the current health-related quality of life, respectively. Other collected data included demographics, medical history, preoperative psychosocial experiences, motivations and expectations for surgery, postoperative complications, and general satisfaction. RESULTS: Fifty patients (63 percent) replied. Of those, 88 percent reported being more satisfied with the appearance of their ears after otoplasty and 93 percent would choose to have this procedure again if given a second chance. The mean Glasgow Children's Benefit Inventory total score was 24.4 and the mean Pediatric Quality of Life Inventory total score was 94.3 for the Child Self-Report and 93.3 for the Parent Proxy-Report, indicating a positive health-related quality-of-life outcome. Linear regression analysis showed that history of teasing and expectations of a "life-changing" event were significant predictors of the Glasgow Children's Benefit Inventory total score (p<0.01). CONCLUSIONS: In this study, parents reported a significant improvement in their children's health-related quality of life following otoplasty. The children themselves also reported having a generally high health-related quality of life after surgery. Possible positive predictive factors to consider include preoperative psychosocial status and expectations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Sequential analysis of mothers' and fathers' reassurance and children's postoperative distress.

OBJECTIVE: Children experience distress after surgery. Associations exist between parent reassurance (e.g., "It's OK") and child distress, but little is known about the causal direction of these interactions. This study examined sequential relations between mothers' and fathers' reassurance and children's distress. METHODS: 146 families with 2- to 11-year-olds undergoing elective surgery participated. Time-event coding and time-window sequential analysis examined whether reassurance preceded or followed child distress. Secondary analyses examined the relation of child sex and parent anxiety with the reassurance/distress contingency. RESULTS: Reassurance was positively correlated with distress; however, nonverbal distress was less likely to start following reassurance and was also more likely to continue following reassurance. Mothers were more likely to reassure following boys' verbal distress, and mothers with higher anxiety were more likely to reassure following nonverbal distress. CONCLUSIONS: Whereas parental reassurance may prevent the start of child distress, it might maintain ongoing child distress.