Nonfulfillment of desired postpartum permanent contraception and resultant maternal and pregnancy health outcomes.

BACKGROUND: Up to half of the patients requesting postpartum permanent contraception do not undergo the desired procedure. Although nonfulfillment of desired postpartum permanent contraception is associated with increased risk of pregnancy within 12 months of delivery, its long-term reproductive and maternal health outcomes are less clear. OBJECTIVE: This study aimed to determine the association of fulfillment of postpartum permanent contraception with number and timing of subsequent pregnancies and maternal health outcomes. STUDY DESIGN: This was a retrospective single-center cohort chart review study of health outcomes in the 4 years following delivery (2016-2018) for 1331 patients with a documented contraceptive plan of female permanent contraception at time of postpartum discharge from 2012 to 2014. Rates of permanent contraception fulfillment within 90 days of delivery and clinical and demographic characteristics associated with permanent contraception were calculated. We determined number of and time to subsequent pregnancies, and diagnoses of medical comorbidities (hypertension, diabetes mellitus, depression, anxiety, asthma, anemia), sexually transmitted infection, and pregnancy comorbidities (preterm birth, gestational diabetes mellitus, gestational hypertension, preeclampsia, postpartum hemorrhage, low birthweight, intrauterine fetal demise) in the 4 years following delivery. RESULTS: Of the 1331 patients desiring permanent contraception postpartum, 588 (44.1%) had their requests fulfilled within 90 days of delivery and 743 (55.8%) did not. Patients who achieved permanent contraception fulfillment tended to have attended more outpatient prenatal visits, delivered via cesarean delivery, and were older, married, college-educated, and privately insured. Patients who received their desired postpartum permanent contraception were less likely to have subsequent intrauterine pregnancies (P<.001). In those who did not achieve permanent contraception, 22 (9.0%) subsequent pregnancies occurred within 6 months of previous deliveries, and 223 (91.0%) occurred after short interpregnancy intervals (within 18 months). Of 178 continued pregnancies, 26 (14.6%) were delivered preterm. There were no differences between the 2 groups in terms of ever attending an outpatient, preventive, or emergency room visit, or in most nonreproductive health outcomes investigated. CONCLUSION: Nonfulfillment of desired postpartum permanent contraception is associated with subsequent maternal reproductive and nonreproductive health ramifications. Given the barriers to permanent contraception, alternative plans for contraception should be discussed proactively if permanent contraception is not provided.

Obstructive sleep apnea syndrome as a rare presentation in a young girl with a central nervous system tumor.

Sleep-related breathing disorders are a common problem in infancy and childhood. The most common type of sleep-related breathing disorder in this age group is obstructive sleep apnea syndrome (OSAS), generally caused by factors affecting airway patency, such as tonsillar hypertrophy or obesity. However, in adults OSAS can also be caused by processes affecting the brainstem, such as central nervous system tumors. This report describes a 2-year-old girl who presented with symptoms of snoring, restless sleep, repeated night-time waking, and apneic events while asleep. She had no comorbidities, and examination revealed normal-sized tonsils. A sleep study demonstrated severe OSAS with an obstructive apnea/hypopnea index of 34. Her OSAS completely resolved on excision of the tumor. The case highlights the importance of neurological examination as part of evaluation of OSAS, especially in cases where tonsils are not enlarged and there are no other risk factors for OSAS. CITATION: Buller F, Kamal MA, Brown SK, et al. Obstructive sleep apnea syndrome as a rare presentation in a young girl with a central nervous system tumor. J Clin Sleep Med. 2022;18(4):1211-1214.

Association of race and ethnicity with postpartum contraceptive method choice, receipt, and subsequent pregnancy.

BACKGROUND: We sought to assess racial/ethnic differences in choice of postpartum contraceptive method after accounting for clinical and demographic correlates of contraceptive use. METHODS: This is a secondary analysis of a single-center retrospective cohort study examining postpartum women from 2012 to 2014. We determined the association between self-identified race/ethnicity and desired postpartum contraception, receipt, time to receipt, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery. RESULTS: Of the 8649 deliveries in this study, 46% were by Black women, 36% White women, 12% Hispanic, and 6% by women of other races. Compared with White women, Black and Hispanic women were more likely to have a postpartum contraception plan for all methods. After multivariable analysis, Hispanic women (relative to White women) were less likely to receive their chosen method (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.64-0.87). Women of races other than Black or Hispanic were less likely to experience a delay in receipt of their desired highly-effective method compared to White women (hazard ratio [HR] = 0.70, 95% CI 0.52-0.94). There were no differences between racial/ethnic groups in terms of postpartum visit adherence. Black women were more likely to be diagnosed with a subsequent pregnancy compared to White women (OR 1.17, 95% CI 1.04-1.32). CONCLUSION: Racial/ethnic variation in postpartum contraceptive outcomes persists after accounting for clinical and demographic differences. While intrinsic patient-level differences in contraceptive preferences should be better understood and respected, clinicians should take steps to ensure that the observed differences in postpartum contraceptive plan methods between racial/ethnic groups are not due to biased counseling.

Sudden onset hearing loss following intra-abdominal surgery: an unusual association.

We describe the case of a 12-year-old boy who reported unilateral hearing loss following laparoscopic appendicectomy for acute appendicitis under general anaesthesia. He was otherwise fit and well with no previous otological history. Formal audiological assessment by pure tone audiogram demonstrated a unilateral high-frequency sensorineural hearing loss (SNHL).In addition to describing his clinical course, a literature review of SNHL following non-otological surgery was performed. We recommend an awareness of this phenomenon, necessitating its prompt recognition, early audiological assessment and management as per sudden onset SNHL guidelines.

Association between neighborhood disadvantage and fulfillment of desired postpartum sterilization.

BACKGROUND: Adequacy of prenatal care is associated with fulfillment of postpartum sterilization requests, though it is unclear whether this relationship is indicative of broader social and structural determinants of health or reflects the mandatory Medicaid waiting period required before sterilization can occur. We evaluated the relationship between neighborhood disadvantage (operationalized by the Area Deprivation Index; ADI) and the likelihood of undergoing postpartum sterilization. METHODS: Secondary analysis of a single-center retrospective cohort study examining 8654 postpartum patients from 2012 to 2014, of whom 1332 (15.4%) desired postpartum sterilization (as abstracted from the medical record at time of delivery hospitalization discharge) and for whom ADI could be calculated via geocoding their home address. We determined the association between ADI and sterilization completion, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery via logistic regression and time to sterilization via Cox proportional hazards regression. RESULTS: Of the 1332 patients included in the analysis, patients living in more disadvantaged neighborhoods were more likely to be younger, more parous, delivered vaginally, Black, unmarried, not college educated, and insured via Medicaid. Compared to patients living in less disadvantaged areas, patients living in more disadvantaged areas were less likely to obtain sterilization (44.8% vs. 53.5%, OR 0.84, 95% CI 0.75-0.93), experienced greater delays in the time to sterilization (HR 1.23, 95% CI 1.06-1.44), were less likely to attend postpartum care (58.9% vs 68.9%, OR 0.86, CI 0.79-0.93), and were more likely to have a subsequent pregnancy within a year of delivery (15.1% vs 10.4%, OR 1.56, 95% CI 1.10-1.94). In insurance-stratified analysis, for patients with Medicaid, but not private insurance, as neighborhood disadvantage increased, the rate of postpartum sterilization decreased. The rate of subsequent pregnancy was positively associated with neighborhood disadvantage for both Medicaid as well as privately insured patients. CONCLUSION: Living in an area with increased neighborhood disadvantage is associated with worse outcomes in terms of desired postpartum sterilization, especially for patients with Medicaid insurance. While revising the Medicaid sterilization policy is important, addressing social determinants of health may also play a powerful role in reducing inequities in fulfillment of postpartum sterilization.

Variation in effectiveness of planned postpartum contraception at two time points from prenatal to postpartum care.

OBJECTIVE: To identify characteristics of women who have consistent plans in terms of contraceptive effectiveness from antepartum to postpartum care. STUDY DESIGN: This is a secondary analysis of a retrospective chart review of women who delivered at a single tertiary care center from 2012 to 2014. Preferred postpartum contraceptive plan was abstracted at three time points (prenatal care, hospital discharge, and outpatient postpartum care) and categorized into three tiers of effectiveness. We then examined consistency between the first two time points for the effectiveness in postpartum contraceptive method planned. RESULTS: Of the 8,394 women in the study cohort, 2,642 (31.5%) had a consistent postpartum contraceptive plan. Women who had a consistent plan were more likely to have higher parity (aOR 2.36, 95% CI 2.06-2.70 for parity 2+), choose highly effective methods of contraception (p < 0.001), achieve their contraception plan (adjusted odds ratio [aOR] 2.16, 95% confidence interval [95% CI] 1.85-2.52), but not more likely to have a subsequent pregnancy within 365 days of delivery (aOR 0.92, 95% CI 0.81-1.05). CONCLUSION: Better understanding contraceptive decision-making as a journey and removing external barriers during that process is a necessary component of pregnancy care. IMPLICATIONS: Counseling and documentation of contraceptive preferences throughout antepartum and postpartum care can help improve contraceptive outcomes.

Desired Sterilization Procedure at the Time of Cesarean Delivery According to Insurance Status.

OBJECTIVE: To evaluate whether women with Medicaid are less likely than their privately insured counterparts to receive a desired sterilization procedure at the time of cesarean delivery. METHODS: This is a secondary analysis of a single-center retrospective cohort examining 8,654 postpartum women from 2012 to 2014, of whom 2,205 (25.5%) underwent cesarean delivery. Insurance was analyzed as Medicaid compared with private insurance. The primary outcome was sterilization at the time of cesarean delivery. Reason for sterilization noncompletion and Medicaid sterilization consent form validity were recorded. Secondary outcomes included postpartum visit attendance, outpatient postpartum sterilization, and subsequent pregnancy within 365 days of delivery. RESULTS: Of the 481 women included in this analysis, 78 of 86 (90.7%) women with private insurance and 306 of 395 (77.4%) women with Medicaid desiring sterilization obtained sterilization at the time of cesarean delivery (relative risk 0.85, 95% CI 0.78-0.94). After multivariable logistic regression, gestational age at delivery (1.02 [1.00-1.03]), adequacy of prenatal care (1.30 [1.18-1.43]), and marital status (1.09 [1.01-1.19]) were associated with achievement of sterilization at the time of cesarean delivery. Sixty-four (66.0%) women who desired but did not receive sterilization at the time of cesarean delivery did not have valid, signed Medicaid sterilization forms, and 10 (10.3%) sterilizations were not able to be completed at the time of surgery owing to adhesions. Sterilization during cesarean delivery was not associated with less frequent postpartum visit attendance for either the Medicaid or privately insured population. Rates of outpatient postpartum sterilization were similar among those with Medicaid compared with private insurance. Among patients who did not receive sterilization at the time of delivery, 15 patients (each with Medicaid) had a subsequent pregnancy within the study period. CONCLUSION: Women with Medicaid insurance received sterilization at the time of cesarean delivery less frequently than privately insured counterparts, most commonly due to the absence of a valid Medicaid sterilization consent form as well as adhesive disease. The constraints surrounding the Medicaid form serve as a significant barrier to achieving desired sterilization.

Assessment and documentation of incontinence-associated dermatitis after implementation of a standardised instrument: a comparative study.

OBJECTIVE: In this study, clinical nurses' documentation of incontinence-associated dermatitis (IAD) were compared with wound expert documentation before and after implementing a valid, reliable severity index (SI) instrument. METHODS: A prospective, non-equivalent, two group comparative design within three hospital medical units. Pre- and post-implementation skin condition documentation were compared by clinician type, and post-implementation IADSI scores were assessed for agreement using standard and weighted Kappa. RESULTS: Of 89 patients (pre-, n=48 and post-, n=38), mean (standard deviation) age was 72.4±13.7 years and 57.3% had IAD. Mean IADSI score was 13.2 (standard deviation: 10.5; range: 0-52), reflecting pink intact skin. Post-implementation, skin documentation between clinicians was more likely to match, from 35.4 to 84.2%, p<0.001. Post-implementation, after controlling for age, gender and race, the odds ration (OR) of matched documentation between clinicians was 5.80 ([95% confidence interval: 1.8, 18.6], p=0.003) compared with pre-implementation. In the post-implementation period, standard Kappas for agreement in clinical nurse-wound expert documentation in the lower back/buttocks/upper thigh areas ranged from 0.82 to 1.0, reflecting very good agreement. Weighted kappas ranged from 0.76 to 1.0, also reflecting good to very good agreement. CONCLUSION: Implementation of an IADSI assessment instrument improved accuracy of IAD documentation.

The Association of Public Insurance with Postpartum Contraception Preference and Provision.

BACKGROUND: Prior studies have noted that public insurance status is associated with increased uptake of postpartum contraception whereas others have pointed to public insurance as a barrier to accessing highly effective forms of contraception. OBJECTIVE: To assess differences in planned method and provision of postpartum contraception according to insurance type. STUDY DESIGN: This is a secondary analysis of a retrospective cohort study examining postpartum women delivered at a single hospital in Cleveland, Ohio from 2012-2014. Contraceptive methods were analyzed according to Tier-based effectiveness as defined by the Centers for Disease Control and Prevention. The primary outcome was postpartum contraception method preference. Additional outcomes included method provision, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery. RESULTS: Of the 8281 patients in the study cohort, 1372 (16.6%) were privately and 6990 (83.4%) were publicly insured. After adjusting for the potentially confounding clinical and demographic factors through propensity score analysis, public insurance was not associated with preference for a Tier 1 versus Tier 2 postpartum contraceptive method (matched adjusted odds ratio [maOR] 0.89, 95% CI 0.69-1.15), but was associated with a preference for Tier 1/2 vs Tier 3/None (maOR 1.41, 95% CI 1.17-1.69). There was no difference between women with private or public insurance in terms of method provision by 90 days after delivery (maOR 0.94, 95% CI 0.75-1.17). Public insurance status was also associated with decreased postpartum visit attendance (maOR 0.54, 95% CI 0.43-0.68) and increased rates of subsequent pregnancy within 365 days of delivery (maOR 1.29, 95% CI 1.05-1.59). CONCLUSION: Public insurance status does not serve as a barrier to either the preference or provision of effective postpartum contraception. Women desiring highly- or moderately effective methods of contraception should have these methods provided prior to hospital discharge to minimize barriers to method provision.

Medicaid and receipt of interval postpartum long-acting reversible contraception.

OBJECTIVE: We sought to evaluate the impact of insurance type on receipt of an interval postpartum LARC, controlling for demographic and clinical factors. STUDY DESIGN: This is a retrospective cohort study of 1072 women with a documented plan of LARC for contraception at time of postpartum discharge. This is a secondary analysis of 8654 women who delivered at 20 weeks or beyond from January 1, 2012, through December 31, 2014, at an urban teaching hospital in Ohio. LARC receipt within 90 days of delivery, time to receipt, and rate of subsequent pregnancy after non-receipt were compared between women with Medicaid and women with private insurance. Postplacental LARC was not available at the time of study completion. RESULTS: One hundred eighty-seven of 822 Medicaid-insured and 43 of 131 privately insured women received a LARC postpartum (22.7% vs 32.8%, P=.02). In multivariable analysis, private insurance status was not significantly associated with LARC receipt (OR 1.29, 95% C.I. 0.83-1.99) though adequate prenatal care was (OR 2.33, 95% C.I. 1.42-4.00). Of women who wanted but did not receive a LARC, 208 of 635 (32.8%) Medicaid patients and 19 of 88 (21.6%) privately insured patients became pregnant within 1 year (P=.02). CONCLUSION: Differences in receipt of interval postpartum LARC were not significant between women with Medicaid insurance versus private insurance after adjusting for clinical and demographic factors. Adequate prenatal care was associated with LARC receipt. Medicaid patients who did not receive a LARC were more likely to become pregnant within one year of delivery than those with private insurance. IMPLICATIONS: While insurance-related barriers have been reduced given recent policy changes, access to care remains an important determinant of postpartum LARC provision and subsequent unintended pregnancy.

Role of Bridge Contraception in Postpartum Long-Acting Reversible Contraception and Sterilization Fulfillment Rates.

OBJECTIVE: To estimate the association of bridge contraception with interval long-acting reversible contraception (LARC) and sterilization fulfillment rates. METHODS: This is a secondary analysis of a retrospective single-center cohort chart review study examining 1,851 postpartum women who requested LARC or sterilization after discharge. Bridge contraception was requested by 597 of these women. Primary outcomes included LARC or sterilization fulfillment, time to fulfillment, postpartum visit attendance, and pregnancy within 365 days of delivery. RESULTS: The rate of LARC or sterilization fulfillment within 90 days of delivery was 147 of 597 (24.6%) women using bridge contraception and 287 of 1,254 (22.9%) women not using bridge contraception (P=.41). After adjusting for maternal age, parity, gestational age, mode of delivery, adequacy of prenatal care, race-ethnicity, and education level, the use of bridge contraception was associated with LARC or sterilization fulfillment (adjusted odds ratio [OR] 1.30, 95% CI 1.02-1.67). Adequacy of prenatal care and black race was associated with fulfillment. The use of bridge contraception was not associated with time to fulfillment (adjusted hazard ratio 1.17, 95% CI 0.95-1.44) or postpartum visit attendance (adjusted OR 0.97, 95% CI 0.77-1.23). The use of bridge contraception was not associated with increased pregnancy within 365 days of delivery (OR 1.00, 95% CI 0.95-1.05; adjusted OR 0.96, 95% CI 0.73-1.26). CONCLUSION: Bridge contraception is associated with increased LARC and sterilization fulfillment after postpartum discharge. Long-acting reversible contraception or sterilization fulfillment after discharge occurred in less than one in four women. Strategies to improve provision of LARC or sterilization before hospital discharge are necessary.

Hyperacusis in children: The Edinburgh experience.

OBJECTIVES: This study aimed to determine the factors associated with hyperacusis in children referred to an audiology-led paediatric hyperacusis clinic in a Paediatric tertiary centre. It also aimed to identify current management strategies in paediatric hyperacusis and their outcomes. METHODS: Retrospective cohort study conducted by case note and AuditBase® review over a 5-year period (March 2010 to March 2015) in a tertiary Paediatric ENT and Audiology service. RESULTS: 412 children were referred with hyperacusis during the 5-year period. All children were assessed and managed within a dedicated Paediatric hyperacusis clinic. Median age at referral was 7 years. 76% were boys (n = 313). On average, children were sensitive to 6 identifiable sound stimuli at presentation (range 1-20). 82% complained of sensitivity to noise from household appliances and hand dryers. 60% had a background history of autistic spectrum disorder (ASD), followed by attention deficit hyperactivity disorder (ADHD) and other neurodevelopmental problems. In 91% management comprised behavioural therapy and provision of a 'sound-ball' (Wellcare® Naturcare Relaxation Therapy Ball) to take home. Of these, 25% did not attend their first review appointment. A further 25% were considered to have sufficient symptom improvement to permit discharge after a single clinic review. Only 2% of children required more than 3 review sessions before achieving resolution of symptoms. CONCLUSIONS: In our paediatric cohort, hyperacusis is more common in boys and in those children with ASD. A combined treatment approach with behavioural therapy and the provision of a sound-ball has a very high success rate in our experience.

Medicaid and fulfillment of desired postpartum sterilization.

OBJECTIVE: We sought to assess fulfillment of sterilization requests while accounting for the complex interplay between insurance, clinical and social factors in a contemporary context that included both inpatient and outpatient postpartum sterilization procedures. STUDY DESIGN: This is a retrospective single-center cohort chart review study of 1331 women with a documented contraceptive plan at time of postpartum discharge of sterilization. We compared sterilization fulfillment within 90days of delivery, time to sterilization and rate of subsequent pregnancy after nonfulfillment between women with Medicaid and women with private insurance. RESULTS: A total of 475 of 1030 Medicaid-insured and 100 of 154 privately insured women received postpartum sterilization (46.1% vs. 64.9%, p<.001). Women with Medicaid had a longer time from delivery to completion of the sterilization request (p<.001). After adjusting for age, parity, gestational age, mode of delivery, adequacy of prenatal care, race/ethnicity, marital status and education level, private insurance status was not associated with either sterilization fulfillment [odds ratio 0.94, 95% confidence interval (CI) 0.54-1.64] or time to sterilization (hazard ratio 1.03, 95% C.I. 0.73-1.34). Of the 555 Medicaid-insured women who did not receive a postpartum sterilization, 267 (48.1%) had valid Title XIX sterilization consent forms at time of delivery. Of women who did not receive sterilization, 132 of 555 Medicaid patients and 5 of 54 privately insured patients became pregnant within 1 year (23.8% vs. 9.3%, p=.023). CONCLUSION: Differences in fulfillment rates of postpartum sterilization and time to sterilization between women with Medicaid versus private insurance are similar after adjusting for relevant clinical and demographic factors. Women with Medicaid are more likely than women with private insurance to have a short interval repeat pregnancy after an unfulfilled sterilization request. IMPLICATIONS: Efforts are needed to ensure that Medicaid recipients who desire sterilization receive timely services.

Randomized controlled study of the effects of 2 fecal management systems on incidence of anal erosion.

PURPOSE: To compare the incidence of anal erosion between 2 indwelling fecal management systems. Anal erosion was defined as localized mucous membrane tissue impairments of the anal canal caused by corrosive fecal enzymes and/or indwelling devices. DESIGN: Randomized comparative effectiveness clinical trial comparing 2 commercially available indwelling fecal management systems. SUBJECTS AND SETTING: The target population was adults cared for on medical, surgical, and neurological intensive care units (ICUs) and non-ICU units with an order for indwelling fecal management system placement. The research setting was a 1200-bed quaternary-care medical center in the Midwestern United States. Seventy-nine patients participated in the study; 41 received system A and 38 received system B. Subjects' mean age was 64 ± 13.6 years (mean ± SD), and 52% were female. METHODS: Nurse researchers inserted 1 of 2 indwelling fecal management systems and assessed patients daily for anal erosion. Data were collected on patient demographics, medical history and insertion date, reason for the fecal management system, volume of water in balloon and balloon pressure daily, diet, body mass index, ease of insertion and removal, amount of resistance, and when and why the device was removed. Anecdotal comments from front-line staff nurses were also recorded. Occurrences of anal ulcer or erosion was compared using logistic regression models that adjusted for length of system use and time to event using Kaplan-Meier estimates and log rank tests. RESULTS: The incidence of anal erosion was 12.7%. There were no differences in incidence of anal erosions between the 2 groups (12.2% vs 13.2% for systems A and B, respectively, P = .88), or in time to development of the erosions (P = .82). Leakage of stool occurred in 70% of patients and was associated with anal erosion (P = .027). CONCLUSIONS: In this randomized comparative effectiveness research study, there was no difference in the incidence of anal erosion between groups. Purchasing decisions cannot be made based on differences in general product characteristics postulated to influence likelihood of anal erosion. Results regarding balloon water volume, mucosa pressure generated, and anal erosions require further study.

The pathology of visible blood vessels on the nasal septum in children with epistaxis.

OBJECTIVE: Epistaxis is common in children, but its cause remains unknown. About half the children who present with epistaxis have prominent vessels on the nasal septum. The aim of this study was to determine the pathological nature of the prominent septal vessels in children with recurrent epistaxis. METHODS: 4mm punch biopsies of the nasal septal mucosa were taken from 5 children undergoing nasal cautery under general anaesthesia. RESULTS: Histology showed that the prominent vessels were thin-walled arterioles and capillaries with a surrounding inflammatory infiltrate. There was no evidence of venous varicosities or arterial microaneurysms. CONCLUSION: We postulate a mechanism for septal neovascularisation due to chronic low-grade inflammation as a cause for recurrent epistaxis in children.

Post-tonsillectomy hemorrhage: cold versus hot dissection.

OBJECTIVE: The aim of our study was to assess the rate of reactionary and secondary posttonsillectomy hemorrhage using "cold" dissection and bipolar diathermy and to determine whether there was any difference in the postoperative hemorrhage rate between the 2 methods. METHODS: This was a prospective study of all patients undergoing tonsillectomy between November 8, 1999 and November 7, 2000 in a tertiary medical centre. The data collected included patient identity, age, gender, date of surgery, method of operation, and complications (if any). The timing of reactionary or secondary posttonsillectomy hemorrhage and the treatment were recorded. We hypothesized no difference in posttonsillectomy hemorrhage rates using the 2 methods. Chi2 test was used for statistical analysis. RESULTS: A total of 349 patients underwent tonsillectomy in the period (134 males, 215 females, mean age was 16.7 years). Of these, 337 were bilateral procedures, 145 patients had tonsillectomy using cold dissection, and 192 patients had bipolar diathermy. Reactionary hemorrhage occurred in 1 patient (0.3%) and 31 patients (9.2%) developed secondary hemorrhage. The hemorrhage rates using cold dissection (n = 8) and bipolar diathermy (n = 24) were 5.5% and 12.5%, respectively ( P < 0.05). CONCLUSIONS: The primary and secondary posttonsillectomy hemorrhage rates were 0.3 and 9.2%, respectively. Tonsillectomy using bipolar diathermy has a statistically significant higher secondary hemorrhage rate than using cold dissection (12.5% vs. 5.5%, P < 0.05).

Human error identification: an analysis of myringotomy and ventilation tube insertion.

OBJECTIVES: To use a human reliability assessment tool to identify commonly occurring errors during myringotomy and ventilation tube (VT) insertion and to quantify the likelihood of error occurrence. METHODS: Error-free task analysis for myringotomy and VT insertion was defined at the outset. Fifty-five consecutive myringotomy and VT insertion procedures were videotaped. The operator was either the senior author (S.S.M.H.) or a trainee in the specialist registrar or senior house officer grade. Three assessors (M.-L.M., M.S.W.L, and S.S.M.H.) blinded to operator identity independently evaluated each procedure. Interobserver agreement was calculated (kappa values). RESULTS: Twelve potential error types were identified. A total of 87 errors were observed in 55 procedures. In 53% of procedures (n = 29) multiple errors were identified. Seven percent of procedures (n = 4) were error free. The 4 most frequent errors identified were (1) failure to perform a unidirectional myringotomy incision (n = 37; 43%); (2) multiple attempts to place VT (n = 14; 16%); (3) multiple attempts to complete the myringotomy (n = 11; 13%); and (4) magnification setting too high (n = 11; 13%). The human error probability was 0.13. Interobserver agreement as expressed by kappa statistics was high. CONCLUSIONS: Human error identification in this most common of otologic procedures is crucial to future error avoidance. Eliminating the 2 most common errors in this model will halve the human error probability. Extending the role of error analysis to error-based teaching as an educational tool has potential.