Pediatric Esophageal Foreign Bodies and Caustic Ingestions.

Foreign body ingestions commonly occur in children aged under 6 years. While serious complications of ingestions are rare, sharp objects, caustics, multiple magnets, and button batteries can be associated with poorer outcomes including gastrointestinal (GI) obstruction, perforation, necrosis, and fistula formation. Initial workup should include history, physical examination, and plain film radiographs that will identify radiopaque objects. Removal of the foreign body is typically warranted if the object is high risk, it is located higher up in the GI tract, the patient is symptomatic, or the object is retained for a prolonged amount of time.

Post-transcriptional capping generates coenzyme A-linked RNA.

NAD can be inserted co-transcriptionally via non-canonical initiation to form NAD-RNA. However, that mechanism is unlikely for CoA-linked RNAs due to low intracellular concentration of the required initiator nucleotide, 3'-dephospho-CoA (dpCoA). We report here that phosphopantetheine adenylyltransferase (PPAT), an enzyme of CoA biosynthetic pathway, accepts RNA transcripts as its acceptor substrate and transfers 4'-phosphopantetheine to yield CoA-RNA post-transcriptionally. Synthetic natural (RNAI) and small artificial RNAs were used to identify the features of RNA that are needed for it to serve as PPAT substrate. RNAs with 4-10 unpaired nucleotides at the 5' terminus served as PPAT substrates, but RNAs having <4 unpaired nucleotides did not undergo capping. No capping was observed when the +1A was changed to G or when 5' triphosphate was removed by RNA pyrophosphohydrolase (RppH), suggesting the enzyme recognizes pppA-RNA as an ATP analog. PPAT binding affinities were equivalent for transcripts with +1A, +1 G, or 5'OH (+1A), indicating that productive enzymatic recognition is driven more by local positioning effects than by overall binding affinity. Capping rates were independent of the number of unpaired nucleotides in the range of 4-10 nucleotides. Capping was strongly inhibited by ATP, reducing CoA-RNA production ~70% when equimolar ATP and substrate RNA were present. Dual bacterial expression of candidate RNAs with different 5' structures followed by CoA-RNA CaptureSeq revealed 12-fold enrichment of the better PPAT substrate, consistent with in vivo CoA-capping of RNA transcripts by PPAT. These results suggest post-transcriptional RNA capping as a possible mechanism for the biogenesis of CoA-RNAs in bacteria.

Environmental impact on pediatric epistaxis and the utility of diagnostic studies: A single-institutional review.

OBJECTIVES: Pediatric epistaxis is a multifactorial disease entity. The objective of this study is to determine the socioeconomic and air-quality contributions to pediatric epistaxis. The study also evaluates the utility of diagnostic lab work as a predictor of bleeding rates and need for operative intervention. METHODS: A case series of pediatric patients treated in an outpatient Otolaryngology clinic at a tertiary care children's hospital in 2021 for epistaxis was performed. Patients with nasal bone trauma (n = 8), consult while inpatient (n = 7), and those with nasal masses (n = 2) were excluded; 181 patients met inclusion criteria. Demographic, clinical, socioeconomic, and air quality (tropospheric ozone, particulate matter) data were recorded. Associations with persistent bleeding and operative interventions were evaluated using logistic regression, Wilcoxon rank-sum, and Spearman rank correlation. RESULTS: Of the 181 patients, 75 (41.4%) were female. Forty-six of 181 (25.4%) had associated allergic symptoms. Twenty-six patients had allergy testing; 14/26 (53.8%) of these had positive results. Re-bleeding was more common in those with allergic symptoms (OR: 2.42, 95% CI: 1.22-4.78, p = 0.01). Patients with re-bleeding lived in counties with more days with ozone over the US standard (median 5 days, range 0-32 days) compared with those with no re-bleeding (median 3 days, range 0-32 days, p = 0.007). There was also an association between the number of visits for re-bleed and percent below poverty level (ρ = 0.259, p = 0.03) as well as the number of days with particulate matter levels over the US standard (ρ = 0.343, p = 0.01). Coagulopathy was present in 9/54 (16.7%) patients, with the majority being Von Willebrand disease (5/54, 9.3%). Easy bruising was not significantly associated with positive lab results. CONCLUSIONS: Environmental pollution, living in a zip code with more residents below the poverty level, and allergic rhinitis were positively associated with recurrent epistaxis. Understanding the geographic background of presenting patients may help direct workup and treatment options.

Minimizing amplification bias during reverse transcription for in vitro selections.

Systematic evolution of ligands through exponential enrichment (SELEX) is widely used to identify functional nucleic acids, such as aptamers and ribozymes. Ideally, selective pressure drives the enrichment of sequences that display the function of interest (binding, catalysis, etc.). However, amplification biases from reverse transcription can overwhelm this enrichment and leave some functional sequences at a disadvantage, with cumulative effects across multiple rounds of selection. Libraries that are designed to include structural scaffolds can improve selection outcomes by sampling sequence space more strategically, but they are also susceptible to such amplification biases, particularly during reverse transcription. Therefore, we tested five reverse transcriptases (RTs)-ImProm-II, Marathon RT (MaRT), TGIRT-III, SuperScript IV (SSIV), and BST 3.0 DNA polymerase (BST)-to determine which enzymes introduced the least bias. We directly compared cDNA yield and processivity for these enzymes on RNA templates with varying degrees of structure under various reaction conditions. In these analyses, BST exhibited excellent processivity, generated large quantities of the full-length cDNA product, displayed little bias among templates with varying structure and sequence, and performed well on long, highly structured viral RNAs. Additionally, six RNA libraries containing either strong, moderate, or no incorporated structural elements were pooled and competed head-to-head in six rounds of an amplification-only selection without external selective pressure using either SSIV, ImProm-II, or BST during reverse transcription. High-throughput sequencing established that BST maintained the most neutral enrichment values, indicating low interlibrary bias over the course of six rounds, relative to SSIV and ImProm-II, and it introduced minimal mutational bias.

Investigating the significance of vestibular aqueduct pneumatization and pediatric hearing loss.

INTRODUCTION: Vestibular aqueduct enlargement on imaging is associated with pediatric hearing loss, though the mechanism is not well understood. After reviewing temporal bone imaging in pediatric patients from our institution with no obvious cause of hearing loss, we postulate that pneumatization of bone surrounding the vestibular aqueduct may also be associated with hearing loss. METHODS: 342 temporal bone CT scans performed at Children's Hospital of Michigan between January 2018 and December 2020 were reviewed. Scans were assessed for the presence, laterality, and degree of vestibular aqueduct pneumatization (PVA). Electronic medical record data was collected on age, gender, hearing status, medical comorbidities, and otologic comorbidities. Cases were secondarily reviewed to ensure validity. 159 patients were included in the final analysis; excluded scans included duplicates, patients with unknown hearing status, patients older than 21 years old, and patients with another known cause of hearing loss including inner ear malformations. RESULTS: 17.6% of patients demonstrated vestibular aqueduct pneumatization. Hearing loss percentage was comparable between the PVA and non-pneumatized group (42.9% vs 42.0%), but hearing loss was more likely to be sensorineural in the PVA group (91.7% vs 80.0%). When patients with only newborn hearing data available were excluded from the PVA group, hearing loss percentage was higher in the PVA group (50% vs 42.0%). Patients with hearing loss in the PVA group were older than those without hearing loss (14.92 years old vs 10.67 years old). CONCLUSION: Hearing loss in enlarged vestibular aqueduct syndrome is typically progressive, bilateral, and sensorineural. Our preliminary findings suggest that vestibular aqueduct pneumatization may be another anomaly associated with a primarily sensorineural hearing loss. Further studies are needed to strengthen this postulated link.

Cost-Effectiveness of Open vs. Endoscopic Repair of Zenker's Diverticulum.

OBJECTIVE: To evaluate the cost-effectiveness of open versus endoscopic surgical repair of Zenker's diverticulum. METHODS: In this study, an economic decision tree was utilized to compare the cost-effectiveness of open surgery compared to endoscopic surgery. The primary outcome in this analysis was the incremental cost-effectiveness ratio (ICER) that was calculated based on the economic decision tree. The probability of post-operative esophageal perforation complications, revision rates, and effectiveness of each procedure along with associated costs were extracted to construct the decision tree. Univariate sensitivity analysis was then utilized to determine how changes in esophageal perforation rate affect the cost-effectiveness of each surgical approach. RESULTS: The ICER of open surgery for Zenker's diverticulum was $67 877, above most acceptable willingness to pay (WTP) thresholds. Additionally, if the probability of esophageal perforation with endoscopic surgery is above 5%, then open surgery becomes a more cost-effective option. Probabilistic sensitivity analysis using Monte Carlo simulations also showed that at the WTP thresholds of $30 000 and $50 000, endoscopic surgery is the most cost-effective method with 83.9% and 67.6% certainty, respectively. CONCLUSION: Open surgery and endoscopic surgery are 2 treatment strategies for Zenker's diverticulum that each have their own advantages and disadvantages that can complicate the decision-making process. With no previous cost-effectiveness analysis of open versus endoscopic surgery for Zenker's diverticulum, our results support the endoscopic approach at most common WTP thresholds. Particularly with the current focus on rising healthcare costs, our results can serve as an important adjunct to medical decision-making for patients undergoing treatment for Zenker's diverticulum.

Nasal Analysis of Classic Animated Movie Villains versus Hero Counterparts.

Opposing facial features between animated villains and heroes have historically been used to demonstrate contrasting morality between characters, and this could have an impact on how humans view someone as good or evil in everyday life. Studies have been done investigating classic dermatologic features of villainous characters. This principle can be applied to nasal features as well. A search for "top animated characters" was performed. Characters were chosen from American Film Institute's "The Top Tens," Rolling Stone's "25 Best Pixar Movie Characters," and Screenrant's "The 30 Best Animated Movie Characters of All Time." Twenty villains and twenty hero counterparts from respective films were chosen. Classic nasal features were analyzed. Twenty villains (14 male, 6 female) and 20 heroes (12 male, 8 female) were analyzed. Sixteen villains (80%) had greater than normal nasal frontal angle versus 18 heroes (90%). Thirteen villains (65%) had an acute nasolabial angle versus two heroes (10%). Two villains (10%) had excess columellar show versus seven heroes (35%). Seven villains (35%) and one hero (5%) had a dorsal hump. Twelve villains (60%) had an overprojected chin versus three heroes (15%). Villains in pre-2000s films more frequently had a dorsal hump, overprojected chin, ptotic tip, pollybeak deformity, and bulbous tip. Heroes in pre-2000s films more frequently had an overrotated tip. Villains and heroes commonly have a greater than normal nasofrontal angle. Villains more commonly have an acute nasolabial angle, underrotated tip, overprojected chin, dorsal hump, and pollybeak deformity. Heroes more commonly have a large nasolabial angle and overrotated tip. Further research in conjunction with psychologists is required to obtain concrete data on how this affects whether an individual in real life is seen as good or evil, and the impact this has on interactions in society, including in the medical field.

Diagnosis and management of congenital floor of mouth masses: A systematic review.

OBJECTIVES: Determine the utility of preoperative imaging and the optimal course of management for congenital floor of mouth (FOM) cysts in infants. METHODS: A systematic review of the literature was performed conforming to PRISMA guidelines. Pubmed, Embase and Cochrane Library databases were queried to identify cases of infants with congenital floor of mouth masses. Patient demographics, presenting findings, imaging, management, complications, and outcomes were determined. RESULTS: 85 patients were evaluated. 98% of patients presented at 16 months of age or younger. The most common presenting symptom was submental mass or swelling, 31.3%. Among the patients that underwent imaging, the suspected diagnosis obtained from imaging findings was consistent with the final pathologic diagnosis 59% of the time reported and inaccurate 34% of the time. There were multiple definitive treatment modalities described in the literature review including surgical excision, 82.3%, marsupialization, 12.9%, chemical injection 2.3%, sclerotherapy 1.2%,% and radiation, 1.2%. Recurrence rate after initial definitive treatment was as follows, surgical excision, 8.8%, marsupialization, 80%, sclerotherapy, 100%, chemical injection, 50%, and radiation, 100%. CONCLUSION: Preoperative imaging studies should not be relied upon alone to determine suspected pathology and subsequent management in pediatric patients with FOM masses. It may be beneficial for these patients to undergo primary surgical excision regardless of imaging studies or suspected pathology. Needle aspiration offers limited addition to pathologic diagnosis and should only be performed in the setting of acute symptomatic management. Surgical excision should be considered as definitive treatment modality in all patients with FOM masses, regardless of the suspected diagnosis of ranula. Further multi-institutional cohort studies could be invaluable to elucidate definitive treatment guidelines in this patient population.

Orbital Roof Fractures: An Evidence-Based Approach.

Importance: There is controversy surrounding the management of orbital roof fractures. Guidelines with regard to when to operate and type of reconstruction are lacking. Categorizing these data will help clinicians make informed decisions about the management of orbital roof fractures and avoid preventable complications. Objective: To perform a systematic review evaluating underlying causes, associated complications, and management of orbital roof fractures including reconstructive options in the general population of children and adults. Evidence Review: A systematic review using the PubMed, EmBase, Cochrane, and MEDLINE databases identified relevant studies for inclusion. Studies were included from 1987 to 2017. Demographics, symptoms, management, reconstruction, and outcomes were reported following preferred reporting items for systematic reviews and meta-analyses guidelines. Inclusion criteria included articles discussing management of traumatic orbital roof fractures across all ages. Included studies were assessed for level of evidence. Findings: Forty-seven studies encompassing 526 patients met inclusion criteria. There were 28 case reports, 15 retrospective case series and 4 retrospective cohort studies. The most common etiologies were motor vehicle accidents (39.5%), falls (30.3%), and assault (11.8%). Periorbital ecchymosis, exophthalmos, and dystopia were the most common initial symptoms. In total, 60.0% of patients underwent surgical repair and 40% of patients were managed conservatively. The most common surgical approach was bicoronal (94.8%), followed by a superolateral orbital rim approach and transpalpebral (5.1%). A variety of grafting materials were utilized, including titanium miniplates (46.2%), bone graft (37.7%), porous polyethylene (2.8%), and silastic implants (2.8%). Overall patients undergoing surgery were adults with clinical symptoms including exophthalmos, diplopia, and gaze restriction as well as patients with dura exposure. Most patients undergoing surgery were those with concomitant fractures. The most common fractures among the surgical patients were frontal bone (32.2%), ethmoid (25.2%), and zygomaticomaxillary complex/zygoma (12.2%). Conclusions and Relevance: Management of orbital roof fractures varies based on individual clinical features including the presence of exophthalmos, gaze restriction, and concomitant injuries such as dural tears. Surgically, bicoronal approaches were performed most commonly along with reconstruction utilizing titanium miniplates. Conservative management was more common among the pediatric population. This systematic review demonstrates both conservative and surgical measures can lead to positive outcomes in appropriately selected patients.

Quality Improvement in Pain Medicine.

In the last 30 years, pain control in the United States has undergone several evolutions impacting the care of surgical patients. More recently, safe pain control has been a subject of quality improvement efforts by otolaryngologists focusing on minimizing opioid consumption. This article discusses the rising overprescription of opioids, influenced by legislation and governmental agencies, and the steps taken to correct and reform policies to decrease the amount of opioids prescribed. Lastly, specific institutional examples of quality improvement protocols implemented to help decrease opioid consumption and prescription are discussed.

Public Perception of Facial Fillers.

There has been widespread coverage of cosmetic procedures, particularly facial fillers, as minimally invasive options for facial rejuvenation. The authors' objective was to characterize news media's coverage of facial fillers and its role in shaping public perception of these products over the past decade. Public view plays a significant role in policymaking, assisting patient communication, and addressing preconceived notions. Google News was searched for online news coverage related to "facial fillers" from 2008 to 2017. News articles from various sources were reviewed and analyzed with multiple objectives including complications listed, advantages, disadvantages, physician specialties, overall theme of the articles as positive, negative, or neutral and other parametrics. A chi-square test was used for statistical analysis. Of 426 articles meeting inclusion criteria, international news (20.4%), tabloids (18.8%), online health sites (18.3%), and national news (16.9%) were represented. Of articles containing adequate information, coverage was 44.7% positive, 29.9% neutral, and 26.1% negative with no significant change from 2008 to 2017. In addition, 46.0% of papers discussed complications including vascular injury and blindness associated with fillers, with significant increase by 2017 (p < 0.05). Facial fillers media coverage was overall positive, with broad coverage at both national and international levels. Complications were discussed often, and although vascular injury and vision damage are rare complications of fillers, they were frequently cited, potentially leading the public to believe they occur frequently. There were also significant concerns in the news media about greater regulation of products used as facial fillers, and practitioners administrating them. Altogether, these findings provide a comprehensive overview of patient perception and expectations of an increasingly popular and expanding cosmetic procedure.

The use of irradiated corneal patch grafts in pediatric Ahmed drainage implant surgery.

PURPOSE: To describe the use of irradiated cornea for scleral reinforcement in Ahmed glaucoma valve drainage implant (AGV) devices in children. METHODS: The medical records of patients <18 years of age who underwent AGV surgery with irradiated cornea as scleral reinforcement were reviewed retrospectively. The primary outcome measure was erosion of the drainage tube through the corneal patch graft. Secondary outcome measures included other major complications: persistent inflammation, wound dehiscence, transmission of infectious disease, endophthalmitis, and tube/plate self-explantation. RESULTS: A total of 25 procedures (20 patients) met inclusion criteria. Average patient age was 70 months (range, 2 months to 17 years). Mean follow-up was 24.8 months (range, 6 months to 6.2 years). One tube experienced conjunctival exposure through two separate corneal grafts (2/25 cases [8%]), sequentially in the same eye. The first event occurred at month 3.5 after primary implantation of the tube shunt; the second erosion occurred following revision of the existing implant at month 1.5 postoperatively. There were 2 cases of auto-explantation, 2 cases of wound dehiscence, and 1 case of persistent inflammation. There were no cases of endophthalmitis or other infections. CONCLUSIONS: To our knowledge, this is the first report describing the use of corneal patch grafts in children. Irradiated cornea improves cosmesis and enhances visualization of the tube. The risk of tube exposure was found to be low and comparable to other materials used as a patch graft.