Improving Health Literacy of Elective Procedures in Pediatric Otolaryngology.

OBJECTIVE: To identify if the addition of supplementary material, such as video or written resources, to the consent process, can improve a patient's or guardian's health literacy in pediatric otolaryngology. STUDY DESIGN: Prospective randomized crossover design. SETTING: Tertiary Academic Center. METHODS: From April 18, 2022 to August 29, 2023, 151 children scheduled to undergo 1 of 6 procedures by the same provider were queried and completed a 6-question baseline test based on the information. They each watched a 2-minute video and read a written summary about the procedure; the order of resources was randomized. They answered the same 6-questions after viewing each resource. All tests were scored based on accuracy using an ordinal scale of 1 to 6. Resource preference was collected. Wilcoxon signed-rank tests were run to analyze differences in scores after the addition of supplementary resources and logistic regression modeling was run to analyze demographic effects on postresource score differences. RESULTS: Of 151 participants, 74.2% were guardians, with 78.8% having completed a high school or greater education. The Wilcoxon signed-rank test indicated that postresource scores were statistically significantly higher (P < .001) than pretest scores. Logistic regression modeling showed that participants were less likely to show score improved if they were younger than 18 and were of white race. A majority (87.4%) preferred the addition of a video to the consent process. CONCLUSION: The addition of video or written resources significantly improves understanding of elective procedures. The development of procedure-specific resources can supplement the consent process and ensure decision-makers have adequate health literacy for informed decision-making.

Assessing Dysphagia in the Child.

Swallowing problems in children can occur for a variety of reasons, and assessment varies based on the age of the child, underlying medical problems, and results of the clinical swallow evaluation. The need for interdisciplinary management with speech language pathologists skilled in the management of children with dysphagia is imperative to identify the components of swallowing that are impaired and provide specific recommendations for safe and adequate nutrition supporting growth, development, and oral feeding if possible. This study focuses on the types of assessment tools available and how and when they are utilized for children of different ages and abilities.

Tracheostomy-Related Swallowing Issues in Children.

Children with tracheostomies have multiple challenges with respect to achieving normal deglutition. These children may have underlying neurologic or genetic conditions that can predispose to dysphagia, but even in children without underlying comorbidities, the presence of a tracheostomy tube impacts the mechanics of swallowing, leading to difficulty with different consistencies as well as management of normal oral secretions. Intubation prior to tracheostomy also impacts sensation in the upper aerodigestive tract increasing the risk of aspiration. Occlusion of the tracheostomy with a speaking valve or cap improves outcomes in swallow and prognosis for oral feeding.

Exploration of the Utility of the Generic ICHOM Standard Set Measures in Evaluating the Speech of Patients with Cleft Lip/Palate.

Background: The International Consortium of Health Outcome Measurements (ICHOM) standard set for cleft care appraisal recommends clinicians assess articulation with percentage consonants correct (PCC) and velopharyngeal function with velopharyngeal competency rating (VPC-R). This study explores the utility and limitations of these generic measures in detecting cleft speech sound disorders by comparing them with two cleft-specific speech-rating systems, cleft audit protocol of speech-augmented Americleft modification (CAPS-A-AM) and Pittsburgh weighted speech scale (PWSS). Methods: Consecutive children with repaired, nonsyndromic cleft lip/palate, aged 5 years or older (n = 27) underwent prospective speech evaluations conducted at a single academic institution. These evaluations were conducted, recorded, and evaluated by blinded speech-language pathologists experienced with all tools. Results: When comparing measures of articulation, PCC scores correlated better with scores for relevant subcomponents of CAPS-A-AM than PWSS. When comparing measures of velopharyngeal function, VPC-R scores correlated well with relevant components of both scales. Using a "screening test versus diagnostic test" analogy, VPC-R ratings were 87.5% sensitive and 73.7% specific for detecting velopharyngeal dysfunction according to subcomponents of CAPS-A-AM, and 70.6% sensitive and 100% specific according to subcomponents of PWSS. Conclusions: This exploratory study demonstrates that PCC and VPC-R perform moderately well in detecting articulatory and velopharyngeal dysfunction in patients with cleft lip/palate; however, these tools cannot describe nuances of cleft speech sound disorder. Thus, although PCC and VPC-R adequately track basic minimum outcomes, we encourage teams to consider extending the standard set by adopting a cleft-specific measurement system for further evaluation of the tools.

Opioid and non-opioid analgesic prescribing practices for pediatric adenotonsillectomy in a tertiary care center.

IMPORTANCE: The U.S. is in an opioid epidemic with greater than 40,000 deaths annually. Pediatric adenotonsillectomy is one of the most common and painful otolaryngology surgeries performed, often associated with opioid prescriptions. OBJECTIVE: To understand postoperative prescribing practices of adenotonsillectomy in a tertiary care institution and associated postoperative emergency department (ED) visits. DESIGN: Descriptive analysis of retrospective cohort data. SETTING: Tertiary academic healthcare institution. PARTICIPANTS: Pediatric patients <18yo undergoing adenotonsillectomy between 2013 and 2016. INTERVENTIONS/EXPOSURES: Postoperative analgesic regimens assessed including opioid and non-opioid analgesic prescriptions upon discharge from tonsillectomy surgery. MAIN OUTCOMES AND MEASURES: Main outcomes included ED presentation within 30-days of surgery and reoperation. Secondary outcomes included reason for ED presentation and relation to prescribed analgesics. Data was analyzed between November 2021-February 2022. RESULTS: 200 patients were included in the study with 69% prescribed opioids, and 51% prescribed non-opioid analgesics. Number of opioid doses ranged widely with a median of 37 (Q1, Q3: 0, 62). There were no demographic differences in patients prescribed opioids from those who were not. Of those patients who presented to the ED, 81% were not specifically prescribed acetaminophen (p < 0.001). Regression analysis models were not predictive of postoperative analgesic regimen or 30-day ED presentation (p > 0.05) CONCLUSIONS: Wide ranges of post tonsillectomy prescribing practices currently exist in our institution. Prescribing acetaminophen may help to reduce 30-day ED presentation rate. Larger prospective studies are needed to optimize pain control regimens and reduce variability of opioid prescribing practices. Standardization of postoperative pain medication doses may also reduce postoperative ED presentations.

Impact of maternal cytomegalovirus seroconversion on newborn and childhood hearing loss.

Objectives/hypothesis: The objective of this study is to describe long-term hearing outcomes in infants born to mothers with a known cytomegalovirus (CMV) positivity who were not tested for congenital CMV. Study type: Clinical research study. Design: Retrospective cohort study. Methods: Retrospective chart review was performed for mothers seropositive to CMV. Mother-infant dyads (130) were identified between January 1, 2013 and January 1, 2017. Outcomes data was collected through June 1, 2020. Demographics, risk factors for hearing loss, evidence of CMV infection, other causes of hearing loss, need for speech therapy services, and results of all hearing tests were collected. Results: All 130 infants were asymptomatic and 5 were tested for congenital CMV. Five were negative for CMV and excluded from analyses. Of the remaining 125, only 1 had low-viral avidity IgG antibodies. None had IgM antibodies. Four children (3.2%) had hearing loss at last audiogram and one child had delayed onset SNHL due to an enlarged vestibular aqueduct. Speech therapy for communication was required for 33 children (26.4%). Conclusions: Knowledge of maternal perinatal CMV status can allow for education about possible sequelae of cCMV, as well as trigger an alert for testing babies born to mothers with low-viral avidity IgG during the first trimester, when the risk of vertical transmission is highest. Also, babies born to CMV positive mothers may be more at risk for communication delays necessitating intervention. Studies focusing on the impact of maternal CMV related to childhood communication deficits could elucidate any direct relationships.

Pre- Versus Post-Tonsillectomy Intraoperative Bupivacaine Injection in the Pediatric Population: An Age- and Surgical Indication-Stratified Analysis.

OBJECTIVES: Postoperative respiratory depression is of concern in children undergoing adenotonsillectomy receiving postoperative opioids and may be mitigated with intraoperative bupivacaine. This study aims to compare the impact of bupivacaine on postoperative pain and sedation in various pediatric age and surgical indication subgroups. METHODS: This is a case series with chart review of 181 patients <18 years old undergoing adenotonsillectomy at a tertiary care center (2013-2016). Postoperative outcomes were compared between those who received intraoperative bupivacaine before (pre-tonsillectomy) or after (post-tonsillectomy) tonsil removal and those who did not (none) using χ2 test and analysis of variance. Subanalysis was performed after stratifying into age and surgical indication subgroups. RESULTS: Ninety-eight patients were included in the pre-tonsillectomy group, 47 in the post-tonsillectomy group, and 36 in the none group. The number of postanesthesia care unit opioid doses (P = .159) and pain scores at arrival (P = .362) or discharge (P = .255) were not significantly different between treatment groups overall. Among 0- to 5-year-olds, pre-tonsillectomy injection was associated with lowest mean (SD) discharge pain score of 0.55 (1.29) pre-tonsillectomy versus 0.71 (1.37) post-tonsillectomy versus 2 (1.63) none group (P = .004). Among 12- to 17-year-olds, no injection was associated with lowest mean (SD) discharge pain score of 2.33 (0.52) pre-tonsillectomy versus 5 (2.65) post-tonsillectomy versus 1.63 (1.60) none group (P = .020). Injection in patients with obstructive sleep apnea and/or sleep-disordered breathing did not improve postoperative outcomes. CONCLUSION: Intraoperative bupivacaine may improve pain scores in younger pediatric populations, though it may not impact the amount of postoperative opioid use. Prospective analysis with a larger sample size is warranted to better outline opioid usage and pain control in this group.

A Systematic Review on the Association Between Vestibular Dysfunction and Balance Performance in Children With Hearing Loss.

OBJECTIVES: The objective of this study was to understand the functional impact of vestibular dysfunction on balance control in children with hearing loss. The vestibular system is an important contributor to maintaining balance. In adults, vestibular dysfunction is known to lead to unsteadiness and falls. Considerably less is known about the effects of vestibular dysfunction in children with hearing loss. DESIGN: We conducted a systematic review in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We included articles on children with hearing loss who underwent vestibular and balance testing. The Downs and Black checklist was used to assess the risk of bias. RESULTS: A total of 20 articles were included in this systematic review, of which, 17 reported an association between vestibular dysfunction and balance abnormalities in children with hearing loss. Bias (as measured by the Downs and Black Checklist) was a concern, as most studies were nonblinded cohort studies or case series selected through convenience sampling. CONCLUSIONS: Research to date has predominantly found that children with concomitant hearing loss and vestibular impairment tend to perform more poorly on balance measures than either children with hearing loss and normal vestibular function or children with both normal-hearing and normal vestibular function. A standardized approach to assessing both vestibular function and balance would better characterize the impact of vestibular dysfunction in children with hearing loss at the population level.

Loss to follow up of failed hearing screen and missed opportunities to detect congenital cytomegalovirus are better identified with the implementation of a new electronic health record system protocol.

INTRODUCTION: Congenital CMV (cCMV) is the leading cause of non-genetic sensorineural hearing loss. Babies with cCMV can present with hearing loss any time but failing the initial hearing screen should trigger cCMV testing. cCMV must be identified within 3 weeks after birth to differentiate congenital from acquired CMV, yet follow-up hearing screens may not occur until after 21 days. A new electronic health record protocol to test cCMV in babies who fail their initial hearing screen was established at our institution in 2013. The purpose of this study is to evaluate adherence and deviations from this protocol. METHODS: All term infants born in 2013-2016 who failed initial hearing screen were included. The records were reviewed retrospectively. Demographic data, dates of hearing screens, CMV testing results and follow-up hearing test results were collected. RESULTS: A total of 19,069 newborn babies were screened between 2013 and 2016. Babies who were in the neonatal intensive care unit whether premature or not were excluded as these infants are often in the hospital longer than 3 weeks so audiologic diagnostic testing may be delayed. Among term newborns screened, 1358 failed initial screen and 444 failed subsequent hearing testing prior to discharge. We identified 60 babies who did not follow up and 59 underwent additional audiologic testing. Overall 38 babies were tested for cCMV with 2 positives. We found an increase in cCMV testing over time and a significant decrease between physical distance from birth hospital and outpatient audiologic follow-up testing within 21 days of birth. DISCUSSION: Our results are consistent with a 0.4% rate of cCMV in full-term babies who failed their newborn hearing screen. From 2013 to 2016, more babies received CMV tests, but post-screening follow up was still delayed. Further research is necessary to address factors affecting follow up. Use of electronic health record eased identification of results and improved tracking.

Vestibular Dysfunction and Gross Motor Milestone Acquisition in Children With Hearing Loss: A Systematic Review.

OBJECTIVE: To describe the impact of vestibular dysfunction on gross motor development in children with hearing loss. DATA SOURCES: MEDLINE (PubMed), Embase (Elsevier), Web of Science (Clarivate), and the Cumulative Index of Nursing and Allied Health Literature (EBSCO). REVIEW METHODS: A systematic review was reported in concordance with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Articles on children with hearing loss who underwent at least 1 instrumented measure of vestibular function and had gross motor milestones assessed were included. The Downs and Black checklist was used to assess risk of bias and methodological quality. RESULTS: Eleven articles were included in the systematic review. Three articles stratified quantitative results of gross motor milestone acquisition by severity of vestibular impairment. Over half of studies were case series published within the last 5 years. This systematic review showed that children with hearing loss and severe, bilateral vestibular dysfunction demonstrate delayed gross motor milestones. However, it was difficult to draw conclusions on whether milder forms of vestibular dysfunction significantly affect gross motor milestone acquisition in children with hearing loss. The reason is that most studies were of low to moderate quality, used different assessment methods, and contained results that were descriptive in nature. CONCLUSIONS: This emerging area would benefit from future research, such as higher-quality studies to assess vestibular function and gross motor milestones. This would allow for better characterization of the impacts of vestibular impairment, especially milder forms, in children with hearing loss.

Adherence to American Academy of Otolaryngology-Head and Neck Surgery Clinical Practice Guidelines: A Systematic Review.

OBJECTIVE: Clinical practice guidelines synthesize and disseminate the best available evidence to guide clinical decisions and increase high-quality care. Since 2004, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published 16 guidelines. The objective of this review was to evaluate clinicians' adherence to these guidelines' recommendations as measured in the literature. DATA SOURCES: We searched PubMed, Embase, and Web of Science on August 29, 2019, for studies published after June 1, 2004. REVIEW METHODS: We systematically identified peer-reviewed studies in English that reported clinician adherence to AAO-HNSF guideline recommendations. Two authors independently reviewed and abstracted study characteristics, including publication date, population, sample size, guideline adherence, and risk of bias. RESULTS: The search yielded 385 studies. We excluded 331 studies during title/abstract screening and 32 more after full-text review. The remaining 22 studies evaluated recommendations from 8 of the 16 guidelines. The Otitis Media with Effusion, Polysomnography, Tonsillectomy, and Sinusitis guidelines were studied most. Study designs included retrospective chart reviews (7, 32%), clinician surveys (7, 32%), and health care database analyses (8, 36%). Studies reported adherence ranging from 0% to 99.8% with a mean of 56%. Adherence varied depending on the recommendation evaluated, type of recommendation, clinician type, and clinical setting. Adherence to the polysomnography recommendations was low (8%-65.3%). Adherence was higher for the otitis media with effusion (76%-90%) and tonsillectomy (43%-98.9%) recommendations. CONCLUSIONS: Adherence to recommendations in the AAO-HNSF guidelines varies widely. These findings highlight areas for further guideline dissemination, research about guideline adoption, and quality improvement.

Airway findings in children with tracheostomies: When is diagnostic bronchoscopy and laryngoscopy indicated?

OBJECTIVES: To determine the utility of diagnostic laryngoscopy and bronchoscopy in children with tracheostomies and to describe the incidence of airway findings. METHODS: Retrospective cohort study examining children with tracheostomies who underwent direct laryngoscopy and bronchoscopy (DLB) at Duke University Hospital between 2008 and 2016. RESULTS: A total of 81 patients who underwent 114 bronchoscopies met inclusion criteria. The median time between tracheostomy and first DLB was 13 months (IQR 4.25-14.75). Sixty-six patients were diagnosed with findings on DLB (81.5%). Suprastomal granulation tissue was the most common complication (59.0%), followed by increased tracheal secretions (23%), stomal and peristomal granulation (13.2%), tracheal ulcer (3.3%), and suprastomal collapse (1.6%). The proportion of patients with airway findings who underwent endoscopy >6 months post-tracheostomy was higher than those <6 months post-tracheostomy, although this did not reach statistical significance (90.6% vs. 75.5%, p = 0.087). However, when examining tracheostomy-related findings, the proportion of patients with airway findings who underwent DLB >6 months post-tracheostomy (61%) compared to <6 months post-tracheostomy (36%) was significantly different (p = 0.026). Patients who were symptomatic before bronchoscopy were more likely to have positive findings (91.9% vs. 72.7%, p = 0.027) and patients were more likely to be symptomatic if they had DLB >6 months after tracheostomy versus <6 months after tracheostomy (68.8% vs. 30.6%; p < 0.001). CONCLUSION: The high incidence of airway findings, especially tracheostomy-related findings, noted on DLB supports the continued use of airway endoscopies in children post-tracheostomy. Timing of DLB may play a role in determining utility with evaluation and symptomatic patients should be more closely monitored as they demonstrate higher rates of airway findings.

Geographic and Racial Disparities in Infant Hearing Loss.

OBJECTIVE: Approximately 1 to 2 of every 1000 American newborns has hearing loss identified by newborn screening. This study was designed to determine if infant hearing loss is more common in socioeconomically disadvantaged communities. STUDY DESIGN: In this retrospective study, we analyzed electronic medical record data using geostatistical models. SETTING: Infants were residents of Durham County, North Carolina, born in 2 hospitals of the Duke University Health System. This county includes the city of Durham and surrounding suburban and rural communities. SUBJECTS AND METHODS: Subjects were hearing-screened newborns, born between 2005 and 2016, whose residential address was in Durham County, North Carolina. This was a retrospective study using medical record data. We used Bayesian regression models with smoothing of coordinate date to identify both spatial and nonspatial predictors of infant hearing loss. RESULTS: We identified 19,348 infants from Durham County, of whom 675 had failed initial hearing screening and 191 had hearing loss confirmed on follow-up. Hearing loss was significantly associated with minority race (odds ratio [OR], 2.45; 95% confidence interval, 1.97-3.06), as well as lower gestational age and maternal sexually transmitted infections. We identified significant geographic heterogeneity, with a higher probability of hearing loss in poorer urban neighborhoods (local OR range, 0.59-1.39). Neighborhood disadvantage was a significant predictor of hearing loss, as was high local seroprevalence of cytomegalovirus (CMV) among pregnant women. CONCLUSIONS: Urban, low-income neighborhoods have a high prevalence of infant hearing loss compared with more affluent surrounding communities, particularly among minorities. This distribution may be attributable to congenital CMV infection.

Double Carina: A Novel Tracheo-Bronchial Anomaly Found During a Pediatric Airway Evaluation.

OBJECTIVES: To present a novel pediatric airway anomaly encountered on direct laryngoscopy and bronchoscopy, further characterized with computed tomography imaging of the chest. STUDY DESIGN: Case report and literature review. METHODS: Review of the clinical presentation, operative findings, and imaging findings of an infant who presented with respiratory distress in the setting of multiple congenital abnormalities. A brief literature review supplements the case presentation. RESULTS: While multiple tracheobronchial anomalies have long been reported, this is the first report of a double or false carina: a system of symmetric paired upper and lower bronchi connected by a central conduit. Operative evaluation was limited given the narrow lumen, and postoperative imaging aided in further characterization of the pediatric airway. CONCLUSIONS: This is the first report of a novel tracheobronchial anomaly presenting as a double carina. Tracheobronchial anomalies are diverse and should be considered when performing operative airway evaluations. Imaging can be a helpful adjunct with anatomic characterization.

Osseointegrated implants for auricular prostheses: An alternative to autologous repair.

OBJECTIVES/HYPOTHESIS: This study compares the hospital cost of osseointegrated implants for retention of an auricular prosthesis to autologous ear reconstruction. STUDY DESIGN: Retrospective review. METHODS: This study includes patients who underwent reconstruction for either congenital or acquired ear defects at Duke University Medical Center during 2009 to 2015. RESULTS: A total of nine patients had autologous repair representing nine operative ears, and 16 patients had an osseointegrated implant representing 18 operative ears (two bilateral). The average age for the autologous repair was 11.6 years with 56% male versus 40.7 years with 56% male for the osseointegrated implant patients. For autologous patients, indications for surgery were anotia/microtia in 8/9 (89%) and trauma in 1/9 (11%) versus 6/16 (387.5%) anotia/microtia, 8/16 (50%) cancer, and 2/16 (132.5%) trauma in the osseointegrated implant group. The mean number of surgeries was 3.1 for autologous repairs and 1.0 for osseointegrated repairs (mean difference confidence interval [CI]: -2.4 to -1.8, P < .001). The average cost to the hospital for an osseointegrated repair was $6,491.39 versus $10,047.93 for autologous repairs (CI: $6,496.38 to $-616.68, P = .02) CONCLUSIONS: Osseointegrated implants for retaining an auricular prosthesis has a similar cost to autologous repair of ear defects, but patients underwent an average of two more surgeries with autologous repair. Patients should be able to choose the reconstruction option that best suits their condition and preferences. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:2153-2156, 2018.

Otolaryngologist adherence to the AAO-HNSF Allergic Rhinitis Clinical Practice Guideline.

BACKGROUND: In February 2015, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNSF) published the Allergic Rhinitis Clinical Practice Guideline (AR-CPG). The objective of this study was to assess otolaryngologists' perception of the accuracy and adherence to the AR-CPG. METHODS: A survey was distributed to fellows of the American Academy of Otolaryngic Allergy and members of the American Academy of Otolaryngology-Head and Neck Surgery Foundation. A total of 601 otolaryngologists responded. The survey evaluated otolaryngologists' demographic data, perception of the accuracy of the guideline, and adherence to the guideline action statements. RESULTS: The majority of respondents were actively practicing (544 [90.5%]), for a duration of 11-30 years (308 [51.2%]), in a private practice setting (387 [64.4%]). The cohort was largely fellowship trained (348 [57.9%]) and had reviewed the guideline (428 [71.2%]). Most respondents perceived the guideline as being correct "a great deal" (295 [69.7%]) and deviated from the guideline "only a little" (302 [71.6%]). High rates of adherence to the strong guideline recommendations were observed. Respondents "always/most of the time" recommended intranasal steroids (581 [97.6%]), and oral antihistamines (439 [74%]) as primary therapy. Otolaryngologists in practice for longer were more likely to deviate from the guideline recommendations by obtaining sinonasal imaging (p = 0.007) and recommending oral leukotriene receptor antagonists as primary therapy (p = 0.0001). CONCLUSION: Overall perception of the correctness of and adherence to the AR-CPG was high in this cohort. Targeted education resources should be provided to otolaryngologists in practice for longer in efforts to reduce harmful or unnecessary variations in care.

Coblation of suprastomal granulomas in tracheostomy-dependent children.

OBJECTIVE: Suprastomal granulomas pose a persistent challenge for tracheostomy-dependent children. They can limit phonation, cause difficulty with tracheostomy tube changes and prevent decannulation. We describe the use of the coblator for radiofrequency plasma ablation of suprastomal granulomas in five consecutive children from September 2012 to January 2016. METHOD: Retrospective case series at a tertiary medical center. RESULTS: The suprastomal granuloma could be removed with the coblator in all 5 cases. Three were removed entirely endoscopically and 2 required additional external approach through the tracheal stoma for complete removal. There were no intraoperative or postoperative complications. One patient was subsequently decannulated and 2 patients have improved tolerance of their speaking valves. Two patients remain ventilator dependent, but their bleeding and difficulty with tracheostomy tube changes resolved. Three of the patients have had subsequent re-evaluation with bronchoscopy, demonstrating resolution or markedly decreased size of the granuloma. This technique is time efficient, simple and minimizes risks associated with other techniques. The relatively low temperature and use of continuous saline irrigation with the coblator device minimizes the risk of airway fires. Additionally, the risk of hypoxia from keeping a low fractional inspiratory oxygen level (FIO2) to prevent fire is avoided. The concurrent suction in the device decreases blood and tissue displacement into the distal airway. CONCLUSION: Coblation can be used safely and effectively with an endoscopic or external approach to remove suprastomal granulomas in tracheostomy-dependent children. More studies that are larger and have longer follow-up are needed to evaluate the use of this technique.