OBJECTIVE:Current guidelines recommend overnight admission for children with severe obstructive sleep apnea (OSA) and obesity undergoing tonsillectomy, although most have uneventful postoperative courses. We aimed to identify low-risk subgroups within this high-risk population who may be candidates for same-day discharge. METHODS:Retrospective cohort study of children aged 2-18 years with obesity (≥ 95th BMI percentile) and severe OSA (AHI ≥ 10 events/h and/or SpO2 nadir < 80%) undergoing tonsillectomy at a tertiary children's hospital (2021-2024). The primary outcome was a severe perioperative event: ICU admission, prolonged hospitalization (> 48 h), or need for advanced respiratory support. Bayesian logistic regression using informative priors identified predictors. Model-based risk stratification and simplified clinical rules were evaluated using sensitivity, specificity, and negative predictive value. RESULTS:Among 304 children, 36 (11.8%) experienced a severe event. SpO2 nadir was the strongest predictor (β = -0.668, 95% CrI [-1.164, -0.172], directional probability 99.6%), followed by Class III obesity (97.0%) and AHI (95.0%). Model-derived stratification identified 33% of patients with < 5% predicted probability of severe events. A clinical rule combining AHI < 25 events/h and SpO2 nadir > 85% showed sensitivity 85.7% and negative predictive value 99.5%, corresponding to an observed event rate < 5%. CONCLUSION:Most obese children with severe OSA do not experience severe perioperative events. Simple polysomnographic criteria can identify very low-risk patients who may be candidates for same-day discharge planning. These findings support a more individualized approach to postoperative admission; prospective validation is needed before implementation. LEVEL OF EVIDENCE: 4:

To identify clinical characteristics that may be associated with persistence or progression of mild sleep-disordered breathing (SDB) in children who are observed without surgery. This is a secondary analysis of the control arm of the Pediatric Adenotonsillectomy Trial for Snoring (PATS), which randomized 458 children aged 3.0 to 12.9 years with mild SDB (snoring with obstructive apnea–hypopnea index [oAHI] < 3 events/hour) to early adenotonsillectomy (eAT) versus watchful waiting with supportive care (WWSC). Participants were assessed at baseline and 12 months with the Pediatric Sleep Questionnaire–Sleep-Related Breathing Disorder (PSQ-SRBD) scale and polysomnography (PSG). We tested for factors predictive of either (1) PSG progression defined by a 12-month oAHI ≥ 3 or (2) symptom persistence or progression defined by a 12-month PSQ-SRBD score ≥ 0.33. A total of 234 participants were observed (mean age 6.2 years, 111 [47

STUDY OBJECTIVES:To examine clinically-meaningful benefit that may be achieved by early adenotonsillectomy (eAT) vs. watchful waiting with supportive care (WWSC) in children with mild sleep-disordered breathing (MSDB, snoring but little or no obstructive sleep apnea), and to identify baseline demographic, symptom, physical exam, historical, or polysomnographic features that may predict such benefit. MATERIALS AND METHODS:Secondary analysis of participants (aged 3.0-12.9 years) in the 12-month multi-center randomized clinical trial of eAT vs. WWSC for MSDB, the Pediatric Adenotonsillectomy Trial for Snoring (PATS). Meaningful benefit was defined as a composite outcome of clinically-significant change in at least 2 of 4 domains - behavior, quality of life, subjective sleepiness, and blood pressure - each of which had shown greater improvement 12 months after AT versus WWSC in PATS. RESULTS:Among 363 participants, the mean age was 6.6 (SD 2.3) years, 199 (55%) were > 5 years old at enrollment, and 185 (51%) were male. A total of 115 (65%) vs. 73 (39%) in the eAT vs. WWSC arms, respectively, experienced clinically-meaningful improvement on ≥2 domains (p < 0.01). Among variables explored for effect modification - including demographics, health factors, symptoms and signs, and polysomnographic data - only a high Mallampati score of III or IV vs. I or II showed predictive value (OR 4.16, 95% CI [1.22, 15.6], p = 0.027). CONCLUSIONS:Clinically-meaningful positive outcomes occur more often after eAT vs. WWSC for children with MSDB. However, many clinical features accessible prior to AT, with the intriguing exception of a high Mallampati score, may not help to identify which children stand to benefit. CLINICAL TRIAL:Pediatric Adenotonsillectomy for Snoring (PATS); HYPERLINK "https://clinicaltrials.gov/study/NCT02562040;" https://clinicaltrials.gov/study/NCT02562040; Registration number: NCT02562040.

BACKGROUND:Pediatric patients with high-risk obstructive sleep apnea (OSA) undergoing adenotonsillectomy (AT) are at increased risk for postoperative complications. While prior studies have identified risk factors using univariate analysis and logistic regression, the mediating variables that explain how OSA severity leads to postoperative complications have not been studied. Identifying these mediating factors can guide risk stratification and targeted interventions for this vulnerable patient population. METHODS:307 pediatric patients (<18 years) with high-risk OSA who underwent AT and polysomnography (PSG) from 2019 to 2021 were included. Causal-mediation analysis was conducted. Primary outcomes were intensive care unit (ICU) intervention, major respiratory intervention, and prolonged hospitalization (>48 h). Twenty-five different patient characteristics and PSG parameters were analyzed as mediators. RESULTS:The relationship between high-risk OSA and all three postoperative complications is mediated by O2 nadir (P < 0.001), CO2 max (P<0.002), and time spent with oxygen saturation below 90% (TST O2 <90%) (P < 0.001). Sensitivity analyses revealed that the effects are sensitive to moderate levels of unmeasured confounding. CONCLUSION:Prior univariate analysis identified O2 nadir and CO2 max as significantly associated with postoperative complications. In this study, TST O2 <90% emerged as a novel and consistent mediator, suggesting it may be an important marker for identifying high-risk patients that simple OSA severity scores may miss. While causal mediation analysis clarified which variables acted as candidate mediators, sensitivity analysis revealed that they are sensitive to moderate levels of unmeasured confounding and should be interpreted cautiously.

ABSTRACT Objective To evaluate how sociodemographic and neighborhood factors are associated with use of preoperative polysomnography (PSG) in children undergoing tonsillectomy, and to assess whether these factors are associated with return for postoperative PSG, surgical success, or postoperative complications. Methods We analyzed 940 children undergoing tonsillectomy at a tertiary children's hospital (2016–2024). Multivariable logistic regression estimated associations between sociodemographic factors (race, ethnicity, insurance, language), neighborhood opportunity (Child Opportunity Index [COI]), and preoperative PSG. Sequential models examined pathways of association. Doubly robust models estimated the association between PSG and postoperative complications. Results Preoperative PSG was performed in 389 of 940 children (41.4%). In adjusted models, Black race (adjusted odds ratio [aOR], 1.79; 95% CI, 1.18–2.72), non‐English language (aOR, 2.26; 95% CI, 1.45–3.52), Medicaid insurance (aOR, 1.52; 95% CI, 1.06–2.17), and lower COI (aOR per 1‐SD increase, 0.81; 95% CI, 0.67–0.99) were associated with higher odds of having preoperative PSG prior to tonsillectomy. Obesity was also strongly associated with preoperative PSG (aOR, 2.49; 95% CI, 1.77–3.51), second only to medical complexity. The association for Hispanic ethnicity attenuated by approximately 80% in sequential models. Sociodemographic and neighborhood factors were not associated with return for postoperative PSG or surgical success; those outcomes were associated with preoperative apnea‐hypopnea index (AHI) and medical complexity. In doubly robust models, preoperative PSG was associated with higher complication odds (aOR, 2.07; 95% CI, 1.09–3.93), consistent with confounding by indication rather than a causal effect of testing. Conclusion Social and neighborhood factors were associated with preoperative PSG use but not with surgical success. The critical equity question in pediatric tonsillectomy may lie upstream, in who reaches tertiary surgical evaluation at all. Level of Evidence 4.

OBJECTIVES:To determine the prevalence of periodic limb movements (PLMS) in children with obstructive sleep apnea (OSA) and assess the effect of adenotonsillectomy (AT) on PLMS. METHODS:Charts of children with OSA who underwent AT were reviewed for demographics, obstructive apnea-hypopnea index, and PLMS before and after AT. Prevalence of elevated periodic limb movement index (PLMI), defined as PLMS > 5 events/h, was compared with χ2 test or Fisher's exact. Paired t-test and Wilcoxon signed rank test were used to compare PLMI pre-and post-AT. RESULTS:Elevated PLMI occurred in 114 (9.8%) of 1159 children (676 male,483 female, median age = 5). The prevalence of elevated PLMI was similar in gender, ethnicity, race, and weight categories. Compared to toddlers, the odds of elevated PLMI increased 22.1 times in preschoolers (p ≤ 0.001), 35.4 times in grade-schoolers (p ≤ 0.001), and 30.8 times in teenagers (p ≤ 0.001). Compared to children with mild OSA, the odds of elevated PLMI increased 2.3 times in children with moderate OSA (p = 0.007) and 1.9 times in those with severe OSA (p = 0.01). Of the 54 children who had a polysomnogram after AT, 46 (85%) resolved and 8 (15%) had persistent elevated PLMI. PLMI after AT decreased from 11.9 ± 7.6 to 2.9 ± 6.5 (p ≤ 0.001). CONCLUSIONS:Elevated PLMI is common in children with OSA undergoing AT. PLMI resolves after AT in most children with OSA. LEVEL OF EVIDENCE: 4:

Introduction Mild sleep-disordered breathing (mSDB) in children is associated with both neurobehavioral morbidity and reduced quality of life (QOL). However, the association between symptom burden and QOL with executive function is not well understood, and it is not known whether QOL and symptom burden may help identify children with neurocognitive dysfunction. Objective To assess associations among executive function, QOL, and symptom burden in children with mSDB. Design, Setting, and Participants This cross-sectional study was a secondary analysis of the multicenter Pediatric Adenotonsillectomy Trial for Snoring, which included children aged 3 to 12 years randomized to watchful waiting or adenotonsillectomy for mSDB (snoring and an obstructive apnea-hypopnea index <3) between June 29, 2016, and February 1, 2021. The data for this report were analyzed between December 22, 2020, and October 3, 2024. Exposure Pediatric mSDB. Main Outcomes and Measures Quality of life was assessed using the Obstructive Sleep Apnea-18 (OSA-18), and symptom burden was assessed using the Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder Scale (PSQ-SRBD). Executive function, including self-control and working memory, was measured using the Behavior Rating Inventory of Executive Function Global Executive Composite (BRIEF GEC), and inhibitory control and sustained attention were measured by the GoNoGo vigilance test. Partial Pearson correlations and multiple linear regression models were used to assess the associations among QOL, symptoms, and executive function. Results The sample included 459 children (mean [SD] age, 6.1 [2.3] years; 230 female [50.1%]). Moderate correlations were found between the BRIEF GEC and the PSQ-SRBD and OSA-18 (r = 0.58 [95% CI, 0.51-0.64] and 0.59 [95% CI, 0.52-0.64], respectively). After adjusting for age, sex, race and ethnicity, body mass index percentile, household income, maternal education, attention-deficit/hyperactivity disorder, test characteristics, and disease severity, both OSA-18 and PSQ-SRBD scores were associated with the BRIEF GEC (beta = 0.41 [95% CI, 0.36-0.47] and 3.66 [95% CI, 3.17-4.15], respectively). In the fully adjusted model, PSQ-SRBD was also associated with GoNoGo inhibitory control (beta = -0.04 [95% CI, -0.08 to -0.01]) and sustained attention (beta = -0.05 [95% CI, -0.10 to -0.01]). Conclusions and Relevance In this study, disease-specific QOL and symptom burden were associated with executive function in children with mSDB. These findings may be useful in identifying those children who are at risk for neurocognitive dysfunction.

Background: Aberrant subclavian artery (ASA) with or without Kommerell's diverticulum (KD) is a rare anatomic aortic arch anomaly that can cause dysphagia and/or life-threatening rupture. The objective of this study is to compare outcomes of ASA/KD repair in patients with a left versus right aortic arch. Methods: Using the Vascular Low Frequency Disease Consortium methodology, a retrospective review was performed of patients >= 18 years old with surgical treatment of ASA/KD from 2000 to 2020 at 20 institutions. Results: 288 patients with ASA with or without KD were identified; 222 left-sided aortic arch (LAA), and 66 right-sided aortic arch (RAA). Mean age at repair was younger in LAA 54 vs. 58 years (P = 0.06). Patients in RAA were more likely to undergo repair due to symptoms (72.7% vs. 55.9%, P = 0.01), and more likely to present with dysphagia (57.6% vs. 39.1%, P < 0.01). The hybrid open/endovascular approach was the most common repair type in both groups. Rates of intraoperative complications, death within 30 days, return to the operating room, symptom relief and endoleaks were not significantly different. For patients with symptom status follow-up data, in LAA, 61.7% had complete relief, 34.0% had partial relief and 4.3% had no change. In RAA, 60.7% had complete relief, 34.4% had partial relief and 4.9% had no change. Conclusions: In patients with ASA/KD, RAA patients were less common than LAA, presented more frequently with dysphagia, had symptoms as an indication for intervention, and underwent treatment at a younger age. Open, endovascular and hybrid repair approaches appear equally effective, regardless of arch laterality.

Importance The American Academy of Otolaryngology-Head and Neck Surgery Foundation has recommended yearly surgeon self-monitoring of posttonsillectomy bleeding rates. However, the predicted distribution of rates to guide this monitoring remain unexplored. Objective To use a national cohort of children to estimate the probability of bleeding after pediatric tonsillectomy to guide surgeons in self-monitoring of this event. Design, Settings, and Participants This retrospective cohort study used data from the Pediatric Health Information System for all pediatric (<18 years old) patients who underwent tonsillectomy with or without adenoidectomy in a children's hospital in the US from January 1, 2016, through August 31, 2021, and were discharged home. Predicted probabilities of return visits for bleeding within 30 days were calculated to estimate quantiles for bleeding rates. A secondary analysis included logistic regression of bleeding risk by demographic characteristics and associated conditions. Data analyses were conducted from August 7, 2022 to January 28, 2023. Main Outcomes and Measures Revisits to the emergency department or hospital (inpatient/observation) for bleeding (primary/secondary diagnosis) within 30 days after index discharge after tonsillectomy. Results Of the 96 415 children (mean [SD] age, 5.3 [3.9] years; 41 284 [42.8%] female; 46 954 [48.7%] non-Hispanic White individuals) who had undergone tonsillectomy, 2100 (2.18%) returned to the emergency department or hospital with postoperative bleeding. The predicted 5th, 50th, and 95th quantiles for bleeding were 1.17%, 1.97%, and 4.75%, respectively. Variables associated with bleeding after tonsillectomy were Hispanic ethnicity (OR, 1.19; 99% CI, 1.01-1.40), very high residential Opportunity Index (OR, 1.28; 99% CI, 1.05-1.56), gastrointestinal disease (OR, 1.33; 99% CI, 1.01-1.77), obstructive sleep apnea (OR, 0.85; 99% CI, 0.75-0.96), obesity (OR,1.24; 99% CI, 1.04-1.48), and being more than 12 years old (OR, 2.48; 99% CI, 2.12-2.91). The adjusted 99th percentile for bleeding after tonsillectomy was approximately 6.39%. Conclusions and Relevance This retrospective national cohort study predicted 50th and 95th percentiles for posttonsillectomy bleeding of 1.97% and 4.75%. This probability model may be a useful tool for future quality initiatives and surgeons who are self-monitoring bleeding rates after pediatric tonsillectomy.

Introduction Deep interarytenoid groove (DIG) may cause swallowing dysfunction in children; however, the management of DIG has not been established.Objective We evaluated the subjective and objective outcomes of interarytenoid augmentation with injection in children with DIG.Methods Consecutive children under 18 years of age who underwent injection laryngoplasty for DIG were reviewed. Data pertaining to demographics, past medical history, past surgical history, and results of pre and postoperative video fluoroscopic swallow study (VFSS) were obtained. The primary outcome measure was the presence of thin liquid aspiration or penetration on postoperative VFSS. The secondary outcome measure was caregiver-reported improvement of symptoms.Results Twenty-seven patients had VFSS before and after interarytenoid augmentation with injection (IA). Twenty (70%) had thin liquid penetration and 12 (44%) had thin liquid aspiration before the IA. Thin liquid aspiration resolved in 9 children (45%) and persisted in 11 (55%). Of the 12 children who had thin liquid aspiration prior to IA, 6 (50%) had resolution of thin liquid aspiration after IA.Conclusions Injection laryngoplasty is a safe tool to improve swallowing function in children with DIG. Further studies are needed to assess the long-term outcomes of IA and identify predictors of successful IA in children with DIG.

Accessing healthy food is paramount to one’s nutritional status, a known factor in postoperative morbidity and long-term mortality. The relationship between a patient’s food accessibility and outcomes following surgical resection in pancreatic ductal adenocarcinoma (PDAC) is unknown. The objective of this study was to compare postoperative outcomes and long-term survival of PDAC patients residing in low and high food accessibility areas who underwent surgical resection. Adult PDAC patients undergoing surgical resection at a single tertiary academic center from 2011 to 2021 were identified retrospectively. Patient addresses were mapped onto the United States Department of Agriculture (USDA) Food Access Research Atlas to determine food accessibility status. Those with residence in areas designated by the USDA as having limited access to healthy food were classified as having “low food accessibility” (LFA). Those not classified as having LFA were labeled as having “high food accessibility” (HFA). Demographics, comorbidities, neoadjuvant treatment status, tumor characteristics, postoperative complications, hospital stay characteristics, overall survival, and recurrence rates were collected. Data were evaluated using descriptive statistics and Cox-Proportional Hazard models for survival. In total, 89 patients met inclusion criteria, of which 23 (25.8%) patients resided in areas of LFA. No significant differences existed in patient age, sex, or other sociodemographics. Patient BMI was higher for LFA patients than HFA patients (28.3 vs 24.6, p = 0.0070). Major comorbidities were comparable except for an increased rate of diabetes in LFA patients (56.5% vs 29.2%, p = 0.0194). Both groups underwent neoadjuvant treatment at similar rates. Tumor grade was significantly different for the groups with LFA patients having higher rates of poor differentiation compared to HFA patients (39.1% G3 vs 9.4% G3, p = 0.0015). Lymphovascular invasion, perineural invasion, and number of positive lymph nodes were similar. Minor complications, readmission, and recurrence did not demonstrate differences between groups but LFA patients suffered from higher rates of major complication (52.2% vs 27.3%, p = 0.0296). Total hospital length of stay and ICU length of stay were also similar. Overall survival was 12.1 months in LFA patients and 15.2 months in HFA patients but was not significantly different (p = 0.16). Low food accessibility is associated with greater rates of major complications in PDAC patients undergoing tumor resection yet does not significantly impact overall survival in this deadly disease. Awareness of patient food accessibility status may be beneficial in recognizing those who might benefit the most from nutritional prehabilitation and those less able to act on nutritional recommendations. Citation Format: Christopher M. Liu, Devon C. Freudenberger, Salem Rustom, Vignesh Vudatha, Shreya Raman, Teja Devarakonda, Kelly M. Herremans, Andrea N. Riner, Luke Wolfe, Jose G. Trevino. Food accessibility and its impact on clinical outcomes in patients undergoing surgery for pancreatic ductal adenocarcinoma [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr B124.

Abstract Introduction  Alterations in upper airway flow dynamics and sites of airway obstruction immediately after tonsillectomy and adenoidectomy (TA) have not been assessed. Identification of the changes in airway obstruction patterns after TA potentially improves the surgical management of children with obstructive sleep apnea (OSA). Objective  To evaluate the effect of TA on upper airway obstruction patterns detected with drug-induced sleep endoscopy (DISE). Methods  The medical records of patients who underwent pre-TA DISE during the induction of anesthesia and post-TA DISE at the end of TA were reviewed. Data pertaining to polysomnography and DISE findings were analyzed. Results  Twenty-seven patients (15 male and 12 females aged between 2 and 18 years old) were identified. All patients had obstruction at multiple sites of the upper airway. Prior to TA, airway obstruction was at the level of the velum in 27 patients, of the oropharynx/lateral walls in 27, of the tongue in 7, and of the epiglottis in 4. After TA, airway obstruction was at the level of the velum in 24 patients, of the oropharynx/lateral walls in 16, of the tongue in 6, and of the epiglottis in 4. The degree of obstruction at the levels of the velum and oropharynx/lateral walls after TA was significantly decreased. Conclusions  Drug-induced sleep endoscopy performed prior to TA revealed that most of the sites of airway obstruction persisted after TA in OSA children with multiple sites of airway obstruction. Further studies in larger group of children with OSA are needed to establish the value of DISE findings in predicting residual OSA after TA, surgical planning, determining the need for post TA sleep study, and counseling caregivers.

ImportanceThe American Academy of Otolaryngology–Head and Neck Surgery Foundation has recommended yearly surgeon self-monitoring of posttonsillectomy bleeding rates. However, the predicted distribution of rates to guide this monitoring remain unexplored.ObjectiveTo use a national cohort of children to estimate the probability of bleeding after pediatric tonsillectomy to guide surgeons in self-monitoring of this event.Design, Settings, and ParticipantsThis retrospective cohort study used data from the Pediatric Health Information System for all pediatric (<18 years old) patients who underwent tonsillectomy with or without adenoidectomy in a children’s hospital in the US from January 1, 2016, through August 31, 2021, and were discharged home. Predicted probabilities of return visits for bleeding within 30 days were calculated to estimate quantiles for bleeding rates. A secondary analysis included logistic regression of bleeding risk by demographic characteristics and associated conditions. Data analyses were conducted from August 7, 2022 to January 28, 2023.Main Outcomes and MeasuresRevisits to the emergency department or hospital (inpatient/observation) for bleeding (primary/secondary diagnosis) within 30 days after index discharge after tonsillectomy.ResultsOf the 96 415 children (mean [SD] age, 5.3 [3.9] years; 41 284 [42.8%] female; 46 954 [48.7%] non-Hispanic White individuals) who had undergone tonsillectomy, 2100 (2.18%) returned to the emergency department or hospital with postoperative bleeding. The predicted 5th, 50th, and 95th quantiles for bleeding were 1.17%, 1.97%, and 4.75%, respectively. Variables associated with bleeding after tonsillectomy were Hispanic ethnicity (OR, 1.19; 99% CI, 1.01-1.40), very high residential Opportunity Index (OR, 1.28; 99% CI, 1.05-1.56), gastrointestinal disease (OR, 1.33; 99% CI, 1.01-1.77), obstructive sleep apnea (OR, 0.85; 99% CI, 0.75-0.96), obesity (OR,1.24; 99% CI, 1.04-1.48), and being more than 12 years old (OR, 2.48; 99% CI, 2.12-2.91). The adjusted 99th percentile for bleeding after tonsillectomy was approximately 6.39%.Conclusions and RelevanceThis retrospective national cohort study predicted 50th and 95th percentiles for posttonsillectomy bleeding of 1.97% and 4.75%. This probability model may be a useful tool for future quality initiatives and surgeons who are self-monitoring bleeding rates after pediatric tonsillectomy.

Abstract Objectives Thyroglossal duct cyst (TGDC) is the most common pediatric congenital neck mass. The Sistrunk procedure is the standard method of excision and is associated with low rates of recurrence. This study aimed to review our institution's outcomes following the Sistrunk procedure, specifically the rates of wound complications and cyst recurrence. Methods This was a retrospective case series of pediatric patients undergoing the Sistrunk procedure from June 2009 to April 2021. Results A total of 273 patients were included. Of these, 139 (53%) patients were male and 181 (66%) were white. The average age at the time of surgery was 7.1 years. The overall cyst recurrence rate was 11%. The most common wound complications were seroma (14%) and surgical site infections (SSIs) (12%). Wound complications were associated with prior history of cyst infection (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.07–3.60, z‐test 2.2, p = .03). Pediatric surgery was associated with fewer wound complications (OR 0.18; 95% CI 0.05–0.6, z‐test −2.78, p = .005). However, pediatric surgery operated on fewer patients with a history of cyst infection (36% vs. 55%, p = .012). Drain placement and postoperative antibiotics did not affect rates of wound complications. Conclusions Prior cyst infection is associated with increased rates of postoperative wound complications. Postoperative antibiotics and drain placement did not significantly affect complication rates. Level of Evidence 4.

OBJECTIVE:To estimate the incidence of inpatient and ambulatory pediatric tonsillectomies in the United States in 2019.STUDY DESIGN:Cross-sectional analysis.SETTING:Healthcare Cost and Utilization Project databases.METHODS:We determined national incidences of hospital-based ambulatory procedures, inpatient admissions, and readmissions among pediatric tonsillectomy patients, ages 0 to 20 years, using the Kids Inpatient Database, Nationwide Ambulatory Surgery Sample, and Nationwide Readmission Database. We described the demographics, commonly associated conditions, complications, and predictors of readmission.RESULTS:An estimated 559,900 ambulatory and 7100 inpatient tonsillectomies were performed in 2019. Among inpatients, the majority were male (59%) and the largest ethnic group was white (37%). Adenotonsillar hypertrophy (ATH), 79%, and obstructive sleep apnea (OSA), 74%, were the most frequent diagnosis and Medicaid (61%) was the most frequent primary payer. The majority of ambulatory tonsillectomy patients were female (52%) and white (65%); ATH, OSA, and Medicaid accounted for 62%, 29%, and 45% of cases, respectively, (all p < .001 when compared to inpatient cases). Common inpatient complications were bleeding (2%), pain/nausea/vomiting (5.6%), and postprocedural respiratory failure (1.7%). On the other hand, ambulatory complications occurred in less than 1% of patients. The readmission rate was 5.2%, with pain/nausea/vomiting and bleeding accounting for 35% and 23% of overall readmissions. All Patient Refined Diagnosis Related Groups severity of illness subclass predicted readmission (odds ratio = 2.18, 95% confidence interval = 1.73-2.73, p < .001).CONCLUSION:A total of 567,000 pediatric ambulatory and inpatient tonsillectomies were performed in 2019; the majority were performed in ambulatory settings. The index admission severity of illness was associated with readmission risk.

Objective: Aberrant subclavian artery (ASA) and Kommerell's diverticulum (KD) are rare vascular anomalies that may be associated with lifestyle-limiting and life-threatening complications. The aim of this study is to report contemporary outcomes after invasive treatment of ASA/KD using a large international dataset. Methods: Patients who underwent treatment for ASA/KD (2000-2020) were identified through the Vascular Low Frequency Disease Consortium, a multi-institutional collaboration to investigate uncommon vascular disorders. We report the early and mid-term clinical outcomes including stroke and mortality, technical success, and other operative outcomes including reintervention rates, patency, and endoleak. Results: Overall, 285 patients were identified during the study period. The mean patient age was 57 years; 47% were female and 68% presented with symptoms. A right-sided arch was present in 23%. The mean KD diameter was 47.4 mm (range, 13.0-108.0 mm). The most common indication for treatment was symptoms (59%), followed by aneurysm size (38%). The most common symptom reported was dysphagia (44%). A ruptured KD was treated in 4.2% of cases, with a mean diameter of 43.9 mm (range, 18.0-100.0 mm). An open procedure was performed in 101 cases (36%); the most common approach was ASA ligation with subclavian transposition. An endovascular or hybrid approach was performed in 184 patients (64%); the most common approach was thoracic endograft and carotid-subclavian bypass. A staged operative strategy was employed more often than single setting repair (55% vs 45%). Compared with endovascular or hybrid approach, those in the open procedure group were more likely to be younger (49 years vs 61 years; P < .0001), female (64% vs 36%; P < .0001), and symptomatic (85% vs 59%; P < .0001). Complete or partial symptomatic relief at 1 year after intervention was 82.6%. There was no association between modality of treatment and symptom relief (open 87.2% vs endovascular or hybrid approach 78.9%; P = .13). After the intervention, 11 subclavian occlusions (4.5%) occurred; 3 were successfully thrombectomized resulting in a primary and secondary patency of 95% and 96%, respectively, at a median follow-up of 39 months. Among the 33 reinterventions (12%), the majority were performed for endoleak (36%), and more reinterventions occurred in the endovascular or hybrid approach than open procedure group (15% vs 6%; P = .02). The overall survival rate was 87.3% at a median follow-up of 41 months. The 30-day stroke and death rates were 4.2% and 4.9%, respectively. Urgent or emergent presentation was independently associated with increased risk of 30-day mortality (odds ratio [OR], 19.8; 95% confidence interval [CI], 3.3-116.6), overall mortality (OR, 3.6; 95% CI, 1.2-11.2) and intraoperative complications (OR, 8.3; 95% CI, 2.8-25.1). Females had a higher risk of reintervention (OR, 2.6; 95% CI, 1.0-6.5). At an aneurysm size of 44.4 mm, receiver operator characteristic curve analysis suggested that 60% of patients would have symptoms. Conclusions: Treatment of ASA/KD can be performed safely with low rates of mortality, stroke and reintervention and high rates of symptomatic relief, regardless of the repair strategy. Symptomatic and urgent operations were associated with worse outcomes in general, and female gender was associated with a higher likelihood of reintervention. Given the worse overall outcomes when symptomatic and the inherent risk of rupture, consideration of repair at 40 mm is reasonable in most patients. ASA/KD can be repaired in asymptomatic patients with excellent outcomes and young healthy patients may be considered better candidates for open approaches versus endovascular or hybrid modalities, given the lower likelihood of reintervention and lower early mortality rate. (J Vasc Surg 2023;77:1339-48.)

Relative abundances of bacterial species in the gut microbiome have been linked to many diseases. Species of gut bacteria are ecologically differentiated by their abilities to metabolize different glycans, making glycan delivery a powerful way to alter the microbiome to promote health. Here, we study the properties and therapeutic potential of chemically diverse synthetic glycans (SGs). Fermentation of SGs by gut microbiome cultures results in compound-specific shifts in taxonomic and metabolite profiles not observed with reference glycans, including prebiotics. Model enteric pathogens grow poorly on most SGs, potentially increasing their safety for at-risk populations. SGs increase survival, reduce weight loss, and improve clinical scores in mouse models of colitis. Synthetic glycans are thus a promising modality to improve health through selective changes to the gut microbiome.

Objective. Emergence delirium (ED) is associated with behavioral disturbances and psychomotor agitation, increased risk of selfinjury, delayed discharge, and parental dissatisfaction with quality of care. Otolaryngology procedures are associated with an increased risk of ED. The aims of this study were to determine the prevalence of ED in children who had tonsillectomy and adenoidectomy (T&A), assess the characteristics of children who had ED, and ascertain the recovery times of patients with ED. Methods. Charts of patients who had tonsillectomy and adenoidectomy between Jan 1, 2018 and March 26, 2020 at a tertiary children’s hospital were reviewed. Data collection included demographics, body mass index, indication for T&A, Pediatric Anesthesia Emergence Delirium (PAED) score, American Society of Anesthesiologists (ASA) physical status classification, total anesthesia time, postanesthesia care phase I time, and postanesthesia care phase II time. Results. Of the 4974 patients who underwent T&A, ED occurred in 1.3% of patients. Toddlers (2.9%) and male children (1.6%) had a significantly higher prevalence of ED. Prevalence of ED was similar amongst patients with recurrent tonsillitis, patients with obstructive sleep disordered breathing, and patients with both obstructive sleep apnea (OSA) and recurrent tonsillitis. The prevalence of ED was not different amongst ASA I, ASA II, and ASA III. Males with ED had longer total anesthesia times (41 v. 34 minutes, p=0.02) and ASA I patients with ED had longer phase I times (p=0.04) in the postanesthesia care unit (PACU). There was no significant difference in total anesthesia time, phase I time, or phase II time when compared across the subgroups of gender, age, indication for T&A, severity of obstructive sleep apnea (OSA), and ASA score. Conclusions. Males, toddlers, and preschool-age children were more likely to have ED. Males with ED had longer total anesthesia times. ED was associated with longer phase I times in ASA I patients.