Publications by authors named "Matthew Brigger"

66 Publications

Bronchial stenting in infants with severe bronchomalacia: Technique and outcomes.

Int J Pediatr Otorhinolaryngol 2021 Jun 6;145:110703. Epub 2021 Apr 6.

Division of Pediatric Otolaryngology, Rady Children's Hospital and UC San Diego School of Medicine, 3020, Children's Way, San Diego, CA, USA. Electronic address:

Objectives: To report the first use of a balloon expandable bare metal stent for treating infant bronchomalacia.

Background: Infant bronchomalacia often requires prolonged mechanical ventilation and can be life-threatening. Effective treatment for severe infant bronchomalacia continues to be elusive. We present three cases of bronchial stenting for no-option or treatment refractory infant bronchomalacia.

Methods: Three consecutive cases of stenting to relieve conservative treatment refractory severe infant bronchomalacia were performed between February 2019 and December 2020. Initial diagnosis was confirmed with Computed Tomography (CT) angiography. Patients underwent rigid micro laryngoscopy, bronchoscopy, and flexible bronchoscopy to evaluate the airway. Initial conservative management strategies were pursued. Patients failing initial conservative management strategies were considered for rescue bronchial stenting.

Results: Our initial clinical experience with a coronary bare metal stent for these procedures has been favorable. The stent was easy to deploy with precision. We did not encounter stent embolization or migration. There was sufficient stent radial strength to relieve bronchomalacia without causing restenosis or erosion. There was no significant granulation tissue formation. In one patient, the stent was removed after 12 months of somatic growth; this was uneventful and bronchial patency was maintained. There were no complications in any of our patients regarding stent placement and reliability.

Conclusion: In cases of three infants with severe bronchomalacia, we found that bronchial stenting with the bare metal coronary stent was effective in relieving bronchial stenosis.
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http://dx.doi.org/10.1016/j.ijporl.2021.110703DOI Listing
June 2021

Undifferentiated recurrent fevers in pediatrics are clinically distinct from PFAPA syndrome but retain an IL-1 signature.

Clin Immunol 2021 05 24;226:108697. Epub 2021 Feb 24.

Department of Pediatrics, Division of Allergy, Immunology and Rheumatology, University of California-San Diego, La Jolla, CA, United States of America; Rady Children's Foundation, Rady Children's Hospital, San Diego, CA, United States of America. Electronic address:

Autoinflammatory disorders of the innate immune system present with recurrent episodes of inflammation often beginning in early childhood. While there are now more than 30 genetically-defined hereditary fever disorders, many patients lack a clear diagnosis. Many pediatric patients are often grouped with patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome despite failing to meet diagnostic criteria. Here, we categorize these patients as syndrome of undifferentiated recurrent fever (SURF), and identify the unique features which distinguish them from the PFAPA syndrome. SURF patients were more likely to report gastrointestinal symptoms of nausea, vomiting and abdominal pain, and experienced inconsistent responses to on-demand steroid therapy compared to PFAPA patients. For this previously undefined cohort, an optimal course of therapy remains uncertain, with medical and surgical therapies largely driven by parental preference. A subset of patients with SURF underwent tonsillectomy with complete resolution. Flow cytometric evaluation demonstrates leukocytic populations distinct from PFAPA patients, with reduced CD3+ T cell numbers. SURF patient tonsils were predominantly characterized by an IL-1 signature compared to PFAPA, even during the afebrile period. Peripheral blood signatures were similar between groups suggesting that PFAPA and SURF patient tonsils have localized, persistent inflammation, without clinical symptoms. These data suggest that SURF is a heterogenous syndrome on the autoinflammatory disease spectrum.
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http://dx.doi.org/10.1016/j.clim.2021.108697DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8089050PMC
May 2021

Metagenomic sequencing and evaluation of the host response in the pediatric aerodigestive population.

Pediatr Pulmonol 2021 02 14;56(2):516-524. Epub 2020 Dec 14.

Department of Surgery, Division of Pediatric Otolaryngology, Rady Children's Hospital San Diego, University of California San Diego, San Diego, California, USA.

Objectives: To assess the diagnostic utility of metagenomic sequencing in pediatric aerodigestive clinic patients being evaluated for chronic aspiration. We hypothesize that using a metagenomics platform will aid in the identification of microbes not found on standard culture.

Study Design And Methods: Twenty-four children referred to an aerodigestive clinic were enrolled in a prospective, single-site, cross-sectional cohort study. At the time of clinical evaluation under anesthesia, two samples were obtained: an upper airway sample and a sample from bronchoalveolar lavage (BAL). Samples were sent for routine culture and analyzed using Explify® Respiratory, a CLIA Laboratory Developed Test which identifies respiratory commensals and pathogens through RNA and DNA sequencing. Since RNA was sequenced in the course of the metagenomic analysis to identify organisms (RNA viruses and bacteria), the sequencing approach also captured host derived messenger RNA during sample analysis. This incidentally obtained host transcriptomic data were analyzed to evaluate the host immune response. The results of these studies were correlated with the clinical presentation of the research subjects.

Results: In 10 patients, organisms primarily associated with oral flora were identified in the BAL. Standard culture was negative in three patients where clinical metagenomics led to a result with potential clinical significance. Transcriptomic data correlated with the presence or absence of dysphagia as identified on prior videofluoroscopic evaluation of swallowing.

Conclusions: Clinical metagenomics allows for simultaneous analysis of the microbiota and the host immune response from BAL samples. As the technologies in this field continue to advance, such testing may improve the diagnostic evaluation of patients with suspected chronic aspiration.
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http://dx.doi.org/10.1002/ppul.25198DOI Listing
February 2021

Postmortem diagnosis of PPA2-associated sudden cardiac death from dried blood spot in a neonate presenting with vocal cord paralysis.

Cold Spring Harb Mol Case Stud 2020 10 7;6(5). Epub 2020 Oct 7.

Rady Children's Institute of Genomic Medicine, University of California San Diego, La Jolla, California 92093, USA.

Biallelic variants in inorganic pyrophosphatase 2 (PPA2) are known to cause infantile sudden cardiac failure (OMIM #617222), but relatively little is known about phenotypic variability of these patients prior to their death. We report a 5-wk-old male with bilateral vocal cord paralysis and hypertension who had a sudden unexpected cardiac death. Subsequently, molecular autopsy via whole-genome sequencing from newborn dried blood spot identified compound heterozygous mutations in PPA2, with a paternally inherited, pathogenic missense variant (c.514G > A; p.Glu172Lys) and a novel, maternally inherited missense variant of uncertain significance (c.442A > T; p.Thr148Ser). This report expands the presenting phenotype of patients with PPA2 variants. It also highlights the utility of dried blood spots for postmortem molecular diagnosis.
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http://dx.doi.org/10.1101/mcs.a005611DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7552926PMC
October 2020

The role of bioresorbable intraluminal airway stents in pediatric tracheobronchial obstruction: A systematic review.

Int J Pediatr Otorhinolaryngol 2020 Dec 30;139:110405. Epub 2020 Sep 30.

Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of California San Diego, 200 W Arbor Dr. MC8895, San Diego, CA, 92103, USA; Division of Pediatric Otolaryngology, Department of Surgery, Rady Children's Hospital, San Diego, CA, 3020 Children's Way, San Diego, CA, 92123, USA. Electronic address:

Introduction: Tracheal stenosis and tracheobronchomalacia are complicated, patient-specific diseases that can be treated with intraluminal stenting. Most commonly, silicone and metal stents are utilized, however, they pose significant early and late morbidity and are further complicated by growth of the airway in the pediatric population. Given recent improvements in materials science, there is a growing body of evidence suggesting a strong role for bioresorbable intraluminal stents in treating pediatric tracheobronchial obstruction.

Methods: A PubMed.gov literature search was performed on December 3, 2019 and May 15, 2020, and a 2-researcher systematic review was performed following the PRISMA criteria. The following search query was utilized: (((((((bioresorbable) OR bioabsorbable) OR resorbable) OR absorbable) OR biodegradable AND airway) OR trachea) AND stent. A pooled statistical analysis was performed on all reported pediatric patients using SPSS software.

Results: 1369 publications were screened and 26 articles with original data were identified. Materials used included polydioxanone (PDO), poly-l-lactic acid (PLLA), polyglycolic acid/poly-l-lactide co-polymer with Proglactin 910 (Vicryl®-PDS®), polycaprolactone (PCL), magnesium alloys, and co-polymers in varying proportions. Twelve articles presented data on human subjects, 8 of which were case series and case reports on pediatric populations using polydioxanone (PDO) stents. Pooled statistical analysis demonstrated an average age of 19 months (range 0.25-144), 56.5% associated with a cardiovascular anomaly, and overall complication rate of 21.7%, with a stent fragment foreign body being the most common (8.7%), followed by significant granulation tissue (4.3%), stent migration (4.3%), and local stenosis (4.3%). Comparative analysis demonstrated short-term improvement (up to 1 month) has a statistically significant association with tracheobronchomalacia versus tracheal stenosis on chi-squared test (p = 0.001). The remaining analyses did not yield statistical significance.

Conclusion: The reported application of bioresorbable materials as intraluminal airway stents is positive. All comparative animal studies report biocompatibility and fewer morbidities compared to metal and silicone stents, however, in human studies there are concerns over the short interval of degradation and the potential for obstructive foreign bodies in poorly seated stents. Overall, there are clear, reproducible advantages to bioresorbable intraluminal stents in pediatric airway obstruction, as well as common pitfalls, that warrant further research.
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http://dx.doi.org/10.1016/j.ijporl.2020.110405DOI Listing
December 2020

International Pediatric Otolaryngology Group (IPOG): Consensus recommendations on the prenatal and perinatal management of anticipated airway obstruction.

Int J Pediatr Otorhinolaryngol 2020 Nov 8;138:110281. Epub 2020 Aug 8.

Department of Otolaryngology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.

Objective: To make recommendations on the identification, routine evaluation, and management of fetuses at risk for airway compromise at delivery.

Methods: Recommendations are based on expert opinion by members of the International Pediatric Otolaryngology Group (IPOG). A two-iterative Delphi method questionnaire was distributed to all members of the IPOG and responses recorded. The respondents were given the opportunity to comment on the content and format of the survey, which was modified for the second round. "Consensus" was defined by >80% respondent affirmative responses, "agreement" by 51-80% affirmative responses, and "no agreement" by 50% or less affirmative responses.

Results: Recommendations are provided regarding etiologies of perinatal airway obstruction, imaging evaluation, adjunct evaluation, multidisciplinary team and decision factors, micrognathia management, congenital high airway obstruction syndrome management, head and neck mass management, attended delivery procedure, and delivery on placental support procedure.

Conclusions: Thorough evaluation and thoughtful decision making are required to optimally balance fetal and maternal risks/benefits.
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http://dx.doi.org/10.1016/j.ijporl.2020.110281DOI Listing
November 2020

Predictors of Pediatric Tracheostomy Outcomes in the United States.

Otolaryngol Head Neck Surg 2020 09 21;163(3):591-599. Epub 2020 Apr 21.

Division of Otolaryngology, Department of Surgery, University of California San Diego, San Diego, California, USA.

Objectives: To investigate the outcomes of pediatric tracheostomy as influenced by demographics and comorbidities.

Study Design: Retrospective national database review.

Setting: Fifty-two children's hospitals across the United States.

Subjects And Methods: Hospitalization records from Pediatric Health Information System database dated 2010 to 2018 with patients younger than 18 years and procedure codes for tracheostomy were extracted. The primary outcome was total length of stay. The secondary outcomes were 30-day readmission, mortality, and posttracheostomy length of stay.

Results: A total of 14,155 children were included in the analysis. The median total length of stay was 77 days and increased from 59 to 103 days between 2010 and 2018 ( < .001). The median posttracheostomy length of stay was 34 days and also increased from 27 to 49 days ( < .001). On multivariate regression analyses, the total and posttracheostomy lengths of stay were significantly increased in children younger than 1 year, patients of black race, hospitals in the non-West regions, those discharged to home, and those with comorbidities. Socioeconomic indicators such as insurance type and estimated household income were associated with no difference or small effect sizes. Regions and comorbidities were associated with differences in 30-day readmission (overall 26%), while in-hospital mortality was primarily associated with age and comorbidities (overall 8.6%).

Conclusion: Pediatric tracheostomy requires substantial health care resources with length of stay escalating over recent years. Age, race, region, discharge destination, and comorbidities were associated with differences in length of stay.
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http://dx.doi.org/10.1177/0194599820917620DOI Listing
September 2020

Modest benefit of frenotomy for infants with ankyloglossia and breastfeeding difficulties.

Int J Pediatr Otorhinolaryngol 2020 Jun 9;133:109985. Epub 2020 Mar 9.

Division of Pediatric Otolaryngology, Rady Children's Hospital San Diego, San Diego, CA, USA; Department of Surgery, Division of Otolaryngology, University of California San Diego School of Medicine, San Diego, CA, USA. Electronic address:

Introduction: With nationwide effort to increase breastfeeding rates in newborns and infants in recent years, there has been a dramatic increase in the diagnosis of ankyloglossia, and the resultant otolaryngology referral for frenotomy. Overall, there is a paucity of data on the expected benefit of frenotomy in this population and the subsequent breastfeeding rate. The objectives of this study were to assess the effect of office-based frenotomy on improving breastfeeding difficulties among infants with ankyloglossia from a patient-centered perspective and examine associated effects of frenotomy and ankyloglossia type on breastfeeding.

Methods: Maternal-infant dyads were referred to a tertiary care otolaryngology practice for assessment of ankyloglossia. A prospective cohort study was conducted in this population from January 2017 to September 2018. Mothers completed questionnaires regarding the quality of breastfeeding before the frenotomy procedure in the office and were subsequently contacted by phone to complete the same questionnaires 1 week and 3 months after the initial encounter. Treating physicians reported ankyloglossia type and expected improvement at the time of the procedure. Descriptive statistics and paired analyses were used to analyze post-frenotomy breastfeeding outcomes and ascertain likelihood of improvement.

Results: During the study period, the mothers of 343 infants agreed to participate in the study by completing the initial questionnaire. Of these infants, 314 (91.5%) underwent frenotomy. Most infants were classified as having either type I (35.3%) or type II (45.2%) ankyloglossia with 16.9% having posterior ankyloglossia and 2.6% with no ankyloglossia. At 1-week post-frenotomy the largest group of patients (35%) had mild improvement in breastfeeding abilities compared to baseline with 14% and 7% reporting moderate or marked improvement respectively. At 3 months after the initial consultation, significantly more patients reported moderate (27%) or marked (17%) improvement when compared to baseline although the exclusively breastfeeding rate at 3 months was low at 20.3% for this cohort.

Conclusions: This prospective study demonstrated that frenotomy had a modestly positive effect on breastfeeding ability from the mother's perspective in infants referred for ankyloglossia. It is important to educate patients on the multi-factorial nature of breastfeeding and to set realistic expectations prior to recommending the procedure.
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http://dx.doi.org/10.1016/j.ijporl.2020.109985DOI Listing
June 2020

The role of 3D printing in pediatric airway obstruction: A systematic review.

Int J Pediatr Otorhinolaryngol 2020 May 1;132:109923. Epub 2020 Feb 1.

Division of Otolaryngology-Head & Neck Surgery, Department of Surgery, University of California San Diego, 200 W Arbor Dr. MC8895, San Diego, CA 92103, USA; Division of Pediatric Otolaryngology, Department of Surgery, Rady Children's Hospital, 3020 Children's Way, San Diego, CA, 92123, USA.

Background: Tracheomalacia and tracheal stenosis are complicated, patient-specific diseases that require a multidisciplinary approach to diagnose and treat. Surgical interventions such as aortopexy, slide tracheoplasty, and stents potentially have high rates of morbidity. Given the emergence of three-dimensional (3D) printing as a versatile adjunct in managing complex pathology, there is a growing body of evidence that there is a strong role for 3D printing in both surgical planning and implant creation for pediatric airway obstruction.

Methods: A structured PubMed.gov literature search was utilized, and a two-researcher systematic review was performed following the PRISMA criteria. The following search query was utilized: (((((3D printing) OR three-dimensional printing) OR 3D printed) OR three-dimensional printed) AND trachea) OR airway.

Results: Over 23,000 publications were screened. Eight literature reviews and thirty-seven original papers met inclusion criteria. Of the thirty-seven original papers, eleven discussed 3D printing for surgical planning and twenty-six discussed 3D printing implants for interventions.

Conclusion: The reported application of 3D printing for management of pediatric airway obstruction is emerging with positive and broad applications. 3D printing for surgical planning not only improves pre-operative assessment of surgical approach and stent customization, but also helps facilitate patient/family education. 3D printing for custom implantable interventions is focused on bioresorbable external airway splints and biological grafts, with both animal studies and human case reports showing good results in improving symptoms.
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http://dx.doi.org/10.1016/j.ijporl.2020.109923DOI Listing
May 2020

Immune Dysregulation in the Tonsillar Microenvironment of Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis (PFAPA) Syndrome.

J Clin Immunol 2020 01 5;40(1):179-190. Epub 2019 Dec 5.

Department of Pediatrics, Division of Allergy, Immunology and Kawasaki Disease, University of California San Diego, La Jolla, CA, USA.

Periodic Fever, Aphthous stomatitis, Pharyngitis and Adenitis (PFAPA) syndrome is an inflammatory disorder of childhood classically characterized by recurrent fevers, pharyngitis, stomatitis, cervical adenitis, and leukocytosis. While the mechanism is unclear, previous studies have shown that tonsillectomy can be a therapeutic option with improvement in quality of life in many patients with PFAPA, but the mechanisms behind surgical success remain unknown. In addition, long-term clinical follow-up is lacking. In our tertiary care center cohort, 62 patients with PFAPA syndrome had complete resolution of symptoms after surgery (95.3%). Flow cytometric evaluation demonstrates an inflammatory cell population, distinct from patients with infectious pharyngitis, with increased numbers of CD8+ T cells (5.9% vs. 3.8%, p < 0.01), CD19+ B cells (51% vs. 35%, p < 0.05), and CD19+CD20+CD27+CD38-memory B cells (14% vs. 7.7%, p < 0.01). Cells are primed at baseline with increased percentage of IL-1β positive cells compared to control tonsil-derived cells, which require exogenous LPS stimulation. Gene expression analysis demonstrates a fivefold upregulation in IL1RN and TNF expression in whole tonsil compared to control tonsils, with persistent activation of the NF-κB signaling pathway, and differential microbial signatures, even in the afebrile period. Our data indicates that PFAPA patient tonsils have localized, persistent inflammation, in the absence of clinical symptoms, which may explain the success of tonsillectomy as an effective surgical treatment option. The differential expression of several genes and microbial signatures suggests the potential for a diagnostic biomarker for PFAPA syndrome.
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http://dx.doi.org/10.1007/s10875-019-00724-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7085444PMC
January 2020

Advanced practice providers and children's hospital-based pediatric otolarynology practices.

Int J Pediatr Otorhinolaryngol 2020 Feb 7;129:109770. Epub 2019 Nov 7.

Connecticut Children's Medical Center, Hartford, CT, USA; Department of Otolaryngology - Head and Neck Surgery, University of Connecticut School of Medicine, Farmington, CT, USA.

Introduction: Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting.

Methods: Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice.

Results: A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3-29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2-9) and number of outpatient APP (mean/median/range = 6.3/5/1-30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p<.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0-5, 6-10 and > 11 years of tenure were $76-100K (65%), $100-150K (77%) and $100-150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale.

Discussion: The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity.
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http://dx.doi.org/10.1016/j.ijporl.2019.109770DOI Listing
February 2020

Auricular acupuncture for adult tonsillectomy.

Laryngoscope 2020 08 11;130(8):1907-1912. Epub 2019 Oct 11.

Department of Otolaryngology, Naval Medical Center San Diego, San Diego, California, U.S.A.

Objectives: Adult tonsillectomy causes significant postoperative pain that can last over 14 days, but narcotic regimens only provide a modest reduction in pain. Auricular acupuncture has been demonstrated to improve pain with minimal complications. This study compared acupuncture versus control for pain, opioid consumption, nausea, and return of diet and activity following tonsillectomy.

Methods: A prospective, single-blinded randomized controlled trial was performed on 134 adults undergoing tonsillectomy at a tertiary care teaching hospital. Each patient was randomized to receive either auricular (Battlefield protocol) acupuncture with auricular bandages or bandages alone while under general anesthesia. Subjects journaled daily postoperative pain, diet, activity, and opioid consumption, then returned to the clinic on postoperative day 14 for a final questionnaire and evaluation.

Results: Ninety-nine patients completed the study with 50 patients in the acupuncture group and 49 patients in the control group. Pain scores for the acupuncture group following tonsillectomy were significantly lower than the control group on the day of surgery (2.9, 4.3; P = .01), but there was no statistically significant difference in pain thereafter. There was an equivalent level of postoperative narcotic usage, nausea, emesis, functional activity and diet between the two groups. The main complication following tonsillectomy was secondary hemorrhage and there was no significant difference between the two groups (20%, 10%; P = .13).

Conclusion: Auricular acupuncture provides increased pain relief on the day of surgery, an effect that seems to diminish after 24 hours.

Level Of Evidence: 1b Laryngoscope, 130: 1907-1912, 2020.
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http://dx.doi.org/10.1002/lary.28338DOI Listing
August 2020

The increasing cost of pediatric otolaryngology care.

Int J Pediatr Otorhinolaryngol 2019 Aug 15;123:175-180. Epub 2019 May 15.

Department of Pediatric Otolaryngology, Rady Children's Hospital San Diego, San Diego, CA, USA.

Introduction: Defining the costs associated with healthcare is vital to determining and understanding ways to reduce costs and improve quality of healthcare delivery. The objective of the present study was to identify the current public health burden of inpatient admissions for conditions commonly treated by pediatric otolaryngologists and compare trends in healthcare utilization with other common surgical diagnoses.

Methods: A retrospective cohort study using the Kids' Inpatient Database for pediatric discharges in the United States from 2000 to 2012. A list of the top 500 admission diagnoses was identified and subsequently grouped into surgical diagnoses typically managed by otolaryngologists and those managed by any other surgical discipline with the top 10 in each category included. Database analyses generated national estimates of summary statistics and comparison of trends over the twelve-year period.

Results: Of the top pediatric admission diagnoses, the most common conditions managed by surgical specialties involved inflammatory or infectious causes. Hospital charges significantly increased during this time across all diagnoses. On average, the charges for otolaryngologic diagnoses increased by 37.13% while costs increased by almost 12%. In comparison, the charges for non-otolaryngologic diagnoses increased by 35.87% and the costs by 10.43%.

Conclusions: The public health impact and rising costs of healthcare are substantial. It is of critical significance that the healthcare system be aware of opportunities and lessons that may be learned across specialties to identify the primary drivers of healthcare cost while maintaining high quality standards for patient care.
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http://dx.doi.org/10.1016/j.ijporl.2019.05.011DOI Listing
August 2019

Carinal Resection and Reconstruction for an Obstructing Inflammatory Myofibroblastic Tumor in a Child.

World J Pediatr Congenit Heart Surg 2020 03 22;11(2):226-228. Epub 2019 May 22.

Department of Pediatric Cardiac Surgery, Mount Sinai Hospital, NY, USA.

Inflammatory myofibroblastic tumor (IMT) is a rare soft tissue tumor characterized by proliferation of fibroblastic cells associated with an inflammatory infiltrate. Inflammatory myofibroblastic tumors have a predilection for the pediatric population and are usually found in the lung parenchyma but rarely at the carina. They rarely metastasize but can be locally destructive. Surgical resection is the cornerstone of therapy, which results in excellent survival despite risk of local recurrence. We present the case of a nine-year-old girl with an IMT mass at the carina and obstructing the left main stem bronchus, requiring extensive resection and reconstruction.
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http://dx.doi.org/10.1177/2150135119837202DOI Listing
March 2020

Comparison of Ibuprofen vs Acetaminophen and Severe Bleeding Risk After Pediatric Tonsillectomy: A Noninferiority Randomized Clinical Trial.

JAMA Otolaryngol Head Neck Surg 2019 06;145(6):494-500

Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.

Importance: Ibuprofen is an effective analgesic after tonsillectomy alone or tonsillectomy with adenoidectomy, but concerns remain about whether it increases postoperative hemorrhage.

Objective: To investigate the effect of ibuprofen compared with acetaminophen on posttonsillectomy bleeding (PTB) requiring surgical intervention in children.

Design, Setting, And Participants: A multicenter, randomized, double-blind noninferiority trial was conducted at 4 tertiary medical centers (Massachusetts Eye and Ear Infirmary, Boston; Naval Medical Center, San Diego, California; Naval Medical Center, Portsmouth, Virginia; Madigan Army Medical Center, Tacoma, Washington). A total of 1832 children were assessed for eligibility (presence of sleep-disordered breathing or obstructive sleep apnea, adenotonsillar hypertrophy, or infectious tonsillitis undergoing extracapsular tonsillectomy by electrocautery). Of these, 1091 were excluded because they did not meet eligibility criteria (n = 681) or refused to participate (n = 410); thus, 741 children aged 2 to 18 years undergoing tonsillectomy alone or tonsillectomy with adenoidectomy were enrolled between May 3, 2012, and January 20, 2017.

Interventions: Participants were randomized to receive ibuprofen, 10 mg/kg (n = 372), or acetaminophen, 15 mg/kg (n = 369), every 6 hours for the first 9 postoperative days.

Main Outcomes And Measures: Rate and severity of posttonsillectomy bleeding were recorded using a postoperative bleeding severity scale: type 1 (bleeds that were observed at home or evaluated in the emergency department without further intervention), type 2 (bleeds that required readmission for observation), and type 3 (bleeds that required a return to the operating room for control of hemorrhage). Type 3 bleeding was the main outcome measure. The noninferiority margin was set at 3%, and modified intention-to-treat analysis was used.

Results: Of the 741 children enrolled, 688 children (92.8%) (median [interquartile range] age, 5 [4] years; 366 boys [53.2%]) received the study medication and were included in a modified intention-to-treat analysis. The rate of bleeding requiring operative intervention was 1.2% in the acetaminophen group and 2.9% in the ibuprofen group (difference, 1.7%; 97.5% CI upper limit, 3.8%; P = .12 for noninferiority). There were no significant adverse events or deaths.

Conclusions And Relevance: This study could not exclude a higher rate of severe bleeding in children receiving ibuprofen after tonsillectomy alone or tonsillectomy with adenoidectomy. This finding should be considered when selecting a postoperative analgesic regimen. Further studies are needed to understand if bleeding risk is affected when ibuprofen is used for a shorter duration or in combination with acetaminophen for postoperative analgesia.

Trial Registration: ClinicalTrials.gov identifier: NCT01605903.
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http://dx.doi.org/10.1001/jamaoto.2019.0269DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583024PMC
June 2019

Recurrent group A tonsillitis is an immunosusceptibility disease involving antibody deficiency and aberrant T cells.

Sci Transl Med 2019 02;11(478)

Division of Vaccine Discovery, La Jolla Institute for Immunology (LJI), La Jolla, CA 92037, USA.

"Strep throat" is highly prevalent among children, yet it is unknown why only some children develop recurrent tonsillitis (RT), a common indication for tonsillectomy. To gain insights into this classic childhood disease, we performed phenotypic, genotypic, and functional studies on pediatric group A (GAS) RT and non-RT tonsils from two independent cohorts. GAS RT tonsils had smaller germinal centers, with an underrepresentation of GAS-specific CD4 germinal center T follicular helper (GC-T) cells. RT children exhibited reduced antibody responses to an important GAS virulence factor, streptococcal pyrogenic exotoxin A (SpeA). Risk and protective human leukocyte antigen (HLA) class II alleles for RT were identified. Lastly, SpeA induced granzyme B production in GC-T cells from RT tonsils with the capacity to kill B cells and the potential to hobble the germinal center response. These observations suggest that RT is a multifactorial disease and that contributors to RT susceptibility include HLA class II differences, aberrant SpeA-activated GC-T cells, and lower SpeA antibody titers.
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http://dx.doi.org/10.1126/scitranslmed.aau3776DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6561727PMC
February 2019

Pediatric Dysphonia: A Cross-Sectional Survey of Subspecialty and Primary Care Clinics.

J Voice 2020 Mar 17;34(2):301.e1-301.e5. Epub 2018 Sep 17.

Department of Otolaryngology; Naval Medical Center San Diego; San Diego, California; Rady Children's Hospital; University of California San Diego; San Diego, California.

Objectives: Prevalence data for pediatric dysphonia are sparse and primarily collected either in the community or within pediatric otolaryngology clinics. The objectives were to determine the prevalence of dysphonia in children undergoing outpatient medical evaluation, and to ascertain whether the prevalence varies across pediatric subspecialty clinic populations in comparison to primary care.

Study Design: Cross-sectional survey.

Setting: Tertiary care military medical center.

Subjects And Methods: Five hundred sixteen surveys were administered to caregivers of children undergoing evaluation in pediatric primary care and subspecialty clinics consisting of the pediatric voice-related quality of life (PVRQOL) instrument and questions regarding previous voice-related symptoms and diagnoses. Survey responses and PVRQOL scores were stratified by clinic type and compared to general pediatrics.

Results: A total of 492 surveys were analyzed. The overall prevalence of dysphonia in this cohort based on PVRQOL is 19.3%. Every clinic except endocrinology and ophthalmology individually had an elevated prevalence compared to the expected community prevalence (11%). Compared to general pediatrics, PVRQOL scores were lower in developmental pediatrics (P < 0.001), genetics (P < 0.001), and otolaryngology (P = 0.033) clinics. Children from genetics and developmental pediatrics were more likely to have had speech therapy.

Conclusions: In this cohort of children seeking care within a medical center, overall prevalence of dysphonia was quite high in comparison to community-based prevalence data. Not surprisingly, patients of developmental pediatrics, genetics and pediatric otolaryngology have lower PVRQOL scores than primary care. These results emphasize that all practitioners caring for children should seek to identify voice disorders and reinforce that subspecialists who treat developmentally challenged children should exert particular vigilance.
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http://dx.doi.org/10.1016/j.jvoice.2018.08.017DOI Listing
March 2020

Intracranial complications of pediatric sinusitis: Identifying risk factors associated with prolonged clinical course.

Int J Pediatr Otorhinolaryngol 2018 Sep 12;112:10-15. Epub 2018 Jun 12.

Rady Children's Hospital San Diego, Otolaryngology, San Diego, CA, USA; Department of Surgery, University of California San Diego, San Diego, CA, USA.

Objective: Intracranial extension is one of the most serious and morbid complications of pediatric sinusitis. Managing this complication continues to be challenging even after widespread pneumococcal vaccination adoption. We aim to identify risk factors associated with complicated clinical courses, and to assess for altering microbial communities and increased antibiotic resistance.

Methods: A retrospective review was conducted of sinus procedures performed at a single institution for acute sinusitis with intracranial extension, and 16 cases were identified. Variables collected included patient demographics, vaccination status, laboratory results, imaging data, antibiotic therapy, sinus and intracranial cultures, perioperative and surgical reports, and hospital course.

Results: The average patient age was 11.9 years, and 75% were male. The dominant microbial organisms were gram positive in 93.8% (15/16) of cases and 37.5% (6/16) were anaerobic. There were no cases of resistant bacterial growth, and only one case of Streptococcus pneumoniae. Increased antibiotic therapy duration was associated with anaerobic and polymicrobial sinus cultures. A significant increase in length of hospital stay was identified in polymicrobial sinus cultures and frontal sinus involvement. Intracranial abscess re-accumulation was associated with sinus cultures positive for fusobacterium (p = 0.036), polymicrobial infections (p = 0.034), and involvement of brain parenchyma (p = 0.036). Patients with frontal sinus involvement required a greater number of surgical procedures for abscess drainage (p = 0.046). An anaerobic intracranial culture was associated with an increased number of revision craniotomies (p < 0.001). Parenchymal involvement of the infection was associated with an increased number of surgical complications.

Conclusions: Frontal sinus involvement, and anaerobic and polymicrobial sinus cultures were predictive of a more severe infection requiring more surgical interventions, prolonged intravenous antibiotic treatment and overall hospital length of stay. Streptococcus pneumoniae was not prevalent in our series, and there seems to be a shift in the microbial profile of this patient subset, compared to previous studies, which can likely be attributed to the adoption of pneumococcal vaccinations. Sinus cultures were more predictive of a complicated clinical course compared to intracranial cultures, suggesting the importance of a thorough sinus debridement and obtaining directed sinus cultures.
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http://dx.doi.org/10.1016/j.ijporl.2018.06.019DOI Listing
September 2018

Development of Human-Derived Cell Culture Lines for Recurrent Respiratory Papillomatosis.

Otolaryngol Head Neck Surg 2018 10 15;159(4):638-642. Epub 2018 May 15.

1 Pediatric Otolaryngology, Rady Children's Specialist Medical Foundation, San Diego, California, USA.

Recurrent respiratory papillomatosis (RRP) is mainly caused by human papillomavirus (HPV) 6 and 11. While various adjuvant therapies have been reported, no effective therapy has been documented to universally "cure" this disease. In the era of precision medicine, it would be valuable to identify effective intervention based on drug sensitivity testing and/or molecular analysis. It is essential to be able to successfully carry out in vitro culture and expand tumor cells directly from patients to accomplish this goal. Here we report the result of successful culture of HPV-infected cell lines (success rate 70%, 9/13) that express the E6/E7 RNA transcript, using pathologic tissue biopsies from patients treated at our institution. The availability of such a system would enable ex vivo therapeutic testing and disease modeling.
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http://dx.doi.org/10.1177/0194599818774754DOI Listing
October 2018

Multimodal Treatment of Rhinocerebral Mucormycosis in a Pediatric Patient With Relapsed Pre-B Acute Lymphoblastic Leukemia.

Pediatr Infect Dis J 2018 06;37(6):555-558

Rady Children's Hospital - San Diego, California.

A 17-year-old girl developed invasive rhinocerebral mucormycosis during intensive re-induction chemotherapy for relapsed pre-B acute lymphoblastic leukemia. Due to the high case fatality rate for invasive mucormycosis in profoundly immunosuppressed patients, an aggressive treatment regimen was pursued. In addition to the standard of care treatments with intravenous amphotericin and aggressive surgical debridements, she received intraventricular amphotericin to the brain via an Ommaya reservoir, hyperbaric oxygen treatments, filgrastim, intravenous immunoglobulin and antifungal in vitro synergy testing to allow for more targeted antifungal therapy with the addition of micafungin. After a 3-month treatment course, it was determined that her mucormycosis was under appropriate control, allowing her to continue treatment for her leukemia with hematopoietic stem cell transplant with a plan for continued intravenous antifungal therapy through engraftment.
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http://dx.doi.org/10.1097/INF.0000000000001839DOI Listing
June 2018

Foxtail Ingestion in an Asymptomatic Child: A True Emergency?

Otolaryngol Head Neck Surg 2018 02 7;158(2):395-396. Epub 2017 Nov 7.

2 Division of Pediatric Otolaryngology, Rady Children's Hospital-San Diego; Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of California-San Diego, San Diego, California, USA.

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http://dx.doi.org/10.1177/0194599817742136DOI Listing
February 2018

Esophageal dilation in head and neck cancer patients: A systematic review and meta-analysis.

Laryngoscope 2018 01 12;128(1):111-117. Epub 2017 May 12.

Department of Surgery, division of Otolaryngology-Head & Neck Surgery, University of California, San Diego, California, U.S.A.

Objective: To characterize the safety profile and effectiveness of esophageal dilation in head and neck cancer patients.

Methods: A systematic review was undertaken for articles reporting outcomes of esophageal dilation in head and neck cancer patients. The Medline, Scopus, Web of Science, and Cochrane databases were searched in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Complications related to esophageal dilation in head and neck cancer patients was the primary outcome of interest. Success rates, demographic data, cancer staging, and treatment data were assessed secondarily. Statistical analyses included both qualitative and quantitative assessments. A limited meta-analysis and pooling of the data was performed using a random effects model.

Results: Of the collective 8,243 initial candidate articles, 15 retrospective studies containing data for a collective 449 patients were ultimately included in the analysis. There was significant heterogeneity in the outcomes data. With an overall complication rate of 10.6% (95% confidence interval [CI]: 4.1%,17%) and a pooled success rate of 72.9% (95% CI: 65.7%,80.1%) per patient, the articles generally supported the use of dilation.

Conclusion: Head and neck cancer patients experience a higher rate of complications following dilation compared to patients with other causes of benign stricture. Esophageal dilation is effective in improving dysphagia, but these benefits are often transient and thus necessitate repeat interventions. Laryngoscope, 128:111-117, 2018.
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http://dx.doi.org/10.1002/lary.26618DOI Listing
January 2018

The Efficacy of Adenotonsillectomy for Obstructive Sleep Apnea in Children with Down Syndrome: A Systematic Review.

Otolaryngol Head Neck Surg 2017 09 9;157(3):401-408. Epub 2017 May 9.

1 Otolaryngology/Head and Neck Surgery, Rady Children's Hospital San Diego/University of California, San Diego, San Diego, California, USA.

Objective Determine the efficacy of adenotonsillectomy in children with Down syndrome. Data Sources Databases included PubMed, EMBASE, CINAHL, and Google Scholar. The search was inclusive of all references available through January 5, 2017. Review Methods A systematic review of the medical literature addressing adenotonsillectomy in treating obstructive sleep apnea in children with Down syndrome was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Data were pooled using a random-effects model where possible. The quality of studies was graded using the Methodological Index for Nonrandomized Studies criteria. Results Of the 957 articles screened, 5 met inclusion for the qualitative analysis and 3 met criteria for the quantitative analysis. The findings of the qualitative analysis were that adenotonsillectomy has a positive effect on children with Down syndrome but in many cases is noncurative, up to 75% need postoperative breathing support, there is a high rate of immediate postoperative airway needs, and there is no change in sleep efficiency or architecture. The articles consistently reported moderate success in improving polysomnographic parameters, and limited pooling of the data demonstrated a mean decrease of the apnea-hypopnea index by 51% (95% confidence interval [CI], 46%-55%). Conclusion A 51% reduction in the preoperative apnea-hypopnea index can be expected with the intervention of adenotonsillectomy alone in children with Down syndrome. This information is useful for counseling and managing patient and family expectations. It also serves as a reminder to clinicians to obtain a postoperative sleep study, as many of these patients will need nighttime airway support or secondary sleep surgery.
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http://dx.doi.org/10.1177/0194599817703921DOI Listing
September 2017

Pediatric Trainees Managing a Difficult Airway: Comparison of Laryngeal Mask Airway, Direct, and Video-Assisted Laryngoscopy.

OTO Open 2017 Apr-Jun;1(2):2473974X17707916. Epub 2017 May 8.

Department of Otolaryngology-Head and Neck Surgery, Naval Medical Center San Diego, San Diego, California, USA.

Objective: Difficult airway management is a key skill required by all pediatric physicians, yet training on multiple modalities is lacking. The objective of this study was to compare the rate of, and time to, successful advanced infant airway placement with direct laryngoscopy, video-assisted laryngoscopy, and laryngeal mask airway (LMA) in a difficult airway simulator. This study is the first to compare the success with 3 methods for difficult airway management among pediatric trainees.

Study Design: Randomized crossover pilot study.

Setting: Tertiary academic medical center.

Methods: Twenty-two pediatric residents, interns, and medical students were tested. Participants were provided 1 training session by faculty using a normal infant manikin. Subjects then performed all 3 of the aforementioned advanced airway modalities in a randomized order on a difficult airway model of a Robin sequence. Success was defined as confirmed endotracheal intubation or correct LMA placement by the testing instructor in ≤120 seconds.

Results: Direct laryngoscopy demonstrated a significantly higher placement success rate (77.3%) than video-assisted laryngoscopy (36.4%, = .0117) and LMA (31.8%, = .0039). Video-assisted laryngoscopy required a significantly longer amount of time during successful intubations (84.8 seconds; 95% CI, 59.4-110.1) versus direct laryngoscopy (44.9 seconds; 95% CI, 33.8-55.9) and LMA placement (36.6 seconds; 95% CI, 24.7-48.4).

Conclusions: Pediatric trainees demonstrated significantly higher success using direct laryngoscopy in a difficult airway simulator model. However, given the potential lifesaving implications of advanced airway adjuncts, including video-assisted laryngoscopy and LMA placement, more extensive training on adjunctive airway management techniques may be useful for trainees.
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http://dx.doi.org/10.1177/2473974X17707916DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6239019PMC
May 2017

T cells control the generation of nanomolar-affinity anti-glycan antibodies.

J Clin Invest 2017 Apr 13;127(4):1491-1504. Epub 2017 Mar 13.

Vaccines targeting glycan structures at the surface of pathogenic microbes must overcome the inherent T cell-independent nature of immune responses against glycans. Carbohydrate conjugate vaccines achieve this by coupling bacterial polysaccharides to a carrier protein that recruits heterologous CD4 T cells to help B cell maturation. Yet they most often produce low- to medium-affinity immune responses of limited duration in immunologically fit individuals and disappointing results in the elderly and immunocompromised patients. Here, we hypothesized that these limitations result from suboptimal T cell help. To produce the next generation of more efficacious conjugate vaccines, we have explored a synthetic design aimed at focusing both B cell and T cell recognition to a single short glycan displayed at the surface of a virus-like particle. We tested and established the proof of concept of this approach for 2 serotypes of Streptococcus pneumoniae. In both cases, these vaccines elicited serotype-specific, protective, and long-lasting IgG antibodies of nanomolar affinity against the target glycans in mice. We further identified a requirement for CD4 T cells in the anti-glycan antibody response. Our findings establish the design principles for improved glycan conjugate vaccines. We surmise that the same approach can be used for any microbial glycan of interest.
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http://dx.doi.org/10.1172/JCI91192DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5373877PMC
April 2017

A Systematic Review.

Otolaryngol Head Neck Surg 2017 03 10;156(3):435-441. Epub 2017 Jan 10.

2 The Voice Clinic of Indiana, Carmel, Indiana, USA.

Objectives (1) To systematically identify studies evaluating the use of intralesional cidofovir or bevacizumab as an adjunct in adult recurrent respiratory papillomatosis, determine disease severity and functional outcomes, and assess study quality. (2) To compare outcomes between the 2 adjuncts. Data Sources Ovid Medline, EMBASE, Scopus, and Clinical-Trials.gov . Review Methods Data sources were systematically searched. A priori inclusion and exclusion criteria were instituted. Quality was evaluated with the Newcastle-Ottawa Quality Assessment Scale. A priori criteria were instituted to select studies suitable for comparison. Results A total of 254 identified studies led to 16 for full-text review, including 14 for cidofovir and 2 for bevacizumab. Disease severity outcomes were reported in all studies, including remission rate, Derkay scores, time interval between operations, and/or lesion volume reduction. Remission rate was the most commonly reported (14 studies). Functional outcomes were reported in 5 studies (36%), including quality-of-life questionnaires, acoustic/aerodynamic analysis, and perceptual voice analysis. Voice-related quality of life was the most commonly reported (2 studies). Of 16 studies, 12 (75%) were rated poor quality. Reports almost invariably showed improved disease severity and functional outcomes following treatment; however, variable outcome measures and inadequate follow-up disallowed direct comparison of adjuncts. Conclusion Remission rate was the most commonly reported disease severity outcome, and voice-related quality of life was the most commonly reported functional outcome. Most studies were of poor quality. No studies met criteria for comparative analysis between adjuncts. Future research would be improved by reporting consistent and comparable disease severity and functional outcomes, treatment protocols, and follow-up.
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http://dx.doi.org/10.1177/0194599816683384DOI Listing
March 2017

Recurrent Pneumonia in an Infant.

JAMA Otolaryngol Head Neck Surg 2017 03;143(3):307-308

Rady Children's Hospital San Diego, Otolaryngology (ENT), San Diego, California.

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http://dx.doi.org/10.1001/jamaoto.2016.2429DOI Listing
March 2017

A Cytokine-Independent Approach To Identify Antigen-Specific Human Germinal Center T Follicular Helper Cells and Rare Antigen-Specific CD4+ T Cells in Blood.

J Immunol 2016 08 24;197(3):983-93. Epub 2016 Jun 24.

La Jolla Institute for Allergy and Immunology, La Jolla, CA 92037; Division of Infectious Diseases, University of California, San Diego, La Jolla, CA 92093; Center for HIV/AIDS Vaccine Immunology and Immunogen Discovery, La Jolla, CA 92037; and

Detection of Ag-specific CD4(+) T cells is central to the study of many human infectious diseases, vaccines, and autoimmune diseases. However, such cells are generally rare and heterogeneous in their cytokine profiles. Identification of Ag-specific germinal center (GC) T follicular helper (Tfh) cells by cytokine production has been particularly problematic. The function of a GC Tfh cell is to selectively help adjacent GC B cells via cognate interaction; thus, GC Tfh cells may be stingy cytokine producers, fundamentally different from Th1 or Th17 cells in the quantities of cytokines produced. Conventional identification of Ag-specific cells by intracellular cytokine staining relies on the ability of the CD4(+) T cell to generate substantial amounts of cytokine. To address this problem, we have developed a cytokine-independent activation-induced marker (AIM) methodology to identify Ag-specific GC Tfh cells in human lymphoid tissue. Whereas Group A Streptococcus-specific GC Tfh cells produced minimal detectable cytokines by intracellular cytokine staining, the AIM method identified 85-fold more Ag-specific GC Tfh cells. Intriguingly, these GC Tfh cells consistently expressed programmed death ligand 1 upon activation. AIM also detected non-Tfh cells in lymphoid tissue. As such, we applied AIM for identification of rare Ag-specific CD4(+) T cells in human peripheral blood. Dengue, tuberculosis, and pertussis vaccine-specific CD4(+) T cells were readily detectable by AIM. In summary, cytokine assays missed 98% of Ag-specific human GC Tfh cells, reflecting the biology of these cells, which could instead be sensitively identified by coexpression of TCR-dependent activation markers.
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http://dx.doi.org/10.4049/jimmunol.1600318DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4955771PMC
August 2016

International Pediatric ORL Group (IPOG) laryngomalacia consensus recommendations.

Int J Pediatr Otorhinolaryngol 2016 Jul 7;86:256-61. Epub 2016 Apr 7.

Division of Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.

Objective: To provide recommendations for the comprehensive management of young infants who present with signs or symptoms concerning for laryngomalacia.

Methods: Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG).

Results: Consensus recommendations include initial care and triage recommendations for health care providers who commonly evaluate young infants with noisy breathing. The consensus statement also provides comprehensive care recommendations for otolaryngologists who manage young infants with laryngomalacia including: evaluation and treatment considerations for commonly debated issues in laryngomalacia, initial work-up of infants presenting with inspiratory stridor, treatment recommendations based on disease severity, management of the infant with feeding difficulties, post-surgical treatment management recommendations, and suggestions for acid suppression therapy.

Conclusion: Laryngomalacia care consensus recommendations are aimed at improving patient-centered care in infants with laryngomalacia.
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http://dx.doi.org/10.1016/j.ijporl.2016.04.007DOI Listing
July 2016

Airway Management in Severe Combat Maxillofacial Trauma.

Otolaryngol Head Neck Surg 2015 Oct 27;153(4):532-7. Epub 2015 Mar 27.

Department of Otolaryngology/Head and Neck Surgery, Naval Medical Center San Diego, San Diego, California, USA.

Objectives: Airway stabilization is critical in combat maxillofacial injury as normal anatomical landmarks can be obscured. The study objective was to characterize the epidemiology of airway management in maxillofacial trauma.

Study Design: Retrospective database analysis.

Setting: Military treatment facilities in Iraq and Afghanistan and stateside tertiary care centers.

Subjects: In total, 1345 military personnel with combat-related maxillofacial injuries sustained March 2004 to August 2010 were identified from the Expeditionary Medical Encounter Database using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes.

Methods: Descriptive statistics, including basic demographics, injury severity, associated injuries, and airway interventions, were collected. A logistic regression was performed to determine factors associated with the need for tracheostomy.

Results: A total of 239 severe maxillofacial injuries were identified. The most common mechanism of injury was improvised explosive devices (66%), followed by gunshot wounds (8%), mortars (5%), and landmines (4%). Of the subjects, 51.4% required intubation on their initial presentation. Of tracheostomies, 30.4% were performed on initial presentation. Of those who underwent bronchoscopy, 65.2% had airway inhalation injury. There was a significant relationship between the presence of head and neck burn and association with airway inhalation injury (P < .0001). There was also a significant relationship between the severity of facial injury and the need for intubation (P = .002), as well as the presence of maxillofacial fracture and the need for tracheostomy (P = .0001).

Conclusions: There is a high incidence of airway injury in combat maxillofacial trauma, which may be underestimated. Airway management in this population requires a high degree of suspicion and low threshold for airway stabilization.
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http://dx.doi.org/10.1177/0194599815576916DOI Listing
October 2015
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