Amelia F. Drake

The Impact of Sleep-Disordered Breathing on Cognition and Behavior in Children: A Review and Meta-Synthesis of the Literature

OBJECTIVES: The goal of this review is to provide a synthesis of the current literature addressing the effects of sleep-disordered breathing on cognition and behavior in children aged 2–18. STUDY DESIGN AND SETTING: A computerized search was performed to include studies between 1966 and 2001. Studies were assessed based on research question, sampling, intervention, outcomes, confounding, and statistical methods. Sensitivity analyses were performed for quantitative assessments of selection bias, misclassification, and confounding. RESULTS: Seventeen reports with 5312 patients were reviewed. The majority of these studies demonstrated poor sampling, insufficient consideration of confounders, and imprecise use of statistical tools. However, there was little evidence of bias in two studies when scrutinized using a sensitivity analysis. CONCLUSIONS: Despite suggested links between daytime behavior problems and neurocognitive deficits, there is little certainty for causality based on the quality of the evidence. SIGNIFICANCE: By discussing the quality of the current evidence, we hope to improve study design and contribute to the development of an understanding of this complex topic.

Immunohistochemical Localization of Nitric Oxide Synthase Activity in Upper Respiratory Epithelium

Nitric oxide (NO) production in the respiratory epithelium of the upper airways has recently been described. To better delineate the role of epithelial NO, the authors of this study attempted to identify the cell type responsible for the production of NO in rat tracheal epithelium and human nasal epithelium. They localized the activity of NO through immunohistochemical analysis with an antibody to L‐citrulline, a marker for activity of the L‐arginine‐dependent nitric oxide synthase (NOS) pathway. Using anti‐inducible NOS (iNOS) and anti‐constitutive NOS (cNOS) antibodies, they also attempted to identify the specific NO isotypes that were present.

Multicenter Interrater and Intrarater Reliability in the Endoscopic Evaluation of Velopharyngeal Insufficiency

OBJECTIVE To explore interrater and intrarater reliability (R (inter) and R (intra), respectively) of a standardized scale applied to nasoendoscopic assessment of velopharyngeal (VP) function, across multiple centers. DESIGN Multicenter blinded R (inter) and R (intra) study. SETTING Eight academic tertiary care centers. PARTICIPANTS Sixteen otolaryngologists from 8 centers. MAIN OUTCOME MEASURES Raters estimated lateral pharyngeal and palatal movement on nasoendoscopic tapes from 50 different patients. Raters were asked to (1) estimate gap size during phonation and (2) note the presence of the Passavant ridge, a midline palatal notch on the nasal surface of the soft palate, and aberrant pulsations. Primary outcome measures were R (inter) and R (intra) coefficients for estimated gap size, lateral wall, and palatal movement; kappa coefficients for the Passavant ridge, a midline palatal notch on the nasal soft palate, and aberrant pulsations were also calculated. RESULTS The R (inter) coefficients were 0.63 for estimated gap size, 0.41 for lateral wall movement, and 0.43 for palate movement; corresponding R (intra) coefficients were 0.86, 0.79, and 0.83, respectively. Interrater kappa values for qualitative features were 0.10 for the Passavant ridge; 0.48 for a notch on the nasal surface of the soft palate, 0.56 for aberrant pulsations, and 0.39 for estimation of gap size. CONCLUSIONS In these data, there was good R (intra) and fair R (inter) when using the Golding-Kushner scale for rating VP function based on nasoendoscopy. Estimates of VP gap size demonstrate higher reliability coefficients than total lateral wall, mean palate estimates, and categorical estimate of gap size. The reliability of rating qualitative characteristics (ie, the presence of the Passavant ridge, aberrant pulsations, and notch on the nasal surface of the soft palate) is variable.

Nasal airway size in cleft and noncleft children

Although the effects of cleft lip and palate on nasal airway size and breathing have been reported for adults, little information is available on children. The present study assessed the effect of age on nasal cross‐sectional size and, in particular, whether type of cleft influenced the outcome. The results indicate that, while the cleft nose continues to grow with age, it remains about 30% smaller than the noncleft nose. The airway is smallest in patients with unilateral cleft lip and palate and is largest in those with bilateral clefts. The prevalence of oral breathing is considerably higher in the cleft population in comparison to noncleft.

Nasal cavity area in term infants determined by acoustic rhinometry

The present study was undertaken to determine whether a modification to commercially available acoustic rhinometry (AR) instrumentation might allow equipment designed for use in adults to determine accurately the nasal cavity configuration of infants and children. The standard wave tube was replaced with a version having a narrow (0.312‐cm2) internal diameter (ID). Before use with neonates, the accuracy of this instrument was evaluated using the nasal cavity of a full‐term infant cadaver. Acoustic nasal area curves were compared to area measurements of polyvinylsiloxane nasal casts and direct volume measurements of the specimen. AR correlated well with nasal cast data (r = .88) for total nasal cavity area. The acoustic method underestimated the total area at the nasal valve by only 1.8 mm2 (22.1 mm2 vs. 23.9 mm2) and overestimated choanal area by 10 mm2 (56.9 mm2 vs. 46.9 mm2). In addition, AR measured total nasal volume to within 5.2% of the value obtained by direct measurement. In a cohort of 10 normal, term infants, the mean acoustic value for total nasal valve area was 19.2 ± 0.05 mm2 and for total nasal volume was 1.76 ± 0.53 cm3. This, the first report of nasal area and volume information in live infants, suggests that the modified AR device has utility both in airway research and as a nasal patency screening tool in the pediatric population.

Get on your boots: Preparing fourth-year medical students for a career in surgery, using a focused curriculum to teach the competency of professionalism

INTRODUCTION Few educational programs exist for medical students that address professionalism in surgery, even though this core competency is required for graduate medical education and maintenance of board certification. Lapses in professional behavior occur commonly in surgical disciplines, with a negative effect on the operative team and patient care. Therefore, education regarding professionalism should begin early in the surgeons formative process, to improve behavior. The goal of this project was to enhance the attitudes and knowledge of medical students regarding professionalism, to help them understand the role of professionalism in a surgical practice. METHODS We implemented a 4-h seminar, spread out as 1-h sessions over the course of their month-long rotation, for 4th-year medical students serving as acting interns (AIs) in General Surgery, a surgical subspecialty, Obstetrics/Gynecology, or Anesthesia. Teaching methods included lecture, small group discussion, case studies, and journal club. Topics included Cognitive/Ethical Basis of Professionalism, Behavioral/Social Components of Professionalism, Managing Yourself, and Leading While You Work. We assessed attitudes about professionalism with a pre-course survey and tracked effect on learning and behavior with a post-course questionnaire. We asked AIs to rate the egregiousness of 30 scenarios involving potential lapses in professionalism. RESULTS A total of 104 AIs (mean age, 26.5 y; male to female ratio, 1.6:1) participated in our course on professionalism in surgery. Up to 17.8% of the AIs had an alternate career before coming to medical school. Distribution of intended careers was: General Surgery, 27.4%; surgical subspecialties, 46.6%; Obstetrics/Gynecology, 13.7%; and Anesthesia, 12.3%. Acting interns ranked professionalism as the third most important of the six core competencies, after clinical skills and medical knowledge, but only slightly ahead of communication. Most AIs believed that professionalism could be taught and learned, and that the largest obstacle was not enough time in the curriculum. The most effective reported teaching methods were mentoring and modeling; lecture and journal club were the effective. Regarding attitudes toward professionalism, the most egregious examples of misconduct were substance abuse, illegal billing, boundary issues, sexual harassment, and lying about patient data, whereas the least egregious examples were receiving textbooks or honoraria from drug companies, advertising, self-prescribing for family members, and exceeding work-hour restrictions. The most important attributes of the professional were integrity and honesty, whereas the least valued were autonomy and altruism. The AIs reported that the course significantly improved their ability to define professionalism, identify attributes of the professional, understand the importance of professionalism, and integrate these concepts into practice (all P < 0.01). CONCLUSIONS Although medical students interested in surgery may already have well-formed attitudes and sophisticated knowledge about professionalism, this core competency can still be taught to and learned by trainees pursuing a surgical career.

Assessing the effects of odorants on nasal airway size and breathing.

A technique was developed to obtain continuous measurements of both respiratory behavior and nasal patency in response to well-controlled odorant stimulation. An automated apparatus similar to that described by Walker et al. (27) was used to present precise concentrations of an odorant. The pressure-flow technique (28) was used to continuously measure nasal airway cross-sectional area, nasal airflow rate, air volume and time characteristics associated with breathing before and during odorant stimulation. Immediately following each odorant presentation, subjects entered their psychophysical responses into a microcomputer via an electronic mouse. Respiratory and psychophysical responses of ten normal subjects to four concentrations of acetic acid during eight odorant trials were recorded; eight clean-air trials were also conducted. At the highest concentration, changes in respiratory behavior were observed as early as 200 ms after stimulus onset in some subjects. Inspiratory volumes during odorant presentation were lower than those seen just before stimulation. The magnitude of this decrease was directly related to the concentration of acetic acid and to the perceived intensity of the odor and degree of nasal irritation.

Lateral cricoid cuts as an adjunctive measure to enlarge the stenotic subglottic airway: an anatomic study

The technique of laryngotracheoplasty, with an anterior approach, with or without a posterior cut, and with or without anterior or posterior cartilage grafts, has been described previously. On occasion, a severely stenotic subglottis or aberrant shape to the cricoid cartilage makes division of the lateral aspects of the cricoid cartilage desirable. In attempting to delineate the relationship of the recurrent laryngeal nerve to proposed lateral cricoid cuts, an anatomic study was conducted. Dissections of neonatal, infant, child and adult larynges and trachea were carried out, with the relative distance of a cut through the lateral cricoid cartilage to the recurrent laryngeal nerve measured and outlined. The distance was very close in the fetal larynx (measuring 1.5 mm in the 23rd week of gestational age), with an increase in dimension in the infant and child, increasing to a distance of over 1 cm in the mature adult. The clinical significance of this relationship to proposed cuts of the lateral cricoid in different age groups is discussed.

Clinical care in craniofacial microsomia: a review of current management recommendations and opportunities to advance research.

Craniofacial microsomia (CFM) is a complex condition associated with microtia, mandibular hypoplasia, and preauricular tags. It is the second most common congenital facial condition treated in many craniofacial centers and requires longitudinal multidisciplinary patient care. The purpose of this article is to summarize current recommendations for clinical management and discuss opportunities to advance clinical research in CFM.

Surgical Applications of Ultrathin Flexible Bronchoscopes in Infants

Ultrathin flexible bronchoscopes with controlled distal angulation allow the conventional diagnostic examination of the lower airways of even the smallest infants. These instruments may be passed through small endotracheal or tracheostomy tubes while ventilation is maintained. It is thus possible, under direct visualization, to control the manipulation of surgical instruments where they could not otherwise be seen, or to study airway dynamics and anatomy intraoperatively without extubating the patient.