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Switchgrass ( Panicum virgatum L.) can be infected by the rust pathogen ( Puccinia novopanici ) and results in lowering biomass yields and quality. Label-free quantitative proteomics was conducted on leaf extracts harvested from non-infected and infected plants from a susceptible cultivar (Summer) at 7, 11, and 18 days after inoculation (DAI) to follow the progression of disease and evaluate any plant compensatory mechanisms to infection. Some pustules were evident at 7 DAI, and their numbers increased with time. However, fungal DNA loads did not appreciably change over the course of this experiment in the infected plants. In total, 3830 proteins were identified at 1% false discovery rate, with 3632 mapped to the switchgrass proteome and 198 proteins mapped to different Puccinia proteomes. Across all comparisons, 1825 differentially accumulated switchgrass proteins were identified and subjected to a STRING analysis using Arabidopsis ( A. thaliana L.) orthologs to deduce switchgrass cellular pathways impacted by rust infection. Proteins associated with plastid functions and primary metabolism were diminished in infected Summer plants at all harvest dates, whereas proteins associated with immunity, chaperone functions, and phenylpropanoid biosynthesis were significantly enriched. At 18 DAI, 1105 and 151 proteins were significantly enriched or diminished, respectively. Many of the enriched proteins were associated with mitigation of cellular stress and defense.

Study Objectives: Children with snoring and mild sleep-disordered breathing may be at increased risk for neurocognitive deficits despite few obstructive events. We hypothesized that actigraphy-based sleep duration and continuity associate with neurobehavioral functioning and explored whether these associations vary by demographic and socioeconomic factors., Methods: 298 children enrolled in the Pediatric Adenotonsillectomy Trial, ages 3 to 12.9 years, 47.3% from racial or ethnic minority groups, with habitual snoring and an apnea-hypopnea index < 3 were studied with actigraphy (mean 7.5 ± 1.4 days) and completed a computerized vigilance task (Go-No-Go) and a test of fine motor control (9-Hole Pegboard). Caregivers completed the Behavior Rating Inventory of Executive Function. Regression analyses evaluated associations between sleep exposures (24-hour and nocturnal sleep duration, sleep fragmentation index, sleep efficiency) with the Behavior Rating Inventory of Executive Function Global Executive Composite index, pegboard completion time (fine motor control), and vigilance (d prime on the Go-No-Go), adjusting for demographic factors and study design measures., Results: Longer sleep duration, higher sleep efficiency, and lower sleep fragmentation were associated with better executive function; each additional hour of sleep over 24 hours associated with more than a 3-point improvement in executive function ( P = .002). Longer nocturnal sleep ( P = .02) and less sleep fragmentation ( P = .001) were associated with better fine motor control. Stronger associations were observed for boys and children less than 6 years old., Conclusions: Sleep quantity and continuity are associated with neurocognitive functioning in children with mild sleep-disordered breathing, supporting efforts to target these sleep health parameters as part of interventions for reducing neurobehavioral morbidity., Clinical Trial Registration: Registry: ClinicalTrials.gov; Name: Pediatric Adenotonsillectomy for Snoring (PATS); URL: https://clinicaltrials.gov/ct2/show/NCT02562040; Identifier: NCT02562040., Citation: Robinson KA, Wei Z, Radcliffe J, et al. Associations of actigraphy measures of sleep duration and continuity with executive function, vigilance, and fine motor control in children with snoring and mild sleep-disordered breathing. J Clin Sleep Med . 2023;19(9):1595-1603., (© 2023 American Academy of Sleep Medicine.)

Objectives: To develop consensus statements for the scoring of pediatric drug induced sleep endoscopy in the diagnosis and management of pediatric obstructive sleep apnea., Methods: The leadership group identified experts based on defined criteria and invited 18 panelists to participate in the consensus statement development group. A modified Delphi process was used to formally quantify consensus from opinion. A modified Delphi priori process was established, which included a literature review, submission of statements by panelists, and an iterative process of voting to determine consensus. Voting was based on a 9-point Likert scale. Statements achieving a mean score greater than 7 with one or fewer outliers were defined as reaching consensus. Statements achieving a mean score greater than 6.5 with two or fewer outliers were defined as near consensus. Statements with lower scores or more outliers were defined as no consensus., Results: A total of 78 consensus statements were evaluated by the panelists at the first survey - 49 achieved consensus, 18 achieved near consensus, and 11 did not achieve consensus. In the second survey, 16 statements reached consensus and 5 reached near consensus. Regarding scoring, consensus was achieved on the utilization of a 3-point Likert scale for each anatomic site for maximal observed obstructions of <50% (Score 0, no-obstruction), ≥ 50% but <90% (Score 2, partial obstruction), and ≥ 90% (Score 3, complete obstruction). Anatomic sites to be scored during DISE that reached consensus or near-consensus were the nasal passages, adenoid pad, velum, lateral pharyngeal walls, tonsils (if present), tongue base, epiglottis, and arytenoids., Conclusion: This study developed consensus statements on the scoring of DISE in pediatric otolaryngology using a modified Delphi process. The use of a priori process, literature review, and iterative voting method allowed for the formal quantification of consensus from expert opinion. The results of this study may provide guidance for standardizing scoring of DISE in pediatric patients., Competing Interests: Declaration of competing interest All authors declare no conflict of interest or financial interest in relation to this manuscript., (Copyright © 2023. Published by Elsevier B.V.)

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., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Objective: Obstructive sleep apnea (OSA) is prevalent in children with sickle cell disease (SCD). We compared the demographic, clinical, and polysomnographic characteristics of children with and without SCD., Methods: This retrospective chart review included children with SCD (n = 89) and without SCD (n = 192) ages 1-18 years referred for polysomnography (PSG) for OSA., Results: Children with SCD were predominantly African American when compared to the non-SCD group (95% vs. 28%, p < 0.001). The non-SCD group had a higher BMI z-score (1.3 vs. 0.1, p < 0.001) and a higher percentage of patients classified as obese (52% vs. 13%, p < 0.001). In children with SCD, 43% had severe OSA and 5.6% had no OSA. In the non-SCD group, 67% had severe OSA and 4.7% had no OSA. The SCD compared to the non-SCD group had a lower mean apnea-hypopnea index (AHI) (13.6 vs. 22.4, p = 0.006) but a higher percent sleep time below 90% oxygen saturation (10.5% vs. 3.5%, p < 0.001). Predicted probability for severe OSA in children with SCD decreased with increasing age (OR = 0.81, 95% CI: 0.70-0.93)., Conclusion: Children with SCD referred for PSG are at risk for severe OSA. Compared with the non-SCD group, most children were African American with lower rates of obesity and lower AHIs but longer periods of nocturnal hypoxemia. Likelihood for severe OSA decreased with increasing age for the SCD group., Level of Evidence: 3, retrospective comparative study Laryngoscope, 133:1766-1772, 2023., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA)., Methods: Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus., Results: The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated., Conclusion: This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy., (© 2022 ARS-AAOA, LLC.)

Objectives: To examine the relationship between neighborhood-level advantage and severe obstructive sleep apnea (OSA) in children., Methods: A retrospective case-control study was conducted on 249 children who underwent adenotonsillectomy and had full-night polysomnography conducted within 6 months prior. Patients were divided into more or less socioeconomically disadvantaged groups using a validated measure, the area deprivation index (ADI). The primary outcomes were the relationship between the apnea-hypopnea index (AHI) and the presence of severe OSA, and the secondary outcome was residual moderate or greater OSA after tonsillectomy., Results: Of the 249 children included in the study, 175 (70.3%) were socially disadvantaged (ADI > 50). The median (interquartile range [IQR]) age was 9.4 (7.3-12.3) years, 129 (51.8%) were male, and the majority were White (151, 60.9%), Black (51, 20.6%), and/or of Hispanic (155, 62.5%) ethnicity. A total of 140 (56.2%) children were obese. The median (IQR) AHI was 8.9 (3.9-20.2). There was no significant difference in the median AHI or the presence of severe OSA between the more and less disadvantaged groups. Severe OSA was found to be associated with obesity (odds ratio [OR] = 3.13, 95% confidence interval [CI] = 1.83-5.34), and residual moderate or greater OSA was associated with older age (OR = 1.20, 95% CI = 1.05-1.38)., Conclusions: The ADI was not significantly associated with severe OSA or residual OSA in this cohort of children. Although more neighborhood-level disadvantage may increase the risk of comorbidities associated with OSA, it was not an independent risk factor in this study., Level of Evidence: Level 4., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

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.

High-biomass-yielding southerly adapted switchgrasses ( Panicum virgatum L.) frequently suffer from unpredictable winter hardiness at more northerly sites arising from damage to rhizomes that prevent effective spring regrowth. Previously, changes occurring over the growing season in rhizomes sampled from a cold-adapted tetraploid upland cultivar, Summer, demonstrated a role for abscisic acid (ABA), starch accumulation, and transcriptional reprogramming as drivers of dormancy onset and potential keys to rhizome health during winter dormancy. Here, rhizome metabolism of a high-yielding southerly adapted tetraploid switchgrass cultivar, Kanlow-which is a significant source of genetics for yield improvement-was studied over a growing season at a northern site. Metabolite levels and transcript abundances were combined to develop physiological profiles accompanying greening through the onset of dormancy in Kanlow rhizomes. Next, comparisons of the data to rhizome metabolism occurring in the adapted upland cultivar Summer were performed. These data revealed both similarities as well as numerous differences in rhizome metabolism that were indicative of physiological adaptations unique to each cultivar. Similarities included elevated ABA levels and accumulation of starch in rhizomes during dormancy onset. Notable differences were observed in the accumulation of specific metabolites, the expression of genes encoding transcription factors, and several enzymes linked to primary metabolism.

Infectious pseudoaneurysm is a rare condition characterized by arterial wall dilation, usually due to an adjacent infectious focus. We present an 8-year-old male with a 3-day history of progressive, severe headache 2 weeks after treatment for a parapharyngeal abscess. Computed tomography revealed a left internal carotid artery (ICA) pseudoaneurysm inferior to the skull base and a small parapharyngeal abscess inferior to the pseudoaneurysm. The patient was admitted for intravenous antibiotic treatment and underwent transfemoral endovascular coil occlusion of the cervical ICA pseudoaneurysm without complications. We discuss the presentation and management of rare vascular complications of parapharyngeal abscesses involving major arteries of the neck and the role of neurointerventional embolization in these cases.

Purpose: Polysomnography (PSG) is considered the best objective study to diagnose and quantify sleep disorders. However, PSG involves multiple electrodes and is usually performed in a sleep laboratory that in itself may change the physiology of sleep. One of the parameters that can change during PSG is the sleep position, leading to more supine sleep. The aim of this study was to quantify the amount of supine sleep during PSG and compare it to consecutive nights of a home sleep apnea test (HSAT) in the same patients., Methods: This prospective study evaluated 22 consecutive patients undergoing PSG followed by HSAT. Sleep position was analyzed during PSG and subsequently on 2 to 6 nights (mean 3.7 nights) at home, and the amount of supine sleep was recorded during each night., Results: Of 22 patients, there were 12 men (55%). The median age was 60.0 years for women and 45.5 years for men. Median proportion of supine sleep during PSG and HSAT was 61% and 26% (p < 0.001), respectively. Four "phenotypes" were identified according to their sleep position during PSG and HSAT, with 5 patients sleeping mainly supine during all nights, 7 patients sleeping mainly non-supine during all nights, 3 patients sleeping in different positions during each night, and 7 patients sleeping supine during PSG but non-supine at home, during HSAT., Conclusions: There is a higher proportion of supine sleep during PSG compared to home sleep. We identified a subgroup of patients who slept mainly supine during PSG and mainly non-supine during HSAT. PSG may overestimate OSA severity in a specific phenotype of patients., (© 2022. The Author(s).)

Objectives: To determine predictors of obstructive sleep apnea (OSA) in underweight children and to describe the demographic, clinical, and polysomnographic characteristics of an ethnically diverse population of underweight children with OSA., Study Design: Case-control study., Setting: University of Texas Southwestern Medical Center and Children's Medical Center of Dallas., Methods: Underweight children aged 2 to 18 years who underwent a polysomnogram for suspected OSA between January 2014 and December 2020 were included. Underweight was defined as body mass index <5th percentile per Centers for Disease Control and Prevention guidelines. Children with apnea-hypopnea index <1.0 served as a control group. Univariate and multiple logistic regression analysis was used to determine the predictors of OSA. Significance was set at P < .05., Results: An overall 124 children met inclusion criteria: mean age, 6.4 years; 50% female; 44% Hispanic, 31% African American, and 18% Caucasian. A total of 83 children had OSA (apnea-hypopnea index ≥1.0). Height was negatively correlated with OSA (odds ratio, 0.94; 95% CI, 0.88-0.99; P = .02) while allergic rhinitis (odds ratio, 2.97; 95% CI, 1.24-7.08; P = .01) and tonsillar hypertrophy (odds ratio, 3.38; 95% CI, 1.42-8.02; P = .01) were predictors for the presence of OSA. No demographic or clinical characteristics were predictors for severe OSA., Conclusion: Underweight children with OSA, as compared with those without OSA, are more likely to have decreased height, tonsillar hypertrophy, and allergic rhinitis. There are no predictors of severe OSA in underweight children. We recommend polysomnography for the diagnosis of OSA in symptomatic underweight children with large tonsils, especially when they have a history of allergies.

Key Message: We investigate the genetic basis of panicle architecture in switchgrass in two mapping populations across a latitudinal gradient, and find many stable, repeatable genetic effects and limited genetic interactions with the environment. Grass species exhibit large diversity in panicle architecture influenced by genes, the environment, and their interaction. The genetic study of panicle architecture in perennial grasses is limited. In this study, we evaluate the genetic basis of panicle architecture including panicle length, primary branching number, and secondary branching number in an outcrossed switchgrass QTL population grown across ten field sites in the central USA through multi-environment mixed QTL analysis. We also evaluate genetic effects in a diversity panel of switchgrass grown at three of the ten field sites using genome-wide association (GWAS) and multivariate adaptive shrinkage. Furthermore, we search for candidate genes underlying panicle traits in both of these independent mapping populations. Overall, 18 QTL were detected in the QTL mapping population for the three panicle traits, and 146 unlinked genomic regions in the diversity panel affected one or more panicle trait. Twelve of the QTL exhibited consistent effects (i.e., no QTL by environment interactions or no QTL × E), and most (four of six) of the effects with QTL × E exhibited site-specific effects. Most (59.3%) significant partially linked diversity panel SNPs had significant effects in all panicle traits and all field sites and showed pervasive pleiotropy and limited environment interactions. Panicle QTL co-localized with significant SNPs found using GWAS, providing additional power to distinguish between true and false associations in the diversity panel., (© 2022. The Author(s).)

Objectives: To describe the management of a 5-year old female with a painless, mobile cheek mass., Methods: A retrospective chart review of presentation, imaging, pathology and management., Results: Magnetic resonance imaging showed a heterogenous mass with solid and lipomatous components. The mass was a lipoblastoma on histopathology and was excised completely with no evidence of recurrence., Conclusions: The diagnosis and management of a cheek mass in a child is challenging. Imaging is important but not diagnostic. Surgical excision is the primary management of a lipoblastoma.

Objectives/hypothesis: To reanalyze the growth trajectory and assess longitudinal changes of children undergoing adenotonsillectomy (AT) versus watchful waiting (WW) enrolled in the Childhood Adenotonsillectomy Trial (CHAT) study and to determine if an AT increases the risk of obesity in children., Study Design: Reanalysis of prospective cohort investigation., Methods: The study analyzed publicly available data from CHAT, including 3 months visit data not previously included in a prior publication. Statistical comparisons and mixed-effects modeling were done using age- and sex-specific BMI expressed as a percentage of the 95th percentile (%BMIp95). P < .05 was considered significant., Results: Children in the AT group, especially if underweight at baseline, had an increased rate of weight gain, with 100% of underweight children in the AT group becoming normal weight compared to 20% for WW. However, the rate of weight gain, as measured by the %BMIp95 trajectory for both AT and WW groups, was not significantly different when baseline weight status and obstructive sleep apnea (OSA) resolution were accounted for. Comparisons of %BMIp95 between treatment groups at baseline, 3- and 7-month follow-up visits also failed to identify statistically significant differences (P > .05). Overall for the entire cohort, resolution of OSA was associated with a decreased weight trajectory (P < .001)., Conclusions: AT compared to WW is not associated with an increased risk of excessive weight gain. Otolaryngologists should be aware of this updated analysis when discussing AT surgical outcomes with families., Level of Evidence: 2 Laryngoscope, 132:1289-1294, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Study Objectives: Obstructive sleep apnea is associated with neurobehavioral dysfunction, but the relationship between disease severity as measured by the apnea-hypopnea index and neurobehavioral morbidity is unclear. The objective of our study is to compare the neurobehavioral morbidity of mild sleep-disordered breathing versus obstructive sleep apnea., Methods: Children 3-12 years old recruited for mild sleep-disordered breathing (snoring with obstructive apnea-hypopnea index < 3) into the Pediatric Adenotonsillectomy Trial for Snoring were compared to children 5-9 years old recruited for obstructive sleep apnea (obstructive apnea-hypopnea 2-30) into the Childhood Adenotonsillectomy Trial. Baseline demographic, polysomnographic, and neurobehavioral outcomes were compared using univariable and multivariable analysis., Results: The sample included 453 participants with obstructive sleep apnea (median obstructive apnea-hypopnea index 5.7) and 459 participants with mild sleep-disordered breathing (median obstructive apnea-hypopnea index 0.5). By polysomnography, participants with obstructive sleep apnea had poorer sleep efficiency and more arousals. Children with mild sleep-disordered breathing had more abnormal executive function scores (adjusted odds ratio 1.96, 95% CI 1.30-2.94) compared to children with obstructive sleep apnea. There were also elevated Conners scores for inattention (adjusted odds ratio 3.16, CI 1.98-5.02) and hyperactivity (adjusted odds ratio 2.82, CI 1.83-4.34) in children recruited for mild sleep-disordered breathing., Conclusions: Abnormal executive function, inattention, and hyperactivity were more common in symptomatic children recruited into a trial for mild sleep-disordered breathing compared to children recruited into a trial for obstructive sleep apnea. Young, snoring children with only minimally elevated apnea-hypopnea levels may still be at risk for deficits in executive function and attention., Trial Registration: Pediatric Adenotonsillectomy for Snoring (PATS), NCT02562040; Childhood Adenotonsillectomy Trial (CHAT), NCT00560859., (Published by Oxford University Press on behalf of Sleep Research Society (SRS) 2022.)

It is well documented that body position significantly affects breathing indices during sleep in patients with obstructive sleep apnea. They usually worsen while changing from a non-supine to a supine position. Therefore, body position should be an accurately measured and credible parameter in all types of sleep studies. The aim of this study was to specify the accuracy of a neck-based monitoring device (Clebre, Olsztyn, Poland) mounted at the suprasternal notch, in determining a supine and non-supine sleeping position, as well as specific body positions during sleep, in comparison to polysomnography (PSG). A sleep study (PSG along with a neck-based audio-motion sensor) was performed on 89 consecutive patients. The accuracy in determining supine and non-supine positions was 96.9%±3.9% and 97.0%±3.6%, respectively. For lateral positions, the accuracy was 98.6%±2% and 97.4%±4.5% for the right and left side, respectively. The prone position was detected with an accuracy of 97.3%±5.6%. The study showed a high accuracy in detecting supine, as well as other gross positions, during sleep based on a sensor attached to the suprasternal notch, compared to the PSG study. We feel that the suprasternal notch is a promising area for placing wireless sleep study devices.

Objectives/hypothesis: To determine the impact of race on outcomes after pediatric tracheostomy., Study Design: Retrospective case series., Methods: A case series of tracheostomies at an urban, tertiary care children's hospital between 2014 and 2019 was conducted. Children were grouped by race to compare neurocognition, mortality, and decannulation rate., Results: A total of 445 children with a median age at tracheostomy of 0.46 (interquartile range [IQR]: 0.97) years were studied. The cohort was 32% Hispanic, 31% White, 30% Black, 2.9% Asian, and 4.3% other race. Black compared to White children had a lower median birth weight (2,022 vs. 2,449 g, P = .005), were more often extremely premature (≤28 weeks gestation: 62% vs. 57%, P = .007), and more frequently had bronchopulmonary dysplasia (BPD) (35% vs. 17%, P = .002). Hispanic compared to Black children had higher median birth weight (2,529 g, P < .001), less extreme prematurity (44%, P < .001), and less BPD (21%, P = .04). The proportion of Black children was higher (30% vs. 19%, P < .001), while the proportion of Hispanic children with a tracheostomy was lower (32% vs. 42%, P = .003) compared to the racial distribution of all pediatric admissions. Racial differences were not seen for rates of severe neurocognitive disability (P = .51), decannulation (P = .17), or death (P = .92) after controlling for age, sex, prematurity, and ventilator dependence., Conclusion: Black children disproportionately underwent tracheostomy and had a higher comorbidity burden than White or Hispanic children. Hispanic children had proportionally fewer tracheostomies. Neurocognitive ability, decannulation, and mortality were similar for all races implying that health disparities by race may not change long-term outcomes after pediatric tracheostomy. Laryngoscope, 132:1118-1124, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Panicum mosaic virus (PMV), the type member of the genus Panicovirus in the family Tombusviridae, naturally infects switchgrass (Panicum virgatum L.). PMV and its molecular partner, satellite panicum mosaic virus (SPMV), interact synergistically in coinfected millets to exacerbate the disease phenotype and increase the accumulation of PMV compared to plants infected with PMV alone. In this study, we examined the reaction of switchgrass cvs. Summer and Kanlow to PMV and PMV+SPMV infections at 24°C and 32°C. Switchgrass cv. Summer was susceptible to PMV at both temperatures. In contrast, cv. Kanlow was tolerant to PMV at 24°C, but not at 32°C, suggesting that Kanlow harbors temperature-sensitive resistance to PMV. At 24°C, PMV was readily detected in inoculated leaves, but not in upper uninoculated leaves of Kanlow, suggesting that resistance to PMV was likely mediated by abrogation of long-distance virus transport. Coinfection by PMV and SPMV at 24°C and 32°C in cv. Summer, but not in Kanlow, caused increased symptomatic systemic infection and mild disease synergism with slightly increased PMV accumulation compared to plants infected with PMV alone. These data suggest that the interaction between PMV and SPMV in switchgrass is cultivar-dependent, manifested in Summer but not in Kanlow. However, co-inoculation of cv. Kanlow with PMV+SPMV caused an enhanced asymptomatic infection, suggesting a role of SPMV in enhancement of symptomless infection in a tolerant cultivar. These data suggest that enhanced asymptomatic infections in a virus-tolerant switchgrass cultivar could serve as a source of virus spread and play an important role in panicum mosaic disease epidemiology under field conditions. Our data reveal that the cultivar, coinfection with SPMV, and temperature influence the severity of symptoms elicited by PMV in switchgrass., (© 2022. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Polyploidy results from whole-genome duplication and is a unique form of heritable variation with pronounced evolutionary implications. Different ploidy levels, or cytotypes, can exist within a single species, and such systems provide an opportunity to assess how ploidy variation alters phenotypic novelty, adaptability, and fitness, which can, in turn, drive the development of unique ecological niches that promote the coexistence of multiple cytotypes. Switchgrass, Panicum virgatum, is a widespread, perennial C4 grass in North America with multiple naturally occurring cytotypes, primarily tetraploids (4×) and octoploids (8×). Using a combination of genomic, quantitative genetic, landscape, and niche modeling approaches, we detect divergent levels of genetic admixture, evidence of niche differentiation, and differential environmental sensitivity between switchgrass cytotypes. Taken together, these findings support a generalist (8×)–specialist (4×) trade-off. Our results indicate that the 8× represent a unique combination of genetic variation that has allowed the expansion of switchgrass’ ecological niche and thus putatively represents a valuable breeding resource.

Objectives: To identify predictors of obstructive sleep apnea (OSA) after adenotonsillectomy (T&A) in children under 3 years of age and to describe the characteristics of children with OSA under 3 years of age undergoing T&A in an ethnically diverse population. Methods: We examined 87 children under 3 years with T&A and pre- and post-operative polysomnography (PSG) between 8/2012 and 3/2020 at a large tertiary care hospital. Differences were compared for covariates including demographics, comorbidities, and respiratory parameters. Regression was used to identify predictors of persistent severe OSA. Significance was set at P < .05. Results: Of the 87 children in the study, 64 (74%) were male, 26 (30%) were obese, 34 (39%) were Hispanic, and 35 (40%) were Black. Most children (94%) had improvements in OSA severity as measured by the apnea-hypopnea index (AHI) after T&A, but 78% had persistent OSA (AHI ≥1) after surgery. Children with persistent mild, compared to moderate-severe OSA, were more likely to have gastroesophageal reflux disease (GERD) (50% versus 24%, P = .025), a craniofacial disorder (30% versus 10%, P = .025), Down syndrome (20% versus 5%, P = .031), or pre-operative severe OSA. Conclusions: This study of an ethnically diverse population found that T&A is an effective procedure at improving, but not resolving, OSA in children under 3 years. Children with Down syndrome, craniofacial abnormalities, GERD, or pre-operative severe OSA who are under 3 years old are at high risk for persistent OSA and may benefit from post-operative PSG. Future study should examine complications and long-term outcomes of T&A in this age group.

Objective: To evaluate outcomes of tonsillectomy and predictors for persistent obstructive sleep apnea (OSA) in children with Down syndrome in an ethnically diverse population., Study Design: Case series with chart review., Setting: UT Southwestern/Children's Medical Center Dallas., Methods: Polysomnographic, clinical, and demographic characteristics of children with Down syndrome ages 1 to 18 years were collected, including pre- and postoperative polysomnography. Simple and multivariable regression models were used for predictors for persistent OSA. P ≤ .05 was considered significant., Results: Eighty-one children were included with a mean age of 6.6 years, 44 of 81 (54%) males, and 53 of 81 (65%) Hispanic. Preoperatively, 60 of 81 (74%) patients had severe OSA. Posttonsillectomy improvements occurred for apnea-hypopnea index (27.9 to 14.0, P < .001), arousal index (25.2 to 18.8, P = .004), percent time with oxygen saturations <90% (8.8% to 3.4%, P = .003), and oxygen nadir (81.4% to 85%, P < .001). Forty-seven children (58%) had persistent OSA. Fifteen children (18.5%) had increased apnea-hypopnea index postoperatively: 2 from mild to moderate, 2 from mild to severe, and 2 from moderate to severe obstructive sleep apnea. Persistent OSA predictors were asthma (odds ratio, 4.77; 95% CI, 1.61-14.09; P = .005) and increasing age (odds ratio, 1.25; 95% CI, 1.09-1.43; P = .001)., Conclusion: Children with Down syndrome are at high risk for persistent OSA after tonsillectomy with about 20% worsening after tonsillectomy. Asthma and increasing age are predictors for persistent OSA in children with Down syndrome.

Objective: To compare recovery from tonsillectomy using thermal welding forceps (TWF), controlled ablation (CA), and monopolar electrosurgery (MES) in children., Methods: This was a prospective single blinded observational study using data from electronic medical record (EMR) and caregiver completed patient diary, conducted at a community-based children's hospital within an academic program with tonsillectomy performed by attending surgeons. Children aged 3-17 years undergoing tonsillectomy or adenotonsillectomy by TWF, CA, or MES over a 4-year period were included. Demographics, intraoperative time for tonsillectomy, blood loss, patient diary documentation of pain levels, analgesic doses, diet type and events per day were recorded. In addition, EMR documentation of morbidity events (bleeding, visits for bleeding, return to operating room [OR], total visits or admissions, poor oral intake or dehydration) were noted. To assess for differences in baseline characteristics, we utilized analysis of variance and Pearson's χ 2 test. To determine primary outcomes, we used a multilevel mixed-effect linear regression model., Results: A total of 369 children were enrolled, and 346 who met inclusion criteria underwent tonsillectomy. The children were categorized by the instrument used by the surgeons: CA 32.4% (n = 112), MES 36.7% (n = 127), and TWF 30.9% (n = 107). Mean age overall was 6.8 ± 3.2 years, with 57.4% female and 42.6% male. Diary return rate was 52.3% (n = 181) overall, with CA at 48.2% (n = 54), MES at 44.8% (n = 57), and TWF at 65.4% (n = 70). Average pain on the day of surgery was different between instruments with CA having the lowest level of 2.0 compared to 2.7 for TWF and MES (p = 0.001). Maximum pain level for day of surgery were lowest for CA at 2.7 compared to 3.4 for MES and 3.5 for TWF (p = 0.003). Pain levels were lowest for TWF after postoperative day (POD) 6. Overall rate of bleeding was 9.3%, with 2.6% return to surgery for control of bleeding. TWF had the lowest rate of bleeds (4.7% versus CA 11.6% and MES 11.0%), return to surgery (0.0% versus CA 2.7% and MES 4.7%), the earliest and final return to regular diet at POD 5.8 and 8.1, respectively without reaching statistical significance., Conclusion: CA had significantly lowest early pain levels on day 0-1 and trended lowest up to POD 6, after which TWF was lowest but did not reach statistical significance. TWF had the earliest return to regular diet. Children undergoing CA and MES are more likely to have a postoperative bleed and a return to the OR than TWF suggesting improved ability to seal vessels with the latter instrument. Further study with a larger sample is needed., (Published by Elsevier B.V.)

Objective: To describe characteristics and outcomes of infants admitted as neonates requiring tracheostomy placement., Methods: A cross-sectional analysis of the Kids' Inpatient Database (KID) between 2003 and 2016 included all children admitted within the first 28 days of life that had a tracheostomy placed prior to discharge. Patient characteristics and surgical outcomes were compared between term (≥37 weeks gestation) and preterm (<37 weeks gestation) infants. A subset analysis for Black or African American neonates was performed given disproportional preterm births., Results: An estimated 4268 (95% CI: 4123-4414) tracheostomies were performed in infants admitted as a neonate with preterm infants accounting for 47% (1998/4268). Among preterm children, 20% were Black or African American compared to 12% in the term group (P < .001). More preterm infants had bronchopulmonary dysplasia (46% vs. 14%, P < .001), cardiac defects (66% vs. 58%, P < .001) and developed pneumonia, newborn sepsis, or sepsis during admissions (P < .001). Laryngotracheal anomalies (25% vs. 18%, P < .001) and vocal cord paralysis (11% vs. 4.9%, P < .001) were more common in term infants. Median length of stay (LOS) (154 vs. 100 days, P < .001) and total charges ($1,395,106 vs. $917,478, P < .001) were greater among preterm infants. Mortality was no different between groups (13% vs. 15%, P = .07). Characteristics strongly associated with preterm status were newborn sepsis (OR: 2.31, 95% CI: 1.97-2.72, P < .001), bronchopulmonary dysplasia (OR: 2.17, 95% CI: 1.77-2.65, P < .001) and Black or African American race (OR: 1.78, 95% CI: 1.46-2.17, P < .001). The following factors increased among all neonates between the baseline year 2003 to the final study year 2016: complications of care (OR: 1.9, 95% CI: 1.5-2.5, P < .001); sepsis (OR: 4.1, 95% CI: 3.0-5.5, P < .001); congenital cardiac anomalies (OR: 5.8, 95% CI: 4.5-7.4, P < .001); and respiratory failure (OR: 1.9, 95% CI: 1.5-2.4, P < .001). Compared to other races, median LOS and total charges were greater among Black or African American infants., Conclusion: Tracheostomies among preterm infants admitted as neonates reflect a growing and complex group with increased costs and hospitalization lengths. Black or African American children are disproportionately born preterm with higher costs and LOS compared to other racial cohorts. Future work will be necessary to design quality-improvement initiatives to improve outcomes for this vulnerable population., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objectives: Adenotonsillectomy (AT) is the first line of treatment for pediatric obstructive sleep apnea (OSA). In some treatment guidelines, children with moderate to severe OSA, defined as apnea-hypopnea index (AHI) ≥ 5, may be recommended AT regardless of symptoms. The differences in outcomes between children randomized to watchful waiting with supportive care (WWSC) or AT were compared based on baseline OSA severity threshold of AHI≥ 5., Methods: A secondary analysis of the Childhood Adenotonsillectomy Trial, a randomized controlled trial of children with OSA aged 5-9 years who underwent AT or WWSC, was performed. The primary outcome was the change in neurocognition measured by Developmental Neuropsychological Assessment (NEPSY). Secondary outcomes included changes in behavior, symptoms of OSA, and quality of life. Outcomes were measured at baseline and the seven-month follow-up after grouping children based on whether their AHI was greater than or equal to 5. Comparisons were performed using two-way analysis of covariance (ANCOVA) while controlling for age, sex and race. Differences in treatment effect were measured using Cohen's d., Results: Of the 397 children included, 203 received WWSC and 194 underwent AT. The treatment effects on post-randomization changes in neurocognition, measured by NEPSY in children with AHI ≥5 (Cohen's d = 0.1 [95% CI, -0.1 to 0.4]) was not significantly different from children with AHI <5 (Cohen's d = 0.1 [95% CI, -0.1 to 0.4]). Furthermore, among children in the AT group alone, the effects of AT on post-treatment changes in NEPSY did not differ based on AHI threshold (Cohen's d = -0.06 [95% CI, -0.3 to 0.2]). Additionally, the treatment effects on post-randomization changes in behavior, symptoms, and quality of life did not vary based on AHI threshold., Conclusion: The outcomes of neurocognition, behavior, symptoms, and quality of life did not differ between children with OSA randomized to WWSC or AT based on OSA severity threshold alone. Additionally, the effects of AT on post-treatment outcomes did not differ based on AHI threshold., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objectives/hypothesis: To determine whether the severity of obstructive sleep apnea (OSA) is affected by weight gain velocity (WGV) in adolescents with Down syndrome., Study Design: Retrospective case series., Methods: We performed a retrospective case series of children with Down syndrome, aged 9-19, referred for polysomnography (PSG) due to suspected OSA at an academic children's hospital. We determined the velocity (slope of change) of yearly weight gain using a mixed effect linear regression model. Subsequently, we determined if velocity of yearly weight gain was greater in adolescents with severe OSA (apnea-hypopnea index > 10). Significance was set at P < .05., Results: A total of 77 adolescents with Down syndrome were identified. The average age was 12.5 years (standard deviation = 3.1); 44 (57%) were male and 46 (60%) were Hispanic. The majority, 51 (66%) had severe OSA. The velocity of yearly weight gain prior to PSG in Down syndrome adolescents was similar regardless of OSA severity (mean diff in weight gain at PSG between severe and nonsevere OSA = -1.42, 95% confidence interval = -5.8 to 2.9, P = .52). Down syndrome adolescents with severe OSA weighed more at PSG (58.4 kg vs. 40.9 kg, P < .001) and all years prior to PSG. These findings remained even when controlling for age at PSG., Conclusions: Severe OSA in adolescents with Down syndrome is associated with weight. There was no significant difference in WGV in children with Down syndrome with or without severe OSA., Level of Evidence: 3 Laryngoscope, 131:2598-2602, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To develop an expert consensus statement on pediatric drug-induced sleep endoscopy (DISE) that clarifies controversies and offers opportunities for quality improvement. Pediatric DISE was defined as flexible endoscopy to examine the upper airway of a child with obstructive sleep apnea who is sedated and asleep., Methods: Development group members with expertise in pediatric DISE followed established guidelines for developing consensus statements. A search strategist systematically reviewed the literature, and the best available evidence was used to compose consensus statements regarding DISE in children 0 to 18 years old. Topics with significant practice variation and those that would improve the quality of patient care were prioritized., Results: The development group identified 59 candidate consensus statements, based on 50 initial proposed topics, that focused on addressing the following high-yield topics: (1) indications and utility, (2) protocol, (3) optimal sedation, (4) grading and interpretation, (5) complications and safety, and (6) outcomes for DISE-directed surgery. After 2 iterations of the Delphi survey and removal of duplicative statements, 26 statements met the criteria for consensus; 11 statements were designated as no consensus. Several areas, such as the role of DISE at the time of adenotonsillectomy, were identified as needing further research., Conclusion: Expert consensus was achieved for 26 statements pertaining to indications, protocol, and outcomes for pediatric DISE. Clinicians can use these statements to improve quality of care, inform policy and protocols, and identify areas of uncertainty. Future research, ideally randomized controlled trials, is warranted to address additional controversies related to pediatric DISE.

Purpose: Immune checkpoint inhibition (ICI) therapy has improved patient outcomes in advanced non-small cell lung cancer (NSCLC), but better biomarkers are needed. A clinically validated, blood-based proteomic test, or host immune classifier (HIC), was assessed for its ability to predict ICI therapy outcomes in this real-world, prospectively designed, observational study., Materials and Methods: The prospectively designed, observational registry study INSIGHT (Clinical Effectiveness Assessment of VeriStrat® Testing and Validation of Immunotherapy Tests in NSCLC Subjects) (NCT03289780) includes 35 US sites having enrolled over 3570 NSCLC patients at any stage and line of therapy. After enrolment and prior to therapy initiation, all patients are tested and designated HIC-Hot (HIC-H) or HIC-Cold (HIC-C). A prespecified interim analysis was performed after 1-year follow-up with the first 2000 enrolled patients. We report the overall survival (OS) of patients with advanced stage (IIIB and IV) NSCLC treated in the first-line (ICI-containing therapies n=284; all first-line therapies n=877), by treatment type and in HIC-defined subgroups., Results: OS for HIC-H patients was longer than OS for HIC-C patients across treatment regimens, including ICI. For patients treated with all ICI regimens, median OS was not reached (95% CI 15.4 to undefined months) for HIC-H (n=196) vs 5.0 months (95% CI 2.9 to 6.4) for HIC-C patients (n=88); HR=0.38 (95% CI 0.27 to 0.53), p<0.0001. For ICI monotherapy, OS was 16.8 vs 2.8 months (HR=0.36 (95% CI 0.22 to 0.58), p<0.0001) and for ICI with chemotherapy OS was unreached vs 6.4 months (HR=0.41 (95% CI 0.26 to 0.67), p=0.0003). HIC results were independent of programmed death ligand 1 (PD-L1). In a subgroup with PD-L1 ≥50% and performance status 0-1, HIC stratified survival significantly for ICI monotherapy but not ICI with chemotherapy., Conclusion: Blood-based HIC proteomic testing provides clinically meaningful information for immunotherapy treatment decision in NSCLC independent of PD-L1. The data suggest that HIC-C patients should not be treated with ICI alone regardless of their PD-L1 expression., Competing Interests: Competing interests: PRW: Speaker’s Bureau (Genentech), Consultant (Biodesix), Ownership/stock interest/employment (Circulogene, Theranostics). DO: Speaker’s Bureau (Bayer), Consultant (Coherus, Abbvie), Ownership/stock interest (Karyopham), Honorarium (Daiichi-Sankyo, Rigel), Contracted/supported research grant (Helsinn, MEI, FibroGen). RP: Consultant (AstraZeneca, Tesaro, Amgen, Roche), Honorarium (Cardinal Health), Contracted/supported research grant (E.R. Squibb Sons, Gilead Sciences, Takeda, AstraZeneca, Genentech, Roche, Janssen, Celgene, Lilly). ESS: Speaker’s Bureau (Biodesix; Caris SL; Paradigm Dx; Guardant Health; Genentech; Pfizer; Amgen; Novartis; Boehringer-Ingelheim; Merck; AstraZeneca; Dova; Sanofigenzyme, Oncocyte, Eli Lilly), Consultant (Astra Zeneca, Lilly, BluePrint Medicine, Inivata/Neogenomics). JMO: Speaker’s Bureau (Pfizer-Padcev, Astellas, Xtandi), Advisory Board (Janssen-Zytiga, Pfizer-Padcev). EP: Speaker’s Bureau (TG Therapeutics), Advisory Board (Flatiron Health), Consultant (Eli Lilly; Eisai). BG: Speaker’s Bureau (Boehrenger Ingelheim), Advisory Board (GlaxoSmithKline). LT: Employment (Biodesix). WA: Consultant (Calithera Biosciences, AstraZeneca), Contracted/supported research grant (AstraZeneca, Bristol-Myers Squibb, Loxo)., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To identify predictors of severe obstructive sleep apnea (OSA) in children under 3 years of age and to compare demographics, comorbidities, and polysomnographic characteristics of infants and toddlers with OSA., Study Design: Retrospective case series., Methods: We examined children under 3 years of age who had polysomnogram between August 2012 and March 2020. Demographics, clinical, and polysomnographic parameters were compared in children age 0-1 versus 1-3 years and 0-2 versus 2-3 years and severe versus mild-moderate OSA. Univariate analysis was used to compare age groups; multiple logistic regression for predictors of severe OSA. Significance was set at P < .05., Results: Of the 413 children, 267 (65%) were male and 131 (32%) obese. The population included Hispanic (41%), African American (28%), and Caucasian (25%) children. A total of 98.5% had OSA and 35% had severe OSA. Children under 1 year of age more commonly had gastroesophageal reflux disease (GERD) (38% vs. 23%; P = .014); tonsillar hypertrophy was more common in children over 2 years of age (56% vs. 34%, P = .001). Down syndrome (odds ratio (OR): 3.16, 95% confidence interval (CI) = 1.14-8.68, P = .026) and tonsillar hypertrophy (OR: 1.97, 95% CI = 1.28-3.02, P = .002) were predictors of severe OSA., Conclusion: Children under 3 years of age with OSA are more likely to be male and have GERD. Down syndrome and tonsillar hypertrophy are predictors of severe OSA, and children with these conditions should be prioritized for polysomnography., Level of Evidence: 4 Laryngoscope, 131:E2603-E2608, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To maximize vaccination compliance in children undergoing cochlear implantation and thus minimize meningitis-related complications. To present a Quality Improvement (QI) Project for 23-valent pneumococcal polysaccharide vaccine (PPSV-23) administration within a pediatric cochlear implant program., Methods: We identified children from birth through 21 years of age with cochlear implants or cochlear implant candidates who were seen at Children's Health Medical Center/UT Southwestern Medical Center, Dallas between 12/2018 and 01/2020. Protocols were developed for physicians and nurses using electronic medical record (EMR) smart phrases with prompts to review and document vaccine status and plan. Charts were reviewed for six consecutive cycles of 6-12 weeks for vaccine documentation and plan compliance. Regular feedback was provided to physicians and nurses. A cochlear implant EMR registry was developed for increased surveillance of vaccine administration., Results: Physicians and nurses showed an improvement in vaccine documentation from the start of the project to the first data cycle review (61%-90% and 20%-91% for physicians and nurses respectively). This was followed by a regression in the third to fourth review cycles (decrease to 67% and 80% compliance). Vaccine documentation compliance improved after subsequent review and feedback, and peaked during the final cycle of the review (83% and 100% compliance). During the year-long QI project, one child with a cochlear implant missed the PPSV-23 vaccine but was identified during cycle review and vaccinated. This occurred during the third cycle, and for the remaining three cycles there were no missed vaccinations. On completion of the QI project, a formal vaccination oversight program was introduced with a physician/nurse team that reviews the cochlear implant EMR registry monthly for children who have not been vaccinated. In the 13 months since the completion of the QI project there has been 100% compliance with no children who missed vaccination., Conclusion: We present a vaccination program with oversight to address missed vaccinations. Implementation of a QI project followed by transition to a formal vaccination oversight program eliminated missed PPSV-23 vaccinations in children with cochlear implants. We recommend that cochlear implant programs use similar approaches to ultimately minimize potential meningitis-related complications in patients with cochlear implants., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objectives: To study a case series of preterm and extremely preterm infants, comparing their decannulation and survival rates after tracheostomy., Methods: We performed a single-institution longitudinal study of preterm infants with a tracheostomy. Infants were categorized as premature (born > 28 weeks and < 37 weeks) and extremely premature (born ≤ 28 weeks). Decannulation and survival rates were determined using the Kaplan-Meier method. Neurocognitive quality of life (QOL) was reported as normal, mild/moderately, and severely impaired. Statistical significance was set at P < .05., Results: This study included 240 patients. Of those, 111 were premature and 129 were extremely preterm. The median age (interquartile range) at tracheostomy was 4.8 months (0.4). Premature infants were more likely than extremely preterm to have airway obstruction (54% vs. 32%, P < .001); whereas extremely preterm infants were more likely to have bronchopulmonary dysplasia (68% vs. 15%, P < .001) and to be ventilation-dependent (68% vs. 54%, P < .001). The 5-year decannulation rate for premature infants was 46% and for extremely preterm was 64%. The 5-year survival rate post-tracheostomy for preterm was 79% and for extremely preterm was 73%. The log-rank test of equality showed that decannulation and survival were similar (P > .05) for both groups, even after controlling for potentially confounding factors like race, age, gender, birth weight, and age at tracheostomy. For neurocognitive QOL, 47% of patients survived with severely impaired QOL after tracheostomy. Preterm had 56% with severely impaired QOL and extremely preterm had 40% with severely impaired QOL (P = .03)., Conclusion: This study demonstrated that the time to decannulation and the likelihood of survival did not vary among premature and extremely premature infants even when controlling for other confounding variables., Level of Evidence: 3b Laryngoscope, 131:417-422, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Long-term climate change and periodic environmental extremes threaten food and fuel security 1 and global crop productivity 2-4 . Although molecular and adaptive breeding strategies can buffer the effects of climatic stress and improve crop resilience 5 , these approaches require sufficient knowledge of the genes that underlie productivity and adaptation 6 -knowledge that has been limited to a small number of well-studied model systems. Here we present the assembly and annotation of the large and complex genome of the polyploid bioenergy crop switchgrass (Panicum virgatum). Analysis of biomass and survival among 732 resequenced genotypes, which were grown across 10 common gardens that span 1,800 km of latitude, jointly revealed extensive genomic evidence of climate adaptation. Climate-gene-biomass associations were abundant but varied considerably among deeply diverged gene pools. Furthermore, we found that gene flow accelerated climate adaptation during the postglacial colonization of northern habitats through introgression of alleles from a pre-adapted northern gene pool. The polyploid nature of switchgrass also enhanced adaptive potential through the fractionation of gene function, as there was an increased level of heritable genetic diversity on the nondominant subgenome. In addition to investigating patterns of climate adaptation, the genome resources and gene-trait associations developed here provide breeders with the necessary tools to increase switchgrass yield for the sustainable production of bioenergy.

Objective: In 2012, Black or African American children constituted 21% of pediatric tracheostomies while representing approximately 15% of the US population. It is unclear if this discrepancy is due to differences in associated diagnoses. This study aimed to analyze the incidence of pediatric tracheostomy in the United States from 2003 to 2016 and to determine the odds of placement among Black children when compared with other children., Study Design: Retrospective., Setting: Academic hospital., Subjects and Methods: We used the 2003 to 2016 Kid Inpatient Database to determine the incidence of pediatric tracheostomy in the United States and determine the odds of tracheostomy placement in Black children when compared with other children., Results: A total of 26,034 pediatric tracheostomies were performed between 2003 and 2016, among which, 21% were Black children. The median age was 7 years (interquartile range [IQR] = 0 to 17); 43% were ≤2 years old, and 62% were male. The most common principal diagnosis was respiratory failure (72%). When compared with other children, Black children were more likely to undergo tracheostomy (odds ratio [OR] = 1.2; 95% CI, 1.1-1.3), which increased among children younger than 2 years old (OR = 1.5; 95% CI, 1.4-1.5). Black children with tracheostomies were also more likely to be diagnosed with laryngeal stenosis and bronchopulmonary dysplasia and to have an extended length of stay ( P < .001)., Conclusion: Black children are 1.2 times more likely to undergo tracheostomy in the United States compared with other children. Further investigation is warranted to evaluate if there are underlying anatomical, environmental, or psychosocial factors that contribute to this discrepancy.

Objective: To determine the best anesthetic technique for DISE based on a retrospective review of the current literature and to highlight research gaps that should be addressed in future studies., Methods: A comprehensive retrospective review of the literature on anesthetic regimens for pediatric DISE through March 2020 was performed. Specific medical subject heading (MesH) terms included: drug-induced sleep endoscopy and anesthesia, DISE, child, obstructive sleep apnea, sleep disordered breathing., Results: Twelve articles were included. One study was a retrospective comparative study while the remaining 11 were case series. Five studies described anesthetic technique for DISE pre-T&A, two post-T&A, and four both pre- and post-T&A. The heterogeneity of the studies did not allow for a meta-analysis. A total of 1110 children ages 2 months to 19 years were included. Sedation depth and anesthetic outcomes with DISE were infrequently described. Eleven studies used a sevoflurane inhalational induction and mostly transitioned to a total IV anesthetic for maintenance. Propofol was the most commonly used sole anesthetic. A total of three studies used a combination of remifentanil and propofol, one used dexmedetomidine alone, one used sevoflurane alone, and one compared different regimens. Dexmedetomidine and ketamine have the most favorable profile for pediatric DISE but are not universally used. DISE completion, as reported in two studies, was 93% and 100%., Conclusion: There are several anesthetic regimens for DISE that achieve good sedation and outcomes. The combination of ketamine and dexmedetomidine may be the ideal regimen. Limited data and lack of protocols/high-quality studies exist on anesthetic regimens for pediatric DISE., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To develop an expert-based consensus of recommendations for the diagnosis and management of pediatric obstructive sleep apnea., Methods: A two-iterative Delphi method questionnaire was used to formulate expert recommendations by the members of the International Pediatric Otolaryngology Group (IPOG)., Results: Twenty-six members completed the survey. Consensus recommendations (>90% agreement) are formulated for 15 different items related to the clinical evaluation, diagnosis, treatment, postoperative management and follow-up of children with OSA., Conclusion: The recommendations formulated in this IPOG consensus statement may be used along with existing clinical practice guidelines to improve the quality of care and to reduce variation in care for children with OSA., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To better characterize associations between Actinomyces and tonsillolith versus nontonsillolith tonsillectomy specimens., Study Design: Bi-institutional retrospective case-case study., Setting: University and county hospital., Subjects and Methods: Adult patients with a clinical history of tonsilloliths who underwent tonsillectomy from January 2006 to December 2018 were included. Patients undergoing tonsillectomy for tonsillar hypertrophy and chronic tonsillitis were identified as comparative cases. Similarly, patients with ipsilateral oropharyngeal cancer (OPC) who underwent contralateral tonsillectomy of a normal-appearing tonsil for prophylaxis against a second primary cancer were also included as comparative cases., Results: The study population comprised 134 patients who underwent tonsillectomy: 62 tonsillolith and 72 nontonsillolith (tonsillar hypertrophy, n = 30; chronic tonsillitis, n = 30; normal-appearing contralateral tonsil in patients with ipsilateral OPC, n = 12). Actinomyces was reported in 11% of the patients with tonsilloliths on initial pathology reports but in 95% after re-evaluation (n = 54 of 57). Actinomyces prevalence was significantly higher in patients with tonsilloliths as compared with patients with recurrent tonsillitis (73%, n = 22 of 30, P < .001) and normal-appearing contralateral tonsils in patients with ipsilateral OPC (58%, n = 7 of 12, P < .001). Actinomyces prevalence was not significantly different between patients with tonsilloliths and tonsillar hypertrophy (83%, n = 25 of 30, P = .11)., Conclusion: The prevalence of Actinomyces in tonsillolith tonsil specimens is high; however, Actinomyces routinely colonizes nontonsillolith tonsil specimens. Therefore, Actinomyces is unlikely to be the primary driver of tonsillolith pathogenesis, and Actinomyces- targeted treatment of tonsilloliths may not be effective. Treatment strategies addressing tonsilloliths should be further investigated.

Objective: To evaluate for differences in time to decannulation and survival rates for pediatric tracheotomy patients based on ventilator status upon discharge., Study Design: Retrospective longitudinal cohort study., Methods: A single-institution longitudinal study of pediatric tracheostomy patients was conducted. Patients were categorized based on mechanical ventilation status on discharge and principal reason for tracheostomy. Survival rates were determined using the Kaplan-Meier method. The Wilcoxon's Rank Sum test and Cox regression analysis evaluated differences in survival times and time to decannulation based on primary indication for tracheotomy and ventilation status., Results: Chart review identified 305 patients who required a tracheostomy under the age of 3. The median age at the time of tracheotomy was 5.2 months. The indications for tracheotomy in these patients were airway obstruction in 145 (48%), respiratory failure in 214 (70%), and pulmonary toilet in 10 (3.3%). Seventy-nine percent of patients were ventilator dependent at discharge. At the conclusion of the study period, 55% of patients were alive with tracheostomy in place, 30% patients were decannulated, and 15% patients were deceased. Patients with ventilator dependence at initial discharge, bronchopulmonary dysplasia, or airway obstruction were more likely to be decannulated. Hispanic patients were less likely to be decannulated. Patients had an equal probability of death regardless of ventilator status at discharge., Conclusions: This study demonstrated that the time to decannulation and likelihood of decannulation varies based on the indication for the tracheostomy. The majority of patients with a tracheostomy were not decannulated at the conclusion of this study. Median time to decannulation was 2.5 years for patients with a median death time of 6 months., Level of Evidence: 2b Laryngoscope, 130:2319-2324, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Local adaptation is an important process in plant evolution, which can be impacted by differential pathogen pressures along environmental gradients. However, the degree to which pathogen resistance loci vary in effect across space and time is incompletely described. To understand how the genetic architecture of resistance varies across time and geographic space, we quantified rust (Puccinia spp.) severity in switchgrass (Panicum virgatum) plantings at eight locations across the central USA for 3 yr and conducted quantitative trait locus (QTL) mapping for rust progression. We mapped several variable QTLs, but two large-effect QTLs which we have named Prr1 and Prr2 were consistently associated with rust severity in multiple sites and years, particularly in northern sites. By contrast, there were numerous small-effect QTLs at southern sites, indicating a genotype-by-environment interaction in rust resistance loci. Interestingly, Prr1 and Prr2 had a strong epistatic interaction, which also varied in the strength and direction of effect across space. Our results suggest that abiotic factors covarying with latitude interact with the genetic loci underlying plant resistance to control rust infection severity. Furthermore, our results indicate that segregating genetic variation in epistatically interacting loci may play a key role in determining response to infection across geographic space., (© 2020 The Authors. New Phytologist © 2020 New Phytologist Trust.)

Objectives/hypothesis: Bronchopulmonary dysplasia (BPD) and invasive respiratory support is increasing among extremely preterm neonates. Yet, it is unclear if there is a corresponding increase in tracheostomies. We hypothesize that in extremely preterm neonates with BPD, the incidence of tracheostomy has increased., Study Design: Retrospective cross-sectional analysis., Methods: We analyzed the 2006 to 2012 Kids' Inpatient Databases (KID) for hospital discharges of nonextremely preterm neonates (gestational age >28 weeks and <37 weeks or birth weight >1,500 g) and extremely preterm neonates (gestational age ≤28 weeks or birth weight ≤1,500 g). We studied tracheostomy placement trends in these two populations to see if they are increasing among extremely preterm neonates, especially those with BPD., Results: The study included 1,418,681 preterm neonates (52% male, 50% white, 19% black, 20% Hispanic, 4.2% Asian), of whom 118,676 (8.4%) were extremely preterm. A total of 2,029 tracheostomies were performed, of which 803 (0.68%) were in extremely preterm neonates. The estimated percent change of occurrence of extremely preterm neonates with BPD increased 17% between 2006 and 2012, and tracheostomy placement increased 31%. Amongst all who received tracheostomies, mortality rate was higher in extremely preterm neonates compared to nonextremely preterm neonates (18% vs. 14%, P = .05). However, in extremely preterm neonates, those with tracheostomies had a lower mortality rate compared to those without (18% vs. 24%, P = .002)., Conclusions: Extremely preterm neonates, compared to nonextremely preterm neonates, experienced a marked increase in tracheostomies placed from 2006 to 2012 as well as an increased incidence of BPD, confirming our primary study hypothesis., Level of Evidence: 4 Laryngoscope, 130: 2056-2062, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Heart rate variability (HRV), a noninvasive indicator of autonomic regulation of cardiac rhythm, may represent the physiologic burden of obstructive sleep apnea (OSA). We hypothesized that the treatment-related effects of OSA on HRV in children are causally attributable to the improvement in OSA severity., Study Design: Secondary analysis of outcomes from the Childhood Adenotonsillectomy Trial (CHAT)., Setting: Analysis of database., Subjects and Methods: Time- and frequency-domain HRV parameters along with polysomnographic (PSG) and demographic variables were obtained from the CHAT study, which compared early adenotonsillectomy (eAT) to watchful waiting (WW) in children with OSA. The relative contributions of PSG variables and covariates to each HRV parameter were quantified. The proportion of changes in HRV parameters causally attributable to changes in OSA severity, measured by the apnea-hypopnea index (AHI) and oxygen desaturation index (ODI), was estimated., Results: In total, 404 children aged 5 to 10 years were included. The median (interquartile range) age was 6 (3-9) years. The median body mass index percentile was 82 (53), 195 (48%) children were male, and 147 (36%) were African American. The average heart rate during PSG was the strongest independent predictor of each HRV parameter ( P < .001). Although eAT resulted in statistically significant changes in the majority of HRV parameters, these effects were not causally attributable to treatment-related changes in AHI or ODI., Conclusions: The average heart rate strongly modulates HRV in children with OSA. Although eAT results in discernible changes in HRV, it appears to not be causally attributable to specific treatment-related changes in AHI or ODI.

Objectives: Recent evidence suggests that children with mental health disorders are more likely to have postoperative complications. Our aim was to determine if mental health disorders affect postoperative complications after tonsillectomy with or without adenoidectomy (T&A)., Setting: Cross-sectional analysis of national databases., Subjects and Methods: The 2006 to 2016 Kids Inpatient Database and the 2014 Nationwide Readmission Database were used to identify children (age <21 years) who underwent T&A. We compared children with mental health disorders (eg, autism, developmental delays, or mood disorders) to those without a mental health disorder. We contrasted gender, race, length of stay, complications, and 30-day readmissions., Results: We estimated that 37,386 children underwent T&A, and there were 2138 (5.7%) diagnosed with a mental health disorder. Children with mental health disorders were older (6.0 vs 5.3 years, P < .001), more commonly males (64% vs 58%, P < .001), had a longer length of stay (3.4 days vs 2.3 days, P < .001), and had higher total charges even after controlling for length of stay ($19,000 vs $14,000, P < .001). Children with a mental health disorder were more likely to have a complication (odds ratio [OR] = 2.1; 95% confidence interval [CI], 1.7 to 3.4; P < .001) including intubation, mechanical ventilation, or both (OR = 3.3; 95% CI, 2.6 to 3.8; P < .001). The 30-day all-cause readmission rate was higher (12% vs 4.0%, P < .001)., Conclusion: Children with mental health disorders, especially development delays, have more frequent complications, longer lengths of stay, and readmissions than children without mental health disorders. This information should be included in preoperative counseling.

Objectives/hypothesis: To evaluate a cohort of obese adolescents with obstructive sleep apnea (OSA) to determine if increased yearly weight gain was a predictor of severe OSA., Study Design: Retrospective cohort study., Methods: Obese adolescents (body mass index percentile >95% for that age and sex based upon the Centers for Disease Control and Prevention weight classifications), ages 12 to 17 years, referred for full night polysomnography (PSG) were analyzed. We examined demographics, weight classifications, yearly weight gain from age 9 years onward, PSG data (apnea-hypopnea index), and tonsil size. We performed a mixed-effect linear regression model to test whether the velocity of weight gain was increased in obese patients with severe OSA when compared to those without severe OSA., Results: This study included 166 obese adolescents, 105 with and 61 without severe OSA. The average age was 14 years and was predominately male (57%) and Hispanic (44%). The regression analysis found that the yearly change in weight among obese adolescents with severe OSA was significantly higher than those without (B = 1.4, standard error = 0.50, P = .005, 95% confidence interval: 0.42-2.4). For the group with severe OSA, weight increased 6.5 kg every year before their PSG, whereas for those without, weight increased 5.1 kg per year., Conclusions: The rate of weight gain over time is an important predictor of severe OSA in obese adolescents., Level of Evidence: 3b Laryngoscope, 130:1339-1342, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Introduction: Mild obstructive sleep-disordered breathing (oSDB), characterised by habitual snoring without frequent apnoeas and hypopnoeas on polysomnography, is prevalent in children and commonly treated with adenotonsillectomy (AT). However, the absence of high-level evidence addressing the role of AT in improving health and behavioural outcomes has contributed to significant geographical variations in care and potential for surgery to be both overused and underused., Methods and Analysis: The Pediatric Adenotonsillectomy Trial for Snoring (PATS) is a single-blinded, multicentre randomised controlled trial designed to evaluate the effect of AT in treating mild oSDB. Four hundred sixty eligible children, aged 3.0-12.9 years old, will be randomised to either early adenotonsillectomy or to watchful waiting with supportive care (WWSC) with a 1:1 ratio. The study's coprimary endpoints are (1) change from baseline in executive behaviour relating to self-regulation and organisation skills as measured by the Behavioural Rating Inventory of Executive Function (BRIEF) Global Composite Score (GEC); and (2) change from baseline in vigilance as measured on the Go-No-Go (GNG) signal detection parameter (d-prime). A mixed effects model will be used to compare changes in the BRIEF GEC score and GNG score at 6 and 12 months from baseline between the AT arm and the WWSC arm., Ethics and Dissemination: The study protocol was approved by the institutional review board (IRB) at Children's Hospital of Philadelphia (CHOP) on 3 October 2014 (14-0 11 214). The approval of CHOP as the central IRB of record was granted on 29 February 2016. The results will be published in peer-reviewed journals and presented at academic conferences. The data collected from the PATS study will be deposited in a repository (National Sleep Research Resource, sleepdata.org) after completion of the study to maximise use by the scientific community., Trial Registration Number: NCT02562040; Pre-results., Competing Interests: Competing interests: JPB is a full-time employee of Philips, a company that focuses on sleep and respiratory care. JPB also has a part-time appointment at Brigham and Women’s Hospital. JPB's interests have been reviewed and are managed by BWH and Partners HealthCare in accordance with their conflict of interest policies. RDC reports service on the boards of the American Academy of Sleep Medicine, Associated Professional Sleep Societies, American Board of Sleep Medicine, American Academy of Sleep Medicine Foundation, International Paediatric Sleep Association and the not-for-profit Sweet Dreamzzz. He serves as an author and editor for UpToDate. FH has received research funding from Jazz pharmaceuticals and is a consultant for Biogen (Spinraza); none is relevant to this manuscript. CLR is a member of the American Academy of Medicine and the American Academic of Sleep Medicine Foundation Board of Directors. She has received institutional research funding from Jazz Pharmaceuticals and from Flamel (Avadel) Pharmaceuticals unrelated to the submitted work. KR reports non-financial support from Boehringer Ingelheim, grants and non-financial support from TEVA, non-financial support from GSK, non-financial support from Merck, grants from Flamel, grants from Jazz and grants from Astra Zeneca outside the submitted work. SR received institutional grants from Jazz Pharmaceuticals and consulting fees from Jazz Pharmaceuticals and Respicardia., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)