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Schild SD, Magge HN, Behzadpour HK, Mantilla-Rivas E, Afsar NM, Rana MS, Manrique M, Oh AK, Reilly BK. Impact of upper airway obstruction management in Robin Sequence on need for myringotomy tubes. Int J Pediatr Otorhinolaryngol 2024; 180:111964. [PMID: 38714046 DOI: 10.1016/j.ijporl.2024.111964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/12/2024] [Accepted: 05/03/2024] [Indexed: 05/09/2024]
Abstract
OBJECTIVE Investigate an association between upper airway obstruction (UAO) management in Robin Sequence (RS) and need for bilateral myringotomy and tubes (BMT). METHODS Retrospective chart review of RS patients treated at a tertiary free-standing pediatric hospital from 1995 to 2020 was performed. Patients were grouped based on airway management: conservative, tracheostomy, tongue-lip adhesion (TLA), and mandibular distraction osteogenesis (MDO). Demographic data, cleft palate (CP) association, numbers of BMT and ear infections, and audiogram data including tympanograms were collected. One-way ANOVA and Chi-square/Fisher's exact tests were used to compare continuous and categorical data, respectively. Multivariable regression analysis was used to compare BMT rates between treatment groups. RESULTS One hundred forty-eight patients were included, 70.3 % of which had CP. Most patients (67.6 %) had at least one BMT; 29.1 % required two or more BMT. The rate of BMT was higher in patients with CP compared to those with intact palates (p = 0.003; 95 % CI 1.30-3.57) and those treated with tracheostomy (p = 0.043; 95 % CI 1.01, 2.27). Surgically managed patients were more likely to have hearing loss (67.5 % vs. 35.3 %, p = 0.017) and ear infections (42.1 % vs. 20.0 %, p = 0.014) pre-compared to post-procedure for airway management. CONCLUSION Most RS patients require at least 1 set of BMT. Those with CP and/or treated with tracheostomy had a higher likelihood of needing BMT. Rate of hearing loss and ear infection was higher in surgically managed RS patients. Patients with RS and overt CP require a statistically higher number of BMTs compared to those with either submucous cleft palate or intact palate.
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Affiliation(s)
- Sam D Schild
- Division of Otolaryngology - Head and Neck Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Hari N Magge
- The George Washington University School of Medicine and Health Sciences, Washington. D.C, USA
| | - Hengameh K Behzadpour
- Division of Otolaryngology - Head and Neck Surgery, Children's National Hospital, Washington. D.C, USA
| | - Esperanza Mantilla-Rivas
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington. D.C, USA
| | - Nina M Afsar
- The George Washington University School of Medicine and Health Sciences, Washington. D.C, USA
| | - Md Sohel Rana
- Division of Surgery, Children's National Hospital, Washington. D.C, USA
| | - Monica Manrique
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington. D.C, USA
| | - Albert K Oh
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington. D.C, USA
| | - Brian K Reilly
- Division of Otolaryngology - Head and Neck Surgery, Children's National Hospital, Washington. D.C, USA.
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Lloyd AM, Behzadpour HK, Rana MS, Espinel AG. Factors associated with tracheostomy decannulation in infants with bronchopulmonary dysplasia. Int J Pediatr Otorhinolaryngol 2023; 175:111754. [PMID: 37847941 DOI: 10.1016/j.ijporl.2023.111754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 09/05/2023] [Accepted: 10/10/2023] [Indexed: 10/19/2023]
Abstract
OBJECTIVE Premature infants represent a unique subset of patients who may require tracheostomy. Bronchopulmonary dysplasia (BPD) is among one of the most common sequelae of prematurity contributing to the need for prolonged ventilation requiring tracheostomy after other airway options have been exhausted. Our objective is to understand socioeconomic barriers to decannulation and identify factors that accelerate safe decannulation, focusing on patients with BPD. METHODS An existing internal database from a tertiary pediatric hospital of patients undergoing tracheostomy prior to one year old was reviewed. Data from January 1, 2005 through December 31, 2020 was used to compare patients who were successfully decannulated to those who were not. A further subset of infants with BPD were identified and analyzed. Of those decannulated, survival analysis was used to identify factors associated with decreased time to decannulation. RESULTS We identified 303 infants who underwent tracheostomy at less than one year old with 125 of those infants having a diagnosis of BPD. Of the 125 infants with BPD, 44 (35.2 %) were decannulated and 81 (64.8 %) were not. There was no significant difference in sex, race, ethnicity, insurance status, comorbidities, or presence of syndromes between those patients with BPD who were decannulated and those who were not. Those who were not decannulated had a significantly longer length of hospital stay, prolonged ventilator requirements after tracheostomy, and were more likely to be discharged home on the ventilator (p = 0.030; 0.020; 0.002, respectively). Of the 44 decannulated patients, mean and median time to decannulation were 37.9 and 27.8 months respectively (range 10.8-160.6 months). There was an inverse association with decannulation and both Black race (HR: 0.30) and neurological comorbidity (HR: 0.37) on multivariate analysis. Black race, presence of syndrome, and length of ventilator dependence were significantly associated with increased time to decannulation. Time to decannulation from time off the ventilator was not significantly influenced by sex, race, ethnicity, state of residence, or insurance status, but was significantly influenced by age (95 % CI: -6.9, -0.1; P = 0.044). While time from discharge to first follow up visit did not significantly impact time to decannulation, every additional follow up visit increased time to decannulation by 3.78 months when adjusting for confounding variables. CONCLUSION In infants with BPD under one year requiring tracheostomy, socioeconomic factors were not found to influence likelihood of decannulation, however Black race, presence of underlying syndrome, and increased length of ventilator dependence were associated with prolonged timing. Children with more frequent follow up visits similarly had an increased time to decannulation, illustrating a vital point in the process. Ventilator weaning protocols and standardized decannulation protocols in patients with BPD, along with caregiver education, can safely expedite and facilitate decannulation.
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Affiliation(s)
- Ashley M Lloyd
- Division of Otolaryngology, George Washington University Hospital, Washington, DC, USA.
| | - Hengameh K Behzadpour
- Division of Pediatric Otolaryngology, Children's National Hospital, Washington, DC, USA
| | - Md Sohel Rana
- Department of Surgery, Children's National Hospital, Washington, DC, USA
| | - Alexandra G Espinel
- Division of Pediatric Otolaryngology, Children's National Hospital, Washington, DC, USA
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Glick AF, Farkas JS, Magro J, Shah AV, Taye M, Zavodovsky V, Rodriguez RH, Modi AC, Dreyer BP, Famiglietti H, Yin HS. Management of Discharge Instructions for Children With Medical Complexity: A Systematic Review. Pediatrics 2023; 152:e2023061572. [PMID: 37846504 PMCID: PMC10598634 DOI: 10.1542/peds.2023-061572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 10/18/2023] Open
Abstract
CONTEXT Children with medical complexity (CMC) are at risk for adverse outcomes after discharge. Difficulties with comprehension of and adherence to discharge instructions contribute to these errors. Comprehensive reviews of patient-, caregiver-, provider-, and system-level characteristics and interventions associated with discharge instruction comprehension and adherence for CMC are lacking. OBJECTIVE To systematically review the literature related to factors associated with comprehension of and adherence to discharge instructions for CMC. DATA SOURCES PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, Web of Science (database initiation until March 2023), and OAIster (gray literature) were searched. STUDY SELECTION Original studies examining caregiver comprehension of and adherence to discharge instructions for CMC (Patient Medical Complexity Algorithm) were evaluated. DATA EXTRACTION Two authors independently screened titles/abstracts and reviewed full-text articles. Two authors extracted data related to study characteristics, methodology, subjects, and results. RESULTS Fifty-one studies were included. More than half were qualitative or mixed methods studies. Few interventional studies examined objective outcomes. More than half of studies examined instructions for equipment (eg, tracheostomies). Common issues related to access, care coordination, and stress/anxiety. Facilitators included accounting for family context and using health literacy-informed strategies. LIMITATIONS No randomized trials met inclusion criteria. Several groups (eg, oncologic diagnoses, NICU patients) were not examined in this review. CONCLUSIONS Multiple factors affect comprehension of and adherence to discharge instructions for CMC. Several areas (eg, appointments, feeding tubes) were understudied. Future work should focus on design of interventions to optimize transitions.
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Affiliation(s)
| | | | - Juliana Magro
- Health Sciences Libraries, NYU Langone Health, New York, New York
| | | | | | | | | | - Avani C. Modi
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | | | - H. Shonna Yin
- Department of Pediatrics
- Department of Population Health, NYU Langone Health, New York, New York
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Killien EY, Grassia KL, Butler EK, Mooney SJ, Watson RS, Vavilala MS, Rivara FP. Variation in tracheostomy placement and outcomes following pediatric trauma among adult, pediatric, and combined trauma centers. J Trauma Acute Care Surg 2023; 94:615-623. [PMID: 36730091 PMCID: PMC10038845 DOI: 10.1097/ta.0000000000003848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Tracheostomy placement is much more common in adults than children following severe trauma. We evaluated whether tracheostomy rates and outcomes differ for pediatric patients treated at trauma centers that primarily care for children versus adults. METHODS We conducted a retrospective cohort study of patients younger than 18 years in the National Trauma Data Bank from 2007 to 2016 treated at a Level I/II pediatric, adult, or combined adult/pediatric trauma center, ventilated >24 hours, and who survived to discharge. We used multivariable logistic regression adjusted for age, insurance, injury mechanism and body region, and Injury Severity Score to estimate the association between the three trauma center types and tracheostomy. We used augmented inverse probability weighting to model the likelihood of tracheostomy based on the propensity for treatment at a pediatric, adult, or combined trauma center, and estimated associations between trauma center type with length of stay and postdischarge care. RESULTS Among 33,602 children, tracheostomies were performed in 4.2% of children in pediatric centers, 7.8% in combined centers (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.20-1.81), and 11.2% in adult centers (aOR, 1.81; 95% CI, 1.48-2.22). After propensity matching, the estimated average tracheostomy rate would be 62.9% higher (95% CI, 37.7-88.1%) at combined centers and 85.3% higher (56.6-113.9%) at adult centers relative to pediatric centers. Tracheostomy patients had longer hospital stay in pediatric centers than combined (-4.4 days, -7.4 to -1.3 days) or adult (-4.0 days, -7.2 to -0.9 days) centers, but fewer children required postdischarge inpatient care (70.1% pediatric vs. 81.3% combined [aOR, 2.11; 95% CI, 1.03-4.31] and 82.4% adult centers [aOR, 2.51; 95% CI, 1.31-4.83]). CONCLUSION Children treated at pediatric trauma centers have lower likelihood of tracheostomy than children treated at combined adult/pediatric or adult centers independent of patient or injury characteristics. Better understanding of optimal indications for tracheostomy is necessary to improve processes of care for children treated throughout the pediatric trauma system. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Elizabeth Y. Killien
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Kalee L. Grassia
- Department of Pediatric Critical Care Medicine, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Elissa K. Butler
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Department of Surgery, University of Montreal, Montreal, Quebec, Canada
| | - Stephen J. Mooney
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - R. Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
| | - Monica S. Vavilala
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Frederick P. Rivara
- Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, USA
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, WA
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, WA
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Sullivan GA, Sincavage J, Reiter AJ, Hu AJ, Rangel M, Smith CJ, Ritz EM, Shah AN, Gulack BC, Raval MV. Disparities in Utilization of Same-Day Discharge Following Appendectomy in Children. J Surg Res 2023; 288:1-9. [PMID: 36934656 DOI: 10.1016/j.jss.2023.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/12/2023] [Accepted: 02/18/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Disparities in the delivery of pediatric surgical care exist for racial and ethnic minority groups. Utilization of same-day discharge (SDD) following appendectomy for acute, uncomplicated appendicitis is increasing; however, rates among diverse populations have not been explored to evaluate equitable care delivery and healthcare utilization. Our objective was to determine whether race and ethnicity are associated with rates of SDD and postdischarge healthcare utilization. We hypothesized that racial and ethnic minority groups would have lower rates of SDD. METHODS This retrospective cohort study used data from the 2015-2019 American College of Surgeons National Surgical Quality Improvement Program-Pediatric clinical registry and included children who underwent appendectomy. Patients with complicated appendicitis were excluded. Primary exposure was racial or ethnic group. The primary outcome was SDD, and secondary outcomes included postdischarge emergency department visits and hospital readmissions. RESULTS Of 37,579 simple appendicitis patients, SDD after appendectomy occurred in 10,012 (26.6%). On multivariable analysis, Black or African American race was associated with lower likelihood of SDD (adjusted odds ratio [aOR]: 0.85; 95% confidence interval [95% CI]:0.79-0.92; P < 0.0001). Hispanic ethnicity was associated with higher likelihood of SDD (aOR: 1.19; 95% CI: 1.12-1.25; P < 0.0001). Likelihood of postoperative emergency department visits was higher in Black or African American patients (aOR: 1.36; 95% CI: 1.14-1.62; P < 0.001) and Hispanic patients (aOR: 1.37; 95% CI: 1.12-1.58; P < 0.0001). Hospital readmission rates were similar across groups. CONCLUSIONS Rates of SDD following appendectomy vary among racial and ethnic groups. Interventions to achieve equitable healthcare delivery including SDD after appendectomy are needed.
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Affiliation(s)
- Gwyneth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - John Sincavage
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Audra J Reiter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Andrew J Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Melissa Rangel
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Charesa J Smith
- Department of Surgery, University of Illinois Chicago, Chicago, Illinois
| | - Ethan M Ritz
- Rush Research Informatics Core, Rush University Medical Center, Chicago, Illinois
| | - Ami N Shah
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Brian C Gulack
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
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Omar M, Qatanani AM, Douglas NO, Nawash BS, Ibrahim T, Kaleem SZ, McKinnon BJ. Sociodemographic disparities in pediatric cochlear implantation outcomes: A systematic review. Am J Otolaryngol 2022; 43:103608. [PMID: 35988363 DOI: 10.1016/j.amjoto.2022.103608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine the impact of sociodemographic factors on post-operative performance outcomes among PCI recipients across the world. METHODS A qualitative systematic review of PubMed, Scopus, Web of Science, and Embase was undertaken for studies analyzing the association of sociodemographic factors with measures of PCI outcomes published before July 18, 2021. Study quality assessment tools from the National Institutes of Health (NIH) were used to assess for risk of bias. RESULTS Out of 887 unique abstracts initially retrieved, 45 papers were included in the final qualitative systematic review. Sociodemographic disparities in PCI outcomes from 4702 PCI recipients were studied in 19 countries, with 14 studies conducted in the United States of America, published within the years of 1999 to 2021. Parental education and socioeconomic status (e.g. income) were the most investigated disparities in PCI outcomes with 24 and 17 identified studies, respectively. CONCLUSION Socioeconomic status was a consistently reported determinant of PCI outcomes in the USA and elsewhere, and parental education, the most reported disparity, consistently impacted outcomes in countries outside the USA. This study is limited by our inability to perform a meta-analysis given the lack of standardization across measures of sociodemographic variables and assessment measures for PCI outcomes. Future studies should address the literature gap on racial and ethnic disparities among PCI outcomes and use standardized measures for sociodemographic variables and PCI outcomes to facilitate meta-analyses on the topic. Targeting the mechanisms of these disparities may mitigate the impact of the sociodemographic factors on PCI outcomes.
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