Pediatric Postoperative Outcomes for Severe and Very Severe Obstructive Sleep Apnea Syndrome

OBJECTIVE

To determine if increasing obstructive sleep apnea syndrome (OSAS) severity, as determined by preoperative polysomnography data, is an independent risk for respiratory complications and level of follow-up care after adenotonsillectomy or tonsillectomy.

METHODS

A retrospective analysis of patients ≤21 years of age with severe OSAS (obstructive apnea-hypopnea index [OAHI] >10) undergoing adenotonsillectomy or tonsillectomy. Patients were categorized based on preoperative polysomnography data (PSG). Outcome measures including respiratory complications were collected via chart review. Logistic regression was used in the analysis of all parameters, and Wilcoxon Rank Sum tests were used for analysis of both OAHI and oxygen saturation nadir as continuous variables. All surgeries were performed at Johns Hopkins Hospital, a tertiary care center.

RESULTS

We identified 358 patients with severe OSAS who had adenotonsillectomy or tonsillectomy. OAHI >40 and oxygen saturation nadir <80% were significantly associated with postoperative respiratory complications. Increasing OAHI and O2 saturation <80% was each associated with unplanned continuous positive airway pressure (CPAP) initiations postoperatively. There was no association between hypercarbia and presence of any complications.

CONCLUSION

Patients with very severe OSAS (preoperative OAHI ≥40) as determined by preoperative PSG may be at higher risk of developing respiratory complications postoperatively. However, there does not appear to be a linear association with increasing severity of OAHI on regression analysis. Further research is needed to understand factors associated with complications in severe and very severe OAHI.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Remote ultrasound diagnostics disrupting traditional military frontline healthcare delivery

Accurate and reliable diagnostic capability is essential in deployed healthcare to aid decision-making and mitigate risk. This is important for both the patient and the deployed healthcare system, especially when considering the prioritisation of scarce aeromedical evacuation assets and frontline resources. Novel ultrasound tele-guidance technology presents a valuable diagnostic solution for remotely deployed military clinicians. This report discusses the first use of a consultant radiologist guiding a clinician, untrained in ultrasound, to perform an ultrasound scan via a live tele-guidance feed in the deployed environment using the Butterfly iQ+ tele-guidance system. Distance scanning provided a diagnostic quality report when compared with locally performed imaging to improve patient care and maintain operational output. This example demonstrates feasibility of remote point-of-care imaging systems in provision of location-agnostic high-quality diagnostic capability. Future opportunities to develop care pathways using bedside tele-diagnostics will democratise access, drive efficiency and improve patient care experience and outcomes.

Assessing the utility of head computed tomography in the role 2 hospital setting on operation TRENTON

Operation TRENTON was the British government’s humanitarian contribution to the United Nations Mission in South Sudan. This included the Bentiu-based role 2 medical facility, deployed to provide medical support to approximately 2000 UN peacekeepers and UN staff in the region of the country’s largest Protection of Civilian camps. A portable CT brain scanner was installed due to concern over the risk of head injuries and the extended clinical timelines. We provide a short reflection on the utility of this imaging capability in the deployed role 2 environment.

Combat Application Tourniquet fares well in a chemical, biological, radiological or nuclear dress state

INTRODUCTION

There is a need for a military tourniquet to control catastrophic haemorrhage in a chemical, biological, radiological or nuclear (CBRN) threat environment. No published data exist as to the efficacy of tourniquets while wearing British military CBRN individual protective equipment (IPE).

METHODS

12 volunteers from the counter CBRN instructors' course allowed testing on 24 legs. A Combat Application Tourniquet (C-A-T) was applied to all volunteers at the level of the midthigh. 12 legs were tested while wearing CBRN IPE (both operator and simulated casualty), and the control group of 12 legs was tested while wearing conventional combat dress state (both operator and simulated casualty). The order of leg laterality and dress state were sequenced according to a prerandomised system. Efficacy was measured via use of an ultrasound probe at the popliteal artery. Tourniquets were considered effective if arterial flow was completely occluded on ultrasound imaging. Data were collected on time to successful application, failure of tourniquets and pain scores as rated by the visual analogue scale (1-10).

RESULTS

There were no failures of tourniquet application in the CBRN group, and two failures (17%) in the control group. Failures were pain threshold exceeded (n=1) and tourniquet internal strap failure (n=1). The mean application time for the CBRN group was 28.5 s (SD 11.7) and 23.7 s (SD 9.8) for the conventional combat group. There was no statistically significant difference (p=0.27). The median CBRN pain score was 2.0 (IQR 2.0-3.5). The median control pain score was 4.0 (IQR 3-6). This was a statistically significant difference (p=0.002).

CONCLUSION

C-A-Ts applied to simulated casualties in CBRN IPE at the midthigh are at least as efficacious as those applied to the midthigh in a conventional combat dress state. The pain experienced was less in CBRN IPE than when in a conventional combat dress state.

Abstract P3-10-12: ERBB2 copy number analysis of invasive breast carcinoma using digital droplet PCR and targeted next-generation sequencing: A focus on 'non-classical' HER2 FISH groups using the 2018 ASCO/CAP HER2 testing guideline

Background: Non-classical HER2 FISH results were recently reclassified in the 2018 HER2 guidelines update, and concurrent IHC testing was recommended as part of additional workup to determine the final HER2 status in these groups. In this study, we explored the genomic landscape of HER2 FISH groups using digital droplet PCR (ddPCR) and targeted next-generation sequencing (NGS) on invasive breast carcinomas.

Methods: Fifty-one clinical samples with HER2 FISH and IHC results were included in our analysis and classified into FISH groups based on the updated 2018 ASCO/CAP HER2 testing guideline: (i) Group 1A with ratio ≥2 and signals/cell ≥6, (ii) Group 1B with ratio ≥2 and signals/cell ≥4 and &lt;6, (iii) Group 2 with ratio ≥2 and signals/cell &lt;4, (iv) Group 3 with ratio &lt;2 and signals/cell ≥6, (v) Group 4 with ratio &lt;2 and signals/cell ≥4 and &lt;6, and (vi) Group 5 with ratio &lt;2 and signals/cell &lt;4. Formalin-fixed paraffin-embedded samples were analyzed using two ddPCR assays each targeting an exon in the ERBB2 tyrosine kinase domain (exon 19 and 21, respectively) and a 130-gene NGS-based assay. For ddPCR, ERBB2 amplification status was determined from ddPCR ratios by using a recently published algorithm (Otsuji et al. 2017). For targeted NGS, ERBB2 amplification was called when copy number gains were detected in the majority of exons in ERBB2 (&gt;50% of exons).

Results: Mean ddPCR ratios varied amongst the different FISH groups (P &lt; 0.0001). As expected, patients with Group 1A had the highest mean ddPCR ratios compared to those with other FISH findings (P &lt; 0.0001). Furthermore, there was a correlation between ERBB2 ddPCR ratios and HER2 FISH ratios (ρe19 = 0.4435, P = 0.001 and ρe21 = 0.4644, P = 0.0006). Using ddPCR, ERBB2 amplifications were detected in all classically amplified Group 1A cases (5/5) and in none of the classically non-amplified Group 5 cases (0/12). Interestingly, ddPCR assays called ERBB2 amplification in four cases with non-classical results: one in Group 2 (1/6), two in Group 3 (2/6), and one in Group 4 (1/17), including two cases in Groups 3 and 4 which also showed concomitant HER2 overexpression by IHC (3+). Similarly, targeted NGS revealed ERBB2 amplification in all Group 1A cases (5/5) and in none of the Group 5 cases (0/12). Furthermore, NGS detected amplification in three non-classical cases: one in Group 1B (1/5), one in Group 3 (1/6), and one in Group 4 (1/17), including one case in Group 1B which was not called amplified by ddPCR. Notably, the three cases with amplification by NGS were the only three cases in the non-classical groups with HER2 overexpression by IHC. Overall, there was a strong concordance between ERBB2 amplification status by ddPCR/NGS and HER2 overexpression by IHC (κe19 = 0.79, κe21 = 0.92, κNGS = 1.0).

Conclusion: ERBB2 amplification using ddPCR and NGS is correlated with HER2 overexpression in both classical and non-classical FISH groups, thus providing genomic evidence to support the recent recommendation for concurrent IHC testing in cases with unusual FISH results. Our findings also highlight a potential role of ddPCR and targeted NGS in the workup of challenging HER2 cases.

Citation Format: Yang S-R, Bouhlal Y, De La Vega FM, Ballard M, West RB, Sibley RK, Kuo CJ, Vilborg A, Allison KH. ERBB2 copy number analysis of invasive breast carcinoma using digital droplet PCR and targeted next-generation sequencing: A focus on 'non-classical' HER2 FISH groups using the 2018 ASCO/CAP HER2 testing guideline [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-10-12.

Military assistance to the civil authority: medical liaison with the Manchester clinicians after the Arena bombing

UK Defence Medical Services’ personnel have experienced an intense exposure to patients injured during war over the last decade and a half. As some bitter lessons of war surgery were relearned and innovative practices introduced, outcomes for patients impr oved consistently as experience accumulated. The repository of many of the enduring lessons learnt at the Role 4 echelon of care remain at the Queen Elizabeth Hospital Birmingham (QEHB), with the National Health Service and Defence Medical Services personnel who treated the returning casualties. On 22 May 2017, a terrorist detonated an improvised explosive device at the Manchester Arena, killing 22 and wounding 159 people. In the aftermath of the event, QEHB was requested to provide support to the Manchester clinicians and teleconferencing and then two clinical visits were arranged. This short report describes the nature of the visits, outlines the principles of Military Aid to the Civil Authority and looks to the future role of the Defence Medical Services in planning and response to UK terrorism events.

The Combat Application Tourniquet Versus the Tactical Mechanical Tourniquet

BACKGROUND

Exsanguination from limb injury is an important battlefield consideration that is mitigated with the use of emergency tourniquets. The Combat Application Tourniquet (C-A-T®) is the current British military standard tourniquet.

METHODS

We tested the self-application of a newer tourniquet system, the Tactical Mechanical Tourniquet (TMT), against self-application of the C-A-T. A total of 24 healthy British military volunteers self-applied the C-A-T and the TMT to their mid thigh in a randomized, sequential manner. Popliteal artery flow was monitored with a portable ultrasound machine, and time until arterial occlusion was measured. Pain scores were also recorded. Results The volunteers allowed testing on their lower limbs (n = 48 legs). The C-A-T was applied successfully to 22 volunteers (92%), and the TMT was successfully applied to 17 (71%). Median time to reach complete arterial occlusion was 37.5 (interquartile range [IQR], 27-52) seconds with the C-A-T, and 35 (IQR, 29-42) seconds with the TMT. The 2.5-second difference in median times was not significant (ρ = .589). The 1-in-10 difference in median pain score was also not significant (ρ = .656). The success or failure of self-application between the two tourniquet models as assessed by contingency table was not significant (p= .137).

CONCLUSION

The TMT is effective when self-applied at the mid thigh. It does not offer an efficacy advantage over the C-A-T.

Periodically varying externally imposed environmental effects on population dynamics

Effects of externally imposed periodic changes in the environment on population dynamics are studied with the help of a simple model. The environmental changes are represented by the temporal and spatial dependence of the competition terms in a standard equation of evolution. Possible applications of the analysis are on the one hand to bacteria in Petri dishes and on the other to rodents in the context of the spread of the Hantavirus epidemic. The analysis shows that spatiotemporal structures emerge, with interesting features which depend on the interplay of separately controllable aspects of the externally imposed environmental changes.

Impact of prenatal care with reduced frequency of visits in a residency teaching program

OBJECTIVE

To determine if decreasing the number of prenatal visits for routine obstetric patients affects pregnancy outcome.

STUDY DESIGN

A historical control study was designed to include 734 deliveries from January 1 to December 31, 1991, in women who had prenatal care per American College of Obstetricians and Gynecologists Committee Opinion no. 79, January 1990, guidelines for uncomplicated obstetric care. A prospective study cohort of women with 711 deliveries from January 1 to December 31, 1994, underwent prenatal care with modified guidelines to include: first visit at 6-12 weeks to confirm dating and obtain initial laboratory data, second visit at 16-20 weeks to obtain maternal serum alpha-fetoprotein screening, third visit at 24-28 weeks for 28-week laboratory data, fourth visit at 32 weeks, fifth visit at 36 weeks, sixth visit at 38 weeks, seventh visit at 40 weeks and weekly thereafter. Pregnancy outcomes included estimated fetal weight, gestational age at delivery, preeclampsia, Apgar score at one and five minutes and delivery mode. Neonatal outcomes, including stillbirth rate, preterm delivery rate, intraventricular hemorrhage rate, bronchopulmonary dysplasia and neonatal mortality, were evaluated.

RESULTS

There were no statistically significant differences in perinatal or neonatal outcomes with decreased prenatal visits from an average of 12 per pregnancy to 8.

CONCLUSION

Prenatal visits can be decreased in a teaching hospital in women with uncomplicated pregnancies from the standard number, 12-14 visits, to an average of 7 or 8 per patient without adverse perinatal outcomes.

Disturbance of cerebral function in people exposed to drinking water contaminated with aluminium sulphate: retrospective study of the Camelford water incident

OBJECTIVE

To establish whether people exposed to drinking water contaminated with 20 tonnes of aluminium sulphate in the Camelford area of Cornwall in the south west of England in July 1988 had suffered organic brain damage as opposed to psychological trauma only.

DESIGN

Retrospective study of affected people.

PARTICIPANTS

55 affected people and 15 siblings nearest in age to one of the group but who had not been exposed to the contaminated water were studied.

MAIN OUTCOME MEASURES

Various clinical and psychological tests to determine medical condition and anxiety levels in affected people. Assessment of premorbid IQ (pFSIQ) with the national adult reading test, a computerised battery of psychomotor testing, and measurement of the difference in latencies between the flash and pattern visual evoked potentials in all participants.

RESULTS

The mean (SE) pFSIQ was above average at 114.4 (1.1). The most sensitive of the psychomotor tests for organic brain disease was the symbol digit coding (SDC) test (normal score 100, abnormal <85). PARTICIPANTS performed less well on this test (54.5 (6.0)) than expected from their pFSIQ (P<0.0001) and a little less poorly on the averaged less discriminating tests within the battery (86.1 (2.5), P<0.0001). In a comparison with the 15 sibling pairs (affected people's age 41.0 (3.3) years v sibling age of 42.7 (3.1) years (P=0.36) the exposed people had similar pFSIQ (114.7 (2.1)) to their siblings (116.3 (2.1), (P=0.59) but performed badly on the symbol digit coding test (51.8 (16.6)) v (87.5 (4.9) for siblings, P=0.03). The flash-pattern differences in exposed people were greater than in 42 unrelated control subjects of similar age (27.33 (1.64) ms v 18. 57 (1.47) ms, P=0.0002). The 15 unexposed siblings had significantly better flash-pattern differences than their affected siblings (13.4 (2.4) ms v 29.6 (2.9) ms, P=0.0002). No effect of anxiety could be shown on these measurements from the analysis of the anxiety scores of exposed people.

CONCLUSION

People who were exposed to the contaminated water at Camelford suffered considerable damage to cerebral function, which was not related to anxiety. Follow up studies would be required to determine the longer term prognosis for affected individuals.

Individual differences in preschoolers' physiological and verbal responses to videotaped angry interactions

Individual differences in selection of intensity of angry interactions and physiological and self-reported responses to interadult anger were examined in preschoolers (N = 34). Children watched two videotaped angry interactions between adults, while their heart rates and skin conductance responses and levels were monitored; then they were interviewed. Before the second argument, children were given the perceived choice of watching an intense or mild angry exchange. Individual differences in responding to the angry interactions were found. Both (a) children with relatively higher externalizing behavior problems and (b) boys who chose to watch intense anger had lower tonic heart rates; 80% of boys with externalizing problems chose to watch intense anger. Further, children who chose to watch intense anger (a) exhibited lower declines in heart rates upon the presentation of the argument, (b) perceived the actors as more angry, and (c) reported lower amounts of distress during the argument than those who chose mild anger.

Intraperitoneally injected cholecystokinin-octapeptide activates pica in rats

Cholecystokinin-octapeptide (CCK-8) was injected intraperitoneally into rats to see if it could cause them to eat kaolin (clay)--a pica behavior which has been shown to indicate gastric distress. In the first study, a single large dose of CCK-8 (20 micrograms/kg) failed to produce pica. In the second study, 4 smaller doses of CCK-8 (8 micrograms/kg), 30 min apart, produced significant ingestion of kaolin compared to the baseline condition of vehicle injections. The pica was comparable to that observed in another group of rats given a toxic dose of LiCl (127 mg/kg, IP). It is concluded that intraperitoneal injections of CCK-8 can induce a state of gastric distress in the rat.

Response to adults' angry behavior in children of alcoholic and nonalcoholic parents

Children from alcoholic (COAs) and nonalcoholic (NCOAs) homes (N = 35; M age = 8.02 years) were presented with videotaped segments of angry and friendly interactions matched for mode of expression of affect (verbal, indirect, nonverbal, destructive or constructive, and aggressive or affectionate) and were interviewed following each segment. Children perceived all forms of expression of anger as more negative and expressed more anger and distress in response to them. Angry adults also were perceived as having more negative feelings toward children than friendly adults. Whereas male NCOAs responded with more anger than female NCOAs, male COAs responded with less anger than female COAs. COAs more often proposed solutions to adults' interactions than NCOAs; this primarily reflected a higher rate of indirect responses intended to make others feel better. Finally, COA status and problem behaviors were associated, but analyses indicated that higher incidences of marital discord in the homes of COAs accounted for this relation.

Work therapy and return to work

In summary, data were selected for 1 year on patients treated in the Work Tolerance Program at the Hand Rehabilitation Center in Philadelphia. The type of information obtained has been used to obtain a profile of the patient population in the Work Tolerance Program. Statistical analysis was used, not only to formulate patient demographics, but also to evaluate the length of treatment of patients in the Work Tolerance Program. This period averaged 6 weeks. The statistical analysis also revealed there was significant interaction between the type of injury and the patient's diagnosis, and the rate of return to work. The patients with injuries to bone and nerve required longer periods of treatment until they returned to work than did patients with injuries to soft tissue or combination injuries. Our statistical analysis revealed that in 1982, 75 per cent of the patients in the Work Tolerance Program returned to work to regular or modified jobs. The length of time from injury to return to work was 63 per cent longer for patients with Workers' Compensation coverage than for patients with private insurance coverage. Because the statistical analysis that 60 per cent of the patients treated in the Work Tolerance Program were Workers' Compensation insured, and 80 per cent of the patients treated in the Work Tolerance Program were secondarily referred, it should be recognized that all patients with severe hand injuries would benefit from an immediate referral to a Hand Rehabilitation Center of excellence to facilitate their therapeutic management and expedite their recovery from time of injury to return to work. This study was restricted to the analysis of length of treatment and rate of return to work. Future studies should study the effect of early referral and the application of specific treatments.

Onchocerciasis in Sudan: the Abu Hamed focus

The current status of onchocerciasis in Abu Hamed, Northern Province, Sudan, was studied. Of 208 persons attending out-patient clinics in villages in this region, 71 were microfilariae-positive on skin snips or had palpable nodules. Microfilariae and worms in nodules were identified as Onchocerca volvulus. No microfilariae were seen in peripheral blood. Most nodules and microfilariae were found in the pelvic region, but the intensity of infection was uniformly low (av. less than 3 mf/mg). Despite this, signs of onchocercal dermatitis were common and severe, especially over the buttocks. Papular eruptions and scarring often appeared to lead to black-grey hyperpigmentation, but no cases were seen of the unilateral, hyper-reactive 'sowda' described in Arabs in Yemen. No microfilariae were detected in the eyes of any of the patients who had positive outer canthus snips. Serum retinol concentrations were normal but mildly elevated concentrations of serum IgG, IgM and IgA were detected in many patients. Immunoglobulin E values in a sample of 20 microfilariae-positive patients were markedly higher than normal, with most in the 4,000 to 15,000 U/ml range. Eosinophil levels in differential counts of peripheral blood from the 208 villagers were markedly elevated. In skin snip surveys of over 400 villagers and school pupils, sample prevalence rates of 2 to 17.5% were recorded. Simulium biting was seasonal (November to May) and peaked in March. Over-all, the results indicate that O. volvulus infection persists in the Abu Hamed region as a serious cause of skin disease in the absence of other complicating filariases.

A parental perspective on the Honeylands Home Visiting Project for severely handicapped infants provided by three mothers of older handicapped children

Three mothers of severely handicapped children, who had not attended Honeylands nor received any home visiting, were asked to attend and participate in the monthly group meetings for the second year of the three year project (Rayner 1978). They each then decided to visit a family with their home therapist. They comment on the responsibility undertaken by all parties to this work; parents, therapist and supportive team.