Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea in a Patient with Cerebral Palsy.

INTRODUCTION: Obstructive sleep apnea (OSA) is common amongst patients with cerebral palsy in part due to significant hypotonia. Hypoglossal nerve stimulation (HGNS) is a novel tool used to treat sleep apnea when there is failure with CPAP. To our knowledge, the literature has not discussed HGNS as a treatment option for severe OSA in patients with cerebral palsy. METHODS: Case report and literature review. RESULTS: A 28-year-old male with cerebral palsy, neuromuscular deformity, proximal junction kyphosis, and developmental delay presented with severe obstructive sleep apnea and was intolerant to CPAP and BiPAP. After HGNS implantation, a sleep study revealed improved ventilation and oxygenation at 2.4 V; AHI decreased from baseline of 112 to 12 events per hour with only mild intermittent snoring. The patient's family reported increased utilization compared with previous CPAP use. CONCLUSION: HGNS can be a safe and effective treatment modality for OSA in this patient population. Laryngoscope, 134:2478-2479, 2024.

Inhaled corticosteroid prescriptions in the ED for recurrent asthma using IT clinical decision support: revisit after cessation of an incentive program.

INTRODUCTION: The objective of this study was to assess whether inhaled corticosteroid (ICS) prescription rates for patients with poorly controlled asthma presenting to the emergency department (ED) remained high with a clinical support system in place, after a financial incentive program ended. This study is the second phase of a previous study done at our institution. The first phase demonstrated that the introduction of an electronic alert system advising providers to prescribe ICS to patients with poorly controlled asthma, along with a financial incentive, increased ICS prescription rates from 2% to 77%. Clinical support systems are necessary to improve control for patients with asthma, as prescribing ICS in the ED has not previously been standard of care. METHODS: This retrospective study identified 96 eligible patients during the study period of January 1, 2019 to December 31, 2019. Subjects included patients aged 4-18 with at least two ED visits for asthma within 365 days and no recent ICS prescription. For subjects meeting these criteria, an electronic alert activated, advising the provider to prescribe ICS. RESULTS: ICS prescription rate without the incentive remained high at 0.74 (0.59, 0.86) and was not significantly different than the rate with the incentive of 0.77 (0.65, 0.87), with p value 0.82. No significant differences were detected in baseline characteristics between patients discharged with and without an ICS prescription. CONCLUSIONS: This study confirmed that an electronic alert advising ICS prescription in the ED for patients with recurrent asthma visits is effective, even without a financial incentive.

Inhaled corticosteroids prescriptions increased in the ED for recurrent asthma exacerbations by automated electronic reminders in the ED.

Objective: The objective of this study was to evaluate the impact of an electronic alert on the prescription rate of inhaled corticosteroids (ICS) by ED providers for poorly controlled persistent asthmatic children.Methods: Study subjects included asthmatic patients age 4-18 presenting to the ED at Phenix Children's Hospital between February 9, 2018 and December 4, 2018, with a history of at least two previous ED visits for acute exacerbation of asthma within 365 days, no active ICS prescription within 90 days, and free from developmental delay, bronchopulmonary dysplasia due to prematurity, cystic fibrosis, sickle cell disease, and/or interstitial ling disease. Patients meeting these criteria triggered an electronic alert prompting the medical provider to prescribe ICS or indicate reason for not prescribing. Instruction on the alert was provided to ED attending physicians and residents by email and through several educational sessions held prior to the implementation.Results: Among 62 patients without prior ICS who were discharged home from the ED, ICS was prescribed for 48 (77%). No statistically significant differences were detected in baseline characteristics between patients discharged home from the ED with and without ICS prescription. While ICS was prescribed by a larger proportion of physicians (56%) compared to residents (42%), statistical significance was not reached. For the 14 (33%) patients who were discharged home without ICS, no reason was provided to indicate why ICS were not prescribed.Conclusion: An electronic alert incorporated into the ED workflow to populate a discharge order set is effective to initiate asthma controller medication for poorly controlled pediatric patients. Additional data describing reasons for not prescribing ICS can further refine recommendations for ICS prescriptions, and provide a comprehensive strategy to support clinical decision for pediatric asthma control in acute care settings.

Variability in asthma quality and costs in children with different Medicaid insurance plans in Maricopa County.

OBJECTIVE: To describe the variation in asthma quality and costs among children with different Medicaid insurance plans. METHODS: We used 2013 data from the Center for Health Information and Research, which houses a database that includes individuals who have Medicaid insurance in Arizona. We analyzed children ages 2-17 years-old who lived in Maricopa County, Arizona. Asthma medication ratio (AMR, a measure of appropriate asthma medication use), outpatient follow-up within 2 weeks after asthma-related hospitalization (a measure of continuity of care), asthma-related hospitalizations, and all emergency department (ED) visits were the primary quality metrics. Direct costs were reported in 2013 $US dollars. We used one-way analysis of variance to compare the health plans for AMR and per member cost (total, ER, and hospital), and the chi-squared test for the outpatient follow-up measure. We used coefficient of variation to identify variation of each measure across all individuals in the study. RESULTS: In 2013, 90,652 children in Maricopa County were identified as having asthma. The average patient-weighted AMR for children with persistent asthma was 0.35, well short of the goal of ≥0.70, and only 36% of hospitalized asthma patients had outpatient follow-up within 2 weeks of hospitalization. AMR, total costs, and ED costs varied significantly (p <.0001) when comparing health plans while hospital costs and outpatient follow-up showed no significant variation. CONCLUSIONS: Targeting appropriate medication use for asthma may help reduce variation, improve outcomes, and increase healthcare value for children with asthma and Medicaid insurance in the US.

Asthma treatment and outcomes for children in the emergency department and hospital.

OBJECTIVE: To describe and compare the treatment of acute asthma exacerbations in children given in the emergency department (ED) and admitted to acute care floor in the hospital or intensive care unit (ICU). METHODS: A retrospective chart review of visits for acute exacerbation of asthma treated at Phoenix Children's Hospital between January 1, 2014 and December 31, 2016. RESULTS: A total of 287 asthma exacerbation cases were identified including 106 (37%) ED visits, 134 (47%) hospital floor and 47 (16%) ICU admissions. A history of a previous ED visit (ED 88%, Floor 60% and ICU 68%; p < 0.0001) and prior pulmonology inpatient consultation (ED 30%, Floor 19% and ICU 15%; p = 0.05) varied significantly. Pulmonology inpatient consultations were performed more frequently in the ICU than on the hospital floor (54% versus 8%; p < 0.0001). Although overall 145 (51%) of the cases were already on inhaled corticosteroids (ICS) at the time of visit with no differences across locations, ICS initiation/step-up was greater in the ICU (72%) than on the hospital floor (54%) and ED (2%) (p < 0.0001). A recommendation given to the family for follow-up with pulmonology was more frequent for patients who had been admitted to the ICU (68%) as compared to those only admitted to the floor (31%) or ED (4%) (p < 0.0001). Readmission rates were similar for patients previously admitted to the hospital (Floor 42%; ICU 40%), but significantly higher for previous ED visits (77%) (p < 0.0001). CONCLUSIONS: Physicians in the ED have an opportunity to provide preventative care in the acute care setting and should be encouraged to initiate treatment with ICS. Consideration should be given to develop a program or clinical pathway focused on long-term asthma management and maintenance to reduce readmissions and long hospital stays.

Lead Time to Appointment and No-Show Rates for New and Follow-up Patients in an Ambulatory Clinic.

High rates of no-shows in outpatient clinics are problematic for revenue and for quality of patient care. Longer lead time to appointment has variably been implicated as a risk factor for no-shows, but the evidence within pediatric clinics is inconclusive. The goal of this study was to estimate no-show rates and test for association between appointment lead time and no-show rates for new and follow-up patients. Analyses included 534 new and 1920 follow-up patients from pulmonology and gastroenterology clinics at a freestanding children's hospital. The overall rate of no-shows was lower for visits scheduled within 0 to 30 days compared with 30 days or more (23% compared with 47%, P < .0001). Patient type significantly modified the association of appointment lead time; the rate of no-shows was higher (30%) among new patients compared with (21%) follow-up patients with appointments scheduled within 30 days (P = .004). For appointments scheduled 30 or more days' lead time, no-show rates were statistically similar for new patients (46%) and follow-up patients (0.48%). Time to appointment is a risk factor associated with no-shows, and further study is needed to identify and implement effective approaches to reduce appointment lead time, especially for new patients in pediatric subspecialties.

Sarcoidosis and Histoplasmosis: Is One a Consequence of the Other? A Case Report and Review of the Literature.

Sarcoidosis involves abnormal collections of inflammatory cells (granulomas) which may form as nodules in multiple organs. 90% of affected patients have respiratory tract abnormalities. We present a 61-year-old male with sarcoidosis who was admitted for respiratory distress. Fibrosing mediastinitis was seen in the chest computograph. Management was conservative and included steroids, antibiotics, and oxygen therapy. Sarcoidosis and fibrosing mediastinitis are rare. Fibrosing mediastinitis is more commonly seen with histoplasmosis. We explore the clinical similarities between histoplasmosis and sarcoidosis. We also explore the potential cause and effect relationship and workup for each disease entity.

The FEF25-75 and its decline as a predictor of methacholine responsiveness in children.

BACKGROUND: Methacholine challenge (MCC) is an important diagnostic tool for asthma, especially in patients in whom routine pulmonary function testing (PFT) is normal or equivocal. The basis for a positive test per American Thoracic Society (ATS) guidelines is a methacholine concentration < or = 16 mg/mL that causes a 20% decrease in forced expiratory volume in 1 second (FEV(1)) (termed the PC20 for FEV(1)). There is little information in the medical literature that utilizes other flow rates during MCC, including small airway function parameters such as the forced expiratory flow rate 25-75% (FEF(25-75)). We question whether the FEF(25-75) may be a useful parameter to monitor during MCC and whether it may be predictive of a positive MCC. HYPOTHESIS: The baseline FEF(25-75) and its decline during a MCC are useful in the interpretation of a MCC. METHODS: We retrospectively analyzed all MCC performed at this institution between December 1998 and December 2006. Parameters reviewed included age, gender, race, weight, height, baseline PFT data including FVC, FEV(1), FEF(25-75), and forced expiratory time, methacholine PC20 for FEV(1), the relative changes from baseline for FEV(1) and FEF(25-75) during the MCC, and clinical symptoms during the MCC. RESULTS: A total of 532 MCC were completed during the 8-year study period in children 4 to 18 years of age. A total of 203 MCC (38%) were positive (defined by a PC20 < or = 16 mg/mL) and 329 studies were negative (62%). The baseline % predicted FEF(25-75) in positive MCC was 82.4 +/- 21.9 vs. 98.7 +/- 21.3 in the negative studies (p < 0.001). The FEF(25-75)/FVC ratio in positive MCC was 0.82 +/- 0.21 vs. 0.97 +/- 0.23 in negative studies (p < 0.001). In the positive MCC, the decrease in FEF(25-75) was much faster and of much greater degree than in the negative challenges. When a significant reduction in FEF(25-75) was defined as greater than 10% by the second concentration of methacholine (0.25 mg/mL), the sensitivity for a positive MCC was 63%, the specificity was 71%, the positive predictive value was 57%, and the negative predictive value was 76%. A comparison of the baseline FEF(25-75) to the PC20 for the positive MCCs revealed no statistical significance. CONCLUSIONS: The FEF(25-75) and its decline during a MCC appear to be useful information and potentially predictive of a positive MCC. We suggest that the forced expiratory flow rate 25-75% (FEF(25-75)) be considered as an adjunct to the FEV(1) to define a positive study.