Pediatric Pain and Pain Management After Ambulatory Plastic Surgery: Trends in the Age of Opioid Awareness.

BACKGROUND: Overprescribing by physicians has been shown to be a major contributor to the opioid epidemic. Although pediatric ambulatory plastic surgery patients are commonly prescribed opioids for postoperative pain control, there is a lack of evidence for their necessity. This study aimed to investigate the role of prescribed narcotics in the ambulatory pediatric plastic surgery setting. METHODS: All assenting patients/guardians, ages 0 to 17 years, who underwent an ambulatory plastic surgery procedure by 1 attending surgeon from March 2018 to March 2019, were asked to participate in the study. A questionnaire was distributed at the first postoperative visit to interrogate postoperative pain, management, and narcotic use. RESULTS: A total of 95 patients/guardians completed the questionnaire. Seventy-eight percent (74) of patients picked up the narcotic medication, with 33% (31) taking at least 1 dose of narcotics, and only 9% (9) taking 4 or more doses. Patients overall found no difference in efficacy of the narcotics versus nonprescription analgesics (3.93/5 and 4.31/5, P = 0.11). Age was a significant predictor, with older patients requiring more narcotics (odds ratio, 1.12; 95% confidence interval, 1.02-1.24; P = 0.019). The type of surgery a patient underwent was not a significant predictor of the amount of narcotic used. Few patients knew how to properly dispose of the excess narcotics, with almost 50% still having it stored in their homes. CONCLUSIONS: This study demonstrates that the majority of pediatric ambulatory plastic surgery patients do not require narcotic pain medications and experience adequate pain relief with over-the-counter analgesics. Importantly, education on proper disposal of narcotic medications may be a simple, yet effective target to decrease opioid availability for abuse.

Neuroendocrine carcinoma of the endometrium: Disease course, treatment, and outcomes.

OBJECTIVE: Neuroendocrine carcinoma of the endometrium (NECE) is a rare malignancy. We examined the natural history and outcomes of women with NECE compared to patients with poorly differentiated endometrioid endometrial cancer (EC). METHODS: The National Cancer Database (NCDB) was used to identify women with NECE and women with poorly differentiated EC from 2004 to 2015. Clinical, demographic, and treatment characteristics were compared between groups. Kaplan-Meier survival curves and multivariable Cox proportional hazard regression models were used to identify associations between tumor histology and survival. RESULTS: A total of 28,291 women with EC and 364 women with NECE were identified. Patients with NECE were more often non-white and presented with later stage disease compared to patients with EC. Women with NECE were more likely to receive adjuvant chemotherapy (60.2% vs. 29.6%), but were less likely to receive radiation (28.0% vs. 47.6%) (P < 0.001 for both). Median survival was 17 months (95% CI, 12-23) for NECE and 144 months (95% CI, 140-148) for EC. 5-year survival was 38.3% (95% CI, 32.7-43.8%) for NECE vs. 68.8% (95% CI, 68.2-69.4%) for EC. In a multivariable model, the hazard ratio for death for women with NECE compared to EC was 2.32 (95% CI, 1.88-2.88). Similar findings were noted when the analysis was limited to women with stage I (HR = 1.62; 95% CI, 1.01-2.61), and stage III (HR = 2.57; 95% CI, 1.88-3.53) neoplasms. CONCLUSIONS: NECE is a rare and aggressive uterine carcinoma. Compared to patients with poorly differentiated EC, patients with NECE present with later stage disease and have decreased survival.

A Comparison of Early Versus Late Prenatal Magnetic Resonance Imaging in the Diagnosis of Cleft Palate.

BACKGROUND: Prenatal ultrasound is the standard modality to screen for fetal craniofacial malformations, but can be limited by sonographer experience, oligohydramnios, and maternal obesity. Fetal magnetic resonance imaging (MRI) can be used as an adjunct to ultrasound, but there is a paucity of literature on its performance. The objective of this study was to examine the accuracy of fetal MRI for prenatal diagnosis of craniofacial abnormalities in an at-risk patient population and to determine if accuracy is maintained before and after 24 weeks gestational age (GA). METHODS: This was a retrospective review of a single-center fetal MRI database including cases from March 2011 to November 2018. All cases were referred for MRI due to a suspected orofacial cleft or micrognathia upon screening ultrasound. Magnetic resonance imaging was performed and interpreted by dedicated fetal MRI radiologists. Prenatal findings were correlated with postnatal anatomy. RESULTS: Sixty-one cases were identified. Ten were lost to follow-up and 9 underwent termination of pregnancy. Among the remaining 42 cases, MRI possessed a sensitivity of 91.7% and negative predictive value (NPV) of 90% for prenatal diagnosis of cleft palate. When performed at early GA, fetal MRI (n = 20) demonstrated sensitivity and NPV of 100% for cleft palate diagnosis. For cleft lip, MRI had 93.1% sensitivity and 86.7% NPV without significant decrease in accuracy at early GA. For micrognathia, MRI demonstrated 100% sensitivity and NPV overall, as well as at early and late gestational ages. CONCLUSIONS: Fetal MRI is an accurate method for prenatal diagnosis of cleft palate, cleft lip, and micrognathia. Furthermore, it remains highly accurate even when performed before 24 weeks GA. We advocate the use of fetal MRI as an adjunct imaging modality to standard ultrasound for the evaluation of suspected fetal craniofacial anomalies to provide complete and accurate counseling to prospective parents and facilitate the planning of appropriate postnatal care.

Congenital diaphragmatic hernia in 22q11.2 deletion syndrome.

We report the important association of congenital diaphragmatic hernia (CDH) and 22q11.2 deletion syndrome (22q11.2DS). The prevalence of CDH in our cohort of patients with 22q11.2DS is 0.8% (10/1246), which is greater than in the general population (0.025%). This observation suggests that 22q11.2DS should be considered when a child or fetus presents with CDH, in particular when other clinical findings associated with the 22q11.2DS are present, such as congenital cardiac defects. Furthermore, this finding may lead to the identification of an additional locus for diaphragmatic hernia in the general population. © 2016 Wiley Periodicals, Inc.

Whole-Genome and Whole-Exome Sequencing in Pediatric Oncology: An Assessment of Parent and Young Adult Patient Knowledge, Attitudes, and Expectations.

PURPOSE: The complexity of results generated from whole-genome sequencing (WGS) and whole-exome sequencing (WES) adds challenges to obtaining informed consent in pediatric oncology. Little is known about knowledge of WGS and WES in this population, and no validated tools exist in pediatric oncology. METHODS: We developed and psychometrically evaluated a novel WGS and WES knowledge questionnaire, the Precision in Pediatric Sequencing Knowledge Questionnaire (PIPseqKQ), to identify levels of understanding among parents and young adult cancer survivors (≥ 18 years old), off therapy for at least 1 year from a single-institution pediatric oncology outpatient clinic. Participants also completed health literacy and numeracy questionnaires. All participants provided written informed consent. RESULTS: One hundred eleven participants were enrolled: 76 were parents, and 35 were young adults. Of the total cohort, 77 (69%) were female, 63 (57%) self-identified as white, and 74 (67%) self-identified as non-Hispanic. Sixty-six (59%) had less than a college degree. Adequate health literacy (n = 87; 80%) and numeracy (n = 89; 80%) were demonstrated. Internal consistency was high (Cronbach's α = .88), and test-retest reliability was greater than the 0.7 minimum requirement. Scores were highest for genetic concepts related to health and cancer and lowest for WGS and WES concepts. Health literacy and educational attainment were significantly associated with PIPseqKQ scores. Overall, participants felt the benefits of WGS and WES outweighed the potential risks. CONCLUSION: Parents and young adult cancer survivors have some genetics knowledge, but they lack knowledge about WGS and WES. The PIPseqKQ is a reliable tool that can identify deficits in knowledge, identify perceptions of risks and benefits of WGS and WES, and help clinicians tailor their consent discussions to best fit families. The PIPseqKQ also may inform the development of educational tools to better facilitate the informed consent process in pediatric oncology.