Multicenter mortality and morbidity associated with pulmonary hypertension in the pediatric intensive care unit.

Despite advances in the diagnosis and management of pediatric pulmonary hypertension (PH), children with PH represent a growing inpatient population with significant morbidity and mortality. To date, no studies have described the clinical characteristics of children with PH in the pediatric intensive care unit (PICU). A retrospective multicenter cohort study of 153 centers in the Virtual PICU Systems database who submitted data between 1 January 2009 and 31 December 2015 was performed. A total of 14,880/670,098 admissions (2.2%) with a diagnosis of PH were identified. Of these, 2190 (14.7%) had primary PH and 12,690 (85.3%) had secondary PH. Mortality for PH admissions was 6.8% compared to 2.3% in those admitted without PH (odds ratio = 3.1; 95% confidence interval = 2.9-3.4). Compared to patients admitted to the PICU without PH, those with PH were younger, had longer length of stay, higher illness severity scores, were more likely to receive invasive mechanical ventilation, cardiopulmonary resuscitation, extracorporeal membrane oxygenation, and more likely to have co-diagnoses of sepsis, heart failure, and respiratory failure. In a multivariate model, factors significantly associated with mortality for children with PH included age < 6 months or > 16 years, invasive mechanical ventilation, and co-diagnoses of heart failure, sepsis, hemoptysis, disseminated intravascular coagulation, stroke, and multi-organ dysfunction syndrome. Despite therapeutic advances, the disease burden and mortality of children with PH remains significant. Further investigation of the risk factors associated with clinical deterioration and mortality in this population could improve the ability to prognosticate and inform clinical decision-making.

Salivary duct stenosis: Short-term symptom outcomes after sialendoscopy-assisted salivary duct surgery.

OBJECTIVES: To prospectively assess short-term symptom change after sialendoscopy-assisted salivary duct surgery (SASDS) for salivary duct stenosis. STUDY DESIGN: Prospective cohort study. METHODS: Patients with obstructive sialadenitis from duct stenosis completed the 20-item Chronic Obstructive Sialadenitis Symptoms (COSS) Questionnaire (scored 0-100) prior to SASDS and 3 months postoperatively. RESULTS: Thirty glands in 19 patients with endoscopically confirmed salivary duct stenosis showed overall symptom improvement, with a mean COSS score reduction of 12.9 points (standard deviation [SD] 13.1) to a mean postoperative score of 25.1 (range 0-75.5) (P < 0.001) with six (20%) glands (5 patients) achieving complete symptom resolution. Symptoms improved significantly for parotid glands (n = 20) by 16.6 points (SD 15.9) (P < 0.0001). For distal duct stenoses (n = 25), significant symptom improvement was seen in cases treated with dilation only (n = 17; partial stenoses) with a mean 20.6 point COSS reduction (SD 19.0) (P < 0.0005) and in cases treated with sialodochoplasty (n = 5; 4 complete, 1 partial stenosis) with a mean 13.8 point reduction (SD 4.7) (P < 0.005). Symptom scores did not improve after SASDS in proximal stenoses (n = 3) and distal stenoses cases not amenable to treatment (n = 3). CONCLUSION: SASDS for salivary duct stenosis often can improve obstructive salivary symptoms; however, many patients report persistent symptoms after surgery. Partial duct stenoses or distal duct stenoses are associated with the greatest improvements in COSS scores after SASDS. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2770-2776, 2017.

Sialadenitis without sialolithiasis: Prospective outcomes after sialendoscopy-assisted salivary duct surgery.

OBJECTIVES: To prospectively assess symptoms before and after sialendoscopy-assisted salivary duct surgery (SASDS) in patients with symptomatic sialadenitis without sialolithiasis. STUDY DESIGN: Prospective cohort study. METHODS: Patients with chronic obstructive sialadenitis without sialolithiasis (COSWS) completed the Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire prior to SASDS and 3 months postoperatively. RESULTS: Of 80 consecutive patients in a 20-month period, 20 surveyed patients underwent SASDS for COSWS in 37 symptomatic glands. Major symptom improvement (> 10 COSS score reduction) was reported in 24 of 37 (65%) of all glands, including 14 of 21 (67%) of radioactive iodine (RAI)-induced cases and 10 of 13 (77%) of idiopathic sialadenitis cases. A significant reduction in postoperative mean COSS scores was seen overall (12.6 points, standard deviation [SD] 19.3, P < 0.05 to a post-SASDS mean score of 26.6). However, 19 of 37 (51%) glands demonstrated postoperative COSS scores above 25, denoting persistent disease. Mean COSS score reductions in RAI-induced sialadenitis (12.4 points, SD 22.7, P < 0.05) and idiopathic sialadenitis (16.3 points, SD 13.7, P < 0.005) groups were significant, with post-SASDS COSS mean scores of 30.6 (SD 19.8) and 20.8 (SD 13.8), respectively. Ducts with stenoses treated with dilation or sialodochoplasty showed significant COSS improvements of 21.1 (SD 17.9) and 12.4 points (SD 10.7), respectively (P < 0.05). In a multivariate analysis, both the presence of stenosis and sialodochoplasty were independent predictors of complete or partial resolution (post-COSS score < 25) and major symptom improvement (P < 0.05). CONCLUSION: SASDS provides short-term symptom reduction in patients with COSWS; particularly in RAI-induced and idiopathic sialadenitis, and in duct stenosis amenable to dilation or sialodochoplasty. However, approximately half of the glands did not achieve meaningful symptom resolution. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:1073-1079, 2017.

Sialendoscopy-assisted surgery and the chronic obstructive sialadenitis symptoms questionnaire: A prospective study.

OBJECTIVES/HYPOTHESIS: To prospectively assess symptoms of obstructive sialadenitis before and after sialendoscopy-assisted salivary duct surgery (SASDS) using the chronic obstructive sialadenitis symptoms (COSS) questionnaire to determine and predict impact of interventions. STUDY DESIGN: Prospective cohort study. METHODS: Adult patients with chronic obstructive sialadenitis who underwent SASDS were asked to complete the COSS questionnaire and the Short-Form-8 (SF-8) quality-of-life (QOL) survey prior to surgery and 3 months postoperatively. Chronic obstructive sialadenitis symptoms surveys were scored on a scale from 0 to 100. RESULTS: Forty patients undergoing SASDS, including 54 glands, completed preoperative and postoperative surveys. Overall, the mean COSS score improved from 36.1 (standard error of the mean [SEM] 2.6) preoperatively to 13.5 (SEM 2.4) 3 months postoperatively (p < 0.001). Submandibular gland cases had a significant mean score reduction of 27.8 (from 38.1 to 10.3; p < 0.005). Parotid gland cases had a significant mean score reduction of 13.6 (from 32.6 to 19.0; p < 0.0001). Patients with sialolithiasis-related sialadenitis had greater COSS score improvement after surgery than those with radioactive iodine- or inflammatory-related disease. An improvement in symptoms was seen for 100% and 47% of patients with sialolithiasis and inflammatory etiologies, respectively. The pre- and post-SASDS SF-8 QOL scores were not significantly different. CONCLUSIONS: Obstructive sialadenitis-related symptoms significantly declined 3 months after SASDS. The COSS questionnaire was able to measure changes in sialadenitis symptoms not captured in the SF-8 QOL survey. This is the first study to prospectively survey sialadenitis-specific symptoms to determine impact of surgical interventions. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1343-1348, 2016.

The Chronic Obstructive Sialadenitis Symptoms Questionnaire to assess sialendoscopy-assisted surgery.

OBJECTIVES/HYPOTHESIS: Introduce the Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire to quantify chronic sialadenitis symptoms and assess the impact of sialendoscopic-assisted salivary duct surgery (SASDS). STUDY DESIGN: Retrospective outcome symptoms questionnaire study. METHODS: The COSS questionnaire assesses the severity of sialadenitis symptoms from 0 to 100. Patients who underwent SASDS from April 2006 to December 2013 completed the COSS questionnaire and the ShortForm8 Health Survey (SF-8) based on current symptoms, and reported whether they had complete, partial, or no symptomatic response to SASDS. RESULTS: Sixty-six of the 156 (43%) contacted patients completed the questionnaires who had had symptoms in 26 submandibular ducts and 53 parotid ducts. The mean COSS score was higher for parotid ducts (12.0; interquartile range [IQR] 1.0-20.0) than for submandibular ducts (7.6; IQR 0.5-15.0) but not significantly so (P = 0.20). Thirty-eight (60%) patients reported complete resolution of symptoms, with a mean COSS score of 4.5 (IQR 0-7). Twenty-one (33%) patients reported partial resolution, with a mean COSS score of 18.5 (IQR 11.3-22.8). Five (8%) patients reported no improvement, with a mean COSS score of 25.1 (IQR 15.2-35). Thirty-six (46%) ducts with sialoliths had a significantly lower mean COSS score (5.8; IQR 0-9.5) compared to those without sialoliths (14.2; IQR 4.5-21.5, P = 0.0004). There was no significant difference in SF-8 survey scores between these groups. CONCLUSION: The COSS questionnaire is a novel survey instrument to measure obstructive sialadenitis symptom severity that could be helpful in defining outcomes of SASDS. COSS scores under 10 correlate with complete resolution of symptoms, whereas scores between 10 and 25 correlate with partial resolution.