Factors Associated With Safe Prescription Opioid Disposal After Surgery in Adolescents.

INTRODUCTION: Unused prescription opioids contribute to diversion, unintended exposure, and poisonings in adolescents. Factors associated with safe prescription opioid disposal for adolescents undergoing surgery are unknown. METHODS: Parents of adolescents (13-20 y) undergoing surgery associated with an opioid prescription were enrolled preoperatively. Parents completed a baseline survey measuring sociodemographics and family history of substance abuse and two postoperative surveys capturing opioid use and disposal at 30 and 90 d. Safe disposal was defined as returning opioids to a healthcare facility, pharmacy, take-back event, or a police station. Factors associated with safe opioid disposal were assessed using bivariate analysis. RESULTS: Of 119 parent-adolescent dyads, 90 (76%) reported unused opioids after surgery. The majority of parents reporting unused opioids completed the surveys in English (80%), although many (44%) spoke another language at home. Most reported income levels <$60,000 (54%), did not attend college (69%), and had adequate health literacy (66%). Most parents (78%) did not report safe opioid disposal. Safe opioid disposal was associated with younger patient age, (median 14 y, IQR 13-16.5 versus median 15.5 y, IQR 14-17, P = 0.031), fewer days taking opioids (median 5, IQR 2-6 versus median 7, IQR 4-14, P = 0.048), and more leftover pills (median 20, IQR 10-35 versus median 10, IQR 5-22, P = 0.008). CONCLUSIONS: Most parents fail to safely dispose of unused opioids after their adolescent's surgery. Younger patient age, shorter duration of opioid use, and higher number of unused pills were associated with safe disposal. Interventions to optimize prescribing and educate parents about safe opioid disposal are warranted.

Adolescent and Parent Perceptions of Postoperative Opioid Use: A Qualitative, Thematic Analysis.

BACKGROUND: Little is known about how families make decisions regarding postoperative prescription opioid consumption. This qualitative study examines adolescent and parent perspectives on postoperative prescription opioid use. METHODS: We recruited adolescents aged 13-20 years old who received a postoperative opioid prescription and their parents from a previous longitudinal cohort study. We employed purposive sampling for recruitment to reflect local community sociodemographics including race/ethnicity, health literacy, and Spanish-language preference then conducted thematic analysis of focus group feedback. RESULTS: Participants met in four virtual focus groups: adolescents from English-speaking households(n = 2), adolescents from Spanish-speaking households(n = 5), English-speaking parents(n = 4), and Spanish-speaking parents (n = 4). Five themes emerged: Parents (1) feared opioid use would result in overdose or addiction and (2) desired information about alternative medical and behavioral strategies to minimize use. (3) Parents felt empowered to manage their adolescent's opioid use and trusted their adolescent to prompt them for opioids. Adolescents trusted their parents to manage their opioid use but maintained their autonomy to limit opioid consumption when experiencing undesirable side effects. (4) Some adolescents and parents endorsed a preference for "not taking medication" in their households. (5) Both parents and adolescents reported previous knowledge of opioids prior to surgery, with adolescents learning more nuanced information about opioid safety after their surgeries. CONCLUSIONS: Families feel empowered to manage their postoperative prescription opioid use but fear the negative effects of opioids and desire information on alternatives. Evidence-based, family-centric education from providers in a language preferred by the family could mitigate families' concerns and contribute to improved pain control and safety. LEVEL OF EVIDENCE: IV.

Sex-based Disparities in the Management of Pediatric Gonadal Torsion.

INTRODUCTION: In 2015, the U.S. News and World Report (USNWR) implemented a quality metric to expedite surgery for testicular torsion (TT), but not ovarian torsion (OT). This study examined OR timing among children with suspected TT and OT before and after this metric. METHODS: A single-center retrospective cohort study of children (1-18yr) who underwent surgery for suspected gonadal torsion was performed. Time to OR (TTOR) from hospital presentation to surgery start was calculated. An interrupted time series analysis identified changes in TTOR for suspected TT versus OT after the 2015 USNWR quality metric. RESULTS: Overall, 216 patients presented with TT and 120 with OT. Median TTOR for TT was 147 min (IQR:99-198) versus 462 min (IQR:308-606) for OT. Post-quality metric, children with TT experienced a 27.8 min decrease (95% CI:-51.7,-3.9, p = 0.05) in annual median TTOR. No significant decrease was observed for children with OT (p = 0.22). Children with history of a known ovarian mass (N = 62) experienced a shorter TTOR compared to those without (422 vs 499min; p = 0.04). CONCLUSION: Implementation of a national quality metric for TT expedited surgical care for children with TT, but not children with OT. These findings highlight the need for equitable quality metrics for children presenting with suspected gonadal torsion. LEVEL OF EVIDENCE: III. TYPE OF STUDY: Retrospective Comparative Study, Observational Cohort Study.

Opioid consumption before discharge predicts outpatient opioid use in adolescents undergoing surgery.

BACKGROUND: The majority of adolescents undergoing surgery report unused prescription opioids after surgery, increasing the risk of diversion, misuse, and addiction. Adult studies have demonstrated that opioid use 24 hours before discharge corresponds with opioid use at home. We hypothesized that inpatient opioid consumption is associated with outpatient opioid use in adolescents. METHODS: Adolescents aged 13-20 years undergoing elective surgery associated with an opioid prescription were prospectively recruited. Parent-adolescent dyads were surveyed preoperatively to assess sociodemographics, health literacy, and baseline substance use, and opioid use was measured at 30- and 90-days postoperatively. Medical records were reviewed to calculate cumulative opioid use during hospitalization. Inpatient and postoperative opioid use was converted to oral morphine equivalents. Adjusting for age, sex, race, health literacy, alcohol use, pain score, and surgery, multivariable linear regression identified factors associated with outpatient oral morphine equivalent use 90 days postoperatively. RESULTS: Overall, 103 adolescents were enrolled. Median oral morphine equivalents used from 24 and 48 hours before discharge and throughout the hospitalization were 30.8 (interquartile range:11.7-45.0), 67.5 (interquartile range:37.5-94.3), and 97.5 (interquartile range:18.0-152.7), respectively. Regression analysis demonstrated that adolescent-reported pain at discharge (P = .028) and cumulative oral morphine equivalents used 24 hours (P < .001) and 48 hours (P = .003) before discharge were significantly associated with postoperative oral morphine equivalents use at home. Oral morphine equivalents consumption 24 hours before discharge estimated cumulative oral morphine equivalents use 90 days postoperatively at a 1-to-5 ratio in 94.1% of patients. CONCLUSION: For adolescents undergoing surgery, patient-reported pain at discharge and oral morphine equivalents administered 24 hours before discharge are associated with cumulative outpatient opioid use. Tailoring outpatient prescriptions to total oral morphine equivalent consumption 24 hours before discharge could reduce excess opioid prescribing.

The impact of COVID-19 on racial and ethnic disparities in presentation with perforated appendicitis in children: A retrospective cohort study.

Background: Children from racial and ethnic minority groups have higher prevalence of perforated appendicitis, and the COVID-19 pandemic worsened racial and ethnic health-related disparities. We hypothesized that the incidence of perforated appendicitis worsened for children from racial and ethnic minorities during the COVID-19 pandemic. Methods: We performed a retrospective cohort study of the Pediatric Health Information System for children ages 2-18y undergoing appendectomy pre-pandemic (3/19/2019-3/18/2020) and intra-pandemic (3/19/2020-3/30/2021). The primary outcome was presentation with perforated appendicitis. Multivariable logistic regression with mixed effects estimated the likelihood of presentation with perforated appendicitis. Covariates included race, ethnicity, pandemic status, Child Opportunity Index, gender, insurance, age, and hospital region. Results: Overall, 33,727 children underwent appendectomy: 16,048 (47.6 %) were Non-Hispanic White, 12,709 (37.7 %) were Hispanic, 2261 (6.7 %) were Non-Hispanic Black, 960 (2.8 %) were Asian, and 1749 (5.2 %) Other. Overall perforated appendicitis rates were unchanged during the pandemic (37.4 % intra-pandemic, 36.4 % pre-pandemic, p = 0.06). Hispanic children were more likely to present with perforated appendicitis intra-pandemic versus pre-pandemic (OR 1.18, 95%CI: 1.07, 1.13). Hispanic children had higher odds of perforated appendicitis versus Non-Hispanic White children pre-pandemic (OR 1.10, 95%CI: 1.00, 1.20) which increased intra-pandemic (OR 1.19, 95%CI: 1.09, 1.30). Publicly-insured children had increased odds of perforated appendicitis intra-pandemic versus pre-pandemic (OR 1.14, 95%CI: 1.03, 1.25), and had increased odds of perforated appendicitis versus privately-insured children (intra-pandemic OR 1.26, 95%CI: 1.16, 1.36; pre-pandemic OR 1.12, 95%CI: 1.04, 1.22). Conclusions: During the COVID-19 pandemic, Hispanic and publicly-insured children were more likely to present with perforated appendicitis, suggesting that the pandemic exacerbated existing disparities in healthcare for children with appendicitis. Key message: We found that Hispanic children and children with public insurance were more likely to present with perforated appendicitis during the COVID-19 pandemic. Public health efforts aimed at ameliorating racial and ethnic disparities created during the COVID-19 pandemic should consider increasing healthcare access for Hispanic children to address bias, racism, and systemic barriers that may prevent families from seeking care.

Analysis of pediatric sternal fractures using the Kid's Inpatient Database (KID).

PURPOSE: This study aims to determine if sternal fracture is a predictor of discharge requiring additional care and mortality. METHODS: Blunt pediatric trauma admissions (<18 years) in the Kid's Inpatient Database (2016) were included in analysis. Weighted incidence of sternal fracture was calculated and adjusted for using survey weight, sampling clusters, and stratum. Regression analysis was used to identify factors associated with poor outcomes. RESULTS: Annual incidence of sternal fracture in the pediatric blunt trauma population was 0.43 per 100,000. Of 50,076 patients identified, 236 had sternal fractures. The sternal fracture patients were older (median 16 vs 10 years, P < 0.001) and motor vehicle accident was more frequently the mechanism of injury (78% vs 24%, P < 0.001). Common injuries associated with sternal fracture included clavicle fracture (43%), abdominal organ injury (28%), spinal fracture (47%), lung injury (65%), and rib fracture (47%).  Sternal fracture patients were more frequently discharged to receive additional care (22% vs 5%, P < 0.001) and to die of their injuries (3.8% vs 0.9%, P < 0.001). When adjusting for other factors associated with poor outcomes, sternal fracture was not an independent predictor of mortality or discharge to care. CONCLUSIONS: Sternal fracture is a severe injury in the pediatric population, but it is not independently associated with need for a higher level of care after discharge or mortality.

Clinical Significance of Pulmonary Nodules in the Pretransplant Evaluation of Liver Transplant Recipients With Hepatocellular Carcinoma.

OBJECTIVES: Pulmonary nodules are common in patients with hepatocellular carcinoma who are being evaluated for a possible liver transplant. MATERIALS AND METHODS: In this retrospective study, we analyzed the records of liver transplant recipients at our institution with a primary diagnosis of hepatocellular carcinoma who received transplants between 2000 and 2015. All patients had magnetic resonance imaging-confirmed disease within Milan criteria and a concurrent staging chest computed tomography. Patient survival was estimated using Kaplan-Meier methods and compared between pulmonary nodule characteristic groups. A Cox proportional hazards model was constructed for adjusted analysis. RESULTS: Of the 197 liver transplant recipients who met our study inclusion criteria (median follow-up, 40 mo), 115 (58.4%) had a total of 231 pulmonary nodules, with 57 (49.6%) having multiple nodules and 108 (93.9%) having nodules ≤ 1 cm. The presence of pulmonary nodules did not negatively affect patient survival, per our univariate and multivariate analysis, nor did their presence affect their number, location, laterality, shape, edge, density, or the presence of calcifications (P ≥.05). However, pulmonary nodules ≥ 1 cm were associated with decreased overall survival. CONCLUSIONS: In our pretransplant evaluation of patients with hepatocellular carcinoma, pulmonary nodules ≤ 1 cm did not portend worse patient or graft survival posttransplant.