Association of dexmedetomidine use with haemodynamics, postoperative recovery, and cost in paediatric anaesthesia: a hospital registry study.

BACKGROUND: Dexmedetomidine utilisation in paediatric patients is increasing. We hypothesised that intraoperative use of dexmedetomidine in children is associated with longer postanaesthesia care unit length of stay, higher healthcare costs, and side-effects. METHODS: We analysed data from paediatric patients (aged 0-12 yr) between 2016 and 2021 in the Bronx, NY, USA. We matched our cohort with the Healthcare Cost and Utilization Project-Kids' Inpatient Database (HCUP-KID). RESULTS: Among 18 104 paediatric patients, intraoperative dexmedetomidine utilisation increased from 51.7% to 85.7% between 2016 and 2021 (P<0.001). Dexmedetomidine was dose-dependently associated with a longer postanaesthesia care unit length of stay (adjusted absolute difference [ADadj] 19.7 min; 95% confidence interval [CI]: 18.0-21.4 min; P<0.001, median length of stay of 122 vs 98 min). The association was magnified in children aged ≤2 yr undergoing short (≤60 min) ambulatory procedures (ADadj 33.3 min; 95% CI: 26.3-40.7 min; P<0.001; P-for-interaction <0.001). Dexmedetomidine was associated with higher total hospital costs of USD 1311 (95% CI: USD 835-1800), higher odds of intraoperative mean arterial blood pressure below 55 mm Hg (adjusted odds ratio [ORadj] 1.27; 95% CI: 1.16-1.39; P<0.001), and higher odds of heart rate below 100 beats min-1 (ORadj 1.32; 95% CI: 1.21-1.45; P<0.001), with no preventive effects on emergence delirium requiring postanaesthesia i.v. sedatives (ORadj 1.67; 95% CI: 1.04-2.68; P=0.034). CONCLUSIONS: Intraoperative use of dexmedetomidine is associated with unwarranted haemodynamic effects, longer postanaesthesia care unit length of stay, and higher costs, without preventive effects on emergence delirium.

Development and validation of a score for prediction of postoperative respiratory complications in infants and children (SPORC-C).

BACKGROUND: In infants and children, postoperative respiratory complications are leading causes of perioperative morbidity, mortality, and increased healthcare utilisation. We aimed to develop a novel score for prediction of postoperative respiratory complications in paediatric patients (SPORC for children). METHODS: We analysed data from paediatric patients (≤12 yr) undergoing surgery in New York and Boston, USA for score development and external validation. The primary outcome was postoperative respiratory complications within 30 days after surgery, defined as respiratory infection, respiratory failure, aspiration pneumonitis, pneumothorax, pleural effusion, bronchospasm, laryngospasm, and reintubation. Data from Children's Hospital at Montefiore were used to create the score by stepwise backwards elimination using multivariate logistic regression. External validation was conducted using a separate cohort of children who underwent surgery at Massachusetts General Hospital for Children. RESULTS: The study included data from children undergoing 32,187‬ surgical procedures, where 768 (2.4%) children experienced postoperative respiratory complications. The final score consisted of 11 predictors, and showed discriminatory ability in development, internal, and external validation cohorts with areas under the receiver operating characteristic curve of 0.85 (95% confidence interval: 0.83-0.87), 0.84 (0.80-0.87), and 0.83 (0.80-0.86), respectively. CONCLUSION: SPORC is a novel validated score for predicting the likelihood of postoperative respiratory complications in children that can be used to predict postoperative respiratory complications in infants and children.

A pragmatic methodology to extract anesthetic and physiological data from the electronic health record.

BACKGROUND/AIMS: Traditional manual methods of extracting anesthetic and physiological data from the electronic health record rely upon visual transcription by a human analyst that can be labor-intensive and prone to error. Technical complexity, relative inexperience in computer coding, and decreased access to data warehouses can deter investigators from obtaining valuable electronic health record data for research studies, especially in under-resourced settings. We therefore aimed to develop, pilot, and demonstrate the effectiveness and utility of a pragmatic data extraction methodology. METHODS: Expired sevoflurane concentration data from the electronic health record transcribed by eye was compared to an intermediate preprocessing method in which the entire anesthetic flowsheet narrative report was selected, copy-pasted, and processed using only Microsoft Word and Excel software to generate a comma-delimited (.csv) file. A step-by-step presentation of this method is presented. Concordance rates, Pearson correlation coefficients, and scatterplots with lines of best fit were used to compare the two methods of data extraction. RESULTS: A total of 1132 datapoints across eight subjects were analyzed, accounting for 18.9 h of anesthesia time. There was a high concordance rate of data extracted using the two methods (median concordance rate 100% range [96%, 100%]). The median time required to complete manual data extraction was significantly longer compared to the time required using the intermediate method (240 IQR [199, 482.5] seconds vs 92.5 IQR [69, 99] seconds, p = .01) and was linearly associated with the number of datapoints (rmanual = .97, p < .0001), whereas time required to complete data extraction using the intermediate approach was independent of the number of datapoints (rintermediate = -.02, p = .99). CONCLUSIONS: We describe a pragmatic data extraction methodology that does not require additional software or coding skills intended to enhance the ease, speed, and accuracy of data collection that could assist in clinician investigator-initiated research and quality/process improvement projects.

Thirty-Day Complication Rates After Gender-Affirming Bottom Surgery: An Analysis of the NSQIP Database From 2010 to 2020.

PURPOSE: Gender-affirming bottom surgeries (GABS) play a central role in treating gender dysphoria to improve quality of life for transgender and nonbinary (TGNB) patients. However, there exists limited data on operative risks and outcomes for patient populations undergoing GABS. The goal of this study is to identify sociodemographic and clinical risk factors for determining 30-day postoperative complications in patients undergoing GABS. METHODS: The ACS-NSQIP database from 2010 to 2020 was used to identify patients undergoing gender affirmation surgery (GAS) using Current Procedural Terminology (CPT) codes included in transfeminine and transmasculine bottom surgery. IBS-SPSS software was used to perform a multivariate analysis to determine risk factors for increased 30-day postoperative complications including unplanned reoperation and readmission rates. RESULTS: A total of 1809 GABS were performed in the NSQIP database from 2010 to 2020. There was an upward trend in GABS procedures throughout the years, with 2017 having the most GABS (n = 629). Transmasculine patients with a BMI of 29 and over were at a greater risk for wound complications (P < 0.05). Diabetic transfeminine patients were also at a greater risk for wound complications (P < 0.05). CONCLUSIONS: This study identified that several sociodemographic and clinical risk factors, such as BMI and diabetes mellitus type 2, had increased postoperative complications for patients undergoing gender-affirming bottom surgeries. Wound care management and patient education are essential in GABS to prevent long-term complications. Physician awareness of risk factors and social determinants of health can help prevent and improve postoperative care education and patient compliance.

Comparison of the effects of sugammadex versus neostigmine for reversal of neuromuscular block on hospital costs of care.

BACKGROUND: Sugammadex reversal of neuromuscular block facilitates recovery of neuromuscular function after surgery, but the drug is expensive. We evaluated the effects of sugammadex on hospital costs of care. METHODS: We analysed 79 474 adult surgical patients who received neuromuscular blocking agents and reversal from two academic healthcare networks between 2016 and 2021 to calculate differences in direct costs. We matched our data with data from the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) to calculate differences in total costs in US dollars. Perioperative risk profiles were defined based on ASA physical status and admission status (ambulatory surgery vs hospitalisation). RESULTS: Based on our registry data analysis, administration of sugammadex vs neostigmine was associated with lower direct costs (-1.3% lower costs; 95% confidence interval [CI], -0.5 to -2.2%; P=0.002). In the HCUP-NIS matched cohort, sugammadex use was associated with US$232 lower total costs (95% CI, -US$376 to -US$88; P=0.002). Subgroup analysis revealed that sugammadex was associated with US$1042 lower total costs (95% CI, -US$1198 to -US$884; P<0.001) in patients with lower risk. In contrast, sugammadex was associated with US$620 higher total costs (95% CI, US$377 to US$865; P<0.001) in patients with a higher risk (American Society of Anesthesiologists physical status ≥3 and preoperative hospitalisation). CONCLUSIONS: The effects of using sugammadex on costs of care depend on patient risk, defined based on comorbidities and admission status. We observed lower costs of care in patients with lower risk and higher costs of care in hospitalised surgical patients with severe comorbidities.

Publisher Correction: Super-resolution fight club: assessment of 2D and 3D single-molecule localization microscopy software.

In the version of this paper originally published, Figure 4a contained errors that were introduced during typesetting. The bottom 11° ThunderSTORM image is an xz view but was incorrectly labeled as xy, and the low x-axis value in the four line profiles was incorrectly set as -60 instead of -50. These errors have been corrected in the PDF and HTML versions of the paper.

Super-resolution fight club: assessment of 2D and 3D single-molecule localization microscopy software.

With the widespread uptake of two-dimensional (2D) and three-dimensional (3D) single-molecule localization microscopy (SMLM), a large set of different data analysis packages have been developed to generate super-resolution images. In a large community effort, we designed a competition to extensively characterize and rank the performance of 2D and 3D SMLM software packages. We generated realistic simulated datasets for popular imaging modalities-2D, astigmatic 3D, biplane 3D and double-helix 3D-and evaluated 36 participant packages against these data. This provides the first broad assessment of 3D SMLM software and provides a holistic view of how the latest 2D and 3D SMLM packages perform in realistic conditions. This resource allows researchers to identify optimal analytical software for their experiments, allows 3D SMLM software developers to benchmark new software against the current state of the art, and provides insight into the current limits of the field.

Tuning axial and lateral localization precision in 3D super-resolution microscopy with variable astigmatism.

Astigmatism imaging is a three-dimensional (3D) single molecule fluorescence microscopy approach that yields super-resolved spatial information on a rapid time scale from a single image. It is ideally suited for resolving structures on a sub-micrometer scale and temporal behavior in the millisecond regime. While traditional astigmatism imaging utilizes a cylindrical lens, adaptive optics enables the astigmatism to be tuned for the experiment. We demonstrate here how the precisions in x, y, and z are inter-linked and vary with the astigmatism, z-position, and photon level. This experimentally driven and verified approach provides a guide for astigmatism selection in biological imaging strategies.

Decreased Electroencephalographic Alpha Power During Anesthesia Induction Is Associated With EEG Discontinuity in Human Infants.

BACKGROUND: Electroencephalogram (EEG) discontinuity can occur at high concentrations of anesthetic drugs, reflecting suppression of electrocortical activity. This EEG pattern has been reported in children and reflects a deep state of anesthesia. Isoelectric events on the EEG, a more extreme degree of voltage suppression, have been shown to be associated with worse long-term neurologic outcomes in neonates undergoing cardiac surgery. However, the clinical significance of EEG discontinuities during pediatric anesthesia for noncardiac surgery is not yet known and merits further research. In this study, we assessed the incidence of EEG discontinuity during anesthesia induction in neurologically normal infants and the clinical factors associated with its development. We hypothesized that EEG discontinuity would be associated with sevoflurane-induced alpha (8-12 Hz) power during the period of anesthesia induction in infants. METHODS: We prospectively recorded 26 channels of EEG during anesthesia induction in an observational cohort of 54 infants (median age, 7.6 months; interquartile range [IQR] [4.9-9.8 months]). We identified EEG discontinuity, defined as voltage amplitude <25 microvolts for >2 seconds, and assessed its association with sevoflurane-induced alpha power using spectral analysis and multivariable logistic regression adjusting for clinically important variables. RESULTS: EEG discontinuity was observed in 20 of 54 subjects (37%), with a total of 25 discrete events. Sevoflurane-induced alpha power in the posterior regions of the head (eg, parietal or occipital regions) was significantly lower in the EEG discontinuity group (midline parietal channel on the electroencephalogram, International 10-20 System [Pz]; 8.3 vs 11.2 decibels [dBs]; P = .004), and this association remained after multivariable adjustment (adjusted odds ratio [aOR] = 0.51 per dB increase in alpha power [95% CI, 0.30-0.89]; P = .02). There were no differences in the baseline (unanesthetized) EEG between groups in alpha power or power in any other frequency band. CONCLUSIONS: We demonstrate that EEG discontinuity is common during anesthesia induction and is related to the level of sevoflurane-induced posterior alpha power, a putative marker of cortical-thalamic circuit development in the first year of life. This association persisted even after adjusting for age and propofol coadministration. The fact that this difference was only observed during anesthesia and not in the baseline EEG suggests that otherwise hidden brain circuit properties are unmasked by general anesthesia. These neurophysiologic markers observed during anesthesia may be useful in identifying patients who may have a greater chance of developing discontinuity.

Simultaneous Zygomatic Osteotomies With Reduction Mandibuloplasty - An Approach to Mid- and Lower-Facial Feminization in the Transfeminine Patient.

BACKGROUND: Facial feminization surgery (FFS) is effective at treating gender dysphoria associated with anthropometrically masculine facial features. For many transgender women, FFS is a crucial component of the gender transition process. The purpose of this study is to report our experience with a pragmatic technique for simultaneous mid- and lower-face feminization by zygomatic osteotomy malarplasty and reduction mandibuloplasty. METHODS: The technique to perform zygomatic osteotomy malarplasty and reduction mandibuloplasty is described, utilizing harvested bone from the mandible for bone grafting the zygomatic osteotomy gap. A retrospective chart review was performed for patients who underwent simultaneous middle and lower FFS using the described technique. Independent reviewers evaluated cropped preoperative and postoperative photographs of the mid and lower face and assigned each photograph a "femininity score." RESULTS: Seventeen transgender women underwent simultaneous zygomatic osteotomy malarplasty and reduction mandibuloplasty over the study period with adequate follow-up (average 11.1 months). Transient nerve weaknesses were the primary complications noted. A statistically significant improvement in femininity score was reported in postoperative photographs, compared to preoperative photographs ( P < 0.01). CONCLUSIONS: The technique described in this study is an effective application of craniofacial approaches and techniques for feminizing the facial skeleton in transgender women by utilizing harvested mandibular bone for simultaneous malarplasty.

Microscope calibration protocol for single-molecule microscopy.

Single-molecule microscopy allows for the investigation of the dynamics of individual molecules and the visualization of subcellular structures at high spatial resolution. For single-molecule imaging experiments, and particularly those that entail the acquisition of multicolor data, calibration of the microscope and its optical components therefore needs to be carried out at a high level of accuracy. We propose here a method for calibrating a microscope at the nanometer scale, in the sense of determining optical aberrations as revealed by point source localization errors on the order of nanometers. The method is based on the imaging of a standard sample to detect and evaluate the amount of geometric aberration introduced in the optical light path. To provide support for multicolor imaging, it also includes procedures for evaluating the geometric aberration caused by a dichroic filter and the axial chromatic aberration introduced by an objective lens.

Electroencephalographic assessment of infant spinal anesthesia: A pilot prospective observational study.

INTRODUCTION: Spinal anesthesia is utilized as an alternative to general anesthesia in infants for some surgeries. After spinal anesthesia, infants often become less conscious without administration of sedative medications. The aim of this study was to assess electroencephalographic (EEG) correlates after spinal anesthesia in a cohort of infants. PATIENTS AND METHODS: This pilot study included 12 infants who underwent spinal anesthesia. Unprocessed electroencephalography was recorded. The electroencephalogram was interpreted by four neurologists. Processed analyses compared electroencephalogram changes 30 min after spinal anesthesia to baseline. RESULTS: Following spinal anesthesia, all 12 infants became sedated. Electroencephalography in all 12 demonstrated Stage 2 sleep with the appearance of sleep spindles (12-14 Hz) in the frontal and central leads in 8/12 (67%) of subjects. The median time to onset of sleep spindles was 24.7 interquartile range (21.2, 29.9) min. The duration of sleep spindles was 25.1 interquartile range (5.8, 99.8) min. Voltage attenuation and background slowing were the most common initial changes. Compared to baseline, the electroencephalogram 30 min after spinal anesthesia showed significantly increased absolute delta power (p = 0.02) and gamma power (p < 0.0001); decreases in beta (p = 0.0006) and higher beta (p < 0.0001) were also observed. The Fast Fourier Transform power ratio difference for delta/beta was increased (p = 0.03). Increased coherence was noted in the delta (p = 0.02) and theta (p = 0.04) bandwidths. DISCUSSION: Spinal anesthesia in infants is associated with increased electroencephalographic slow wave activity and decreased beta activity compared to the awake state, with appearance of sleep spindles suggestive of normal sleep. The etiology and significance of the observed voltage attenuation and background slowing remains unclear. CONCLUSIONS: The EEG signature of infant spinal anesthesia is distinct from that seen with general anesthesia and is consistent with normal sleep. Further investigation is required to better understand the etiology of these findings. Our preliminary findings contribute to the understanding of the brain effects of spinal anesthesia in early development.

Clinical Characteristics and Outcomes of Hospitalized and Critically Ill Children and Adolescents with Coronavirus Disease 2019 at a Tertiary Care Medical Center in New York City.

OBJECTIVE: To describe the clinical profiles and risk factors for critical illness in hospitalized children and adolescents with coronavirus disease 2019 (COVID-19). STUDY DESIGN: Children 1 month to 21 years of age with COVID-19 from a single tertiary care children's hospital between March 15 and April 13, 2020 were included. Demographic and clinical data were collected. RESULTS: In total, 67 children tested positive for COVID-19; 21 (31.3%) were managed as outpatients. Of 46 admitted patients, 33 (72%) were admitted to the general pediatric medical unit and 13 (28%) to the pediatric intensive care unit (PICU). Obesity and asthma were highly prevalent but not significantly associated with PICU admission (P = .99). Admission to the PICU was significantly associated with higher C-reactive protein, procalcitonin, and pro-B type natriuretic peptide levels and platelet counts (P < .05 for all). Patients in the PICU were more likely to require high-flow nasal cannula (P = .0001) and were more likely to have received Remdesivir through compassionate release (P < .05). Severe sepsis and septic shock syndromes were observed in 7 (53.8%) patients in the PICU. Acute respiratory distress syndrome was observed in 10 (77%) PICU patients, 6 of whom (46.2%) required invasive mechanical ventilation for a median of 9 days. Of the 13 patients in the PICU, 8 (61.5%) were discharged home, and 4 (30.7%) patients remain hospitalized on ventilatory support at day 14. One patient died after withdrawal of life-sustaining therapy because of metastatic cancer. CONCLUSIONS: We describe a higher than previously recognized rate of severe disease requiring PICU admission in pediatric patients admitted to the hospital with COVID-19.

Electroencephalographic Findings and Clinical Behavior During Induction of Anesthesia With Sevoflurane in Human Infants: A Prospective Observational Study.

Seizures and interictal epileptiform discharges (IEDs) have been described during sevoflurane. We prospectively estimated their incidence in 54 otherwise neurologically healthy infants by obtaining the full-head video electroencephalogram (EEG). No infants had clinical seizures, but 1 had an electrographic seizure; 3 others had focal IEDs (7.4%; 95% confidence interval [CI], 2.1%-17.9%). We detected no differences in demographic or clinical characteristics between normal and abnormal EEG groups. Diffuse slowing was the most common initial EEG change followed by fast (α, ß) activity in all head leads. Larger studies with more statistical power are needed to further investigate the hypotheses generated with this research.

Optimizing Perioperative Red Blood Cell Utilization and Wastage in Pediatric Craniofacial Surgery.

Utilization, wastage, and adverse consequences of assigning one full red blood cell (RBC) unit were investigated for children undergoing craniosynostosis surgery. The authors hypothesized that significant RBC wastage in the perioperative period exists for pediatric craniofacial surgery. The authors sought to determine what factors could guide patient-specific blood product preparation by evaluating utilization and wastage of RBCs in pediatric patients undergoing surgical correction of craniosynostosis. Eighty-five children with craniosynostosis undergoing surgical correction at our institution between July 2013 and June 2015 were identified. Fifty-three patients received RBC transfusion in the perioperative period, while 32 patients were not transfused. Primary outcome measures were intraoperative, postoperative, and total percent of RBC wastage. Secondary analysis compared the impact of patient weight and procedure type on perioperative RBC wastage. Of the 53 patients who received perioperative RBC transfusion, 35 patients received a volume of blood less than the full volume of the RBC unit while 18 patients received the full volume of blood. There was no significant relationship between perioperative RBC wastage, the type of craniofacial procedure performed, or the duration of surgical time. Children who received a perioperative transfusion and had RBC wastage weighed significantly less than those who received a full volume. These findings suggest that for craniofacial surgical patients weighing less than 10 kg, a protocol that splits cross-matched RBC units can decrease perioperative RBC wastage and blood donor exposure. A future prospective study will determine the success of this intervention as well as the potential to decrease exposure to multiple blood donors.

A Novel Application of Virtual Surgical Planning to Facial Feminization Surgery.

Feminization of the frontonasal-orbital complex is a critical aspect in surgical management of gender dysphoria. Here, we describe our utilization of a prefabricated cutting guide to facilitate frontal sinus setback.

The Impact of Ethnicity on Craniosynostosis in the United States.

While many studies have examined potential risk factors for nonsyndromic craniosynostosis, there have been no publications to date investigating the role of ethnicity in the United States. The current study was undertaken as the first multi-center investigation to examine the relationship between ethnicity and nonsyndromic craniosynostosis, looking at both overall prevalence as well as potential correlation between ethnicity and pattern of affected suture site. A chart review of patients diagnosed with nonsyndromic craniosynostosis treated at four major children's hospitals was performed to obtain ethnicity data. Analysis was preformed based on ethnic group as well as suture site affected. To account for potentialOne regional selection bias, the KID database (1997-2012) was utilized to identify all cases of craniosynostosis on a national level. This data was analyzed against birth rates by ethnicity obtained from CDC WONDER natality database.Amongst the 2112 cases of nonsyndromic craniosynostosis at all institutions, Caucasians and African Americans were consistently the predominant ethnic groups. There was a statistically significant difference in the distribution of affected suture type with African Americans more likely to present with unicoronal synostosis and Caucasians more likely to present with metopic synostosis (P = 0.005). The national data revealed that there were more cases of craniosynostosis in Caucasians and fewer in African Americans than expected when compared to population birth rates. Our findings demonstrate that the Caucasian race is associated with increased rates of synostosis.

A Novel Association of Martorell Ulcer With Liddle Syndrome.

Pseudohyperaldosteronism, or Liddle syndrome, is a rare, autosomal dominant condition characterized by early-onset hypertension, often associated with hypokalemia and metabolic alkalosis. Martorell hypertensive ischemic leg ulcer is a rare, underdiagnosed ulcer characterized by subcutaneous arteriolosclerosis, classically appearing over the dorsolateral lower extremity or Achilles tendon in patients with hypertension and diabetes. It presents an important diagnostic challenge because it can appear grossly similar to other entities such as pyoderma gangrenosum or venous stasis ulcers, but requires surgical intervention. This article presents a case study of surgical management of a Martorell ulcer in a 69-year-old woman with Liddle syndrome. To the authors' knowledge, this is the first case reported in the literature of this rare ulcer occurring secondary to this rare cause of hypertension.