Utilization of immediate extubation in a multidisciplinary pathway for pediatric liver transplantation associated with improved postoperative outcomes.

BACKGROUND: Immediate extubation is becoming more common in liver transplantation. However, limited data exist on how to identify pediatric patients with potential for successful immediate extubation and how this intervention may affect recovery. METHODS: This retrospective review evaluated patients who underwent liver transplantation from 2015 to 2021 at Children's Healthcare of Atlanta. Preoperative status and intraoperative management were evaluated and compared. Outcomes comprised thrombosis, surgical reexploration, retransplantation, as well as reintubation, high flow nasal cannula (HFNC) usage, postoperative infection, the length of stay (LOS), and mortality. RESULTS: A total of 173 patients were analyzed, with 121 patients (69.9%) extubated immediately. The extubation group had older age (median 4.0 vs 1.25 years, p = .048), lower PELD/MELD (28 vs. 34, p = .03), decreased transfusion (10.2 vs. 41.7 mL/kg, p < .001), shorter surgical time (332 vs. 392 min, p < .001), and primary abdominal closure (81% vs. 40.4%, p < .001). Immediate extubation was associated with decreased HFNC (0.21 vs. 0.71 days, p = .02), postoperative infection (9.9% vs. 26.9%, p = .007), mortality (0% vs. 5.8%, p = .036), and pediatric intensive care unit LOS (4.7 vs. 11.4 days, p < .001). The complication rate was lower in the extubation group (24.8% vs. 36.5%), but not statistically significant. CONCLUSIONS: Approximately 70% of patients were able to be successfully extubated immediately, with only 2.5% requiring reintubation. Those immediately extubated had decreased need for HFNC, lower infection rates, shorter LOS, and decreased mortality. Our results show that with proper patient selection and a multidisciplinary approach, immediate extubation allows for improved recovery without increased respiratory complications after pediatric liver transplantation.

Management and outcomes of obstructive sleep apnea in infants.

OBJECTIVE: To characterize the clinical characteristics of infants with obstructive sleep apnea (OSA), define the resolution rate of infant OSA, and identify factors associated with OSA resolution. METHODS: We identified infants diagnosed with OSA via retrospective chart review at less than one year of age at a tertiary care center. We identified patient comorbidities, flexible or rigid airway evaluations, surgical procedures, and oxygen/other respiratory support administration. We identified infants as having resolved OSA based on clinical or polysomnogram resolution. We compared the frequency of comorbid diagnoses and receipt of interventions in infants with resolved versus non-resolved OSA by χ2 analysis. RESULTS: 83 patients were included. Prematurity was found in 35/83 (42%), hypotonia-related diagnoses in 31/83 (37%), and craniofacial abnormalities in 34/83 (41%). Resolution was observed in 61/83 (74%), either clinically or by polysomnogram, during follow up. On χ2 analysis, surgical intervention was not associated with likelihood of resolution (73% versus 74% in those without surgical intervention, p = 0.98). Patients with airway abnormalities on flexible or rigid evaluation were less likely to have OSA resolution than those without (63% versus 100%, p = 0.010), as were patients with hypotonia-related diagnoses (58% versus 83%, p = 0.014). In patients with laryngomalacia, there was no association of supraglottoplasty with increased resolution (88% with supraglottoplasty versus 80% without, p = 1.00). CONCLUSIONS: We identified a group of infants with OSA with diverse comorbidities. There was a high rate of resolution. This data can assist with treatment planning and family counselling for infants with OSA. A prospective clinical trial is needed to better assess consequences of OSA in this age.

Critical Degree of Orbital Floor Displacement Drives Operative Repair of Zygomaticomaxillary Complex Fractures: Findings from a 10-Year Retrospective Study.

Among zygomaticomaxillary complex (ZMC) fractures presenting to a tertiary urban academic center, the authors hypothesized the presence of both clinical and radiographic predictors of operative management. The investigators conducted a retrospective cohort study of 1,914 patients with facial fractures managed at an academic medical center in New York City between 2008 and 2017. The predictor variables were based on both clinical data and features of pertinent imaging studies, and the outcome variable was an operative intervention. Descriptive and bivariate statistics were computed and the p-value was set at 0.05. In total, 196 patients sustained ZMC fractures (5.0%) and 121 (61.7%) ZMC fractures were treated surgically. All patients who presented with globe injury, blindness, retrobulbar injury, restricted gaze, or enophthalmos and a concurrent ZMC fracture were managed surgically. The most common surgical approach was the gingivobuccal corridor (31.9% of all approaches), and there were no significant immediate postoperative complications. Younger patients (38.9 ± 18 years vs. 56.1 ± 23.5 years, p < 0.0001) and patients with greater than or equal to 4 mm of orbital floor displacement were more likely to receive surgical treatment than observation (82 vs. 56%, p = 0.045), as were patients with comminuted orbital floor fractures (52 vs. 26%, p = 0.011). In this cohort, patients more likely to undergo surgical reduction were young patients with ophthalmologic symptoms on presentation and at least 4 mm displacement of the orbital floor. Low kinetic energy ZMC fractures may warrant surgical management as often as high-energy ZMC fractures. While orbital floor comminution has been shown to be a predictor for operative reduction, in this study we also demonstrated a difference in the rate of reduction based on the severity of orbital floor displacement. This may have significant implications in both the triage and selection of patients most suitable for operative repair.

Risk Factors for Post-Tonsillectomy Respiratory Events in Children With Severe Obstructive Sleep Apnea.

OBJECTIVES/HYPOTHESIS: To identify risk factors for postoperative respiratory events in pediatric patients with severe obstructive sleep apnea (OSA). METHODS: Retrospective single-institution retrospective cohort study of pediatric patients with severe OSA who were admitted postoperatively after tonsillectomy. Patients who experienced respiratory events after surgery were identified and differences between the respiratory event and no event groups were compared. RESULTS: There were 887 patients included in this study. 14.8% (n = 131) experienced a documented respiratory event. The following risk factors were found to be most significant: %sleep time with O2  < 90% (tb90) (95% CI = 1.07-1.14, OR = 1.10, p < 0.001), Black race (95% CI = 1.53-3.58, OR = 2.34, p < 0.001), primary neurologic co-morbidity (1.67-6.32, OR = 3.27, p < 0.001), Down syndrome (1.25-5.94, OR = 2.72, p = 0.01), and age (0.84-0.94, OR = 0.88, p < 0.001). Regression modeling demonstrated that the rate of respiratory events increased with tb90. CONCLUSIONS: Our results demonstrate that there are other potential risk factors outside of AHI and O2 nadir that are associated with respiratory events after tonsillectomy. Black race and prolonged desaturations during polysomnography (PSG) are independent risk factors. Measures of abnormal gas exchange on PSG may be better at identifying at risk patients. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1251-1256, 2023.

Prevalence of Emergence Delirium in Children Undergoing Tonsillectomy and Adenoidectomy.

Objective: Emergence delirium (ED) is associated with behavioral disturbances and psychomotor agitation, increased risk of selfinjury, delayed discharge, and parental dissatisfaction with quality of care. Otolaryngology procedures are associated with an increased risk of ED. The aims of this study were to determine the prevalence of ED in children who had tonsillectomy and adenoidectomy (T&A), assess the characteristics of children who had ED, and ascertain the recovery times of patients with ED. Methods: Charts of patients who had tonsillectomy and adenoidectomy between Jan 1, 2018 and March 26, 2020 at a tertiary children's hospital were reviewed. Data collection included demographics, body mass index, indication for T&A, Pediatric Anesthesia Emergence Delirium (PAED) score, American Society of Anesthesiologists (ASA) physical status classification, total anesthesia time, postanesthesia care phase I time, and postanesthesia care phase II time. Results: Of the 4974 patients who underwent T&A, ED occurred in 1.3% of patients. Toddlers (2.9%) and male children (1.6%) had a significantly higher prevalence of ED. Prevalence of ED was similar amongst patients with recurrent tonsillitis, patients with obstructive sleep disordered breathing, and patients with both obstructive sleep apnea (OSA) and recurrent tonsillitis. The prevalence of ED was not different amongst ASA I, ASA II, and ASA III. Males with ED had longer total anesthesia times (41 v. 34 minutes, p=0.02) and ASA I patients with ED had longer phase I times (p=0.04) in the postanesthesia care unit (PACU). There was no significant difference in total anesthesia time, phase I time, or phase II time when compared across the subgroups of gender, age, indication for T&A, severity of obstructive sleep apnea (OSA), and ASA score. Conclusions: Males, toddlers, and preschool-age children were more likely to have ED. Males with ED had longer total anesthesia times. ED was associated with longer phase I times in ASA I patients.

Essential inpatient otolaryngology: what COVID-19 has revealed.

PURPOSE: To identify areas of critical otolaryngology contributions to inpatient care resistant to disruption by the COVID-19 pandemic. METHODS: Medical records of 614 otolaryngology consults seen between January and June of 2019 and 602 seen between January and June of 2020 were reviewed. Extracted data included patient demographics, SARS-CoV-2 status, medical comorbidities, consult location, consult category, reason for consult, procedures performed, and overall outcome. Prevalence of data items was compared using t tests and Chi-squared tests. RESULTS: The number of monthly consults to the otolaryngology service remained approximately stable after the onset of the COVID-19 pandemic. However, there was a substantial increase in ICU consults and a decrease in ER and floor consults. The proportion of otology, rhinology, and head and neck consults decreased while that of airway consults-most of which were tracheostomy-related-greatly increased. While the top ten reasons for consult remained essentially the same, they dramatically increased as a percentage of consults during COVID-19 (55-92%), whereas there was a dramatic decrease in the proportion of less frequent consults. CONCLUSION: The changes in otolaryngology consultation patterns seen after the onset of the pandemic are multifactorial, but may be attributed to novel pathologies, attitudes, and policies. Nonetheless, these patterns reveal that a set of core otolaryngologic issues, including acute airway issues, head and neck lesions, severe sinusitis and epistaxis, are essential and need to be addressed in the inpatient setting, whereas the significant drop in other consults suggests that they may be appropriately managed on an outpatient basis.

Anesthetic Management of Children With Propionic Acidemia Undergoing Esophagogastroduodenoscopy.

Propionic acidemia is a rare genetic disorder of metabolism that predisposes patients to metabolic acidosis, lethargy, neurologic dysfunction, developmental delays, and cardiomyopathy. Perioperative anesthetic management is guided toward mitigating the effects of preoperative fasting times, maintaining normovolemia, and preventing cardiovascular complications secondary to underlying cardiomyopathy. Commonly used anesthetic agents may have undesirable side effects in these patients. Propofol, the lactate in Lactated Ringer's, and neuromuscular blocking agents that undergo ester hydrolysis are poorly metabolized and can lead to metabolic acidosis. Opioids, such as fentanyl and morphine, should be used judiciously in patients with coexisting developmental delays to avoid oversedation and delayed time to resuming oral intake postanesthesia. In addition, inhaled anesthetics have direct myocardial depressive effects and can compromise cardiac function in the setting of pre-existing cardiomyopathy. The perioperative period represents a critical time in this population and appropriate planning is crucial to prevent perioperative morbidity. We present a case of an eight-year-old child undergoing esophagogastroduodenoscopy under general anesthesia and describe the anesthetic concerns we addressed to provide a safe perioperative course.

Trends in Patient, Physician, and Public Perception of Ulnar Collateral Ligament Reconstruction Using Social Media Analytics.

BACKGROUND: Social media posts regarding ulnar collateral ligament (UCL) injuries and reconstruction surgeries have increased in recent years. PURPOSE: To analyze posts shared on Instagram and Twitter referencing UCL injuries and reconstruction surgeries to evaluate public perception and any trends in perception over the past 3 years. STUDY DESIGN: Cross-sectional study. METHODS: A search of a 3-year period (August 2016 and August 2019) of public Instagram and Twitter posts was performed. We searched for >22 hashtags and search terms, including #TommyJohn, #TommyJohnSurgery, and #tornUCL. A categorical classification system was used to assess the sentiment, media format, perspective, timing, accuracy, and general content of each post. Post popularity was measured by number of likes and comments. RESULTS: A total of 3119 Instagram posts and 267 Twitter posts were included in the analysis. Of the 3119 Instagram posts analyzed, 34% were from patients, and 28% were from providers. Of the 267 Twitter posts analyzed, 42% were from patients, and 16% were from providers. Although the majority of social media posts were of a positive sentiment, over the past 3 years, there was a major surge in negative sentiment posts (97% increase) versus positive sentiment posts (9% increase). Patients were more likely to focus their posts on rehabilitation, return to play, and activities of daily living. Providers tended to focus their posts on education, rehabilitation, and injury prevention. Patient posts declined over the past 3 years (-28%), whereas provider posts increased substantially (110%). Of posts shared by health care providers, 4% of posts contained inaccurate or misleading information. CONCLUSION: The majority of patients who post about their UCL injury and reconstruction on social media have a positive sentiment when discussing their procedure. However, negative sentiment posts have increased significantly over the past 3 years. Patient content revolves around rehabilitation and return to play. Although patient posts have declined over the past 3 years, provider posts have increased substantially with an emphasis on education.

Anesthetic management of children undergoing drug-induced sleep endoscopy: A retrospective review.

OBJECTIVE: To determine the best anesthetic technique for DISE based on a retrospective review of the current literature and to highlight research gaps that should be addressed in future studies. METHODS: A comprehensive retrospective review of the literature on anesthetic regimens for pediatric DISE through March 2020 was performed. Specific medical subject heading (MesH) terms included: drug-induced sleep endoscopy and anesthesia, DISE, child, obstructive sleep apnea, sleep disordered breathing. RESULTS: Twelve articles were included. One study was a retrospective comparative study while the remaining 11 were case series. Five studies described anesthetic technique for DISE pre-T&A, two post-T&A, and four both pre- and post-T&A. The heterogeneity of the studies did not allow for a meta-analysis. A total of 1110 children ages 2 months to 19 years were included. Sedation depth and anesthetic outcomes with DISE were infrequently described. Eleven studies used a sevoflurane inhalational induction and mostly transitioned to a total IV anesthetic for maintenance. Propofol was the most commonly used sole anesthetic. A total of three studies used a combination of remifentanil and propofol, one used dexmedetomidine alone, one used sevoflurane alone, and one compared different regimens. Dexmedetomidine and ketamine have the most favorable profile for pediatric DISE but are not universally used. DISE completion, as reported in two studies, was 93% and 100%. CONCLUSION: There are several anesthetic regimens for DISE that achieve good sedation and outcomes. The combination of ketamine and dexmedetomidine may be the ideal regimen. Limited data and lack of protocols/high-quality studies exist on anesthetic regimens for pediatric DISE.

Regionally specified human pluripotent stem cell-derived astrocytes exhibit different molecular signatures and functional properties.

Astrocytes display diverse morphologies in different regions of the central nervous system. Whether astrocyte diversity is attributable to developmental processes and bears functional consequences, especially in humans, is unknown. RNA-seq of human pluripotent stem cell-derived regional astrocytes revealed distinct transcript profiles, suggesting differential functional properties. This was confirmed by differential calcium signaling as well as effects on neurite growth and blood-brain barrier formation. Distinct transcriptional profiles and functional properties of human astrocytes generated from regionally specified neural progenitors under the same conditions strongly implicate the developmental impact on astrocyte diversity. These findings provide a rationale for renewed examination of regional astrocytes and their role in the pathogenesis of psychiatric and neurological disorders.

Retrieval of ocean subsurface particulate backscattering coefficient from space-borne CALIOP lidar measurements.

A new approach has been proposed to determine ocean subsurface particulate backscattering coefficient bbp from CALIOP 30° off-nadir lidar measurements. The new method also provides estimates of the particle volume scattering function at the 180° scattering angle. The CALIOP based layer-integrated lidar backscatter and particulate backscattering coefficients are compared with the results obtained from MODIS ocean color measurements. The comparison analysis shows that ocean subsurface lidar backscatter and particulate backscattering coefficient bbp can be accurately obtained from CALIOP lidar measurements, thereby supporting the use of space-borne lidar measurements for ocean subsurface studies.

Working words: real-life lexicon of North American workers.

OBJECTIVE: This study describes a new computer methodology for analyzing workers' free text work descriptions. METHODS: Computerized lexical analysis was applied to work descriptions of participants in the Lung Health Study, a smoking-cessation study in persons with early chronic obstructive pulmonary disease. Text was parsed and analyzed as single term roots and pairs of roots commonly occurring together. RESULTS: The frequencies of terms reflect the work of a population; our subjects' most frequently used terms included "sale, office, service, business, engine[er], secretary, construct, driv[e], comput[e], teach, truck." Standard classification schemes (NAICS and SOC) and textbooks use terms inconsistent with those of actual workers. Many common empirical terms imply both industry and job information content, although traditional coding schemes separate industry and job title. CONCLUSIONS: Formal analyses of language may facilitate communication, identify translation priorities, and allow automated work coding.