Adenotonsillectomy for obstructive sleep apnea in children with cerebral palsy: Risks and benefits.

OBJECTIVES: To determine outcomes following adenotonsillectomy for obstructive sleep apnea (OSA) and the impact of motor and swallowing impairment on respiratory complications in children with Cerebral Palsy (CP). METHODS: A retrospective review of children with CP and sleep disordered breathing (SDB) who underwent adenotonsillectomy (2003-2021) was performed. Children with CP were age-matched to children without CP. Motor and swallowing function was assessed using the Gross Motor Functional Classification System (GMFCS) and the Eating and Drinking Ability Classification System (EDACS). The primary outcome was postoperative obstructive apnea-hypopnea index (OAHI). Secondary outcomes were cure rate, complications, and need for additional interventions. RESULTS: Ninety-seven children with CP were assessed for SDB, and 74 underwent polysomnography. Moderate or severe OSA was found in 49% (36/74). Adenotonsillectomy was performed in 30% (29/97). All children who underwent adenotonsillectomy experienced an initial reduction in OAHI (31.7/h to 2.9/h, p < 0.0001). Children with CP were less likely to achieve an OAHI<1 compared with children without CP (62.5% vs 81.8%, p = 0.23). Children with CP had more postoperative complications (43.5% vs. 8.7%) and greater odds of respiratory complications compared with children without CP (OR 8.9 95% CI 2.1-37.9). Children with CP and a GMFCS score of 5 and EDACS score between 3 and 5 had more respiratory complications post-adenotonsillectomy compared to those with GMFCS<5 (p = 0.002) and EDACS<3 (p = 0.031). CONCLUSION: Children with CP had an improved OAHI initially following adenotonsillectomy but had higher rates of post-adenotonsillectomy complications. Respiratory complications after adenotonsillectomy were more common in children with motor and swallowing impairment. Findings may provide better preoperative planning for caregivers.

Adapting medical education during crisis: Student-Faculty partnerships as an enabler of success.

Restrictions imposed by the COVID-19 pandemic have required medical educators to reimagine almost every aspect of undergraduate medical training, including curriculum delivery and assessments in a short timeline. In this personal view article, executive members of the University of Toronto medical student government and Faculty leads of pre-clerkship and clerkship education highlight five practical ways in which a student-Faculty partnership enabled the rapid and smooth adaptation of curricula during the COVID-19 pandemic. These included involving students as partners in decision making to contribute learner perspectives early, agile and collaborative meeting structures, frequent and consistent communication with the student body, providing learners with Faculty perspectives from the frontlines, and striking a balance in the level of feedback collected from students. These strategies may be of utility to medical administrators, educators, and student leaders in future crises affecting medical learners.

Risks and Benefits of Adenotonsillectomy in Children With Cerebral Palsy With Obstructive Sleep Apnea: A Systematic Review.

OBJECTIVES/HYPOTHESIS: Assess the risks and benefits of adenotonsillectomy (AT) for obstructive sleep apnea (OSA) in children with cerebral palsy (CP). STUDY DESIGN: Systematic review. METHODS: We conducted a systematic review of Medline, Embase, and Cochrane Central Registry from 1946 to 2021. Broad search concepts included cerebral palsy, pediatric, tonsillectomy/adenoidectomy, and sleep. Additional articles were identified by searching reference lists. Studies on the safety and efficacy of AT for OSA management in children with CP were included. RESULTS: Fifteen articles met inclusion criteria. Articles were classified into one or more of four themes: intraoperative risk (n = 1), postoperative risk (n = 3), postoperative care requirements (n = 6), and surgical outcomes (n = 7). No intraoperative anesthetic complications were reported. Postoperatively, respiratory complications including pneumonia were common and necessitated additional airway management. Following AT, children with CP required close postoperative observation, experienced increased lengths of stay, and had increased odds of unplanned intensive care unit (ICU) admission. Benefits following AT were improvement in OSA as measured by a reduction in obstructive apnea-hypopnea index (OAHI) as well as improved quality of life in some; however, many patients went on to require tracheostomy due to persistent OSA. CONCLUSIONS: Children with CP who undergo AT have a significant risk of developing a postoperative respiratory complication. Realistic counseling of families around increased perioperative risks in this population is imperative and close postoperative monitoring is critical. Many children will obtain a reduction in OAHI, but additional surgical management is often required, including tracheostomy. Further research is needed to determine the best management strategy for OSA in children with CP. Laryngoscope, 132:687-694, 2022.

Outpatient versus inpatient superficial parotidectomy: clinical and pathological characteristics.

BACKGROUND: Superficial parotidectomy has a potential to be performed as an outpatient procedure. The objective of the study is to evaluate the safety and selection profile of outpatient superficial parotidectomy compared to inpatient parotidectomy. METHODS: A retrospective review of individuals who underwent superficial parotidectomy between 2006 and 2016 at a tertiary care center was conducted. Primary outcomes included surgical complications, including transient/permanent facial nerve palsy, wound infection, hematoma, seroma, and fistula formation, as well as medical complications in the postoperative period. Secondary outcome measures included unplanned emergency room visits and readmissions within 30 days of operation due to postoperative complications. RESULTS: There were 238 patients included (124 in outpatient and 114 in inpatient group). There was no significant difference between the groups in terms of gender, co-morbidities, tumor pathology or tumor size. There was a trend towards longer distance to the hospital from home address (111 Km in inpatient vs. 27 in outpatient, mean difference 83 km [95% CI,- 1 to 162 km], p = 0.053). The overall complication rates were comparable between the groups (24.2% in outpatient group vs. 21.1% in inpatient, p = 0.56). There was no difference in the rate of return to the emergency department (3.5% vs 5.6%, p = 0.433) or readmission within 30 days (0.9% vs 0.8%, p = 0.952). CONCLUSION: Superficial parotidectomy can be performed safely as an outpatient procedure without elevated risk of complications.

PACS-1 and adaptor protein-1 mediate ACTH trafficking to the regulated secretory pathway.

The regulated secretory pathway is a specialized form of protein secretion found in endocrine and neuroendocrine cell types. Pro-opiomelanocortin (POMC) is a pro-hormone that utilizes this pathway to be trafficked to dense core secretory granules (DCSGs). Within this organelle, POMC is processed to multiple bioactive hormones that play key roles in cellular physiology. However, the complete set of cellular membrane trafficking proteins that mediate the correct sorting of POMC to DCSGs remain unknown. Here, we report the roles of the phosphofurin acidic cluster sorting protein - 1 (PACS-1) and the clathrin adaptor protein 1 (AP-1) in the targeting of POMC to DCSGs. Upon knockdown of PACS-1 and AP-1, POMC is readily secreted into the extracellular milieu and fails to be targeted to DCSGs.

In-hospital outcomes after switching from a bivalirudin-first strategy to an unfractionated heparin-first strategy for percutaneous coronary interventions.

BACKGROUND: The optimal anticoagulation strategy for percutaneous coronary interventions (PCIs) remains debated. We report outcomes after switching from a bivalirudin-first to an unfractionated heparin (UFH)-first strategy for PCIs in a large academic center. METHODS: Patients undergoing PCI from June 1st 2013-May 31st, 2015 were identified through the National Cardiovascular Data Registry (NCDR), and divided into the "bivalirudin era" (June 2013-July 2014) and the "UFH era" (October 2014-May 2015). Bleeding outcomes were compared using multivariable logistic regression adjusted for potential confounders. RESULTS: A total of 1,145 patients were identified (bivalirudin era =752, UFH era =393). Radial access for PCI increased over time, and was lower in the bivalirudin era (26% vs. 34%, P<0.05). There were 32 major bleeds (4.3%) in the bivalirudin era and 29 major bleeds (7.4%) in the UFH era (P=0.03), with the majority being hemoglobin drops (≥3 g/dL) without overt clinical bleeding (85.7% of bleeds in the bivalirudin era and 86.2% of bleeds in the UFH era). After adjustments for other common major causes of bleeding, bivalirudin was associated with 78% lower odds of bleeding (OR =0.22; 95% CI: 0.05-0.91). CONCLUSIONS: An increase in major bleeding events occurred after switching to an UFH-first strategy, primarily associated with hemoglobin drop (≥3 g/dL) without overt clinical bleeding. Major overt bleeding was rare (0.3%) and similar in both groups. These results suggest a UFH-first strategy for PCI may have a role in patients with low bleeding risk.

Management of Percutaneous Coronary Intervention Complications.

OPINION STATEMENT: With the recent increase in complex coronary interventions including percutaneous coronary intervention (PCI) for chronic total occlusions and complex higher risk (and indicated) patients, the spectrum of potential periprocedural complications and their prompt management has become even more relevant. Vascular access-related problems remain the most prevalent of all PCI complications and with randomized controlled trial data from over 20,000 patients supporting the superiority of radial over femoral access in reducing bleeding and vascular complications, a default radial strategy should be promoted. The European Society of Cardiology guidelines have acknowledged this by giving a class 1 (level of evidence: A) recommendation for a radial approach for PCI. The US society guidelines, however, have thus far lagged behind. Each individual patient undergoing a PCI should be risk-stratified objectively using available risk prediction models based on patient comorbidities and anatomical and procedural complexities. Customized informed consent should therefore be provided to all patients and should include the potential risks from radiation injury. Here, we review the current data related to common periprocedural complications related to PCI.

Interpreting cardiac troponin results from highly sensitive assays in patients with chronic kidney disease: acute coronary syndromes and beyond.

Cardiac troponin assays have become an indispensable tool in the diagnosis of acute myocardial infarction (MI). However, asymptomatic patients with chronic kidney disease often exhibit elevated levels of cardiac troponins with near ubiquitous detection using the new high-sensitive assays. This poses a challenge to physicians faced with differentiating between acute MI and a noncardiac etiology of chest pain or equivalent. Rather than rely on absolute cutoffs it is necessary to follow trends in levels at least over several hours. Even in the absence of an acute MI there is an association between chronic elevations of these biomarkers, underlying structural heart disease and poor prognosis. Although in the chronic setting the underlying cause of cardiac troponin elevation is likely a combination of factors, it should prompt further investigation for modifiable risk factors.

Lysophosphatidic acid receptors 1 and 2 play roles in regulation of vascular injury responses but not blood pressure.

Phenotypic modulation of vascular smooth muscle cells (SMCs) is essential for the development of intimal hyperplasia. Lysophosphatidic acid (LPA) is a serum component that can promote phenotypic modulation of cultured SMCs, but an endogenous role for this bioactive lipid as a regulator of SMC function in vivo has not been established. Ligation injury of the carotid artery in mice increased levels in the vessel of both autotaxin, the lysophospholipase D enzyme responsible for generation of extracellular LPA, and 2 LPA responsive G protein-coupled receptors 1 (LPA1) and 2 (LPA2). LPA1(-/-)2(-/-) mice were partially protected from the development of injury-induced neointimal hyperplasia, whereas LPA1(-/-) mice developed larger neointimal lesions after injury. Growth in serum, LPA-induced extracellular signal-regulated protein kinase activation, and migration to LPA and serum were all attenuated in SMCs isolated from LPA1(-/-)2(-/-) mice. In contrast, LPA1(-/-) SMCs exhibited enhanced migration resulting from an upregulation of LPA3. However, despite their involvement in intimal hyperplasia, neither LPA1 nor LPA2 was required for dedifferentiation of SMCs following vascular injury or dedifferentiation of isolated SMCs in response to LPA or serum in vitro. Similarly, neither LPA1 nor LPA2 was required for LPA to elicit a transient increase in blood pressure following intravenous administration of LPA to mice. These results identify a role for LPA1 and LPA2 in regulating SMC migratory responses in the context of vascular injury but suggest that additional LPA receptor subtypes are required for other LPA-mediated effects in the vasculature.