Airway Management in Pierre Robin Sequence: The Vancouver Classification.

BACKGROUND: Pierre Robin sequence (PRS) is a triad of micrognathia, glossoptosis, and respiratory distress. There is no standard clinical classification used in the management of neonatal airway in patients with PRS. The goal of our study was to review the presentation and management of patients with PRS and formulate a clinical grading system and treatment algorithm. METHODS: A 10-year retrospective review of all neonates diagnosed with PRS was performed after obtaining institutional ethics approval. Patients were identified using our cleft lip and palate program database. Inclusion criteria were 2 of the following 3 clinical features-glossoptosis, retrognathia, or airway obstruction. We collected demographic data, clinical information (coexisting airway morbidity, maxillary-mandibular discrepancy, type of intervention used, complications, and outcomes (feeding, length of stay, and airway status) during the first year of life. RESULTS: Sixty-three patients met our inclusion criteria. Of these, 55 (87%) had cleft palate and 17 (27%) were syndromic. Forty-eight (76%) patients were managed by prone positioning. Of the 15 surgically managed patients, the initial procedure was floor of mouth release in 7, mandibular distraction osteogenesis (MDO) in 4, and tongue-lip adhesion in 4. Five patients with coexisting airway morbidity needed a second surgery; 2 had MDO and 3 tracheostomies (one patient was later decannulated). Seven (47%) of the surgically managed patients required a gastrostomy tube. CONCLUSION: At present, there is no consensus on neonatal airway management in infants with PRS. From our review of 63 patients with PRS, we hereby propose a simple 4-point classification system and treatment algorithm, based on clinical features.

HISTORIQUE: Le syndrome de Pierre-Robin (SPR) désigne une triade de micrognathie, de glossoptose et de détresse respiratoire. Aucune classification clinique standard n'est utilisée pour assurer l'ouverture des voies respiratoires chez les nouveau-nés présentant un SPR. La présente étude visait à examiner la présentation et la prise en charge des patients ayant un SPR ainsi qu'à formuler un système de classement clinique et un algorithme de traitement. MÉTHODOLOGIE: Après avoir obtenu l'approbation du comité d'éthique de leur établissement, les chercheurs ont procédé à une analyse rétrospective sur dix ans de tous les nouveau-nés ayant reçu un diagnostic de SPR. Ils ont recensé les patients dans leur base de données de fentes labiales et palatines. Deux des trois caractéristiques cliniques suivantes constituaient les critères d'inclusion : glossoptose, rétrognatie ou obstruction des voies respiratoires. Les chercheurs ont recueilli les données démographiques, l'information clinique (morbidité coexistante des voies respiratoires, malocclusion maxillo-mandibulaire, type d'intervention utilisé, complications et résultats cliniques [alimentation, durée du séjour hospitalier et état des voies respiratoires]) jusqu'à l'âge d'un an. RÉSULTATS: Soixante-trois patients respectaient les critères d'inclusion. De ce nombre, 55 (87 %) avaient une fente palatine et 17 (27 %), un SPR. Quarante-huit patients (76 %) ont été traités par positionnement en décubitus ventral. Des 15 patients opérés, sept ont subi une libération du plancher buccal, quatre, une ostéogenèse par distraction de la mandibule (ODM) et quatre, une adhésion de la langue et de la lèvre. Cinq patients ayant une morbidité concomitante des voies respiratoires ont dû être opérés une deuxième fois. Deux avaient une ODM et trois, une trachéostomie (un a été décannulé par la suite). Sept patients opérés (47 %) ont eu besoin d'une sonde de gastrostomie. CONCLUSION: À l'heure actuelle, il n'y a pas de consensus sur la prise en charge des voies respiratoires chez les nourrissons ayant un SPR. D'après l'analyse de 63 patients ayant ce syndrome, les auteurs proposent un système de classification simple en quatre points et un algorithme de traitement reposant sur les caractéristiques cliniques.

Additional post-natal diagnoses following antenatal diagnosis of isolated cleft lip +/− palate.

INTRODUCTION: Cleft lip with or without palate (CLP) can be diagnosed antenatally through ultrasound, and may be categorised as apparently isolated versus associated with other malformations. Limited data exist on the long-term outcomes following antenatal diagnosis of apparently isolated CLP. AIM: This study examined the long-term post-natal outcomes of CLP when found in isolation antenatally, in order to determine the rates of unexpected additional anomalies, developmental delay or genetic syndromes. PATIENTS AND METHODS: A retrospective chart review of antenatal and post-natal medical charts was completed for a ten-year period between January 2000 and December 2009. At least 2 years of available post-natal clinical information was required for inclusion in the study. RESULTS: A total of 97 cases of antenatally isolated CLP were ascertained. Fifteen pregnancies were terminated. Follow-up data were available for 81 liveborns, though 4 were lost to follow-up prior to 2 years of age. Twelve of the 77 children meeting study criteria were identified to have other major malformations and/or developmental disability either later in the pregnancy or post-natally. Findings included familial clefting syndromes, trisomy 21, autism spectrum disorders, brain malformations, fetal alcohol syndrome and Kabuki syndrome, among other findings. Another 11 children had additional anomalies of minor impact. Examples of findings include a perimembranous ventricular septal defect, mild unilateral optic nerve hypoplasia, mild pulmonary artery stenosis with a small atrial septal defect, and transient delays in fine and gross motor skills. No children with clefting of the lip only had major additional diagnoses.

Nursing perspectives on factors influencing interdisciplinary teamwork in the Canadian primary care setting.

AIMS AND OBJECTIVES: This study investigated nurses' roles and their perspectives on the factors that influence interdisciplinary teamwork within Canadian primary care setting. BACKGROUND: Interdisciplinary teams have shown to lead to better system- and patient-level outcomes and, accordingly, have became important aspects of healthcare systems especially within primary care settings. Nurses play a key role in these primary care teams, particularly with respect to chronic disease management. DESIGN: A focused ethnography design using semi-structured individual interviews was conducted. METHODS: Interviews were conducted with 20 primary care nurses between July 2010-May 2011. Interviews were recorded, transcribed, and content and thematic analysis was performed. RESULTS: Nurses experienced increasing scope of practice and professional responsibility as they transitioned into the primary care setting. Nine major roles of primary care nurses were identified. Several factors that facilitate or hinder teamwork were identified and categorised under four theme areas: (1) organisation/leadership (e.g. having common goals and mandate, unclear descriptions of team members' roles); (2) team relationships (e.g. closed loop of communication, trust, respect); (3) process/support (e.g. unclear referral process and reporting structure, large patient panels); and (4) physical environment (e.g. decentralised model of care). CONCLUSIONS: Nurses' roles within primary care setting appear to be focused mainly on case management. Minimal orientation and lack of preparation of nurses for their roles, vagueness of these roles among the interdisciplinary primary care team members and lack of communication appeared to be among the most important factors that influence teamwork and nurses' functioning within these teams. RELEVANCE TO CLINICAL PRACTICE: Given that nurses play a key role in interdisciplinary primary care teams, particularly in managing chronic disease patients, approaches to improve chronic disease management and care of these patients should incorporate strategies to ensure effective preparation of these nurses for their roles within these teams and settings.

Canadian rural-urban differences in end-of-life care setting transitions.

Few studies have focused on the care setting transitions that occur in the last year of life. People living in rural areas may have more difficult care setting transitions and also more moves in the last year of life as health changes occur. A mixed-methods study was conducted to gain an understanding of the number and implications or impact of care setting transitions in the last year of life for rural Canadians. Rural Albertans had significantly more healthcare setting transitions than urbanites in the last year of life (M=4.2 vs 3.3). Online family respondents reported 8 moves on average occurred in the last year of life. These moves were most often identified (65%) on a likert-type scale as "very difficult," with the free text information revealing these trips were often emotionally painful for themselves and physically painful for the decedent. Eleven informants were then interviewed until data saturation, with constant-comparative data analysis conducted. Moving from place to place for needed care in the last year of life was identified as common and concerning for rural people and their families, with three data themes developing: (a) needed care in the last year of life is scattered across many places, (b) traveling is very difficult for terminally-ill persons and their caregivers, and (c) local rural services are minimal. These findings indicate planning is needed to avoid unnecessary end-of-life care setting transitions and to make needed moves for essential services in the last year of life less costly, stressful, and socially disruptive for rural people and their families.

Randomized controlled trial of mindfulness-based therapy for dyspnea in chronic obstructive lung disease.

OBJECTIVES: Patients with chronic obstructive lung disease (COPD) suffer from significant dyspnea and may benefit from complementary and alternative medicine (CAM) therapies aimed at mitigating symptoms. The objective of this study was to test the efficacy of a mindfulness-based breathing therapy (MBBT) on improving symptoms and health-related quality of life in those with COPD. DESIGN: We conducted a randomized controlled trial of 8-week mindfulness-based breathing therapy (MBBT) compared to support groups to test efficacy on improving symptoms and health-related quality of life in those with COPD. SETTING: The setting for this study was an academic-affiliated veterans healthcare system. SUBJECTS: The subjects consisted of 86 patients with COPD. INTERVENTIONS: MBBT included weekly meetings practicing mindfulness mediation and relaxation response. OUTCOME MEASURES: The main outcome measure was a post 6-minute-walk test (6MWT) Borg dyspnea assessment. Other outcome measures included health-related quality of life measures, 6MWT distance, symptom scores, exacerbation rates, and measures of stress and mindfulness. Analysis of covariance compared differences in outcomes between groups; paired t test evaluated changes within groups. RESULTS: Participants were predominantly elderly men with moderate to severe COPD. We found no improvements in dyspnea (post 6MWT Borg difference between the MBBT and support group was 0.3 (95% confidence interval [CI]: -1.1, 1.7). We found no differences between groups in almost all other outcome measures by either intention-to-treat analysis or within the subset that completed assigned group sessions. For the physical summary scale of the generic Short Form-36 for Veterans, the difference between outcomes favored the support group (4.3, 95% CI: 0.4, 8.1). Participant retention was low compared to mind-body trials that randomize from CAM wait lists. CONCLUSIONS: This trial found no measurable improvements in patients with COPD receiving a mindfulness-based breathing CAM therapy compared to a support group, suggesting that this intervention is unlikely to be an important therapeutic option for those with moderate-to-severe COPD.