Integrated microtia and aural atresia management.

Objectives: To present recommendations for the coordinated evaluation and management of the hearing and reconstructive needs of patients with microtia and aural atresia. Methods: A national working group of 9 experts on microtia and atresia evaluated a working document on the evaluation and treatment of patients. Treatment options for auricular reconstruction and hearing habilitation were reviewed and integrated into a coordinated care timeline. Results: Recommendations were created for children with microtia and atresia, including diagnostic considerations, surgical and non-surgical options for hearing management and auricular reconstruction, and the treatment timeline for each option. These recommendations are based on the collective opinion of the group and are intended for otolaryngologists, audiologists, plastic surgeons, anaplastologists, and any provider caring for a patient with microtia and ear canal atresia. Close communication between atresia/hearing reconstruction surgeon and microtia repair surgeon is strongly recommended.

Acute pediatric tracheitis: Distinguishing the disease by tracheostomy status.

OBJECTIVES: Tracheitis is an upper airway infection that often presents in patients with tracheostomies and can potentially cause airway obstruction. This study aims to use a nationwide database to identify a large cohort of pediatric patients admitted with tracheitis to elucidate the management and resource utilization associated with the disease both with and without tracheostomies. METHODS: The Kids' Inpatient Database (KID) 2012 was used to identify 2394 weighted discharges with acute tracheitis, with or without obstruction, as the primary diagnosis. Data on prior tracheostomy status, demographics, hospital characteristics, management, and resource utilization were obtained. Two groups of interest, based on presence of prior tracheostomy, were studied. Linear regression was performed to determine independent predictors of total charges. RESULTS: The mean age was 5.52 years (SD: 5.54), mean length of stay (LOS) was 6.37 days (SD: 10.18), and mean total charges were $60,996.61 (SD: 107,798.41). Patients with prior tracheostomy had lower rates of endoscopy and endotracheal intubation than patients without (p < 0.0005). There was no significant difference in LOS (p = 0.076) or total charges (p = 0.210) between the groups based on prior tracheostomy status. CONCLUSION: Pediatric tracheitis should be differentiated on the basis of tracheostomy status. We propose that tracheitis diagnosis codes should be distinguished by the presence of tracheostomy as "open" and the absence of tracheostomy as "closed."

Factors affecting completion of sleep studies in pediatric patients with sleep-disordered breathing.

OBJECTIVES/HYPOTHESIS: To determine demographic factors associated with failure to complete ordered polysomnograms (PSGs) in pediatric patients with sleep-disordered breathing (SDB). STUDY DESIGN: Retrospective case series. METHODS: This study was conducted at an urban safety-net hospital and included 829 patients with SDB, ages 0 to 18 years, for whom PSGs were ordered during a 1-year time period. Factors including age, race, language, and insurance status were reported for each patient. The data were reviewed by univariate and multivariate analyses to determine factors associated with failure to complete the PSGs. RESULTS: Of 829 patients, 200 (24%) failed to complete the PSGs. By univariate analysis, age was the only significant factor affecting completion (P < .01), with toddlers having the highest rate of completion (81%) and teenagers the lowest (68%). Primary language and insurance type were not significantly associated with completion rate. Hispanics were more likely than non-Hispanic whites to complete the PSGs (81% vs. 70%), but this did not achieve statistical significance. By multivariate analysis, the teenage group remained significantly less likely to complete sleep study than toddlers (P = .04). There was again no statistically significant difference for race by multivariate analysis. CONCLUSIONS: Among pediatric patients with SDB, age is a significant factor affecting completion of PSGs. Racial minorities and non-English-speaking patients were not less likely to complete PSGs. Other demographic factors do not appear to be associated with completion of PSGs. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:E258-E262, 2020.

Association of a Multidisciplinary Care Approach With the Quality of Care After Pediatric Tracheostomy.

IMPORTANCE: Incidence of tracheostomy placement in children is increasing, and these children continue to have high incidences of morbidity and mortality. A multidisciplinary tracheostomy program may help improve the quality of care received by these patients. OBJECTIVE: To determine whether implementation of a multidisciplinary tracheostomy program can improve the care of children who received a tracheostomy through reduction in tracheostomy-related adverse events (TRAEs), improved tracheostomy education, and caregiver preparedness. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study was conducted from January 2015 to June 2018 at a pediatric tertiary referral center in Boston, Massachusetts. The participants included 700 children who had received a tracheostomy, most of whom were aged birth to 18 years, but some patients with congenital disorders were much older. EXPOSURES: Institution of a multidisciplinary tracheostomy team (MDT) whose activities included conducting staff meetings, organizing outpatient clinics, conducting inpatient tracheostomy ward rounds, and conducting inpatient tracheostomy rounds at a local rehabilitation hospital. Quality improvement initiatives included monitoring standardized TRAEs and distributing standardized tracheostomy "go-bags." MAIN OUTCOMES AND MEASURES: Reduction of TRAEs and improved caregiver preparedness through distribution of tracheostomy go-bags were assessed following the establishment of a multidisciplinary tracheostomy program. RESULTS: In total, 700 children who had received a tracheostomy during the study period were actively followed up by the MDT. Of these children, 378 (54.0%) were males and 322 (46.0%) were females; mean (SD) age was 4.1 (6.1) years. More than 60 new pediatric tracheostomies were performed annually at the referral center. Reported TRAEs were reduced by 43.0% from the first to the third year after the implementation of a standardized, closed-loop monitoring system (from a mean [SD] of 6.1 [5.2] TRAEs per 1000 inpatient tracheostomy-days in 2015 to a mean [SD] of 4.0 [2.5] in 2018). The most common TRAE was unplanned decannulation, which occurred 64 times during the study period. On average, 10 patients were seen in each monthly multidisciplinary tracheostomy clinic. Clinic interventions included continuing care (146 [52.5%]), communication enhancement (67 [23.6%]), plans for decannulation (52 [18.6%]), and referrals for comorbidities (13 [4.6%]). Approximately 19 inpatients were seen during biweekly rounds and 8 during monthly rounds at a local rehabilitation hospital. A total of 297 patients received standardized tracheostomy go-bags, and more than 70 positive bag checks were performed in the monthly MDT clinics. A positive bag check refers to the incidence when a family is given a go-bag and also uses it. In contrast, a negative bag check refers to when a family is given a go-bag but neither brings it to the clinic nor acknowledges that they use it. CONCLUSIONS AND RELEVANCE: This study's findings suggest that a multidisciplinary tracheostomy program may be a powerful tool for enhancing patient safety and quality improvement. Ongoing studies will develop measurable pediatric tracheostomy outcome metrics and assess long-term outcomes.

Standardization of pediatric tracheostomy care with "Go-bags".

OBJECTIVES: To describe how pediatric tracheostomy emergency supplies and education are standardized with the use of "Go-bags" and to demonstrate how this has impacted tracheostomy-related adverse events. METHODS: A prospective study was completed at an urban pediatric tertiary care center. Standardized "Go-bags" of tracheostomy supplies were provided to pediatric patients with tracheostomy. All caregivers received standardized tracheostomy education. Check lists were used to monitor contents at return visits or admissions. Tracheostomy related adverse events were tracked on all patients with tracheostomy from July 2016 to May 2018, and rates were compared for patients who had received a "Go-bag" to those who had not. RESULTS: 292 "Go-bags" were distributed during the two-year study period. 35% were distributed by inpatient respiratory therapists, 23% by the home ventilation team, and 22% by a tracheostomy clinic nurse. Supply checks have led to more than 185 cases of emergency tracheostomy equipment replacement. 35% of tracheostomy-related adverse event (TRAE) occurred in patients who did not have a "Go-bag", while 22% of TRAEs occurred in patients who had "Go-bags". CONCLUSION: Standardized pediatric tracheostomy care is critical to patient safety, both in and out of the hospital. Standardized tracheostomy "Go-bags" are a simple and efficient method to educate caregivers, improve the quality of care for children with tracheostomy, and ultimately reduce tracheostomy related adverse events.

Outcomes of Children with Mild Obstructive Sleep Apnea Treated Nonsurgically: A Retrospective Review.

OBJECTIVE: Obstructive sleep apnea (OSA) is characterized by partial or complete obstruction of the upper airway and is commonly caused by adenotonsillar hypertrophy in children. Accordingly, adenotonsillectomy is considered first-line treatment. However, in cases of mild OSA, nonsurgical management has been proposed as an alternative. The purpose of this study was to determine the outcomes of pediatric patients with mild obstructive sleep apnea (OSA) treated without surgical intervention. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care university medical center. SUBJECTS AND METHODS: The medical records of children ages 2 to 18 years with OSA at Boston Medical Center from January 2000 to April 2017 were reviewed. Children with mild OSA (apnea- hypopnea index [AHI] between 1 and 5), who were managed nonsurgically and had serial polysomnograms, were included. Serial sleep studies were compared to assess for patterns of change. RESULTS: Of the 201 patients with mild OSA who were identified, 104 (52%) opted for initial nonsurgical management. Of those, 91 had a follow-up sleep study to reassess their OSA. Forty-two (46 %) had a greater than 20% decrease in AHI and 38 (41%) had a greater than 20% increase on the second sleep study. The remaining 11 had changes less than 20% in either direction. There was not a significant difference in the proportion of patients with an increase vs decrease in AHI on follow-up sleep study ( P > .05). CONCLUSIONS: Mild pediatric OSA has approximately equal chances of worsening or improvement over time without surgical intervention, which is useful for counseling parents on treatment options.

Inpatient Pediatric Epistaxis: Management and Resource Utilization.

OBJECTIVES: Epistaxis is a common condition that rarely warrants hospital admission in the pediatric population, making its inpatient management difficult to study. This study aims to use a nationwide database to analyze trends in the treatment of pediatric patients admitted with epistaxis and determine factors impacting total charges. METHODS: The latest (2012) version of the Kids' Inpatient Database (KID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality was used to identify weighted discharges with the primary diagnosis of epistaxis. Information regarding demographics, comorbidities, treatment, hospital burden, and other admission details were obtained. Linear regression was used to analyze factors suspected to increase cost. RESULTS: Among 372 weighted discharges, the mean age was 9.68 years (SD = 5.79), and 60.0% were male. The most common comorbidities were thrombocytopenia, von Willebrand disease, and chronic sinusitis. The majority of admissions with epistaxis (56.7%) did not undergo any procedure to control epistaxis. Mean total charges was $30 208 (SD = $62 683) with a mean length of stay of 2.46 days (SD = 3.31). Independent predictors of increased charges included longer length of stay, admission from the emergency department, and median household income within the third quartile for patients' ZIP codes. Midwest hospital region independently predicted decreased charges. Having a procedure to control epistaxis did not significantly impact cost. CONCLUSIONS: Pediatric epistaxis admissions often do not require long hospital stays or procedural control of the bleed. However, significant charges are incurred treating epistaxis. Awareness of factors impacting these charges can potentially improve resource utilization.

Topical Plasminogen as Adjunctive Treatment in Recurrent Ligneous Conjunctivitis.

Ligneous conjunctivitis is a rare, autosomal recessive, membranous conjunctivitis characterized by a deficiency in type 1 plasminogen. The absence of normal plasmin activity results in the formation of fibrin-rich, membranous material that typically manifests on the palpebral conjunctiva. Surgical treatment often causes irritation of the conjunctiva and accelerated recurrence of pseudomembranes. In this interventional case report, the authors document the results of treatment with topical plasminogen following conjunctival pseudomembrane excision in a 32-year-old woman. The patient underwent pseudomembrane excision in the OS followed immediately by hourly topical application of plasminogen eye drops. The plasminogen was prepared from pooled human plasma purchased under Food and Drug Administration approval from DiaPharma. Follow-up evaluation at 1 week, 1 month, and 5 months showed no evidence of recurrent pseudomembranous change. Adjunctive topical plasminogen application appears to be an effective and safe method of controlling pseudomembrane recurrence in patients with ligneous conjunctivitis.

Aesthetic considerations in upper eyelid retraction surgery.

PURPOSE: Classically, the aesthetic outcomes of eyelid retraction surgery in patients with thyroid-associated orbitopathy have been described in reference to eyelid margin position and marginal reflex distance. A critically important component of upper eyelid contour is the tarsal platform show (TPS). With this study, the authors aimed to assess the hypothesis that modification of the tarsal platform in posterior eyelid retraction surgery has a significant effect on the final aesthetic outcome. METHODS: In a retrospective, observational, case-cohort study, the authors reviewed the medical records of 36 patients with thyroid-associated orbitopathy who underwent primary eyelid retraction surgery by 1 surgeon. Patients who underwent eyelid retraction surgery at the time of orbital decompression were excluded. The surgical technique consisted of posterior approach conjunctival release of Müeller muscle and graded recession of the levator aponeurosis. To address lateral flare, dissection was carried toward the lateral orbital rim with spreading of the lateral horn of the levator aponeurosis. Outcome measures were millimeters of TPS, millimeters of brow fat span, and symmetry of the eyelid margin position. Randomized preoperative and postoperative standardized photographs were evaluated in masked fashion by 4 surgeons to grade cosmetic outcomes. RESULTS: Fifteen patients (24 eyelids) met the inclusion criteria. Mean follow-up period was 6 months (range, 3-12). Mean TPS increased from 2.27 mm (standard deviation, 1.9 mm) to 4.77 mm (standard deviation, 1.7 mm; p < 0.05). Mean brow fat span remained unchanged, from 13.22 mm (standard deviation, 2.2 mm) to 13.25 mm (standard deviation, 1.9; p > 0.05). Evaluation of the aesthetic outcomes (eyelid contour, eyelid symmetry, and TPS) by 4 masked observers characterized the relevance of TPS in the postoperative aesthetics of eyelid contour and symmetry. CONCLUSIONS: In upper eyelid retraction surgery, the ability to control the TPS has a significant impact on the final aesthetic outcome. Posterior approach eyelid retraction surgery can control eyelid contour and can represent an ideal surgical approach in carefully selected patients. However, it has limited ability to control upper orbital volume and eyebrow and orbital fat (brow fat span). This can result in relative overelongation of the TPS. Factors such as ethnic characteristics, bony asymmetry, brow fat span, and premorbid TPS influence cosmetic outcomes achieved by the anterior or posterior approach. For optimal aesthetic results in eyelid retraction surgery, the decision for anterior versus posterior approach should be individualized.

Suicidio y homicidio en Chile / Suicide and homicide in Chile

En este trabajo se analizan las tasas de suicidio y homicidios ocurridos en Chile entre los años 1986-2000 enrelación con las variables sexo, grupos de edad, método empleado, y su tendencia. El diseño corresponde a un estudio de cohorte histórica. Se calcula la razón de tasas y para precisar si la diferencia es significativa, se calcularon los límites de confianza. La razón de tasas entre hombres se ve un aumento de las tasas con la edad. En Chile se ha observado un aumento significativo en las tasas de suicidio para el período 1986-2000, con respecto a homicidio, sólo se encontró un aumento significativo para el año 2000, el ahorcamiento da cuenta de la mayor parte de los casos.