Longer upper airway lengths in Robin Sequence: A case-control study using computed tomography.

BACKGROUND: Direct laryngoscopy and intubation are often difficult in children with Robin Sequence. Previous research characterizing anatomic airway differences has focused on parameters influencing airway patency; there is a paucity of data pertaining to intubation trajectories and depth. Such information could impact airway management approaches and decrease the incidence of endotracheal tube malpositioning. AIM: The study goal was to examine whether longitudinal airway parameters pertaining to intubation are different in children with Robin Sequence compared with age-matched controls. METHOD: This case-control study compared patients with RS <4 years of age who had computed tomography scans of the head and neck to age- and sex-matched controls. Measurements were made of the nasopharynx, oropharynx, hypopharynx, tongue, hyoid, and the front teeth to vocal cord, nares to vocal cord, and nasion-basion distances. Statistical analysis was performed using multiple ANCOVA models with the categorical predictor of Robin Sequence vs control and potential covariates including subject height/length, weight, and age. RESULTS: Thirty-three patients with Robin Sequence and 33 control subjects were included. After controlling for subject height/length, mean front teeth to vocal cord distance was 1.2 cm longer (95% CI: 0.9 to 1.6 cm, P < .001) and mean nares to vocal cord distance was 0.8 cm longer (95% CI: 0.4 to 1.2 cm, P < .001) in patients with Robin Sequence than in controls. The tongue was positioned on average 0.5 cm higher (95% CI: 0.3 to 0.8, P < .001) and 0.9 cm more posterior (95% CI: 0.6 to 1.0 cm, P < .001) in cases than in controls. Moreover, in patients with Robin Sequence, the hyoid was positioned on average 0.5 cm more inferiorly (95% CI: 0.2 to 0.8 cm, P < .001) and 0.2 cm more posteriorly (95% CI: 0.1 to 0.4 cm, P < .01) than controls. CONCLUSION: In patients with Robin Sequence under 4 years of age, the mean front teeth to vocal cord distance was found to be 1.2 cm longer while the mean nares to vocal cord distance was found to be 0.8 cm longer controlling for subject length. Clinicians should account for these differences when selecting and placing endotracheal tubes, particularly those with a preformed bend.

School Absence Associated With Childhood Pain in the United States.

OBJECTIVE: The objective of this study was to estimate the national burden of school absenteeism associated with pain among 6 to 17-year-old children in the United States. METHODS: Data were analyzed from a large, nationally representative sample from the 2012 National Health Interview Survey. Associations between pain and school absence were analyzed using multivariate negative binomial models controlling for sociodemographic and clinical characteristics. RESULTS: The sample contained 8641 participants, of whom 30.3% reported pain over the preceding 12 months. Mean number of parent-reported school days missed across the entire sample was 3 per child; however pain was associated with an additional 1.5 reported missed school days per child. Furthermore, pain was associated with higher rates of chronic absenteeism (missing >15 d of school): 6.1% of children with pain was chronically absent as compared with 1.3% of children without pain. Extrapolated to the nation, childhood pain in the United States was associated with 22.2 million additional days of missed school, whereas childhood asthma, in comparison, was associated with 8 million additional days of school missed. DISCUSSION: Associations between pain and school absenteeism highlight the need for interventions aimed at improving school attendance among children with pain.

Current pain management strategies for patients with erythromelalgia: a critical review.

Erythromelalgia (EM) is a rare disorder characterized by erythematous, warm, painful extremities, which is often precipitated by cold conditions. The pathophysiology of EM is incompletely understood. Recent investigations have identified sodium channelopathy as a genetic cause for this pain condition, classified as primary inherited EM. Other subtypes are idiopathic EM and secondary EM. The management of pain in EM is challenging as no single therapy has been found to be effective. There is varying response to pharmacotherapy and significant variability within this clinical population, resulting in a stepwise trial and error approach. Consequently, EM is often associated with poorer health-related quality of life with higher morbidity. There is currently no consensus or guidelines on management of pain in EM. This is a review of the literature on management of pain using pharmacologic, procedural intervention and nonpharmacologic treatment in children and adults with EM.

The 'four-hour target' and the impact on Australian metropolitan acute surgical services.

BACKGROUND: The National Emergency Access Targets (NEAT), introduced in 2012, guides the clearance of emergency department (ED) presentations within 4 h of initial presentation. We aim to assess the impact of NEAT on acute surgical services at a large metropolitan centre. METHODS: A retrospective cohort study was performed and data were collected from electronic patient management systems. The control group was represented by ED presentations between June and September 2011, 1 year prior to the introduction of NEAT. The two study groups consisted of ED presentations between June and September 2012 and 2013 respectively. Outcome measures included time to appendicectomy and cholecystectomy, inpatient length of stay (IPLOS) (for operative and non-operative cases), out-of-hours operating and hospital mortality rates. RESULTS: In total, 2619 inpatient episodes were included, with a trend showing increasing admissions throughout the study periods (P < 0.001). Time to surgical review and ED length of stay decreased significantly (P < 0.001). Time from emergency presentation to emergency appendicectomy and cholecystectomy remained unchanged and procedures performed out-of-hours increased significantly from 20.9% to 42.9% (P < 0.001). Median IPLOS for operative and non-operative patients was reduced during the study from 2.05 to 1.84 days (P < 0.001). Inter-unit transfers within 48 h of presentation increased significantly from 5.3% to 14.7% (P < 0.001). CONCLUSIONS: The early results following the implementation of NEAT have been correlated with increased efficiency in ED clearance and increased burden on surgical operative and inpatient outcomes. While improvements in IPLOS were observed, they must be considered in the context of increased lower-acuity admissions and out-of-hours operating.

Clearing emergency departments and clogging wards: National Emergency Access Target and the law of unintended consequences.

OBJECTIVE: To assess ED length of stay (EDLOS), access block, inpatient length of stay (IPLOS) and waiting times before and after the implementation of the National Emergency Access Target (NEAT). METHODS: This was designed as a retrospective cohort study and data was collected from electronic patient management systems. The control group represented all emergency presentations between June 2011 and September 2011, 1 year prior to the introduction of NEAT. The study groups were assessed and included all ED presentations between June and September 2012 and 2013 respectively. Main outcome measures were waiting times, EDLOS, proportion of patients cleared from the ED within NEAT goals, hospital length of stay and hospital mortality rates. RESULTS: A cumulative total of 76 935 patients were included in the study. During the course of the study, clearance from the ED within NEAT targets rose from 49.0% to 53.2% [relative risk (RR) 1.09; 95% CI, 1.07-1.11; P < 0.001]. ED waiting times decreased from 1.05 h [interquartile range (IQR), 0.43-2.27] to 0.45 h (IQR, 0.17-1.22) (P < 0.001) and time from bed-request to ward access increased. Utilisation of emergency short stay units (SSU) increased significantly across the study period from 6.5% to 13.4% (P < 0.001). Rates of inpatient transfers increased eightfold (RR, 7.93; 95% CI, 5.98-10.51; P < 0.001) and IPLOS increased by 21% from 2.05 (IQR, 0.75-4.96) to 2.50 days (IQR, 1.12-4.99) (P < 0.001). Hospital mortality remained unchanged from 3.0% to 3.3% (RR, 1.10; 95% CI, 0.91-1.34; P = 0.311). CONCLUSIONS: At the current institution NEAT success has been guarded, likely secondary to availability of inpatient beds. The implementation of NEAT appears to have reduced emergency waiting times. These early results suggest concurrent a detrimental effect on IPLOS; however, some of this effect may be a result of a large increase in short stay admissions.