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1.
Int J Pediatr Otorhinolaryngol ; 151: 110963, 2021 Oct 27.
Artigo em Inglês | MEDLINE | ID: mdl-34736006

RESUMO

OBJECTIVES: To 1) describe health outcomes and outpatient healthcare use after pediatric tracheostomy, and 2) identify populations with higher morbidity that may benefit from improved post-operative monitoring. METHODS: Optum's commercial insurance database was queried from 2003 to 2019. Children aged 0-18 who received tracheostomy identified. Mortality, decannulation, tracheostomy complications, and home ventilator dependence were determined, as well as physician office visits and specialty type. The effect that patient characteristics (age, sex, ethnicity, prematurity, and presence versus absence of chronic lung disease [CLD], congenital heart disease [CHD], neurologic impairment [NI], and upper airway obstruction [UAO]) had on outcomes were compared. RESULTS: 1231 children were identified. Infants accounted for 33% of patients and 40% of the cohort was premature. The most common comorbid conditions were NI (76%), UAO (69%), CLD (48%), and CHD (35%). Within 5 years postoperatively, 25% died, 45% had home ventilator dependence, 53% had a complication, and 10% were decannulated. CHD was associated with higher risk of death (HR,1.98; 95% CI 1.22, 3.21), while UAO was associated with lower risk of death (HR,0.51; 95% CI 0.32, 0.83) and higher probability of decannulation (HR,3.56, 95% CI 1.08, 11.74). The median number of physician office visits was 6 per year (IQR 3,10). The most common specialty types were pediatrics (32%), pulmonary medicine (10%), and otolaryngology (8%). NI was associated with greater number of office visits (mean difference/year, 4.10; 95% CI 2.00, 6.19) while Hispanic ethnicity was associated with fewer visits (mean difference/year, -2.94; 95%CI -5.42, -0.45). CONCLUSIONS: UAO was associated with lower risk of mortality and higher probability of decannulation, while NI was associated with greater outpatient healthcare utilization. Social disparities in outpatient tracheostomy care were observed.

2.
Neuron ; 2021 Nov 08.
Artigo em Inglês | MEDLINE | ID: mdl-34767769

RESUMO

Despite the importance of dopamine for striatal circuit function, mechanistic understanding of dopamine transmission remains incomplete. We recently showed that dopamine secretion relies on the presynaptic scaffolding protein RIM, indicating that it occurs at active zone-like sites similar to classical synaptic vesicle exocytosis. Here, we establish using a systematic gene knockout approach that Munc13 and Liprin-α, active zone proteins for vesicle priming and release site organization, are important for dopamine secretion. Furthermore, RIM zinc finger and C2B domains, which bind to Munc13 and Liprin-α, respectively, are needed to restore dopamine release after RIM ablation. In contrast, and different from typical synapses, the active zone scaffolds RIM-BP and ELKS, and RIM domains that bind to them, are expendable. Hence, dopamine release necessitates priming and release site scaffolding by RIM, Munc13, and Liprin-α, but other active zone proteins are dispensable. Our work establishes that efficient release site architecture mediates fast dopamine exocytosis.

3.
Otolaryngol Head Neck Surg ; : 1945998211047146, 2021 Sep 21.
Artigo em Inglês | MEDLINE | ID: mdl-34546823

RESUMO

OBJECTIVE: To improve hospital price transparency, the Centers for Medicare & Medicaid Services (CMS) requires, as of January 2021, that all hospitals reveal charges for specific items and services. This analysis investigates whether otolaryngology residency-affiliated hospitals have complied with this new regulation, and it evaluates the variability in hospital-reported charges for pediatric tonsillectomy. STUDY DESIGN: Cross-sectional analysis. SETTINGS: Subset of hospitals affiliated with otolaryngology residency programs. METHODS: Hospital websites were searched to determine compliance rates with CMS guidelines by posting a price transparency tool and specific charges for Current Procedural Terminology code 42820 (tonsillectomy and adenoidectomy, <12 years old). Various charges were collected: gross charge, discounted cash price, deidentified minimum and maximum negotiated charges, hospital fees, and physician fees. RESULTS: Overall 104 unique hospitals were analyzed: 81 (78%) provided pricing data, but only 28 (27%) complied with CMS guidelines. The median reported total gross charge was $13,239 (range, $600-$41,957); deidentified minimum negotiated charge, $9222 (range, $337-$25,164); and deidentified maximum negotiated charge, $17,355 (range, $1002-$54,987). Hospital fees (median, $11,900; range, $2304-$38,831) were consistently higher than physician fees (median, $1827; range, $420-$5063). All estimates included a disclaimer stating that values likely underrepresent true prices. CONCLUSION: Hospital compliance with the new regulation remains low, which limits efforts toward improved price transparency. There is wide variability in reported charges for pediatric tonsillectomy and adenoidectomy.

4.
Front Mol Neurosci ; 14: 726133, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34539344

RESUMO

One important function of GABA B receptors is the control of neuronal activity to prevent overexcitation and thereby excitotoxic death, which is a hallmark of cerebral ischemia. Consequently, sustained activation of GABA B receptors with the selective agonist baclofen provides neuroprotection in in vitro and in vivo models of cerebral ischemia. However, excitotoxic conditions severely downregulate the receptors, which would compromise the neuroprotective effectiveness of baclofen. On the other hand, recent work suggests that sustained activation of GABA B receptors stabilizes receptor expression. Therefore, we addressed the question whether sustained activation of GABA B receptors reduces downregulation of the receptor under excitotoxic conditions and thereby preserves GABA B receptor-mediated inhibition. In cultured neurons subjected to oxygen and glucose deprivation (OGD), to mimic cerebral ischemia, GABA B receptors were severely downregulated. Treatment of the cultures with baclofen after OGD restored GABA B receptor expression and reduced loss of neurons. Restoration of GABA B receptors was due to enhanced fast recycling of the receptors, which reduced OGD-induced sorting of the receptors to lysosomal degradation. Utilizing the middle cerebral artery occlusion (MCAO) mouse model of cerebral ischemia, we verified the severe downregulation of GABA B receptors in the affected cortex and a partial restoration of the receptors after systemic injection of baclofen. Restored receptor expression recovered GABA B receptor-mediated currents, normalized the enhanced neuronal excitability observed after MCAO and limited progressive loss of neurons. These results suggest that baclofen-induced restoration of GABA B receptors provides the basis for the neuroprotective activity of baclofen after an ischemic insult. Since GABA B receptors regulate multiple beneficial pathways, they are promising targets for a neuroprotective strategy in acute cerebral ischemia.

5.
Otolaryngol Head Neck Surg ; : 1945998211032901, 2021 Jul 27.
Artigo em Inglês | MEDLINE | ID: mdl-34311618

RESUMO

OBJECTIVE: To identify social determinants of health care that are associated with poorer pediatric well-differentiated thyroid cancer (WDTC) outcomes and increased stage at presentation. STUDY DESIGN: Using the SEER database (Surveillance, Epidemiology, and End Results), we retrospectively gathered data on pediatric WDTC across the United States between 1973 and 2015. SETTING: All patients between 0 and 19 years old with a diagnosis of WDTC were included. METHODS: Patient variables were analyzed for relationships to AJCC stage at presentation (American Joint Committee on Cancer), overall survival, and disease-specific survival. RESULTS: Among 3913 patients with pediatric thyroid cancer, 3185 were female (81.4%), 3366 had papillary thyroid cancer (85.3%), and 367 had follicular thyroid cancer (9.4%). Two- and 5-year overall and disease-specific survival approached 100%. However, when outcomes were analyzed by specific populations, male sex, non-Caucasian race, poverty, and language isolation were linked to worse overall survival. Male sex and poverty were associated with poorer disease-specific survival. Regarding overall AJCC stage at presentation, male sex and Black race were related to higher overall presenting AJCC stage. Later AJCC T stage at presentation was seen in male, Hispanic, Asian, and Black patients. There were no variables significantly related to following through with recommended surgery. CONCLUSION: Pediatric WDTC continues to carry an excellent prognosis in the United States. However, when we consider specific populations, the social determinants of health care affect survival and disease burden at presentation: male sex, poverty, language isolation, and race affected survival and/or AJCC stage at presentation in pediatric WDTC.

6.
Head Neck ; 43(10): 2946-2953, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-34117674

RESUMO

BACKGROUND: Sinonasal adenocarcinoma (SNAC) is a rare tumor. The impact of health disparities on survival, stage at presentation, and utilization of surgery is not well understood in patients with SNAC. METHODS: The Surveillance, Epidemiology, and End Results database was queried for cases of SNAC from 1973 to 2015. Cases were analyzed to assess for disparities in presentation, treatment, and survival. RESULTS: SNAC was identified in 630 patients. In a multivariate model of overall survival, an age increase of 10 years (Hazard Ratio (HR) = 1.37, p < 0.001), male sex (HR = 1.26, p = 0.045), and more recent decade of diagnosis (HR = 0.74, p < 0.001) were significantly related to time-to-death. There is a higher rate of SNAC-related death in counties with more rural populations (p = 0.027). CONCLUSION: Future interventions targeting rural and less well-educated populations may improve care with the goal of increasing the span of healthy life and reducing survival disparities related to SNAC.


Assuntos
Adenocarcinoma , Neoplasias dos Seios Paranasais , Adenocarcinoma/epidemiologia , Adenocarcinoma/terapia , Criança , Demografia , Humanos , Masculino , Neoplasias dos Seios Paranasais/epidemiologia , Neoplasias dos Seios Paranasais/terapia , Estudos Retrospectivos , Fatores Socioeconômicos
9.
J Cell Commun Signal ; 15(2): 251-267, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33620645

RESUMO

Gastric cancer is one of the leading causes of cancer-related death worldwide. The transcription factor YY1 regulates diverse biological processes, including cell proliferation, development, DNA damage responses, and carcinogenesis. This study was designed to explore the role of YY1 regulated transcription in gastric cancer. YY1 silencing in gastric cancer cells has resulted in the inhibition of Wnt/ß-catenin, JNK/MAPK, ERK/MAPK, ER, and HIF-1α signaling pathways. Genome-wide mRNA profiling upon silencing the expression YY1 gene in gastric cancer cells and comparison with the previously identified YY1 regulated genes from other lineages revealed a moderate overlap among the YY1 regulated genes. Despite the differing genes, all the YY1 regulated gene sets were expressed in most of the intestinal subtype gastric tumors and a subset of diffuse subtype gastric tumors. Integrative functional genomic analysis of the YY1 gene sets revealed an association among the pathways Wnt/ß-catenin, Rapamycin, Cyclin-D1, Myc, E2F, PDGF, and AKT. Further, the drugs capable of inhibiting YY1 mediated transcription were identified as suitable targeted therapeutic candidates for gastric tumors with activated YY1. The data emerging from the investigation would pave the way for the development of YY1-based targeted therapeutics for gastric cancer.

11.
Int J Pediatr Otorhinolaryngol ; 142: 110625, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33454453

RESUMO

OBJECTIVES: In pediatric patients undergoing endoscopic laryngeal cleft repair, immediate postoperative dysphagia is not well-characterized. This study examined whether worsened dysphagia is present in the immediate postoperative period as detected by clinical swallow evaluation, and evaluated how this relates to postoperative change in presenting symptoms and findings on swallow studies. METHODS: A retrospective cohort was conducted at a tertiary academic medical center, evaluating all pediatric patients who underwent endoscopic laryngeal cleft repair by a single surgeon from October 2014 through December 2018. All patients underwent instrumental swallow evaluation preoperatively and clinical swallow evaluation within 24 h following surgery. RESULTS: Thirty-nine patients met inclusion criteria. Based on clinical swallow evaluation performed within 24 h after surgery, 4 patients (10%) were recommended to thicken their diet from preoperative baseline; all others were unchanged. All patients were admitted to the PICU for observation; 34 (87%) discharged on postoperative day 1. Thirty-seven patients attended 6-week follow-up, with 2 (5%) requiring thicker diet since discharge; all others were stable or improved. Prevalence of recurrent respiratory infections, subjective dysphagia, chronic cough, and wheezing significantly decreased after surgery. No statistically significant change occurred in prevalence of aspiration or penetration on instrumental swallow studies postoperatively. CONCLUSION: Endoscopic laryngeal cleft repair is well-tolerated in pediatric patients, and most do not have obviously worsened dysphagia at immediate postoperative evaluation. Improvement in symptoms postoperatively may be a more useful indicator of surgical outcomes beyond instrumental swallow studies alone. The relative stability of these patients provides further evidence that they can likely be managed on the floor or as outpatients rather than in the ICU postoperatively.


Assuntos
Transtornos de Deglutição , Laringe , Criança , Anormalidades Congênitas , Transtornos de Deglutição/diagnóstico , Transtornos de Deglutição/etiologia , Humanos , Laringe/anormalidades , Laringe/cirurgia , Período Pós-Operatório , Estudos Retrospectivos
12.
Laryngoscope ; 131(6): E1941-E1949, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33405268

RESUMO

OBJECTIVES/HYPOTHESIS: The purpose of this study is to develop consensus on key points that would support the use of systemic bevacizumab for the treatment of recurrent respiratory papillomatosis (RRP), and to provide preliminary guidance surrounding the use of this treatment modality. STUDY DESIGN: Delphi method-based survey series. METHODS: A multidisciplinary, multi-institutional panel of physicians with experience using systemic bevacizumab for the treatment of RRP was established. The Delphi method was used to identify and obtain consensus on characteristics associated with systemic bevacizumab use across five domains: 1) patient characteristics; 2) disease characteristics; 3) treating center characteristics; 4) prior treatment characteristics; and 5) prior work-up. RESULTS: The international panel was composed of 70 experts from 12 countries, representing pediatric and adult otolaryngology, hematology/oncology, infectious diseases, pediatric surgery, family medicine, and epidemiology. A total of 189 items were identified, of which consensus was achieved on Patient Characteristics (9), Disease Characteristics (10), Treatment Center Characteristics (22), and Prior Workup Characteristics (18). CONCLUSION: This consensus statement provides a useful starting point for clinicians and centers hoping to offer systemic bevacizumab for RRP and may serve as a framework to assess the components of practices and centers currently using this therapy. We hope to provide a strategy to offer the treatment and also to provide a springboard for bevacizumab's use in combination with other RRP treatment protocols. Standardized delivery systems may facilitate research efforts and provide dosing regimens to help shape best-practice applications of systemic bevacizumab for patients with early-onset or less-severe disease phenotypes. LEVEL OF EVIDENCE: 5 Laryngoscope, 131:E1941-E1949, 2021.


Assuntos
Inibidores da Angiogênese/uso terapêutico , Bevacizumab/uso terapêutico , Infecções por Papillomavirus/tratamento farmacológico , Infecções Respiratórias/tratamento farmacológico , Consenso , Técnica Delfos , Humanos , Internacionalidade
13.
Fetal Diagn Ther ; 48(1): 70-77, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33080593

RESUMO

INTRODUCTION: In utero interventions are performed in fetuses with "isolated" major congenital anomalies to improve neonatal outcomes and quality of life. Sequential in utero interventions to treat 2 anomalies in 1 fetus have not yet been described. CASE PRESENTATION: Here, we report a fetus with a large left-sided intralobar bronchopulmonary sequestration (BPS) causing mediastinal shift, a small extralobar BPS, and concomitant severe left-sided congenital diaphragmatic hernia (CDH). At 26-week gestation, the BPS was noted to be increasing in size with a significant reduction in right lung volume and progression to fetal hydrops. The fetus underwent ultrasound-guided ablation of the BPS feeding vessel leading to complete tumor regression. However, lung development remained poor (O/E-LHR: 0.22) due to the left-sided CDH, prompting fetal endoscopic tracheal occlusion therapy at 28-week gestation to allow increased lung growth. After vaginal delivery, the newborn underwent diaphragmatic repair with resection of the extralobar sequestration. He was discharged home with tracheostomy on room air at 9 months. DISCUSSION/CONCLUSION: Sequential in utero interventions to treat 2 severe major anomalies in the same fetus have not been previously described. This approach may be a useful alternative in select cases with otherwise high morbidity/mortality. Further studies are required to confirm our hypothesis.

14.
Otolaryngol Head Neck Surg ; 164(5): 1040-1043, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33048019

RESUMO

It is impossible to secure the airway of a patient with "neck-only" breathing transorally or transnasally. Surgical removal of the larynx (laryngectomy) or tracheal rerouting (tracheoesophageal diversion or laryngotracheal separation) creates anatomic discontinuity. Misguided attempts at oral intubation of neck breathers may cause hypoxic brain injury or death. We present national data from the American Academy of Otolaryngology-Head and Neck Surgery, the American Head and Neck Society, and the United Kingdom's National Reporting and Learning Service. Over half of US otolaryngologist respondents reported instances of attempted oral intubations among patients with laryngectomy, with a mortality rate of 26%. UK audits similarly revealed numerous resuscitation efforts where misunderstanding of neck breather status led to harm or death. Such data underscore the critical importance of staff education, patient engagement, effective signage, and systems-based best practices to reliably clarify neck breather status and provide necessary resources for safe patient airway management.


Assuntos
Manuseio das Vias Aéreas/normas , Intubação Intratraqueal/métodos , Intubação Intratraqueal/normas , Laringectomia , Otolaringologia , Pesquisas sobre Serviços de Saúde , Humanos , Intubação Intratraqueal/efeitos adversos , Boca , Segurança do Paciente
15.
Laryngoscope ; 131(5): 1168-1174, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33034397

RESUMO

OBJECTIVES/HYPOTHESIS: Create a competency-based assessment tool for pediatric esophagoscopy with foreign body removal. STUDY DESIGN: Blinded modified Delphi consensus process. SETTING: Tertiary care center. METHODS: A list of 25 potential items was sent via the Research Electronic Data Capture database to 66 expert surgeons who perform pediatric esophagoscopy. In the first round, items were rated as "keep" or "remove" and comments were incorporated. In the second round, experts rated the importance of each item on a seven-point Likert scale. Consensus was determined with a goal of 7 to 25 final items. RESULTS: The response rate was 38/64 (59.4%) in the first round and returned questionnaires were 100% complete. Experts wanted to "keep" all items and 172 comments were incorporated. Twenty-four task-specific and 7 previously-validated global rating items were distributed in the second round, and the response rate was 53/64 (82.8%) with questionnaires returned 97.5% complete. Of the task-specific items, 9 reached consensus, 7 were near consensus, and 8 did not achieve consensus. For global rating items that were previously validated, 6 reached consensus and 1 was near consensus. CONCLUSIONS: It is possible to reach consensus about the important steps involved in rigid esophagoscopy with foreign body removal using a modified Delphi consensus technique. These items can now be considered when evaluating trainees during this procedure. This tool may allow trainees to focus on important steps of the procedure and help training programs standardize how trainees are evaluated. LEVEL OF EVIDENCE: 5. Laryngoscope, 131:1168-1174, 2021.


Assuntos
Competência Clínica/normas , Consenso , Esofagoscopia/educação , Internato e Residência/normas , Cirurgiões/normas , Criança , Técnica Delfos , Esofagoscópios , Esofagoscopia/instrumentação , Esôfago/diagnóstico por imagem , Esôfago/cirurgia , Corpos Estranhos/diagnóstico , Corpos Estranhos/cirurgia , Humanos , Cirurgiões/educação , Cirurgiões/estatística & dados numéricos , Inquéritos e Questionários/estatística & dados numéricos
16.
Laryngoscope ; 131(5): E1722-E1729, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33026683

RESUMO

OBJECTIVES: Assess national trends in opioid prescription following pediatric tonsillectomy: 1) overall percentage receiving opioids and mean quantity, 2) changes during 2009-2017, and 3) determinants of prescription patterns. METHODS: Cross-sectional analysis using 2009-2017 Optum claims data to identify opioid-naïve children aged 1-18 with claims codes for tonsillectomy (n = 82,842). Quantities of opioids filled in outpatient pharmacies during the perioperative period were extracted and converted into milligram morphine equivalents (MMEs) for statistical comparison. Demographic, clinical, and socioeconomic predictors of opioid fill rate and quantity were determined using regression analyses. RESULTS: In 2009, 83.3% of children received opioids, decreasing to 58.3% by 2017. Rates of all-cause readmissions and post-tonsillectomy hemorrhages were similar over time. Mean quantity received was 153.47MME (95% confidence intervals [95%CI]: 151.19, 155.76) and did not significantly change during 2009-2017. Opioids were more likely in older children and those with higher household income, but less likely in children with obstructive sleep apnea, other comorbidities, and Hispanic race. Higher quantities of opioids were more likely in older children, while lower quantities were associated with female sex, Hispanic race, and higher household income. Outpatient steroids were prescribed to 8.04% of patients, who were less likely to receive opioids. CONCLUSION: While the percentage of children receiving post-tonsillectomy opioids decreased during 2009-2017, prescribed quantities remain high and have not decreased over time. Prescription practices were also influenced by clinical and sociodemographic factors. These results highlight the need for guidance, particularly with regard to opioid quantity, in children after tonsillectomy. LEVEL OF EVIDENCE: N/A Laryngoscope, 131:E1722-E1729, 2021.


Assuntos
Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Tonsilectomia/efeitos adversos , Adolescente , Criança , Pré-Escolar , Estudos Transversais , Prescrições de Medicamentos/normas , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Manejo da Dor/normas , Manejo da Dor/estatística & dados numéricos , Manejo da Dor/tendências , Dor Pós-Operatória/etiologia , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Padrões de Prática Médica/tendências , Estudos Retrospectivos , Estados Unidos
17.
Otolaryngol Head Neck Surg ; 164(5): 984-1000, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-32960148

RESUMO

OBJECTIVE: In the chronic phase of the COVID-19 pandemic, questions have arisen regarding the care of patients with a tracheostomy and downstream management. This review addresses gaps in the literature regarding posttracheostomy care, emphasizing safety of multidisciplinary teams, coordinating complex care needs, and identifying and managing late complications of prolonged intubation and tracheostomy. DATA SOURCES: PubMed, Cochrane Library, Scopus, Google Scholar, institutional guidance documents. REVIEW METHODS: Literature through June 2020 on the care of patients with a tracheostomy was reviewed, including consensus statements, clinical practice guidelines, institutional guidance, and scientific literature on COVID-19 and SARS-CoV-2 virology and immunology. Where data were lacking, expert opinions were aggregated and adjudicated to arrive at consensus recommendations. CONCLUSIONS: Best practices in caring for patients after a tracheostomy during the COVID-19 pandemic are multifaceted, encompassing precautions during aerosol-generating procedures; minimizing exposure risks to health care workers, caregivers, and patients; ensuring safe, timely tracheostomy care; and identifying and managing laryngotracheal injury, such as vocal fold injury, posterior glottic stenosis, and subglottic stenosis that may affect speech, swallowing, and airway protection. We present recommended approaches to tracheostomy care, outlining modifications to conventional algorithms, raising vigilance for heightened risks of bleeding or other complications, and offering recommendations for personal protective equipment, equipment, care protocols, and personnel. IMPLICATIONS FOR PRACTICE: Treatment of patients with a tracheostomy in the COVID-19 pandemic requires foresight and may rival procedural considerations in tracheostomy in their complexity. By considering patient-specific factors, mitigating transmission risks, optimizing the clinical environment, and detecting late manifestations of severe COVID-19, clinicians can ensure due vigilance and quality care.


Assuntos
COVID-19/prevenção & controle , Controle de Infecções/normas , Cuidados Pós-Operatórios , Traqueostomia , Infecção Hospitalar/prevenção & controle , Humanos , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Pandemias , Equipamento de Proteção Individual , Complicações Pós-Operatórias/prevenção & controle , SARS-CoV-2
18.
Laryngoscope ; 131(1): 209-217, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32040207

RESUMO

OBJECTIVE: The mechanism by which recurrent croup occurs is unknown. Gastroesophageal reflux is commonly implicated, although this relationship is only loosely documented. We conducted a systematic review with a meta-analysis component to evaluate the relationship between recurrent croup and gastroesophageal reflux disease (GERD), and to assess for evidence of improvement in croup symptoms when treated. STYLE DESIGN: Systematic Review and Meta Analysis. METHODS: We searched five separate databases. Studies were included if they discussed the relationship between croup and GERD in children, >5 subjects, and available in English. Literature retrieved was assessed according to pre-specified criteria. Retrieved articles were reviewed by two independent authors and decisions mediated by a third author. If there was a difference of opinion after first review, a second review was performed to obtain consensus. Heterogeneity was calculated and summarized in forest plots. RESULTS: Of 346 initial records, 15 met inclusion criteria. These were two retrospective cohort and 13 cross-sectional studies. Thirteen of 15 articles support an association between recurrent croup and GERD. Although heterogeneity is high among studies that reported prevalence of GERD, there is less uncertainty in results for improvement to recurrent croup after GERD treatment. Most studies lacked a control group and all carry a moderate-to-high risk of bias. CONCLUSION: There is limited evidence linking GERD to recurrent croup; Further research is needed to assess for causality as most studies are retrospective, lack a control group, and have a study design exposing them to bias. Patients treated with reflux medication appear to demonstrate a reduced incidence of croup symptoms. LEVEL OF EVIDENCE: 1 Laryngoscope, 131:209-217, 2021.


Assuntos
Crupe/etiologia , Refluxo Gastroesofágico/complicações , Pré-Escolar , Humanos , Lactente , Recidiva
20.
Int J Pediatr Otorhinolaryngol ; 140: 110490, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33229032

RESUMO

To illustrate a previously unreported method of tracheal stent removal that appears to cause less mucosal injury we present a case of a 9-year-old Down syndrome patient with a history of tracheoesophageal fistula, brought to our attention after recurrent bouts of exacerbating cough and tracheo-bronchitis. Endoscopic examination under general anesthesia noted the presence of severe tracheomalacia with inspiratory collapse, and a 10-mm balloon expandable metallic stent (BEMS) was deployed and symptomatic improvement was noted. The initial stent was then removed to consider a definitive procedure using the typical grasping fashion with an alligator forceps and expected mucosal excoriation was noted. Due to symptom recurrence, the patient underwent placement of a second BEMS stent. Initial improvement was noted followed by recurrent episodes of respiratory distress due to granulation tissue formation and stent compression and a decision to remove the stent was made. A new method of stent removal deemed ABC (airway balloon collapse) method was utilized where an expandable airway balloon is placed outside the stent between the stent and tracheal wall and then inflated to collapse the stent, facilitating easy removal.


Assuntos
Obstrução das Vias Respiratórias , Estenose Traqueal , Obstrução das Vias Respiratórias/etiologia , Obstrução das Vias Respiratórias/cirurgia , Broncoscopia , Criança , Remoção de Dispositivo , Tecido de Granulação , Humanos , Stents/efeitos adversos , Traqueia/cirurgia , Estenose Traqueal/etiologia , Estenose Traqueal/cirurgia
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