scholarly journals PERIOPERATIVE OPIOID EXPOSURE PATTERNS IN PEDIATRIC ACL PATIENTS: A TEN YEAR ADMINISTRATIVE DATABASE STUDY

2020 ◽  
Vol 8 (4_suppl3) ◽  
pp. 2325967120S0027
Author(s):  
Dharman Anandarajan ◽  
Brendan A. Williams ◽  
Nathan Markiewitz ◽  
Divya Talwar ◽  
Lawrence Wells
Keyword(s):  
Pediatric Patients ◽  
Cruciate Ligament ◽  
National Level ◽  
Bayesian Regression ◽  
Pediatric Care ◽  
Administrative Database ◽  
Study Cohort ◽  
Prescribing Practices ◽  
Database Study ◽  
Commercial Insurance

Background: Pediatric patients sustaining anterior cruciate ligament (ACL) or related injuries are at high risk for opioid exposure in the acute, perioperative and postoperative phases of injury. Early and repeated exposure to these medications may increase the risk of future misuse. While variation in opioid prescribing practices has been documented in the outpatient setting and other realms of pediatric care, perioperative opioid exposure in this procedural cohort has not been previously examined on a national level. Purpose: To assess for demographic, temporal, regional, and hospital-level variability in perioperative opioid exposure in pediatric ACL patients. Methods: The Pediatric Health Information Systems Database (PHIS) was used to identify pediatric patients (≤18 years old) undergoing surgical treatment for ACL injury between January 2008 and December 2017. Perioperative opioids were converted to a morphine equivalent dose (MED) and summed for each patient. A hierarchical bayesian regression was performed to identify demographic factors that predicted opioid exposure while adjusting for the effect of hospital. Results: The study cohort included 23,071 patients across 52 hospitals. We report model estimates in Table 1 and mean MME by hospital in Figure 1. Compared to older adolescents (15-18yo), younger adolescents (11-14yo; b=-0.13 95% Credible Interval[-0.19, -0.07]) and children <10yo (b=-1.62 [-1.72, -1.52]) received less MED. Patients located in an observation unit (b=-1.15 [-1.25, -1.06]) or an inpatient unit (b=-1.31;[-1.42, -1.20]) received less MED than patients in an ambulatory surgical setting. Patients with commercial insurance also were dispensed more MED compared to those with other payers (b=0.10 [0.04, 0.16]). Female patients received less opioids than male patients (b=-0.08 [-0.13, -0.02]). Of the hospital random effects, the 95% credible intervals of 24 (46%) intercepts and 21 (40%) slopes did not include zero. Conclusions: This administrative database study identified hospital and patient-level characteristics predictive of perioperative narcotic exposure among pediatric ACL patients. Those who were older, in an ambulatory surgery setting, or had commercial insurance received more opioids. Cumulative perioperative opioid exposure has not declined on a national level in recent years and significant variability in opioid exposure exists between hospitals. Future work should seek to identify and utilize opioid-minimizing practices that appear present in some clinical settings. [Table: see text][Figure: see text]

Non-Pediatric Nurses’ Willingness to Provide Care to Pediatric Patients during a Disaster: An Assessment of Pediatric Surge Capacity in Four Midwestern Hospitals

2021 ◽  
pp. 1-6
Author(s):  
Terri Rebmann ◽  
Rachel L. Charney ◽  
Rebecca L. Eschmann ◽  
M. Colleen Fitzpatrick
Keyword(s):  
Pediatric Patients ◽  
Response Rate ◽  
Mass Casualty ◽  
Pediatric Care ◽  
Pediatric Nurses ◽  
Surge Capacity ◽  
Factors Associated ◽  
Pediatric Hospitals ◽  
Survey Response Rate ◽  
Mass Casualty Event

Abstract Objective: To assess non-pediatric nurses’ willingness to provide care to pediatric patients during a mass casualty event (MCE). Methods: Nurses from 4 non-pediatric hospitals in a major metropolitan Midwestern region were surveyed in the fall of 2018. Participants were asked about their willingness to provide MCE pediatric care. Hierarchical logistical regression was used to describe factors associated with nurses’ willingness to provide MCE pediatric care. Results: In total, 313 nurses were approached and 289 completed a survey (response rate = 92%). A quarter (25.3%, n = 73) would be willing to provide MCE care to a child of any age; 12% (n = 35) would provide care only to newborns in the labor and delivery area, and 16.6% (n = 48) would only provide care to adults. Predictors of willingness to provide care to a patient of any age during an MCE included providing care to the youngest-age children during routine duties, reporting confidence in calculating doses and administering pediatric medications, working in the emergency department, being currently or previously certified in PALS, and having access to pediatric-sized equipment in the unit or hospital. Conclusion: Pediatric surge capacity is lacking among nurses. Increasing nurses’ pediatric care self-efficacy could improve pediatric surge capacity and minimize morbidity and mortality during MCEs.

scholarly journals Injuries to the anterolateral ligament are observed more frequently compared to lesions to the deep iliotibial tract (Kaplan fibers) in anterior cruciate ligamant deficient knees using magnetic resonance imaging

2021 ◽  
Author(s):  
Armin Runer ◽  
Dietmar Dammerer ◽  
Christoph Kranewitter ◽  
Johannes M. Giesinger ◽  
Benjamin Henninger ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Cruciate Ligament ◽  
Injury Rate ◽  
Anterolateral Ligament ◽  
Anatomical Reconstruction ◽  
Level Of Evidence ◽  
Iliotibial Tract ◽  
Anterolateral Complex ◽  
Anterior Cruciate ◽  
Combined Injuries

Abstract Purpose To determine the accuracy of detection, injury rate and inter- and intrarater reproducibility in visualizing lesions to the anterolateral ligament (ALL) and the deep portion of the iliotibial tract (dITT) in anterior cruciate ligament (ACL) deficient knees. Methods Ninety-one consecutive patients, out of those 25 children (age 14.3 ± 3.5 years), with diagnosed ACL tears were included. Two musculoskeletal radiologists retrospectively reviewed MRI data focusing on accuracy of detection and potential injuries to the ALL or dITT. Lesion were diagnosed in case of discontinued fibers in combination with intra- or peri-ligamentous edema and graded as intact, partial or complete tears. Cohen’s Kappa and 95% confidence intervals (95% CI) were determined for inter- and intrarater reliability measures. Results The ALL and dITT were visible in 52 (78.8%) and 56 (84.8%) of adult-and 25 (100%) and 19 (76.0%) of pediatric patients, respectively. The ALL was injured in 45 (58.5%; partial: 36.4%, compleate: 22.1%) patients. Partial and comleate tears, where visualized in 21 (40.4%) and 16 (30.8%) adult- and seven (28.0%) and one (4%) peditric patients. A total of 16 (21.3%; partial: 13.3%, compleate: 8.0%) dITT injuries were identified. Partal and complete lesions were seen in seven (12.5%) and five (8.9%) adult- and three (15.8%) and one (5.3%) pediatric patients. Combined injuries were visualized in nine (12.7%) patients. Inter-observer (0.91–0.95) and intra-observer (0.93–0.95) reproducibility was high. Conclusion In ACL injured knees, tears of the ALL are observed more frequently compared to lesions to the deep iliotibial tract. Combined injuries of both structures are rare. Clinically, the preoperative visualization of potentially injured structures of the anterolateral knee is crucial and is important for a more personalized preoperative planning and tailored anatomical reconstruction. The clinical implication of injuries to the anterolateral complex of the knee needs further investigation. Level of evidence II.

Pediatric care coordination and risk tiering: Moving beyond claims data

2021 ◽  
pp. 1-9
Author(s):  
Hillary E. Swann-Thomsen ◽  
Jared Vineyard ◽  
John Hanks ◽  
Rylon Hofacer ◽  
Claire Sitts ◽  
...  
Keyword(s):  
Care Coordination ◽  
Chronic Conditions ◽  
Pediatric Patients ◽  
Classification Model ◽  
Pediatric Care ◽  
Care Needs ◽  
Accurate Identification ◽  
Special Health Care ◽  
Pediatric Populations ◽  
Mean Differences

PURPOSE: The goal of this study was to evaluate the performance of a pediatric stratification tool that incorporates health and non-medical determinants to identify children and youth with special health care needs (CYSHCN) patients according to increasing levels of complexity and compare this method to existing tools for pediatric populations. METHODS: This retrospective cohort study examined pediatric patients aged 0 to 21 years who received care at our institution between 2012 and 2015. We used the St. Luke’s Children’s Acuity Tool (SLCAT) to evaluate mean differences in dollars billed, number of encounters, and number of problems on the problem list and compared the SLCAT to the Pediatric Chronic Conditions Classification System version2 (CCCv2). RESULTS: Results indicate that the SLCAT assigned pediatric patients into levels reflective of resource utilization and found that children with highly complex chronic conditions had significantly higher utilization than those with mild and/or moderate complex conditions. The SLCAT found 515 patients not identified by the CCCv2. Nearly half of those patients had a mental/behavioral health diagnosis. CONCLUSIONS: The findings of this study provide evidence that a tiered classification model that incorporates all aspects of a child’s care may result in more accurate identification of CYSHCN. This would allow for primary care provider and care coordination teams to match patients and families with the appropriate amount and type of care coordination services.

scholarly journals Comparison of Cancer Patients to Non-Cancer Patients among COVID-19 Inpatients at a National Level

Cancers ◽  
2021 ◽  
Vol 13 (6) ◽  
pp. 1436
Author(s):  
Alain Bernard ◽  
Jonathan Cottenet ◽  
Philippe Bonniaud ◽  
Lionel Piroth ◽  
Patrick Arveux ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Cancer Patients ◽  
Mortality Risk ◽  
Hospital Admissions ◽  
National Level ◽  
Administrative Database ◽  
Hospital Death ◽  
Solid Cancer ◽  
Hematological Cancer ◽  
Risk Of Death

(1) Background: Several smaller studies have shown that COVID-19 patients with cancer are at a significantly higher risk of death. Our objective was to compare patients hospitalized for COVID-19 with cancer to those without cancer using national data and to study the effect of cancer on the risk of hospital death and intensive care unit (ICU) admission. (2) Methods: All patients hospitalized in France for COVID-19 in March–April 2020 were included from the French national administrative database, which contains discharge summaries for all hospital admissions in France. Cancer patients were identified within this population. The effect of cancer was estimated with logistic regression, adjusting for age, sex and comorbidities. (3) Results: Among the 89,530 COVID-19 patients, we identified 6201 cancer patients (6.9%). These patients were older and were more likely to be men and to have complications (acute respiratory and kidney failure, venous thrombosis, atrial fibrillation) than those without cancer. In patients with hematological cancer, admission to ICU was significantly more frequent (24.8%) than patients without cancer (16.4%) (p < 0.01). Solid cancer patients without metastasis had a significantly higher mortality risk than patients without cancer (aOR = 1.4 [1.3–1.5]), and the difference was even more marked for metastatic solid cancer patients (aOR = 3.6 [3.2–4.0]). Compared to patients with colorectal cancer, patients with lung cancer, digestive cancer (excluding colorectal cancer) and hematological cancer had a higher mortality risk (aOR = 2.0 [1.6–2.6], 1.6 [1.3–2.1] and 1.4 [1.1–1.8], respectively). (4) Conclusions: This study shows that, in France, patients with COVID-19 and cancer have a two-fold risk of death when compared to COVID-19 patients without cancer. We suggest the need to reorganize facilities to prevent the contamination of patients being treated for cancer, similar to what is already being done in some countries.

scholarly journals Risk Factors for Failure After Anterior Cruciate Ligament Reconstruction in a Pediatric Population: A Prediction Algorithm

2021 ◽  
Vol 9 (3) ◽  
pp. 232596712199116
Author(s):  
Nicholas J. Lemme ◽  
Daniel S. Yang ◽  
Brooke Barrow ◽  
Ryan O’Donnell ◽  
Alan H. Daniels ◽  
...  
Keyword(s):  
Risk Factors ◽  
Anterior Cruciate Ligament ◽  
Anterior Cruciate Ligament Reconstruction ◽  
Ligament Reconstruction ◽  
Pediatric Patients ◽  
Cruciate Ligament ◽  
Adult Patients ◽  
Collateral Ligament ◽  
Cruciate Ligament Reconstruction ◽  
Anterior Cruciate

Background: Anterior cruciate ligament reconstruction (ACLR) in pediatric patients is becoming increasingly common. There is growing yet limited literature on the risk factors for revision in this demographic. Purpose: To (1) determine the rate of pediatric revision ACLR in a nationally representative sample, (2) ascertain the associated patient- and injury-specific risk factors for revision ACLR, and (3) examine the differences in the rate and risks of revision ACLR between pediatric and adult patients. Study Design: Case-control study; Level of evidence, 3. Methods: The PearlDiver patient record database was used to identify adult patients (age ≥20 years) and pediatric patients (age <20 years) who underwent primary ACLR between 2010 and 2015. At 5 years postoperatively, the risk of revision ACLR was compared between the adult and pediatric groups. ACLR to the contralateral side was also compared. Multivariate logistic regression was used to determine the significant risk factors for revision ACLR and the overall reoperation rates in pediatric and adult patients; from these risk factors, an algorithm was developed to predict the risk of revision ACLR in pediatric patients. Results: Included were 2055 pediatric patients, 1778 adult patients aged 20 to 29 years, and 1646 adult patients aged 30 to 39 years who underwent ACLR. At 5 years postoperatively, pediatric patients faced a higher risk of revision surgery when compared with adults (18.0 % vs 9.2% [adults 20-29 years] and 7.1% [adults 30-39 years]; P < .0001), with significantly decreased survivorship of the index ACLR ( P < .0001; log-rank test). Pediatric patients were also at higher risk of undergoing contralateral ACLR as compared with adults (5.8% vs 1.6% [adults 20-29 years] and 1.9% [adults 30-39 years]; P < .0001). Among the pediatric cohort, boys (odds ratio [OR], 0.78; 95% CI, 0.63-0.96; P = .0204) and patients >14 years old (OR, 0.62; 95% CI, 0.45-0.86; P = .0035) had a decreased risk of overall reoperation; patients undergoing concurrent meniscal repair (OR, 1.84; 95% CI, 1.43-2.38; P < .0001) or meniscectomy (OR, 2.20; 95% CI, 1.72-2.82; P < .0001) had an increased risk of revision surgery. According to the risk algorithm, the highest probability for revision ACLR was in girls <15 years old with concomitant meniscal and medial collateral ligament injury (36% risk of revision). Conclusion: As compared with adults, pediatric patients had an increased likelihood of revision ACLR, contralateral ACLR, and meniscal reoperation within 5 years of an index ACLR. Families of pediatric patients—especially female patients, younger patients, and those with concomitant medial collateral ligament and meniscal injuries—should be counseled on such risks.

scholarly journals Clinical outcomes of pediatric macular edema associated with non-infectious uveitis

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Anh Hong Nguyen ◽  
Bethlehem Mekonnen ◽  
Eric Kim ◽  
Nisha R. Acharya
Keyword(s):  
Visual Acuity ◽  
Macular Edema ◽  
San Francisco ◽  
Pediatric Patients ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Study Cohort ◽  
Common Diagnosis ◽  
Corticosteroid Injections

Abstract Background Macular edema (ME) is the most frequent cause of irreversible visual impairment in patients with uveitis. To date, little data exists about the clinical course of ME in pediatric patients. A retrospective, observational study was performed to examine the visual and macular thickness outcomes of ME associated with chronic, noninfectious uveitis in pediatric patients. Methods Pediatric patients with noninfectious uveitis complicated by ME seen in the University of California San Francisco Health System from 2012 to 2018 were identified using ICD-9 and ICD-10 codes. Data were collected from medical records including demographics, diagnoses, ocular history, OCT imaging findings, complications, and treatments at first encounter and at 3, 6, 9, and 12-month follow-up visits. Cox proportional hazards regression was used to investigate the association between different classes of treatment (steroid drops, steroid injections, oral steroids and other immunosuppressive therapies) and resolution of macular edema. Results The cohort comprised of 21 children (26 eyes) with a mean age of 10.5 years (SD 3.3). Undifferentiated uveitis was the most common diagnosis, affecting 19 eyes (73.1%). The majority of observed macular edema was unilateral (16 patients, 76.2%) and 5 patients had bilateral macular edema. The mean duration of follow-up at UCSF was 35.3 months (SD 25.7). By 12 months, 18 eyes (69.2%) had achieved resolution of ME. The median time to resolution was 3 months (IQR 3–6 months). Median best-corrected visual acuity (BCVA) at baseline was 0.54 logMAR (Snellen 20/69, IQR 20/40 to 20/200). Median BCVA at 12 months was 0.1 logMAR (Snellen 20/25, IQR 20/20 to 20/50) Corticosteroid injections were associated with a 4.0-fold higher rate of macular edema resolution (95% CI 1.3–12.2, P = 0.01). Conclusions Although only 15% of the pediatric patients with uveitis in the study cohort had ME, it is clinically important to conduct OCTs to detect ME in this population. Treatment resulted in 69% of eyes achieving resolution of ME by 12 months, accompanied with improvement in visual acuity. Corticosteroid injections were significantly associated with resolution of macular edema.

scholarly journals USE CAUTION WHEN ASSESSING PRE-OPERATIVE LEG LENGTH DISCREPANCY IN PEDIATRIC PATIENTS WITH ANTERIOR CRUCIATE LIGAMENT INJURIES

2020 ◽  
Vol 8 (4_suppl3) ◽  
pp. 2325967120S0028
Author(s):  
Lindsay M. Schlichte ◽  
Peter D. Fabricant ◽  
Christine Goodbody ◽  
Daniel W. Green
Keyword(s):  
Anterior Cruciate Ligament ◽  
Pediatric Patients ◽  
Cruciate Ligament ◽  
Weight Bearing ◽  
Acl Injury ◽  
Leg Length ◽  
Full Extension ◽  
X Ray ◽  
Length Discrepancy ◽  
Anterior Cruciate

Background: Pre- and post-operative standing hip to ankle radiography is critical for monitoring potential post-operative growth arrest and resultant length and angular deformities after pediatric anterior cruciate ligament (ACL) reconstruction. During acquisition of pre-operative standing alignment radiographs, it is possible that patients are lacking full extension, not weight bearing comfortably, or leaning resulting in inaccurate measurements. Purpose: This study aims to assess both pre- and post-operative radiographic measurements to assess if the standing pre-operative x-ray is a accurate and reliable source for baseline measurements. Methods: We retrospectively reviewed prospectively collected pre-operative and first post-operative full-length hip-to-ankle radiographs in a cohort of skeletally immature athletes who presented with an acute ACL injury and underwent subsequent surgical reconstruction. Initially, leg length discrepancy for 25 patients was measured by 3 orthopedic surgeons (top of femoral head to center of tibial plafond). The intraclass correlation was almost perfect (ICC (2,1) = .996) therefore, 1 surgeon measured the remaining 94 radiographs. Measurements for both the injured and uninjured legs were obtained for comparison and surgeons were blinded to the injured side. Results: A total of 119 pediatric patients (mean age 13.4, range 7-14 years) were included (83 males and 36 females). Patient were categorized as either having ≥5mm, ≥10mm, or ≥15mm LLD on pre-operative standing x-ray. Sixty-two patients (52%) were found to have a pre-operative LLD ≥ 5mm. Forty-one (66%) of these patients tore their ACL on the limb measuring shorter. At 6 month post-operative standing x-ray, 35 patients (56%) resolved to ≤5mm LLD. Eighteen patients had a pre-operative LLD of ≥ 10mm. At 6 month post-operative standing x-ray, 13 (72%) patients resolved to ≤5mm LLD. Five patients had a pre-operative LLD of ≥ 15mm. At 6 month post-operative standing x-ray, 4 (80%) resolved ≤5mm. All patients with a pre-operative LLD of ≥ 13mm had sustained an ACL injury on the limb measuring shorter Conclusion: Of the pediatric ACL patients initially presenting with a pre-operative LLD of ≥ 10mm, 72% demonstrated apparent correction of their LLD on their 6 month standing x-ray. This high rate of LLD pre-operatively but not post operatively calls into question the accuracy of pre-operative standing alignment radiographs for patients after an ACL tear. Surgeons and radiology technicians should be aware of injured patients potentially lacking full extension, leaning, or not weight bearing comfortably, and should consider delaying preoperative radiographic length and alignment analysis until after the patient is able to fully straighten the injured knee and weight bear comfortably.

scholarly journals It's Not Just a Needlestick: Exploring Phlebotomists' Knowledge, Training, and Use of Comfort Measures in Pediatric Care to Improve the Patient Experience

2019 ◽  
Vol 3 (5) ◽  
pp. 847-856
Author(s):  
Julie Piazza ◽  
Sandra Merkel ◽  
Harry Neusius ◽  
Susan Murphy ◽  
Joan Gargaro ◽  
...  
Keyword(s):  
Child Development ◽  
Patient Experience ◽  
Pediatric Patients ◽  
Child Life ◽  
Patient Comfort ◽  
Pediatric Care ◽  
Training Methods ◽  
Hospital System ◽  
Topical Anesthetics ◽  
And Training

Abstract Background Blood draws are a routine element of the pediatric patient experience. They are also associated with the greatest fear and pain for a child. Because of the limited literature regarding phlebotomists' knowledge, experience, training, or stress related to their use of comfort techniques during pediatric blood draws, this study explored current practices and training methods. Phlebotomist training tends to focus on clinical technique rather than pediatric or patient comfort support. The study includes aims to develop a measurement for phlebotomists' use of comfort techniques for pediatric blood draws. Method Focus groups of parent advocates (n = 24) and pediatric phlebotomists (n = 11) reviewed the survey questionnaire, and it was revised before being e-mailed to hospital system phlebotomists (n = 128). Results Almost half of the sample group lacked training in child development. The most frequently used comfort measures were words of explanation and reassurance, positioning of the child, and distraction. Requesting child life specialist support and using pain management devices or topical anesthetics were used less often. Primary challenges to performing pediatric blood draws were anxious patients and parents. Conclusion Phlebotomists' use of available comfort measures occurs infrequently. Including child development and comfort techniques in training programs is essential to providing pediatric patients with a more satisfactory experience.

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