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BACKGROUND - Transbronchial lung biopsies are commonly performed for a variety of indications. Although generally well tolerated, complications such as bleeding do occur. Description of bleeding severity is crucial both clinically and in research trials; to date, there is no validated scale that is widely accepted for this purpose. Can a simple, reproducible tool for categorizing the severity of bleeding after transbronchial biopsy be created?
METHODS - Using the modified Delphi method, an international group of bronchoscopists sought to create a new scale tailored to assess bleeding severity among patients undergoing flexible bronchoscopy with transbronchial lung biopsies. Cessation criteria were specified a priori and included reaching > 80% consensus among the experts or three rounds, whichever occurred first.
RESULTS - Thirty-six expert bronchoscopists from eight countries, both in academic and community practice settings, participated in the creation of the scale. After the live meeting, two iterations were made. The second and final scale was vetted by all 36 participants, with a weighted average of 4.47/5; 53% were satisfied, and 47% were very satisfied. The panel reached a consensus and proposes the Nashville Bleeding Scale.
CONCLUSIONS - The use of a simplified airway bleeding scale that can be applied at bedside is an important, necessary tool for categorizing the severity of bleeding. Uniformity in reporting clinically significant airway bleeding during bronchoscopic procedures will improve the quality of the information derived and could lead to standardization of management. In addition to transbronchial biopsies, this scale could also be applied to other bronchoscopic procedures, such as endobronchial biopsy or endobronchial ultrasound-guided needle aspiration.
Copyright © 2020. Published by Elsevier Inc.
BACKGROUND - Perinatal hemorrhagic stroke in late preterm and term neonates is understudied. We describe two-month and two-year neurological outcomes in a prospective cohort.
METHODS - Neonates ≥36 weeks' gestation with spontaneous hemorrhagic stroke (parenchymal and intraventricular) presenting at age ≤28 days were enrolled between March 2007 and May 2015 at three tertiary pediatric centers. Hemorrhagic transformation of arterial ischemic stroke or cerebral sinovenous thrombosis was excluded. The Pediatric Stroke Outcome Measure (PSOM) assessed outcomes. Wilcoxon signed-rank tests evaluated change over time.
RESULTS - Twenty-six neonates were included (median age: 1 day, interquartile range [IQR] 0 to 16; median gestational age: 38.3 weeks, IQR 37.0 to 39.0). Hemorrhage was isolated intraventricular in seven (27%), isolated intraparenchymal in six (23%), and a combination in 10 (39%). Three neonates (12%) died during hospitalization; one died later due to cardiac disease. Among 22 survivors, outcomes were assessed at a median of 2.1 months (IQR 1.7 to 3.3) in 96% and 1.9 years (IQR 1.3 to 2.0) in 73%. Median PSOM scores were 0.0 (IQR 0.0 to 1.0) and 0.25 (IQR 0.0 to 1.3), respectively. At two years, 45% of patients had no or nonimpairing deficits (PSOM <1.0), 30% had mild deficits (PSOM 1.0 to 2.0), and 5% had moderate deficits (PSOM 2.5 to 4.5). Over time, 31% worsened and 6% improved. Although total PSOM scores did not change significantly (P = 0.08), language subscores worsened (P = 0.009). No child developed epilepsy.
CONCLUSIONS - Perinatal hemorrhagic stroke survivors had favorable outcomes in early childhood; at two years moderate to severe deficits occurred in 5%. Language deficits may emerge over time, warranting close follow-up.
Copyright © 2019 Elsevier Inc. All rights reserved.
In this comprehensive systematic review and meta-analysis of group design studies of nonpharmacological early interventions designed for young children with autism spectrum disorder (ASD), we report summary effects across 7 early intervention types (behavioral, developmental, naturalistic developmental behavioral intervention [NDBI], TEACCH, sensory-based, animal-assisted, and technology-based), and 15 outcome categories indexing core and related ASD symptoms. A total of 1,615 effect sizes were gathered from 130 independent participant samples. A total of 6,240 participants, who ranged in age from 0-8 years, are represented across the studies. We synthesized effects within intervention and outcome type using a robust variance estimation approach to account for the nesting of effect sizes within studies. We also tracked study quality indicators, and report an additional set of summary effect sizes that restrict included studies to those meeting prespecified quality indicators. Finally, we conducted moderator analyses to evaluate whether summary effects across intervention types were larger for proximal as compared with distal effects, and for context-bound as compared to generalized effects. We found that when study quality indicators were not taken into account, significant positive effects were found for behavioral, developmental, and NDBI intervention types. When effect size estimation was limited to studies with randomized controlled trial (RCT) designs, evidence of positive summary effects existed only for developmental and NDBI intervention types. This was also the case when outcomes measured by parent report were excluded. Finally, when effect estimation was limited to RCT designs and to outcomes for which there was no risk of detection bias, no intervention types showed significant effects on any outcome. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
OBJECTIVES - When examining vaccination coverage, researchers must make decisions about how to define outcome measures based on many factors, including the timing of doses. Different operationalizations of the same outcome can often lead to different findings and can affect the ability to make comparisons across studies. This methodological article aimed to illustrate the implications of two options for operationalizing human papillomavirus (HPV) vaccination based on timing: initiation of the first dose at any age vs before the 13th birthday (on time).
STUDY DESIGN - Cross-sectional observational design.
METHODS - The 2014 National Immunization Survey for Teens (N = 16,439 adolescents aged 13-17 years) was analyzed using multivariate logistic regression for each outcome measure and effect modification by gender.
RESULTS - Age was positively associated with initiation at any age but negatively associated with on-time initiation. Gender modified the effect of race/ethnicity for both measures of initiation, but the pattern across groups was different for the two outcomes. Gender modified the effect of provider recommendation for initiation at any age, while gender modified the effects of age and region for on-time initiation.
CONCLUSION - Decisions of how to operationalize outcomes of HPV vaccine initiation among adolescents can lead to different conclusions about the role of age and gender differences for several predictive variables. To inform the development of public health efforts that promote on-time HPV vaccination among male and female adolescents, researchers should consider the importance of dose timing when operationalizing outcome measures. We recommend including on-time receipt of the HPV vaccine as an outcome measure.
Copyright © 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
OBJECTIVE - To determine the efficacy of nasal saline irrigation (NSI) in reducing symptoms and improving quality of life in pediatric patients with acute (ARS) or chronic (CRS) rhinosinusitis.
DATA SOURCES - We searched the PubMed/MEDLINE and Embase electronic databases (indexed January, 1950 through April, 2017).
REVIEW METHODS - Studies assessing the efficacy of NSI in pediatric patients with ARS or CRS were selected for analysis. Outcome measures, including symptom scores and parental surveys, were analyzed. Two independent reviewers evaluated each abstract and article.
RESULTS - Of the 272 articles identified using our search strategy, only 1 study, focusing on the use of NSI in pediatric ARS, met all inclusion criteria. No studies investigating NSI in pediatric CRS were included for analysis. In general, studies demonstrated significant improvement of symptom scores with the use of NSI in pediatric rhinosinusitis; but, the use of varied outcome measures, control treatments, and NSI delivery made including studies and drawing conclusions difficult. No quantitative meta-analysis could be performed.
CONCLUSION - NSI may provide benefit for ARS in children; however, additional high-quality studies with defined outcome measures are needed to determine the quantitative efficacy of this therapy in the pediatric patients with rhinosinusitis-especially in pediatric CRS.
Copyright © 2018 Elsevier B.V. All rights reserved.
PURPOSE - Nephrolithiasis is an increasingly common ailment in the United States. Ureteroscopic management has supplanted shockwave lithotripsy as the most common treatment of upper tract stone disease. Ureteral stricture is a rare but serious complication of stone disease and its management. The impact of new technologies and more widespread ureteroscopic management on stricture rates is unknown. We describe our experience in managing strictures incurred following ureteroscopy for upper tract stone disease.
MATERIALS AND METHODS - Records for patients managed at four tertiary care centers between December 2006 and October 2015 with the diagnosis of ureteral stricture following ureteroscopy for upper tract stone disease were retrospectively reviewed. Study outcomes included number and type (endoscopic, reconstructive, or nephrectomy) of procedures required to manage stricture.
RESULTS - Thirty-eight patients with 40 ureteral strictures following URS for upper tract stone disease were identified. Thirty-five percent of patients had hydronephrosis or known stone impaction at the time of initial URS, and 20% of cases had known ureteral perforation at the time of initial URS. After stricture diagnosis, the mean number of procedures requiring sedation or general anesthesia performed for stricture management was 3.3 ± 1.8 (range 1-10). Eleven strictures (27.5%) were successfully managed with endoscopic techniques alone, 37.5% underwent reconstruction, 10% had a chronic stent/nephrostomy, and 10 (25%) required nephrectomy.
CONCLUSIONS - The surgical morbidity of ureteral strictures incurred following ureteroscopy for stone disease can be severe, with a low success rate of endoscopic management and a high procedural burden that may lead to nephrectomy. Further studies that assess specific technical risk factors for ureteral stricture following URS are needed.
AIM - Previous research investigating outcomes after pediatric intracerebral hemorrhage (ICH) has generally been limited to global and sensorimotor outcomes. This study examined cognitive outcomes after spontaneous ICH in school-aged children with serial assessments over 2 years after stroke.
METHOD - Seven children (age range 6-16y, median 13; six males, one female; 57% white, 43% black) presenting with spontaneous ICH (six arteriovenous malformations) were assessed at 3 months, 12 months, and 24 months after stroke. The Pediatric Stroke Outcome Measure (PSOM) quantified neurological outcome and Wechsler Intelligence Scales measured cognitive outcomes: verbal comprehension, perceptual reasoning, working memory, and processing speed.
RESULTS - PSOM scales showed improved neurological function over the first 12 months, with mild to no sensorimotor deficits and moderate overall deficits at 1- and 2-year follow-ups (median 2-year sensorimotor PSOM=0.5, total PSOM=1.5). Changes in cognitive function indicated a different trajectory; verbal comprehension and perceptual reasoning improved over 24 months; low performance was sustained in processing speed and working memory. Age-normed centile scores decreased between 1- and 2-year follow-ups for working memory, suggesting emerging deficits compared with peers.
INTERPRETATION - Early and serial cognitive testing in children with ICH is needed to assess cognitive functioning and support children in school as they age and cognitive deficits become more apparent and important for function.
WHAT THIS PAPER ADDS - In children with intracerebral hemorrhage (ICH), motor function improved between 3 months and 24 months. Improvements in cognitive function were variable between 3 months and 24 months. Working memory centiles declined, suggesting emerging deficits compared with peers. Processing speed improved but remained significantly below the 50th centile. Cognitive impact of ICH may increase with age in children.
© 2017 Mac Keith Press.
BACKGROUND - Although systems of 3-dimensional image-guided surgery are a valuable adjunct across numerous procedures, differences in organ shape between that reflected in the preoperative image data and the intraoperative state can compromise the fidelity of such guidance based on the image. In this work, we assessed in real time a novel, 3-dimensional image-guided operation platform that incorporates soft tissue deformation.
METHODS - A series of 125 alignment evaluations were performed across 20 patients. During the operation, the surgeon assessed the liver by swabbing an optically tracked stylus over the liver surface and viewing the image-guided operation display. Each patient had approximately 6 intraoperative comparative evaluations. For each assessment, 1 of only 2 types of alignments were considered: conventional rigid and novel deformable. The series of alignment types used was randomized and blinded to the surgeon. The surgeon provided a rating, R, from -3 to +3 for each display compared with the previous display, whereby a negative rating indicated degradation in fidelity and a positive rating an improvement.
RESULTS - A statistical analysis of the series of rating data by the clinician indicated that the surgeons were able to perceive an improvement (defined as a R > 1) of the model-based registration over the rigid registration (P = .01) as well as a degradation (defined as R < -1) when the rigid registration was compared with the novel deformable guidance information (P = .03).
CONCLUSION - This study provides evidence of the benefit of deformation correction in providing an accurate location for the liver for use in image-guided surgery systems.
Copyright © 2017 Elsevier Inc. All rights reserved.
Over 4 million children in the United States suffer from chronic health conditions, including cancer, sickle cell disease, and diabetes. Because of major advances in the early identification and treatment of these conditions, survival rates for these children continue to rise, and the majority now lives into adulthood. However, increases in survival have come with costs related to long-term effects of disease processes and treatments. Foremost among these consequences is impairment in brain development and neurocognitive function that may affect a substantial portion of children with chronic health conditions and follow many into adulthood. Impaired cognitive function may contribute to impairment in educational and occupational attainment, mental health, and quality of life for children with chronic conditions. Despite the significance and scope of this problem, advances in the identification and understanding of neurocognitive problems and the delivery of effective clinical care have been hindered in part because research has been "siloed"-conducted on each chronic condition in isolation. This review examines, for the first time, neurocognitive problems in a selected set of 6 chronic pediatric health conditions-leukemia, brain tumors, sickle cell disease, congenital heart disease, Type 1 diabetes, and traumatic brain injury-to define the magnitude of the problem and identify directions for future research and clinical care. Psychologists from many areas of specialization, including pediatric psychology, educational and school psychology, neuropsychology, behavioral medicine, and adult primary care, are uniquely positioned to contribute to every phase of this work, including research, identification, and intervention. (PsycINFO Database Record
(c) 2017 APA, all rights reserved).
OBJECTIVE - Drug-resistant epilepsy is a devastating disorder associated with diminished quality of life (QOL). Surgical resection leads to seizure freedom and improved QOL in many epilepsy patients, but not all individuals are candidates for resection. In these cases, neuromodulation-based therapies such as vagus nerve stimulation (VNS) are often used, but most VNS studies focus exclusively on reduction of seizure frequency. QOL changes and predictors with VNS remain poorly understood.
METHOD - Using the VNS Therapy Patient Outcome Registry, we examined 7 metrics related to QOL after VNS for epilepsy in over 5000 patients (including over 3000 with ≥12months follow-up), as subjectively assessed by treating physicians. Trends and predictors of QOL changes were examined and related to post-operative seizure outcome and likelihood of VNS generator replacement.
RESULTS - After VNS therapy, physicians reported patient improvement in alertness (58-63%, range over follow-up period), post-ictal state (55-62%), cluster seizures (48-56%), mood change (43-49%), verbal communication (38-45%), school/professional achievements (29-39%), and memory (29-38%). Predictors of net QOL improvement included shorter time to implant (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.6), generalized seizure type (OR, 1.2; 95% CI, 1.0-1.4), female gender (OR, 1.2; 95% CI, 1.0-1.4), and Caucasian ethnicity (OR, 1.3; 95% CI, 1.0-1.5). No significant trends were observed over time. Patients with net QOL improvement were more likely to have favorable seizure outcomes (chi square [χ]=148.1, p<0.001) and more likely to undergo VNS generator replacement (χ=68.9, p<0.001) than those with worsened/unchanged QOL.
SIGNIFICANCE - VNS for drug-resistant epilepsy is associated with improvement on various QOL metrics subjectively rated by physicians. QOL improvement is associated with favorable seizure outcome and a higher likelihood of generator replacement, suggesting satisfaction with therapy. It is important to consider QOL metrics in neuromodulation for epilepsy, given the deleterious effects of seizures on patient QOL.
Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.