Improving Care for Childhood Obesity: A Quality Improvement Initiative.

Obesity affected 13.7 million children in the United States in 2015. The American Academy of Pediatrics (AAP) offers an evidence-based approach to obesity management, but adherence to recommendations is suboptimal. Our objective was to improve provider adherence to the AAP recommendations for care of patients with obesity by making systematic changes in our practice for patients of ages > 2 and younger than 19 years with a BMI > 95th percentile. METHODS: We performed a retrospective chart review of 417 qualifying encounters to assess adherence in the six months preceding the initiative. We measured adherence as a proportion of eligible patients who had (1) obesity on the problem list; (2) laboratory work offered; (3) counseling provided; (4) early follow-up recommended; (5) referral to a weight management program. In 2018, a multidisciplinary QI team conducted plan-do-study-act cycles to educate providers on the AAP recommendations and improve obesity-related care systems. The initiative lasted 18 months. RESULTS: During the initiative, we tracked 885 patient encounters via chart review. We witnessed continued improvement in 4 out of 5 measures. For early follow-up offered, we saw improvement after PDSA 1, followed by a decline after PDSA 3. Providers ordered laboratory tests in only 13% of encounters for eligible children ages younger than 6 years versus 45% for ages older than 6 years, an age-dependent disparity that persisted despite the QI initiative. CONCLUSION: Our pediatric practice sustained improvement in adherence to AAP recommendations. There is a need to assess the reasons behind the care disparity based on patient ages.

Postoperative prophylactic antibiotics for facial fractures: A systematic review and meta-analysis.

OBJECTIVE: Perioperative antibiotic prophylaxis in patients undergoing surgery for maxillofacial fractures is standard practice. However, the use of postoperative antibiotic prophylaxis remains controversial. This systematic review and meta-analysis sought to evaluate the effect of postoperative antibiotic therapy on the incidence of surgical site infection (SSI) in patients with maxillofacial fractures. METHODS: MEDLINE, Embase, and the Cochrane Library were searched from inception through October 2017. Randomized controlled trials (RCTs) and cohort studies evaluating the efficacy of pre-, peri-, and postoperative antibiotic prophylaxis in preventing SSI in maxillofacial fractures were included. Data were extracted from studies using a standardized data collection form, with two reviewers independently performing extraction and quality assessment for each study. Risk ratios (RRs) for SSI were pooled using a random-effects model. RESULTS: Among 2,150 potentially eligible citations, 13 studies met inclusion criteria and provided data to be included in a meta-analysis. The addition of postoperative antibiotic prophylaxis to a standard preoperative and/or perioperative antibiotic regimen showed no significant difference in the risk of SSI (RR = 1.11 [95% CI: 0.86-1.44], P > .1). There were also no differences in the risk of SSI when restricting the analysis to mandibular fractures (eight studies, RR = 1.22 [95% CI: 0.92-1.62]) or open surgical techniques (eight studies, RR = 1.02 [95% CI: 0.62-1.67]). A sensitivity analysis did not find any significant differences in risk when restricting to RCTs (seven trials, RR = 1.00 [95% CI: 0.61-1.67]) or cohort studies (six studies, RR = 1.21 [95% CI: 0.89-1.63]). CONCLUSIONS: Our findings, along with the available evidence, does not support the routine use of postoperative antibiotic prophylaxis in patients with maxillofacial fractures. Avoiding the unnecessary use of antibiotic therapy in the postoperative period could have important implications for healthcare costs and patient outcomes. Laryngoscope, 129:82-95, 2019.

Surgical management of large scalp infantile hemangiomas.

BACKGROUND: Infantile Hemangiomas (IH) are the most common benign tumor of infancy, occurring in over 10% of newborns. While most IHs involute and never require intervention, some scalp IHs may cause severe cosmetic deformity and threaten tissue integrity that requires surgical excision. CASE DESCRIPTION: We present our experience with two infants who presented with large scalp IH. After vascular imaging, the patients underwent surgical resection of the IH and primary wound closure with excellent cosmetic outcome. We detail the surgical management of these cases and review the relevant literature. CONCLUSION: In some cases the IHs leave behind fibro-fatty residuum causing contour deformity. Surgery is often required for very large lesions causing extensive anatomical and/or functional disruption. The goal of surgical intervention is to restore normal anatomic contour and shape while minimizing the size of the permanent scar.

Endovascular thrombolysis for pediatric cerebral sinus venous thrombosis with tissue plasminogen activator and abciximab.

Cerebral sinus venous thrombosis (CSVT) is a relatively rare but potentially devastating disease. Medical management of CSVT with systemic anticoagulation has been the mainstay treatment strategy with these patients. However, some patients may not respond to this treatment or may present with very severe symptoms indicating more aggressive management strategies. The authors present the case of a pediatric patient who presented with severe CSVT, who underwent successful recanalization with endovascular tissue plasminogen activator (tPA) and abciximab. To the authors' knowledge there are no cases of endovascular thrombolysis for CSVT described in the literature in which abciximab has been used in conjunction with tPA. The authors also review the literature regarding the agents used and outcome in pediatric patients with CSVT after endovascular thrombolysis. The use of abciximab in conjunction with tPA may be considered in patients whose blood is hypercoagulable and in whom the treatment strategy is to obtain acute recanalization and long-term venous patency. However, the use of adjunctive agents increases the risk of hemorrhagic complications and must be done judiciously.