Hospital Admissions in Pediatric Patients With Tracheostomies Based on Rurality and Insurance Status.

OBJECTIVE: Determine whether rurality or public insurance status is associated with greater 30-day readmission after tracheostomy in pediatric patients. STUDY DESIGN: Retrospective cohort. SETTING: Pediatric Health Information System (PHIS) Database. METHODS: Patients within PHIS who underwent tracheostomy from 2013 to 2017 were included. Rural status was defined by rural-urban commuting area codes. Insurance status was based on the primary payer. All-cause 30-day readmissions and tracheostomy-related readmissions were recorded. Multivariate logistic regression was performed to test for differences in readmissions between cohorts. RESULTS: Among patients, 1092 were rural, and 4329 were publicly insured, with no significant association between rurality and insurance. Compared to nonrural patients, rural patients were more frequently white, less frequently ventilator dependent, and more likely discharged home rather than to a care facility. Publicly insured patients were more frequently non-white. Twenty-eight percent of patients were readmitted within 30 days of discharge. Odds of 30-day readmission were lower in rural patients (odds ratio [OR]: 0.80, 95% confidence interval [CI]: 0.68-0.95, p = .01) but higher in publicly insured (OR: 1.24, 95% CI: 1.09-1.42, p = .001) controlling for age at tracheostomy, sex, race, and ventilator dependence. The odds of tracheostomy-related admission did not differ by rurality but were higher in publicly insured children (1.39, 95% CI: 1.03-1.88, p = .03). CONCLUSION: Readmission within 30 days following tracheostomy was more likely in publicly insured patients and less likely in rural patients. These findings help identify at-risk patients when considering discharge planning and follow-up. More work is needed to understand long-term tracheostomy outcomes in these groups.

Validation of a three-dimensional printed pediatric middle ear model for endoscopic surgery training.

Objective: The purpose of this study is to assess the anatomical appropriateness of a three-dimensional (3D) printed pediatric middle ear model with a replaceable middle ear unit as an endoscopic ear surgery (EES) simulator. Methods: Single-blinded, prospective, proof-of-concept study conducted in a simulation operative suite. A simulator was developed through segmentation of source images and multi-material 3D printing. Subjects were asked to point to seven anatomical sites before and after a short anatomy presentation of a human middle ear photograph. They also filled out a survey about the feasibility of the model. Outcome variables included survey scores, pre-anatomy lesson (PreAL) and post-anatomy lesson (PostAL) quiz scores. Results: There were 24 participants (19 residents, 1 fellow, and 4 attendings), none with self-reported proficiency in EES. The PreAL mean score was 4.42 and PostAL quiz mean score was 5.32 (average improvement of 43% [CI = 17%-70%]; p = .003). The higher the level of training, the higher the PreAL scores (0.55 points per year of training; p = .004). The subspecialty (otology, other, in-training) was also associated with the PreAL scores (p = .004). Total survey score means were 22.8 (out of 30). Conclusion: The results of our study suggest that our model has adequate anatomical high fidelity to mimic a real, pediatric temporal bone for EES. As 3D printing technologies continue to advance, the quality of ear models has the potential to provide improved surgical training for pediatric EES. Level of Evidence: 4.

The accuracy of a portable sleep monitor to diagnose obstructive sleep apnea in adolescent patients.

STUDY OBJECTIVES: The efficacy of portable-monitor (PM) sleep testing in children is not well understood. While most studies have evaluated PM in a lab setting, the utility of PM in the home environment is relatively unknown. We sought to determine whether home PM accurately diagnoses obstructive sleep apnea in adolescents and to assess patient satisfaction with home PM sleep testing. METHODS: We evaluated adolescents (age 12-18 years) with suspected obstructive sleep apnea using a PM device. In addition to in-laboratory polysomnography (PSG), all participants had PM testing performed twice, once in their home and once concurrent to in-laboratory PSG. PM was compared to PSG using 2 primary outcomes: the apnea-hypopnea index and oxygen desaturation index. All participants were approached for interview to evaluate their experience with PM sleep testing. RESULTS: Twenty adolescents participated. Bland-Altman analysis comparing the apnea-hypopnea index and oxygen desaturation index determined by home or in-laboratory PM to in-laboratory PSG revealed mostly agreement; however, some deviations were observed when either parameter was markedly increased. While PM testing tended to underestimate the apnea-hypopnea index, the diagnostic agreement between home PM and PSG was 80% (by the White-Westbrook method). Most preferred PM to PSG and found PM easy to very easy to set up. CONCLUSIONS: In a small cohort of adolescents, our study supports the application of home PM in the diagnosis of suspected obstructive sleep apnea. Until studies implementing PM using larger cohorts become readily available, the findings from this preliminary study could contribute to adolescents receiving sleep apnea therapy more promptly. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Identifier: NCT03748771. At the time of issue publication, this registration is not publicly available because the trial includes a device that is not approved or cleared for use in pediatric populations. Once the device is FDA cleared, the registration will become public.

Pediatric Basilar Skull Fracture Mechanisms and Trends From 2007 to 2018.

OBJECTIVES: To evaluate the specific mechanism and trend of injury resulting in pediatric basilar skull fractures. STUDY DESIGN: Retrospective chart review of a trauma database. SETTING: Tertiary care children's hospital. METHODS: Patients ≤18 years old with basilar skull fractures were identified via the trauma database for admissions from 2007 to 2018. Patients were identified with ICD-9 codes (801.0, 801.1, 801.2, 801.3 or 801.4) and ICD-10 codes (S02.1, S02.10, S02.11, S02.19) for skull base fractures (International Classification of Diseases, Ninth Revision and Tenth Revision). RESULTS: A total of 729 patients were included: 251 females and 478 males. The 2 most common mechanisms of injury are multilevel falls and unhelmeted rider falls. Multilevel falls occur more in the toddler age group (average age, 4 years), and unhelmeted rider falls are seen in the older age group (average age, 11.2 years). Helmeted rider and motor vehicle accident basilar skull injuries are relatively uncommon. There was a spike in television/entertainment center mechanisms of injury in toddlers from 2007 to 2011 but has since decreased. CONCLUSION: Pediatric basilar skull fractures are costly to the health care system, as patients spent more time in intensive care unit beds with a charge limited to hospital rooms between $1.7 and $2.7 million per year. The protective effect of helmets is demonstrated by unhelmeted rider injuries being the second-most common mechanism of basilar skull fractures and by helmeted rider injuries being rare. The small proportion of basilar skull fractures from motor vehicle accidents is an example of policy and behavioral changes resulting in decreased injury.

Compassion Meditation for Veterans with Posttraumatic Stress Disorder (PTSD): a Nonrandomized Study.

Compassion meditation (CM) is a contemplative practice that is intended to cultivate the ability to extend and sustain compassion toward self and others. Although research documents the benefits of CM in healthy populations, its use in the context of psychopathology is largely unexamined. The purpose of this study was to refine and initially evaluate a CM protocol, Cognitively Based Compassion Training (CBCT®), for use with Veterans with PTSD. To this end, our research team developed and refined a manualized protocol, CBCT-Vet, over 4 sets of groups involving 36 Veterans. This protocol was delivered in 8-10 sessions, each lasting 90-120 min and led by a CBCT®-trained clinical psychologist. Quantitative and qualitative data were used to identify areas to be improved and to assess change that occurred during the treatment period. Based on pooled data from this series of groups, CM appears to be acceptable to Veterans with PTSD. Group participation was associated with reduced symptoms of PTSD (partial eta squared = .27) and depression (partial eta squared = .19), but causality should not be inferred given the nonrandomized design. No change was observed in additional outcomes, including positive emotion and social connectedness. The results of this open trial support additional exploration of CM as part of the recovery process for Veterans with PTSD.

The theoretical and empirical basis for meditation as an intervention for PTSD.

In spite of the existence of good empirically supported treatments for posttraumatic stress disorder (PTSD), consumers and providers continue to ask for more options for managing this common and often chronic condition. Meditation-based approaches are being widely implemented, but there is minimal research rigorously assessing their effectiveness. This article reviews meditation as an intervention for PTSD, considering three major types of meditative practices: mindfulness, mantra, and compassion meditation. The mechanisms by which these approaches may effectively reduce PTSD symptoms and improve quality of life are presented. Empirical evidence of the efficacy of meditation for PTSD is very limited but holds some promise. Additional evaluation of meditation-based treatment appears to be warranted.