A series of new current procedural terminology codes have been created that allow health-care providers to code and bill for pediatric home apnea monitoring in the United States. Apnea monitors have ...been used at home on pediatric patients at risk for sudden death for > 30 years without the benefit of evidence-based efficacy studies. Nevertheless, new apnea monitor devices with expanded capability have been developed. Recommended indications for pediatric home apnea monitors are outdated and vague. It is important for the prescribing health-care provider to understand device function, as well as the pathophysiology of cardiorespiratory events in different disease states in order to make logical decisions about which monitor to prescribe, or whether to prescribe one at all. This article will review what apnea monitors are designed to do, common misperceptions about device indications vs device capability, and updated suggestions regarding the prescription, billing, and coding of pediatric apnea monitors for pediatric practice management.
Chronic intermittent hypoxia and hedgehog (Hh) pathway dysregulation are associated with nonalcoholic fatty liver disease (NAFLD) progression. In this study, we determined the relationship between ...obstructive sleep apnea (OSA)/nocturnal hypoxia and Hh signaling in pediatric NAFLD. Adolescents with histologic NAFLD (n = 31) underwent polysomnogram testing, laboratory testing, and Sonic Hh (SHh), Indian hedgehog (IHh), glioblastoma‐associated oncogene 2 (Gli2), keratin 7 (K7), α‐smooth muscle actin (α‐SMA), and hypoxia‐inducible factor 1α (HIF‐1α) immunohistochemistry. Aspartate aminotransferase (AST) correlated with SHh, r = 0.64; Gli2, r = 0.4; α‐SMA, r = 0.55; and K7, r = 0.45 (P < 0.01), as did alanine aminotransferase (ALT) (SHh, r = 0.51; Gli2, r = 0.43; α‐SMA, r = 0.51; P < 0.02). SHh correlated with NAFLD activity score (r = 0.39), whereas IHh correlated with inflammation (r = −0.478) and histologic grade (r = −0.43); P < 0.03. Subjects with OSA/hypoxia had higher SHh (4.0 ± 2.9 versus 2.0 ± 1.5), Gli2 (74.2 ± 28.0 versus 55.8 ± 11.8), and α‐SMA (6.2 ± 3.3 versus 4.3 ± 1.2); compared to those without (P < 0.03). OSA severity correlated with SHh (r = 0.31; P = 0.09) and Gli2 (r = 0.37; P = 0.04) as did hypoxia severity, which was associated with increasing SHh (r = −0.53), Gli2 (r = −0.52), α‐SMA (r = −0.61), and K7 (r = −0.42); P < 0.02. Prolonged O2 desaturations <90% also correlated with SHh (r = 0.55) and Gli2 (r = 0.61); P < 0.05. Conclusion: The Hh pathway is activated in pediatric patients with NAFLD with nocturnal hypoxia and relates to disease severity. Tissue hypoxia may allow for functional activation of HIF‐1α, with induction of genes important in epithelial‐mesenchymal transition, including SHh, and NAFLD progression.
Chronic intermittent hypoxia and dysregulation of the Hedgehog (Hh) pathway are associated with NAFLD progression. In adolescents with biopsy proven NASH and sleep apnea, the severity of their obstructive sleep apnea correlated with SHh (r = 0.31, P = 0.09) and Gli2 positively (r = 0.37, P = 0.04). The severity of hypoxia was also associated with increasing SHh (r = −0.53), GLI2 (r = −0.52), α‐SMA (r = −0.61), and K7(r = −0.42), P < 0.02. The Hh pathway is activated in pediatric NAFLD patients with nocturnal hypoxia and relates to disease severity.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Understanding the long-term neuropsychological consequences of sleep disorders in children poses a significant challenge to researchers. Since children are in a state of rapidly changing cognition ...and neurobehavioral function, impacts on development may have profound consequences. Recent studies now demonstrate that mild sleep apnea and snoring, once considered within the spectrum of normal sleep patterns, are associated with deficits of neuropsychological function. Preliminary data suggest that some of these cognitive deficits may be reversible following treatment of mild sleep apnea in children; however, factors such as age at treatment, duration of sleep disordered breathing, pre-morbid intellectual level, socioeconomic status, or the effectiveness of treatment may adversely affect long-term outcome. Furthermore, it is imperative that researchers determine whether the developing brain exhibits critical periods of plasticity during which episodes of sleep-disordered breathing might cause long-term or permanent neuropsychological effects.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
While the Accreditation Council for Graduate Medical Education limited first year resident-physicians to 16 consecutive work hours from 2011 to 2017, resident-physicians in their second year or ...higher were permitted to work up to 28 h consecutively. This paper describes the Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS) study, a clustered-randomized crossover clinical trial designed to evaluate the effectiveness of eliminating traditional shifts of 24 h or longer for second year or higher resident-physicians in pediatric intensive care units (PICUs).
ROSTERS was a multi-center non-blinded trial in 6 PICUs at US academic medical centers. The primary aim was to compare patient safety between the extended duration work roster (EDWR), which included shifts ≥24 h, and a rapidly cycling work roster (RCWR), where shifts were limited to a maximum of 16 h. Information on potential medical errors was gathered and used for classification by centrally trained physician reviewers who were blinded to the study arm. Secondary aims were to assess the relationship of the study arm to resident-physician sleep duration, work hours and neurobehavioral performance.
The study involved 6577 patients with a total of 38,821 patient days (n = 18,749 EDWR, n = 20,072 RCWR). There were 413 resident-physician rotations included in the study (n = 203 EDWR, n = 210 RCWR). Resident-physician questionnaire data were over 95% complete.
Results from data collected in the ROSTERS study will be evaluated for the impact of resident-physician schedule roster on patient safety outcomes in PICUs, and will allow for examination of a number of secondary outcome measures.
ClinicalTrials.gov Identifier: NCT02134847
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
(Abstracted from N Engl J Med 2020;382:2514–2523)Over the last 4 decades, a body of literature has studied the effect of extended shifts (working ≥24 hours) for resident physicians on their alertness ...and performance, and by extension, patient safety. Since then, the results of further studies have been inconsistent.
Childhood sleep-disordered breathing (SDB) has been known to be associated with health and cognitive impacts for more than a century, and yet our understanding of this disorder is in its infancy. ...Neuropsychological consequences in children with snoring or subtle breathing disturbances not meeting the traditional definition of sleep apnea suggest that "benign, or primary snoring" may be clinically significant, and that the true prevalence of SDB might be underestimated. There is no standard definition of SDB in children. The polysomnographic technology used in many sleep laboratories may be inadequate to diagnose serious but subtle forms of clinically important airflow limitation. In the last several years, advances in digital technology as well as new observational studies of respiratory and arousal patterns in large populations of healthy children have led to alternative views of what constitutes sleep-related breathing and arousal abnormalities that may refine our diagnostic criteria. This article reviews our knowledge of childhood SDB, highlights recent advances in technology, and discusses diagnostic and treatment strategies that will advance the management of children with pediatric SDB.
What do Ovaries have to do with Sleeping? Sundaram, Shikha S., MD, MSCI; Halbower, Ann C., MD
The Journal of pediatrics,
10/2011, Volume:
159, Issue:
4
Journal Article
Peer reviewed
Open access
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
A series of new current procedural terminology codes have been created that allow health-care providers to code and bill for
pediatric home apnea monitoring in the United States. Apnea monitors have ...been used at home on pediatric patients at risk
for sudden death for > 30 years without the benefit of evidence-based efficacy studies. Nevertheless, new apnea monitor devices
with expanded capability have been developed. Recommended indications for pediatric home apnea monitors are outdated and vague.
It is important for the prescribing health-care provider to understand device function, as well as the pathophysiology of
cardiorespiratory events in different disease states in order to make logical decisions about which monitor to prescribe,
or whether to prescribe one at all. This article will review what apnea monitors are designed to do, common misperceptions
about device indications vs device capability, and updated suggestions regarding the prescription, billing, and coding of
pediatric apnea monitors for pediatric practice management.
apnea monitor
apparent life-threatening event
billing
cardiorespiratory monitor
coding
infant monitor
sudden infant death syndrome
The choice and variety of pediatric masks for continuous positive airway pressure (CPAP) is limited in the US. Therefore, clinicians often prescribe modified adult masks. Until recently a mask for ...children aged < 7 years was not available. This study evaluated apnea-hypopnea index (AHI) equivalence and acceptability of a new pediatric CPAP mask for children aged 2-7 years (Pixi; ResMed Ltd, Sydney, Australia).
Patients aged 2-7 years were enrolled and underwent in-lab baseline polysomnography (PSG) using their previous mask, then used their previous mask and the VPAP III ST-A flow generator for ≥ 10 nights at home. Thereafter, patients switched to the Pixi mask for ≥ 2 nights before returning for a PSG during PAP therapy via the Pixi mask. Patients then used the Pixi mask at home for ≥ 21 nights. Patients and their parents/guardians returned to the clinic for follow-up and provided feedback on the Pixi mask versus their previous mask.
AHI with the Pixi mask was 1.1 ± 1.5/h vs 2.6 ± 5.4/h with the previous mask (p = 0.3538). Parents rated the Pixi mask positively for: restfulness of the child's sleep, trouble in getting the child to sleep, and trouble in having the child stay asleep. The Pixi mask was also rated highly for leaving fewer or no marks on the upper lip and under the child's ears, and being easy to remove.
The Pixi mask is suitable for children aged 2-7 years and provides an alternative to other masks available for PAP therapy in this age group.
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