The American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy, Asthma & Immunology (ACAAI) have jointly accepted responsibility for establishing the “Practice ...parameter for the diagnosis and management of primary immunodeficiency.” This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.
Purpose We developed a minimally invasive epicardial pacemaker implantation method for infants and congenital heart disease patients for whom a transvenous approach is contraindicated. The piglet is ...an ideal model for technical development. Description In 5 piglets we introduced a needle through subxiphoid approach under thoracoscopic guidance, inserting a wire into the pericardial space. Pacing leads were affixed to the left ventricular free wall and left atrial appendage. After verifying functionality with atrial and ventricular pacing and sensing, animals were euthanized. Pacemaker monitoring occurred daily for 4 days in the fifth animal. Evaluation Through minimally invasive pericardial access, we directly visualized and fixated pacing leads to the left ventricle and left atrial appendage, successfully pacing atrium and ventricle. Epicardial structures were visualized. One piglet had contralateral pneumothorax, which resolved with needle decompression. No other adverse events occurred. Conclusions Minimally invasive epicardial pacemaker implantation in an infant model is feasible and effective. This innovation may be of value for pacing and resynchronization in infants and congenital heart disease patients. Survival studies with permanent generator implantation are under way.
Abstract Background Soccer continues to gain popularity among youth athletes, and increased numbers of children playing soccer can be expected to result in increased injuries. Objective We reviewed ...children with soccer injuries severe enough to require trauma activation at our Level I trauma center to determine injury patterns and outcome. Our goal is to raise awareness of the potential for injury in youth soccer. Methods A retrospective review was performed using the trauma registry and electronic medical records at a Level I trauma center to identify children (< 18 years old) treated for soccer injury from 1999–2009. Data reviewed include age, gender, mechanism, injury, procedures, and outcome. Results Eighty-one children treated for soccer injury were identified; 38 (47%) were male. Of these, 20 had injury severe enough to require trauma team activation and 61 had minor injury. Mean age was 14 years old (range 5–17 years, SD 2.3). Lower extremity was the most common site of injury (57%), followed by upper extremity (17%), head (16%), and torso (10%). Mechanisms were: kicked or kneed in 27 patients (33%), collision with another player in 25 (31%), fall in 18 (22%), struck by ball in 10 (12%), and unknown in 1 (1%). Procedures included reduction of fractures, splenectomy, abdominal abscess drainage, and surgical feeding access. Long hospitalizations were recorded in some cases. There were no deaths. Conclusion Although less common, injury requiring prolonged hospital admission and invasive operative procedures exist in the expanding world of youth soccer. With increasing participation in the sport, we anticipate greater numbers of these child athletes presenting with serious injury.
Abstract Background Cardiac disease is a leading cause of stroke in children, yet limited data support the current stroke prevention and treatment recommendations. A multidisciplinary panel of ...clinicians was convened in February 2014 by the International Pediatric Stroke Study group to identify knowledge gaps and prioritize clinical research efforts for children with cardiac disease and stroke. Results Significant knowledge gaps exist, including a lack of data on stroke incidence, predictors, primary and secondary stroke prevention, hyperacute treatment, and outcome in children with cardiac disease. Commonly used diagnostic techniques including brain computed tomography and ultrasound have low rates of stroke detection, and diagnosis is frequently delayed. The challenges of research studies in this population include epidemiologic barriers to research such as small patient numbers, heterogeneity of cardiac disease, and coexistence of multiple risk factors. Based on stroke burden and study feasibility, studies involving mechanical circulatory support, single ventricle patients, early stroke detection strategies, and understanding secondary stroke risk factors and prevention are the highest research priorities over the next 5-10 years. The development of large-scale multicenter and multispecialty collaborative research is a critical next step. The designation of centers of expertise will assist in clinical care and research. Conclusions There is an urgent need for additional research to improve the quality of evidence in guideline recommendations for cardiogenic stroke in children. Although significant barriers to clinical research exist, multicenter and multispecialty collaboration is an important step toward advancing clinical care and research for children with cardiac disease and stroke.
Background Electromagnetic navigational bronchoscopy (ENB) is a commonly used technique to obtain biopsies of peripheral pulmonary lesions. Little is known about risk factors for complications with ...this procedure. The aim of this study was to assess the complication rate associated with ENB and the relationship of complications to patient- and procedure-related factors. Methods Consecutive ENB procedures at an academic medical center between May 11, 2011, and September 11, 2015, were reviewed retrospectively. Preoperative characteristics, including pulmonary function, procedure characteristics, and the occurrence of complications, were recorded. Results In all, 361 procedures were performed on 341 patients. Complications occurred in 30 of 361 (8.3%), the most common of which was pneumothorax (27, 7.5%). Complications were not related to age, sex, American Society of Anesthesiologists grade, or pulmonary function test result. Patients with complications had longer procedure times (50 versus 73 minutes, p = 0.03), and had more interventional modalities used (2.4 versus 3.2, p = 0.001). Multiple logistic regression demonstrated that bronchoalveolar lavage was significantly associated with complications (odds ratio 6.40; 95% confidence interval: 1.68 to 24.3, p = 0.006). Conclusions Electromagnetic navigational bronchoscopy is safe, and the rate of complications is not elevated among patients with poor lung function. Bronchoalveolar lavage performed during ENB was associated with elevated risk of complications and should be studied further.
Epicardial implantable cardioverter-defibrillator (ICD) placement in infants, children, and patients with complex cardiac anatomy requires an open surgical thoracotomy and is associated with ...increased pain, longer length of stay, and higher cost.
The purpose of this study was to compare an open surgical epicardial placement approach with percutaneous pericardial placement of an ICD lead system in an infant piglet model.
Animals underwent either epicardial placement by direct suture fixation through a left thoracotomy or minimally invasive pericardial placement with thoracoscopic visualization. Initial lead testing and defibrillation threshold testing (DFT) were performed. After the 2-week survival period, repeat lead testing and DFT were performed before euthanasia.
Minimally invasive placement was performed in 8 piglets and open surgical placement in 7 piglets without procedural morbidity or mortality. The mean initial DFT value was 10.5 J (range 3-28 J) in the minimally invasive group and 10.0 J (range 5-35 J) in the open surgical group (P = .90). After the survival period, the mean DFT value was 12.0 J (range 3-20 J) in the minimally invasive group and 12.3 J (range 3-35 J) in the open surgical group (P = .95). All lead and shock impedances, R-wave amplitudes, and ventricular pacing thresholds remained stable throughout the survival period.
Compared with open surgical epicardial ICD lead placement, minimally invasive pericardial placement demonstrates an equivalent ability to effectively defibrillate the heart and has demonstrated similar lead stability. With continued technical development and operator experience, the minimally invasive method may provide a viable alternative to epicardial ICD lead placement in infants, children, and adults at risk of sudden cardiac death.
Background Ventilator-associated pneumonia (VAP) represents one of the driving forces behind antibiotic use in the ICU. In a previous study, we established a defined algorithm for treatment of ...hospital-acquired VAP dictated by the causative pathogen. The purpose of the current study was to evaluate the impact of this algorithm for hospital-acquired VAP on recurrence and charges in trauma patients. Study Design Patients with VAP secondary to MRSA, Acinetobacter baumannii , Pseudomonas aeruginosa , Stenotrophomonas maltophilia , or Enterobacteriaceae during 5 years subsequent to the previous study were evaluated. All VAP were diagnosed using quantitative cultures of the bronchoalveolar lavage effluent. Duration of antimicrobial therapy was dictated by the causative pathogen. If microbiologic resolution, defined as <103 colony-forming units/mL, was achieved, therapy was stopped by day 10. The remainder received 14 days of therapy. Recurrence was defined as >105 colony-forming units/mL on subsequent bronchoalveolar lavage performed within 2 weeks after completion of appropriate therapy. Results Five hundred and twenty-nine VAP episodes were identified in 381 patients. Overall recurrence was unchanged compared with the previous study (1.5% vs 2%; p = 0.3). There was a decrease in the number of bronchoalveolar lavages performed per patient compared with the previous study (1.6 vs 2.3; p = 0.24) and a reduction of 4.8 antibiotic days per VAP episode compared with the previous study. Both changes resulted in a cumulative reduction of $3,535.04 per patient, for a savings of $1.35 million during the study period. Conclusions Hospital-acquired VAP can be managed effectively by a defined course of therapy dictated by the causative pathogen. Adherence to an established algorithm simplified the management of VAP and contributed to a cumulative reduction in patient charges without impacting recurrence.
Abstract Background context Survival data and rates of recurrence after en bloc resection for cervical spinal tumors are limited to single case reports and small case series, making the true risk of ...recurrence after this procedure unknown. Purpose To report two cases of cervical chordoma managed via en bloc resection. To conduct a systematic review of the existing literature to determine the overall incidence of disease-free survival and investigate potential prognostic factors of recurrence. Study design Case report and systematic review. Methods We present the cases of a 60-year-old woman and a 76-year-old man who underwent en bloc resection of C3–C6 and C2 chordomas, respectively. A complete MEDLINE search was then undertaken for all articles reporting survival data for en bloc resections of primary tumors of the cervical spine. Exclusion criteria included non-English articles, lack of explicit mention or description of en bloc technique, age less than 16, no demographic or survival information reported, and follow-up less than 1 month. Survivorship analysis was conducted, and Kaplan-Meier plots were created with the primary outcome of interest being any tumor recurrence. Results A total of 10 articles comprising 18 cases were included for analysis with a mean follow-up of 47.4±41.5 months. Mean operative time, estimated blood loss, and length of hospitalization were 18.6 hours, 2.9 L, and 34.6 days, respectively. Postoperative complications occurred in eight of the nine patients in which these data were reported. There were three cases of local recurrence, occurring at 12, 44, and 113 months, and one case of distant metastasis, occurring at 12 months postoperatively. With the available data, 1- and 5-year disease-free survival rates of 88.2% and 73.5% were calculated. On Cox proportional hazards analysis, no factors were found to be predictive of recurrence. Conclusions In this systematic review of the literature, en bloc resection provided good disease-free survival rates in patients with primary tumors of the cervical spine. However, there are insufficient data on long-term subjective outcomes in these patients, and larger series are needed to determine the efficacy compared with piecemeal resection techniques. Other investigators should be encouraged to publish their results so that combined analyses like these may be performed with larger sample sizes.
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