Objectives
To analyze a multidisciplinary tracheostomy team’s effect on length of stay and cost.
Methods
An airway management program using a balanced scorecard was created to track key performance ...measures. Interventions included weekly rounding, standardized placement, postoperative care, and caregiver education. Process measures included time to first education, speech-language pathology consultation rates, and pretracheostomy consultations. Outcome measures focused on the total length of stay, 30-day revisit rates after discharge, accidental decannulation rate, and standardized cost. Regression analysis was used to predict the program’s effect on length of stay and total cost.
Results
In total, 239 children met inclusion. The mean time to first education class was reduced from 13.7 to 1.9 days (P < .001). The speech-language pathology consultation rate increased from 68% to 95% (P < .001), and the presurgical consultation rate with the tracheostomy team increased from 14% to 93% (P < .001). The length of stay decreased from 133 to 96 days (P = .006). Total costs were lower for short admissions but higher for prolonged admissions. Revisits within 30 days remained stable over time (18%).
Discussion
Establishing a multidisciplinary tracheostomy team results in improvements in quality metrics when caring for children with tracheostomies. Controlling for associated factors showed the mean length of stay decreased significantly in the first full year of program implementation. Cost analysis estimated significant reductions for tracheostomy patients spending less time in the hospital.
Implications for Practice
A airway management program can positively affect tracheostomy processes and outcomes.
Objectives
To determine if socioeconomic disadvantage impacts perioperative outcomes after tracheostomy.
Methods
We performed a retrospective case series of children who underwent tracheostomy. ...Children were divided into less and more disadvantaged groups based on their community's Area Deprivation Index (ADI), a validated socioeconomic vulnerability measure. Primary outcomes were the length of stay, total cost, in‐hospital mortality, and 30‐day all‐cause readmission after tracheostomy placement. Length of stay was further analyzed using parametric survival analysis.
Results
A total of 239 patients met inclusion criteria, with 153 (64%) residing in more disadvantaged communities. Children from more disadvantaged communities were less likely to be White (42% vs. 26%, P = .009) and more likely to have Medicaid coverage (90% vs. 62%, P < .001). The two groups had similar medical complexity and comorbidities. The main outcome measures showed differences in median total length of stay (113 vs. 79 days, P = .04) and median total cost ($461 000 vs. $279 000, P = .01). Children with tracheostomies who were from more disadvantaged communities also had increased risk of prolonged hospitalizations (HR = 0.63, 95% CI = 0.48–0.83, P = .001). Readmissions, mortality rates, and quality of life scores were similar between groups.
Conclusions
Community disadvantage was associated with differences in hospitalization length and costs after pediatric tracheostomy placement. Further research should continue to describe how health disparities impact children's safe and efficient care with tracheostomies.
Level of Evidence
4 Laryngoscope, 131:2603–2609, 2021
Mortality Among Children with a Tracheostomy Teplitzky, Taylor B.; Brown, Ashley F.; Brooks, Rebecca L. ...
The Laryngoscope,
February 2023, 2023-02-00, 20230201, Letnik:
133, Številka:
2
Journal Article
Recenzirano
Objectives
To characterize the cause of death among children with a tracheostomy.
Study Design
Prospective cohort.
Methods
All pediatric patients (<18 years) who had a tracheostomy placed at a ...tertiary care institution between 2015 and 2020 were included. The location and cause of death were recorded along with patient demographics and age.
Results
A total of 271 tracheostomies were placed with 46 mortalities reviewed for a mortality rate of 16.8%. Mean age at placement was 1.7 years (SD: 3.4) and mean age at death was 2.9 years (SD: 3.5). Most tracheostomies were placed for respiratory failure (N = 33, 72%). The mean time to death after tracheostomy was 1.2 years (SD: 1.2) and 28% (N = 13) occurred during the same admission as placement. Mean time to death after hospital discharge was 1.3 years (SD: 1.3). Etiology of death was respiratory failure (33%, N = 15), cardiopulmonary arrest (15%, N = 7), unknown (43%, N = 20), or secondary to a tracheostomy‐related complication for 9% (N = 4). Location of death was in intensive care units for 41% (N = 19) and 30% died at home (N = 14). Comfort care measures were taken for 37% (N = 17). Severe neurological disability (HR: 4.06, p = 0.003, 95% CI: 1.59–10.34) and congenital heart disease (HR: 2.36, p = 0.009, 95% CI: 1.24–4.48) correlated with time to death on Cox proportional hazard modeling.
Conclusions
Nearly one‐third of children with a tracheostomy who expire will do so during the same admission as tracheostomy placement. Although progression of underlying disease will lead to most deaths, 9% will be a result of a tracheostomy‐related complication, which represents a meaningful target for quality improvement initiatives.
Level of Evidence
3 Laryngoscope, 133:403–409, 2023
To determine survival among critically ill children when caregivers decline tracheostomy placement.
Retrospective cohort.
All children (<18 years) obtaining a pre-tracheostomy consultation at a ...tertiary children's hospital between 2016 and 2021 were included. Comorbidities and mortality were compared between children of caregivers that declined or agreed to tracheostomy.
Tracheostomy was declined for 58 children but was placed for 203 children. After consultation, mortality was 52% (30/58) when declining and 21% (42/230) when agreeing to tracheostomy (p < 0.001) at a mean of 10.7 months (standard deviation SD: 16) and 18.1 months (SD: 17.1), respectively (p = 0.07). For those declining, 31% (18/58) died during the hospitalization within a mean of 1.2 months (SD: 1.4) while 21% (12/58) died at a mean of 23.6 months (SD: 17.5) after discharge. Among children of caregivers declining tracheostomy, older age (odds ratio OR: 0.85, 95% confidence interval CI: 0.74-0.97, p = 0.01) and chronic lung disease (OR: 0.18, 95% CI: 0.04-0.82, P = .03) were associated with lower odds of mortality but sepsis (OR: 9.62, 95% CI: 1.161-57.43, p = 0.01) and intubation (OR: 4.98, 95% CI: 1.24-20.08, p = 0.02) were associated with higher odds of mortality. Median survival after declining tracheostomy was 31.9 months (interquartile range IQR: 2.0-50.7) and declining placement was associated with increased mortality risk (hazard ratio HR: 4.04, 95% CI: 2.49-6.55, p < 0.001).
When caregivers declined tracheostomy placement, less than half of critically ill children in this cohort survived with younger age, sepsis, and intubation associated with higher mortality. This information offers valuable insight for families weighing decisions pertaining to pediatric tracheostomy placement.
3 Laryngoscope, 133:3602-3607, 2023.
Caregiver quality of life after pediatric tracheostomy Wynings, Erin M.; Chorney, Stephen R.; Brooks, Rebecca L. ...
International journal of pediatric otorhinolaryngology,
January 2023, 2023-Jan, 2023-01-00, 20230101, Letnik:
164
Journal Article
Recenzirano
To determine the impact of a child with a tracheostomy on caregiver quality of life.
A repeated cross-sectional analysis included families with tracheostomy-dependent children between 2019 and 2021. ...Caregivers were surveyed using the PedsQL™ Family Impact Module with assessments at tracheostomy placement and during ambulatory office visits.
Two-hundred and fifty-five surveys were performed with 66 at tracheostomy placement (26%) and 189 at follow-up visits (74%). Compared to families with healthy children, total scores at placement (77.2 vs. 87.6, P < .001) and follow-up visits (78.9 vs. 87.6, P < .001) were significantly lower among pediatric tracheostomy families. Caregivers were likely to report significant improvement in emotional functioning (6.2 points; 95% CI: 0.5–12, P = .03) and worry (9 points, 95% CI: 2.1–15.9, P = .01) over time. Demographic variables demonstrated no confounding or interactive effects.
The presence of a tracheostomy is associated with lower caregiver quality of life scores in the short- and long-term compared to caregivers of healthy children. Providers should be sensitive to these challenges and provide appropriate support for families of tracheostomy-dependent children.
Emerging evidence suggests cancer stem cells (CSCs) may initiate new tumors in anaplastic thyroid carcinoma (ATC), one of the most aggressive solid tumors in humans. However, the involvement of CSCs ...in human tumorigenesis has not been previously studied in authenticated ATC cell lines. Here we demonstrate a functional role of CSCs in four new validated human ATC cell lines (THJ-11T, THJ-16T, THJ-21T and THJ-29T). We identified and enriched CSCs using a spheroid-forming assay. About 3 to 9% of cells from four ATC cell lines formed thyrospheres. The thyrospheres expressed the stem cell markers NANOG and Oct4 and possessed the ability to self-renew. Injection of these thyrospheres into the thyroids of NOD/SCID Il2rg-/- mice resulted in the formation of metastatic tumors that recapitulated the clinical features of human ATC. To our knowledge, this is the first in vivo characterization of thyroid CSCs using validated human ATC cell lines. The availability of disease-specific thyrospheres and our orthotopic tumor models will enable the elucidation of disease mechanisms and the environmental niche of CSCs. They may also be useful for preclinical therapeutic screening and for monitoring the effects of biological therapies on ATC.
Rationale
Animal studies and anecdotal human reports suggest that cannabinoids have antinociceptive effects. Controlled human studies have produced mixed results.
Objectives
We sought to reduce ...existing variability by investigating the effects of intravenous delta-9-tetrahydrocannabinol (THC) in several pain paradigms within the same human subjects, addressing some of the limitations to the published literature.
Methods
In this exploratory randomized, double-blind, placebo-controlled, cross-over study, healthy human subjects received 0.01 mg/kg or 0.03 mg/kg intravenous THC or placebo (ethanol vehicle) infused over 10 min on three test days, each separated by at least 72 h. Capsaicin (250 μg) was injected intradermally to induce chemical pain and hyperalgesia. Four other forms of acute pain were induced: mechanical (von Frey filament), hot and cold (thermode), and electrical (pulse generator). Pain ratings were obtained before drug administration, at peak drug effects, and 2 h after drug administration and included both objective and subjective measures. THC drug effects and vital signs were also collected during experimental sessions. Nonparametric analysis with repeated measures was performed.
Results
THC induced euphoria, perceptual and cognitive alterations, and tachycardia in a dose-related manner, but failed to have significant effects in experimentally induced acute chemical, mechanical, thermal, or electrical pain and capsaicin-induced hyperalgesia.
Conclusions
In this exploratory controlled study, intravenous THC lacked significant antinociceptive properties in experimental models of acute pain and capsaicin-induced hyperalgesia in healthy human subjects. Continued study of THC and other cannabinoids through high-quality, controlled studies in both healthy volunteers and patients with pain conditions is warranted to inform the growing demand for the clinical application of cannabinoids in pain management.
Cannabis and agonists of the brain cannabinoid receptor (CB1R) produce acute memory impairments in humans. However, the extent to which cannabinoids impair the component processes of encoding and ...retrieval has not been established in humans. The objective of this analysis was to determine whether the administration of Δ9-Tetrahydrocannabinol (THC), the principal psychoactive constituent of cannabis, impairs encoding and/or retrieval of verbal information.
Healthy subjects were recruited from the community. Subjects were administered the Rey-Auditory Verbal Learning Test (RAVLT) either before administration of THC (experiment #1) (n=38) or while under the influence of THC (experiment #2) (n=57). Immediate and delayed recall on the RAVLT was compared. Subjects received intravenous THC, in a placebo-controlled, double-blind, randomized manner at doses known to produce behavioral and subjective effects consistent with cannabis intoxication.
Total immediate recall, short delayed recall, and long delayed recall were reduced in a statistically significant manner only when the RAVLT was administered to subjects while they were under the influence of THC (experiment #2) and not when the RAVLT was administered prior.
THC acutely interferes with encoding of verbal memory without interfering with retrieval. These data suggest that learning information prior to the use of cannabis or cannabinoids is not likely to disrupt recall of that information. Future studies will be necessary to determine whether THC impairs encoding of non-verbal information, to what extent THC impairs memory consolidation, and the role of other cannabinoids in the memory-impairing effects of cannabis.
Cannabinoids, Neural Synchrony, and Information Processing (THC-Gamma)
http://clinicaltrials.gov/ct2/show/study/NCT00708994
NCT00708994
Pharmacogenetics of Cannabinoid Response
http://clinicaltrials.gov/ct2/show/NCT00678730
NCT00678730
•The study examined the effects of intravenous delta-9 tetrahydrocannabinol (THC) on encoding and retrieval of verbal memory.•The study utilized a randomized, double-blind, placebo-controlled design.•When encoding of verbal information occurred before the administration of THC, recall was not impaired.•When encoding occurred under the influence of THC, recall was impaired.•Therefore, THC acutely interferes with encoding of verbal memory without interfering with retrieval.
Current models of attention propose that we can tune attention in a top-down controlled manner to a specific feature value (e.g., shape, color) to find specific items (e.g., a red car; ...feature-specific search). However, subsequent research has shown that attention is often tuned in a context-dependent manner to the relative features that distinguish a sought-after target from other surrounding nontarget items (e.g., larger, bluer, and faster; relational search). Currently, it is unknown whether search will be feature-specific or relational in search for multiple targets with different attributes. In the present study, observers had to search for 2 targets that differed either across 2 stimulus dimensions (color, motion; Experiment 1) or within the same stimulus dimension (color; Experiment 2: orange/redder or aqua/bluer). We distinguished between feature-specific and relational search by measuring eye movements to different types of irrelevant distractors (e.g., relatively matching vs. feature-matching). The results showed that attention was biased to the 2 relative features of the targets, both across different feature dimensions (i.e., motion and color) and within a single dimension (i.e., 2 colors; bluer and redder). The results were not due to automatic intertrial effects (dimension weighting or feature priming), and we found only small effects for valid precueing of the target feature, indicating that relational search for two targets was conducted with relative ease. This is the first demonstration that attention is top-down biased to the relative target features in dual target search, which shows that the relational account generalizes to multiple target search.
Public Significance Statement
In the quest to successfully navigate an overwhelmingly abundant visual world we have honed the ability to select only the behaviorally relevant visual input. Still, in search for a certain item, other irrelevant items can "capture" attention and distract us. While current theories of attention predict that only target-similar items can attract attention, the present study shows that all attributes that match the relative features of sought-after target items (e.g., redder) can attract attention and the gaze. This suggest that attention is by default tuned to relative features, even in search for 2 possible target attributes. This dramatically increases the number of items that can attract attention and the gaze and distract us from an ongoing task, but may convey benefits in natural environments where the specific feature values of objects typically vary.
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