Publications by authors named "Steven J Staffa"

107 Publications

Dosing of Opioid Medications During and After Pediatric Cardiac Surgery for Children With Down Syndrome.

J Cardiothorac Vasc Anesth 2021 Aug 15. Epub 2021 Aug 15.

Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, 300 Longwood Ave, Boston, MA. Electronic address:

Objective: To determine whether children with Down syndrome (DS) receive higher doses of opioid medications compared with children without DS for repair of complete atrioventricular canal (CAVC).

Design: A retrospective chart review of children with and without DS who underwent primary repair of CAVC. The exclusion criteria included unbalanced CAVC and patients undergoing biventricular staging procedures. The primary outcome was oral morphine equivalents (OME) received in the first 24 hours after surgery. The secondary outcomes included intraoperative OME, OME at 48 and 72 hours, nonopioid analgesic and sedative medications received, pain scores, time to extubation, and length of stay.

Setting: A pediatric academic medical center in the United States.

Participants: One hundred thirty-one patients with DS and 24 without, all
Interventions: Not applicable.

Measurements And Main Results: Patients with DS were older than patients without DS (median 96.3 days [interquartile range {IQR} 70.7-128.2] v 75.9 days [IQR 49.8-107.3], p = 0.033) but otherwise not statistically different in the baseline characteristics. There was no difference in OME received in the first 24 hours postoperatively between groups (3.01 mg/kg [IQR 1.23-5.43] v 3.57 mg/kg [IQR 1.54-7.06], p = 0.202). OME at 48 and 72 hours was lower in the DS group compared with the control group. Similar amounts of opioid and non-opioid analgesics and sedatives were otherwise given to both groups of patients. Median pain scores did not differ between groups.

Conclusions: These results suggested that patients with DS undergoing CAVC repair do not have increased opioid requirements compared with a similar control group.
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http://dx.doi.org/10.1053/j.jvca.2021.08.019DOI Listing
August 2021

Predictors of anti-reflux procedure failure in complex esophageal atresia patients.

J Pediatr Surg 2021 Aug 14. Epub 2021 Aug 14.

Department of General Surgery, Boston Children's Hospital, Boston, MA USA. Electronic address:

Background: Anti-reflux procedures (ARP) in esophageal atresia (EA) patients can be challenging and prone to failure. These challenges become more evident with increasing complexity of EA. We sought to determine predictors of ARP failure in complex EA patients.

Methods: Single-institution retrospective review of complex EA patients (e.g. long-gap EA, esophageal strictures, hiatal hernia, and reoperative ARP) who underwent an ARP from 2002 to 2019. ARP failure was defined as hiatal hernia recurrence, wrap migration/loosening, or need for reoperation. Predictors of failure were evaluated using univariate and multivariable time-to-event analysis.

Results: 121 patients underwent 140 ARP at a median age of 13.5 months (IQR 7, 26.5). Nissen fundoplication (89%) was the most common ARP. Mesh (bovine pericardium) reinforcement was used in 41% of the patients. Median follow-up was 3.2 years (IQR 0.9, 5.8); 44 instances of ARP failure occurred (31%), though only 20 (14%) required reoperation. Median time to failure was 8.7 months (IQR 3.2, 25). Though fewer mesh-reinforced ARP failed (21% with vs 39% without, p = 0.02), on multivariable analysis only partial fundoplication (aHR 2.22 [95% CI 1.01-4.78]) and minimally invasive repair (aHR 2.57 [95% CI 1.12-6.01]) were significant predictors of ARP failure.

Conclusion: In our practice of complex EA patients, where ARP fail in nearly one third of cases, a Nissen fundoplication performed via laparotomy provided the lowest risk of ARP failure.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.08.005DOI Listing
August 2021

Sequestration of Midazolam, Fentanyl, and Morphine by an Ex Vivo Cardiopulmonary Bypass Circuit.

ASAIO J 2021 Jun 24. Epub 2021 Jun 24.

Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.

Cardiopulmonary bypass (CPB) circuits can significantly sequester intravenous anesthetics. Adsorption of medications by our institution's standard circuit (Terumo CAPIOX FX05 oxygenator; noncoated polyvinylchloride tubing) has not been described. We prepared ex vivo CPB circuits with and without oxygenators. Medication combinations studied included midazolam (0.5 mg), fentanyl (50 [micro]g), midazolam (0.5 mg) with morphine (0.5 mg), and midazolam (0.5 mg) with fentanyl (50 [micro]g). Medications were administered after obtaining baseline samples. Samples were drawn at 2, 5, 15, 30, 60, 120, and 180 minutes, and analyzed for concentration of injected medications. Midazolam demonstrated no sequestration after 180 minutes. Fentanyl concentration at 180 minutes was lower with an oxygenator (52.7 +/- 12.5 vs. 110.9 +/- 12.0 ng/ml, P = 0.00432). More fentanyl was found in solution after 180 minutes when given with midazolam compared to fentanyl given alone in the presence of an oxygenator (101 +/- 22.3 vs. 52.7 +/- 12.5 ng/ml, P = 0.044). Less midazolam was present after 180 minutes when given with morphine compared to midazolam given alone in the absence of an oxygenator (1264.9 +/- 425.6 vs. 2124 +/- 254 ng/ml, P = 0.037). We successfully characterized the adsorption of various combinations of midazolam, fentanyl, and morphine to our CPB circuit, showing that fentanyl and midazolam behave differently based on other medications present.
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http://dx.doi.org/10.1097/MAT.0000000000001506DOI Listing
June 2021

Nutrition delivery and growth outcomes in infants with long-gap esophageal atresia who undergo the Foker process.

J Pediatr Surg 2021 Jul 24. Epub 2021 Jul 24.

Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA 02115, United States. Electronic address:

Background: Predictors of growth outcomes in patients with long-gap esophageal atresia (LGEA) are not known. We examined nutrition and growth in-hospital and post-discharge in LGEA patients who underwent the Foker Process (FP).

Methods: Single-center, retrospective cohort study of infants with LGEA undergoing primary (non-rescue) FP from 2014 to 2020. Weight-for-age z scores (WAZ, 0 = average), macronutrient prescription, anthropometry, and clinical variables were collected. Longitudinal median regression evaluated differences in WAZ over time. Multivariable median regression examined variables associated with change in WAZ at 1 year.

Results: 45 patients met criteria, with median (IQR) age at repair of 4 (2, 5.8) months and WAZ of -0.96 (-1.55, -0.40). On admission, 11% were moderately (WAZ < -2) and 9% were severely (WAZ < -3) malnourished. Lower admission WAZ was significantly associated with improvement in WAZ at 1-year follow-up (p = 0.002); EA type (59% type A), esophageal leak (16%), median days paralyzed (13), ventilated (21), on parenteral nutrition (35), or to full enteral nutrition (35) were not associated with change in WAZ. Median WAZ remained stable while in-hospital, and patients maintained their growth curves through 3-year follow-up.

Conclusion: Throughout infancy, most primary FP LGEA patients have weight for age that is below average. Using targeted nutritional intervention, those who present with malnutrition can still achieve adequate growth despite prolonged and complicated hospital courses.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.07.014DOI Listing
July 2021

Pharmacogenomics fail to explain proton pump inhibitor refractory esophagitis in pediatric esophageal atresia.

Neurogastroenterol Motil 2021 Aug 1:e14217. Epub 2021 Aug 1.

Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA.

Background: Esophagitis is prevalent in patients with esophageal dysmotility despite acid suppression, likely related to poor esophageal clearance. Esophageal atresia (EA) is a classic model of dysmotility where this observation holds true. In adult non-dysmotility populations, failure of esophagitis to respond to proton pump inhibitors (PPI) has been linked to variants in CYP2C19 that influence the activity of the encoded enzyme. It is unknown if CYP2C19 metabolizer phenotype contributes to PPI-refractory, non-allergic esophagitis in EA.

Methods: We performed a cross-sectional study of 314 children with (N = 188) and without (N = 126) EA who were on PPI therapy at the time of endoscopy to evaluate for possible gastroesophageal reflux disease. Patients with eosinophilic esophagitis and/or fundoplication were excluded. Clinical and histology data were collected. Genomic DNA from biopsy samples was genotyped for polymorphisms in CYP2C19.

Results: CYP2C19 metabolizer phenotypes were not associated with presence or severity of esophagitis (P = 0.994). In a multivariate logistic regression adjusted for potential confounders, EA was the strongest and only significant predictor of esophagitis (odds ratio 2.72, P = 0.023). Using negative binomial regression, we found that CYP2C19 phenotype was not a significant predictor of eosinophil count in children with PPI-refractory esophagitis.

Conclusions: Patients with EA are significantly more likely to experience PPI-refractory, non-allergic esophagitis than controls regardless of CYP2C19 metabolizer phenotype, suggesting that factors other than CYP2C19 genetics, including dysmotility, are the primary drivers of esophagitis in EA. CYP2C19 genotype failed to predict PPI-refractory, non-allergic esophagitis in both EA and non-EA children.
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http://dx.doi.org/10.1111/nmo.14217DOI Listing
August 2021

Statistical Development and Validation of Clinical Prediction Models.

Anesthesiology 2021 09;135(3):396-405

Summary: Clinical prediction models in anesthesia and surgery research have many clinical applications including preoperative risk stratification with implications for clinical utility in decision-making, resource utilization, and costs. It is imperative that predictive algorithms and multivariable models are validated in a suitable and comprehensive way in order to establish the robustness of the model in terms of accuracy, predictive ability, reliability, and generalizability. The purpose of this article is to educate anesthesia researchers at an introductory level on important statistical concepts involved with development and validation of multivariable prediction models for a binary outcome. Methods covered include assessments of discrimination and calibration through internal and external validation. An anesthesia research publication is examined to illustrate the process and presentation of multivariable prediction model development and validation for a binary outcome. Properly assessing the statistical and clinical validity of a multivariable prediction model is essential for reassuring the generalizability and reproducibility of the published tool.
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http://dx.doi.org/10.1097/ALN.0000000000003871DOI Listing
September 2021

Time to achieve delivery of nutrition targets is associated with clinical outcomes in critically ill children.

Am J Clin Nutr 2021 Jul 28. Epub 2021 Jul 28.

Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.

Background: Optimal nutrition in critically ill children involves a complex interplay between the doses, route, and timing of macronutrient delivery.

Objectives: We aimed to examine the association between the time to achieve delivery of 60% of the prescribed energy and protein targets and clinical outcomes in mechanically ventilated children.

Methods: We conducted a prospective, observational cohort study of mechanically ventilated children admitted to pediatric intensive care units (PICUs) worldwide. Daily energy and protein delivery were recorded for up to 10 d in the PICU. We calculated "adequacy" as the percentage of the prescribed energy or protein goal delivered by enteral nutrition (EN), parenteral nutrition (PN), and total nutrition (EN + PN). Based on the days required to reach 60% energy or protein adequacy after PICU admission, we categorized patients into 3 groups: early (≤3 d), pragmatic (4 to 7 d), and late (more than 7 d). The primary outcome was 60-d all-cause mortality; secondary outcomes were the incidence of acquired infections and 28-d ventilator-free days (VFDs).

Results: From 77 participating PICUs, 1844 patients, with a median age of 1.64 y (IQR, 0.47-7.05), were included; the 60-d mortality rate was 5.3% (n = 97). The average adequacies of delivery via EN + PN was 49% (IQR, 26-70) for energy and 66% (IQR, 44-89) for protein. In multivariable models adjusted for confounders, mortality was significantly lower in patients who achieved targets within 7 d, for energy (adjusted HR, 0.48; 95% CI: 0.28-0.82; P = 0.007) or protein (adjusted HR, 0.55; 95% CI: 0.33-0.94; P = 0.027) delivery. There were no clinically significant differences in infections or VFDs between groups.

Conclusions: Achieving 60% of energy or protein delivery targets within the first 7 d after PICU admission is associated with lower 60-d mortality in mechanically ventilated children, and is not associated with a greater incidence of infections or a reduction in VFDs compared to later achievement of targets. This trial was registered at clinicaltrials.gov as NCT03223038.
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http://dx.doi.org/10.1093/ajcn/nqab244DOI Listing
July 2021

Effect of Sequential and Simultaneous Patching Regimens in Unilateral Amblyopia.

Am J Ophthalmol 2021 Jul 22. Epub 2021 Jul 22.

Department of Ophthalmology, Boston Children's Hospital; Department of Ophthalmology, Harvard Medical School. Electronic address:

Purpose: Many clinicians treat unilateral amblyopia with glasses alone and initiate patching when needed; others start glasses and patching simultaneously. In this study, we reviewed the outcomes of the two approaches at our institution.

Design: Retrospective non-randomized clinical trial METHODS: Setting: Institutional practice.

Patient Population: All patients diagnosed with amblyopia at Boston Children's Hospital between 2010 and 2014.

Inclusion Criteria: Unilateral amblyopia visual acuity (VA): 20/40-20/200 with interocular difference ≥ 3 lines, age 3-12 years, with a 6-month visit.

Exclusion Criteria: Deprivation amblyopia, prior amblyopia treatment, treatment other than patching, surgery. Patients were categorized as "simultaneous treatment" (concurrent glasses and patching therapy at their first visit) or "sequential treatment" (glasses alone at first visit followed by patching therapy at second visit.) Observation Procedures: Patient demographics, VA, and stereopsis were compared.

Outcome Measures: VA and stereopsis at the last visit on treatment.

Results: We identified 98 patients who met inclusion criteria: 36 received simultaneous treatment and 62 sequential treatment. Median amblyopic eye VA improved similarly between the simultaneous (∆0.40 (0.56, 0.30 logMAR) and sequential (∆0.40 (0.52, 0.27 logMAR) groups. Patients without stereopsis at first visit had better stereopsis outcomes with sequential treatment (5.12 (4.00, 7.51) log stereopsis) compared to simultaneous treatment (8.01 (5.65, 9.21) log stereopsis, p ≤ 0.046).

Conclusions: VA improved approximately 4 lines regardless of treatment type. For children without stereopsis at first presentation, sequential patching yielded better stereopsis outcomes. These findings require further validation and highlight the importance of evaluating stereopsis in future studies.
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http://dx.doi.org/10.1016/j.ajo.2021.07.012DOI Listing
July 2021

Importance of Preserved Tricuspid Valve Function for Effective Soft Robotic Augmentation of the Right Ventricle in Cases of Elevated Pulmonary Artery Pressure.

Cardiovasc Eng Technol 2021 Jul 14. Epub 2021 Jul 14.

Department of Cardiac Surgery, Harvard Medical School, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.

Purpose: In clinical practice, many patients with right heart failure (RHF) have elevated pulmonary artery pressures and increased afterload on the right ventricle (RV). In this study, we evaluated the feasibility of RV augmentation using a soft robotic right ventricular assist device (SRVAD), in cases of increased RV afterload.

Methods: In nine Yorkshire swine of 65-80 kg, a pulmonary artery band was placed to cause RHF and maintained in place to simulate an ongoing elevated afterload on the RV. The SRVAD was actuated in synchrony with the ventricle to augment native RV output for up to one hour. Hemodynamic parameters during SRVAD actuation were compared to baseline and RHF levels.

Results: Median RV cardiac index (CI) was 1.43 (IQR, 1.37-1.80) L/min/m and 1.26 (IQR 1.05-1.57) L/min/m at first and second baseline. Upon PA banding RV CI fell to a median of 0.79 (IQR 0.63-1.04) L/min/m. Device actuation improved RV CI to a median of 0.87 (IQR 0.78-1.01), 0.85 (IQR 0.64-1.59) and 1.11 (IQR 0.67-1.48) L/min/m at 5 min (p = 0.114), 30 min (p = 0.013) and 60 (p = 0.033) minutes respectively. Statistical GEE analysis showed that lower grade of tricuspid regurgitation at time of RHF (p = 0.046), a lower diastolic pressure at RHF (p = 0.019) and lower mean arterial pressure at RHF (p = 0.024) were significantly associated with higher SRVAD effectiveness.

Conclusions: Short-term augmentation of RV function using SRVAD is feasible even in cases of elevated RV afterload. Moderate or severe tricuspid regurgitation were associated with reduced device effectiveness.
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http://dx.doi.org/10.1007/s13239-021-00562-7DOI Listing
July 2021

Virtual reality prototype for binocular therapy in older children and adults with amblyopia.

J AAPOS 2021 Aug 8;25(4):217.e1-217.e6. Epub 2021 Jul 8.

Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address:

Purpose: To evaluate the best-corrected visual acuity and stereoacuity gains in children >7 years of age and adults with unilateral amblyopia treated with a prototype virtual reality-based binocular amblyopia therapy.

Methods: In this randomized, double masked, cross-in clinical trial, patients at Boston Children's Hospital with unilateral anisometropic and/or strabismic amblyopia and history of prior amblyopia treatment failure were randomized to either a full-treatment group (8 weeks of binocular treatment using therapeutic software application in virtual reality headset) or a sham-crossover group (4 weeks of sham treatment followed by 4 weeks of binocular treatment). Amblyopic eye visual acuity and stereoacuity were evaluated at 4, 8, and 16 weeks' follow-up.

Results: The study cohort included 20 participants (10 females), with a median age of 9 years (range, 7-38 years). In the full-treatment group (11 patients), the mean amblyopic eye logMAR visual acuity at 16 weeks was 0.49 ± 0.26, compared with 0.47 ± 0.20 at baseline. In the sham-crossover group, it was 0.51 ± 0.18 at 16 weeks, compared with 0.53 ± 0.21 at baseline. Stereoacuity (log arcsec) was significantly improved, from 7.3 ± 2 at baseline to 6.6 ± 2.3 at 8 weeks (P < 0.001) and 6.7 ± 2.6 at 16 weeks (P < 0.001). No significant adverse events (diplopia, asthenopia, or worsening strabismus) were noted in either group.

Conclusions: Although the virtual reality-based prototype for binocular amblyopia therapy did not significantly improve visual acuity in the amblyopic eyes of older children and adults, stereoacuity did significantly improve compared with baseline; improvements were clinically minute. However, larger studies are required to confirm the results.
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http://dx.doi.org/10.1016/j.jaapos.2021.03.008DOI Listing
August 2021

Synergy in Nanomedicine: What It Is Not, and What It Might Be.

Nano Lett 2021 07 29;21(13):5457-5460. Epub 2021 Jun 29.

Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston Massachusetts 02115, United States.

Interactions between nanoformulations delivering two or more drugs-or a drug and some other therapeutic modality-are often described as synergistic. In fact, synergy is a specific term of art, with important therapeutic implications. The term is often misused in the nanoscience literature. Here we discuss what synergy is and an approach to demonstrating it rigorously.
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http://dx.doi.org/10.1021/acs.nanolett.1c01894DOI Listing
July 2021

The Liver Retransplantation Risk Score: a prognostic model for survival after adult liver retransplantation.

Transpl Int 2021 Jun 23. Epub 2021 Jun 23.

Division of HPB Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.

High-risk combinations of recipient and graft characteristics are poorly defined for liver retransplantation (reLT) in the current era. We aimed to develop a risk model for survival after reLT using data from the European Liver Transplantation Registry, followed by internal and external validation. From 2006 to 2016, 85 067 liver transplants were recorded, including 5581 reLTs (6.6%). The final model included seven predictors of graft survival: recipient age, model for end-stage liver disease score, indication for reLT, recipient hospitalization, time between primary liver transplantation and reLT, donor age, and cold ischemia time. By assigning points to each variable in proportion to their hazard ratio, a simplified risk score was created ranging 0-10. Low-risk (0-3), medium-risk (4-5), and high-risk (6-10) groups were identified with significantly different 5-year survival rates ranging 56.9% (95% CI 52.8-60.7%), 46.3% (95% CI 41.1-51.4%), and 32.1% (95% CI 23.5-41.0%), respectively (P < 0.001). External validation showed that the expected survival rates were closely aligned with the observed mortality probabilities. The Retransplantation Risk Score identifies high-risk combinations of recipient- and graft-related factors prognostic for long-term graft survival after reLT. This tool may serve as a guidance for clinical decision-making on liver acceptance for reLT.
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http://dx.doi.org/10.1111/tri.13956DOI Listing
June 2021

Outcomes of a multicomponent safe surgery intervention in Tanzania's Lake Zone: a prospective, longitudinal study.

Int J Qual Health Care 2021 Jun;33(2)

Assist International, 800 South Stockton Avenue, Ripon, CA 95366, USA.

Background: Evidence-based strategies for improving surgical quality and patient outcomes in low-resource settings are a priority.

Objective: To evaluate the impact of a multicomponent safe surgery intervention (Safe Surgery 2020) on (1) adherence to safety practices, teamwork and communication, and documentation in patient files, and (2) incidence of maternal sepsis, postoperative sepsis, and surgical site infection.

Methods: We conducted a prospective, longitudinal study in 10 intervention and 10 control facilities in Tanzania's Lake Zone, across a 3-month pre-intervention period in 2018 and 3-month post-intervention period in 2019. SS2020 is a multicomponent intervention to support four surgical quality areas: (i) leadership and teamwork, (ii) evidence-based surgery, anesthesia and equipment sterilization practices, (iii) data completeness and (iv) infrastructure. Surgical team members received training and mentorship, and each facility received up to a $10 000 infrastructure grant. Inpatients undergoing major surgery and postpartum women were followed during their stay up to 30 days. We assessed adherence to 14 safety and teamwork and communication measures through direct observation in the operating room. We identified maternal sepsis (vaginal or cesarean delivery), postoperative sepsis and SSIs prospectively through daily surveillance and assessed medical record completeness retrospectively through chart review. We compared changes in surgical quality outcomes between intervention and control facilities using difference-in-differences analyses to determine areas of impact.

Results: Safety practices improved significantly by an additional 20.5% (95% confidence interval (CI), 7.2-33.7%; P = 0.003) and teamwork and communication conversations by 33.3% (95% CI, 5.7-60.8%; P = 0.02) in intervention facilities compared to control facilities. Maternal sepsis rates reduced significantly by 1% (95% CI, 0.1-1.9%; P = 0.02). Documentation completeness improved by 41.8% (95% CI, 27.4-56.1%; P < 0.001) for sepsis and 22.3% (95% CI, 4.7-39.8%; P = 0.01) for SSIs.

Conclusion: Our findings demonstrate the benefit of the SS2020 approach. Improvement was observed in adherence to safety practices, teamwork and communication, and data quality, and there was a reduction in maternal sepsis rates. Our results support the emerging evidence that improving surgical quality in a low-resource setting requires a focus on the surgical system and culture. Investigation in diverse contexts is necessary to confirm and generalize our results and to understand how to adapt the intervention for different settings. Further work is also necessary to assess the long-term effect and sustainability of such interventions.
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http://dx.doi.org/10.1093/intqhc/mzab087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8240014PMC
June 2021

Trends in Pediatric MRI sedation/anesthesia at a tertiary medical center over time.

Paediatr Anaesth 2021 Sep 22;31(9):953-961. Epub 2021 Jun 22.

Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital & Harvard Medical School, Boston, MA.

Background: Each year, hundreds of thousands of children require sedation/anesthesia to facilitate MRI scans. Anesthetic techniques for accomplishing sedation/anesthesia vary widely between institutions and providers, with unclear implications for patient safety.

Aims: We sought to establish trends in anesthetic practice for pediatric MRI sedation/anesthesia across a 7-year period and determine rates of adverse events, considering technique used, age, and ASA physical classification status (ASA-PS).

Methods: Using established data resources, we analyzed 24 052 anesthetics performed by anesthesiologists for MRI scans between 5/1/2013 and 12/31/2019 on patients less than 18 years old, focusing on medications used, trends of use, and associated adverse events. Adverse events (hypoxia, hypotension, bradycardia) were defined by deviation from age norms and accessed via the electronic anesthetic record database. The Cochran-Armitage test was used to assess trends over time in categorical data, and one-way ANOVA was used to analyze continuous data. Multivariable logistic regression analysis was implemented to determine the independent associations between anesthetic technique and adverse events while adjusting for age, ASA-PS, and weight.

Results: The most significant trends noted were a decrease in "propofol-only" anesthetic techniques and an increase in propofol and dexmedetomidine combination techniques. Mild desaturation (80-89% SpO ) occurred in 4.22% of cases with more significant hypoxia much rarer (0.44% of cases having desaturation <70% SpO ). Bradycardia occurred in 2.39% of cases and hypotension in 1.75% of cases. Major adverse events were rare.

Conclusions: We provide the largest report of the nature of MRI sedation/anesthesia as practiced by anesthesiologists in a large children's hospital. We demonstrate that, even in a large system, anesthetic techniques are pliable and shift significantly over time. Our data also support a high level of safety within our system, despite a case mix likely higher in risk than those in most of the previously published studies.
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http://dx.doi.org/10.1111/pan.14225DOI Listing
September 2021

Evaluating Surgical Decision-making in Nonsyndromic Sagittal Craniosynostosis Using a Digital 3D Model.

Plast Reconstr Surg Glob Open 2021 May 21;9(5):e3493. Epub 2021 May 21.

Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Mass.

Surgical correction of craniosynostosis addresses potentially elevated intracranial pressure and the cranial deformity. In nonsyndromic sagittal synostosis, approximately 15% of patients have elevated intracranial pressure. The decision to operate therefore likely reflects a combination of aesthetic goals, prevention of brain growth restriction over time, surgeon training and experience, and parental expectations. This study examines clinical factors that influence surgical decision-making in nonsyndromic sagittal synostosis.

Methods: An online survey sent to craniofacial and neurosurgeons presented 5 theoretical patients with varying severities of sagittal synostosis. For each cephalic index, 4 separate clinical scenarios were presented to assess influences of parental concern and developmental delay on the decision to operate.

Results: Fifty-six surveys were completed (response rate = 28%). Participants were predominantly from North America (57%), had over 10 years of experience (75%), and performed over 20 craniosynostosis procedures annually (50%). Thirty percent of respondents indicated they would operate regardless of head shape and without clinical and/or parental concern. Head shape was the greatest predictor of decision to operate ( < 0.001). Parental concern and developmental delay were independently associated with decision to operate ( < 0.001). Surgeons with more experience were also more likely to operate across all phenotypes (OR: 2.69, < 0.004).

Conclusions: Surgeons responding to this survey were more strongly compelled to operate on children with nonsyndromic sagittal craniosynostosis when head shape was more severe. Additional factors, including parental concern and developmental delay, also influence the decision to operate, especially for moderate phenotypes. Geographic and subspecialty variations were not significant.
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http://dx.doi.org/10.1097/GOX.0000000000003493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8140767PMC
May 2021

The Association Between Race and Adverse Postoperative Outcomes in Children With Congenital Heart Disease Undergoing Noncardiac Surgery.

Anesth Analg 2021 May 13. Epub 2021 May 13.

Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Background: The association between race and perioperative outcomes has been evaluated in adult cardiac surgical and in healthy pediatric patients but has not been evaluated in children with congenital heart disease (CHD) presenting for noncardiac procedures. This study compares the incidence of the primary outcome of 30-day mortality and adverse postoperative outcomes following noncardiac surgery between Black and White children with CHD, stratified by severity.

Methods: This is a retrospective study. Comparison of outcomes between Black and White children was performed using the 2012-2018 American College of Surgeons National Surgical Quality Improvement Program Pediatric database and after stratification for severity of CHD and propensity score matching.

Results: A total of 55,859 patients were included, and divided into 28,601 minor, 23,839 major, and 3419 severe CHD. Black and White children in each category were matched and compared. Following matching in the overall CHD cohort, there were significantly higher rates of the following adverse postoperative outcomes among Black patients as compared to White patients: 30-day mortality (1.84% vs 1.49%; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.05-1.48; P = .014), composite secondary outcomes (19.90% vs 17.88%; OR, 1.14; 95% CI, 1.08-1.21; P < .001), cardiac arrest (1.42% vs 0.98%; OR, 1.46; 95% CI, 1.19-1.79; P < .001), 30-day reoperation (7.59% vs 6.67%; OR, 1.15; 95% CI, 1.05-1.25; P = .002), and reintubation (3.9% vs 2.95%; OR, 1.34; 95% CI, 1.19-1.52; P < .001). No significant statistical interaction between race and CHD severity was found. Following matching and within the minor CHD cohort, Black children had significantly higher rates of composite secondary outcome (17.44% vs 15.60%; OR, 1.15; 95% CI, 1.05-1.25; P = .002), cardiac arrest (1.02% vs 0.53%; OR, 1.94; 95% CI, 1.37-2.76; P < .001), 30-day reoperation (7.19% vs 5.77%; OR, 1.26; 95% CI, 1.11-1.43; P < .001), and thromboembolic complications (0.49% vs 0.23%; OR, 2.17; 95% CI, 1.29-3.63; P = .003) compared to White children. In the major CHD cohort, Black children had significantly higher rates of 30-day mortality (2.75% vs 2.05%; OR, 1.35; 95% CI, 1.08-1.69; P = .008) and reintubation (4.82% vs 3.72%; OR, 1.32; 95% CI, 1.11-1.56; P = .002). There were no statistically significant differences in outcomes in the severe CHD category for 30-day mortality (3.36% vs 3.3%; OR, 1.02; 95% CI, 0.60-1.73; P = .946), composite secondary outcome (22.65% vs 21.36%; OR, 1.08; 95% CI, 0.86-1.36; P = .517) nor the components of the composite secondary outcomes.

Conclusions: Race is associated with postoperative mortality and complications in children with minor and major CHD undergoing noncardiac surgery. No significant association was observed between race and postoperative outcomes in patients with severe CHD. This is consistent with previous findings wherein in patients with severe CHD, residual lesion burden and functional status is the leading predictor of outcomes following noncardiac surgery. Nevertheless, there is no evidence that the relationship between race and outcomes differs across the CHD severity categories. Future studies to understand the mechanisms leading to the racial difference, including institutional, clinical, and individual factors are needed.
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http://dx.doi.org/10.1213/ANE.0000000000005571DOI Listing
May 2021

Identifying Characteristics Predictive of Lost-to-Follow-Up Status in Amblyopia.

Am J Ophthalmol 2021 May 13;230:200-206. Epub 2021 May 13.

From the Harvard Medical School, Boston, Massachusetts; Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts. Electronic address:

Purpose: To identify demographic and disease-related characteristics predictive of Lost-to-Follow-Up (LTFU) status in amblyopia treatment and create a risk model for predicting LTFU status.

Design: Retrospective cohort study METHODS: Setting: Single-center, ophthalmology department at Boston Children's Hospital (BCH).

Patients: 2037 patients treated for amblyopia at BCH between 2010 and 2014.

Observation Procedure: LTFU was defined as patients who did not return after initial visit, excluding those who came for second opinion. Multiple variables were tested for association with LTFU status.

Outcome Measure: Odds ratio of LTFU risk associated with each variable. Multivariate logistic regression was used to create a risk score for predicting LTFU status.

Results: A large proportion of patients (23%) were LTFU after first visit. Older age, nonwhite race, lack of insurance, previous glasses or atropine treatment, and longer requested follow-up intervals were independent predictors of LTFU status. A multivariable risk score was created to predict probability of LTFU (area under the curve 0.68).

Conclusions: Our comprehensive amblyopia database allows us to predict which patients are more likely to be LTFU after baseline visit and develop strategies to mitigate these effects. These findings may help with practice efficiency and improve patient outcomes in the future by transitioning these analyses to an electronic medical record that could be programmed to provide continually updated decision support for individual patients based on large data sets.
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http://dx.doi.org/10.1016/j.ajo.2021.05.002DOI Listing
May 2021

Timing of Ocular Hypertension After Pediatric Closed-Globe Traumatic Hyphema: Implications for Surveillance.

Am J Ophthalmol 2021 May 12. Epub 2021 May 12.

Harvard Medical School, Boston, MA; Boston Children's Hospital, Boston, MA; Massachusetts Eye and Ear, Boston, MA. Electronic address:

Purpose: To evaluate the timing of ocular hypertension (OHT) after pediatric closed-globe injury (CGI) and traumatic hyphema. We hypothesize that OHT will occur at different times based on injury characteristics.

Design: Retrospective, cohort study.

Methods: SETTING: : Single-center, tertiary-care, pediatric hospital.

Participants: Subjects included patients ≤18 years of age at the time of injury who suffered CGI and traumatic hyphema between 2002 and 2019.

Observation Procedure(s): Intraocular pressure and injury demographics were abstracted for every visit after injury. OHT was defined as >21 mmHg at presentation or after a reading of ≤21 mmHg at a prior visit.

Main Outcome Measures: The primary outcome measure was the timing of OHT categorized into 4 periods: presentation, acute (day 1-7), sub-acute (day 8-28), or late (day >28). Secondary outcome measures were identification of risks factors for OHT by multivariable logistic regression.

Results: OHT occurred in 119 (39%) of the 305 subject eyes. OHT occurred in 35 patients at presentation, 69 times acutely, 35 times sub-acutely, and 36 times late. Pupil damage predicted acute-period OHT (p=0.004). OHT at presentation predicted sub-acute period OHT (p=0.004). Iridodialysis and cataract predicted late-period OHT (p=0.007 and p<0.001, respectively).

Conclusions: OHT after CGI and traumatic hyphema in pediatric patients is common. Injury demographics predict this complication. Integration of these risk factors with current literature allows proposal of a risk-stratification tool to guide efficient surveillance for OHT.
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http://dx.doi.org/10.1016/j.ajo.2021.04.033DOI Listing
May 2021

Abdominal ultrasound findings contribute to a multivariable predictive risk score for surgical necrotizing enterocolitis: A pilot study.

Am J Surg 2021 Apr 27. Epub 2021 Apr 27.

Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA. Electronic address:

Background: Abdominal ultrasound (AUS) is a promising adjunct to abdominal x-ray (AXR) for evaluating necrotizing enterocolitis (NEC). We developed a multivariable risk score incorporating AUS to predict surgical NEC.

Methods: 83 patients were evaluated by AXR and AUS for suspected NEC. A subset had surgical NEC. Multivariate logistic regression determined predictors of surgical NEC, which were incorporated into a risk score.

Results: 14/83 patients (16.9%) had surgical NEC. 10/83 (12.0%) patients required acute intervention, while 4/83 (4.8%) patients only required delayed surgery. Four predictors of surgical NEC were identified: abdominal wall erythema (OR: 8.2, p = 0.048), portal venous gas on AXR (OR: 29.8, p = 0.014), and echogenic free fluid (OR: 17.2, p = 0.027) and bowel wall thickening (OR: 12.5, p = 0.030) on AUS. A multivariable risk score incorporating these predictors had excellent area-under-the-curve of 0.937 (95% CI: 0.879-0.994).

Conclusions: AUS, as an adjunct to physical exam and AXR, has utility for predicting surgical NEC.
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http://dx.doi.org/10.1016/j.amjsurg.2021.04.025DOI Listing
April 2021

Using Reticulocyte Hemoglobin Equivalent as a Marker for Iron Deficiency and Responsiveness to Iron Therapy.

Mayo Clin Proc 2021 06 2;96(6):1510-1519. Epub 2021 May 2.

Department of Laboratory Medicine, Boston Children's Hospital, and Department of Pathology, Harvard Medical School, Boston, MA. Electronic address:

Objective: To assess the accuracy of a simplified approach for the diagnosis of iron deficiency anemia (IDA) based on the complete blood cell count (CBC) and reticulocyte analysis.

Patients And Methods: Five hundred fifty-six consecutive, nonselected patients referred for diagnosis and/or treatment of anemia were included in this diagnostic study to compare the performance of reticulocyte hemoglobin equivalent (RET-He) versus traditional biochemical markers for diagnosis and treatment of IDA. Complete blood count, serum ferritin, iron, and transferrin saturation were performed as clinically indicated. Reticulocyte hemoglobin equivalent was measured with a Sysmex XN-450 analyzer on the residual CBC sample. The study period was from September 20, 2017, through and including November 15, 2018.

Results: Patients (N=556) were studied at baseline, of whom 150 were subsequently treated with intravenous iron. Receiver operating characteristic analysis yielded an RET-He cut-off of 30.7 pg to identify IDA (area under curve, 0.733; 95% CI, 0.692 to 0.775), with 68.2% sensitivity and 69.7% specificity. Patients (n=240) were seen at follow-up, with 57 treated and 183 not treated with intravenous iron. Responsiveness was defined as a hemoglobin increase of ≥1.0 g: a combination of RET-He <28.5 pg and hemoglobin value <10.3 g/dL had 84% sensitivity and 78% specificity as response predictor (area under the curve, 0.749; 95% CI, 0.622 to 0.875).

Conclusion: Data from CBC and RET-He can identify patients with IDA, determine need for and responsiveness to intravenous iron, and reduce time for therapeutic decisions. Limitations of this study are uncontrolled design, its single-site and retrospective nature, and that it requires prospective validation.
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http://dx.doi.org/10.1016/j.mayocp.2020.10.042DOI Listing
June 2021

Preoperative hematocrit and platelet count are associated with blood loss during spinal fusion for children with neuromuscular scoliosis.

J Perioper Pract 2021 Apr 7:1750458920962634. Epub 2021 Apr 7.

Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.

Aim: To assess the relationship of preoperative hematology laboratory results with intraoperative estimated blood loss and transfusion volumes during posterior spinal fusion for pediatric neuromuscular scoliosis.

Methods: Retrospective chart review of 179 children with neuromuscular scoliosis undergoing spinal fusion at a tertiary children's hospital between 2012 and 2017. The main outcome measure was estimated blood loss. Secondary outcomes were volumes of packed red blood cells, fresh frozen plasma, and platelets transfused intraoperatively. Independent variables were preoperative blood counts, coagulation studies, and demographic and surgical characteristics. Relationships between estimated blood loss, transfusion volumes, and independent variables were assessed using bivariable analyses. Classification and Regression Trees were used to identify variables most strongly correlated with outcomes.

Results: In bivariable analyses, increased estimated blood loss was significantly associated with higher preoperative hematocrit and lower preoperative platelet count but not with abnormal coagulation studies. Preoperative laboratory results were not associated with intraoperative transfusion volumes. In Classification and Regression Trees analysis, binary splits associated with the largest increase in estimated blood loss were hematocrit ≥44% vs. <44% and platelets ≥308 vs. <308 × 10/L.

Conclusions: Preoperative blood counts may identify patients at risk of increased bleeding, though do not predict intraoperative transfusion requirements. Abnormal coagulation studies often prompted preoperative intervention but were not associated with increased intraoperative bleeding or transfusion needs.
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http://dx.doi.org/10.1177/1750458920962634DOI Listing
April 2021

The Use of Regional Catheters in Children Undergoing Repair of Aortic Coarctation.

J Cardiothorac Vasc Anesth 2021 Feb 15. Epub 2021 Feb 15.

Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA. Electronic address:

Objective: The objective was to assess the effectiveness and safety of peripheral regional anesthesia in congenital cardiac surgical patients undergoing thoracotomy for aortic coarctation.

Design: A retrospective chart review of pediatric patients (<18 years) who underwent surgical repair of congenital heart diseases via thoracotomy between September 2013 and July 2018 was done. Among patients who underwent coarctation repair, a propensity score was used to match patients who received a regional catheter (C) versus traditional medical treatment only (M).

Setting: A single center children's hospital.

Participants: The median age was 172 days (IQR 64-1315) in group C and 176 days (IQR 71-1146) in group M (SMD = 0.07). The median weight was 6.8 kg (IQR 4.8-13.6) in group C and 7.7 kg (4.6-17.4) in group M (SMD = 0.003).

Measurements And Main Result: Outcomes assessed were postoperative hospital length of stay, median pain scores in the first 24 and 48 hours, and total morphine equivalent use in the first 24 and 48 hours. Complications related to the catheters were reviewed. The median oral morphine equivalent dose administered in the first 24 hours was lower in group C than group M (0.8 mg/kg, IQR 0.5-1.1 vs. 1.4 mg/kg, IQR 0.9-1.7, p = 0.019). There were no major complications related to the catheters, including hematoma.

Conclusions: Peripheral regional catheters may be used to reduce opioid requirements in patients after CoA repair. Due to the low risk of these catheters, they should be considered as part of a pain management strategy for pediatric patients undergoing thoracotomy and should be incorporated into strategies to improve outcomes.
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http://dx.doi.org/10.1053/j.jvca.2021.02.032DOI Listing
February 2021

Home Run Derby Participation in Major League Baseball Players: Is There Associated Injury Risk and Impact on Second-Half Performance?

Orthop J Sports Med 2021 Feb 26;9(2):2325967120983350. Epub 2021 Feb 26.

Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, Providence, Rhode Island, USA.

Background: The Major League Baseball (MLB) All-Star Game (ASG) Home Run Derby (HRD) remains a highly anticipated event, during which contestants can take hundreds of maximum-effort swings en route to hitting a multitude of home runs. Critics have openly questioned the risk-benefit of HRD participation as it pertains to injury, alterations in swing mechanics, and timing.

Purpose: To determine whether participation in the MLB ASG HRD was associated with both increased injury risk and decline in second-half performance in MLB players.

Study Design: Cohort study; Level of evidence, 3.

Methods: MLB players who participated in the HRD between 2006 and 2019 were identified through publicly available internet databases. A control group of ASG participants who had the highest home run totals in the first half of the corresponding MLB season were selected as a control group. Multivariable linear regression was used to determine independent associations between HRD participation and batting metrics in the second half of the season. Multivariable logistic regression also assessed the impact of HRD participation on injured list placement during the second half of the concurrent MLB season.

Results: A total of 114 HRD participants and 114 ASG participant controls competed during the study period. No statistically significant differences were seen in batting metrics in the second half of the MLB season between HRD participants and ASG controls, although HRD participants had a significantly lower wins-above-replacement statistic for the season compared with controls (4.69 ± 2.06 vs 5.33 ± 2.08; = .021). HRD participation was not significantly associated with injury during the second half. The number of HRD rounds in which a player participated did not result in a statistically significant increased odds of injury during the second half of the MLB season.

Conclusion: HRD participants did not have increased odds of being placed on the injured list during the second half of the MLB season compared with controls, nor did they experience second-half performance declines in offensive production versus controls when multivariable linear regression analysis was performed.
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http://dx.doi.org/10.1177/2325967120983350DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934056PMC
February 2021

Prenatal Imaging Diagnosis of Suprarenal Lesions.

Fetal Diagn Ther 2021 17;48(3):235-242. Epub 2021 Mar 17.

Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts, USA,

Introduction: Prenatal suprarenal lesions represent diverse pathologies. This study investigated prenatal imaging features and regression patterns associated with specific lesion diagnoses.

Methods: This is a multicenter retrospective review of fetuses with prenatally diagnosed suprarenal lesions between 2001 and 2019. Prenatal ultrasound and MRI characteristics, postnatal imaging, and clinical course were reviewed. Prenatal imaging findings were compared by the most common diagnoses and regression patterns.

Results: Forty-four fetuses were prenatally diagnosed with suprarenal lesions. Diagnoses included pulmonary sequestration (n = 12; 27.3%), adrenal hemorrhage (n = 12; 27.3%), upper quadrant cyst (including 2 duplication cysts, 1 splenic cyst, and 3 indeterminate cysts), neuroblastoma (n = 4), adrenal hyperplasia (n = 3), bilateral adrenal calcifications (n = 1), and indeterminate lesions (n = 6). Sequestrations were uniformly left-sided (100 vs. 50%; p = 0.014) and diagnosed earlier in gestation than adrenal hemorrhages (p = 0.025). Sequestrations were also significantly more likely to have a prenatal feeding vessel (p = 0.005), low T1 MRI signal (p = 0.015), and no MRI blood products (p = 0.018) compared to adrenal hemorrhages. When comparing all 44 patients, a prenatal feeding vessel and low T1 signal on prenatal MRI were significantly associated with lesion persistence (p = 0.003; p = 0.044).

Discussion/conclusion: Imaging findings on prenatal ultrasound and MRI aid in the diagnosis of suprarenal lesions, including differentiating pulmonary sequestrations and adrenal hemorrhages.
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http://dx.doi.org/10.1159/000512689DOI Listing
March 2021

Long-term outcomes of truncus arteriosus repair: A modulated renewal competing risks analysis.

J Thorac Cardiovasc Surg 2021 Feb 12. Epub 2021 Feb 12.

Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass. Electronic address:

Objective: In this study, we sought to identify independent risk factors for mortality and reintervention after early surgical correction of truncus arteriosus using a novel statistical method.

Methods: Patients undergoing neonatal/infant truncus arteriosus repair between January 1984 and December 2018 were reviewed retrospectively. An innovative statistical strategy was applied integrating competing risks analysis with modulated renewal for time-to-event modeling.

Results: A total of 204 patients were included in the study. Mortality occurred in 32 patients (15%). Smaller right ventricle to pulmonary artery conduit size and truncal valve insufficiency at birth were significantly associated with overall mortality (right ventricle to pulmonary artery conduit size: hazard ratio, 1.34; 95% confidence interval, 1.08-1.66, P = .008; truncal valve insufficiency: hazard ratio, 2.5; 95% confidence interval, 1.13-5.53, P = .024). truncal valve insufficiency at birth, truncal valve intervention at index repair, and number of cusps (4 vs 3) were associated with truncal valve reoperations (truncal valve insufficiency: hazard ratio, 2.38; 95%, confidence interval, 1.13-5.01, P = .02; cusp number: hazard ratio, 6.62; 95% confidence interval, 2.54-17.3, P < .001). Right ventricle to pulmonary artery conduit size 11 mm or less was associated with a higher risk of early catheter-based reintervention (hazard ratio, 1.54; 95% confidence interval, 1.04-2.28, P = .03) and reoperation (hazard ratio, 1.96; 95% confidence interval, 1.33-2.89, P = .001) on the right ventricle to pulmonary artery conduit.

Conclusions: Smaller right ventricle to pulmonary artery conduit size and truncal valve insufficiency at birth were associated with overall mortality after truncus arteriosus repair. Quadricuspid truncal valve, the presence of truncal valve insufficiency at the time of diagnosis, and truncal valve intervention at index repair were associated with an increased risk of reoperation. The size of the right ventricle to pulmonary artery conduit at index surgery is the single most important factor for early reoperation and catheter-based reintervention on the conduit.
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http://dx.doi.org/10.1016/j.jtcvs.2021.01.136DOI Listing
February 2021

Epidural analgesia for reduction of postoperative systemic opioid use following selective dorsal rhizotomy in children.

J Neurosurg Pediatr 2021 Mar 12:1-6. Epub 2021 Mar 12.

Departments of1Neurosurgery and.

Objective: Selective dorsal rhizotomy (SDR) requires significant postoperative pain management, traditionally relying heavily on systemic opioids. Concern for short- and long-term effects of these agents has generated interest in reducing systemic opioid administration without sacrificing analgesia. Epidural analgesia has been applied in pediatric patients undergoing SDR; however, whether this reduces systemic opioid use has not been established. In this retrospective cohort study, the authors compared postoperative opioid use and clinical measures between patients treated with SDR who received postoperative epidural analgesia and those who received systemic analgesia only.

Methods: All patients who underwent SDR at Boston Children's Hospital between June 2013 and November 2019 were reviewed. Treatment used the same surgical technique. Postoperative systemic opioid dosage (in morphine milligram equivalents per kilogram [MME/kg]), pain scores, need for respiratory support, vomiting, bowel movements, and length of hospital and ICU stay were compared between patients who received postoperative epidural analgesia and those who did not, by using the Wilcoxon rank-sum test or Fisher's exact test.

Results: A total of 35 patients were identified, including 18 females (51.4%), with a median age at surgery of 6.1 years. Thirteen patients received postoperative epidural and systemic analgesia and 22 patients received systemic analgesia only. Groups were otherwise similar, with treatment selection based solely on surgeon routine. Patients who received epidural analgesia required less systemic morphine milligram equivalents/kg on postoperative days (PODs) 0-4 (p ≤ 0.042). Patients who did not receive epidural analgesia were more likely to require respiratory support on POD 1 (45% vs 8%; p = 0.027). Reported pain scores did not differ between groups, although patients receiving epidural analgesia trended toward less severe pain on PODs 1 and 2. Groups did not differ with respect to postoperative vomiting or time to first bowel movement, although epidural analgesia use was associated with a longer hospital stay (median 7 vs 5 days; p < 0.001).

Conclusions: Patients who received postoperative epidural analgesia required less systemic opioid use and had at least equivalent reported pain scores on PODs 1-4, and they required less respiratory support on POD 1, although they remained in the hospital longer when compared to patients who received systemic analgesia only. A larger prospective study is needed to confirm whether epidural analgesia lowers systemic opioid use in children, contributes to a safer postoperative hospital stay, and results in better pain control following SDR.
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http://dx.doi.org/10.3171/2020.9.PEDS20501DOI Listing
March 2021

A survey of the global impact of COVID-19 on the practice of pediatric anesthesia: A study from the pediatric anesthesia COVID-19 Collaborative Group.

Paediatr Anaesth 2021 06 3;31(6):720-729. Epub 2021 May 3.

Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.

Background: Pediatric anesthesiology has been greatly impacted by COVID-19 in the delivery of care to patients and to the individual providers. With this study, we sought to survey pediatric centers and highlight the variations in care related to perioperative medicine during the COVID-19 pandemic, including the availability of protective equipment, the practice of pediatric anesthesia, and economic impact.

Aim: The aim of the survey was to determine how COVID-19 directly impacted pediatric anesthesia practices during the study period.

Methods: A survey concerning four major domains (testing, safety, clinical management/policy, economics) was developed. It was pilot tested for clarity and content by members of the Pediatric Anesthesia COVID-19 Collaborative. The survey was administered by email to all Pediatric Anesthesia COVID-19 Collaborative members on September 1, 2020. Respondents had six weeks to complete the survey and were instructed to answer the questions based on their institution's practice during September 1 - October 13, 2020.

Results: Sixty-three institutions (100% response rate) participated in the COVID-19 Pediatric Anesthesia Survey. Forty-one hospitals (65%) were from the United States, and 35% included other countries. N95 masks were available to anesthesia teams at 91% of institutions (n = 57) (95% CI: 80%-96%). COVID-19 testing criteria of anesthesia staff and guidelines to return to work varied by institution. Structured simulation training aimed at improving COVID-19 safety and patient care occurred at 62% of institutions (n = 39). Pediatric anesthesiologists were economically affected by a reduction in their employer benefits and restriction of travel due to employer imposed quarantine regulations.

Conclusion: Our data indicate that the COVID-19 pandemic has impacted the testing, safety, clinical management, and economics of pediatric anesthesia practice. Further investigation into the long-term consequences for the specialty is indicated.
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http://dx.doi.org/10.1111/pan.14174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8250770PMC
June 2021

Management strategies for recurrent pediatric craniopharyngioma: new recommendations.

J Neurosurg Pediatr 2021 Mar 5:1-8. Epub 2021 Mar 5.

1Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts.

Objective: The goal of this study was to identify the independent risk factors for recurrence or progression of pediatric craniopharyngioma and to establish predictors of the appropriate timing of intervention and best management strategy in the setting of recurrence/progression, with the aim of optimizing tumor control.

Methods: This is a retrospective cohort study of all pediatric patients with craniopharyngioma who were diagnosed and treated at Boston Children's Hospital between 1990 and 2017. This study was approved by the institutional review board at Boston Children's Hospital. All statistical analyses were performed using Stata software.

Results: Eighty patients (43 males and 37 females) fulfilled the inclusion criteria. The mean age at the time of diagnosis was 8.6 ± 4.4 years (range 1.2-19.7 years). The mean follow-up was 10.9 ± 6.5 years (range 1.3-24.6 years). Overall, 30/80 (37.5%) patients developed recurrence/progression. The median latency to recurrence/progression was 12.75 months (range 3-108 months). Subtotal resection with no adjuvant radiotherapy (p < 0.001) and fine calcifications (p = 0.008) are independent risk factors for recurrence/progression. An increase (%) in the maximum dimension of the tumor at the time of recurrence/progression was considered a statistically significant predictor of the appropriate timing of intervention.

Conclusions: Based on the identified independent risk factors for tumor recurrence/progression and the predictors of appropriate timing of intervention in the setting of recurrence/progression, the authors propose an algorithm for optimal management of recurrent pediatric craniopharyngioma to increase the likelihood of tumor control.
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http://dx.doi.org/10.3171/2020.9.PEDS20606DOI Listing
March 2021

Burnout Rate and Risk Factors among Anesthesiologists in the United States.

Anesthesiology 2021 05;134(5):683-696

Background: Physician burnout, widespread across medicine, is linked to poorer physician quality of life and reduced quality of care. Data on prevalence of and risk factors for burnout among anesthesiologists are limited. The objective of the current study was to improve understanding of burnout in anesthesiologists, identify workplace and personal factors associated with burnout among anesthesiologists, and quantify their strength of association.

Methods: During March 2020, the authors surveyed member anesthesiologists of the American Society of Anesthesiologists. Burnout was assessed using the Maslach Burnout Inventory Human Services Survey. Additional survey questions queried workplace and personal factors. The primary research question was to assess rates of high risk for burnout (scores of at least 27 on the emotional exhaustion subscale and/or at least 10 on the depersonalization subscale of the Maslach Burnout Inventory Human Services Survey) and burnout syndrome (demonstrating all three burnout dimensions, consistent with the World Health Organization definition). The secondary research question was to identify associated risk factors.

Results: Of 28,677 anesthesiologists contacted, 13.6% (3,898) completed the survey; 59.2% (2,307 of 3,898) were at high risk of burnout, and 13.8% (539 of 3,898) met criteria for burnout syndrome. On multivariable analysis, perceived lack of support at work (odds ratio, 6.7; 95% CI, 5.3 to 8.5); working greater than or equal to 40 h/week (odds ratio, 2.22; 95% CI, 1.80 to 2.75); lesbian, gay, bisexual, transgender/transsexual, queer/questioning, intersex, and asexual status (odds ratio, 2.21; 95% CI, 1.35 to 3.63); and perceived staffing shortages (odds ratio, 2.06; 95% CI, 1.76 to 2.42) were independently associated with high risk for burnout. Perceived lack of support at work (odds ratio, 10.0; 95% CI, 5.4 to 18.3) and home (odds ratio, 2.13; 95% CI, 1.69 to 2.69) were most strongly associated with burnout syndrome.

Conclusions: The prevalence of burnout among anesthesiologists is high, with workplace factors weighing heavily. The authors identified risk factors for burnout, especially perceived support in the workplace, where focused interventions may be effective in reducing burnout.

Editor’s Perspective:
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http://dx.doi.org/10.1097/ALN.0000000000003722DOI Listing
May 2021

Generic and Disease-specific Health-related Quality of Life in Pediatric Intestinal Failure.

J Pediatr Gastroenterol Nutr 2021 Sep;73(3):338-344

Center for Advanced Intestinal Rehabilitation (CAIR), Boston Children's Hospital.

Objective: The aim of the study was to assess overall and disease-specific health-related quality of life (hrQOL) in patients with pediatric intestinal failure (PIF) and caregivers and elucidate differences from healthy and chronic gastrointestinal (GI) illness cohorts.

Methods: Cross-sectional study of patients with PIF and their caregivers managed at a multidisciplinary intestinal rehabilitation program using the PedsQL Generic Core and the Gastrointestinal Symptoms Module to assess generic and disease-specific hrQOL, respectively. These data were compared to established healthy and chronic GI disease controls.

Results: A total of 53 patients (mean age 6.2 ± 3.9 years) and their caregivers were studied. Patients reported lower generic hrQOL than healthy children (73.0 vs 83.84, P < 0.001), but no difference from patients with chronic GI disease (73.0 vs 77.79). In contrast, PIF caregivers perceived similar generic hrQOL compared to a healthy cohort (78.9 vs 82.70), but higher when compared to the GI disease cohort (78.9 vs 72.74, P < 0.01). Patients with PIF and caregivers reported lower psychosocial health scores than healthy controls. Patients and caregivers reported similar disease-specific hrQOL to a cohort with chronic GI disease but significantly lower disease-specific hrQOL than a healthy cohort (P < 0.001 both groups).

Conclusions: Patients with PIF and their caregivers have disparate perceptions of generic hrQOL when compared to healthy and chronic GI disease controls. Both patients and caregivers, however, had significantly lower scores in psychosocial health than healthy controls. In addition, disease-specific hrQOL was substantially lower than healthy controls for PIF patients and caregivers. Further investigation to expand on these findings and identify modifiable variables to improve the psychosocial health score and disease-specific factors would be of high value.
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http://dx.doi.org/10.1097/MPG.0000000000003102DOI Listing
September 2021
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