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Persons with drug-resistant epilepsy may benefit from epilepsy surgery and should undergo presurgical testing to determine potential candidacy and appropriate intervention. Institutional expertise can influence use and availability of evaluations and epilepsy surgery candidacy. This census survey study aims to examine the influence of geographic region and other center characteristics on presurgical testing for medically intractable epilepsy.We analyzed annual report and supplemental survey data reported in 2020 from 206 adult epilepsy center directors and 136 pediatric epilepsy center directors in the United States. Test utilization data were compiled with annual center volumes, available resources, and US Census regional data. We used Wilcoxon rank-sum, Kruskal-Wallis, and chi-squared tests for univariate analysis of procedure utilization. Multivariable modeling was also performed to assign odds ratios (ORs) of significant variables.The response rate was 100% with individual element missingness 11% across 342 observations undergoing univariate analysis. A total of 278 complete observations were included in the multivariable models, and significant regional differences were present. For instance, compared to centers in the South, those in the Midwest used neuropsychological testing (OR = 2.87, 95% confidence interval [CI] = 1.2-6.86; p = .018) and fluorodeoxyglucose-positron emission tomography (OR = 2.74, 95% CI = = 1.14-6.61; p = .025) more commonly. For centers in the Northeast (OR = .46, 95% CI = .23-.93; p = .031) and West (OR = .41, 95% CI = .19-.87; p = .022), odds of performing single-photon emission computerized tomography were lower by nearly 50% compared to those in the South. Center accreditation level, demographics, volume, and resources were also associated with varying individual testing rates.Presurgical testing for drug-resistant epilepsy is influenced by US geographic region and other center characteristics. These findings have potential implications for comparing outcomes between US epilepsy centers and may inject disparities in access to surgical treatment.

Background and ObjectiveNearly one-third of persons with epilepsy will continue having seizures despite trialing multiple antiseizure medications. Epilepsy surgery may be beneficial in these cases, and evaluation at a comprehensive epilepsy center is recommended. Numerous palliative and potentially curative approaches exist, and types of surgery performed may be influenced by center characteristics. This article describes epilepsy center characteristics associated with epilepsy surgery access and volumes in the United States.MethodsWe analyzed National Association of Epilepsy Centers 2019 annual report and supplemental survey data obtained with responses from 206 adult epilepsy center directors and 136 pediatric epilepsy center directors in the United States. Surgical treatment volumes were compiled with center characteristics, including US Census region. We used multivariable modeling with zero-inflated Poisson regression models to present ORs and incidence rate ratios of receiving a given surgery type based on center characteristics.ResultsThe response rate was 100% with individual element missingness less than 4% across 352 observations undergoing univariate analysis. Multivariable models included 319 complete observations. Significant regional differences were present. The rates of laser interstitial thermal therapy (LITT) were lower at centers in the Midwest (incidence rate ratio [IRR] 0.74, 95% CI 0.59–0.92;p= 0.006) and Northeast (IRR 0.77, 95% CI 0.61–0.96;p= 0.022) compared with those in the South. Conversely, responsive neurostimulation implantation rates were higher in the Midwest (IRR 1.45, 95% CI 1.1–1.91;p= 0.008) and West (IRR 1.91, 95% CI 1.49–2.44;p< 0.001) compared with the South. Center accreditation level, institution type, demographics, and resources were also associated with variations in access and rates of potentially curative and palliative surgical interventions.DiscussionEpilepsy surgery procedure volumes are influenced by US epilepsy center region and other characteristics. These variations may affect access to specific surgical treatments for persons with drug resistant epilepsy across the United States.

The aim of the study was to determine the variables associated with high-quality (HQ) versus low-quality (LQ) three-dimensional rotational angiography (3DRA) and create guides for optimization of approach to 3DRA in congenital cardiac catheterization (CCC). CCC has adopted 3DRA as a mainstay, but there has not been systematic analysis of approach to and factors associated with HQ 3DRA. This was a single-center, retrospective study of 3DRAs using Canon Infinix-I platform. Reconstructions were graded by 3 interventionalists. Quality was dichotomized into HQ and LQ. Univariable analyses and multivariable logistic regression models were performed. From 8/2016 to 12/2018, 208 3DRAs were performed in 195 CCCs; median age 7 years (2, 16), weight 23 kg (12, 57). The majority of 3DRAs were performed in patients with biventricular physiology (N = 137, 66%) and in pulsatile sites (N = 144, 69%). HQ 3DRA (N = 182, 88%) was associated with greater total injection volume [2.20 mL/kg (1.44, 3.29) vs. 1.62 mL/kg (1.10, 1.98), p = 0.005] and more dilute contrast solution [60% (50, 100) vs. 100% (60, 100), p = 0.007], but not with contrast volume administered (p = 0.2) on univariable analysis. On multivariable logistic regression, HQ 3DRA was significantly associated with patient weight [OR 0.97 (95% CI (0.94, 0.99), p = 0.018], total injection volume [OR 1.04 (95% CI 1.01, 1.07) p = 0.011], and percent contrast solution [OR 0.97 (95% CI 0.95, 1.00), p = 0.022]. These data resulted in creation of scatter plots and a novel 3DRA Nomogram for estimating the probability of HQ 3DRA. This is the first study to create evidence-based contrast dose guides and nomogram for 3DRA in CCC. HQ 3DRA was associated with lower weight, higher total injection volumes, and more dilute contrast solution.

To assess the association between epilepsy characteristics and proxy-reported health-related quality of life (HRQoL) in children and young people with non-ambulatory cerebral palsy (CP) and seizures.This was a cross-sectional study of 164 children and young people (74 females, 90 males; mean age 10 years 6 months, range 2-21 years, SD 5 years 5 months). Caregivers completed the Child Health Index of Life with Disabilities (CPCHILD) in an outpatient setting. We utilized univariable linear regression and multivariable modeling to study relationships between variables and CPCHILD scores.Gross Motor Function Classification System levels were 37% IV and 63% V. Sociodemographic factors included the Child Opportunity Index (median 51, interquartile range [IQR] 25-80). A median of 2 (IQR 1-3) antiseizure medications (ASMs) were used, and days with seizures ranged from 0 (30%) to 28 (20%) days in the previous 4 weeks. Total CPCHILD scores decreased 2.3 points for each ASM (95% confidence interval [CI] -4.1 to -0.42). Compared to persons with focal epilepsy, those with generalized epilepsy had lower total CPCHILD scores (-5.7; 95% CI -11 to -0.55). Number of days with seizures was not associated with total CPCHILD scores.Proxy-reported HRQoL was affected by epilepsy-specific features in children and young people with severe CP.

Background and ObjectivesPersons with epilepsy, especially those with drug resistant epilepsy (DRE), may benefit from inpatient services such as admission to the epilepsy monitoring unit (EMU) and epilepsy surgery. The COVID-19 pandemic caused reductions in these services within the US during 2020. This article highlights changes in resources, admissions, and procedures among epilepsy centers accredited by the National Association of Epilepsy Centers (NAEC).MethodsWe compared data reported in 2019, prior to the COVID-19 pandemic, and 2020 from all 260 level 3 and level 4 NAEC accredited epilepsy centers. Data were described using frequency for categorical variables and median for continuous variables and were analyzed by center level, center population category, and geographical location. Qualitative responses from center directors to questions regarding the impact from COVID-19 were summarized utilizing thematic analysis. Responses from the NAEC center annual reports as well as a supplemental COVID-19 survey were included.ResultsEMU admissions declined 23% (-21,515) in 2020, with largest median reductions in level 3 centers [-55 admissions (-44%)] and adult centers [-57 admissions (-39%)]. The drop in admissions was more substantial in the East North Central, East South Central, Mid Atlantic, and New England US Census divisions. Survey respondents attributed reduced admissions to re-assigning EMU beds, restrictions on elective admissions, reduced staffing, and patient reluctance for elective admission. Treatment surgeries declined by 371 cases (5.7%), with the largest reduction occurring in VNS implantations [-486 cases (-19%)] and temporal lobectomies [-227 cases (-16%)]. All other procedure volumes increased, including a 35% (54 cases) increase in corpus callosotomies.DiscussionIn the US, access to care for persons with epilepsy declined during the COVID-19 pandemic in 2020. Adult patients, those relying on level 3 centers for care, and many persons in the eastern half of the US were most affected.

BackgroundLeft ventricular hypertrophy (LVH) associated with hypertension (HTN) is a predictor of cardiovascular (CV) events in adulthood. LVH is defined using left ventricular mass indexed to height2.7(LVMI-ht2.7) with current guidelines using the adult cutoff of 51 g/ht2.7; however, the pediatric cutoff is lower. Adults with congenital heart disease (CHD) have higher rates of HTN compared to the general adult population. Data on the prevalence of elevated blood pressure (SBP) in youths with CHD is limited. The aim of our study was to determine the prevalence of elevated BP and LVH in adolescents with CHD.MethodsWe retrospectively analyzed echocardiograms from patients with CHD from 2012-2019. Patients with biventricular CHD aged 13-17 years with documented BP, height, weight, and measurement of LVMI-ht2.7were included. We defined LVH using the pediatric cutoff of LVMI-ht2.7≥ 38.6 g/ht2.7. Patients were grouped by BP category into normotensive (NT, SBP < 120 mm Hg), Elevated BP (E-BP, 120 ≤ SBP < 130 mm Hg), Stage 1 HTN (HTN-1, 130 ≤ SBP < 140 mm Hg), and Stage 2 HTN (HTN-2, SBP ≥ 140 mm Hg). Prevalence of LVH was reported in each group defined as LVMI-HT2.7≥ 38.6 g/ht2.7.Results855 patients were included. Mean (± standard deviation, SD) age was 15.5±1.5 years with 485/855 (56.7%) male, SBP 117±13.5 mmHg, and LVMI-ht2.734.2±10.5 g/ht2.7. 493/855 (57.7%) were in the NT group, 214/855 (25%) in E-BP, 99/855 (11.6%) in HTN-1, and 49/855 (5.7%) in HTN-2. Prevalence of LVH increased with higher SBP with 96/493 (19.5%) in NT, 80/214 (37.4%) in E-BP, 32/99 (32.3%) in HTN-1, and 20/49 (40.8%) in HTN-2. Of youths with LVH, 49/228 (21.5%) met adult criteria of ≥ 51 g/ht2.7. Age, male sex, and body mass index (BMI) percentile were significantly associated with increased LVMI-ht2.7.ConclusionsYouths with CHD have a high prevalence of elevated BP, HTN, and LVH. BMI is a significant risk factor for the development of LVH in this population. These findings support early screening for HTN in this group because youths with CHD have baseline increased CV risk that may be compounded by obesity and long-term HTN.Clinical PerspectiveWhat is new?The prevalence of abnormal blood pressure and LVH in adolescents with CHD is understudied and our data show that HTN and LVH are common in this population.One-fifth of adolescents with biventricular congenital heart disease and left ventricular hypertrophy met adult criteria for left ventricular hypertrophy.What are the clinical implications?Left ventricular hypertrophy secondary to hypertension is linked to adverse cardiac events in adulthood.Early screening and detection for abnormal blood pressure in the adolescent congenital heart disease population may lead to earlier initiation of lifestyle interventions or pharmacotherapy and mitigate long-term adverse clinical and financial outcomes in an already vulnerable population.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes long-term pulmonary sequelae in adults, but little is known about pulmonary outcomes in pediatrics.The aim of this study was to describe long-term subjective and objective pulmonary abnormalities after SARS-CoV-2 infection in pediatric populations.Single-center, retrospective cohort of patients seen in post-coronavirus disease 2019 (COVID-19) pulmonary clinic in 2021. Subjects evaluated had persistent pulmonary symptoms 4 weeks or more after initial infection. Clinical testing included a 6-min walk test (6MWT), chest X-ray, pre- and postbronchodilator spirometry, plethysmography, and diffusion capacity. Patients were followed 2-to-3-months after the initial visit with repeat testing. The primary outcome was the presence of abnormal pulmonary function testing. Secondary measures included variables associated with pulmonary outcomes.Eighty-two adolescents were seen at a median of 3.5 months postinfection, with approximately 80% reporting two or more symptoms at clinic presentation (cough, chest pain, dyspnea at rest, and exertional dyspnea). At follow-up (~6.5 months) exertional dyspnea persisted for most (67%). Spirometry was normal in 77% of patients, but 31% had a positive bronchodilator response. No abnormalities were noted on plethysmography or diffusion capacity. Clinical phenotypes identified included inhaled corticosteroid responsiveness, paradoxical vocal fold motion disorder, deconditioning, and dysautonomia. Multivariable modeling demonstrated that obesity, anxiety, and resting dyspnea were associated with reduced 6MWT, while female sex and resting dyspnea were associated with higher Borg Dyspnea and Fatigues scores.This is the largest study to date of pediatric patients with long-term pulmonary sequelae post-COVID-19. Identified clinical phenotypes and risk factors warrant further study and treatment.

BACKGROUND The Gleason scoring system is the most widely used method to assess prostate adenocarcinoma pathology however interobserver variability is significant. Gleason score, PSA level, and clinical stage comprise the NCCN risk stratification that guides treatment decision making. Given the importance of an accurate Gleason score and wide interobserver variability, referral centers routinely review outside pathology at the time of consultation. We sought to address the impact a secondary pathology review had on radiation therapy treatment recommendations in men with prostate cancer at our institution. METHODS We retrospectively collected patient data on 342 patients seen at our institution from January 2012 to December 2018. Clinicopathologic data were used to subdivide patients into risk groups and available treatment options per NCCN criteria. Cases reviewed by our genitourinary pathologist (GUP) were compared with reports from outside pathologists. Inter-rater reliability between pathologists was assessed with weighted Cohen's kappa statistic and agreement of treatment options was determined by McNemar's exact tests. RESULTS GUP scored more cores positive in 16.47% of cases on secondary review. Primary Gleason score was changed in 12.28% of patients and secondary score in 26.02% of cases. Total Gleason score was different in 29.24% of cases, 19.01% were downgraded and 10.23% upgraded. The weighted kappa statistic was 0.759 (95% confidence interval [CI]: 0.711, 0.807). 18.77% of patients were assigned to a different NCCN risk group following secondary review. The weighted kappa statistic comparing NCCN risk stratification was 0.802 (95% CI: 0.754, 0.850). Secondary review influenced radiation therapy recommendations pertaining to brachytherapy boost and androgen deprivation therapy in men with high risk disease (χ2 = 5.33, p = 0.0386; χ2 = 8.05, p = 0.0072, respectively). Kappa statistic was found to be highest when GUP assessed high-risk disease versus all other categories (κ = 0.823, 95% CI: 0.750, 0.895). CONCLUSIONS We found nearly one in five men (18.7%) was assigned a different NCCN risk group and thus offered potentially different treatment options after a secondary pathology review at our institution. Given the inherent nature of prostate cancer and lung disease-specific survival associated with modern therapies, our study demonstrates the importance of a secondary pathology review and its potential impact on radiation therapy recommendations.

Infective endocarditis (IE) is an uncommon disease in children that, when present, is accompanied by significant morbidity and mortality. The presence of congenital heart disease often complicates management. The aim of the present study is to describe the characteristics and outcomes of children undergoing surgery for IE.A retrospective chart review from 2004 to 2020 was conducted to identify consecutive patients younger than age 20 years with IE undergoing surgery.A total of 94 patients with IE were identified, of whom 47 underwent surgery at a median age of 16.7 years. Thirty-one patients (65.95%) had congenital heart disease. Vegetation and embolic phenomena occurred in 41 and 29 patients (87.23% and 61.7%), respectively, with the brain as most common location (57.1%). Native valve involvement had a greater tendency to embolize (P .001). Staphylococcus spp was the most common organism (49%). The mitral valve was the most affected (31.9%). Seven (14.9%) patients had multivalvar involvement and valve replacement was the most common procedure performed (37 patients; 78.7%). There were 3 operative deaths (6.4%). Median length of hospital stay was 21 days. Risk factors for prolonged hospital stay were time to surgery in days (P .001) and native valvar involvement (P = .05). Five patients (10.6%) had postoperative recurrent IE. Survival at 1 and 5 years was 93.6% and 89.4%, respectively.Children with IE can undergo surgery with acceptable results. The morbidity, but not mortality, is driven by embolic complications. Staphylococcus spp and native valve involvement are significant risk factors. VIDEO ABSTRACT.

To implement a quality improvement (QI) scorecard as a tool for enhancing quality and safety efforts in level 1 and 2 community hospital nurseries affiliated with Nationwide Children's Hospital.A QI scorecard was developed for data collection, analytics, and reporting of neonatal quality metrics and cross-sector collaboration. Newborn characteristics were included for risk stratification, as were clinical and process measures associated with neonatal morbidity and mortality. Quality and safety activities took place in community hospital newborn nurseries in Ohio, and education was provided in both online and in-person collaborations, followed by local team sessions at partner institutions. Baseline (first 12 months) and postbaseline comparisons of clinical and process measures were analyzed by logistic regression, adjusting for potential confounders.In logistic regression models, at least 1 center documented improvements in each of the 4 process measures, and 3 of the 4 centers documented improvements in compliance with glucose checks obtained within 90 minutes of birth among at-risk infants.Collaborative QI projects led to improvements in perinatal metrics associated with important outcomes. Formation of a center-driven QI scorecard is feasible and provides community hospitals with a framework for collecting, analyzing, and reporting neonatal QI metrics.

Low back pain is a debilitating condition with poor patient outcomes despite the use of a wide variety of diagnostic and treatment modalities. A lack of objective metrics to support clinical decision-making may be a reason for these poor outcomes. This study aimed to compare patient recovery following lumbar fusion surgery using an objective motion-based metric (functional performance) and subjective patient-reported outcomes for pain, disability and kinesophobia.A prospective observational study was conducted on 121 patients that received a lumbar fusion surgery. A wearable motion system was used to quantify three-dimensional multi-planar lumbar motion and benchmark each patient's lumbar function prior to surgery and post-operatively at follow-up time points for up to 2 years. Patient recovery profiles after surgery were evaluated using the acquired functional motion data and compared to patient-reported outcomes.Our results found significant improvement after surgery in objective functional performance as well as patient-reported pain, disability, and kinesophobia. However, we found a delayed response in the objective metric, with meaningful improvement occurring only 6 months after fusion surgery. In contrast, we found significant improvement in all subjective scores as early as 6 weeks post-surgery.Objective motion-based metric provides a unique perspective to assessing patient's functional recovery. While it is associated with dimensions of pain, disability and fear avoidance, it is also distinct and assesses a uniquely different dimension of functional health. This information can form the basis for the use of objective metrics to gauge patient recovery after lumbar fusion surgery.

Background Intrauterine devices (IUDs) and the contraceptive implant are long acting reversible contraception (LARC) methods commonly used by adolescents. Gynecology visits and insertion of LARC devices can provoke anxiety and pain for adolescents. Research on non-pharmacological interventions for management of adolescent anxiety and pain and is lacking; we aimed to determine the impact of non-pharmacologic interventions on patient reported pain and anxiety during office LARC insertions. Methods Patients undergoing an office LARC insertion were eligible. After IRB approval, a systematic controlled trial was conducted; allocating patients to an intervention group (aromatherapy, Buzzy Bee device, aromatherapy + Buzzy Bee device, nursing bedside support) using an alternating sequence. Three outcome variables were analyzed: self-reported pain scores and responses to 2 survey questions (regarding perceived effectiveness of the intervention on pain and anxiety). Numeric data was summarized using medians/IQRs and categorical data as frequency/percent. Chi-squared tests were used to detect differences by group in categorical variables and Kruskal-Wallis tests in continuous variables. A linear mixed effects model determined pain score association with age, time, procedure, and intervention. Proportional odds ordinal regression models were used for survey questions (age, procedure, intervention as possible predictor variables). Results 58%) underwent IUD insertion. Intervention groups were roughly equal in size. After adjusting for age, procedure, and time, we found no evidence for an effect of intervention on pain scores [(χ]_3^2=1.7,p=0.64). Variability in pain scores was driven by time point and procedure. Nexplanon insertions had lower pain scores throughout compared to IUD insertions. There was little evidence of an effect of intervention on the pain effectiveness survey question (χ_3^2=4.1,p=0.25) or anxiety effectiveness survey question after controlling for age and procedure (χ_3^2=2.5,p=0.47). However, the effect of procedure was significant in both models (pain: p=0.01, anxiety: p=0.05). Conclusions IUD insertion was more painful than Nexplanon insertion regardless of age; this may impact preprocedural counseling. When controlling for age and procedure, pain scores did not differ among intervention groups. The value of bedside nursing support cannot be underestimated. Ongoing research regarding non-pharmacologic interventions is needed to help minimize patient anxiety/discomfort and increase acceptability of office gynecologic procedures.