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Lingual tonsil hypertrophy is an uncommon cause of upper aerodigestive tract pathology. We present the case of a 17-year-old boy who developed severe dysphagia and subsequent weight loss as a result of lingual tonsil hypertrophy. He was successfully treated with plasmamediated radiofrequency-based ablation (Coblation). In the past, traditional surgical procedures for lingual tonsil hypertrophy were difficult to perform and recovery was difficult, but the introduction of Coblation has made lingual tonsillectomy much easier. [ABSTRACT FROM AUTHOR]

Background: Infection with viral pneumonia (PNA) is known to offset the coagulation cascade. Recent studies assessing novel SARS-CoV-2 infection observed a high frequency of systemic thrombotic events resulting in ambiguity if severity of infection or specific viral strain drive thrombosis and worsen clinical outcomes. Furthermore, limited data exists addressing SARS-CoV-2 in underrepresented patient populations., Objectives: Assess clinical outcomes events and death in patients diagnosed with SARS-CoV-2 pneumonia compared to patients with other types of viral pneumonia., Methods: Retrospective cohort study evaluated electronic medical records in adult patients admitted to University of Illinois Hospital and Health Sciences System (UIHHSS) with primary diagnosis of SARS-CoV-2 PNA or other viral (H1N1 or H3N2) PNA between 10/01/2017 and 09/01/2020. Primary composite outcome was the following event incidence rates: death, ICU admission, infection, thrombotic complications, mechanical ventilation, renal replacement therapy, and major bleeding., Results: Of 257 patient records, 199 and 58 patients had SARS-CoV-2 PNA and other viral PNA, respectively. There was no difference in primary composite outcome. Thrombotic events (n = 6, 3%) occurred solely in SARS-CoV-2 PNA patients in the ICU. A significantly higher incidence of renal replacement therapy (8.5% vs 0%, p=0.016) and mortality (15.6% vs 3.4%, p=0.048) occurred in the SARS-CoV-2 PNA group. Multivariable logistic regression analysis revealed age, presence of SARS-CoV-2, and ICU admission, aOR 1.07, 11.37, and 41.95 respectively, was significantly associated with mortality risk during hospitalization; race and ethnicity were not., Conclusion: Low overall incidence of thrombotic events occurred only in the SARS-CoV-2 PNA group. SARS-CoV-2 PNA may lead to higher incidence of clinical events than those observed in H3N2/H1N1 viral pneumonia, and that race/ethnicity does not drive mortality outcomes., Competing Interests: Declaration of Competing Interest Scott Benken (CareDx, Eurofins, VericiDx, Daichii Sankyo, BMS, Velovis); none relevant to this publication; all authors have no conflicts of interest to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Assessment for risks associated with acute stable COVID-19 is important to optimize clinical trial enrollment and target patients for scarce therapeutics. To assess whether healthcare system engagement location is an independent predictor of outcomes we performed a secondary analysis of the ACTIV-4B Outpatient Thrombosis Prevention trial., Methods: A secondary analysis of the ACTIV-4B trial that was conducted at 52 US sites between September 2020 and August 2021. Participants were enrolled through acute unscheduled episodic care (AUEC) enrollment location (emergency department, or urgent care clinic visit) compared to minimal contact (MC) enrollment (electronic contact from test center lists of positive patients).We report the primary composite outcome of cardiopulmonary hospitalizations, symptomatic venous thromboembolism, myocardial infarction, stroke, transient ischemic attack, systemic arterial thromboembolism, or death among stable outpatients stratified by enrollment setting, AUEC versus MC. A propensity score for AUEC enrollment was created, and Cox proportional hazards regression with inverse probability weighting (IPW) was used to compare the primary outcome by enrollment location., Results: Among the 657 ACTIV-4B patients randomized, 533 (81.1%) with known enrollment setting data were included in this analysis, 227 from AUEC settings and 306 from MC settings. In a multivariate logistic regression model, time from COVID test, age, Black race, Hispanic ethnicity, and body mass index were associated with AUEC enrollment. Irrespective of trial treatment allocation, patients enrolled at an AUEC setting were 10-times more likely to suffer from the adjudicated primary outcome, 7.9% vs. 0.7%; p < 0.001, compared with patients enrolled at a MC setting. Upon Cox regression analysis adjustment patients enrolled at an AUEC setting remained at significant risk of the primary composite outcome, HR 3.40 (95% CI 1.46, 7.94)., Conclusions: Patients with clinically stable COVID-19 presenting to an AUEC enrollment setting represent a population at increased risk of arterial and venous thrombosis complications, hospitalization for cardiopulmonary events, or death, when adjusted for other risk factors, compared with patients enrolled at a MC setting. Future outpatient therapeutic trials and clinical therapeutic delivery programs of clinically stable COVID-19 patients may focus on inclusion of higher-risk patient populations from AUEC engagement locations., Trial Registration: ClinicalTrials.gov Identifier: NCT04498273., (© 2023. The Author(s).)

Background: Patients hospitalized with COVID-19 have an increased incidence of thromboembolism. The role of extended thromboprophylaxis after hospital discharge is unclear., Objective: To determine whether anticoagulation is superior to placebo in reducing death and thromboembolic complications among patients discharged after COVID-19 hospitalization., Design: Prospective, randomized, double-blind, placebo-controlled clinical trial. (ClinicalTrials.gov: NCT04650087)., Setting: Done during 2021 to 2022 among 127 U.S. hospitals., Participants: Adults aged 18 years or older hospitalized with COVID-19 for 48 hours or more and ready for discharge, excluding those with a requirement for, or contraindication to, anticoagulation., Intervention: 2.5 mg of apixaban versus placebo twice daily for 30 days., Measurements: The primary efficacy end point was a 30-day composite of death, arterial thromboembolism, and venous thromboembolism. The primary safety end points were 30-day major bleeding and clinically relevant nonmajor bleeding., Results: Enrollment was terminated early, after 1217 participants were randomly assigned, because of a lower than anticipated event rate and a declining rate of COVID-19 hospitalizations. Median age was 54 years, 50.4% were women, 26.5% were Black, and 16.7% were Hispanic; 30.7% had a World Health Organization severity score of 5 or greater, and 11.0% had an International Medical Prevention Registry on Venous Thromboembolism risk prediction score of greater than 4. Incidence of the primary end point was 2.13% (95% CI, 1.14 to 3.62) in the apixaban group and 2.31% (CI, 1.27 to 3.84) in the placebo group. Major bleeding occurred in 2 (0.4%) and 1 (0.2%) and clinically relevant nonmajor bleeding occurred in 3 (0.6%) and 6 (1.1%) apixaban-treated and placebo-treated participants, respectively. By day 30, thirty-six (3.0%) participants were lost to follow-up, and 8.5% of apixaban and 11.9% of placebo participants permanently discontinued the study drug treatment., Limitations: The introduction of SARS-CoV-2 vaccines decreased the risk for hospitalization and death. Study enrollment spanned the peaks of the Delta and Omicron variants in the United States, which influenced illness severity., Conclusion: The incidence of death or thromboembolism was low in this cohort of patients discharged after hospitalization with COVID-19. Because of early enrollment termination, the results were imprecise and the study was inconclusive., Primary Funding Source: National Institutes of Health.

Outpatient Trials in the Covid-19 Era and BeyondA group of investigators had a meeting at the National Heart, Lung, and Blood Institute in May 2020 to discuss ways to decrease thrombotic complications among symptomatic outpatients with Covid-19. The investigators discuss their approach to three specific challenges: conducting a trial remotely, working through regulatory hurdles, and recruiting a diverse population of participants.

Promoting childhood and adolescent health and long-term well-being requires an emphasis on preventative care and anticipatory guidance. In this review, the authors will focus on pertinent ear, nose, and throat preventative health in children, providing clinicians with relevant and succinct information to counsel children and their parents on the following essential subjects: foreign body aspiration and ingestion, upper respiratory infection prevention, noise exposure risks, aural hygiene, risks of primary and secondhand smoke exposure, and sleep hygiene., Competing Interests: Disclosure The authors have no conflicts of interest, no sponsorships, and no funding sources for this article., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: We aim to clarify the national scope of unmet pediatric hearing care needs and identify specific barriers to hearing care., Study Design: Cross-sectional study of a nationally representative data set., Setting: This study is based on the combined 2016 and 2017 National Survey of Children's Health. This survey covers the physical and emotional health, access to care, and social context of US children and adolescents aged 0 to 17 years., Methods: Analysis of parent-reported responses of children's hearing status, access to care, and perceived barriers., Results: Overall, 0.3% (n = 206,200) of US children surveyed reported needing hearing care, which was not received. A further 1.3% (n = 934,000) reported deafness or problems with hearing, and of these, 6.4% (n = 60,000) reported not receiving necessary hearing care. Rates of insurance coverage between children with deafness/hearing problems and the general population were similar (91.7% vs 93.9%); however, deaf or hard-of-hearing children with unmet hearing care needs were more likely to be from non-White backgrounds (P = .009) and to lack health insurance coverage (P = .001). Rates of unfulfilled hearing care by reason were as follows: 57.5% without eligibility for the service, 45.4% reporting the service was not available in their area, 53.7% with difficulty obtaining an appointment, and 53.5% reporting issues with cost., Conclusion: Over 200,000 children annually do not receive necessary hearing-related care despite high rates of insurance coverage, and nearly 60,000 of these children are deaf or hard of hearing. Cost, eligibility for and distribution of services, and timely appointments are the primary barriers to hearing health care.

Introduction: There is limited efficacy and safety data for direct oral anticoagulants (DOACs) in patients with obesity, and it has been suggested to avoid DOACs in this patient population., Objective: Describe the prescribing pattern of oral anticoagulants in obese patients in an urban university setting and assess efficacy, safety, and adherence., Methods: Retrospective, cohort study in patients ≥18 years with a history of VTE and/or atrial fibrillation. Patients with a BMI >40 kg/m 2 and/or weight >120 kilograms and a prescription for warfarin or a DOAC from August 25, 2014 until August 25, 2017 are included. The primary outcome is the number of warfarin or DOAC prescriptions. Secondary outcomes include thromboembolism and bleeding events. Patient adherence was evaluated using time in therapeutic range (TTR), adherence rate to clinic appointments, and medication possession ratio (MPR)., Results: Of the 276 patients who met eligibility criteria, 158 (57.2%) were prescribed warfarin and 118 (42.8%) were prescribed a DOAC. There was no difference in the rate of stroke or recurrent VTE between groups (3.2% vs. 3.4%, p = 0.944). There was also no difference in the rate of bleeding between groups (16.1% vs. 17.8%, p = 0.707). The TTR for the warfarin group was 44.8 ± 23%, and appointment adherence was 78.6 ± 20%. The MPR for the DOAC group was 0.93 ± 0.24., Conclusions: Despite limited data in obese patients, DOACs are prescribed in this population. Results suggest no difference in safety and efficacy compared to warfarin, but barriers to quality anticoagulation may exist in this population.

Background: Frontotemporal dementia (FTD) is a spectrum of diseases characterised by language, behavioural and motor symptoms. Among the different subcortical regions implicated in the FTD symptomatology, the hypothalamus regulates various bodily functions, including eating behaviours which are commonly present across the FTD spectrum. The pattern of specific hypothalamic involvement across the clinical, pathological, and genetic forms of FTD has yet to be fully investigated, and its possible associations with abnormal eating behaviours have yet to be fully explored., Methods: Using an automated segmentation tool for volumetric T1-weighted MR images, we measured hypothalamic regional volumes in a cohort of 439 patients with FTD (197 behavioural variant FTD [bvFTD]; 7 FTD with associated motor neurone disease [FTD-MND]; 99 semantic variant primary progressive aphasia [svPPA]; 117 non-fluent variant PPA [nfvPPA]; 19 PPA not otherwise specified [PPA-NOS]) and 118 age-matched controls. We compared volumes across the clinical, genetic (29 MAPT, 32 C9orf72, 23 GRN), and pathological diagnoses (61 tauopathy, 40 TDP-43opathy, 4 FUSopathy). We correlated the volumes with presence of abnormal eating behaviours assessed with the revised version of the Cambridge Behavioural Inventory (CBI-R)., Results: On average, FTD patients showed 14% smaller hypothalamic volumes than controls. The groups with the smallest hypothalamic regions were FTD-MND (20%), MAPT (25%) and FUS (33%), with differences mainly localised in the anterior and posterior regions. The inferior tuberal region was only significantly smaller in tauopathies (MAPT and Pick's disease) and in TDP-43 type C compared to controls and was the only regions that did not correlate with eating symptoms. PPA-NOS and nfvPPA were the groups with the least frequent eating behaviours and the least hypothalamic involvement., Conclusions: Abnormal hypothalamic volumes are present in all the FTD forms, but different hypothalamic regions might play a different role in the development of abnormal eating behavioural and metabolic symptoms. These findings might therefore help in the identification of different underlying pathological mechanisms, suggesting the potential use of hypothalamic imaging biomarkers and the research of potential therapeutic targets within the hypothalamic neuropeptides., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Chatbots are software applications to simulate a conversation with a person. The effectiveness of chatbots in facilitating the recruitment of study participants in research, specifically among racial and ethnic minorities, is unknown. The objective of this study is to compare a chatbot versus telephone-based recruitment in enrolling research participants from a predominantly minority patient population at an urban institution. We randomly allocated adults to receive either chatbot or telephone-based outreach regarding a study about vaccine hesitancy. The primary outcome was the proportion of participants who provided consent to participate in the study. In 935 participants, the proportion who answered contact attempts was significantly lower in the chatbot versus telephone group (absolute difference -21.8%; 95% confidence interval [CI] -27.0%, -16.5%; P < 0.001). The consent rate was also significantly lower in the chatbot group (absolute difference -3.4%; 95% CI -5.7%, -1.1%; P = 0.004). However, among participants who answered a contact attempt, the difference in consent rates was not significant. In conclusion, the consent rate was lower with chatbot compared to telephone-based outreach. The difference in consent rates was due to a lower proportion of participants in the chatbot group who answered a contact attempt., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Importance: Acutely ill inpatients with COVID-19 typically receive antithrombotic therapy, although the risks and benefits of this intervention among outpatients with COVID-19 have not been established., Objective: To assess whether anticoagulant or antiplatelet therapy can safely reduce major adverse cardiopulmonary outcomes among symptomatic but clinically stable outpatients with COVID-19., Design, Setting, and Participants: The ACTIV-4B Outpatient Thrombosis Prevention Trial was designed as a minimal-contact, adaptive, randomized, double-blind, placebo-controlled trial to compare anticoagulant and antiplatelet therapy among 7000 symptomatic but clinically stable outpatients with COVID-19. The trial was conducted at 52 US sites between September 2020 and June 2021; final follow-up was August 5, 2021. Prior to initiating treatment, participants were required to have platelet count greater than 100 000/mm3 and estimated glomerular filtration rate greater than 30 mL/min/1.73 m2., Interventions: Random allocation in a 1:1:1:1 ratio to aspirin (81 mg orally once daily; n = 164), prophylactic-dose apixaban (2.5 mg orally twice daily; n = 165), therapeutic-dose apixaban (5 mg orally twice daily; n = 164), or placebo (n = 164) for 45 days., Main Outcomes and Measures: The primary end point was a composite of all-cause mortality, symptomatic venous or arterial thromboembolism, myocardial infarction, stroke, or hospitalization for cardiovascular or pulmonary cause. The primary analyses for efficacy and bleeding events were limited to participants who took at least 1 dose of trial medication., Results: On June 18, 2021, the trial data and safety monitoring board recommended early termination because of lower than anticipated event rates; at that time, 657 symptomatic outpatients with COVID-19 had been randomized (median age, 54 years [IQR, 46-59]; 59% women). The median times from diagnosis to randomization and from randomization to initiation of study treatment were 7 days and 3 days, respectively. Twenty-two randomized participants (3.3%) were hospitalized for COVID-19 prior to initiating treatment. Among the 558 patients who initiated treatment, the adjudicated primary composite end point occurred in 1 patient (0.7%) in the aspirin group, 1 patient (0.7%) in the 2.5-mg apixaban group, 2 patients (1.4%) in the 5-mg apixaban group, and 1 patient (0.7%) in the placebo group. The risk differences compared with placebo for the primary end point were 0.0% (95% CI not calculable) in the aspirin group, 0.7% (95% CI, -2.1% to 4.1%) in the 2.5-mg apixaban group, and 1.4% (95% CI, -1.5% to 5.0%) in the 5-mg apixaban group. Risk differences compared with placebo for bleeding events were 2.0% (95% CI, -2.7% to 6.8%), 4.5% (95% CI, -0.7% to 10.2%), and 6.9% (95% CI, 1.4% to 12.9%) among participants who initiated therapy in the aspirin, prophylactic apixaban, and therapeutic apixaban groups, respectively, although none were major. Findings inclusive of all randomized patients were similar., Conclusions and Relevance: Among symptomatic clinically stable outpatients with COVID-19, treatment with aspirin or apixaban compared with placebo did not reduce the rate of a composite clinical outcome. However, the study was terminated after enrollment of 9% of participants because of an event rate lower than anticipated., Trial Registration: ClinicalTrials.gov Identifier: NCT04498273.

Objectives: To understand national trends in 30-day postoperative readmission following inpatient pediatric tonsillectomy and adenoidectomy., Study Design: Retrospective cohort study., Setting: Nationwide Readmissions Database., Methods: We used the Nationwide Readmissions Database to identify and analyze 30-day readmissions following inpatient tonsillectomy from 2010 to 2015. Using the International Classification of Disease codes, we identified 66,652 patients and analyzed the incidence, causes, risk factors, and costs of 30-day readmission., Results: Of 66,652 patients who underwent inpatient tonsillectomy, 2660 (4.0%) experienced a readmission. Readmitted patients were more commonly aged <2 years (23.4 vs 10.6%, P = .01) and had a greater burden of comorbidities, including preoperative anemia (3.9 vs 1.3%, P < .001), coagulopathy (3.5 vs 1.4%, P < .001), and neurologic disorders (19.1 vs 6.6%, P < .001). Readmitted patients experienced higher rates of postoperative complications (17.4 vs 9.0%, P < .001) and had a longer length of stay (4.5 vs 2.2 days, P < .001). Index cost of hospitalization was higher among readmitted patients ($14,129 vs $7307, P < .001), and each readmission cost an additional $7576. Postoperative hemorrhage (21.3%) and dehydration (17.7%) were the 2 most common causes for readmission. Independent predictors of readmission included age <3 years, multiple comorbidities, and postoperative neurologic complications. The incidences of tonsillectomies and readmissions declined during the study period, most notably between 2010 and 2012., Conclusion: Readmission after inpatient tonsillectomy and adenoidectomy places a substantial financial burden on the health care system. Targeted strategies to improve preoperative assessment and optimize postoperative care may prevent readmission, reduce unnecessary health care expenditures, and improve patient outcomes.

Recent health reforms have created incentives for cardiologists and accountable care organizations to participate in value-based care models for heart failure (HF). Accurate risk stratification of HF patients is critical to efficiently deploy interventions aimed at reducing preventable utilization. The goal of this paper was to compare deep learning approaches with traditional logistic regression (LR) to predict preventable utilization among HF patients. We conducted a prognostic study using data on 93,260 HF patients continuously enrolled for 2-years in a large U.S. commercial insurer to develop and validate prediction models for three outcomes of interest: preventable hospitalizations, preventable emergency department (ED) visits, and preventable costs. Patients were split into training, validation, and testing samples. Outcomes were modeled using traditional and enhanced LR and compared to gradient boosting model and deep learning models using sequential and non-sequential inputs. Evaluation metrics included precision (positive predictive value) at k, cost capture, and Area Under the Receiver operating characteristic (AUROC). Deep learning models consistently outperformed LR for all three outcomes with respect to the chosen evaluation metrics. Precision at 1% for preventable hospitalizations was 43% for deep learning compared to 30% for enhanced LR. Precision at 1% for preventable ED visits was 39% for deep learning compared to 33% for enhanced LR. For preventable cost, cost capture at 1% was 30% for sequential deep learning, compared to 18% for enhanced LR. The highest AUROCs for deep learning were 0.778, 0.681 and 0.727, respectively. These results offer a promising approach to identify patients for targeted interventions.

Purpose: Coronavirus disease 2019 (COVID-19) has been associated with thrombotic complications such as stroke and venous thromboembolism (VTE), and VTE prophylaxis for hospitalized patients with COVID-19 is recommended. However, extended postdischarge VTE prophylaxis and VTE prophylaxis for nonhospitalized patients with COVID-19 are not routinely recommended due to uncertain benefit in these populations., Summary: Here we report development of a pulmonary embolism (PE) in a young patient without other VTE risk factors who was treated for COVID-19 in an emergency department (ED) and discharged home without VTE prophylaxis, which was consistent with current recommendations. The patient presented to the ED 12 days later with complaints of chest pain for 1 day and was found to have a PE within the segmental and subsegmental branches of the left lower lobe., Conclusion: This case suggests that nonhospitalized patients with COVID-19 may be at higher risk for VTE than patients with other medical illnesses and warrants further research into the risk of VTE in outpatients with COVID-19., (© American Society of Health-System Pharmacists 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: How and when to monitor direct oral anticoagulants (DOACs) for safety and efficacy is a question many anticoagulation clinics are trying to answer. A pharmacist-led antithrombosis clinic (ATC) initiated a clinical service to provide oversight for all prescribed DOACs., Objective: Describe the implementation and outcomes of a DOAC screening service., Methods: The service was initiated utilizing a daily electronic prescribing report of DOAC prescriptions. Prescriptions were reviewed by clinical pharmacists to assess patient insurance, eligibility, and accuracy of prescribed doses., Results: In the first year since service implementation in April 2016, 317 new prescriptions and 595 refill prescriptions were reviewed. A DOAC service pharmacist was able to reach 125 (39.4%) of 317 patients about their new prescription and 59 (9.9%) of 595 refill patients to provide education and follow-up on management as needed. Interventions were performed for 79 (28%) of 317 new prescriptions and 86 (14.5%) of 595 refill prescriptions. Common interventions with new prescriptions include contacting the prescriber for a medication or dose change (25.4%), assistance with medication access (21.5%), and coordinating appropriate lab and provider follow up (21.5%). Common interventions with refill prescriptions include recommending appropriate follow-up (50%) and contacting the prescriber for medication or dosage change (24.4%)., Conclusion: Implementation of a DOAC screening service identified and resolved dosing errors, improved medication access, provided patient education, and improved follow-up.

Objective: To present a novel approach for the emergent, pre-hospital management of life-threatening aerodigestive tract foreign body aspiration using a portable, non-powered, suction-generating device (PNSD), in the context of a literature review of emergent pre-hospital management of patients with foreign body airway obstruction., Methods: The PubMed and MEDLINE databases were comprehensively screened using broad search terms. A literature review of pre-hospital management and resuscitative techniques of foreign body airway obstruction was performed. Further, independent measurements of PNSD pressure generation were obtained. Application of a PNSD in cadaveric and simulation models were reviewed. A comparative analysis between a PNSD and other resuscitative techniques was performed., Results: Physiologic data from adult and pediatric human, non-human, and simulation studies show pressure generation ranging from 5.4 to 179 cm H 2 O using well-established resuscitative maneuvers. Laboratory testing demonstrated that a protypic PNSD demonstrated peak airway pressures of 434.23 ± 12.35 cm H 2 O. A simulation study of a PNSD demonstrated 94% reliability in retrieving airway foreign body, while a similar cadaveric study demonstrated 98% reliability, with both studies approaching 100% success rate after multiple attempts. Several case reports have also shown successful application of PNSD in the emergent management of airway foreign body in elderly and disabled patients., Conclusion: PNSDs may play an important role in the emergent, non-operative, pre-hospital management of upper aerodigestive tract foreign body aspiration, particularly in settings and populations with high choking risk. Further characterization of effectiveness and safety in larger cadaveric or simulation studies mimicking physiologic conditions is indicated., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Direct oral anticoagulants (DOACs) are not recommended for venous thromboembolism (VTE) treatment in patients with cancer because their safety and efficacy have not been compared to low molecular weight heparin (LMWH) in large trials. Routine anti-Xa monitoring in cancer patients on LMWH is also not recommended due to limited data correlating anti-Xa levels and outcomes., Objective: Compare the safety and efficacy of DOACs to LMWH and warfarin and assess the relationship of anti-Xa monitoring and outcomes in patients with cancer taking LMWH in an urban university setting., Methods: This retrospective, cohort study analyzed the recurrence of VTE and number of bleeding events in patients with cancer., Results: There were 131 patients included in the analysis. There was no difference seen in the rate of recurrent VTEs between the LMWH, warfarin and DOAC groups (9.3%, 5.9%, 9.1%, p = 0.89). There was also no difference in the rate of bleeding between groups (10.5%, 14.7%, 9.1%, p = 0.576). There was an increased rate of mortality seen in the LMWH group (26.7% vs. 2.9% vs. 18.2%, p = 0.006). There was no difference seen in recurrent VTE (10.3% vs. 8.5%, p = 0.53) or bleeding (10.3% vs. 10.7%, p = 0.661) between the monitored and unmonitored LMWH patients., Conclusion: Results of this analysis suggest DOACs may be as safe and effective as LMWH and warfarin for the treatment of VTE in patients with cancer, and there may be no clinical benefit to routine anti-Xa monitoring in patients on LMWH treatment. However, larger studies are needed to confirm these observations.

Objective: Determine if demographic disparities exist between the diagnosis of otitis media (OM) and the provision of myringotomy and tubes in children., Study Design: Cross-sectional analysis of a national database., Methods: The National Ambulatory Medical Care Survey 2010 and the National Hospital Ambulatory Medical Care Survey-Ambulatory Surgery 2010 were abstracted for cases with a diagnosis of OM and myringotomy and tube (MT) procedures in children, respectively. Sex, race, ethnic, and insurance distributions were computed for OM and MT and then compared for healthcare disparities between rates of OM diagnoses and MT procedures., Results: A total of 13.6 million ambulatory pediatric OM diagnoses were identified in 2010 (55.9% male; 82.4% white, 11.3% black, and 6.3% other; 14.3% Hispanic, 85.7% non-Hispanic). A total of 413 thousand ambulatory myringotomy procedures were identified (59.6% male; 86.0% white, 11.0% black, and 3.0% other; 13.0% Hispanic, 87.0% non-Hispanic). There was no statistically significant difference in the provision of MT versus OM diagnosis according to sex (P = 0.400), race (P = 0.313), or ethnicity (P = 0.228). There was also no statistically significant difference in the percentage of Medicaid coverage for OM children (37.0%) versus those undergoing MT (31.1%; P = 0.376). There does, however, appear to be a statistically higher percentage of non-Hispanic children being diagnosed with otitis media than Hispanic children (P = 0.049)., Conclusion: There were no significant demographic differences in the incidence of children with OM undergoing MT with respect to sex, race, ethnicity, or insurance status. As a specialty, otolaryngology does not appear to exhibit any disparate healthcare access bias in providing MT to children with OM., Level of Evidence: NA Laryngoscope, 128:2898-2901, 2018., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Children undergoing tracheotomy represent a medically vulnerable patient population, and understanding the reasons for revisiting the hospital setting following tracheotomy is critical for improving the quality of care for these patients. This study aims to investigate the incidence and characteristics of revisits following pediatric tracheotomy., Methods: Cross-sectional, population-based study using state databases. The State Inpatient Databases and State Emergency Department Databases for California, Florida, Iowa and New York 2010-11 were linked and examined for cases of pediatric tracheotomy (patients < 18.0 years) and corresponding subsequent 30-day post-discharge revisits. Demographic and descriptive data were analyzed determining the revisit rate, revisit diagnoses, procedures, and discharge dispositions., Results: 2,248 pediatric tracheotomy cases were extracted (60.8% male, mean age 8.3 years). There were 373 inpatient or emergency department revisits (30-day revisit rate, 16.6%), of which 34.3% occurred within 48 h after discharge. Of these, 59.2% were inpatient readmissions. There were ≤10 deaths during these revisits (30-day revisit mortality rate, ≤2.7%). The most common primary revisit diagnoses were "fitting of prosthesis and adjustment of devices" (25.7%, likely representing adjustment/replacement of the tracheotomy tube), respiratory failure (11.0%), intracranial injury (5.4%), pneumonia (4.0%), "other upper respiratory disease" (3.8%), and "complications of surgical procedures or medical care" (3.8%). The most common revisit procedures were endotracheal intubation (11.4%), mechanical ventilation (8.8%), and replacement of tracheostomy tube (≤2.7%). Children discharged to a skilled care facility (47.1%) were more likely than those discharged to home (52.9%) to have a revisit (23.3% versus 12.0%, respectively; p < 0.001)., Conclusions: Children undergoing tracheotomy have a substantial 30-day revisit rate, most notably during the first 48 h after discharge, often involving tracheotomy tube or pulmonary complications. Improvements in discharge planning should target prevention of these complications., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: Investigate the epidemiological characteristics of pediatric epistaxis in the emergency department setting., Study Design: Cross-sectional study using national databases., Methods: Children (age <18 years) presenting with a diagnosis of epistaxis were extracted from the State Emergency Department Databases for New York, Florida, Iowa, and California for the calendar year 2010. Associated diagnoses, procedures, encounter characteristics, and demographic data were examined., Results: There were 18,745 cases of pediatric epistaxis (mean age 7.54 years, 57.4% male). Overall, 6.9% of patients underwent procedures to control epistaxis, of which 93.5% had simple anterior epistaxis control. The distribution of pediatric epistaxis was highest in spring and summer months (p < 0.001). Children from the lowest income quartile comprised a higher proportion of epistaxis presentations (38.8%, p < 0.001), yet were least likely to have an epistaxis control procedure performed (p < 0.001). Most patients had either Medicaid (43.8%) or private insurance (41.3%). Patients with Medicaid and those without healthcare coverage were least likely to undergo an epistaxis control procedure (p < 0.001). White children were more likely to undergo an epistaxis control procedure compared to those of minority backgrounds (p < 0.001)., Conclusions: Most emergency department presentations of pediatric epistaxis are uninvolved cases that do not require procedural intervention. The overrepresentation of low socioeconomic status patients may suggest an overutilization of emergency services for minor cases of epistaxis, and perhaps a lack of access to primary care providers. This is the first study to evaluate racial and socioeconomic factors in relationship to pediatric epistaxis. Further investigation is needed to better elucidate these potential disparities., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: The proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors alirocumab and evolocumab were approved by the FDA in 2015. In anticipation of provider interest and a potential increase in referrals to the on-site specialty pharmacy, we created a pharmacist-managed consultation service., Program Description: The development of a clinic-based pharmacist-managed consultation service for the management of the PCSK9 inhibitor agents alirocumab and evolocumab is described. Key implementation steps included (a) creation of a pharmacy team and collaboration with cardiology; (b) completion of a needs assessment; (c) service creation; (d) collaboration with the on-site specialty pharmacy; (e) development of an electronic consult order and consult pool; (f) personnel training; and (g) service approval and marketing. The service development occurred over 9 months (July 2015-April 2016) and was implemented hospital-wide in May 2016., Observations: The University of Illinois Hospital and Health Sciences System PCSK9 inhibitor consultation service successfully integrated the benefits of a clinical review process, information technology capabilities of an electronic medical record system, and collaboration with the on-site specialty pharmacy to provide a comprehensive service that aimed to facilitate appropriate medication management from prescribing to patient administration and provide monitoring for this class of specialty medications., Implications/recommendations: The PCSK9 pharmacist-managed consultation service provides a method for complex therapies to be managed comprehensively through the collaboration of ambulatory care clinics and outpatient specialty pharmacies., Disclosures: No outside funding supported this study. Groo reports speaker bureau fees from Pfizer and Bristol-Myers Squibb. The other authors have nothing to disclose. All the authors contributed to study concept and design. Atande took the lead in data collection, and data interpretation was performed by Groo and Atanda. The manuscript was written by Atanda and revised by all the authors.

Objectives/hypothesis: Determine the national incidence and disparities for common pediatric otolaryngologic conditions., Study Design: Cross-sectional analysis of a nationally representative database., Methods: The National Health Interview Survey (2012) was analyzed, extracting children with frequent ear infections (FEI), nonstreptococcal sore throat (NSST), streptococcal pharyngitis (SP), hay fever, and sinusitis. Demographic data including age, sex, race, Hispanic ethnicity, geographic region, poverty level, and insurance status were extracted. The annual incidences of these conditions were determined. Disparities in the incidence of each condition was determined according to race and ethnicity, adjusting for other demographic variables., Results: Among 73.3 million children (average age, 8.6 years; 51.1% male), the incidences were: FEI (4.0 million, 5.5% of children), NSST (11.9 million, 20.6% of children), SP (8.0 million, 13.8% of children), hay fever (6.6 million, 9.0% of children), and sinusitis (4.5 million, 7.9% of children). Black and Hispanic children were less likely to be diagnosed with FEI than white children (odds ratio: 0.503 [95% confidence interval: 0.369-0.686] and odds ratio: 0.661 [95% confidence interval: 0.515-0.848]), adjusting for all other demographic variables. Black and Hispanic children were also less likely to be diagnosed with SP than white children (odds ratio: 0.433 [95% confidence interval: 0.342-0.547] and odds ratio: 0.487 [95% confidence interval: 0.401-0.592], respectively). Similar decreased odds ratios for black and Hispanic children were evident for hay fever (odds ratio: 0.704 [95% confidence interval: 0.556-0.890] and odds ratio: 0.708 [95% confidence interval: 0.565-0.888], respectively) and for sinusitis (odds ratio: 0.701 [95% confidence interval: 0.543-0.905] and odds ratio: 0.596 [95% confidence interval:0.459-0.773], respectively)., Conclusions: Black and Hispanic children are consistently less likely to be identified or diagnosed with FEI, hay fever, SP, and sinusitis compared to white children. These data likely highlight a significant health care disparity according to race/ethnicity in otolaryngology., Level of Evidence: 2b Laryngoscope, 127:746-752, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Upper-extremity deep-vein thrombosis (UEDVT) causes significant morbidity and mortality and is not well characterized in the existing literature, particularly in underrepresented minorities such as African Americans., Objective: To describe the characteristics of a cohort of patients with UEDVT seen at an urban academic medical center., Methods: This was a retrospective cohort study among patients with a confirmed UEDVT at the University of Illinois Hospital and Health Sciences System between 1996 and 2011. Patients were identified by ICD-9 code for UEDVT. Variables collected include thrombotic risk factors and outcomes, including recurrent thrombosis and bleeding., Results: We identified 229 patients with UEDVT; 71% were African American, and 11% were diagnosed with sickle cell disease. The average number of UEDVT risk factors was 4.40 ± 1.5, the most common being central venous catheter (CVC) use (178, 78%). In the year following UEDVT, 13% experienced recurrent thrombosis, and 6% experienced major bleeding. Of 181 patients receiving warfarin after an UEDVT, 36% of international normalized ratio (INR) values were therapeutic. Patients with sickle cell disease had a lower proportion of INRs within the target range (25% vs 38%, P < 0.01), and were more likely to be lost to follow-up (67% vs 46%, P = 0.05) and experience a recurrent thrombotic event (29% vs 11%, P = 0.02)., Conclusion: A CVC is the most common risk factor for UEDVT; however, patients with sickle cell disease demonstrate additional unique demographics and risk factors. Patients included in this underrepresented demographic cohort had a low quality of anticoagulation control, particularly those with sickle cell disease., (© The Author(s) 2016.)

With the increased focus and anticipated growth in specialty training and certification within the profession of pharmacy, it is important for the profession to step back and evaluate the manner in which its adopted education and certification systems interface. As a result of specialty practice development, significant growth is occurring in both postgraduate year two (PGY2) pharmacy residency programs and individuals seeking certification by the Board of Pharmacy Specialties. As the profession continues to evolve its specialty training and credentialing systems, it is important to consider the inherent relationship between these systems. This paper considers the current landscape of specialty training and certification, including issues related to the quality of PGY2 training, consistent application of standards across and within PGY2 programs, credentialing of preceptors and program directors, and alignment of training with specialty certification examination content domains. We outline recommendations across three areas: (1) creating consistency between specialty training and certification, (2) aligning qualifications of PGY2 residency program directors and preceptors with the designated specialty area, and (3) assessing program quality in the context of the expectations of specialists established by the profession. The goal of this paper is to stimulate professional dialogue on these issues. Establishing both formal and informal connections between specialty training and certification can serve as the foundation for a rational approach to professional development and the credentialing that will be recognized by stakeholders outside the pharmacy profession. Establishing these connections will also support and advance the profession's mission of meeting the medication needs of patients., (© 2016 Pharmacotherapy Publications, Inc.)

Importance: Pediatric adenotonsillectomy is one of the most frequently performed procedures in the United States. Whereas several studies have focused on tonsillectomy techniques and outcomes, little is known about the overall changes in the distribution of care. Variations in care patterns between academic and nonacademic settings may have important financial and educational effects., Objective: To determine whether regionalization of inpatient pediatric adenotonsillectomy has occurred over the past decade with respect to hospital teaching status and primary expected payer., Design, Setting, and Participants: Secondary analysis of all inpatient admissions following pediatric adenotonsillectomy (age <18 years) in the Nationwide Inpatient Sample during the calendar years 2000, 2005, and 2010., Exposure: Inpatient pediatric tonsillectomy., Main Outcomes and Measures: The percentage distributions of pediatric adenotonsillectomies with respect to hospital teaching status and primary payer were compared according to calendar year to determine temporal changes. Multivariate analysis was conducted with logistic regression to determine year-to-year changes in the proportion of pediatric adenotonsillectomy admissions, controlling for hospital teaching status and expected source of payment., Results: The estimated numbers of inpatient hospital pediatric adenotonsillectomy stays in the United States in 2000, 2005, and 2010 were 12 879 (SE, 1695), 17 245 (SE, 2276), and 13 732 (SE, 2082), respectively. There was a significant increase in the proportion of children admitted to academic hospitals from 60.1% to 69.8% to 78.6%, respectively (P = .045). With respect to teaching hospitals, the primary expected payer distribution shifted significantly, with an increase in Medicaid recipients from 38.4% to 38.9% to 50.5%, and a decline in private insurance from 57.7% to 51.5% to 43.9% (P = .02)., Conclusions and Relevance: Inpatient pediatric adenotonsillectomies are increasingly being regionalized to academic/teaching hospitals. Concurrently, the proportion of patients using Medicaid as the primary payer has increased for inpatient tonsillectomies in teaching hospitals. Such regionalization has important implications for health care reimbursement and distribution of care.

Pulmonary embolism (PE), can be life-threatening without rapid appropriate therapy and often leads to chronic disease and disability. The ambiguity of symptoms makes PE difficult to diagnose, and available imaging strategies have their limitations. Treatment options for acute PE include fibrinolytics, surgical embolectomy, catheter-directed treatment, or vena cava filter placement as well as traditional parenteral anticoagulants, used alone or as a bridge to a vitamin K antagonist (VKA). The direct oral anticoagulants (DOACs) rivaroxaban and apixaban allow for single drug therapy, eliminating the need for initial parenteral anticoagulation, while dabigatran and edoxaban are initiated after a short course of parenteral therapy. The DOACs serve as a viable alternative to warfarin for chronic management for PE. Pulmonary embolism provoked from transient risk factors often requires a short-term course of anticoagulation (3 months). Unprovoked events, and those that occur in the presence of continuing risk factors such as cancer, or clinical markers such as residual vein thrombosis and elevated d-dimers can predict a higher risk of recurrent events and warrant extended anticoagulation. This review evaluates current recommendations for the treatment of PE, including dosing strategies, duration of therapy, and special populations such as renal impairment, malignancy, and obesity., (© The Author(s) 2015.)

Objective: To determine the prevalence and healthcare costs associated with the diagnosis and treatment of acute and chronic tonsillar conditions (ACT) in children., Design: Cross-sectional analysis of the 2006, 2008, and 2010 Medical Expenditure Panel Surveys., Methods: Pediatric patients (age < 18 years) were examined from the above mentioned database. From the linked medical conditions file, cases with a diagnosis of ACT were extracted. Ambulatory visit rates, prescription refills, and ambulatory healthcare costs were then compared between children with and without a diagnosis of ACT and acute versus chronic tonsillitis, with multivariate adjustment for age, sex, ethnicity, region, insurance coverage and comorbid conditions (e.g., asthma and otitis media)., Results: A total of 74.3 million children (mean age 8.55 years, 51% male) were sampled (raw N = 28,873). Of these, 804,229 children (1.1 ± 0.1%) were diagnosed with ACT annually (mean age 7.24 years, 49.1% male); 64.6 ± 2.0% had acute tonsillitis diagnoses and 35.4 ± 2.0% suffered from chronic tonsillitis. Children with ACT incurred an additional 2.3 office visits and 2.1 prescription fills (both p < 0.001) annually compared with those without ACT, adjusting for demographic variables and medical comorbidities, but did not have an increase in emergency department visits (p = 0.123). Children with acute tonsillar diagnoses carried total healthcare expenditures of $1303 ± 390 annually versus $2401 ± 618 for those with chronic tonsillitis (p = 0.193). ACT was associated with an incremental increase in total healthcare expense of $1685 per child, annually (p < 0.001)., Conclusion: The diagnosis of ACT confers a significant incremental healthcare utilization and healthcare cost burden on children, parents and the healthcare system. With its prevalence in the United States, pediatric tonsillitis accounts for approximately $1.355 billion in incremental healthcare expense and is a significant healthcare utilization concern., Level of Evidence: 2C., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objectives/hypothesis: Investigate the incidence and characteristics of revisits following ambulatory pediatric tonsillectomy/adenotonsillectomy., Study Design: Cross-sectional study using national databases., Methods: Ambulatory pediatric (age <18.0 years) tonsillectomy or adenotonsillectomy cases were extracted from the 2010 State Ambulatory Surgery, Emergency Department, and Inpatient databases for New York, Florida, Iowa, and California. First and second revisits within the 14-day postoperative period were tabulated. Diagnoses, procedure codes, and mortality were examined., Results: There were 36,221 pediatric tonsillectomies/adenotonsillectomies (mean age 7.4 years, 51.4% male). Overall, 2,740 patients (7.6%) had a revisit after pediatric tonsillectomy; 402 patients (1.1%) had a second revisit. Among revisits, 6.3% revisited the ambulatory surgery center, 77.5% revisited the emergency department, and 16.2% were readmitted as an inpatient. Among all tonsillectomies, bleeding occurred in 2.0% and 0.5% within the first and second revisits, respectively. A second revisit had a statistically higher association with a primary bleeding diagnosis than the first revisit (P < .001). Among all cases, 0.75% underwent a surgical procedure for bleeding at a first revisit compared to 0.25% during a second revisit. Acute pain was the primary diagnosis in 18.4% and 11.2% of first and second revisits; fever/vomiting/dehydration were primary diagnoses in 28.2% and 17.9%, respectively. There were two mortalities (0.0055%) within the 14-day postoperative interval., Conclusions: This large-scale analysis describes the current rates and diagnoses of revisits, hospital readmission, and surgical intervention following ambulatory pediatric tonsillectomy. Many revisits centered on pain control and dehydration, suggesting that more adequate symptom control may prevent a large proportion of revisits., Level of Evidence: 2b., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To determine if disparities exist for revisits and complications after pediatric tonsillectomy., Study Design: Cross-sectional analysis of multistate databases., Setting: Ambulatory surgery., Methods: Cases of pediatric tonsillectomy with or without adenoidectomy were extracted from state ambulatory surgery databases and linked to state emergency department databases and inpatient databases for California, Iowa, Florida, and New York for 2010 and 2011. Revisit rates and diagnoses within 14 days were analyzed for potential associations of these complications with sex, race, and median household income quartile., Results: There were 79,520 cases of pediatric tonsillectomy that were extracted (50.3% male; mean age, 7.5 years). Overall, 6419 patients (8.1%) incurred a revisit after the procedure. Revisit rates for posttonsillectomy bleeding, acute pain, and fever/dehydration were 2.1%, 1.5%, and 2.2%, respectively. On multivariate analysis, increasing household income quartile was significantly associated with a decreasing rate of all complications: revisits (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.84-0.89), posttonsillectomy bleeding (OR, 0.91; 95% CI, 0.86-0.96), acute pain (OR, 0.79; 95% CI, 0.74-0.84), and fever/dehydration (OR, 0.93; 95% CI, 0.89-0.98). Female sex was associated with a decreased rate of posttonsillectomy hemorrhaging (OR, 0.81; 95% CI, 0.73-0.91). Black and Hispanic children had an increased risk for a revisit after tonsillectomy (OR, 1.11; 95% CI, 1.01-1.22; and OR, 1.17; 95% CI, 1.09-1.26, respectively) and increased odds for acute pain at the revisit (OR, 1.36; 95% CI, 1.10-1.67; and OR, 1.34; 95% CI, 1.14-1.57, respectively) relative to white children. Race was not associated with the rate of hemorrhage posttonsillectomy., Conclusion: Significant disparities, particularly with respect to household income, exist in the incidence of revisits and complications after pediatric tonsillectomy. The disparate burden of increased revisits and acute pain diagnoses after tonsillectomy deserve further attention., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.)

Study Objectives: To characterize the balance of clinical and academic responsibilities of clinical track pharmacy faculty in the United States and evaluate organizational structures that promote satisfactory balance between these responsibilities., Design: Prospective cross-sectional survey., Setting: A 22-item online survey was developed and distributed via Qualtrics software., Participants: Clinical faculty members of the American College of Clinical Pharmacy Adult Medicine, Ambulatory Care, Cardiology, Critical Care, Gastrointestinal/Liver/Nutrition, Immunology/Transplantation, Infectious Disease, and Pediatrics Practice and Research Networks (PRNs) were invited to participate via the PRN electronic mailing list., Measurements and Main Results: The survey comprised questions related to demographics, organizational structure, and balance of clinical and academic responsibilities. A total of 344 participants responded to some or all of the survey questions. The demographics were relatively equally balanced between faculty at state and private academic institutions, academic rank, and practice setting. Expected and actual effort allocations were similar for each of the clinical and academic responsibilities, with direct patient care and clinical teaching representing more than 50% effort allocation cumulatively. Clinical faculty at state institutions devoted a larger proportion of time to clinical service, whereas clinical faculty at private institutions devoted a greater proportion of time to didactic teaching. When asked about time constraints, 157 (69.8%) of the 225 survey participants responding to this question did not believe they had sufficient time to fulfill their nonclinical academic needs. Clinical faculty who were provided "protected time" away from clinical service had a significantly more favorable opinion of this question., Conclusion: Most of the clinical track pharmacy faculty indicated that they have insufficient time to fulfill their nonclinical academic responsibilities. Provision of protected time may alleviate some of these time constraints., (© 2014 Pharmacotherapy Publications, Inc.)

Objectives/hypothesis: To evaluate the postoperative course of children who underwent coblation T&A versus those who underwent coblation partial intracapsular tonsillectomy and adenoidectomy (PITA)., Study Design: Retrospective cohort study., Methods: Records of children undergoing consecutive tonsillectomies from July 2009 to October 2012 were analyzed. All surgeries used a coblation device. Outcomes including intraoperative and postoperative bleeding, pain, and return to preoperative diet were analyzed comparing the coblation T&A and coblation PITA patients., Results: Of 415 patients evaluated, 258 (62.2%) underwent coblation T&A and 157 (37.8%) underwent coblation PITA. Seventeen (4.1%) patients experienced postoperative hemorrhage, 15 (88.2%) of whom underwent T&A and two (11.8%) of whom underwent PITA (P = 0.024). Multivariate analysis demonstrated that coblation T&A was a significant contributor to postoperative hemorrhage, with an odds ratio of 4.8 (95% confidence interval [CI]: 1.08-21.21) compared to coblation PITA. Patients who underwent T&A resumed normal diets significantly later (8 days, SD 4.6) than those who underwent PITA (5.4 days, standard deviation [SD]: 3.4) (P = 0.022). In terms of pain severity, more T&A patients reported "severe" pain and more PITA patients reported "moderate" pain (P = 0.047). More T&A patients experienced a "post-op dip," defined as increased pain during postoperative days 5-9, than did PITA patients (P < 0.001)., Conclusions: Coblation PITA is a safe procedure that has a lower incidence of intraoperative and postoperative bleeding in children compared to coblation T&A. Patients may have less pain and return to preoperative diets sooner than those undergoing coblation T&A., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Epstein-Barr virus (EBV) infection is a potential precursor of post-transplantation lymphoproliferative disorder (PTLD) in the pediatric transplant patient. Positron-emission tomography (PET) imaging is increasingly utilized in this population to monitor for neoplasia and PTLD. We assess the association between EBV serum titers and Waldeyer's ring and cervical lymph node PET positivity in the pediatric transplant recipient., Study Design: Retrospective analysis of EBV serology and PET imaging results in pediatric orthotopic liver transplantation (OLT) recipients., Methods: Imaging results and laboratory data were reviewed for all pediatric OLT recipients from January 2005 to July 2011 at a single institution. Charts were evaluated for PET positivity at Waldeyer's ring or cervical lymphatics, and for EBV serology results. Demographic data extracted include patient sex and age at transplantation., Results: A total of 122 pediatric OLT recipients were reviewed. Twelve patients (10%) underwent PET imaging. Overall, four patients (33%) had evidence of PET positivity at Waldeyer's ring or cervical lymphatics. Five patients (42%) had positive EBV serology. There was a significant association between PET imaging results and EBV DNA serology results (P = .01)., Conclusions: PTLD surveillance in the pediatric transplant recipient is an important component of long-term care in this population. Although PET imaging is a new modality in monitoring pediatric transplant recipients for early signs of PTLD, an association between EBV serology and PET imaging results appears to exist. With increased implementation, PET imaging will likely prove valuable in its ability to monitor the transplant recipient at risk for PTLD., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Determine the incremental health care costs associated with the diagnosis and treatment of acute otitis media (AOM) in children., Study Design: Cross-sectional analysis of a national health-care cost database., Methods: Pediatric patients (age < 18 years) were examined from the 2009 Medical Expenditure Panel Survey. From the linked medical conditions file, cases with a diagnosis of AOM were extracted, along with comorbid conditions. Ambulatory visit rates, prescription refills, and ambulatory health care costs were then compared between children with and without a diagnosis of AOM, adjusting for age, sex, region, race, ethnicity, insurance coverage, and Charlson comorbidity Index., Results: A total of 8.7 ± 0.4 million children were diagnosed with AOM (10.7 ± 0.4% annually, mean age 5.3 years, 51.3% male) among 81.5 ± 2.3 million children sampled (mean age 8.9 years, 51.3% male). Children with AOM manifested an additional +2.0 office visits, +0.2 emergency department visits, and +1.6 prescription fills (all P <0.001) per year versus those without AOM, adjusting for demographics and medical comorbidities. Similarly, AOM was associated with an incremental increase in outpatient health care costs of $314 per child annually (P <0.001) and an increase of $17 in patient medication costs (P <0.001), but was not associated with an increase in total prescription expenses ($13, P = 0.766)., Conclusions: The diagnosis of AOM confers a significant incremental health-care utilization burden on both patients and the health care system. With its high prevalence across the United States, pediatric AOM accounts for approximately $2.88 billion in added health care expense annually and is a significant health-care utilization concern., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To review the literature on pediatric food choking risks, with the long-term goal of supporting legislation regulating the production, labeling, and distribution of high-risk foods., Methods: A PubMed search (Keywords: choking, obstruction, asphyxiation, foreign body, food) was conducted in July-September 2010 with publication dates ranging from 1966 to 2010., Study Selection: Articles related to pediatric foreign body aspiration (FBA) were selected by three independent reviewers. 1145 articles were initially identified. Abstracts were then screened utilizing a tool designed to isolate relevant pediatric choking events; this tool helped to only select abstracts which presented data on patients younger than 18 years of age who had choked on food items. Through this, a total of 72 pertinent articles were isolated (55 observational studies, 17 case reports/series)., Data Extraction: For each study, patient age, sex, foreign body location, presenting signs and symptoms, utility of radiographic studies, and type of foreign body detected in the majority of study participants were determined. A "majority" of patients for each study was predetermined arbitrarily to be 2/3 of the studied population., Results: The majority of patients in each observational study was determined to be: male (87% of all studies) and age <5 years (95% of all studies). Aspirated foreign bodies were mostly detected in the right main bronchus foreign body (72% of all studies), and there were abnormal radiographic signs (81% of all studies) at the time of evaluation. Food-object foreign bodies were the most frequent factors associated with choking (94% of all studies)., Conclusion: Childhood aspiration of food-objects is a significant public health issue. Although there is substantial legislation regulating non-food items that pose a choking hazard, equivalent guidelines do not exist for high-risk foods. Our study identifies and confirms several risk factors for pediatric FBA events. In doing so, it echoes the concerns and suggestions of various groups in supporting the development of legislation which may reduce the incidence of food-object aspiration., (Copyright © 2013. Published by Elsevier Ireland Ltd.)