Contemporary surgical management of severe sialorrhea in children.
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ABSTRACT:
SUBMITTER: Hornibrook J
PROVIDER: S-EPMC3324931 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:Purpose of reviewUrinary tract infection (UTI) in children is a major source of office visits and healthcare expenditure. Research into the diagnosis, treatment, and prophylaxis of UTI has evolved over the past 10 years. The development of new imaging techniques and UTI screening tools has improved our diagnostic accuracy tremendously. Identifying who to treat is imperative as the increase in multi-drug-resistant organisms has emphasized the need for antibiotic stewardship. This review covers the contemporary management of children with UTI and the data-driven paradigm shifts that have been implemented into clinical practice.Recent findingsWith recent data illustrating the self-limiting nature and low prevalence of clinically significant vesicoureteral reflux (VUR), investigational imaging in children has become increasingly less frequent. Contrast-enhanced voiding urosonogram (CEVUS) has emerged as a useful diagnostic tool, as it can provide accurate detection of VUR without the need of radiation. The urinary and intestinal microbiomes are being investigated as potential therapeutic drug targets, as children with recurrent UTIs have significant alterations in bacterial proliferation. Use of adjunctive corticosteroids in children with pyelonephritis may decrease the risk of renal scarring and progressive renal insufficiency. The development of a vaccine against an antigen present on Escherichia coli may change the way we treat children with recurrent UTIs.SummaryThe American Academy of Pediatrics defines a UTI as the presence of at least 50,000 CFU/mL of a single uropathogen obtained by bladder catheterization with a dipstick urinalysis positive for leukocyte esterase (LE) or WBC present on urine microscopy. UTIs are more common in females, with uncircumcised males having the highest risk in the first year of life. E. coli is the most frequently cultured organism in UTI diagnoses and multi-drug-resistant strains are becoming more common. Diagnosis should be confirmed with an uncontaminated urine specimen, obtained from mid-stream collection, bladder catheterization, or suprapubic aspiration. Patients meeting criteria for imaging should undergo a renal and bladder ultrasound, with further investigational imaging based on results of ultrasound or clinical history. Continuous antibiotic prophylaxis is controversial; however, evidence shows patients with high-grade VUR and bladder and bowel dysfunction retain the most benefit. Open surgical repair of reflux is the gold standard for patients who fail medical management with endoscopic approaches available for select populations.
| S-EPMC9108690 | biostudies-literature
Project description:Despite continued efforts to optimize vaccination composition, severe influenza disease requiring intensive care unit (ICU) admission remains a clinical issue. Influenza epidemics and pandemics worldwide continue to challenge clinicians with managing infected patients requiring ICU care. While routine use of antiviral therapy is deployed in ambulatory outpatients, their use in the ICU in patients with hypoxemic respiratory failure is less well established. Additionally, these therapies primarily target the neuraminidase protein, while contemporary research is increasingly demonstrating potential therapeutic benefits of targeting the hemagglutinin protein. These data have given rise to a growing interest in the use of immune modulating therapies for treatment of severe influenza. Additionally, pandemic outbreaks have revealed the growing need for salvage management, wherein lies the potential role for venovenous extracorporeal membrane oxygenation therapy in refractory respiratory failure. In this report, we review the contemporary ICU care of the severe influenza patient.
| S-EPMC7127549 | biostudies-literature
Project description:Background and objectiveBreast cancer-related lymphedema (BCRL) represents a colossal burden in terms of health and patient-reported outcomes. Surgical management plays a prominent role in the psychological and physical well-being of women suffering from BCRL. Therefore, we performed a narrative review of the current surgical management of BCRL and analyzed the postoperative results.MethodsA literature search was conducted across PubMed MEDLINE, Scopus, and Web of Science from database inception through January 2, 2023. We included English-written studies evaluating postoperative outcomes of lymphatic surgery for the management of BCRL.Key content and findingsThe surgical management of lymphedema can be classified into two approaches: (I) physiologic procedures and (II) debulking or ablative procedures. While ablative procedures are intended to lessen the symptomatic burden of lymphedema via the removal of pathological tissues, physiologic procedures are performed to restore the abnormal lymphatic flow by creating bypasses into the venous or lymphatic circulation, or by creating new lymphatic connections by means of lymphangiogenesis. Physiologic procedures generate better outcomes in the early stages of lymphedema as there is some residual physiologic flow and vessels are less fibrotic, while ablative procedures are regarded to be the best alternative in very advanced lymphedema stages. A combination of physiologic and ablative procedures provides more comprehensive surgical management to BCRL.ConclusionsLymphedema is a common complication of breast cancer treatment with an extensive incidence range. Postoperative outcomes of the surgical management of BCRL are heterogeneous despite most studies indicating favorable results after lymphatic surgery.
| S-EPMC10777216 | biostudies-literature
Project description:BackgroundMulticenter studies on idiopathic or viral pericarditis and pericardial effusion (PPE) have not been reported in children. Colchicine use for PPE in adults is supported. We explored epidemiology and management for inpatient hospitalizations for PPE in US children and risk factors for readmission.Methods and resultsWe analyzed patients in the Pediatric Health Information System database for (1) a code for PPE; (2) absence of codes for underlying systemic disease (eg, neoplastic, cardiac, rheumatologic, renal); (3) age ?30 days and <21 years; and (4) discharge between January 1, 2007, and December 31, 2012, from 38 hospitals contributing complete data for each year of the study period. Among 11 364 hospitalizations with PPE codes during the study period, 543 (4.8%) met entry criteria for idiopathic or viral PPE. Significantly more boys were noted, especially among adolescents. No temporal trends were noted. Median age was 14.5 years (interquartile range 7.3 to 16.6 years); 78 patients (14.4%) underwent pericardiocentesis, 13 (2.4%) underwent pericardiotomy, and 11 (2.0%) underwent pericardiectomy; 157 (28.9%) had an intensive care unit stay, including 2.0% with tamponade. Median hospitalization was 3 days (interquartile range 2 to 4 days). Medications used at initial admission were nonsteroidal anti-inflammatory drugs (71.3%), corticosteroids (22.7%), aspirin (7.0%), and colchicine (3.9%). Readmissions within 1 year of initial admission occurred in 46 of 447 patients (10.3%), mostly in the first 3 months. No independent predictors of readmission were noted, but our statistical power was limited. Practice variation was noted in medical management and pericardiocentesis.ConclusionsOur report provides the first large multicenter description of idiopathic or viral PPE in children. Idiopathic or viral PPE is most common in male adolescents and is treated infrequently with colchicine.
| S-EPMC4338740 | biostudies-literature
Project description:Background and objectivesThis prospective phase III study (SIPEXI) investigated efficacy and safety of repeated injections of incobotulinumtoxinA (incoBoNT/A) for treatment of chronic sialorrhea (drooling) associated with neurological disorders (e.g., cerebral palsy, traumatic brain injury) and/or intellectual disability in children/adolescents.MethodsThe study enrolled 2-17-year-olds with sialorrhea due to neurological disorders and/or intellectual disability. Patients received body weight-dependent doses of incoBoNT/A (20 U to 75 U). A main period with 1 injection cycle (placebo-controlled, double-blind, 6-17-year-olds) was followed by an open-label extension with up to 3 further cycles. An additional cohort of 2-5-year-olds received active treatment throughout the study. Co-primary endpoints were the change in unstimulated salivary flow rate (uSFR) from baseline to week 4, and the carers' global impression of change scale (GICS) rating at week 4. Adverse events were recorded.ResultsIn the main period, 220 patients aged 6-17 years were randomized and treated (148 patients in incoBoNT/A group, 72 patients in placebo group). 35 patients aged 2-5 years received incoBoNT/A (no placebo). 214 patients aged 6-17 years and 33 patients aged 2-5 years continued treatment in the open-label extension period. For the 6-17-year-olds, a significant difference between incoBoNT/A and placebo was seen in the mean uSFR decrease (difference: -0.06 g/min; p = 0.0012) and the carers' GICS rating (difference: 0.28 points; p = 0.032) at week 4, in favor of active treatment. The secondary endpoints consistently supported these results. A sustained benefit was observed during the extension. Incidences of adverse events were comparable between incoBoNT/A and placebo and did not increase notably with repeated injections. The most common adverse events were respiratory infections. Efficacy and safety were also favorable in the uncontrolled cohort of 2-5-year-olds.DiscussionBoth co-primary efficacy endpoints were reached and superiority of incoBoNT/A over placebo was confirmed. IncoBoNT/A (up to 75 U, up to 4 cycles) is an effective and well-tolerated treatment for sialorrhea associated with neurological disorders in children.Study registrationsClinicaltrials.gov: NCT02270736 (www.clinicaltrials.gov/ct2/show/results/NCT02270736); EU Clinical Trials Register: 2013-004532-30 (www.clinicaltrialsregister.eu/ctr-search/search?query=2013-004532-30).Classification of evidenceThis study provides Class I evidence that injection of incobotulinumtoxinA decreases drooling in children aged 6-17 years with neurological disorders.
| S-EPMC8520391 | biostudies-literature
Project description:BACKGROUND:Management of anal fistula (AF) remains challenging with many controversies. The purpose of this study was to explore current surgical practice in the management of AF with a focus on technical variations among surgeons. METHODS:An online survey was conducted by inviting all surgeons and physicians on the membership directory of European Society of Coloproctology and American Society of Colon and Rectal Surgeons. An invitation was extended to others via social media. The survey had 74 questions exploring diagnostic and surgical techniques. RESULTS:In March 2018, 3572 physicians on membership directory were invited to take part in the study 510 of whom (14%) responded to the survey. Of these respondents, 492 (96%) were surgeons. Respondents were mostly colorectal surgeons (84%) at consultant level (84%), age ≥ 40 years (64%), practicing in academic (53%) or teaching (30%) hospitals, from the USA (36%) and Europe (34%). About 80% considered fistulotomy as the gold standard treatment for simple fistulas. Endorectal advancement flap was performed using partial- (42%) or full-thickness (44%) flaps. Up to 38% of surgeons performed ligation of the intersphincteric fistula tract (LIFT) sometimes with technical variations. Geographic and demographic differences were found in both the diagnostic and therapeutic approaches to AF. Declared rates of recurrence and fecal incontinence with these techniques were variable and did not correlate with surgeons' experience. Only 1-4% of surgeons were confident in performing the most novel sphincter-preserving techniques in patients with Crohn's disease. CONCLUSIONS:Profound technical variations exist in surgical management of AF, making it difficult to reproduce and compare treatment outcomes among different centers.
| S-EPMC6736896 | biostudies-other
Project description:BackgroundCalcaneofibular impingement is characterized by lateral hindfoot pain and is commonly resulting from calcaneal fracture malunion or severe flatfoot deformity. Lateral calcaneal wall decompression has been used successfully to relieve pain in patients who have calcaneofibular impingement. However, in cases of severe impingement and hindfoot valgus, lateral wall excision may leave only a small remnant of calcaneal bone for weightbearing and can lead to chronic heel pain. We describe a surgical technique using a medial displacement calcaneal osteotomy (MDCO) combined with a lateral wall exostectomy and report on the outcomes from our series of patients.MethodsRetrospective study of a single surgeon's patients was done from 2010 to 2020 who underwent medial slide calcaneal osteotomy and lateral wall exostectomy for calcaneofibular impingement. Descriptive statistics were used to summarize patient characteristics. Our study included 9 patients, 6 females and 3 males, with a mean age of 59 years (range: 19-77) and a mean follow-up of 62 weeks (range: 6-184).ResultsFive had an Achilles split approach, 2 had an oblique lateral approach, and 1 had an extensile lateral approach. Patients achieved radiographic relief of impingement and improvement in pain. Minor skin and soft tissue complications occurred in 3 patients, all of which were associated with laterally based incisions, and all resolved after a 10-day course of oral antibiotics. No major complications, emergency department visits, or readmissions occurred.ConclusionsMDCO and lateral wall exostectomy was a safe and effective treatment for severe calcaneofibular impingement.Level of evidenceLevel IV, retrospective case series.
| S-EPMC8702743 | biostudies-literature
Project description:BACKGROUND:Sialorrhea is common in children with neurological disorders and leads to social isolation, aspiration pneumonia and increased caregiver burden. Sialorrhea management includes anticholinergic medications and a variety of surgeries, but these are limited by side effects, recurrence and risks. OBJECTIVE:We present our method of salivary gland ablation, an interventional radiology treatment for sialorrhea, and report safety and efficacy data from pediatric patients who underwent salivary gland ablation. MATERIALS AND METHODS:Salivary gland ablation uses image-guided sotradecol and ethanol dual-drug injection into the salivary glands. Submandibular and sublingual glands are injected percutaneously using ultrasound. Parotid glands are injected retrograde through Stensen ducts using fluoroscopy. We conducted a retrospective review of the medical records of patients who underwent salivary gland ablation at our institution between 2005 and 2019. Pre- and post-procedure Drooling Frequency and Drooling Severity (DFDS) scale scores were compared and caregiver satisfaction was assessed. We devised two cohorts, one to study patient safety and a subcohort to study clinical efficacy using DFDS scores. RESULTS:One hundred and seventy salivary gland ablation procedures were performed in the 99 patients comprising the safety cohort. Of the procedures, 88.8% resulted in no or minimal complications. Respiratory difficulty, temporary nerve palsy and infection represent the majority of the 11.2% of patients who experienced periprocedural complications. There were no complications resulting in permanent sequelae. Twenty-seven patients met our inclusion criteria for the efficacy subcohort with a mean follow-up time of 5.4 years. DFDS at follow-up decreased from a median score of nine to a seven post-procedure (P=0.000018). The proportion of caregivers who were satisfied with the procedure increased as more glands were ablated, which suggests a causal link between the number of glands ablated and the outcome. CONCLUSION:Salivary gland ablation is a safe and effective procedure with the potential for permanent decrease in symptoms related to sialorrhea.
| S-EPMC7217813 | biostudies-literature
Project description:BackgroundHaemorrhagic stroke, accounting for 10-20% of all strokes, often requires decompressive surgery as a life-saving measure for cases with massive oedema and raised intracranial pressure. This study was conducted to compare the demographics, characteristics and rehabilitation profiles of patients with severe haemorrhagic stroke who were managed surgically versus those who were managed non-surgically.MethodsA single-centre retrospective study of electronic medical records was conducted over a 3-year period from 1 January 2018 to 31 December 2020. The inclusion criteria were first haemorrhagic stroke, age of >18 years and an admission Functional Independence Measure (FIM™) score of 18-40 upon admission to the rehabilitation centre. The primary outcome measure was discharge FIM™. Secondary outcome measures included modified Rankin Scale (mRS), rehabilitation length of stay (RLOS) and complication rates.ResultsA total of 107 patients' records were analysed; 45 (42.1%) received surgical intervention and 62 (57.9%) patients underwent non-surgical management. Surgically managed patients were significantly younger than non-surgical patients, with a mean age of [surgical 53.1 (SD 12) vs. non-surgical 61.6 (SD 12.3), p = 0.001]. Admission FIM was significantly lower in the surgical vs. non-surgical group [23.7 (SD6.7) vs. 26.71 (SD 7.4), p = 0.031). However, discharge FIM was similar between both groups [surgical 53.91 (SD23.0) vs. non-surgical 57.0 (SD23.6), p = 0.625). Similarly, FIM gain (surgical 30.1 (SD 21.1) vs. non-surgical 30.3 (SD 21.1), p = 0.094) and RLOS [surgical 56.2 days (SD 21.5) vs. non-surgical 52.0 days (SD 23.4), p = 0.134) were not significantly different between groups. The majority of patients were discharged home (surgical 73.3% vs. non-surgical 74.2%, p = 0.920) despite a high level of dependency.ConclusionsOur findings suggest that patients with surgically managed haemorrhagic stroke, while older and more dependent on admission to rehabilitation, achieved comparable FIM gains, discharge FIM and discharge home rates after ~8 weeks of rehabilitation. This highlights the importance of rehabilitation, especially for surgically managed haemorrhagic stroke patients.
| S-EPMC10455087 | biostudies-literature
Project description: Not available
| S-EPMC7035719 | biostudies-literature