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Increased complications without neurological benefit are associated with prophylactic spinal cord untethering prior to scoliosis surgery in children with myelomeningocele

Goldstein, Hannah E; Shao, Belinda; Madsen, Peter J; Hartnett, Sara M; Blount, Jeffrey P; Brockmeyer, Douglas L; Campbell, Robert M; Conklin, Michael; Hankinson, Todd C; Heuer, Gregory G; Jea, Andrew H; Kennedy, Benjamin C; Tuite, Gerald F; Rodriguez, Luis; Feldstein, Neil A; Vitale, Michael G; Anderson, Richard C E
PURPOSE:Children with myelomeningocele (MMC) are at increased risk of developing neuromuscular scoliosis and spinal cord re-tethering (Childs Nerv Syst 12:748-754, 1996; Neurosurg Focus 16:2, 2004; Neurosurg Focus 29:1, 2010). Some centers perform prophylactic untethering on asymptomatic MMC patients prior to scoliosis surgery because of concern that additional traction on the cord may place the patient at greater risk of neurologic deterioration peri-operatively. However, prophylactic untethering may not be justified if it carries increased surgical risks. The purpose of this study was to determine if prophylactic untethering is necessary in asymptomatic children with MMC undergoing scoliosis surgery. METHODS:A multidisciplinary, retrospective cohort study from seven children's hospitals was performed including asymptomatic children with MMC < 21 years old, managed with or without prophylactic untethering prior to scoliosis surgery. Patients were divided into three groups for analysis: (1) untethering at the time of scoliosis surgery (concomitant untethering), (2) untethering within 3 months of scoliosis surgery (prior untethering), and (3) no prophylactic untethering. Baseline data, intra-operative reports, and 90-day post-operative outcomes were analyzed to assess for differences in neurologic outcomes, surgical complications, and overall length of stay. RESULTS:A total of 208 patients were included for analysis (mean age 9.4 years, 52% girls). No patient in any of the groups exhibited worsened motor or sensory function at 90 days post-operatively. However, comparing the prophylactic untethering groups with the group that was not untethered, there was an increased risk of surgical site infection (SSI) (31.3% concomitant, 28.6% prior untethering vs. 12.3% no untethering; p = 0.0104), return to the OR (43.8% concomitant, 23.8% prior untethering vs. 17.4% no untethering; p = 0.0047), need for blood transfusion (51.6% concomitant, 57.1% prior untethering vs. 33.8% no untethering; p = 0.04), and increased mean length of stay (LOS) (13.4 days concomitant, 10.6 days prior untethering vs. 6.8 days no untethering; p < 0.0001). In multivariable logistic regression analysis, prophylactic untethering was independently associated with increased adjusted relative risks of surgical site infection (aRR = 2.65, 95% CI 1.17-5.02), unplanned re-operation (aRR = 2.17, 95% CI 1.02-4.65), and any complication (aRR = 2.25, 95% CI 1.07-4.74). CONCLUSION:In this study, asymptomatic children with myelomeningocele who underwent scoliosis surgery developed no neurologic injuries regardless of prophylactic untethering. However, those who underwent prophylactic untethering were more likely to experience SSIs, return to the OR, need a blood transfusion, and have increased LOS than children not undergoing untethering. Based on these data, prophylactic untethering in asymptomatic MMC patients prior to scoliosis surgery does not provide any neurological benefit and is associated with increased surgical risks.
PMID: 31267182
ISSN: 1433-0350
CID: 4619822

Unit of Measurement Used and Parent Medication Dosing Errors

Yin, H Shonna; Dreyer, Benard P; Ugboaja, Donna C; Sanchez, Dayana C; Paul, Ian M; Moreira, Hannah A; Rodriguez, Luis; Mendelsohn, Alan L
BACKGROUND AND OBJECTIVES: Adopting the milliliter as the preferred unit of measurement has been suggested as a strategy to improve the clarity of medication instructions; teaspoon and tablespoon units may inadvertently endorse nonstandard kitchen spoon use. We examined the association between unit used and parent medication errors and whether nonstandard instruments mediate this relationship.METHODS: Cross-sectional analysis of baseline data from a larger study of provider communication and medication errors. English- or Spanish-speaking parents (n = 287) whose children were prescribed liquid medications in 2 emergency departments were enrolled. Medication error defined as: error in knowledge of prescribed dose, error in observed dose measurement (compared to intended or prescribed dose); >20% deviation threshold for error. Multiple logistic regression performed adjusting for parent age, language, country, race/ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease; site.RESULTS: Medication errors were common: 39.4% of parents made an error in measurement of the intended dose, 41.1% made an error in the prescribed dose. Furthermore, 16.7% used a nonstandard instrument. Compared with parents who used milliliter-only, parents who used teaspoon or tablespoon units had twice the odds of making an error with the intended (42.5% vs 27.6%, P = .02; adjusted odds ratio=2.3; 95% confidence interval, 1.2-4.4) and prescribed (45.1% vs 31.4%, P = .04; adjusted odds ratio=1.9; 95% confidence interval, 1.03-3.5) dose; associations greater for parents with low health literacy and non-English speakers. Nonstandard instrument use partially mediated teaspoon and tablespoon-associated measurement errors.CONCLUSIONS: Findings support a milliliter-only standard to reduce medication errors.
PMID: 25022742
ISSN: 0031-4005
CID: 1073512

Liquid medication dosing errors in children: role of provider counseling strategies

Yin, H Shonna; Dreyer, Benard P; Moreira, Hannah A; van Schaick, Linda; Rodriguez, Luis; Boettger, Susanne; Mendelsohn, Alan L
OBJECTIVE: To examine the degree to which recommended provider counseling strategies, including advanced communication techniques and dosing instrument provision, are associated with reductions in parent liquid medication dosing errors. METHODS: Cross-sectional analysis of baseline data on provider communication and dosing instrument provision from a study of a health literacy intervention to reduce medication errors. Parents whose children (<9 years) were seen in 2 urban public hospital pediatric emergency departments (EDs) and were prescribed daily dose liquid medications self-reported whether they received counseling about their child's medication, including advanced strategies (teachback, drawings/pictures, demonstration, showback) and receipt of a dosing instrument. The primary dependent variable was observed dosing error (>20% deviation from prescribed). Multivariate logistic regression analyses were performed, controlling for parent age, language, country, ethnicity, socioeconomic status, education, health literacy (Short Test of Functional Health Literacy in Adults); child age, chronic disease status; and site. RESULTS: Of 287 parents, 41.1% made dosing errors. Advanced counseling and instrument provision in the ED were reported by 33.1% and 19.2%, respectively; 15.0% reported both. Advanced counseling and instrument provision in the ED were associated with decreased errors (30.5 vs 46.4%, P = .01; 21.8 vs 45.7%, P = .001). In adjusted analyses, ED advanced counseling in combination with instrument provision was associated with a decreased odds of error compared to receiving neither (adjusted odds ratio 0.3; 95% confidence interval 0.1-0.7); advanced counseling alone and instrument alone were not significantly associated with odds of error. CONCLUSIONS: Provider use of advanced counseling strategies and dosing instrument provision may be especially effective in reducing errors when used together.
PMID: 24767779
ISSN: 1876-2867
CID: 929972

Febrile seizures: current role of the laboratory investigation and source of the Fever in the diagnostic approach

Teran, Carlos G; Medows, Marsha; Wong, Sze H; Rodriguez, Luis; Varghese, Raymol
OBJECTIVES: The aim of this study was to analyze the value of performing laboratory tests, taking cultures, and imaging, a diagnostic approach for febrile seizures (FSs) still routinely performed despite the American Academy of Pediatrics recommendations not to. Another aim of this study was to identify the most common sources of fever in patients with FSs and to determine whether the occurrence of FSs correlates with the seasons of the year. METHODS: This is a retrospective study that included all patients diagnosed with simple or complex FSs who were seen in the emergency room or inpatient unit from January 2004 to December 2009. RESULTS: Of the 219 patients included in the study, 135 (61.4%) cases had the etiology of the FS diagnosed. Upper respiratory tract infection, otitis media, urinary infection, and pneumonia were the most common diagnoses attributed to the fever. Leukocytosis was present in 48 (24%) of 219, and neutrophilia in 199 (91%) of 219 cases. Low bicarbonate levels were common among every age group. Only 1 blood culture was positive for Salmonella. The incidence of FS was higher during the winter (49.3% of the cases), and it closely paralleled the seasonal variation of viral infections. CONCLUSIONS: Even though laboratory tests, taking cultures, and imaging are performed in daily practice when approaching FSs, the association of FSs with serious infectious disease is rare and usually overestimated. The diagnostic approach should be individualized to each case and correlated with available data like that shown in this study. Parents should be educated with the knowledge that the occurrence of FSs tends to be higher in winter.
PMID: 22653461
ISSN: 0749-5161
CID: 169255