Achieving goal-concordant care: Formal and informal advance care planning for White, Black, and Hispanic older adults

INTRODUCTION

Advance care planning (ACP) aims to ensure that patients receive goal-concordant care (GCC), which is especially important for racially or ethnically minoritized populations at greater risk of poor end-of-life outcomes. However, few studies have evaluated the impact of advance directives (i.e., formal ACP) or goals-of-care conversations (i.e., informal ACP) on such care. This study aimed to examine the relationship between each of formal and informal ACP and goal-concordant end-of-life care among older Americans and to determine whether their impact differed between individuals identified as White, Black, or Hispanic.

METHODS

We conducted a retrospective cohort study using 2012-2018 data from the biennial Health and Retirement Study. We examined the relationships of interest using two, separate multivariable logistic regression models. Model 1 regressed a proxy report of GCC on formal and informal ACP and sociodemographic and health-related covariates. Model 2 added interaction terms between race/ethnicity and the two types of ACP.

RESULTS

Our sample included 2048 older adults. There were differences in the proportions of White, Black, and Hispanic decedents who received GCC (83.1%, 75.3%, and 71.3%, respectively, p < 0.001) and in the use of each type of ACP by racial/ethnic group. In model 1, informal compared with no informal ACP was associated with higher odds of GCC (adjusted odds ratio = 1.38 [95% confidence interval, 1.05-1.82]). In model 2, Black decedents who had formal ACP were more likely to receive GCC than those who did not, but there were no statistically significant differences between decedents of different racial/ethnic groups who had no ACP, informal ACP only, or both types of ACP.

CONCLUSIONS

Our results build on previous work by indicating the importance of incorporating goals-of-care conversations into routine healthcare for older adults and encouraging ACP usage among racially and ethnically minoritized populations who use ACP tools at lower rates.

Applying Life History Theory to Understand Earlier Onset of Puberty: An Adolescent Brain Cognitive Development Cohort Analysis

PURPOSE

Life history theory posits that multigenerational exposure to adversity and deprivation influences childhood growth and development, including pubertal maturation. We applied this ecological, evolutionary theory to examine the contributions of distal and proximal adversity on early puberty, a potentially important marker for population health.

METHODS

Baseline data from 5,645 girls in the adolescent brain cognitive development study were included. Early puberty was defined as midlate/post pubertal development by age 9-11 years. The contributions of multigenerational Black/Indigenous (Black, Indigenous and People of Color [BIPOC]) or Hispanic identities, intergenerational mental health, economic deprivation, personal trauma exposure and mental health, and proximal biological factors of premature birth and body mass index on early puberty were examined with hierarchical modeling.

RESULTS

1,225 girls (21.7%) had early puberty. BIPOC/Hispanic identity, familial adversity, economic deprivation, personal trauma, depression, and a higher body mass index contributed significantly toward early puberty. The effect of multigenerational adversity remained significant across models, but the likelihood of early puberty decreased sequentially for BIPOC and Hispanic youth as proximal adversities were added (e.g., OR decreased from 2.93 to 2.38 for BIPOC youth), supporting a synergistic effect of layered adversity on early puberty.

DISCUSSION

This analysis supports life history theory as a coherent framework to understand early puberty among girls. Findings suggest monitoring pubertal timing as a population health indictor, like birth weight, prematurity, or life expectancy. Addressing early puberty may require policy and social changes to mitigate the negative impact of multiple layers of adversity including racial/ethnic disadvantage, family, and individual mental health and trauma, as well as economic insecurity.

Risk Factors for the Development of Multisite Pain in Children

OBJECTIVE

Chronic pain has economic costs on par with cardiovascular disease, diabetes, and cancer. Despite this impact on the health care system and increasing awareness of the relationship between pain and mortality, efforts to identify simple symptom-based risk factors for the development of pain, particularly in children, have fallen short. This is critically important as pain that manifests during childhood often persists into adulthood. To date, no longitudinal studies have examined symptoms in pain-free children that presage a new, multisite manifestation of pain in the future. We hypothesized that female sex, sleep problems, and heightened somatic symptoms complaints at baseline would be associated with the risk of developing new multisite pain 1 year later.

METHODS

Symptom assessments were completed by parents of youth (ages 9 to 10) enrolled in the Adolescent Brain Cognitive Development study. Multivariate logistic regression models focused on children who developed multisite pain 1 year later (n=331) and children who remained pain free (n=3335).

RESULTS

Female sex (odds ratio [OR]=1.35; 95% CI, 1.07, 1.71; P =0.01), elevated nonpainful somatic symptoms (OR=1.17; 95% CI, 1.06, 1.29; P <0.01), total sleep problems (OR=1.20; 95% CI, 1.07, 1.34; P <0.01), and attentional issues (OR=1.22; 95% CI, 1.10, 1.35; P <0.001) at baseline were associated with new multisite pain 1 year later. Baseline negative affect was not associated with new multisite pain.

DISCUSSION

Identifying symptom-based risk factors for multisite pain in children is critical for early prevention. Somatic awareness, sleep and attention problems represent actionable targets for early detection, treatment, and possible prevention of multisite pain in youth.

Racial/Ethnic Disparities in Mental Healthcare in Youth With Incarcerated Parents

INTRODUCTION

Youth with incarcerated parents experience more adverse childhood experiences than other youth, placing them at higher risk for mental health and substance use disorders. Despite their increased risk, these youth may be less likely to access mental health services, particularly given their racial and ethnic makeup. Therefore, this study aimed to assess racial and ethnic disparities in access to mental health services for youth with incarcerated parents.

METHODS

This secondary data analysis used longitudinal data from 2016 to 2019 from the Adolescent Brain Cognitive Development Study. Logistic regression models assessed the relationships among incarceration, cumulative childhood experiences, DSM-5 diagnoses, and mental health services. Additional analyses stratified these models by race and ethnicity. All analyses were performed in 2022.

RESULTS

Youth with incarcerated parents were more likely to report 4 or more childhood experiences (51% vs 14%; AOR=3.92; 95% CI=3.3, 4.65; p<0.001) and to have received mental health services (25% vs 15%; AOR=1.89; 95% CI=1.6, 2.21; p<0.001) than unexposed youth. However, Black youth with incarcerated parents (19% vs 34%; AOR=0.38; 95% CI=0.27, 0.52; p<0.001) and Latinx youth with incarcerated parents (10% vs 17%; AOR=0.5; 95% CI=0.33, 0.76; p<0.001) were significantly less likely to report receiving mental health services than White youth with incarcerated parents and non-Latinx youth with incarcerated parents, respectively.

CONCLUSIONS

Youth with incarcerated parents were more likely to report utilization of mental health services, but significant racial and ethnic disparities exist between Black and Latinx youth with incarcerated parents compared with that among White and non-Latinx youth with incarcerated parents. There is a continued need to expand mental health services to youth with incarcerated parents and to address racial and ethnic disparities in access to care.

Adolescents and Young Adults With Sickle Cell Disease: Nociplastic Pain and Pain Catastrophizing as Predictors of Pain Interference and Opioid Consumption

OBJECTIVES

Some patients with sickle cell disease (SCD) have features of nociplastic pain. While research suggests that many patients with nociplastic pain consume more opioids due to opioid nonresponsiveness, little is known about the impact of nociplastic pain and pain catastrophizing on opioid consumption and pain interference among adolescents and young adults (AYA) with SCD. The purpose of this study was to (1) characterize nociplastic pain and pain catastrophizing among AYA with SCD, and (2) determine whether these characterizations are associated with subsequent opioid consumption and pain interference 1 month after characterization.

METHODS

Participants completed surveys characterizing nociplastic pain and catastrophizing at a routine clinic visit (baseline). Thereafter, participants received weekly text messages that included pain interference and opioid consumption surveys. Multipredictor 2-part models were used to evaluate the predictive relationships between baseline characterizations and subsequent pain interference, and opioid consumption.

RESULTS

Forty-eight AYA aged 14 to 35 completed baseline measures. Twenty-five percent of participants had scores suggestive of nociplastic pain. Greater nociplastic pain features significantly increased the odds of consuming opioids (odds ratio=1.2) and having greater interference from pain (odds ratio=1.46). Regression analyses found that greater baseline nociplastic pain characteristics were significantly associated with opioid consumption (β=0.13) and pain interference (β=0.061); whereas higher pain catastrophizing scores predicted less opioid consumption (β=-0.03) and less pain interference (β=-0.0007).

DISCUSSION

In this sample of AYA with SCD, features of nociplastic pain predicted higher subsequent opioid consumption and pain interference. Being aware of nociplastic pain features in patients with SCD may better guide individualized pain management.

Associations of Co-occurring Symptom Trajectories With Sex, Race, Ethnicity, and Health Care Utilization in Children

Importance

Co-occurring physical and psychological symptoms during childhood and early adolescence may increase risk of symptom persistence into adulthood.

Objective

To describe co-occurring pain, psychological, and sleep disturbance symptom (pain-PSS) trajectories in a diverse cohort of children and the association of symptom trajectory with health care utilization.

Design, Setting, and Participants

This cohort study was a secondary analysis of longitudinal data from the Adolescent Brain Cognitive Development (ABCD) Study, collected between 2016 and 2022 at 21 research sites across the US. Participants included children with 2 to 4 complete annual symptom assessments. Data were analyzed from November 2022 to March 2023.

Main Outcomes and Measures

Four-year symptom trajectories were derived from multivariate latent growth curve analyses. Pain-PSS scores, including depression and anxiety, were measured using subscales from the Child Behavior Checklist and the Sleep Disturbance Scale of Childhood. Nonroutine medical care and mental health care utilization were measured using medical history and Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) items.

Results

A total of 11 473 children (6018 [52.5%] male; mean [SD] age at baseline, 9.91 [0.63] years) were included in analyses. Four no pain-PSS and 5 pain-PSS trajectories were supported with good or excellent model fit (predicted probabilities, 0.87-0.96). Most children (9327 [81.3%]) had asymptomatic or low, intermittent, or single symptom trajectories. Approximately 1 in 5 children (2146 [18.7%]) had moderate to high co-occurring symptom trajectories that persisted or worsened. Compared with White children, there was a lower relative risk of having moderate to high co-occurring symptom trajectories among Black children (adjusted relative risk ratio [aRRR] range, 0.15-0.38), Hispanic children (aRRR range, 0.58-0.67), and children who identified as another race (including American Indian, Asian, Native Hawaiian, and other Pacific Islader; aRRR range, 0.43-0.59). Less than half of children with moderate to high co-occurring symptom trajectories used nonroutine health care, despite higher utilization compared with asymptomatic children (nonroutine medical care: adjusted odds ratio [aOR], 2.43 [95% CI, 1.97-2.99]; mental health services: aOR, 26.84 [95% CI, 17.89-40.29]). Black children were less likely to report nonroutine medical care (aOR, 0.61 [95% CI, 0.52-0.71]) or mental health care (aOR, 0.68 [95% CI, 0.54-0.87]) than White children, while Hispanic children were less likely to have used mental health care (aOR, 0.59 [95% CI, 0.47-0.73]) than non-Hispanic children. Lower household income was associated with lower odds of nonroutine medical care (aOR, 0.87 [95% CI, 0.77-0.99]) but not mental health care.

Conclusions and Relevance

These findings suggest there is a need for innovative and equitable intervention approaches to decrease the potential for symptom persistence during adolescence.

Racial and Ethnic Differences in Informal and Formal Advance Care Planning Among U.S. Older Adults

OBJECTIVE

To examine advance care planning (ACP) trends among an increasingly diverse aging population, we compared informal and formal ACP use by race/ethnicity among U.S. older adults (≤65 years).

METHODS

We used Health and Retirement Study data (2012-2018) to assess relationships between race/ethnicity and ACP type (i.e., no ACP, informal ACP only, formal ACP only, or both ACP types). We reported adjusted risk ratios with 95% confidence intervals.

RESULTS

Non-Hispanic Black and Hispanic respondents were 1.77 (1.60, 1.96) and 1.76 (1.55, 1.99) times as likely, respectively, to report no ACP compared to non-Hispanic White respondents. Non-Hispanic Black and Hispanic respondents were 0.74 (0.71, 0.78) and 0.74 (0.69, 0.80) times as likely, respectively, to report using both ACP types as non-Hispanic White respondents.

DISCUSSION

Racial/ethnic differences in ACP persist after controlling for a variety of barriers to and facilitators of ACP which may contribute to disparities in end-of-life care.

Biopsychosocial Attributes of Single-region and Multi-region Body Pain During Early Adolescence: Analysis of the ABCD Cohort

OBJECTIVES

Multi-region pain during adolescence is associated with a higher symptom burden and lower quality of life. The purpose of this study was to describe and compare the biopsychosocial attributes of single-region and multi-region pain among healthy young adolescents.

MATERIALS AND METHODS

We analyzed data from 10,320 children aged 10.6 to 14 years who self-reported pain in the Adolescent Brain and Cognitive Development Study. Pain was coded as single-region or multi-region based on body map data.

RESULTS

One in 5 young adolescents indicated recent multi-region pain. Sequential regression supported improved model fit when psychological and sociocultural factors were added to a biological model of pain; however, these models improved the classification of multi-region but not single-region pain. A significant interaction effect of sex and puberty remained constant across models with increased odds of pain at each advancing pubertal stage for both sexes compared with prepuberty, but no difference between girls and boys at late puberty (adjusted odds ratio [OR]=2.45 [1.72, 3.49] and adjusted OR=1.63 [1.20, 2.23], respectively). Psychological factors improved the classification of multi-region pain with significant effects of anxiety, somatic symptoms, and somnolence. Finally, compared with White and non-Hispanic children, Black and Hispanic children were less likely to report pain (adjusted OR=0.70 [0.61, 0.80]; adjusted OR=0.88 [0.78, 0.99], respectively) but had significantly higher pain interference when pain was present (adjusted OR=1.49 [1.29, 1.73] and adjusted OR=1.20 [1.06, 1.35], respectively).

DISCUSSION

Pain is a biopsychosocial phenomenon, but psychological and sociocultural features may be more relevant for multi-region compared with single-region pain during early adolescence.

Prescription Opioid Misuse in Older Adult Surgical Patients: Epidemiology, Prevention, and Clinical Implications

ABSTRACT

The United States and many other developed nations are in the midst of an opioid crisis, with consequent pressure on prescribers to limit opioid prescribing and reduce prescription opioid misuse. This review addresses prescription opioid misuse for older adult surgical populations. We outline the epidemiology and risk factors for persistent opioid use and misuse in older adults undergoing surgery. We also address screening tools and prescription opioid misuse prevention among vulnerable older adult surgical patients (e.g., older adults with a history of an opioid use disorder), followed by clinical management and patient education recommendations. A significant plurality of older adults engaged in prescription opioid misuse obtain opioid medication for misuse from health providers. Thus, nurses can play a critical role in identifying those older adults at a higher risk for misuse and deliver quality care while balancing the need for adequate pain management against the risk for prescription opioid misuse.

A Risk Education Program Decreases Leftover Prescription Opioid Retention: An RCT

INTRODUCTION

Retaining leftover prescription opioids poses the risks of diversion, misuse, overdose, and death for youth and other family members. This study examined whether a new educational program would enhance risk perceptions and disposal intentions among parents and decrease their retention of leftover prescription opioids.

STUDY DESIGN

This study is an RCT (NCT03287622).

SETTING/PARTICIPANTS

A total of 648 parents whose children were prescribed opioid analgesics were recruited from a Midwestern, academic pediatric hospital between 2017 and 2019. Parents were randomized to receive routine information (control) with or without Scenario-Tailored Opioid Messaging Program intervention.

INTERVENTION

The intervention provided opioid risk and mitigation advice using interactive decisional feedback.

MAIN OUTCOME MEASURES

The main outcome measures were parents' perceptions of the riskiness of keeping/sharing opioids and child misuse measured at baseline, Days 3 and 14, their intention to dispose of leftover opioids, and their final retention decisions after the child's use (at or around Day 14).

RESULTS

Perceived riskiness of child misuse and keeping/sharing opioids increased from baseline through Day 14 only for parents in the intervention group (p≤0.006). However, there were no significant differences in risk perceptions between groups and no intervention effect on disposal intentions at either follow-up. Despite these findings, the intervention reduced the likelihood of parents' opioid retention when adjusted for important parent and child covariates (AOR=0.48; 95% CI=0.25, 0.93; p=0.028). Parents who reported past opioid misuse also showed higher retention behavior (AOR=4.78; 95% CI=2.05, 11.10; p<0.001).

CONCLUSIONS

A scenario-specific educational intervention emphasizing the potential risks that leftover opioids pose to children and that provided risk mitigation advice decreased parents' retention of their child's leftover opioid medication. Removing leftover prescription drugs from homes with children may be an important step to reducing diversion, accidental poisoning, and misuse among youth.

TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov NCT03287622.

A Community-Academic Approach to Preventing Substance Use Disorders

BACKGROUND

The coronavirus disease 2019 pandemic and activism against structural racism heightened awareness of racial-ethnic disparities and disproportionate burden among the underserved. The opioid crisis further compounds these phenomena, increasing vulnerability for substance use disorders (SUD). Community-based participatory research can facilitate multidisciplinary collaboration, yet literature on these approaches to prevent and reduce SUD and associated stigma remains limited.

OBJECTIVE

Discrimination, stigma, and multiple crises with health care and systemic barriers increasingly marginalize the underserved, specifically around SUD. The Detroit Area Mental Health Leadership Team (DAMHLT, since 2015), aims to optimize SUD prevention, enhance resiliency and advocacy to advance knowledge on SUD research and influence community-level research and practice.

LESSONS LEARNED

DAMHLT's approach on bidirectionality, community level access to real-time epidemiological data, advocacy (i.e., institutional responsiveness) and dissemination may be translational to other partnerships.

CONCLUSIONS

As we move through an ever-changing pandemic, DAMHLT's lessons learned can inform partnership dynamics and public health strategies such as hesitancy on public health response.

Enhancing risk perception may be insufficient to curtail prescription opioid use and misuse among youth after surgery: A randomized controlled trial

OBJECTIVE

This randomized controlled trial examined whether an interactive, risk-focused educational program was associated with higher risk perceptions and decreased prescription opioid use/misuse among emerging adults.

METHODS

503 participants aged 15-24 years scheduled for ambulatory surgery were randomized to routine prescription education with or without our Scenario-Tailored Opioid Messaging Program (STOMP) provided prior to receipt of a prescribed opioid. Surveys were completed preoperatively, and at days 7&14, months 1&3 postoperatively. Outcomes included analgesic risk perceptions, opioid use, and misuse intentions/behavior.

RESULTS

Compared to Controls, STOMP was associated with stable but higher risk perceptions on day 14 (β = 1.76 [95% CI 0.53, 2.99], p = .005) and month 3 (β = 2.13 [95% CI 0.86, 3.40], p = .001). There was no effect of STOMP or analgesic misuse risk perceptions on days of opioid use or subsequent misuse intentions/behavior. The degree to which participants valued pain relief over analgesic risk (trade-off preference) was, however, associated with prolonged postoperative opioid use and later misuse.

CONCLUSION

Education emphasizing the risks of opioids was insufficient in reducing opioid use and misuse in youth who were prescribed these analgesics for acute pain relief.

PRACTICE IMPLICATIONS

Education may need to better address analgesic expectations to shorten opioid use and mitigate misuse.

Optimizing scalable, technology-supported behavioral interventions to prevent opioid misuse among adolescents and young adults in the emergency department: A randomized controlled trial protocol

Preventing opioid misuse and opioid use disorder is critical among at-risk adolescents and young adults (AYAs). An Emergency Department (ED) visit provides an opportunity for delivering interventions during a rapidly changing opioid landscape. This paper describes pilot data and the protocol for a 2 × 2 factorial randomized controlled trial testing efficacy of early interventions to reduce escalation of opioid (prescription or illicit) misuse among at-risk AYAs. Interventions are delivered using technology by health coaches. AYAs ages 16-30 in the ED screening positive for prescription opioid use (+ ≥ 1 risk factor) or opioid misuse will be stratified by risk severity, sex, and age group. Participants will be randomly assigned to a condition at intake, either a live video health coach-delivered single session or a control condition of an enhanced usual care (EUC) community resource brochure. They are also randomly assigned to one of two post-intake conditions: health coach-delivered portal-like messaging via web portal over 30 days or EUC delivered at 30 days post-intake. Thus, the trial has four groups: health coach-delivered session+portal, health coach-delivered session+EUC, EUC + portal, and EUC + EUC. Outcomes will be measured at 3-, 6-, and 12-months. The primary outcome is opioid misuse based on a modified Alcohol Smoking and Substance Involvement Screening Test. Secondary outcomes include other opioid outcomes (e.g., days of opioid misuse, overdose risk behaviors), other substance misuse and consequences, and impaired driving. This study is innovative by testing the efficacy of feasible and scalable technology-enabled interventions to reduce and prevent opioid misuse and opioid use disorder. Trial Registration:ClinicalTrials.gov University of Michigan HUM00177625 NCT Registration: NCT04550715.

To relieve pain or avoid opioid-related risk? A comparison of parents' analgesic trade-off preferences and decision-making in 2019 versus 2013 in a single U.S. pediatric hospital

BACKGROUND

Analgesic trade-off preferences, or the relative preference for pain relief vs. risk aversion, shape parents' decisions to give prescription opioids to their children. These preferences may be influenced by personal experiences and societal factors.

AIM

To examine whether parental analgesic trade-off preferences and opioid decision-making have shifted toward risk aversion during the opioid crisis in the United States.

METHODS

We conducted a secondary analysis of the preoperative survey data of parents from a single U.S. pediatric hospital whose children aged 5-17 years were to undergo painful surgery in 2013 (Time 1) or 2017/2019 (Time 2). Surveys assessed parents' analgesic trade-off preference (-12 or risk-averse to +12 or pain relief preferent, scores around 0=ambivalent) and their hypothetical decisions to give a prescribed opioid to a child in pain.

RESULTS

Data from 847 parents were included (Time 1, n = 361; Time 2, n = 486). Parents at Time 2 were significantly more risk-averse compared with Time 1 (adj.β: -0.84 [95% CI: -1.09, -0.60]). Parents at Time 2 were more than twice as likely to be risk-averse or ambivalent (OR: 2.17 [95% CI: 1.62, 2.91]). There was a significant interaction effect of Time*Preference on parents' decision to give the opioid (adj. OR: 1.09 [95% CI: 1.03, 1.16]). At Time 2, parents who were ambivalent or risk-averse were less likely than those who preferred to relieve pain to administer the prescribed opioid (OR: 0.57 [95% CI: 0.37, 0.89]). In contrast, there was no association between the preference group and the opioid decision at Time 1.

CONCLUSION

Findings suggest that parents of children scheduled for painful surgery at our pediatric hospital have become more analgesic risk-averse during the past decade. Parents' analgesic trade-off preferences may influence their decisions to administer prescribed opioids after surgery, which may contribute to children's pain outcomes.

Effect of a brief scenario-tailored educational program on parents' risk knowledge, perceptions, and decisions to administer prescribed opioids: a randomized controlled trial

ABSTRACT

This randomized, controlled trial evaluated whether a brief educational program (ie, Scenario-Tailored Opioid Messaging Program [STOMP]) would improve parental opioid risk knowledge, perceptions, and analgesic efficacy; ensure safe opioid use decisions; and impact prescription opioid use after surgery. Parent-child dyads (n = 604) who were prescribed an opioid for short-term use were randomized to routine instruction (Control) or routine plus STOMP administered preoperatively. Baseline and follow-up surveys assessed parents' awareness and perceived seriousness of adverse opioid effects, and their analgesic efficacy. Parents' decisions to give an opioid in hypothetical scenarios and total opioid doses they gave to children at home were assessed at follow-up. Scenario-Tailored Opioid Messaging Program parents gained enhanced perceptions of opioid-related risks over time, whereas Controls did not; however, risk perceptions did not differ between groups except for addiction risk. Scenario-Tailored Opioid Messaging Program parents exhibited marginally greater self-efficacy compared to Controls (mean difference vs controls = 0.58 [95% confidence interval 0.08-1.09], P = 0.023). Scenario-Tailored Opioid Messaging Program parents had a 53% lower odds of giving an opioid in an excessive sedation scenario (odds ratio 0.47 [95% confidence interval 0.28-0.78], P = 0.003), but otherwise made similar scenario-based opioid decisions. Scenario-Tailored Opioid Messaging Program was not associated with total opioid doses administered at home. Instead, parents' analgesic efficacy and pain-relief preferences explained 7%, whereas child and surgical factors explained 22% of the variance in opioid doses. Scenario-tailored education enhanced parents' opioid risk knowledge, perceptions, and scenario-based decision-making. Although this may inform later situation-specific decision-making, our research did not demonstrate an impact on total opioid dosing, which was primarily driven by surgical and child-related factors.

The relationship between parental factors, child symptom profile, and persistent postoperative pain interference and analgesic use in children

OBJECTIVES

Both parental and child factors have been previously associated with persistent or recurrent postoperative pain in children. Yet, little is known about the relative contribution of parent factors or whether child symptom factors might impact the association between parent factors and long-term pain. The aim of this study was to explore the associations between parent factors, child symptomology, and the child's long-term pain outcomes after surgery.

METHODS

This prospective, longitudinal study included parents and their children who were scheduled to undergo spinal fusion for underlying scoliosis. Parents completed baseline surveys about their pain history, pain relief preferences (ie, preference to relieve their child's pain vs avoid analgesic risks), and pain catastrophizing (ie, beliefs about their child's pain). Children were classified previously into high vs low symptom profiles at baseline based on their self-reported pain, catastrophizing, fatigue, depression, and anxiety. Children were assessed 1-year after surgery for their long-term pain interference scores and analgesic use. Serial regression modeling was used to explore whether associations between parent factors and the outcomes were changed when accounting for child factors.

RESULTS

Seventy-six parent/child dyads completed all surveys. Parental preferences and catastrophizing were atemporally associated with the child's baseline psychological-somatic symptom profile. Though parent and child factors were both associated with the long-term pain outcomes, when all three factors were accounted for, the associations between parent factors and long-term pain was fully attenuated by the child's profile.

DISCUSSION

These findings suggest that the relationship between parent factors and long-term postoperative pain outcomes may be dependent on the child's symptom profile at baseline. Since there may be bidirectional relationships between parent and child factors, interventions to mitigate long-term pain should address child symptoms as well as parental factors.

Complications Associated With the Anesthesia Transport of Pediatric Patients: An Analysis of the Wake Up Safe Database

BACKGROUND

Transporting patients under anesthesia care incurs numerous potential risks, especially for those with critical illness. The purpose of this study is to identify and report all pediatric anesthesia transport-associated adverse events from a preexisting database of perioperative adverse events.

METHODS

An extract of the Wake Up Safe database was obtained on December 14, 2017, and screened for anesthesia transport-associated complications. This was defined as events occurring during or immediately after transport or movement of a pediatric patient during or in proximity to their care by anesthesiologists, including repositioning and transfer to recovery or an inpatient unit, if the cause was noted to be associated with anesthesia or handover. Events were excluded if the narrative clearly states that an event was ongoing and not impacted by anesthesia transport, such as a patient who develops cardiac arrest that then requires emergent transfer to the operating room. The search methodology included specific existing data elements that indicate transport of the patient, handover or intensive care status preoperatively as well as a free-text search of the narrative for fragments of words indicating movement. Screened events were reviewed by 3 anesthesiologists for inclusion, and all data elements were extracted for analysis.

RESULTS

Of 2971 events in the database extract, 63.8% met screening criteria and 5.0% (148 events) were related to transport. Events were primarily respiratory in nature. Nearly 40% of all reported events occurred in infants age ≤6 months. A total of 59.7% of events were at least somewhat preventable and 36.4% were associated with patient harm, usually temporary. Of the 86 reported cardiac arrests, 50 (58.1%) had respiratory causes, of which 74% related to anesthesia or perioperative team factors. Respiratory events occurred at all stages of care, with 21.4% during preoperative transport and 75.5% postoperatively. Ninety-three percent of unplanned extubations occurred in patients 6 months and younger. Ten medication events were noted, 2 of which resulted in cardiac arrest. Root causes in all events related primarily to provider and patient factors, with occasional references to verbal miscommunication.

CONCLUSIONS

Five percent of reported pediatric anesthesia adverse events are associated with transport. Learning points highlight the risk of emergence from anesthesia during transport to recovery or intensive care unit (ICU). ICU patients undergoing anesthesia transport face risks relating to transitions in providers, equipment, sedation, and physical positioning. Sedation and neuromuscular blockade may be necessary for transport in some patients but has been associated with adverse events in others.

Behavioral Intervention and Disposal of Leftover Opioids: A Randomized Trial

OBJECTIVES

Leftover prescription opioids pose risks to children and adolescents, yet many parents keep these medications in the home. Our objective in this study was to determine if providing a behavioral disposal method (ie, Nudge) with or without a Scenario-Tailored Opioid Messaging Program (STOMP) (risk-enhancement education) improves parents' opioid-disposal behavior after their children's use.

METHODS

Parents whose children were prescribed a short course of opioids were recruited and randomly assigned to the Nudge or control groups with or without STOMP. Parents completed surveys at baseline and 7 and 14 days. Main outcomes were (1) prompt disposal (ie, immediate disposal of leftovers after use) and (2) planned retention (intention to keep leftovers).

RESULTS

There were 517 parents who took part, and 93% had leftovers after use. Prompt disposal behavior was higher for parents who received both the STOMP and Nudge interventions (38.5%), Nudge alone (33.3%), or STOMP alone (31%) compared with controls (19.2%; P ≤ .02). Furthermore, the STOMP intervention independently decreased planned retention rates (5.6% vs 12.5% no STOMP; adjusted odds ratio [aOR] 0.40 [95% confidence interval (CI) 0.19-0.85]). Higher risk perception lowered the odds of planned retention (aOR 0.87 [95% CI 0.79-0.96]), whereas parental past opioid misuse increased those odds (aOR 4.44 [95% CI 1.67-11.79]).

CONCLUSIONS

Providing a disposal method nudged parents to dispose of their children's leftover opioids promptly after use, whereas STOMP boosted prompt disposal and reduced planned retention. Such strategies can reduce the presence of risky leftover medications in the home and decrease the risks posed to children and adolescents.

An interactive web-based educational program improves prescription opioid risk knowledge and perceptions among parents

Aim: This study evaluated the effect of an interactive, web-based educational program on parents' opioid risk knowledge, risk perceptions, analgesic self efficacy and decision-making. Patients & methods: Totally, 64 parents from a tertiary care pediatric healthcare setting were assessed for risk understanding at baseline, immediately and 3 days after receiving the educational program. Results: Participants gained increased opioid risk knowledge, enhanced risk perceptions as well as enhanced analgesic self efficacy after program exposure. The program had no effect on parental decisions about when to give or withhold a prescribed opioid. Conclusion: The interactive web-based program improved parental knowledge about opioid risks. Program enhancements may be needed to improve pain management decisions about when it is safe to use opioids and when they should be withheld.

Effect of Preemptive Acetaminophen Administered Within 1 Hour of General Anesthesia on Gastric Residual Volume and pH in Children

PURPOSE

Determine whether preoperative oral acetaminophen increases gastric residual volume and lowers gastric pH.

DESIGN

Prospective, randomized.

METHODS

Healthy children, 1 to 14 years, having elective magnetic resonance imaging (MRI) were randomized to oral acetaminophen within 1 hour of induction versus fasting. Gastric volume and pH were measured immediately after intubation. Adverse events were documented from induction through 72 hours post MRI.

FINDINGS

Thirty-seven children completed the study (16 treatment, 21 control). Gastric residual volume between groups was not significantly different. The acetaminophen group had significantly higher pH than control group (1.86 ± 0.42 vs 1.56 ± 0.34; P ≤ .044). Three children in the control and 6 in the treatment group experienced minor adverse events.

CONCLUSIONS

Findings suggest administering oral acetaminophen prior to induction of anesthesia is not associated with increased gastric residual volume and increases the gastric pH. Further study is needed to examine outcomes such as aspiration pneumonitis risk.

A cluster of high psychological and somatic symptoms in children with idiopathic scoliosis predicts persistent pain and analgesic use 1 year after spine fusion

BACKGROUND

Persistent postoperative pain is a significant problem for many children, particularly for those undergoing major surgery such as posterior spine fusion. More than two-thirds report persistent pain after spine fusion, yet factors that may contribute to poorer outcomes remain poorly understood.

AIMS

This prospective, longitudinal study examined how psychologic and somatic symptoms cluster together in children aged 10-17 years with idiopathic scoliosis, and tested the hypothesis that a higher psychological and somatic symptom cluster would predict worse pain outcomes 1 year after fusion.

METHODS

Otherwise healthy children with idiopathic scoliosis completed preoperative surveys measuring recent pain intensity, pain location(s), somatic symptom severity, painDETECT (neuropathic-type pain symptoms), pain interference, fatigue, depression, anxiety, and pain catastrophizing. Pain outcome data were collected during hospitalization, and at 1 year after surgery.

RESULTS

Ninety-five children completed baseline surveys and a cluster analysis differentiated 28 (30%) with a high symptom profile that included; higher depression, fatigue, pain interference, catastrophizing, and painDETECT scores. High symptom cluster membership independently predicted higher pain interference at 1 year (β 9.92 [95% CI 6.63, 13.2], P < 0.001). Furthermore, children in this high symptom cluster reported significantly higher pain intensity and painDETECT scores, and had a 50% higher probability of continued analgesic use at 1 year compared to those in the Low Symptom Cluster (95% CI 21.3-78.5, P = 0.001).

CONCLUSION

Findings from this exploratory study suggest a need to comprehensively assess children with scoliosis for preoperative signs and symptoms that may indicate an underlying vulnerability for persistent pain. This, in turn may help guide a comprehensive perioperative treatment strategy to mitigate the potential for long-term pain trajectories.

Effect of a Scenario-tailored Opioid Messaging Program on Parents' Risk Perceptions and Opioid Decision-making

OBJECTIVES

Poor parental understanding of prescription opioid risks is associated with potentially dangerous decisions that can contribute to adverse drug events (ADE) in children and adolescents. This study examined whether an interactive Scenario-tailored Opioid Messaging Program (STOMP) would (1) enhance opioid risk perceptions and (2) improve the safety of parents' decision-making.

MATERIALS AND METHODS

In total, 546 parents were randomized to receive the STOMP versus control information and 516 completed the program. A baseline survey assessed parents' opioid risk knowledge, perceptions, and preferences for pain relief versus risk avoidance (Pain Relief Preference). Parents then made hypothetical decisions to give or withhold a prescribed opioid for high-risk (excessive sedation) and low-risk (no ADE) scenarios. The STOMP provided immediate feedback with specific risk and guidance information; the control condition provided general information. We reassessed knowledge, perceptions, and decision-making up to 3 days thereafter.

RESULTS

Following the intervention, the STOMP group became more risk avoidant (Pain Relief Preference, mean difference -1.27 [95% confidence interval, -0.8 to -1.75]; P<0.001) and gained higher perceptions of the critical risk, excessive sedation (+0.56 [0.27 to 0.85]; P<0.001). STOMP parents were less likely than controls to give a prescribed opioid in the high-risk situation (odds ratio, -0.14 [-0.24 to -0.05]; P=0.006) but similarly likely to give an opioid for the no ADE situation (P=0.192).

DISCUSSION

The STOMP intervention enhanced risk perceptions, shifted preferences toward opioid risk avoidance, and led to better decisions regarding when to give or withhold an opioid for pain management. Scenario-tailored feedback may be an effective method to improve pain management while minimizing opioid risks.

Propofol Drug Shortage Associated With Worse Postoperative Nausea and Vomiting Outcomes Despite a Mitigation Strategy

Drug shortages negatively affect patient care and outcomes. Postoperative nausea and vomiting (PONV) can be mitigated using risk assessment and prophylaxis. A 2012 propofol shortage provided an opportunity to study the impact of using prophylactic antiemetics and changing the technique from a propofol infusion to inhaled agents in an ambulatory surgery setting. We retrospectively collected data for 2,090 patients regarding PONV risk factors, anesthetic management, and PONV outcomes for periods before, during, and after the shortage. Patients during the propofol shortage experienced a higher incidence of PONV (11% vs 5% before the shortage), greater need for rescue antiemetics (3% vs 1%), and longer duration of stay (mean [SD] = 124 [115] minutes vs 118 [108] minutes). More patients in this group reported PONV at home (14% vs 7%), and 2 required unplanned admission or return to the hospital. During the shortage, patients had a 2-fold increase in the odds of PONV when adjusted for all risk factors. Antiemetics moderated the association between gender and PONV but did not change the effect of the shortage. Findings suggest that despite mitigation efforts, the inability to use propofol infusion was associated with worse PONV outcomes.

Interactive Anatomy-Augmented Virtual Simulation Training

BACKGROUND

Traditionally, clinical psychomotor skills are taught through videos and demonstration by faculty which does not allow for the visualization of internal structures and anatomical landmarks that would enhance the learner skill performance.

METHODS

Sophomore and junior nursing students attending a large Midwestern Institution (N=69) participated in this mixed methods study. Students demonstrated their ability to place a nasogastric tube (NGT) after being randomly assigned to usual training (Control group) or an iPad anatomy-augmented virtual simulation training module (AR group). The ability of the participants to demonstrate competence in placing the NGT was assessed using a 17-item competency checklist. After the demonstration, students completed a survey to elicit information about students' level of training, prior experience with NGT placement, satisfaction with the AR technology, and perceptions of AR as a potential teaching tool for clinical skills training.

RESULTS

The ability to correctly place the NGT through all the checklist items was statistically significant in the AR group compared with the control group (P = 0.011). Eighty-six percent of participants in the AR group rated AR as superior/far superior to other procedural training programs to which they had been exposed, whereas, only 5.9% of participants in the control group rated the control program as superior/far superior (P < 0.001).

CONCLUSIONS/IMPLICATIONS

Overall the AR module was better received compared with the control group with regards to realism, identifying landmarks, visualization of internal organs, ease of use, usefulness, and promoting learning and understanding.

Persistent Opioid Use Among Pediatric Patients After Surgery

BACKGROUND

Despite efforts to reduce nonmedical opioid misuse, little is known about the development of persistent opioid use after surgery among adolescents and young adults. We hypothesized that there is an increased incidence of prolonged opioid refills among adolescents and young adults who received prescription opioids after surgery compared with nonsurgical patients.

METHODS

We performed a retrospective cohort study by using commercial claims from the Truven Health Marketscan research databases from January 1, 2010, to December 31, 2014. We included opioid-naïve patients ages 13 to 21 years who underwent 1 of 13 operations. A random sample of 3% of nonsurgical patients who matched eligibility criteria was included as a comparison. Our primary outcome was persistent opioid use, which was defined as ≥1 opioid prescription refill between 90 and 180 days after the surgical procedure.

RESULTS

Among eligible patients, 60.5% filled a postoperative opioid prescription (88 637 patients). Persistent opioid use was found in 4.8% of patients (2.7%-15.2% across procedures) compared with 0.1% of those in the nonsurgical group. Cholecystectomy (adjusted odds ratio 1.13; 95% confidence interval, 1.00-1.26) and colectomy (adjusted odds ratio 2.33; 95% confidence interval, 1.01-5.34) were associated with the highest risk of persistent opioid use. Independent risk factors included older age, female sex, previous substance use disorder, chronic pain, and preoperative opioid fill.

CONCLUSIONS

Persistent opioid use after surgery is a concern among adolescents and young adults and may represent an important pathway to prescription opioid misuse. Identifying safe, evidence-based practices for pain management is a top priority, particularly among at-risk patients.

A retrospective comparison of intrathecal morphine and epidural hydromorphone for analgesia following posterior spinal fusion in adolescents with idiopathic scoliosis

BACKGROUND

Posterior spinal fusion to correct idiopathic scoliosis is associated with severe postoperative pain. Intrathecal morphine is commonly used for analgesia after adolescent posterior spinal fusion; however, anticipating and managing the increase in pain scores after resolution of analgesic effect of intrathecal morphine analgesia is challenging. In 2014, we developed a clinical protocol detailing both the administration of intrathecal morphine intraoperatively and the transition to routine, scheduled oral analgesics at 18 h postoperatively. The goal of our study was to examine the efficacy of our intrathecal morphine protocol vs epidural hydromorphone for postoperative analgesia after posterior spinal fusion.

METHODS

Following IRB approval, we retrospectively identified developmentally intact children of ages 10-20 years in our electronic database with a diagnosis of idiopathic scoliosis who had undergone elective posterior spinal fusion surgery from June 2014 to April 2015. For the intrathecal morphine group, intrathecal morphine was administered in a dose of 12 μg·kg^-1 (max 1000 μg) prior to incision. Postoperatively, all children in the intrathecal morphine group had an order to receive oral oxycodone (0.1 mg·kg^-1 , max 5 mg) starting at 18 h postintrathecal morphine injection. For the epidural hydromorphone group, catheters were placed by the surgeon and bolused with 5 μg·kg^-1 hydromorphone (max 200 μg) and 1 μg·kg^-1 fentanyl (max 50 μg), followed by a continuous infusion of 40-60 μg·h^-1 , and patient-controlled bolus doses of 5 μg with a lockout interval of 30 min. All patients in both groups had postoperative orders for acetaminophen, diazepam, and ketorolac.

RESULTS

During the study time period, 20 patients received intrathecal morphine and were successfully matched with 20 patients who received epidural hydromorphone. All patients in the intrathecal morphine group were transitioned to oral analgesics on the first postoperative day, without need for intravenous opioids after discharge from the postanesthesia care unit. Compared to the epidural hydromorphone group, the intrathecal morphine group reported lower pain scores in the postanesthesia care unit (difference in means -4.26 [95% CI -6.56, -1.96], P = 0.001) and first 8 h after surgery (difference in means -1.88 [95% CI -3.84, 0.082, P = 0.060) and higher pain scores on the 2nd postoperative day (difference in means 1.60 [95% CI 0.10, 3.10], P = 0.037). The documented time to ambulation and time of Foley catheter removal were statistically earlier in the intrathecal morphine group, and the hospital length of stay was significantly shorter (3.0 ± 0.5 days vs 3.5 ± 0.7 days; P = 0.03). Adverse events did not significantly differ between the groups.

CONCLUSION

The efficacy of intraoperative intrathecal morphine for postoperative analgesia in the posterior spinal fusion patient population has been shown previously; however, the pain and analgesic trajectory, including transition to other analgesics, has not previously been studied. Our findings suggest that for many patients, use of intrathecal morphine in addition to routine administration of nonopioid medications facilitates direct transition to oral analgesics in the early postoperative period and earlier routine ambulation and discharge of posterior spinal fusion patients.

The STBUR questionnaire for identifying children at risk for sleep-disordered breathing and postoperative opioid-related adverse events

BACKGROUND

Children with symptoms of sleep-disordered breathing (SDB) appear to be at risk for perioperative respiratory events (PRAE). Furthermore, these children may be more sensitive to the respiratory-depressant effects of opioids compared with children without SDB.

AIMS

The aim of this prospective observational study was to confirm that otherwise healthy children with symptoms of SDB are at greater risk for PRAE compared with children with no symptoms and to determine if these children are also at increased risk for postoperative opioid-related adverse events (ORAE).

METHODS

Six hundred and seventy-eight parents of children scheduled for surgery completed the Snoring, Trouble Breathing, and Un-Refreshed (STBUR) questionnaire preoperatively. Data regarding the incidence of PRAE were collected prospectively. Postoperative pulse oximetry desaturation alarm events were downloaded from the institutional secondary alarm notification system.

RESULTS

Children with symptoms of SDB per STBUR (≥3 symptoms) had a two-fold increased likelihood of PRAE compared with children without SDB (52.8% vs 27.9% respectively, LR(+) = 2.00, 95% CI = 1.60-2.49, P = 0.0001). A subset analysis of children undergoing airway procedures requiring hospital admittance (n = 179) showed that those with SDB were given the same postoperative opioid doses as children without SDB. However, children with SDB symptoms generated a greater number of postoperative oxygen desaturation alarms (14.14 ± 29.3 vs 7.12 ± 13.2, mean difference = 7.02, 95% CI = 0.39-13.64, P = 0.038) and more frequently required escalation of care (15.3% vs 7.1%, LR(+) = 1.67, 95% CI = 1.22-2.16, P = 0.001) compared with children with no SDB symptoms.

CONCLUSIONS

Children presenting for surgery with SDB symptoms are at increased risk for PRAE. Children undergoing airway-related procedures also appear to be at increased risk for ORAE. Furthermore, regardless of the preoperative assessment of risk using the STBUR questionnaire, children received the same doses of opioids postoperatively. Given the increased incidence of postoperative oxygen desaturations among children with SDB symptoms, it would seem prudent to consider titration of opioid doses according to identified risk.

Evaluation of emergency pediatric tracheal intubation by pediatric anesthesiologists on inpatient units and the emergency department

BACKGROUND AND OBJECTIVES

There are limited data on pediatric emergency tracheal intubation on inpatient units and in the emergency department by anesthesiologists. This retrospective cohort study was designed to describe the frequency of difficult intubation and adverse events associated with emergency tracheal intubation performed by pediatric anesthesiologists in a large children's hospital.

METHODS

All emergency tracheal intubation on inpatient units and the emergency department performed by pediatric anesthesiologists over a 7-year period in children <18 years were identified by querying our perioperative clinical information system. Medical records were comprehensively reviewed to describe the emergency intubation process and outcomes.

RESULTS

One hundred and thirty-two intubations from 120 children (median age 3.3 years) were eligible. The majority of emergency tracheal intubations were successful with 1-2 laryngoscopy attempts, while 14 (10.6%) were difficult. Despite grade 3 view in 3/14 cases, the airway was secured after multiple direct laryngoscopy attempts. Eleven required use of an alternative airway device to secure the airway. A preexisting airway abnormality or craniofacial abnormality was present in 57% of cases with difficult intubation including half with micrognathia or retrognathia. Major intubation-related adverse events such as aspiration, occurred in 5 (3.8%) emergency tracheal intubations. Mild-to-moderate intubation-related adverse events occurred in 23 (17.4%) emergency tracheal intubations including mainstem bronchus intubation (13.6%).

CONCLUSION

A significant rate of difficult intubation and mild-to-moderate intubation-related adverse events were found in emergency tracheal intubations on inpatient units and the emergency department in children performed by a pediatric anesthesiology emergency airway team. Difficult intubation was observed frequently in children with preexisting airway and craniofacial abnormalities and often required the use of an alternative airway device to successfully secure the airway.

Pain outcomes in children who received intrathecal vs intravenous opioids for pain control following major urologic surgery: a retrospective review

BACKGROUND

Intrathecal (IT) opioid administration has been associated with postoperative benefits including reduced pain and opioid use in children. However, the postoperative benefits and risks of IT opioid administration during major urologic surgery in children remain unclear.

AIM

The aim of this study was to compare postoperative pain and adverse event outcomes among children who received IT vs intravenous (IV) opioids during major urologic surgery.

METHODS

We reviewed the medical records of children 3-17 years of age who underwent ureteroneocystostomy or pyeloplasty between 2006 and 2012. Electronically captured anesthetic and surgical data, postanesthesia care recovery unit (PACU) and nursing flowsheets, and daily progress notes through hospital discharge were reviewed. Analgesic techniques (i.e., IT or IV patient/nurse controlled opioids), all analgesic drugs and doses were recorded. Outcome measures included pain scores, need for rescue analgesics, opioid-related adverse events, and their treatments.

RESULTS

Seventy-seven children received IT opioids and 51 received IV opioids. More children in the IV group required rescue analgesics and had higher pain scores at PACU discharge. Children in the IV group required rescue opioids more frequently than the IT group from 0 to 8 h and 8 to 16 h after PACU discharge, but rates were similar by 16-24 h 70% of children in IT group transitioned directly to oral opioids. Seven IT placements were considered as failed due to early need for rescue opioids. Four (8%) of the IV group and seven (9%) of the IT group experienced oxygen desaturation. Two of these, both in IT group required naloxone and one was admitted to ICU for observation. The IT group experienced a higher incidence of pruritus, constipation and hypotension.

CONCLUSION

We observed better postoperative pain control in children who received IT vs IV opioids for the first 16 h with no discernible difference thereafter. The intrathecal group experienced higher incidences of pruritus, constipation, and hypotension.

Urethrocutaneous fistula following hypospadias repair: regional anesthesia and other factors

BACKGROUND

Urethrocutaneous fistula is a well-known complication of hypospadias surgery. A recent prospective study by Kundra et al. (Pediatr Anesth 2012) has suggested that caudal anesthesia may increase the risk of fistula formation. We sought to evaluate this possible association and determine if any other novel factors may be associated with fistula formation.

METHODS

Children who underwent primary hypospadias repair between January 1, 1994 and March 31, 2013 at our tertiary care center were included in this study. Reviewed surgical data included repair type, duration of procedure, use of local anesthetic infiltration, and subcutaneous epinephrine. Analgesic factors included use of caudal and/or penile block, opioid usage, postoperative pain scores, and nausea/vomiting. Postoperative surgical complications and estimates of family household median income by zip code were also reviewed.

RESULTS

Fistula occurrence was not associated with caudal or penile block, severity of postoperative pain, or surgeon experience. A more proximal location of the urethral meatus, longer operating time, and use of subcutaneous epinephrine were significantly more common in patients who developed fistula. As assessed by home address zip code, distance of more than 100 miles and median household income in the bottom 25th percentile of our study population were not associated with fistula, as compared to closer distance or higher income.

CONCLUSION

In this series, we found no association between the use of caudal regional anesthesia and fistula formation. Location of the starting urethral meatus, prolonged surgical duration, and subcutaneous epinephrine use were associated with fistula formation. Our findings call into question the routine use of epinephrine in hypospadias repair.

Sleep-Disordered Breathing--Not Just for Grownups Anymore

Previous research on SDB in children has focus edprimarily on OSA, whereas there is an increasing body of evidence to suggest that children with a spectrum of SDB symptoms may be at risk for perioperative and postoperative adverse events. To this end, it is imperative that these children are identified before surgery so that anesthesia and postoperative pain management plans can be optimized to mitigate risk. Although PSG remains the gold standard as a means to screen for SDB preoperatively,there are now clinically valid tools that can be used as part of the preanesthetic interview to identify children at risk. However, although recent work suggests that implementation of such screening tools may be important in identifying at-risk children and reducing perioperative adverse events through changes in anesthetic management, there is still much to be done with respect to changing the culture of standard postoperative opioid dosing. Perianesthesia nurses are thus in a unique position to help encourage a culture in which SDB in children is recognized asa significant risk for both perioperative and potentially deadly postoperative sequelae.

A comparison of the postoperative pain experience in children with and without attention-deficit hyperactivity disorder (ADHD)

BACKGROUND

Children with attention-deficit hyperactivity disorder (ADHD) may experience pain differently compared to other children, yet the evidence is equivocal regarding whether pain is heightened or dampened. This prospective observational study, therefore, was designed to compare the postoperative pain experiences in children with and without ADHD.

METHODS

Children aged 7-17 years with a diagnosis of ADHD (n = 119) who were scheduled for a surgical procedure requiring postoperative pain management and a matched cohort of children without ADHD were recruited (n = 122). Postoperative pain scores and analgesic use were recorded for 1 week, as was parents' estimate of their child's return to normal activity.

RESULTS

There were no differences in highest pain scores between children with ADHD (3.3 ± 2.5, 0-10 numerical rating scale) and those without (2.8 ± 1.9). Postoperative opioid use was also similar on day 1 following surgery (0.12 ± 0.3 mg·kg(-1) vs 0.08 mg·kg(-1 ) ± 0.1 morphine equivalents, respectively). Children with ADHD, however, had a significantly longer return to normal activity (4.9 ± 3.8 vs 3.8 ± 3.0 days; P < 0.05).

CONCLUSIONS

Results suggest that there were no differences in the postoperative pain experiences of children with and without ADHD. However, the observation that children with ADHD took longer to return to baseline activity will be important in educating parents regarding their child's postoperative experience.