Consideration should be given to a floor-based postoperative management regimen for this patient population.

Practice guidelines recommend nonopioid medications in children after tonsillectomy, but to date, studies have not used recent national data to assess perioperative opioid prescribing patterns or the factors associated with these patterns in this population. Closing this knowledge gap may help in assessing whether such prescribing and prescription duration could be safely reduced. OBJECTIVE To assess national perioperative opioid prescribing patterns, clinical and demographic factors associated with these patterns, and association between these patterns and complications in children after tonsillectomy compared with children not using opioids. DESIGN, SETTING, AND PARTICIPANTS This cohort analysis used the 2016 to 2017 claims data from the database of a large national private insurer in the United States. Opioid-naive children aged 1 to 18 years with a claims code for tonsillectomy with or without adenoidectomy between April 1, 2016, and December 15, 2017, were identified (n = 22 567) and screened against the exclusion criteria. The final sample included 15 793 children. MAIN OUTCOMES AND MEASURES The percentage of children with 1 or more perioperative fills (prescription drug claims for opioids between 7 days before to 1 day after tonsillectomy) was calculated, along with the duration of perioperative prescriptions (days supplied). Linear regression was used to identify the demographic and clinical factors associated with the duration of perioperative opioid prescriptions. Logistic regression was used to assess the association between having 1 or more perioperative fills and their duration and the risk of return visits 2 to 14 days after tonsillectomy for pain or dehydration, secondary hemorrhage, and constipation compared with children not using opioids. RESULTS Among 15 793 children, the mean (SD) age was 7.8 (4.2) years, 12 807 (81.1%) were younger than 12 years, 2986 (18.9%) were between 12 and 18 years of age, and 8289 (52.6%) were female. In total, 9411 (59.6%) children had 1 or more perioperative fills, and the median (25th-75th percentile) duration was 8 (6-10) days; 6382 had no perioperative fills. The probability of having 1 or more perioperative fills and the duration of prescription varied across US census divisions. Having 1 or more perioperative fills was not associated with return visits for pain or dehydration (adjusted odds ratio [AOR], 1.13; 95% CI, 0.95-1.34) or secondary hemorrhage (AOR, 0.90; 95% CI, 0.73-1.10) compared with children not using opioids, but it was associated with increased risk of return visits for constipation (AOR, 2.02; 95% CI, 1.24-3.28). Duration was not associated with return visits for complications. CONCLUSIONS AND RELEVANCE These findings suggest that reducing perioperative opioid prescribing and the duration of perioperative opioid prescriptions may be possible without increasing the risk of these complications.

ecurrent respiratory papillomatosis (RRP) is a disease characterized by benign papillomatous lesions of the upper airway that often cause debilitating dysphonia and may result in airway obstruction. Because of its recurrent nature, multiple surgical excisions are required to manage RRP, resulting in patient morbidity and high health care use. 1,2 Intralesional injections of the antiviral medication cidofovir have been used in an attempt to decrease the frequency of excisions and reduce the burden of disease for the patient 3,4 ; however, there have been concerns that cidofovir may produce adverse effects, including increased risk of malignant transformation. 5 Although several studies have found no increased risk of cancer in patients with RRP who are treated with cidofovir, [6][7][8][9][10][11] the safety profile of intralesional cidofovir injection in patients with RRP is not fully understood. Understanding the safety of intralesional cidofovir is essential for otolaryngologists treating patients with RRP with a high burden of disease who may be seeking adjuvant therapies. This study aims to provide further data on the safety of intralesional adjuvant cidofovir to inform physicians in their decision to offer this treatment to patients.Recurrent respiratory papillomatosis results from human papillomavirus infection, most commonly with subtypes 6 and 11. 12,13 Human papillomavirus is thought to infect the stem cells within the basal layer of the epithelium and either cause active disease or remain dormant. 14 The lesions of RRP IMPORTANCE The use of intralesional cidofovir injections for recurrent respiratory papillomatosis (RRP) remains controversial owing to concern regarding the risks of its use, including increased risk of dysplasia or carcinogenesis.OBJECTIVE To describe the rates of dysplasia, development of malignant lesions, and adverse events associated with use of intralesional cidofovir injections as adjuvant treatment for RRP compared with patients treated without adjuvant cidofovir. DESIGN, SETTING, AND PARTICIPANTSIn this case series performed at a tertiary care referral center, review of electronic medical records on all adult and pediatric patients (N = 154) treated for RRP with adequate follow-up from January 1, 2000, to December 31, 2016, was performed. Data were collected on the use of cidofovir, development and presence of dysplasia or malignant lesions, complications, and intersurgical interval.EXPOSURES Adjuvant intralesional cidofovir or surgical excision only. MAIN OUTCOMES AND MEASURESThe main outcomes measured were the development of dysplasia, malignant lesions, and complications from treatment. These outcomes were determined before collection of data. RESULTSOf the 154 patients included in the analysis, 83 patients (53.9%) received adjuvant intralesional cidofovir and 71 patients (46.1%) underwent surgical excision only. One hundred patients (64.9%) were male; mean age was 27.7 (95% CI, 24.3-31.2) years. Patients were followed up for a median (interquartile range) of 70 (24-118) mont...

No abstract

From 1999 to 2016, opioid-related overdoses rose by 250% among children and adolescents. 1 Acute pain after surgery or injury is the most frequent indication for pediatric opioid prescribing. 2 However, prescribing is variable, and little is known regarding patient-reported opioid consumption and pain after pediatric operations to guide opioid prescribing. 3,4 Methods | As part of a multispecialty quality improvement project to reduce opioid prescribing, this study was deemed exempt by the University of Michigan institutional review board. Children younger than 18 years undergoing umbilical or epigastric herniorrhaphy; laparoscopic appendectomy; inguinal herniorrhaphy and/or hydrocelectomy; adenoidectomy; circumcision; percutaneous pinning for elbow fracture (supracondylar, epicondylar, or condylar); or scrotal-incision orchiopexy at a tertiary care facility were screened for eligibility (April 2018 to November 2018). Exclusion criteria were enrollment in another study, admission greater than 7 days, and any previous or concurrent operations during the study period.Caregivers received pain journals to record postoperative analgesic use. Caregivers were contacted at 7 to 21 days postoperatively by telephone, email, or follow-up appointment regarding pain control and analgesic use. Verbal consent was obtained prior to survey administration. Outpatient opioid prescriptions and emergency department (ED) visits within 30 days of discharge were collected from the electronic medical record. Number of doses was calculated as total quantity divided by minimum dose. Missing responses were excluded on