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Mitchell R.B.,Southwestern Medical Center | Mitchell R.B.,Children's Medical Center Dallas | Hussey H.M.,Surgery Academy | Setzen G.,United Allergy Services | And 8 more authors.
Otolaryngology - Head and Neck Surgery (United States) | Year: 2013

Objective. This clinical consensus statement (CCS) aims to improve care for pediatric and adult patients with a tracheostomy tube. Approaches to tracheostomy care are currently inconsistent among clinicians and between different institutions. The goal is to reduce variations in practice when managing patients with a tracheostomy to minimize complications. Methods. A formal literature search was conducted to identify evidence gaps and refine the scope of this consensus statement. The modified Delphi method was used to refine expert opinion and facilitate a consensus position. Panel members were asked to complete 2 scale-based surveys addressing different aspects of pediatric and adult tracheostomy care. Each survey was followed by a conference call during which results were presented and statements discussed. Results. The panel achieved consensus on 77 statements; another 39 were dropped because of lack of consensus. Consensus was reached on statements that address initial tracheostomy tube change, management of emergencies and complications, prerequisites for decannulation, management of tube cuffs and communication devices, and specific patient and caregiver education needs. Conclusion. The consensus panel agreed on statements that address the continuum of care, from initial tube management to complications in children and adults with a tracheostomy. The panel also highlighted areas where consensus could not be reached and where more research is needed. This consensus statement should be used by physicians, nurses, and other stakeholders caring for patients with a tracheostomy. © American Academy of Otolaryngology-Head and Neck Surgery Foundation 2013.

Roland P.S.,University of Texas at Dallas | Rosenfeld R.M.,SUNY Downstate Medical Center | Brooks L.J.,Children's Hospital of Philadelphia | Friedman N.R.,Childrens Hospital | And 8 more authors.
Otolaryngology - Head and Neck Surgery | Year: 2011

Objective. This guideline provides otolaryngologists with evidence-based recommendations for using polysomnography in assessing children, aged 2 to 18 years, with sleep-disordered breathing and are candidates for tonsillectomy, with or without adenoidectomy. Polysomnography is the electrographic recording of simultaneous physiologic variables during sleep and is currently considered the gold standard for objectively assessing sleep disorders. Purpose. There is no current consensus or guideline on when children 2 to 18 years of age, who are candidates for tonsillectomy, are recommended to have polysomnography. The primary purpose of this guideline is to improve referral patterns for polysomnography among these patients. In creating this guideline, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of anesthesiology, pulmonology medicine, otolaryngology-head and neck surgery, pediatrics, and sleep medicine. Results. The committee made the following recommendations: (1) before determining the need for tonsillectomy, the clinician should refer children with sleep-disordered breathing for polysomnography if they exhibit certain complex medical conditions such as obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses. (2) The clinician should advocate for polysomnography prior to tonsillectomy for sleep-disordered breathing in children without any of the comorbidities listed in statement 1 for whom the need for surgery is uncertain or when there is discordance between tonsillar size on physical examination and the reported severity of sleep-disordered breathing. (3) Clinicians should communicate polysomnography results to the anesthesiologist prior to the induction of anesthesia for tonsillectomy in a child with sleep-disordered breathing. (4) Clinicians should admit children with obstructive sleep apnea documented on polysomnography for inpatient, overnight monitoring after tonsillectomy if they are younger than age 3 or have severe obstructive sleep apnea (apnea-hypopnea index of 10 or more obstructive events/hour, oxygen saturation nadir less than 80%, or both). (5) In children for whom polysomnography is indicated to assess sleep-disordered breathing prior to tonsillectomy, clinicians should obtain laboratory-based polysomnography, when available. © American Academy of Otolaryngology - Head and Neck Surgery Foundation 2011.

Pandharipande P.P.,Vanderbilt University | Girard T.D.,Vanderbilt University | Girard T.D.,Geriatric Research Education and Clinical Center | Jackson J.C.,United Allergy Services | And 22 more authors.
New England Journal of Medicine | Year: 2013

BACKGROUND: Survivors of critical illness often have a prolonged and disabling form of cognitive impairment that remains inadequately characterized. METHODS: We enrolled adults with respiratory failure or shock in the medical or surgical intensive care unit (ICU), evaluated them for in-hospital delirium, and assessed global cognition and executive function 3 and 12 months after discharge with the use of the Repeatable Battery for the Assessment of Neuropsychological Status (population age-adjusted mean [±SD] score, 100±15, with lower values indicating worse global cognition) and the Trail Making Test, Part B (population age-, sex-, and education-adjusted mean score, 50±10, with lower scores indicating worse executive function). Associations of the duration of delirium and the use of sedative or analgesic agents with the outcomes were assessed with the use of linear regression, with adjustment for potential confounders. RESULTS: Of the 821 patients enrolled, 6% had cognitive impairment at baseline, and delirium developed in 74% during the hospital stay. At 3 months, 40% of the patients had global cognition scores that were 1.5 SD below the population means (similar to scores for patients with moderate traumatic brain injury), and 26% had scores 2 SD below the population means (similar to scores for patients with mild Alzheimer's disease). Deficits occurred in both older and younger patients and persisted, with 34% and 24% of all patients with assessments at 12 months that were similar to scores for patients with moderate traumatic brain injury and scores for patients with mild Alzheimer's disease, respectively. A longer duration of delirium was independently associated with worse global cognition at 3 and 12 months (P=0.001 and P=0.04, respectively) and worse executive function at 3 and 12 months (P=0.004 and P=0.007, respectively). Use of sedative or analgesic medications was not consistently associated with cognitive impairment at 3 and 12 months. CONCLUSIONS: Patients in medical and surgical ICUs are at high risk for long-term cognitive impairment. A longer duration of delirium in the hospital was associated with worse global cognition and executive function scores at 3 and 12 months. Copyright © 2013 Massachusetts Medical Society.

Moore M.,United Allergy Services | Tucker M.,Naval Medical Center | Grier T.,Greer Laboratories | Quinn J.,United Allergy Services
Annals of Allergy, Asthma and Immunology | Year: 2010

Background: Allergen extracts can degrade when exposed to temperatures significantly beyond the optimum storage recommendation of 4°C. Many allergen extracts are mailed to their final destinations throughout the year with exposure to varied environmental conditions. Objective: To evaluate the effect of summer mailing on the in vitro and in vivo potency of timothy grass extract. Methods: Standardized timothy grass extracts, 10,000 and 100,000 BAU/mL, were mailed round-trip between San Antonio, Texas, and Phoenix, Arizona, during August 2007. In-transit temperatures were recorded using a portable temperature logger. After mailing of the extracts, we performed quantitative in vitro enzyme-linked immunosorbent assay inhibition and in vivo ID 50EAL (Intradermal Dilution for 50-mm Sum of Erythema Determines Bioequivalent Allergy Units) analysis. Results: Measured extract exposure temperatures were greater than 20°C for 11 days and 30°C for 6 hours during standard mailing in weather temperatures exceeding 38°C. Enzyme-linked immunosorbent assay inhibition results for the 100,000- and 10,000-BAU/mL control samples were 97,900 and 10,580 BAU/mL, respectively, and for the mailed extracts were 96,800 and 7,830 BAU/mL, respectively. These measurements fell within the current Food and Drug Administration lot release limits (67%-149%) and stability limits (50%-200%) relative to the standardized reference. The ID50EAL determinations of the control vs mailed extracts were 12.98 vs 12.28, 12.66 vs 12.32, and 11.97 vs 11.70 for the 3 patients. These differences were not statistically significant. Conclusions: Mailing of timothy grass extract produced no significant reductions in in vitro relative potencies or in vivo skin test reactivity in 3 sensitive patients. © 2010 American College of Allergy, Asthma & Immunology.

Schaffer F.M.,United Allergy Services | Schaffer F.M.,Medical University of South Carolina | Naples A.R.,United Allergy Services | Ebeling M.,Medical University of South Carolina | And 2 more authors.
International Forum of Allergy and Rhinology | Year: 2015

Background: Self-administered allergen immunotherapy is considered controversial. We believe the implementation of a self-administration protocol characterized by patient preselection and a slow buildup phase is safe. Methods: We analyzed 23,614 patient records and associated immunotherapy injections for systemic reactions (SR) during a 1-year period (2011 to 2012). SRs were graded in accordance with the World Allergy Organization (WAO) criteria. Results: Thirty-seven SRs were reported for 23,614 patients who self-administered 2,021,600 injections yielding an annual SR rate of 0.16% (per patient) or 0.002% (per injection). Only 9 of 4643 pediatric (0.19%) and 28 of 18,971 adult patients (0.15%) experienced 1 or more SRs. No deaths (grade V SR) occurred. From 2009 through early 2014, over 90,000 patients received more than 10 million injections in accordance with the United Allergy Services (UAS) protocol without fatalities. Conclusion: We believe this safety profile is due to a preselection of patients to exclude those with a high risk for adverse reactions and a slow immunotherapy buildup phase. In contrast, previous studies documented office-based SRs ranging from approximately 3% to greater than 14%. Thus, the UAS home-immunotherapy SR rate is significantly lower than office-based immunotherapy SR rates (p < 0.0001). The enhanced safety of this protocol results in a decreased frequency and severity of SRs. This safety report, derived from analyses of one of the largest patient cohorts studied, corroborates and expands the observations of previous studies of self-administered subcutaneous immunotherapy in a low-risk patient population by assessing self-administered allergen immunotherapy during the buildup and maintenance phases. © 2014 ARS-AAOA, LLC.

Pun B.T.,Vanderbilt University | Pun B.T.,United Allergy Services | Boehm L.,United Allergy Services
AACN Advanced Critical Care | Year: 2011

A significant portion of critical care patients experience delirium. This form of acute brain dysfunction is associated with increased hospital stay, increased mortality, and greater long-term cognitive deficits. Critical care nurses are on the frontline with these patients and can make a significant impact on patient outcomes, including reducing the negative outcomes and experience of delirium. It is, therefore, imperative that nurses be equipped with a solid knowledge base of understanding delirium, which includes what has been reported specifically unique to delirium in the intensive care unit. This article will provide an overview of delirium and describe an interdisciplinary model of care combining multiple evidence-based practice strategies that nurses can and should use to help systematically reduce modifiable delirium risk factors. In addition, this article will provide an overview of recent reports concerning pharmacologic management of delirium in the intensive care unit. Copyright © 2011 American Association of Critical-Care Nurses.

Schaffer F.M.,United Allergy Services | Schaffer F.M.,Medical University of South Carolina | Garner L.M.,United Allergy Services | Ebeling M.,Medical University of South Carolina | And 3 more authors.
International Forum of Allergy and Rhinology | Year: 2016

Background: We previously reported the safety of a self-administered subcutaneous immunotherapy (SCIT) protocol. Here we report the results of the retrospective efficacy trial of the United Allergy Service (UAS) self-administered SCIT protocol. We hypothesized that by utilizing a slow SCIT buildup phase, designed to attain recommended allergen concentrations on a cumulative basis, efficacious outcomes and clinical relevance would be achieved. Methods: We enrolled 60 SCIT patients and 56 control patients. The study contrasted baseline and treatment period combined symptom plus medication scores (CSMS) as the primary outcome measure and rhinoconjunctivitis quality of life questionnaire (RQLQ) scores as the secondary study outcome measure. Changes in pollen counts were also examined with regard to effects on these efficacy parameters. Results: The treatment group showed significantly improved CSMS (standardized mean difference [SMD]: -1.57; 95% confidence interval [CI], -1.97 to -1.18; p < 0.001) and RQLQ (SMD: -0.91; 95% CI, -1.23 to -0.59; p < 0.001). These treatment group outcome measures were respectively improved by 33% and 29% compared to baseline and greater than 40% in comparison to the control group (p < 0.0001). Significant results were also shown when examining these outcome measures with regards to either monotherapy or poly-allergen SCIT. Furthermore, a comparison to recent meta-analyses of SCIT studies showed equivalent efficacy and clinical relevance. Assessment of pollen counts during the baseline and treatment periods further corroborated the efficacy of the UAS SCIT protocol. Conclusion: These efficacy results, and our previous safety results, show that a carefully designed and implemented self-administered SCIT protocol is efficacious and safe. © 2016 ARS-AAOA, LLC.

Navaie M.,Advance Health | Sharghi L.H.,Advance Health | Cho-Reyes S.,Advance Health | Keefe M.A.,Sharp Rees Stealy Medical Group | And 2 more authors.
Otolaryngology - Head and Neck Surgery (United States) | Year: 2014

Data Sources. Medline, EMBASE, and Cochrane databases.Objective. This review examined the diagnostic approach, surgical treatment, and outcomes of cervical sympathetic chain schwannomas (CSCS) to guide clinical decision making.Review Methods. A literature review from 1998 to 2013 identified 156 articles of which 51 representing 89 CSCS cases were evaluated in detail. Demographic, clinical, and outcomes data were extracted by 2 independent reviewers with high interrater reliability (k = .79). Cases were mostly international (82%), predominantly from Asia (50%) and Europe (27%).Conclusions. On average, patients were 42.6 years old (SD = 13.3) and had a neck mass ranging between 2 to 4 cm (52.7%) or .4 cm (43.2%). Nearly 70% of cases were asymptomatic at presentation. Presurgical diagnosis relied on CT (63.4%), MRI (59.8%), or both (19.5%), supplemented by cytology (33.7%), which was nearly always inconclusive (96.7%). US-treated cases were significantly more likely to receive presurgical MRI than internationally treated cases but less likely to have cytology (P<.05). Presurgical diagnosis was challenging, with only 11% confirmatory accuracy postsurgically. Irrespective of mass size, extracapsular resection (ie, complete resection with nerve sacrifice) was the most frequently (87.6%) performed surgical procedure. Common postsurgical adverse events included Horners syndrome (91.1%), first bite syndrome (21.1%), or both (15.7%), with higher prevalence when mass size was .4 cm. Adverse events persisted in 82.3% of cases at an average 30.0 months (SD = 30.1) follow-up time.Implications for Practice. Given the typical CSCS patient is young and asymptomatic and the likelihood of persistent morbidity is high with standard surgical approaches, less invasive treatment options warrant consideration. © American Academy of Otolaryngology - Head and Neck Surgery Foundation 2014.

SAN ANTONIO, Texas, Oct. 31, 2016 (GLOBE NEWSWIRE) -- United Allergy Services celebrates their partnership with the San Antonio Hispanic Chamber of Commerce (SAHCC) by receiving a commemorative plaque to display in their new home office. United Allergy Services has recently moved into a new office space which was designed with collaboration and their employees in mind. With state-of-the-art office technology, treadmills, table tennis, at-cost snack bar and private and open work spaces available, United Allergy Services has created a work environment that aligns with the opportunities that SAHCC encourages for the Hispanic community of San Antonio. "We are thrilled to welcome United Allergy Services to the San Antonio Hispanic Chamber of Commerce family," said Ramiro Cavazos, President & CEO, SAHCC. "Through this new partnership, we look forward to working together on mutually beneficial programs and resources to help them grow their business." According to the American Academy of Allergy, Asthma & Immunotherapy, over sixty million Americans suffer from allergies. United Allergy Services continues to work with providers within the San Antonio area, as well as health care providers in twenty states across the nation, to provide allergy services to allergy sufferers in need. About United Allergy Services: United Allergy Services ™ (UAS) brings effective and convenient allergy testing and immunotherapy to primary care physicians; pulmonologists; ENT physicians; pediatricians; internal medicine physicians; and healthcare systems that treat the vast majority of patients with seasonal and perennial allergies. UAS' complete service line features in-office UAS Certified Clinical Allergy Specialist staffing and training; quality assurance and regulatory compliance; and supply and inventory management. By empowering physicians to safely administer allergy testing and immunotherapy treatment, UAS has effectively expanded access to immunotherapy to more than 60 million U.S. residents currently suffering from seasonal and perennial allergies. About San Antonio Hispanic Chamber of Commerce: Founded in 1929, America's first Hispanic Chamber and San Antonio's only Five-Star accredited organization by the U.S. Chamber of Commerce, the San Antonio Hispanic Chamber of Commerce continues to be the leader in business assistance, connecting its members to needed resources, providing procurement, marketing and networking opportunities, advocating for legislation affecting small businesses and corporations in the San Antonio metropolitan area, and better training to develop the skills of our local workforce. The San Antonio Hispanic Chamber of Commerce is San Antonio's largest independent business organization with more than 1,300 members. Photos accompanying this release are available at:

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