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Mehl SC, Portuondo JI, Tian Y, Raval MV, King A, Rialon KL, Vogel AM, Wesson DE, Shah SR, Massarweh NN. Hospital Variation in Mortality and Failure to Rescue after Surgery for High-Risk Neonatal Diagnoses. Neonatology 2023; 121:34-45. [PMID: 37844560 DOI: 10.1159/000533825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/23/2023] [Indexed: 10/18/2023]
Abstract
INTRODUCTION A large proportion of postoperative mortality after pediatric surgery occurs among neonates with specific high-risk diagnoses. The extent to which there is hospital-level mortality variation among patients with these diagnoses and whether this variation is associated with differences in failure to rescue (FTR) is unclear. METHODS The Pediatric Health Information System® database (2012-2020) was used to identify patients who underwent surgery for eight high-risk neonatal diagnoses: gastroschisis; volvulus; necrotizing enterocolitis; intestinal atresia; meconium peritonitis; tracheoesophageal fistula; congenital diaphragmatic hernia; and perinatal intestinal perforation. Hospitals were stratified into tertiles of reliability-adjusted inpatient mortality rates (lower than average mortality - tertile 1 [T1]; higher than average mortality - tertile 3 [T3]). Multivariable hierarchical regression was used to evaluate the association between hospital-level, reliability-adjusted mortality and FTR. RESULTS Overall, 20,838 infants were identified across 48 academic, pediatric hospitals. Adjusted hospital mortality rates ranged from 4.0% (95% CI, 0.0-8.2) to 16.3% (12.2-20.4). Median case volume (range, 80-1,238) and number of NICU beds (range, 24-126) were not significantly different across hospital tertiles. Compared to the hospitals with the lowest postoperative mortality (T1), the odds of FTR were significantly higher in hospitals with the highest (T3) postoperative mortality (odds ratio 1.97 [1.50-2.59]). CONCLUSIONS Significant variation in neonatal hospital mortality for high-risk diagnoses does not appear to be explained by hospital structural characteristics. Rather, difference in FTR suggests quality improvement interventions targeting early recognition and management of postoperative complications could improve surgical quality and safety for high-risk neonatal care.
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Affiliation(s)
- Steven C Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Jorge I Portuondo
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Yao Tian
- Surgical Outcomes and Quality Improvement Center, Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Mehul V Raval
- Surgical Outcomes and Quality Improvement Center, Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Kristy L Rialon
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Adam M Vogel
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - David E Wesson
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | | | - Nader N Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, Georgia, USA
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
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Mehl SC, Portuondo JI, Fallon SC, Shah SR, Wesson DE, Vogel AM, King A, Lopez ME, Massarweh NN. Variation in Complications and Mortality According to Infant Diagnosis. Ann Surg 2023; 278:e165-e172. [PMID: 35943204 DOI: 10.1097/sla.0000000000005658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Investigate patterns of infant perioperative mortality, describe the infant diagnoses with the highest mortality burden, and evaluate the association between types of postoperative complications and mortality in infants. BACKGROUND The majority of mortality events in pediatric surgery occur among infants (ie, children <1 y old). However, there is limited data characterizing patterns of infant perioperative mortality and diagnoses that account for the highest proportion of mortality. METHODS Infants who received inpatient surgery were identified in the National Surgical Quality Improvement Program-Pediatric database (2012-2019). Perioperative mortality was stratified into mortality associated with a complication or mortality without a complication. Complications were categorized as wound infection, systemic infection, pulmonary, central nervous system, renal, or cardiovascular. Multivariable logistic regression was used to evaluate the association between different complications and complicated mortality. RESULTS Among 111,946 infants, the rate of complications and perioperative mortality was 10.4% and 1.6%, respectively. Mortality associated with a complication accounted for 38.8% of all perioperative mortality. Seven diagnoses accounted for the highest proportion of mortality events (40.3%): necrotizing enterocolitis (22.3%); congenital diaphragmatic hernia (7.3%); meconium peritonitis (3.8%); premature intestinal perforation (2.5%); tracheoesophageal fistula (1.8%); gastroschisis (1.4%); and volvulus (1.1%). Relative to wound complications, cardiovascular [odds ratio (OR): 19.4, 95% confidence interval (95% CI): 13.9-27.0], renal (OR: 6.88; 4.65-10.2), and central nervous system complications (OR: 6.50; 4.50-9.40) had the highest odds of mortality for all infants. CONCLUSIONS A small subset of diagnoses account for 40% of all infant mortality and specific types of complications are associated with mortality. These data suggest targeted quality improvement initiatives could be implemented to reduce adverse surgical outcomes in infants.
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Affiliation(s)
- Steven C Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Jorge I Portuondo
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Sara C Fallon
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Sohail R Shah
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - David E Wesson
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Adam M Vogel
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Monica E Lopez
- Department of Pediatric Surgery, Section of Surgical Sciences, Vanderbilt University, Nashville, TN
| | - Nader N Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, GA
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA
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Mehl SC, Portuondo JI, Pettit RW, Fallon SC, Wesson DE, Massarweh NN, Shah SR, Lopez ME, Vogel AM. Association of red blood cell transfusion volume with postoperative complications and mortality in neonatal surgery. J Pediatr Surg 2022; 57:492-500. [PMID: 35148899 PMCID: PMC9271128 DOI: 10.1016/j.jpedsurg.2021.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/06/2021] [Accepted: 12/30/2021] [Indexed: 10/31/2022]
Abstract
INTRODUCTION Red blood cell transfusion (RBCT) is commonly administered in neonatal surgical care in the absence of clear clinical indications such as active bleeding or anemia. We hypothesized that higher RBCT volumes are associated with worse postoperative outcomes. METHODS Neonates within the National Surgical Quality Improvement Program-Pediatric database who underwent inpatient surgery (2012-2016) were stratified by weight-based RBCT volume: <20cc/kg, 20-40cc/kg, and >40cc/kg. Postoperative complications were categorized as wound, systemic infection, central nervous system (CNS), renal, pulmonary, and cardiovascular. Multivariable logistic regression and cubic spline analysis were used to evaluate the association between RBCT volume, postoperative complications, and 30-day mortality. Sensitivity analysis was conducted by performing propensity score matching. RESULTS Among 9,877 neonates, 1,024 (10%) received RBCTs. Of those who received RBCT, 53% received <20cc/kg, 27% received 20-40cc/kg, and 20% received >40cc/kg. Relative to neonates who were not transfused, RBCT volume was associated with a dose-dependent increase in renal complications, CNS complications, cardiovascular complications, and 30-day mortality. With cubic spline analysis, a lone inflection point for 30-day mortality was identified at a RBCT volume of 30 - 35 cc/kg. After propensity score matching, the dose-dependent relationship was still present for 30-day mortality. CONCLUSION Total RBCT volume is associated with worse postoperative outcomes in neonates with a significant increase in 30-day mortality at a RBCT volume of 30 - 35 cc/kg. Future prospective studies are needed to better understand the association between large RBCT volumes and poor outcomes after neonatal surgery. LEVEL OF EVIDENCE Level IV, Retrospective cohort study.
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Affiliation(s)
- Steven C Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States, Department of Surgery, Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, United States
| | - Jorge I Portuondo
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Rowland W Pettit
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Sara C Fallon
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States, Department of Surgery, Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, United States
| | - David E Wesson
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States, Department of Surgery, Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, United States
| | - Nader N Massarweh
- Atlanta VA Health Care System, Decatur, GA, United States, Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States, Department of Surgery, Morehouse School of Medicine, Atlanta, GA, United States
| | - Sohail R Shah
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States, Department of Surgery, Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, United States
| | - Monica E Lopez
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Adam M Vogel
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States; Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States.
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Mehl SC, Portuondo JI, Pettit RW, Fallon SC, Wesson DE, Shah SR, Vogel AM, Lopez ME, Massarweh NN. Association of prematurity with complications and failure to rescue in neonatal surgery. J Pediatr Surg 2022; 57:268-276. [PMID: 34857374 PMCID: PMC9125744 DOI: 10.1016/j.jpedsurg.2021.10.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/15/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The majority of failure to rescue (FTR), or death after a postoperative complication, in pediatric surgery occurs among infants and neonates. The purpose of this study is to evaluate the association between gestational age (GA) and FTR in infants and neonates. METHODS National cohort study of 46,452 patients < 1 year old within the National Surgical Quality Improvement Program-Pediatric database who underwent inpatient surgery. Patients were categorized as preterm neonates, term neonates, or infants. Neonates were stratified based on GA. Surgical procedures were classified as low- (< 1% mortality) or high-risk (≥ 1%). Multivariable logistic regression and cubic splines were used to evaluate the association between GA and FTR. RESULTS Preterm neonates had the highest FTR (28%) rates. Among neonates, FTR increased with decreasing GA (≥ 37 weeks, 12%; 33-36 weeks, 15%; 29-32 weeks, 30%; 25-28 weeks 41%; ≤ 24 weeks, 57%). For both low- and high-risk procedures, FTR significantly (trend test, p < 0.01) increased with decreasing GA. When stratifying preterm neonates by GA, all GAs ≤ 28 weeks were associated with significantly higher odds of FTR for low- (OR 2.47, 95% CI [1.38-4.41]) and high-risk (OR 2.27, 95% CI [1.33-3.87]) procedures. A lone inflection point for FTR was identified at 31-32 weeks with cubic spline analysis. CONCLUSIONS The dose-dependent relationship between decreasing GA and FTR as well as the FTR inflection point noted at GA 31-32 weeks can be used by stakeholders in designing quality improvement initiatives and directing perioperative care. LEVEL OF EVIDENCE Level IV, Retrospective cohort study.
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Affiliation(s)
- Steven C. Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, MS390, Houston, TX 77030, United States,Department of Surgery, Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, United States,Corresponding author at: Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, MS390, Houston, TX 77030, United States. (S.C. Mehl)
| | - Jorge I. Portuondo
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, MS390, Houston, TX 77030, United States
| | - Rowland W. Pettit
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, MS390, Houston, TX 77030, United States
| | - Sara C. Fallon
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, MS390, Houston, TX 77030, United States,Department of Surgery, Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, United States
| | - David E. Wesson
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, MS390, Houston, TX 77030, United States,Department of Surgery, Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, United States
| | - Sohail R. Shah
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, MS390, Houston, TX 77030, United States,Department of Surgery, Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, United States
| | - Adam M. Vogel
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, MS390, Houston, TX 77030, United States,Department of Surgery, Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, United States
| | - Monica E. Lopez
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, MS390, Houston, TX 77030, United States,Department of Surgery, Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, United States
| | - Nader N. Massarweh
- Atlanta VA Health Care System, Decatur, GA, United States,Department of Surgery, Division of Surgical Oncology, Emory University School of Medicine, Atlanta, GA, United States,Department of Surgery, Morehouse School of Medicine, Atlanta, GA, United States
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Portuondo JI, Mehl SC, Shah SR, Raval MV, Zhu H, Fallon SC, Wesson DE, Massarweh NN. Association between index complication and outcomes after inpatient pediatric surgery. J Pediatr Surg 2022; 57:1-8. [PMID: 35422334 DOI: 10.1016/j.jpedsurg.2022.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 02/25/2022] [Accepted: 03/17/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE A cascade of complications is believed to be the primary mechanism underlying failure to rescue (FTR), or death of a patient after a postoperative complication. It is unknown whether specific types of index complications are associated with the incidence of secondary complications and FTR after pediatric surgery. METHODS National cohort study of patients within the National Surgical Quality Improvement Program-Pediatric database who underwent inpatient surgery (2012-2019). Index complications were grouped into nine categories (cardiovascular, venous thromboembolism, pulmonary, bleeding/transfusion, renal, central nervous system, wound, infectious, or minor [defined as having an associated mortality rate <1%]). The association between the type of index complication with FTR, secondary complications, reoperation, unplanned readmission, and postoperative length of stay was evaluated with multivariable logistic regression and generalized linear modeling. RESULTS Among 425,386 patients, 15.5% had at least one complication, 16.6% had one or more secondary complications, 13.9% reoperation, 14.5% readmission, and 2.4% FTR. Secondary complication (10.8-59.7%) and FTR (0.3-31.1%) rates varied by type of index complication. Relative to patients who had an index minor complication, those with an index infectious complication were most likely to have secondary complication (Odds Ratio [OR] 10.3, 95% CI [9.36-11.4]). Index CV complications were most strongly associated with FTR (OR 30.7 [24.0-39.4]). Index wound complications had the greatest association with reoperation (OR 21.9 [20.5-23.4]) and readmission (OR 18.7 [17.6-19.9]). Index pulmonary complications had the strongest association with length of stay (coefficient 9.39 [8.95-9.83]). CONCLUSIONS Different types of index complications are associated with different perioperative outcomes. These data can help identify patients potentially at risk for suboptimal outcomes and can inform pediatric quality improvement interventions. TYPE OF STUDY Cohort study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Jorge I Portuondo
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey VA Medical Center, Houston, TX, United States; Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States.
| | - Steven C Mehl
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States; Texas Children's Hospital Department of Surgery, Houston, TX, United States
| | - Sohail R Shah
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States; Texas Children's Hospital Department of Surgery, Houston, TX, United States
| | - Mehul V Raval
- Surgical Outcomes and Quality Improvement Center, Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Huirong Zhu
- Texas Children's Hospital Department of Surgery, Houston, TX, United States
| | - Sara C Fallon
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States; Texas Children's Hospital Department of Surgery, Houston, TX, United States
| | - David E Wesson
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States; Texas Children's Hospital Department of Surgery, Houston, TX, United States
| | - Nader N Massarweh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E DeBakey VA Medical Center, Houston, TX, United States; Michael E DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Suite 404D, Houston, TX 77030, United States; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, United States
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Whitlock RS, Portuondo JI, Commander SJ, Ha TA, Zhu H, Goss JA, Kukreja KU, Leung DH, Terrada DL, Masand PM, Nguyen HN, Nuchtern JG, Wesson DE, Heczey AA, Vasudevan SA. Integration of a dedicated management protocol in the care of pediatric liver cancer: From specialized providers to complication reduction. J Pediatr Surg 2022; 57:1544-1553. [PMID: 34366130 DOI: 10.1016/j.jpedsurg.2021.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Up to a third of children undergoing partial hepatectomy for primary hepatic malignancies experience at least one perioperative complication, with a presumed deleterious effect on both short- and long-term outcomes. We implemented a multidisciplinary treatment protocol in the management of these patients in order to improve complication rates following partial hepatectomy. METHODS A retrospective chart review was completed for all patients < 18 years of age who underwent liver resection at our institution between 2002 and 2019 for primary hepatic cancer. Demographic, intraoperative, postoperative, pathologic, and outcome data were analyzed for perioperative complications using the CLASSIC and Clavien-Dindo (CD) scales, event-free survival (EFS) and overall survival (OS). RESULTS A total of 73 patients were included in the analysis with 33 prior-to and 40 after dedicated provider protocol implementation. Perioperative complication rates decreased from 52% to 20% (p = 0.005) with major complications going from 18% to 10% (p = 0.31). On multivariable logistic regression, protocol implementation was associated with a reduction in any (OR 0.29 [95% CI 0.09 - 0.89]) but not major complications. On multivariate cox models, post protocol implementation was associated with improved event free survival (EFS) (HR 0.19 (0.036 - 0.195). Among patients with a diagnosis of hepatoblastoma (n = 62), the occurrence of a major perioperative complication was associated with a worse EFS (HR=5.45, p = 0.03) on multivariate analysis, however this did not translate into an impact on overall survival. CONCLUSIONS Our results demonstrate that, for children with primary liver malignancies, a dedication of patients to high-volume surgeons can improve rates of complications of liver resections and may improve the oncological outcome of hepatoblastoma.
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Affiliation(s)
- Richard S Whitlock
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States
| | - Jorge I Portuondo
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States
| | - Sarah J Commander
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Tu-Anh Ha
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States
| | - Huirong Zhu
- Outcomes and Impact Service, Texas Children's Hospital, Houston, TX, United States
| | - John A Goss
- Division of Abdominal Transplantation, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, United States
| | - Kamlesh U Kukreja
- Division of Interventional Radiology, Singleton Department of Pediatric Radiology, Texas Children's Liver Tumor Program, Baylor College of Medicine, Houston, TX, United States; Singleton Department of Pediatric Radiology, Texas Children's Liver Tumor Program, Baylor College of Medicine, Houston, TX, United States
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Liver Tumor Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Dolores Lopez Terrada
- Departmant of Pathology, Texas Children's Liver Tumor Program, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, United States
| | - Prakash M Masand
- Singleton Department of Pediatric Radiology, Texas Children's Liver Tumor Program, Baylor College of Medicine, Houston, TX, United States
| | - HaiThuy N Nguyen
- Singleton Department of Pediatric Radiology, Texas Children's Liver Tumor Program, Baylor College of Medicine, Houston, TX, United States
| | - Jed G Nuchtern
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States
| | - David E Wesson
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States
| | - Andras A Heczey
- Texas Children's Cancer and Hematology Center, Texas Children's Liver Tumor Program, Department of Pediatrics, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, United States
| | - Sanjeev A Vasudevan
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States.
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Wesson DE, Johnson BL, Barclay C, Vogel AM, Chelius DC, Dimachkieh AL, Athanassaki ID, Karaviti LP, Sher AC, Hernandez JA, Mahmood NF, Mahajan P, Quintanilla N, Lopez ME. Thyroid surgery outcomes at a children's hospital: The value of a multidisciplinary team approach. J Pediatr Surg 2022; 57:622-629. [PMID: 34301414 DOI: 10.1016/j.jpedsurg.2021.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/24/2021] [Accepted: 06/29/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Our purpose is to describe the structure, function and outcomes of our multidisciplinary pediatric thyroid program and to evaluate our experience in comparison to other high-volume centers. METHODS We reviewed all thyroid operations performed 10/2012 through 09/2019, and examined number of cases per year, patient demographics, procedures, final diagnoses and results. Primary outcomes were hypoparathyroidism and recurrent laryngeal nerve (RLN) injury at 12 months. Data were analyzed using descriptive statistics and univariate analyses. RESULTS We performed 294 thyroid operations on 279 patients. Seventy-nine percent were female. Median age was 15 years (IQR: 12-17). Operations included total thyroidectomy (65%), lobectomy (30%) and completion thyroidectomy (5%). Most common diagnoses were Graves' disease (35%), malignancy (29%), and benign nodule (20%). We developed an evidence-based clinical pathway and conducted weekly multidisciplinary meetings. A clinical data specialist reviewed process and outcome measures routinely. Overall, 6 patients (2.0%) had hypoparathyroidism and 2 (0.7%) had unilateral RLN injury at 12 months. Two of the patients with clinical suspicion of permanent hypoparathyroidism were ultimately weaned off calcium. Both patients with RLN injury had extensive locally advanced malignant disease involving the nerve. CONCLUSIONS Our multidisciplinary team achieved excellent long-term outcomes for pediatric thyroid surgery comparable to other high-volume pediatric and adult centers.
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Affiliation(s)
- David E Wesson
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX 77030, United States
| | - Brittany L Johnson
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX 77030, United States
| | - Charlene Barclay
- Outcomes and Impact Service, Texas Children's Hospital, Houston, TX, United States
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX 77030, United States
| | - Daniel C Chelius
- Division of Pediatric Otolaryngology, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Amy L Dimachkieh
- Division of Pediatric Otolaryngology, Department of Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Ioanna D Athanassaki
- Division of Pediatric Endocrinology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - Lefkothea P Karaviti
- Division of Pediatric Endocrinology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - Andrew C Sher
- Department of Radiology, Texas Children's Hospital, Houston, TX, United States
| | - Jose A Hernandez
- Department of Radiology, Texas Children's Hospital, Houston, TX, United States
| | - Nadia F Mahmood
- Department of Radiology, Texas Children's Hospital, Houston, TX, United States
| | - Priya Mahajan
- Division of Pediatric Oncology, Department of Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - Norma Quintanilla
- Department of Pathology, Texas Children's Hospital, Houston, TX, United States
| | - Monica E Lopez
- Division of Pediatric Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX 77030, United States.
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8
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Mehl SC, Portuondo JI, Vogel AM, Lopez ME, Shah SR, Wesson DE, Massarweh N, Fallon SC. Impact of RBC Transfusion Volume on Postoperative Outcomes in Neonatal Surgery. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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9
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Johnson BL, Gerzina EA, Naik-Mathuria B, Wesson DE, Vogel AM, Niedzwecki CM, Fallon SC. What happens after the hospital? An analysis of longitudinal care needs in children treated for child physical abuse. J Pediatr Surg 2021; 56:1696-1700. [PMID: 34167802 DOI: 10.1016/j.jpedsurg.2021.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/10/2021] [Accepted: 05/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Victims of child physical abuse (CPA) undergo stabilization and social evaluation during initial management. Current data guides the initial hospital course, but few studies evaluate post-hospital care. The aim of this study was to evaluate compliance with recommended post-discharge visits. METHODS A retrospective review of our trauma database at a Level I pediatric trauma center from 2014-2018 was performed. Data included demographics, injuries, and longitudinal outcomes. Descriptive statistics and univariate analyses were performed. RESULTS There were 401 patients (409 unique presentations). Median age was 7 months. Mortality was 6%. Ninety-five percent (358/377) had recommended appointments with multiple specialty services. Compliance with all recommended visits during the first year after injury was 88%. Patients with complex injuries were as likely to comply with recommended follow-up [72% vs. 67%, p = 0.4]; however, they were more likely to still be receiving care at 1 year (58% vs. 14%, p = 0.0001). Those discharged to CPS custody were more likely to be compliant with their follow-up (90% vs. 82%, p = 0.03). CONCLUSION Patients significantly injured due to CPA require more post-hospital care over time. CPA management guidelines should include a mechanism to provide resources to these patients and manage multiple coordinating consultants .
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Affiliation(s)
- Brittany L Johnson
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.
| | - Elizabeth A Gerzina
- Department of Medical Education, Baylor College of Medicine, Houston, Texas, USA
| | - Bindi Naik-Mathuria
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - David E Wesson
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Adam M Vogel
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Christian M Niedzwecki
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Sara C Fallon
- Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
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10
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DeMello AS, Rosenfeld EH, Whitaker B, Wesson DE, Naik-Mathuria BJ. Keeping Children Safe at Home: Parent Perspectives to Firearms Safety Education Delivered by Pediatric Providers. South Med J 2020; 113:219-223. [PMID: 32358616 DOI: 10.14423/smj.0000000000001096] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The aims of this study were to assess parent acceptance of firearms education delivered by clinical providers, determine whether parents engage in firearms safety dialog with their children, and evaluate reasons for ownership and storage behaviors. METHODS The parents of children ages 0 to 18 years completed surveys while in a pediatric inpatient setting in Texas. Demographics, acceptability, current behaviors, and storage practices were queried. Responses between firearms owners and nonowners were analyzed using the Fisher exact and χ2 tests. RESULTS Of the 115 parents who completed surveys, 41% reported owning firearms. Most parents were likely or highly likely to follow their pediatrician's gun safety advice (67%), were accepting of safety videos in waiting rooms (59%), and accepted firearms locks distributed by clinical providers (69%). Nonowners were less likely than owners to have spoken to their children about gun safety (P = 0.004). Parents owned firearms for self-protection and recreation (50%), self-protection only (38%), or recreation only (12%). Owners stored them unloaded (75%), used safety devices (95%), and stored them in the closet of the master bedroom (54%). CONCLUSIONS Talking about firearms safety in a healthcare setting was not a contentious issue in the majority of our sample. Parents were accepting of provider-led firearms guidance regardless of ownership status. This provides an opportunity for providers to focus on effective messaging and time-efficient delivery of firearms safety education.
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Affiliation(s)
- Annalyn S DeMello
- From the Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Eric H Rosenfeld
- From the Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Brian Whitaker
- From the Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - David E Wesson
- From the Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Bindi J Naik-Mathuria
- From the Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
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11
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Rosenfeld EH, Johnson B, Wesson DE, Shah SR, Vogel AM, Naik-Mathuria B. Understanding non-accidental trauma in the United States: A national trauma databank study. J Pediatr Surg 2020; 55:693-697. [PMID: 31103270 DOI: 10.1016/j.jpedsurg.2019.03.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 03/07/2019] [Accepted: 03/28/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND The purpose of this study is to characterize the epidemiology, injury patterns, outcomes and trends of non-accidental trauma (NAT) in the United States using a large national database. METHODS Children <15 years presenting after NAT were identified in the 2007-2014 National Trauma Databank research datasets. Clinical and outcome data were analyzed using descriptive statistics, chi-square and logistic regression. RESULTS Of 678,503 children admitted for traumatic injuries, 3% (19,149) were victims of NAT. The majority (95%) were under 5 years and 71% under 1 year old. The majority (59%) were male. The median injury severity score (ISS) was 10 (IQR:5-19). African Americans were disproportionally affected (27% vs 17% of all traumas), and the majority had public or no insurance (85%). Incidence was highest in the midwest and lowest in the northeast regions of the country, although trends varied over time. NAT resulted in 43% of trauma deaths in children <1 year and 31% of trauma deaths in children <5. Traumatic brain injury (TBI) was the most commonly encountered diagnosis (50%). Polytrauma was common, and certain injury patterns were identified. Urgent operation was required in 6%, 43% were admitted to intensive care, and 9% died. Mortality was independently associated with TBI, thoracic injury, hollow viscus injury and older age. CONCLUSION Non-accidental trauma is a leading cause of trauma mortality in young children. Multiple injuries are common, requiring comprehensive evaluation and early surgical involvement. The data presented in this study could serve as a guide to target injury prevention efforts. LEVEL OF EVIDENCE III STUDY TYPE: Prognostic and Epidemiological.
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Affiliation(s)
- Eric H Rosenfeld
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.
| | - Brittany Johnson
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.
| | - David E Wesson
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.
| | - Sohail R Shah
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.
| | - Adam M Vogel
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.
| | - Bindi Naik-Mathuria
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.
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12
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Yu YR, Cunningham ME, DeMello AS, Chiou EH, Kougias P, Wesson DE, Brandt ML, Lopez ME. Cost-Effectiveness Analysis of the Surgical Management of Infants Less than One Year of Age with Feeding Difficulties. J Pediatr Surg 2020; 55:187-193. [PMID: 31759653 DOI: 10.1016/j.jpedsurg.2019.09.076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/29/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND We compared the cost-effectiveness of the common surgical strategies for the management of infants with feeding difficulty. METHODS Infants with feeding difficulty undergoing gastrostomy alone (GT), GT and fundoplication, or gastrojejunostomy (GJ) tube were enrolled between 2/2017 and 2/2018. A validated GERD symptom severity questionnaire (GSQ) and visual analog scale (VAS) to assess quality of life (QOL) were administered at baseline, 1 month, and every 6 months. Data collected included demographics, resource utilization, diagnostic studies, and costs. VAS scores were converted to quality adjusted life months (QALMs), and costs per QALM were compared using a decision tree model. RESULTS Fifty patients initially had a GT alone (71% laparoscopically), and one had a primary GJ. Median age was 4 months (IQR 3-8 months). Median follow-up was 11 months (IQR 5-13 months). Forty-three did well with GT alone. Six (12%) required conversion from GT to GJ tube, and one required a fundoplication. Of those with GT alone, six (14%) improved significantly so that their GT was removed after a mean of 7 ± 3 months. Overall, the median GSQ score improved from 173 at baseline to 18 after 1 year (p < 0.001). VAS scores also improved from 70/100 at baseline to 85/100 at 1 year (p < 0.001). ED visits (59%), readmissions (47%), and clinic visits (88%) cost $58,091, $1,442,139, and $216,739, respectively. GJ tube had significantly higher costs for diagnostic testing compared to GT (median $8768 vs. $1007, p < 0.001). Conversion to GJ tube resulted in costs of $68,241 per QALM gained compared to GT only. CONCLUSIONS Most patients improved with GT alone without needing GJ tube or fundoplication. GT and GJ tube were associated with improvement in symptoms and QOL. GJ tube patients reported greater gains in QALMS but incurred higher costs. Further analysis of willingness to pay for each additional QALM will help determine the value of care. STUDY AND LEVEL OF EVIDENCE Cost-effectiveness study, Level II.
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Affiliation(s)
- Yangyang R Yu
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Megan E Cunningham
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Annalyn S DeMello
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Eric H Chiou
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Panagiotis Kougias
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Houston, TX
| | - David E Wesson
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Mary L Brandt
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Monica E Lopez
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
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13
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Johnson B, Webb M, Bhalakia A, Beckworth K, Wesson DE, Naik-Mathuria B. Physician-Driven Firearm Storage Education: Does it Work? J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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14
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Merchant N, Viau-Colindres JM, Hicks KA, Balazs AE, Wesson DE, Lopez ME, Karaviti L. McCune-Albright Syndrome With Unremitting Hyperthyroidism at Early Age: Management Perspective for Early Thyroidectomy. Glob Pediatr Health 2019; 6:2333794X19875153. [PMID: 31523703 PMCID: PMC6734602 DOI: 10.1177/2333794x19875153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/01/2019] [Accepted: 07/26/2019] [Indexed: 11/23/2022] Open
Abstract
Background. McCune-Albright syndrome (MAS) is characterized by hyperpigmented macules, endocrinopathies, and fibrous dysplasia. Hyperthyroidism is the second most common endocrinopathy in MAS and its management is challenging, particularly among infants and toddlers. Traditionally, young infants have been treated with antithyroid medications, but remission is likely and these medications have severe side effects and affect the control of other endocrinopathies. Thus, it is reasonable to consider permanent treatment options at an earlier age. In this article, we performed a retrospective chart review and describe 3 children who underwent thyroidectomy at an early age due to complex presentation. Case Descriptions. Case 1 was a female patient who underwent bilateral adrenalectomy due to adrenal hyperplasia and subsequently underwent thyroidectomy at 5 months of age due to unremitting hyperthyroidism with fibrous dysplasia, multiple fractures, and ovarian cysts with vaginal bleeding. Case 2 was a 20-month-old female on methimazole who acquired influenza A, precipitating a thyroid storm, and subsequently developed central precocious puberty. Case 3 was a 4-year-old female who underwent thyroidectomy because of unremitting hyperthyroidism after methimazole cessation due to declining neutrophils. All 3 children experienced no complications from thyroidectomy. Conclusions. Early thyroidectomy by an experienced surgeon is an option for managing MAS-associated hyperthyroidism, even in very young patients, with excellent results.
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Affiliation(s)
- Nadia Merchant
- Baylor College of Medicine, Houston, TX, USA.,Diabetes and Endocrinology, Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Johanna M Viau-Colindres
- Baylor College of Medicine, Houston, TX, USA.,Diabetes and Endocrinology, Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Kelly A Hicks
- Baylor College of Medicine, Houston, TX, USA.,Diabetes and Endocrinology, Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Andrea E Balazs
- Baylor College of Medicine, Houston, TX, USA.,Diabetes and Endocrinology, Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - David E Wesson
- Baylor College of Medicine, Houston, TX, USA.,Pediatric Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Monica E Lopez
- Baylor College of Medicine, Houston, TX, USA.,Pediatric Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Lefkothea Karaviti
- Baylor College of Medicine, Houston, TX, USA.,Diabetes and Endocrinology, Pediatrics, Texas Children's Hospital, Houston, TX, USA
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15
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Cunningham ME, Justus CA, Milewicz AL, Wortley MG, Denner FR, Hollier LH, Nuchtern JG, Wesson DE, Fraser CD, Shah SR. Single-visit surgery: An evaluation from an institutional perspective. J Pediatr Surg 2019; 54:1108-1111. [PMID: 30905415 DOI: 10.1016/j.jpedsurg.2019.02.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 02/21/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND/PURPOSE Elective ambulatory surgical care traditionally involves three independent visits. Single-Visit Surgery (SVS) is an alternative surgical model that consolidates care into one visit. Evaluation of the effect of this novel program on hospital operations is limited. The objective of this study was to analyze SVS from an institutional perspective. METHODS We retrospectively reviewed patients scheduled for SVS at a freestanding children's hospital between January 2016 and August 2017. Data collected included clinic "no show" rates, operating room (OR) utilization, reimbursement rates, and postoperative visits. RESULTS There were 89 patients scheduled for SVS, of which 63% (n=56) were male, and the median age was 6 years [IQR, 4-9]. The SVS clinic "no show" rate was 2% (n=2) compared to the pediatric surgery clinic "no show" rate of 11% (p=0.01). The SVS OR block utilization rate was 90%. Payment was received from third-party payors for 92% of consultations and 100% of operative procedures without securing prior authorization. Postoperatively 25% (n=17) of patients presented to clinic for follow-up, and one child presented to the emergency department for vomiting. There were no hospital admissions. CONCLUSION Single-Visit Surgery is an alternative model of ambulatory surgical care that improves institutional efficiency while also enhancing the patient experience. TYPE OF STUDY Retrospective cohort review LEVEL OF EVIDENCE: III.
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Affiliation(s)
| | | | | | | | | | - Larry H Hollier
- Texas Children's Hospital, Department of Surgery, Houston, TX
| | - Jed G Nuchtern
- Texas Children's Hospital, Department of Surgery, Houston, TX
| | - David E Wesson
- Texas Children's Hospital, Department of Surgery, Houston, TX
| | | | - Sohail R Shah
- Texas Children's Hospital, Department of Surgery, Houston, TX.
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16
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Rosenfeld EH, Yu YR, Fernandes NJ, Karediya A, Wesson DE, Lopez ME, Shah SR, Vogel AM, Brandt ML. Bowel preparation for colostomy reversal in children. J Pediatr Surg 2019; 54:1045-1048. [PMID: 30782438 DOI: 10.1016/j.jpedsurg.2019.01.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/27/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Pediatric bowel preparation protocols used before colostomy reversal vary. The aim of this study is to determine institutional practices at our institution and evaluate the impact of bowel preparations on postoperative outcomes and hospital length of stay in children. METHODS This was a retrospective review of children ≤18 years old undergoing colostomy reversal at Texas Children's Hospital (TCH) between 12/2013 and 8/2017. Preoperative bowel regimens and outcomes were collected and analyzed using descriptive statistics, Wilcoxon Rank-Sum and Fishers Exact tests. Continuous variables are presented as median [IQR]. RESULTS Sixty-one children underwent colostomy reversal. Thirty-eight (62%) did not receive a preoperative bowel preparation. The two cohorts were similar in age, gender, and race. The most common indication for colostomy was anorectal malformation for thirty-seven (61%). Time from admission to surgery (19 h [17, 23] vs 3 [2, 3]; p < 0.01) and HLOS (6 days [5, 8] vs 5 [4, 6]; p = 0.02) were both longer in the bowel preparation cohort. Complications (3 [13%] vs 5 [22%]; p = 0.12) and 90-day readmissions (3 [13%] vs 6 [16%]; p = 0.64) were similar in both cohorts. CONCLUSION Foregoing bowel preparation may have the potential to improve cost and reduce morbidity in children undergoing colostomy closure. LEVEL OF EVIDENCE III. STUDY TYPE Treatment study.
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Affiliation(s)
- Eric H Rosenfeld
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Yangyang R Yu
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Nathaniel J Fernandes
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Aleena Karediya
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - David E Wesson
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Monica E Lopez
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Sohail R Shah
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Adam M Vogel
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Mary L Brandt
- Department of Pediatric Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.
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17
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Abstract
PURPOSE This study examines non-accidental trauma (NAT) fatalities as a percentage of all injury fatalities and identifies injury patterns in NAT admissions to two level 1 pediatric trauma centers. METHODS We reviewed all children (<5years old) treated for NAT from 2011 to 2015. Patient demographics, injury sites, and survival were obtained from both institutional trauma registries. RESULTS Of 4623 trauma admissions, 557 (12%) were due to NAT. However, 43 (46%) of 93 overall trauma fatalities were due to NAT. Head injuries were the most common injuries sustained (60%) and led to the greatest increased risk of death (RR 5.1, 95% CI 2.0-12.7). Less common injuries that increased the risk of death were facial injuries (14%, RR 2.9, 95% CI 1.6-5.3), abdominal injuries (8%, RR 2.8, 95% CI 1.4-5.6), and spinal injuries (3%, RR 3.9, 95% CI 1.8-8.8). Although 76% of head injuries occurred in infants <1year, children ages 1-4years old with head injuries had a significantly higher case fatality rate (27% vs. 6%, p<0.001). CONCLUSION Child abuse accounts for a large proportion of trauma fatalities in children under 5years of age. Intracranial injuries are common in child abuse and increase the risk of death substantially. Preventing NAT in infants and young children should be a public health priority. TYPE OF STUDY Retrospective Review. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Yangyang R Yu
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Annalyn S DeMello
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Christopher S Greeley
- Department of Pediatrics, Section of Public Health Pediatrics, Texas Children's Hospital, Houston, TX, United States
| | - Charles S Cox
- Department of Pediatric Surgery, Children's Memorial Hermann Hospital, Houston, TX, United States
| | - Bindi J Naik-Mathuria
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States
| | - David E Wesson
- Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, United States.
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18
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Style CC, Cruz SM, Lau PE, Lee TC, Wesson DE, Olutoye OO. Surgical Outcomes of Patients with Beckwith-Wiedemann Syndrome. J Pediatr Surg 2018; 53:1042-1045. [PMID: 29551244 DOI: 10.1016/j.jpedsurg.2018.02.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 02/01/2018] [Indexed: 01/03/2023]
Abstract
PURPOSE The purpose of this study was to evaluate treatment and surgical outcomes of patients of Beckwith-Wiedemann Syndrome (BWS) treated at a tertiary children's hospital. METHODS A retrospective review of infants evaluated at Texas Children's Hospital for BWS from August 2000 to December 2016 was performed. Data collected included demographic information, clinical presentation, genetic evaluation, fetal imaging, operative treatment, and outcomes. RESULTS Forty-seven children with a diagnosis of BWS were identified. Sixty-four percent (n=30) had a genetic mutation in an imprinting domain of chromosome 11p15. Thirty-two patients (68%) underwent at least one operation related to BWS with a median of 2 [range: 0-8] surgical procedures per patient. Sixteen underwent omphalocele repair, 12 had partial glossectomies-, 7 underwent surgeries related to hemihypertrophy, and 6 had resection of an embryonal tumor (two adrenal cortical adenoma, one Wilms' tumor, two hepatoblastoma). Overall, survival was 100% with feeding difficulty (47%) being the most frequent complication. CONCLUSION A substantial number of patients with Beckwith-Wiedemann Syndrome will require surgery. However, overall outcomes are similar between those that require surgery and those that do not. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Candace C Style
- Division of Pediatric Surgery, The Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Stephanie M Cruz
- Division of Pediatric Surgery, The Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Patricio E Lau
- Division of Pediatric Surgery, The Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Timothy C Lee
- Division of Pediatric Surgery, The Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - David E Wesson
- Division of Pediatric Surgery, The Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Oluyinka O Olutoye
- Division of Pediatric Surgery, The Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States.
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19
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Lau PE, Cruz SM, Ocampo EC, Nuthakki S, Style CC, Lee TC, Wesson DE, Olutoye OO. Necrotizing enterocolitis in patients with congenital heart disease: A single center experience. J Pediatr Surg 2018. [PMID: 29526349 DOI: 10.1016/j.jpedsurg.2018.02.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the characteristics of patients with congenital heart disease (CHD) who developed necrotizing enterocolitis (NEC). METHODS A retrospective review of neonates with CHD at a tertiary care center between January 2006 and January 2016 was performed. Diagnosis of NEC was based on modified Bell's criteria. Patients were grouped by Risk Adjustment for Congenital Heart Surgery (RACHS-1) or by ductal-dependent (DD) lesions that require a patent ductus arteriosus to supply pulmonary or systemic circulation. RESULTS Of 1811 neonates with CHD, 3.4% (n=61) developed NEC. Eighteen (30%) of these required surgical management. The rate of NEC among DD patients was 5% (n=33/653), compared to 2.4% (n=28/1158) in the non-DD group (p=0.003). RACHS-1 score>2 had a higher rate of NEC 6.2% (41/658) compared to RACHS-1≤2 cases, 1.7% (20/1153) (p=0.005). DD patients and complex patients with RACHS-1>2 were more likely to develop NEC after cardiac surgery. Hypoplastic left heart syndrome patients had a rate of 9% (n=16/185). Surgical NEC was more prevalent in the non-DD group. Mortality was similar among groups. CONCLUSION CHD patients with ductal-dependent lesions or complex cases (RACHS-1 score>2) have higher rates of NEC than non-ductal-dependent patients or RACHS-1 score of 2 or less. Mortality is similar regardless of ductal dependence, but surgical NEC was more prevalent in non-DD patients. LEVEL OF EVIDENCE Level IIb.
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Affiliation(s)
- Patricio E Lau
- The Michael E. DeBakey Department of Surgery-Division of Pediatric Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Stephanie M Cruz
- The Michael E. DeBakey Department of Surgery-Division of Pediatric Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Elena C Ocampo
- Department of Pediatrics-Division of Cardiology, Baylor College of Medicine, Houston, TX, United States
| | - Sushma Nuthakki
- Department of Pediatrics-Division of Neonatology, Baylor College of Medicine, Houston, TX, United States
| | - Candace C Style
- The Michael E. DeBakey Department of Surgery-Division of Pediatric Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Timothy C Lee
- The Michael E. DeBakey Department of Surgery-Division of Pediatric Surgery, Baylor College of Medicine, Houston, TX, United States
| | - David E Wesson
- The Michael E. DeBakey Department of Surgery-Division of Pediatric Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Oluyinka O Olutoye
- The Michael E. DeBakey Department of Surgery-Division of Pediatric Surgery, Baylor College of Medicine, Houston, TX, United States.
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Affiliation(s)
- Monica E Lopez
- Department of Surgery, Texas Children's Hospital, Houston
| | - David E Wesson
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
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Affiliation(s)
- Monica E Lopez
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas2Department of Surgery, Texas Children's Hospital, Houston
| | - David E Wesson
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas2Department of Surgery, Texas Children's Hospital, Houston
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Abbas PI, Peterson ML, Fallon SC, Lopez ME, Wesson DE, Walsh SM, Kellermayer R, Rodriguez JR. Evaluating the impact of infliximab use on surgical outcomes in pediatric Crohn's disease. J Pediatr Surg 2016; 51:786-9. [PMID: 26944181 DOI: 10.1016/j.jpedsurg.2016.02.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 02/07/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND The impact of infliximab (IFX) on surgical outcomes is poorly defined in pediatric Crohn's disease (CD). We evaluated our institution's experience with IFX on postoperative complications and surgical recurrence. METHODS A retrospective review of children who underwent intestinal resection with primary anastomosis for CD from 1/2002 to 10/2014 was performed. Data collected included IFX use and surgical outcomes. Preoperative IFX use was within 3months of surgery. RESULTS Seventy-three patients were included with median age 15years (range: 9-18). The most frequent indications for operation were obstruction (n=26) and fistulae (n=19). Nine patients (13%) had a surgical recurrence at a median of 2.3years (IQR 0.7-3.5). Twenty-two patients received preoperative IFX at median of 26days (IQR 14-46). There were 7 postoperative complications: 2 bowel obstructions, and 5 superficial wound infections. Outcomes of patients stratified by IFX were not different. When stratified by indication, refractory disease was associated with higher preoperative IFX use (IFX use 55% vs. no IFX use 28%, p=0.027). No specific indication was associated with increased reoperation rates. CONCLUSION Pediatric CD patients treated with preoperative IFX undergo intestinal resection with primary anastomosis with acceptable morbidity. The heterogeneous approach to medical management underscores the need for guidelines to direct treatment.
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Affiliation(s)
- Paulette I Abbas
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Michelle L Peterson
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sara C Fallon
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Monica E Lopez
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - David E Wesson
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Seema M Walsh
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas
| | - Richard Kellermayer
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Baylor College of Medicine, Houston, Texas
| | - J Ruben Rodriguez
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.
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Jaramillo S, Rojas Y, Slater BJ, Baker ML, Hicks MJ, Muscal JA, Vece TJ, Wesson DE, Nuchtern JG. Childhood and adolescent tracheobronchial mucoepidermoid carcinoma (MEC): a case-series and review of the literature. Pediatr Surg Int 2016; 32:417-24. [PMID: 26790674 DOI: 10.1007/s00383-015-3849-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2014] [Indexed: 01/30/2023]
Abstract
Tracheobronchial mucoepidermoid carcinomas (MEC) are rare in the pediatric population with literature limited primarily to case reports. Here we present our institutional experience treating MEC in three patients and review the literature of 142 pediatric cases previously published from 1968 to 2013. Although rare, tracheobronchial MEC should be included in the differential diagnosis in a child with recurrent respiratory symptoms. Conservative surgical management is often sufficient to achieve complete resection and good outcomes.
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Affiliation(s)
- Sergio Jaramillo
- Department of Radiation Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Yesenia Rojas
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, 77030, TX, USA
| | - Bethany J Slater
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, 77030, TX, USA
| | - Michael L Baker
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA
| | - M John Hicks
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Jodi A Muscal
- Division of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Timothy J Vece
- Division of Pulmonary Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - David E Wesson
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, 77030, TX, USA
| | - Jed G Nuchtern
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, 77030, TX, USA.
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Carpenter JL, Soeken TA, Correa AJ, Zamora IJ, Fallon SC, Kissler MJ, Fraser CD, Wesson DE. Feeding gastrostomy in children with complex heart disease: when is a fundoplication indicated? Pediatr Surg Int 2016; 32:285-9. [PMID: 26721475 DOI: 10.1007/s00383-015-3854-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Malnutrition is common among children with complex heart disease (CHD). Feeding gastrostomies are often used to improve the nutritional status of such patients. Our purpose was to evaluate a cohort of children with CHD following open Stamm gastrostomy without fundoplication. METHODS We reviewed all CHD patients who underwent feeding gastrostomy placement from 1/1/2004 to 4/7/2015. Demographic data, cardiac diagnoses, operative details, post-operative complications, and the need for GJ feeding and fundoplication were examined. RESULTS Open Stamm gastrostomy was performed in 111 patients. Median age at surgery was 37 weeks (3 weeks-13.7 years); average weight was 5.3 ± 4.9 kg. Thirty-four patients (30 %) experienced a total of 37 minor complications, including tube dislodgement after stoma maturation (20), superficial surgical site infection (13), mechanical failure (3), and bleeding (1). Three patients experienced a major complication (need for return to the OR or peri-operative death <30 days). Three patients required a subsequent fundoplication. Fifty-six surviving patients (62 %) continue gastrostomy feeds, of which 7 (13 %) patients require GJ feeds. CONCLUSION Children with CHD tolerate an open Stamm gastrostomy well with minimal major complications. These results support very selective use of fundoplication in infants and children with CHD who require a feeding gastrostomy.
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Affiliation(s)
- Jennifer L Carpenter
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Dr. Suite 1210, Houston, TX, 77030, USA
| | - Timothy A Soeken
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Dr. Suite 1210, Houston, TX, 77030, USA
| | - Alfred J Correa
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Dr. Suite 1210, Houston, TX, 77030, USA
| | - Irving J Zamora
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Dr. Suite 1210, Houston, TX, 77030, USA
| | - Sara C Fallon
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Dr. Suite 1210, Houston, TX, 77030, USA
| | - Mark J Kissler
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Dr. Suite 1210, Houston, TX, 77030, USA
| | - Charles D Fraser
- Division of Congenital Heart Surgery, Department of Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Dr., Houston, TX, 77030, USA
| | - David E Wesson
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Dr. Suite 1210, Houston, TX, 77030, USA.
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Fallon SC, Kim ME, Hallmark CA, Carpenter JL, Eldin KW, Lopez ME, Wesson DE, Brandt ML, Ruben Rodriguez J. Correlating surgical and pathological diagnoses in pediatric appendicitis. J Pediatr Surg 2015; 50:638-41. [PMID: 25840078 DOI: 10.1016/j.jpedsurg.2014.11.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Revised: 10/30/2014] [Accepted: 11/03/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND The stratification of appendicitis into simple and complex variants has far-reaching implications. While the operative diagnosis made by the surgeon dictates clinical management, the pathologic diagnosis often differs and is frequently used for coding and reimbursement. The purpose of this study was to examine discrepancies between the operative and pathologic diagnoses with subsequent correlation to clinical outcomes. METHODS Patients with acute appendicitis from July 2011 to July 2012 were identified. Diagnoses included simple (normal, acute, and suppurative) and complex (gangrenous and perforated). We evaluated the inter-rater reliability between pathologic and operative diagnoses in the five appendicitis categories. Clinical outcomes of deep and superficial surgical site infections were evaluated according to the pathologic and surgical diagnosis. RESULTS During the study period, we identified 1166 patients with acute appendicitis. The surgeon and pathologist agreed on the specific diagnosis (acute, suppurative, gangrenous, perforated, normal) in 48% of patients (kappa 0.289, 95% CI 0.259-0.324, p=0.001). Agreement on disease severity (simple vs. complex) improved to 82%. The operative diagnosis more accurately predicted infectious complications than the pathologic diagnoses. CONCLUSION Significant discordance exists between surgical and pathologic diagnoses. While the relevance of this discordance to clinical outcomes is still not clear, a potential for incorrect hospital coding and subsequent reimbursement exists. Future quality improvement projects should focus on standardizing the surgical and pathologic diagnoses.
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Affiliation(s)
- Sara C Fallon
- Texas Children's Hospital, Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Michael E Kim
- Texas Children's Hospital, Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Charlene A Hallmark
- Texas Children's Hospital, Surgical Outcomes Center, Division of Pediatric Surgery
| | - Jennifer L Carpenter
- Texas Children's Hospital, Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Karen W Eldin
- Texas Children's Hospital, Department of Pathology, Baylor College of Medicine
| | - Monica E Lopez
- Texas Children's Hospital, Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - David E Wesson
- Texas Children's Hospital, Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Mary L Brandt
- Texas Children's Hospital, Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - J Ruben Rodriguez
- Texas Children's Hospital, Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine.
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26
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Correa JA, Fallon SC, Murphy KM, Victorian VA, Bisset GS, Vasudevan SA, Lopez ME, Brandt ML, Cass DL, Rodriguez JR, Wesson DE, Lee TC. Resource utilization after gastrostomy tube placement: defining areas of improvement for future quality improvement projects. J Pediatr Surg 2014; 49:1598-601. [PMID: 25475801 DOI: 10.1016/j.jpedsurg.2014.06.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 06/22/2014] [Accepted: 06/25/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Gastrostomy tube (GT) placement is a frequent procedure at a tertiary care children's hospital. Because of underlying patient illness and the nature of the device, patients often require multiple visits to the emergency room for GT-related concerns. We hypothesized that the majority of our patient visits to the ER related to gastrostomy tube concerns were not medically urgent. The purpose of this study was to characterize the incidence and indications for GT-related emergency room visits and readmission rates in order to develop family educational material that might allow for these nonurgent concerns to be addressed on an outpatient basis. METHODS We reviewed the medical records of all patients with GT placement in the operating room from January 2011 to September 2012. We evaluated our primary outcome of ER visits at less than 30 days after discharge and 30-365 days after discharge. The purpose of the ER visit was categorized as either mechanical (dislodgement, leaking) or wound-related (infection, granulation tissue). Additional outcomes assessed included readmission rates, reoperation rates, and the use of gastrostomy contrast studies. RESULTS During the study period, 247 patients had gastrostomy tubes placed at our institution at a median age of 15.3 months (range 0.03 months-22 years). Of the total patient population, 219 were discharged less than 30 days after their operation (89%). Of these, 42 (20%) returned to the emergency room a total of 44 times within 30 days of discharge for concerns related to their GT. Avoidable visits related to leaking, mild clogs, and granulation tissue were seen in 17/44 (39%). An additional 40 patients among the entire cohort of 247 (16%) presented to the ER a total of 71 times 31-365 days post-discharge; 59 (83%) of these visits were potentially avoidable. The readmission rate related to the GT was low (4%). CONCLUSIONS Few studies have attempted to quantify the amount of postoperative resources utilized post-GT placement in children. Our findings indicated this is not an insignificant quantity. In response to these findings, we have developed a series of educational materials and identified a dedicated nurse to perform inpatient gastrostomy education to these patients prior to discharge.
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Affiliation(s)
- Jesus A Correa
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Sara C Fallon
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Kathleen M Murphy
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Veronica A Victorian
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - George S Bisset
- Edward B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, Houston, TX
| | - Sanjeev A Vasudevan
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Monica E Lopez
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Mary L Brandt
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Darrell L Cass
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - J Ruben Rodriguez
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - David E Wesson
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Timothy C Lee
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
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Zamora IJ, Fallon SC, Orth RC, Kim ME, Brandt ML, Lopez ME, Wesson DE, Rodriguez JR. Overuse of fluoroscopic gastrostomy studies in a children's hospital. J Surg Res 2014; 190:598-603. [DOI: 10.1016/j.jss.2014.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 03/21/2014] [Accepted: 05/02/2014] [Indexed: 11/30/2022]
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Fallon SC, Delemos D, Christopher D, Frost M, Wesson DE, Naik-Mathuria B. Trauma surgeon becomes consultant: evaluation of a protocol for management of intermediate-level trauma patients. J Pediatr Surg 2014; 49:178-82; discussion 182-3. [PMID: 24439605 DOI: 10.1016/j.jpedsurg.2013.09.052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 09/30/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE At our level 1 pediatric trauma center, 9-54 intermediate-level ("level 2") trauma activations are received per month. Previously, the surgery team was required to respond to and assume responsibility for all patients who had "level 2" trauma activations. In 8/2011, we implemented a protocol where the emergency room (ER) physician primarily manages these patients with trauma consultation for surgical evaluation or admission. The purpose of this study was to prospectively evaluate the effects of the new protocol to ensure that patient safety and quality of care were maintained. METHODS We compared outcomes of patients treated PRE-implementation (10/2010-7/2011) and POST-implementation (9/2011-5/2012), including surgeon consultation rate, utilization of imaging and laboratory testing, ER length of stay, admission rate, and missed injuries or readmissions. Statistical analysis included chi-square and Student's t-test. RESULTS We identified 472 patients: 179 in the PRE and 293 in the POST period. The populations had similar baseline clinical characteristics. The surgical consultation rate in the POST period was only 42%, with no missed injuries or readmissions. The ER length of stay did not change. However, in the POST period there were significant decreases in the admission rate (73% to 44%) and the mean number of CT scans (1.4 to 1), radiographs (2.4 to 1.7), and laboratory tests (5.1 to 3.3) ordered in the emergency room (all p<0.001). CONCLUSION Intermediate-level pediatric trauma patients can be efficiently and safely managed by pediatric emergency room physicians, with surgical consultation only as needed. The protocol change improved resource utilization by decreasing testing and admissions and streamlining resident utilization in an era of reduced duty hours.
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Affiliation(s)
- Sara C Fallon
- Baylor College of Medicine Departments of Pediatric Surgery
| | - David Delemos
- Baylor College of Medicine Departments of Emergency Medicine
| | | | - Mary Frost
- Texas Children's Hospital Trauma Program
| | - David E Wesson
- Baylor College of Medicine Departments of Pediatric Surgery
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Fallon SC, Hassan SF, Larimer EL, Rodriguez JR, Brandt ML, Wesson DE, Palazzi DL, Lopez ME. Modification of an evidence-based protocol for advanced appendicitis in children. J Surg Res 2013; 185:273-7. [PMID: 23835072 DOI: 10.1016/j.jss.2013.05.088] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 05/01/2013] [Accepted: 05/24/2013] [Indexed: 10/26/2022]
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Fallon SC, Brandt ML, Hassan SF, Wesson DE, Rodriguez JR, Lopez ME. Evaluating the effectiveness of a discharge protocol for children with advanced appendicitis. J Surg Res 2013; 184:347-51. [DOI: 10.1016/j.jss.2013.04.081] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 04/12/2013] [Accepted: 04/30/2013] [Indexed: 11/28/2022]
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Fallon SC, Lopez ME, Zhang W, Brandt ML, Wesson DE, Lee TC, Rodriguez JR. Risk factors for surgery in pediatric intussusception in the era of pneumatic reduction. J Pediatr Surg 2013; 48:1032-6. [PMID: 23701778 DOI: 10.1016/j.jpedsurg.2013.02.021] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Accepted: 02/03/2013] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Surgical treatment is still necessary for intussusception management in a subgroup of patients, despite advances in enema reduction techniques. Early identification of these patients should improve outcomes. METHODS The medical records of patients treated for intussusception at our institution from 2006 to 2011 were reviewed. Univariate and multivariate analyses, including stepwise logistic regression, were performed. RESULTS Overall, 379 patients were treated for intussusception, and 101 (26%) patients required operative management, with 34 undergoing intestinal resection. The post-operative complication rate was 8%. On multivariate analysis, failure of initial reduction (OR 9.9,p=0.001 95% CI, 4.6-21.2), a lead point (OR 18.5,p=0.001 95% CI, 6.6-51.8) or free/interloop fluid (OR 3.3,p=0.001 95% CI, 1.6-6.7) or bowel wall thickening on ultrasound (OR 3.3,p=0.001 95% CI, 1.1-10.1), age <1 year at reduction (OR 2.7,p=0.004, 95% CI, 1.4-5.9), and abdominal symptoms>2 days (OR 2.9,p=0.003, 95% CI, 1.4-5.9) were significantly associated with a requirement for surgery. Similarly, a lead point (OR 14.5, p=0.005 95% CI, 2.3-90.9) or free/interloop fluid on ultrasound (OR 19.8, p=0.001 95% CI, 3.4-117) and fever (OR 7.2, p=0.023 95% CI, 1.1-46) were significantly associated with the need for intestinal resection. CONCLUSION Abdominal symptoms>2 days, age<1 year, multiple ultrasound findings, and failure of initial enema reduction are significant predictors of operative treatment for intussusception. Patients with these findings should be considered for early surgical consultation or transfer to a hospital with pediatric surgical capabilities.
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Affiliation(s)
- Sara C Fallon
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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Gwilliam NR, Lazar DA, Brandt ML, Mahoney DH, Wesson DE, Mazziotti MV, Nuchtern JG, Lee TC. An analysis of outcomes and treatment costs for children undergoing splenectomy for chronic immune thrombocytopenia purpura. J Pediatr Surg 2012; 47:1537-41. [PMID: 22901913 DOI: 10.1016/j.jpedsurg.2012.02.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 01/18/2012] [Accepted: 02/14/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE Indications and timing for splenectomy in pediatric chronic immune thrombocytopenic purpura (cITP) are controversial because of high spontaneous remission rates and concern for overwhelming postsplenectomy infection. The objective of this study was to assess the risks, costs, and benefits of medical and surgical intervention for children with cITP. METHODS After receiving institutional review board approval, medical records for all children with cITP who underwent splenectomy from 2002 through 2009 were retrospectively reviewed (n = 22). Preoperative and postoperative data were collected. Medical and surgical costs were calculated based on pharmacy charges per dose and hospital charges, respectively. RESULTS The median age at diagnosis was 11 years (range, 3-16 years). Medical management included steroids (n = 21), intravenous gamma globulin (n = 19), anti-D antibody (n = 19), or a combination of these therapies (n = 22). Nineteen patients (86%) reported side effects from medical therapy. Median age at splenectomy was 13 years (range, 6-18 years), and time to surgery was 23 months from diagnosis (range, 6-104 months). Splenectomy increased platelet counts in all children from a median of 25,500 to 380,000 postoperatively (P < .0001). One child experienced overwhelming postsplenectomy infection after a dog bite (n = 1). At the last follow-up (15 months; range, 1-79 months), 19 patients (86%) were asymptomatic with platelet counts greater than 50,000. Of the 3 children with persistent thrombocytopenia, 2 were diagnosed with secondary cITP. Median cost of splenectomy was significantly less than the cost of medical therapy ($20,803 vs $146,284; P < .0002). CONCLUSION Earlier surgical consultation for children with cITP may be justified given the high success rate and low morbidity, particularly given the significant complication rate and cost of continued medical treatment.
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Affiliation(s)
- Natalie R Gwilliam
- Texas Children's Hospital and the Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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Wesson DE. Pediatric trauma centers: coming of age. Tex Heart Inst J 2012; 39:871-873. [PMID: 23304041 PMCID: PMC3528236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- David E Wesson
- Department of Surgery, Baylor College of Medicine, Houston, Texas 77030, USA.
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Wesson DE. Report of past meeting 61st Annual Meeting of the Section on Surgery-American Academy of Pediatrics. J Pediatr Surg 2010; 45:1375. [PMID: 20620348 DOI: 10.1016/j.jpedsurg.2010.02.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2010] [Accepted: 02/23/2010] [Indexed: 10/19/2022]
Affiliation(s)
- David E Wesson
- AAP Section on Surgery 2009, CCC650, Houston, TX 77030, USA.
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Diamond IR, Parkin PC, Wales PW, Bohn D, Kreller MA, Dykes EH, McLellan BA, Wesson DE. Pediatric blunt and penetrating trauma deaths in Ontario: a population-based study. J Pediatr Surg 2009; 44:981-6. [PMID: 19433183 DOI: 10.1016/j.jpedsurg.2009.01.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Accepted: 01/15/2009] [Indexed: 11/16/2022]
Abstract
PURPOSE The purpose of the study was to describe the mechanisms of injury and causes of death in children dying in a modern, integrated trauma system. METHOD Records of all children (<16 years of age) who died in Ontario from 2001 through 2003 after blunt or penetrating trauma were obtained from the Chief Coroner. Demographics and the nature and causes of injury and the causes of death were recorded. Estimates of the mortality rate were determined using census data. RESULTS There were 234 injury deaths (222 blunt, 12 penetrating) over the 3 years. Thirty (13%) resulted from intentional injury. The median age was 10 (range, 0-15.9) years; 62% were male. Sixty-eight percent resulted from incidents involving motor vehicles (passenger, pedestrian, or cyclist). Most (74%) died at the scene; only 5% survived for more than 24 hours. Devastating craniocervical injury (Abbreviated Injury Scale 5 or 6) was present in 84% and was the only life-threatening injury in 40%. The annual mortality rate averaged 3.2 per 100,000 children. CONCLUSIONS In a modern, integrated trauma system, most pediatric injury deaths occur at the scene from severe head injuries. In this population, strategies to reduce the death rate from pediatric trauma must focus on primary and secondary injury prevention.
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Wesson DE, Stephens D, Lam K, Parsons D, Spence L, Parkin PC. Trends in pediatric and adult bicycling deaths before and after passage of a bicycle helmet law. Pediatrics 2008; 122:605-10. [PMID: 18762532 DOI: 10.1542/peds.2007-1776] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The goals were to examine bicycle-related mortality rates in Ontario, Canada, from 1991 to 2002 among bicyclists 1 to 15 years of age and 16 years of age through adulthood and to determine the effect of legislation (introduced in October 1995 for bicyclists <18 years of age) on mortality rates. METHODS The average numbers of deaths per year and mortality rates per 100000 person-years for the prelegislation and postlegislation periods, and the percentage changes, were calculated for each of the 2 age groups (1-15 years and >/=16 years). Differences before and after legislation in the 2 age groups were modeled in a time series analysis. RESULTS There were 362 bicycle-related deaths in the 12-year period (1-15 years: 107 deaths; >/=16 years: 255 deaths). For bicyclists 1 to 15 years of age, the average number of deaths per year decreased 52%, the mortality rate per 100000 person-years decreased 55%, and the time series analysis demonstrated a significant reduction in deaths after legislation. The estimated change in the number of deaths per month was -0.59 deaths per month. For bicyclists >/=16 years of age, there were only slight changes in the average number of deaths per year and the mortality rate per 100000 person-years, and the time series analysis demonstrated no significant change in deaths after legislation. CONCLUSIONS The bicycle-related mortality rate in children 1 to 15 years of age has decreased significantly, which may be attributable in part to helmet legislation. A similar reduction for bicyclists 16 years of age through adulthood was not identified. These findings support promotion of helmet use, enforcement of the existing law, and extension of the law to adult bicyclists.
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Affiliation(s)
- David E Wesson
- Division of Pediatric Medicine and the Pediatric Outcomes Research Team, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada
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Wesson DE, Nathan T, Rose T, Simoni J, Tran RM. Dietary protein induces endothelin-mediated kidney injury through enhanced intrinsic acid production. Kidney Int 2006; 71:210-7. [PMID: 17164833 DOI: 10.1038/sj.ki.5002036] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Dietary protein as casein (CAS) augments intrinsic acid production, induces endothelin-mediated kidney acidification, and promotes kidney injury. We tested the hypothesis that dietary CAS induces endothelin-mediated kidney injury through augmented intrinsic acid production. Munich-Wistar rats ate minimum electrolyte diets from age 8 to 96 weeks with 50 or 20% protein as either acid-inducing CAS or non-acid-inducing SOY. Urine net acid excretion and distal nephron net HCO3 reabsorption by in vivo microperfusion (Net J(HCO3)) were higher in 50 than 20% CAS but not 50 and 20% SOY. At 96 weeks, 50% compared the 20% CAS had higher urine endothelin-1 excretion (U(ET-1)V) and a higher index of tubulo-interstitial injury (TII) at pathology (2.25+/-0.21 vs 1.25+/-0.13 U, P<0.03), but each parameter was similar in 50 and 20% SOY. CAS (50%) eating NaHCO3 to reduce intrinsic acid production had lower Net J(HCO3), lower U(ET-1)V, and less TII. By contrast, 50% SOY eating dietary acid as (NH4)2SO4 had higher Net J(HCO3), higher U(ET-1)V, and more TII. Endothelin A/B but not A receptor antagonism reduced Net J(HCO3) in 50% CAS and 50% SOY+(NH4)2SO4 animals. By contrast, endothelin A but not A/B receptor antagonism reduced TII in each group. The data support that increased intake of acid-inducing dietary protein induces endothelin B-receptor-mediated increased Net J(HCO3) and endothelin A-receptor-mediated TII through augmented intrinsic acid production.
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Affiliation(s)
- D E Wesson
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA.
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Abstract
Endothelin (ET) is a potent vasoconstrictor that is now known to modulate kidney tubule transport, including kidney tubule acidification. Animals undergoing an acid challenge to systemic acid-base status and with some models of chronic metabolic acidosis have increased kidney ET production. Increased ET production/activity contributes to enhanced kidney tubule acidification that facilitates kidney acid excretion in response to an acid challenge to systemic acid-base status. The data to date support a physiologic role for ET in mediating enhanced kidney acidification in response to acid challenges, but do not support an ET role in maintaining kidney tubule acidification in control, non-acid-challenged states. ET increases acidification in both the proximal and distal nephron and appears to exert its effects both directly and indirectly, the latter through modulating the levels and/or activity or other mediators of kidney tubule acidification. ET also contributes to enhanced kidney acidification in some pathophysiologic states and might contribute to some untoward outcomes associated with these conditions. Whether ET should be a therapeutic target in treating and/or preventing some of these untoward outcomes remains an open question. This review supports continued research into the physiologic and possibly pathophysiologic role of ET in settings of increased kidney tubule acidification.
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Affiliation(s)
- D E Wesson
- Division of Nephrology and Hypertension, Departments of Internal Medicine and Physiology, Texas Tech University Health Sciences Center, Lubbock, Texas 79430, USA.
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Rojas JD, Sennoune SR, Maiti D, Bakunts K, Reuveni M, Sanka SC, Martinez GM, Seftor EA, Meininger CJ, Wu G, Wesson DE, Hendrix MJC, Martínez-Zaguilán R. Vacuolar-type H+-ATPases at the plasma membrane regulate pH and cell migration in microvascular endothelial cells. Am J Physiol Heart Circ Physiol 2006; 291:H1147-57. [PMID: 16679513 DOI: 10.1152/ajpheart.00166.2006] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Microvascular endothelial cells involved in angiogenesis are exposed to an acidic environment that is not conducive for growth and survival. These cells must exhibit a dynamic intracellular (cytosolic) pH (pHcyt) regulatory mechanism to cope with acidosis, in addition to the ubiquitous Na+/H+exchanger and HCO3−-based H+-transporting systems. We hypothesize that the presence of plasmalemmal vacuolar-type proton ATPases (pmV-ATPases) allows microvascular endothelial cells to better cope with this acidic environment and that pmV-ATPases are required for cell migration. This study indicates that microvascular endothelial cells, which are more migratory than macrovascular endothelial cells, express pmV-ATPases. Spectral imaging microscopy indicates a more alkaline pHcytat the leading than at the lagging edge of microvascular endothelial cells. Treatment of microvascular endothelial cells with V-ATPase inhibitors decreases the proton fluxes via pmV-ATPases and cell migration. These data suggest that pmV-ATPases are essential for pHcytregulation and cell migration in microvascular endothelial cells.
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Affiliation(s)
- J D Rojas
- Department of Physiology, Texas Tech University Health Sciences Center, 3601 4th St., Lubbock, TX 79430-6551, USA
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Abstract
BACKGROUND/PURPOSE Because severe dysplasia and carcinoma in children with familial adenomatous polyposis (FAP) younger than 18 years is rare, earlier surgical intervention is not common. The purpose of this study is to report the prevalence of dysplasia and carcinoma among children with FAP in our institution. METHODS From 1998 through 2004, children 18 years or younger with FAP that underwent total proctocolectomy at a large children's hospital were retrospectively reviewed. RESULTS Eleven children underwent surgery for FAP. The mean age at surgery was 13 +/- 3.2 years. Approximately half of the patients who underwent preoperative endoscopy had evidence of dysplasia. Nine (82%) patients had dysplasia on preoperative biopsy and/or operative specimen, and 3 (27%) of these patients had severe dysplasia or carcinoma in situ. Four of the 5 patients without symptoms had evidence of dysplasia. No patients had invasive carcinoma. CONCLUSION We observed a higher incidence of severe colonic dysplasia in young children with FAP compared with the current literature. A significant number of patients with dysplasia at surgery had no symptoms and no evidence of dysplasia on preoperative endoscopic biopsies. These data suggest that earlier intervention in children with FAP may be beneficial and should be investigated further.
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Affiliation(s)
- Sanjeev A Vasudevan
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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Abstract
BACKGROUND/PURPOSE The aim of this study was to determine the presentation, treatment, and outcome of children requiring surgery for peptic ulcer disease (PUD) in the post-histamine 2 -blocker era. METHODS The charts of all children undergoing surgery for PUD in our institution since 1980 were retrospectively reviewed. Data were collected regarding clinical presentation, operative details, postoperative course, and outcome. RESULTS Twenty-nine children (7.2 +/- 7.5 years) required surgery for complications of PUD. Indications for operation were bleeding (n = 11), pneumoperitoneum (n = 13), peritonitis (n = 3), and gastric outlet obstruction refractory to medical therapy (n = 2). For those children with bleeding, 8 had simple oversew of the bleeding ulcer(s), 2 had oversew with vagotomy and pyloroplasty, and 1 required vagotomy and antrectomy. All patients with perforation (n = 16) were treated with simple closure with or without omental patch. One child with gastric outlet obstruction underwent vagotomy and antrectomy and 1 had vagotomy and pyloroplasty. Preoperative risk factors or comorbidities were present in 27 of 29 patients and included steroid or nonsteroidal antiinflammatory drug medications in 13 children (only 3 of whom were receiving antiulcer prophylaxis). Postoperative complications occurred in 11 of 29 patients. Three (10%) children required reoperation for persistent or recurrent ulcer disease and 4 children died. CONCLUSIONS PUD remains a highly morbid and mortal condition in children despite the availability of effective acid-reducing medications. Effective prophylaxis of children receiving steroids and nonsteroidal antiinflammatory drugs may play a role in decreasing the risk of PUD.
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Affiliation(s)
- Mary J Edwards
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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Ehrlich PF, McClellan WT, Wesson DE. Monitoring performance: longterm impact of trauma verification and review. J Am Coll Surg 2005; 200:166-72. [PMID: 15664089 DOI: 10.1016/j.jamcollsurg.2004.09.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2004] [Revised: 09/27/2004] [Accepted: 09/30/2004] [Indexed: 11/23/2022]
Abstract
BACKGROUND This study documents how the verification process at a Level I pediatric trauma center affected patient care through changes in care indicators (CIs) from predesignation through four postverification time frames. An important component of any verification program is its effectiveness, not only at the time of verification but during the time between "examinations." To date, few data exist describing the interval periods and the progression and maturation of a trauma program after initial verification. STUDY DESIGN Forty-seven distinct CIs were monitored monthly through data generated from the trauma registry. Six distinct time periods were identified. PRE (January, June, October 1997), trauma care without monitoring; VER (November 1999 to September 2000), preparation for verification; and four postverification periods: P1 (January to June 2001), P2 (July to December 2001), P3 (January to June 2002), and P4 (July to September 2002). RESULTS Between 1997 and 2002, trauma admissions increased from 200 per year to 313 per year. Mortality rate and Injury Severity Score distributions remained unaltered. Statistically significant (p < 0.05) quantitative and qualitative changes were observed in numbers (percent) of patients reaching clinical criteria. These included prehospital, emergency department, and hospital-based trauma competencies. Trauma patient evaluation (including radiology) and disposition out of the emergency department (<120 minutes) improved in each study section and remained high during the postverification time period. There was a strong pair-wise correlation (p < 0.005, Cronbach alpha 0.8) between CNS charting and acquisition of head CAT scans. Pediatric ICU duration of stay increased in both the (summer) P2 and P4 time periods. Prehospital and emergency department fluid monitoring remained unsatisfactory. CONCLUSIONS Statistically significant changes in patient care indicators were noted to improve during the trauma center designation process, and other key deficiencies were identified and addressed. Maintaining these improvements requires constant monitoring or performance may revert below accepted levels.
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Affiliation(s)
- P F Ehrlich
- Department of Pediatric Surgery, University of Michigan, Ann Arbor, MI 48109-0245, USA
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Abstract
BACKGROUND/PURPOSE Renal tumors are rare in infants less than 6 months of age and may have associated paraneoplastic symptoms. To better define the characteristics of these tumors the authors reviewed their 10-year institutional experience. METHODS The authors searched the pathology database to identify all renal tumors resected at their institution since 1992 (after IRB approval and guidelines). The clinical presentation, operative details, pathology, and outcome for all children < or = 6 months of age were reviewed. RESULTS Of 101 children who had renal tumors resected during this period, 11 (11 %) were 6 months of age or less. Histopathologic examination showed congenital mesoblastic nephroma (CMN) in 7 patients (4 with cellular features), Wilms' tumor in 3 patients, and ossifying renal tumor of infancy in 1. Renal masses were detected antenatally in 2 patients and during newborn examination in 1 patient; however, the mean age at diagnosis was 72 +/- 18 days. Ten children had a palpable abdominal mass, 3 had gross hematuria, and 6 had hypertension (4 CMN; 2 Wilms'). Only 1 child had hypercalcemia (cellular CMN). Ten infants had nephroureterectomy, and 1 had a partial nephrectomy. All patients had either stage I or II disease. At follow-up (mean 4.2 +/- 1.2 years) 10 patients are alive with no evidence of disease. One newborn with hydrops and a very large congenital Wilms' tumor had abdominal compartment syndrome and died during surgery. CONCLUSIONS About 10% of renal masses may occur in infants less than 6 months of age. Although mesoblastic nephroma is the most common renal tumor in this age group, Wilms' tumor also may be seen. Paraneoplastic syndromes, such as hypertension and hypercalcemia, are common in these infants and are not specific for tumor type. These tumors generally present at an early stage and have an excellent prognosis overall.
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Affiliation(s)
- Richard D Glick
- Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Houston, TX 77030-2399, USA
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Warmoth L, Regalado MM, Kimball K, Wesson DE. 342 CIGARETTE SMOKING IS ASSOCIATED WITH ENHANCED RATE OF GFR DECLINE IN SEVERE BUT NOT IN MILD PRIMARY HYPERTENSION. J Investig Med 2004. [DOI: 10.1136/jim-52-suppl1-895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
The last decade has seen considerable improvement in the understanding and treatment of neonatal surgical disorders. Translation of basic molecular biology research to clinical practice has directly improved the understanding and treatment of a number of congenital, developmental disorders, such as Hirschsprung's disease and congenital hyperinsulinism. Miniaturized instruments and improved optics have permitted increased use of videoscopic and minimally invasive techniques to even the smallest infants. Continued improvements in prenatal imaging will permit enhanced understanding of the prenatal natural history of congenital structural disorders and the development of more specific therapies. Finally, rigorous clinical research tools have begun to be applied to rare pediatric surgical disorders with the use of organized multicenter trials. It is an exciting time for all involved in the care of neonates.
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Affiliation(s)
- Darrell L Cass
- Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.
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Abstract
Hypertension and kidney function are intimately related, with each having significant influences on the other. Given the major role played by the kidney in maintenance of extracellular fluid volume and peripheral vascular resistance, the kidney is justifiably a target of investigation to determine its potential role in essential hypertension. Conversely, hypertension is associated with progressive renal failure, and hypertension-associated end-stage renal disease is the second leading cause of end-stage renal disease in the United States. It is therefore important that we continue to investigate the hypertension/renal relationship in an effort to better understand the determinants of essential hypertension and to prevent a major cause of end-stage renal disease.
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Affiliation(s)
- D E Wesson
- Texas Tech University Health Sciences Center, Departments of Internal Medicine and Physiology, 3601 Fourth Street, Lubbock, TX 79430, USA.
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Cass DL, Hawkins E, Brandt ML, Chintagumpala M, Bloss RS, Milewicz AL, Minifee PK, Wesson DE, Nuchtern JG. Surgery for ovarian masses in infants, children, and adolescents: 102 consecutive patients treated in a 15-year period. J Pediatr Surg 2001; 36:693-9. [PMID: 11329568 DOI: 10.1053/jpsu.2001.22939] [Citation(s) in RCA: 191] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE Ovarian pathology, although rare in children, must be included in the differential diagnosis of all girls who present with abdominal pain, an abdominal mass, or precocious puberty. METHODS To improve clinical appreciation of these lesions, the authors reviewed the presentation, evaluation, and outcome of all patients with ovarian pathology surgically treated at their institution since 1985. RESULTS One hundred two girls (aged 9.8 +/- 5.5 years; range, 2 days to 20 years) underwent 106 separate ovarian operations (43 salpingo-oophorectomies, 21 oophorectomies, 33 ovarian cystectomies, and 9 ovarian biopsies). Of those presenting with acute abdominal pain (n = 59), 25 (42%) had ovarian torsion (14 associated with a mature teratoma), and only 1 (2%) had a malignant tumor. In contrast, of those presenting with an abdominal mass (n = 23), 6 (26%) had malignancies. There was no age difference between those with benign disease (9.9 +/- 5.6 years; n = 96) and those with malignant tumors (8.6 +/- 3.9 years, n = 10). Nine children had 10 operations for presumed malignant tumors (3 dysgerminomas, 2 immature teratomas with foci of yolk sac tumor, 2 juvenile granulosa cell tumors, 1 yolk sac tumor, and 1 Sertoli-Leydig cell tumor). These patients all had unilateral salpingo-oophorectomy, 4 had chemotherapy, and all are now disease free at 8.4 +/- 4.1 years follow-up. CONCLUSION Ovarian pathology remains a rare indication for surgery in girls less than 20 years of age. Because most of these lesions are benign, ovarian-preserving operations should be performed whenever feasible.
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Affiliation(s)
- D L Cass
- Departments of Surgery, Pathology, and Pediatrics at the Texas Children's Hospital and the Baylor College of Medicine, Houston, TX, USA
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Dzakovic A, Notrica DM, Smith EO, Wesson DE, Jaksic T. Primary peritoneal drainage for increasing ventilatory requirements in critically ill neonates with necrotizing enterocolitis. J Pediatr Surg 2001; 36:730-2. [PMID: 11329576 DOI: 10.1053/jpsu.2001.22947] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE Primary peritoneal drainage (PPD) is an established therapy for premature neonates with necrotizing enterocolitis (NEC) and free intraperitoneal air. This study seeks to evaluate the efficacy of PPD in ill premature neonates with severe abdominal distension and increasing ventilatory requirements without free intraperitoneal air. METHODS Eleven neonates (gestational age, 27 +/- 0.59 weeks; age, 25 +/- 4.3 days; birth weight, 862 +/- 67 g) with NEC underwent bedside PPD under local anesthesia for rapid clinical deterioration characterized by severe abdominal distension and increasing ventilatory requirements. None showed radiographic evidence of free intraperitoneal air. Mean airway pressure (MAP) and oxygenation-index (OI) were analyzed 24 hours before, immediately before and 24 hours after surgery. The patients were followed up to discharge from hospital. Statistical analyses were performed using analysis of variance (ANOVA) for repeated measures. RESULTS Mean airway pressure (MAP) showed a significant difference (P <.05) increasing from 7.1 +/- 0.75 cm H2O 24 hours before surgery to 11 +/- 1.3 cm H2O immediately before surgery and decreasing to 9.9 +/- 1.1 cm H2O 24 hours after drainage. Likewise, OI measured at the same time intervals showed significant differences (P <.05) deteriorating from 5 +/- 1.2 to 26 +/- 6.9 then improving to 13 +/- 3.5. A significant quadratic effect (P <.03) was evident for MAP and OI (ie, values significantly rose then fell). There were six 30-day survivors (55%), and 3 survived to discharge (27%). Of the long-term survivors, 2 required operative fistula closure, and 1 needed no further surgery. CONCLUSION Bedside PPD for increasing ventilatory requirements and abdominal distension in critically ill neonates with nonperforated NEC is a simple technique that offers rapid stabilization, although ultimate mortality rate remains high.
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Affiliation(s)
- A Dzakovic
- Texas Children's Hospital, Houston, TX, USA
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Silang R, Regalado M, Cheng TH, Wesson DE. Prokinetic agents increase plasma albumin in hypoalbuminemic chronic dialysis patients with delayed gastric emptying. Am J Kidney Dis 2001; 37:287-93. [PMID: 11157368 DOI: 10.1053/ajkd.2001.21291] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hypoalbuminemia is a surrogate of malnutrition in patients with end-stage renal disease undergoing chronic dialysis and commonly improves with prescription of adequate nutrition and dialysis. Nevertheless, some patients remain hypoalbuminemic for poorly understood reasons. We tested the hypotheses that chronic dialysis patients who remain hypoalbuminemic despite prescription of adequate nutrition and dialysis (1) have delayed gastric emptying, and (2) that prokinetic agents will increase plasma albumin (P(alb)) levels in patients with delayed gastric emptying. We retrospectively identified 99 of 343 hemodialysis and peritoneal dialysis patients with hypoalbuminuria (P(alb) < 3.5 mg/dL) and studied those who did not (hypoalbuminemic, n =15) and did (normoalbuminemic, n = 15) increase their P(alb) levels over the subsequent 6 months and met inclusion and exclusion criteria. Gastrointestinal symptom scores determined by an administered questionnaire were not different in hypoalbuminemic and normoalbuminemic patients. Conversely, the half-time (T(1/2)) for radionuclide gastric emptying was longer in hypoalbuminemic than normoalbuminemic patients (74.5 +/- 7.4 versus 46.7 +/- 4.6 minutes; P < 0.004). Hypoalbuminemic patients were prescribed prokinetics and followed prospectively for 6 months, during which time gastric T(1/2) decreased to 53.9 +/- 3.3 minutes (P < 0.01 versus initial) and P(alb) increased from 3.1 +/- 0.2 to 3.5 +/- 0.2 mg/dL (P < 0.004). The net increase in P(alb) level correlated with the net decrease in gastric T(1/2) (r(2) = 0.4; P < 0.04) by linear regression. The data show that some persistently hypoalbuminemic chronic dialysis patients have poor gastric emptying and increase their P(alb) levels in response to prokinetic agents.
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Affiliation(s)
- R Silang
- Departments of Internal Medicine, Radiology, and Physiology, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Abstract
BACKGROUND/PURPOSE To better define the indications for peritoneal drainage (PD) in premature babies with intestinal perforation, the authors reviewed their experience with this procedure in a tertiary neonatal intensive care setting. METHODS The charts of all neonates who underwent PD as initial treatment for intestinal perforation between 1996 and 1999 were reviewed. Those patients with pneumatosis intestinalis on abdominal radiograph had perforated necrotizing enterocolitis (NEC) diagnosed; whereas, those infants with no pneumatosis had isolated intestinal perforation diagnosed. The clinical characteristics and outcomes of these 2 groups were compared. RESULTS Twenty-one premature neonates had primary PD between 1996 and 1999, 10 for isolated intestinal perforation and 11 for perforated NEC. Patients with isolated intestinal perforation had lower birth weights (708 v 949 g; P < .05), were less likely to have started feedings (30% v 91%, P < .05), and the perforation developed at an earlier age (10.6 v 28.0 d, P < .05) compared with the patients who had perforated NEC. Only 2 of 10 infants with isolated perforation required subsequent laparotomy (at 10 weeks for stricture and 12 weeks for a persistent fistula). For these patients, the long-term survival rate was 90%. In contrast, 8 of 11 infants with perforated NEC required laparotomy, and although the 30-day survival rate was 64%, the long-term survival rate was only 27%. CONCLUSIONS Peritoneal drainage provides successful and definitive treatment for most premature babies with isolated intestinal perforation. For neonates with perforation caused by NEC, peritoneal drainage may provide temporary stabilization, but most of these infants require subsequent laparotomy, and few survive.
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Affiliation(s)
- D L Cass
- Department of Surgery, Texas Children 's Hospital and the Baylor College of Medicine, Houston, 77030-2399, USA
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