Development of the Red Flag Scorecard Screening Tool for Identification of Child Physical Abuse in the Emergency Department

BACKGROUND

Child physical abuse (CPA) may have subtle presenting signs and can be challenging to identify, especially at emergency centers that do not treat many children. The purpose of this study is to determine the performance of a simple CPA screening tool to identify children most at risk.

METHODS

A screening tool ("Red Flag Scorecard") was developed utilizing available evidence-based presenting findings and expert consensus. Retrospective chart review of children treated for injuries between 2014 and 2018 with suspected or confirmed CPA at a level I pediatric trauma center was then performed to validate the screening tool. Descriptive statistics and chi square tests were used to analyze the data.

RESULTS

Of 408 cases, median age was 7 months and 60% were male. The majority (69%) were under 1 year of age. The most common history finding was delay in seeking care (58%, 236/408; p = <0.0001), the most common physical exam finding was bruising located away from bony prominences (45%, 182/408), and the most common imaging finding was unexplained brain injury (49%, 201/408). The majority, 84% (343/408), had at least 2 history findings. The combination score of at least 2 history findings and 1 physical/imaging finding was most sensitive (79%). The scorecard would have identified 94% of children who presented with no trauma history (198/211).

CONCLUSION

The Red Flag Scorecard may serve as a quick and effective screening tool to raise suspicion for child physical abuse in emergency centers. Prospective study is planned to validate these results.

LEVEL OF EVIDENCE

IV.

Impact of institutional prophylaxis guidelines on rates of pediatric venous thromboembolism following trauma-A multicenter study from the pediatric trauma society research committee

BACKGROUND

A paucity of data exists with regard to the incidence, management, and outcomes of venous thromboembolism (VTE) in injured children. We sought to determine the impact of institutional chemoprophylaxis guidelines on VTE rates in a pediatric trauma population.

METHODS

A retrospective review of injured children (≤15 years) admitted between 2009 and 2018 at 10 pediatric trauma centers was performed. Data were gathered from institutional trauma registries and dedicated chart review. The institutions were surveyed as to whether they had chemoprophylaxis guidelines in place for high-risk pediatric trauma patients, and outcomes were compared based on the presence of guidelines using χ 2 analysis ( p < 0.05).

RESULTS

There were 45,202 patients evaluated during the study period. Three institutions (28,359 patients, 63%) had established chemoprophylaxis policies during the study period ("Guidelines"); the other seven centers (16,843 patients, 37%) had no such guidelines ("Standard"). There were significantly lower rates of VTE in the Guidelines group, but these patients also had significantly fewer risk factors. Among critically injured children with similar clinical presentations, there was no difference in VTE rate. Specifically within the Guidelines group, 30 children developed VTE. The majority (17/30) were actually not indicated for chemoprophylaxis based on institutional guidelines. Still, despite protocols only one VTE patient in the guidelines group who was indicated for intervention ended up receiving chemoprophylaxis prior to diagnosis. No consistent ultrasound screening protocol was in place at any institution during the study.

CONCLUSION

The presence of an institutional policy to guide chemoprophylaxis for injured children is associated with a decreased overall frequency of VTE, but this disappears when controlling for patient factors. However, the overall efficacy is impacted by a combination of deficits in guideline compliance and structure. Further prospective data are needed to help determine the ideal role for chemoprophylaxis and protocols in pediatric trauma.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

[Respiratory and physical recovery in cervical spinal cord injury. Seventeen years' experience in a weaning and rehabilitation center: An observational study]

INTRODUCTION AND OBJECTIVES

Spinal cord injury (SCI) is a devastating entity that generates substantial disability. The outcome of respiratory and motor features has an impact in human and social well-being. We analyzed demographic characteristics, motor and respiratory outcomes, and determined equipment needs at discharge in a weaning and rehabilitation center.

MATERIAL AND METHOD

Observational, descriptive and retrospective study of medical records between January 2002 and December 2018. Tracheostomised cervical SCI patients with invasive mechanical ventilation were included. Forced vital capacity (upright and supine), maximal inspiratory and expiratory pressures, ASIA and Spinal Cord Independence MeasureIII (SCIMIII) were obtained.

RESULTS

Of 1603 patients, 3.5% had SCI, and 28 met the inclusion criteria. The most frequent level of injury was C4-C5 (17/28), 21/28 had ASIAA classification, and 19 showed no change in either the ASIA or the SCIM score. In all, 22/28 patients were weaned, while 15/28 were decannulated. Twenty four patients were discharged to home. The most relevant change in SCIMIII was in the 5th component of respiration and sphincter subscale, related to weaning and tracheostomy. At discharge, 23/24 patients needed both respiratory and motor aids.

CONCLUSIONS

The admission rate of SCI patients was low in our weaning and rehabilitation center, with almost all being admitted for traumatic causes. Severity remained unchanged in most ASIAA patients. Respiratory recovery was more clinically significant than recovery of motor function. Upon discharge, most of our patients had to be equipped with both respiratory and motor aids.

Pediatric Mild Traumatic Brain Injury: Who Can Be Managed at a Non-pediatric Trauma Center Hospital? A Systematic Review of the Literature

BACKGROUND

Pediatric traumatic brain injury (TBI) affects about 475,000 children in the United States annually. Studies from the 1990s showed worse mortality in pediatric TBI patients not transferred to a pediatric trauma center (PTC), but did not examine mild pediatric TBI. Evidence-based guidelines used to identify children with clinically insignificant TBI who do not require head CT were developed by the Pediatric Emergency Care Applied Research Network (PECARN). However, which patients can be safely observed at a non-PTC is not directly addressed.

METHODS

A systematic review of the literature was conducted, focusing on management of pediatric TBI and transfer decisions from 1990 to 2020.

RESULTS

Pediatric TBI patients make up a great majority of preventable transfers and admissions, and comprise a significant portion of avoidable costs to the health care system. Majority of mild TBI patients admitted to a PTC following transfer do not require ICU care, surgical intervention, or additional imaging. Studies have shown that as high as 83% of mild pediatric TBI patients are discharged within 24 hrs.

CONCLUSIONS

An evidence-based clinical practice algorithm was derived through synthesis of the data reviewed to guide transfer decision. The papers discussed in our systematic review largely concluded that transfer and admission was unnecessary and costly in pediatric patients with mild TBI who met the following criteria: blunt, no concern for NAT, low risk on PECARN assessment, or intermediate risk on PECARN with negative imaging or imaging with either isolated, nondisplaced skull fractures without ICH and/or EDH, or SDH <0.3 cm with no midline shift.

Addition of neurological status to pediatric adjusted shock index to predict early mortality in trauma: A pediatric Trauma Quality Improvement Program analysis

INTRODUCTION

Pediatric adjusted shock index (SIPA) has demonstrated the ability to prospectively identify children at the highest risk for early mortality. The addition of neurological status to shock index has shown promise as a reliable triage tool in adult trauma populations. This study sought to assess the utility of combining SIPA with Glasgow Coma Scale (GCS) for predicting early trauma-related outcomes.

METHODS

Retrospective review of the 2017 Trauma Quality Improvement Program Database was performed for all severely injured patients younger than 18 years old. Pediatric adjusted shock index and reverse SIPA × GCS (rSIG) were calculated. Age-specific cutoff values were derived for reverse shock index multiplied by GCS (rSIG) and compared with their SIPA counterparts for early mortality assessment using area under the receiver operating characteristic curve analyses.

RESULTS

A total of 10,389 pediatric patients with an average age of 11.4 years, 67% male, average Injury Severity Score of 24.1, and 4% sustaining a major penetrating injury were included in the analysis. The overall mortality was 9.3%. Furthermore, 32.1% of patients displayed an elevated SIPA score, while only 27.5% displayed a positive rSIG. On area under the receiver operating characteristic curve analysis, rSIG was found to be superior to SIPA as a predictor for in hospital mortality with values of 0.854 versus 0.628, respectively.

CONCLUSION

Reverse shock index multiplied by GCS more readily predicted in hospital mortality for pediatric trauma patients when compared with SIPA. These findings suggest that neurological status should be an important factor during initial patient assessment. Further study to assess the applicability of rSIG for expanded trauma-related outcomes in pediatric trauma is necessary.

LEVEL OF EVIDENCE

Prognostic study, level IV.

Venous thromboembolic risk stratification in pediatric trauma: A Pediatric Trauma Society Research Committee multicenter analysis

BACKGROUND

Venous thromboembolism (VTE) in injured children is rare, but its consequences are significant. Several risk stratification algorithms for VTE in pediatric trauma exist with little consensus, and all are hindered in development by relying on registry data with known inaccuracies. We performed a multicenter review to evaluate trauma registry fidelity and confirm the effectiveness of one established algorithm across diverse centers.

METHODS

Local trauma registries at 10 institutions were queried for all patients younger than 18 years admitted between 2009 and 2018. Additional chart review was performed on all "VTE" cases and random non-VTE controls to assess registry errors. Corrected data were then applied to our prediction algorithm using 10 real-time variables (Glasgow Coma Scale, age, sex, intensive care unit admission, transfusion, central line placement, lower extremity/pelvic fracture, major surgery) to calculate VTE risk scores. Contingency table classifiers and the area under a receiver operator characteristic curve were calculated.

RESULTS

Registries identified 52,524 pediatric trauma patients with 99 episodes of VTE; however, chart review found that 13 cases were misclassified for a corrected total of 86 cases (0.16%). After correction, the algorithm still displayed strong performance in discriminating VTE-fated encounters (sensitivity, 69%; area under the receiver operating characteristic curve, 0.96). Furthermore, despite wide institutional variability in VTE rates (0.04-1.7%), the algorithm maintained a specificity of >91% and a negative predictive value of >99.7% across centers. Chart review also revealed that 54% (n = 45) of VTEs were directly associated with a central line, usually femoral (n = 34, p < 0.001 compared with upper extremity), and that prophylaxis rates were underreported in the registries by about 50%; still, only 19% of the VTE cases had been on prophylaxis before diagnosis.

CONCLUSION

The VTE prediction algorithm performed well when applied retrospectively across 10 diverse pediatric centers using corrected registry data. These findings can advance initiatives for VTE screening/prophylaxis guidance following pediatric trauma and warrant prospective study.

LEVEL OF EVIDENCE

Clinical decision rule evaluated in a single population, level III.

Contemporary management of pediatric open skull fractures: a multicenter pediatric trauma center study

OBJECTIVE

The authors sought to evaluate the contemporary management of pediatric open skull fractures and assess the impact of variations in antibiotic and operative management on the incidence of infectious complications.

METHODS

The records of children who presented from 2009 to 2017 to 6 pediatric trauma centers with an open calvarial skull fracture were reviewed. Data collected included mechanism and anatomical site of injury; presence and depth of fracture depression; antibiotic choice, route, and duration; operative management; and infectious complications.

RESULTS

Of the fractures among the 138 patients included in the study, 48.6% were frontal and 80.4% were depressed; 58.7% of patients underwent fragment elevation. The average duration of intravenous antibiotics was 4.6 (range 0-21) days. Only 53 patients (38.4%) received a single intravenous antibiotic for fewer than 4 days. and 56 (40.6%) received oral antibiotics for an average of 7.3 (range 1-20) days. Wounds were managed exclusively in the emergency department in 28.3% of patients. Two children had infectious complications, including a late-presenting hardware infection and a superficial wound infection. There were no cases of meningitis or intracranial abscess. Neither antibiotic spectrum or duration nor bedside irrigation was associated with the development of infection.

CONCLUSIONS

The incidence of infectious complications in this population of children with open skull fractures was low and was not associated with the antibiotic strategy or site of wound care. Most minimally contaminated open skull fractures are probably best managed with a short duration of a single antibiotic, and emergency department closure is appropriate unless there is significant contamination or fragment elevation is necessary.

Pediatric adjusted reverse shock index multiplied by Glasgow Coma Scale as a prospective predictor for mortality in pediatric trauma

INTRODUCTION

Shock index and its pediatric adjusted derivative (pediatric age-adjusted shock index [SIPA]) have demonstrated utility as prospective predictors of mortality in adult and pediatric trauma populations. Although basic vital signs provide promise as triage tools, factors such as neurologic status on arrival have profound implications for trauma-related outcomes. Recently, the reverse shock index multiplied by Glasgow Coma Scale (GCS) score (rSIG) has been validated in adult trauma as a tool combining early markers of physiology and neurologic function to predict mortality. This study sought to compare the performance characteristics of rSIG against SIPA as a prospective predictor of mortality in pediatric war zone injuries.

METHODS

Retrospective review of the Department of Defense Trauma Registry, 2008 to 2016, was performed for all patients younger than 18 years with documented vital signs and GCS on initial arrival to the trauma bay. Optimal age-specific cutoff values were derived for rSIG via the Youden index using receiver operating characteristic analyses. Multivariate logistic regression was performed to validate accuracy in predicting early mortality.

RESULTS

A total of 2,007 pediatric patients with a median age range of 7 to 12 years, 79% male, average Injury Severity Score of 11.9, and 62.5% sustaining a penetrating injury were included in the analysis. The overall mortality was 7.1%. A total of 874 (43.5%) and 685 patients (34.1%) had elevated SIPA and pediatric rSIG scores, respectively. After adjusting for demographics, mechanism of injury, initial vital signs, and presenting laboratory values, rSIG (odds ratio, 4.054; p = 0.01) was found to be superior to SIPA (odds ratio, 2.742; p < 0.01) as an independent predictor of early mortality.

CONCLUSION

Reverse shock index multiplied by GCS score more accurately identifies pediatric patients at highest risk of death when compared with SIPA alone, following war zone injuries. These findings may help further refine early risk assessments for patient management and resource allocation in constrained settings. Further validation is necessary to determine applicability to the civilian population.

LEVEL OF EVIDENCE

Prognostic study, level IV.

Identifying Maltreatment in Infants and Young Children Presenting With Fractures: Does Age Matter?

OBJECTIVES

Child abuse is a significant cause of morbidity and mortality in preverbal children who cannot explain their injuries. Fractures are among the most common injuries associated with abuse but of themselves fractures may not be recognized as abusive until a comprehensive child abuse evaluation is completed, often prompted by other signs or subjective features. We sought to determine which children presenting with rib or long-bone fractures should undergo a routine abuse evaluation based on age.

METHODS

A systematic review searching Ovid, PubMed/Medline, Scopus, and CINAHL from 1980 to 2020 was performed. An evidence-based framework was generated by a consensus panel and applied to the results of the systematic review to form recommendations. Fifteen articles were suitable for final analysis.

RESULTS

Studies with comparable age ranges of subjects and sufficient evidence to meet the determination of abuse standard for pediatric patients with rib, humeral, and femoral fractures were identified. Seventy-seven percent of children presenting with rib fractures aged less than 3 years were abused; when those involved in motor vehicle collisions were excluded, 96% were abused. Abuse was identified in 48% of children less than 18 months with humeral fractures. Among those with femoral fractures, abuse was diagnosed in 34% and 25% of children aged less than 12 and 18 months, respectively.

CONCLUSION

Among children who were not in an independently verified incident, the authors strongly recommend routine evaluation for child abuse, including specialty child abuse consultation, for: 1) children aged less than 3 years old presenting with rib fractures and 2) children aged less than 18 months presenting with humeral or femoral fractures (Level of Evidence: III Review).

A simple technique for neoumbilical reconstruction for congenital hernia associated proboscis deformity

INTRODUCTION

Umbilical reconstruction in pediatric patients who have developed a large proboscoid redundancy can be challenging after standard umbilical repair. We present a simple and unique surgical technique that results in a cosmetically appealing reconstruction.

OPERATIVE TECHNIQUE

The operation is initiated with circumferential redundant skin excision and isolation of the hernia sac. Primary fascial repair is performed. Reconstruction utilizes the cut dermal/epidermal edge by approximating it to the exposed fascia just below the skin edge outside of the fascial repair in a purse string fashion for the creation of a neoumbilicus.

CONCLUSION

This simple technique is unique from any currently published methods and results in a cosmetically pleasing reconstruction without evidence of any incision.

LEVEL OF EVIDENCE

Level V: Expert Opinion.

Management and outcomes of peripancreatic fluid collections and pseudocysts following non-operative management of pancreatic injuries in children

BACKGROUND

Peripancreatic fluid collection and pseudocyst development is a common sequela following non-operative management (NOM) of pancreatic injuries in children. Our purpose was to review management strategies and assess outcomes.

METHODS

A multicenter, retrospective review was conducted of children treated with NOM following blunt pancreatic injury at 22 pediatric trauma centers between the years 2010 and 2015. Organized fluid collections were called "acute peripancreatic fluid collection" (APFC) if identified < 4 weeks and "pseudocyst" if > 4 weeks following injury. Data analysis included descriptive statistics Wilcoxon rank-sum, Kruskal-Wallis and t tests.

RESULTS

One hundred patients with blunt pancreatic injury were identified. Median age was 8.5 years (range 1-16). Forty-two percent of patients (42/100) developed organized fluid collections: APFC 64% (27/42) and pseudocysts 36% (15/42). Median time to identification was 12 days (range 7-42). Most collections (64%, 27/42) were observed and 36% (15/42) underwent drainage: 67% (10/15) percutaneous drain, 7% (1/15) needle aspiration, and 27% (4/15) endoscopic transpapillary stent. A definitive procedure (cystogastrostomy/pancreatectomy) was required in 26% (11/42). Patients with larger collections (≥ 7.1 cm) had longer time to resolution. Comparison of outcomes in patients with observation vs drainage revealed no significant differences in TPN use (79% vs 75%, p = 1.00), hospital length of stay (15 vs 25 median days, p = 0.11), time to tolerate regular diet (12 vs 11 median days, p = 0.47), or need for definitive procedure (failure rate 30% vs 20%, p = 0.75).

CONCLUSIONS

Following NOM of blunt pancreatic injuries in children, organized fluid collections commonly develop. If discovered early, most can be observed successfully, and drainage does not appear to improve clinical outcomes. Larger size predicts prolonged recovery.

LEVEL OF EVIDENCE

III STUDY TYPE: Case series.

Long-term sustainability of Washington State's quality improvement initiative for the management of pediatric spleen injuries

BACKGROUND

Initial results of Washington State's quality improvement initiative addressing the management of blunt traumatic pediatric spleen injuries were published in 2008. In this update, we evaluated whether these effects were sustained over time.

METHODS

Data from the Washington Trauma Registry for years 1999-2001 (pre-intervention), 2003-2005 (post-intervention), and 2012-2014 (follow-up) were used in a retrospective cohort study. Children between ages 0 to 14 years who were hospitalized with a traumatic blunt spleen injury were included. Multivariable logistic regression was used to account for patient, injury, and hospital characteristics.

RESULTS

Overall, splenectomies continued to be less common with 8.3% of pediatric patients receiving splenectomies in the follow-up period compared with 14.3% and 7.2% in the preintervention and post-intervention periods (p = 0.034). After adjustment, splenectomies remained less likely to be performed in both post-intervention (OR = 0.37; 95% CI = 0.16-0.90) and follow-up periods (OR = 0.29; 95% CI = 0.12-0.70) compared to pre-intervention. Children were much more likely to be cared for at pediatric trauma hospitals in the follow-up period (OR = 5.13; 95% CI = 2.79-9.43) after adjustment.

CONCLUSIONS

Evaluation of this statewide quality improvement initiative showed that positive changes in management practices persist. This evidence suggests that statewide quality improvement initiatives can be sustainable with minimal ongoing effort.

LEVEL OF EVIDENCE

Level III.

Recommendations on multidisciplinary management of elective surgery in people with haemophilia

Planning and undertaking elective surgery in people with haemophilia (PWH) is most effective with the involvement of a specialist and experienced multidisciplinary team (MDT) at a haemophilia treatment centre. However, despite extensive best practice guidelines for surgery in PWH, there may exist a gap between guidelines and practical application. For this consensus review, an expert multidisciplinary panel comprising surgeons, haematologists, nurses, physiotherapists and a dental expert was assembled to develop practical approaches to implement the principles of multidisciplinary management of elective surgery for PWH. Careful preoperative planning is paramount for successful elective surgery, including dental examinations, physical assessment and prehabilitation, laboratory testing and the development of haemostasis and pain management plans. A coordinator may be appointed from the MDT to ensure that critical tasks are performed and milestones met to enable surgery to proceed. At all stages, the patient and their parent/caregiver, where appropriate, should be consulted to ensure that their expectations and functional goals are realistic and can be achieved. The planning phase should ensure that surgery proceeds without incident, but the surgical team should be ready to handle unanticipated events. Similarly, the broader MDT must be made aware of events in surgery that may require postoperative plans to be changed. Postoperative rehabilitation should begin soon after surgery, with attention paid to management of haemostasis and pain. Surgery in patients with inhibitors requires even more careful preparation and should only be undertaken by an MDT experienced in this area, at a specialized haemophilia treatment centre with a comprehensive care model.

Respiratory muscle strength and state of consciousness values measured prior to the decannulation in different levels of complexity. A longitudinal prospective case series study

OBJECTIVE

To describe the variables related to effective cough capacity and the state of consciousness measured prior to decannulation and compare their measured values between the different areas of care such as the Intensive Care Unit (ICU), General ward and Mechanical Ventilation Weaning and Rehabilitation Centers (MVWRC). Secondarily analyze the evolution of patients once decannulated.

DESIGN

Case series, longitudinal and prospective.

SCOPE

Multicentric 31 ICUs (polyvalent) and 5 MVWRC.

PATIENTS

Tracheostomized adults prior to decannulation.

MEASUREMENTS

Maximum expiratory pressure, peak expiratory flow coughed (PEFC), Glasgow Coma Scale (GCS).

RESULTS

Two hundred and seven decannulated patients, 124 (60%) in ICU, 59 (28%) General ward and 24 (12%) in MVWRC. The PEFC presented differences between the patients (ICU 110 - 190 l/min versus MVWRC 167.5 - 232.5 l/min, p <.01). The GCS was different between General ward (9 -15) versus ICU (10-15) and MVWRC (12-15); p <.01 and p <.01, respectively. There were differences in the days of hospitalization (p <.01), days with tracheostomy (<0.01) and the number of patients referred at home (p =.02) between the different scenarios.

CONCLUSION

There are differences in the values of PEFC and GCS observed when decannulating between different areas. A considerable number of patients are decannulated with values of PEFC and maximum expiratory pressure below the suggested cut-off points as predictors of failure in the literature. No patient in our series was decanulated with an GCS <8, this reflects the importance that the treating team gives to the state of consciousness prior to decannulation.

Impact on Hospital Resources of Systematic Evaluation and Management of Suspected Nonaccidental Trauma in Patients Less Than 4 Years of Age

OBJECTIVE

There has been an increasing movement worldwide to create systematic screening and management procedures for atypical injury patterns in children with the hope of better detecting and evaluating nonaccidental trauma (NAT). A legitimate concern for any hospital considering implementation of a systematic evaluation process is the impact on already burdened hospital resources. We hypothesized that implementation of a guideline that uses red flags related to history, physical, or radiologic findings to trigger a standardized NAT evaluation of patients <4 years would not negatively affect resource utilization at our level II pediatric trauma center.

METHODS

NAT cases were evaluated retrospectively before and prospectively after implementation of the NAT guideline (n = 117 cases before implementation, n = 72 cases postimplementation). Multiple linear and logistic regression, χ², and Wilcoxon rank-sum tests were used to evaluate human, laboratory, technology, and hospital resource usage between cohorts.

RESULTS

Human (child abuse intervention department, ophthalmology, and evaluation by a pediatric surgeon for admitted patients), laboratory (urine toxicology and liver function tests), and imaging (skeletal survey and head or abdominal computed tomography) resource use did not differ significantly between cohorts (all P > .05). Emergency department and hospital lengths of stays also did not differ between cohorts. A significant 13% decrease in the percentage of patients admitted to the hospital was observed (P = .01).

CONCLUSIONS

Structured evaluation and management of pediatric patients with injuries atypical for their age does not confer an added burden on hospital resources and may reduce the percentage of such patients who are hospitalized.

Complications in neonatal surgery

Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.

Using a multidisciplinary and evidence-based approach to decrease undertriage and overtriage of pediatric trauma patients

BACKGROUND

The American College of Surgeons Committee on Trauma (ACS-COT) view over- and undertriage rates based on trauma team activation (TTA) criteria as surrogate markers for quality trauma patient care. Undertriage occurs when classifying patients as not needing a TTA when they do. Over-triage occurs when a TTA is unnecessarily activated. ACS-COT recommends undertriage <5% and overtriage 25-35%. We sought to improve the under-triage and over-triage rates at our Level II Pediatric Trauma Center by updating our outdated trauma team activation criteria in an evidence-based fashion to better identify severely injured children and improving adherance to following established trauma team activation criteria.

METHODS

This study was designed prospectively as a Process Improvement Patient Safety (PIPS) project in two phases. Data was obtained from our trauma registry. Prior to the initiation of Phase I, the TTA was modified using the best available evidence at the time. A Base Station report was modified to include elements of the TTA to be checked when EMS called prior to arrival to guide in activation. Phase I of the study (April 1-June 30, 2011) involved improving adherence to activating a trauma according to our newly revised TTA criteria. Phase II of the study (July 1, 2011-June 30, 2012) moved the trauma team activation responsibility primarily to nursing (collaborating with MDs) and including activation criteria regarding transfers-in from outside hospitals. Triage rates were calculated using the Cribari method: undertriage=patients with an ISS >15 for which a major or modified was not activated, and overtriage=patients with an ISS <16 for which a major was activated.

RESULTS

2011 Q1 YTD data was used as a baseline comparison. Baseline undertriage was 15% and overtriage was 75%. Phase I demonstrated 90% use of the redesigned Base Station report reflecting the new TTA criteria and was validated by RN/MD signatures. This resulted in an undertriage rate of 10% (12/118) and an overtriage rate of 20% (1/5). During Phase II, there was 100% use of the newly redesigned Base Station report. Phase IIa (concluding the data collection for 2011) demonstrated an undertriage rate of 8.4% (19/226) and an overtriage rate of 38% (5/13). Data during Phase IIb indicated an undertriage rate of 4.7% (12/251 pts) and overtriage rate of 54% (7/13). During baseline phase of the study, 50% of major patients went to the OR from the ER. During Phase I all major activations required admission to the PICU (4) or the OR (1). Finally, during Q2 2012 (the last quarter of Phase II), 25% of majors went to OR (2/8), 50% to ICU (4/8), 12.5% to Med-Surg (1/8), and 12.5% to home (1/8).

CONCLUSIONS

Standardization of process resulted in improved, sustainable under-/overtriage rates. Undertriage rates dropped from 15% to 5% undertriage, the ACS-recommended standard. Appropriate triage appears to have correlated with appropriate utilization of resources.

Fluctuations of the anthropometric indices and mortality of patients with incident heart failure: a prospective study in the community

BACKGROUND

The relationship between the fluctuations of the anthropometric indices (AIs) and the prognosis of patients with incident heart failure (HF) in a population-based cohort is unknown.

AIMS

To assess the relationship between the fluctuations of the AIs, body mass index (BMI), waist hip ratio (WHR), and weight height ratio (WHeR) and the prognosis of patients with incident HF.

METHODS

Anthropometric indices were prospectively measured in a 10-year population-based study of 6492 patients with incident HF (GAMIC cohort). 4530 patients (66.7%) died, during a mean follow-up of 72.7 ± 14.2 months. A time-updated analysis of the changes of the AIs was performed to assess their association with mortality and morbidity (hospitalisations and visits).

RESULTS

Patients with incident HF presenting ≥ 5% decrease or ≥ 7% increase of the AIs have an increased mortality [HR ≥ 1.65 (1.52-2.34) or HR ≥ 1.71 (1.58-1.85), respectively, p < 0.001]. Mortality risk increased ≥ 1.43-fold (p = -0.0003) for each 10% change in the AIs. There was an accelerated pattern of reduction in the AIs in the 6 months prior to death, and an accelerated increase in the AIs in the 3 months prior to hospitalisation. These observations were independent of the aetiology (ischaemic vs. non-ischaemic), the type of HF (systolic vs. non-systolic), and other predictors of mortality.

CONCLUSIONS

Time-updated changes (increase or decrease) of the AIs, BMI, WHR and weight height ratio are independently associated with the mortality of patients with incident HF.

Should general surgery residents be taught laparoscopic pyloromyotomies? An ethical perspective

OBJECTIVES

The authors examine the ethical implications of teaching general surgery residents laparoscopic pyloromyotomy.

DESIGN/PARTICIPANTS

Using the authors' previously presented ethical framework, and examining survey data of pediatric surgeons in the United States and Canada, a rigorous ethical argument is constructed to examine the question: should general surgery residents be taught laparoscopic pyloromyotomies?

RESULTS

A survey was constructed that contained 24 multiple-choice questions. The survey included questions pertaining to surgeon demographics, if pyloromyotomy was taught to general surgery and pediatric surgery residents, and management of complications encountered during pyloromyotomy. A total of 889 members of the American Pediatric Surgical Association and Canadian Association of Paediatric Surgeons were asked to participate. The response rate was 45% (401/889). The data were analyzed within the ethical model to address the question of whether general surgery residents should be taught laparoscopic pyloromyotomies.

CONCLUSIONS

From an ethical perspective, appealing to the ethical model of a physician as a fiduciary, the answer is no.

DEFINITIONS

We previously proposed an ethical model based on 2 fundamental ethical principles: the ethical concept of the physician as a fiduciary and the contractarian model of ethics. The fiduciary physician practices medicine competently with the patient’s best interests in mind. The role of a fiduciary professional imposes ethical standards on all physicians, at the core of which is the virtue of integrity, which requires the physician to practice medicine to standards of intellectual and moral excellence. The American College of Surgeons recognizes the need for current and future surgeons to understand professionalism, which is one of the 6 core competencies specified by the Accreditation Council for Graduate Medical Education. Contracts are models of negotiation and ethically permissible compromise. Negotiated assent or consent is the core concept of contractarian bioethics. Nonnegotiable goods are goals for residency training that should never be sacrificed or negotiated away. Fiduciary responsibility to the patient, regardless of level of training, should never be compromised, because doing so violates the professional virtue of integrity. The education of the resident is paramount to afford him or her the opportunity to provide competent care without supervision to future patients. Such professional competence is the intellectual and clinical foundation of fiduciary responsibility, making achievement of educational goals during residency training another nonnegotiable good.

Laparoscopic resection of an intradiaphragmatic pulmonary sequestration: a case report and review of the literature

Extralobar pulmonary sequestrations have been occasionally described in the abdomen but rarely in the diaphragm. We present the case of a 10 month old girl with an intradiaphragmatic pulmonary sequestration. The minimally invasive operative technique is outlined in detail, including the combine use of laparoscopy and thoracoscopy. The case is discussed and the literature is reviewed.

Esophageal atresia associated with a rare vascular ring and esophageal duplication diverticulum: a case report and review of the literature

Esophageal atresia with tracheoesophageal fistula (EA-TEF) associated with a right aortic arch poses a dilemma to the pediatric surgeon, often necessitating an operative approach via a left thoracotomy. A right aortic arch may be associated with a vascular ring, and EA-TEF, too, has been reported in association with a vascular ring. Rarely, esophageal atresia is associated with a second esophageal anomaly, such as a so-called "esophageal lung." To our knowledge, there is no report of all three in one patient. We report the first case of a patient with associated EA-TEF, vascular ring (diverticulum of Kommerell), and esophageal lung. The literature is reviewed for these rare entities.

[Decrease in hospitalizations due to polyvalent medical day hospital]

INTRODUCTION

The day hospital is an alternative to hospitalization. This alternative improves accessibility and comfort of the patients, and avoids hospitalizations. Nevertheless, the efficacy of the polyvalent medical day hospital in avoiding hospitalizations has not been evaluated.

OBJECTIVE

To analyze hospital stays avoided by the polyvalent medical day hospital of a university hospital of the Andalusian Health Service.

METHODS

An observational prospective study of the patients studied and/or treated in the polyvalent medical day hospital of the Hospital Universitario Puerto Real over a one year period.

RESULTS

A total of 9640 patients were attended to, with 1413 procedures and 4921 i.v. treatments. There were 3182 visits to the priority consultation of the polyvalent medical day hospital. The most frequent consultation complaints were constitutional symptoms (15.9%) and anemia (14.5%). After the first visit, 21.5% of the patients were discharged and fewer than 3% were hospitalized. Hospitalization was avoided in 16.8% of the patients, there being a 6.0% decrease in the need for hospital beds (5.0% reduction in the internal medicine unit). Inadequate hospitalizations and 30-day readmissions decreased 93.3% and 4.2%, respectively. The most frequent diagnosis was neoplasm (26.0%), and most of the beds freed up were generated by patients diagnosed of neoplasm (26.7%).

CONCLUSION

With this type of polyvalent medical day hospital, we have observed improved efficiency of health care, freeing up hospital beds by reducing hospitalizations, inadequate hospitalizations and re-admissions in the medical units involved.

Mortality and morbidity of heart failure treated with digoxin. A propensity-matched study

BACKGROUND

The role of digoxin in the prognosis of patients with heart failure (HF) remains unclear.

AIMS

To evaluate the relationship of commencing treatment with digoxin (CTDig) with the mortality and the morbidity of patients with HF.

METHODS

Prospective study over 8 years on 4467 patients with HF. Main outcomes were all-cause and cardiovascular mortality, hospitalisations and visits. We analyse the independent relationship of CTDig, with the mortality and the morbidity, stratifying patients for cardiovascular comorbidity, after propensity score-matching for potential confounders (1421 patients who CTDig vs. another 1421 patients non-exposed to digoxin).

RESULTS

During a median follow up of 46.1 months, 1872 patients (65.9%) died, and 2203 (77.5%) were hospitalised. CTDig was associated with a lower all-cause mortality (HR = 0.90 [95% CI, 0.84-0.97]), and cardiovascular mortality (HR = 0.87 [0.81-0.96]), hospitalisation (HR = 0.91 [0.86-0.97]), 30-day readmission for HF (HR = 0.88 [0.79-0.95]), and visits (HR = 0.94 [0.90-0.98]) (p < 0.001 in all cases), after adjustment for the propensity to take digoxin, other medications, and other potential confounders. These effects of digoxin were independent of gender, or type of HF (systolic or non-systolic).

CONCLUSION

The data suggest that therapy with digoxin is associated with an improved mortality and morbidity of HF, including women and patients with non-systolic HF.

Utilization patterns and associated costs of factor assistance programmes among persons with haemophilia: a single institution review

Although individuals with haemophilia have benefited from advances and the availability of safe, effective factor replacement products, high treatment costs and insurance coverage limits remains a significant concern among persons with this disease. Many uninsured haemophiliacs turn to emergency rooms for treatment and/or patient assistance programmes for treatment of a bleed or injury. However, neither of these options is a sustainable solution for managing the care of patients with this costly disease. This study was conducted to examine the use of factor assistance programmes and estimate annual amounts of factor dispensed by each programme along with their associated costs. Retrospective review of pharmacy and medical record of all patients who attended the Gulf States Hemophilia and Thrombophilia Center, and who were enrolled in any factor assistance programme(s) between January 2007 and December 2010 was performed. During the 4-year observation period, approximately 19% of the centre's haemophilia patient population was enrolled and received free factor products from at least one patient assistance programme. In addition, approximately 9.1 million dollars (US) worth of factor replacement therapy was donated to our patients during the study time. Although assistance programmes have helped many uninsured individuals with haemophilia to receive free factor products, they are not an enduring answer to the insurance problems many of our patients face. More effort needs to be focused on how to effectively manage uninsured persons with haemophilia to ensure that their health care and treatment needs are adequately met.

An alternative to open incision and drainage for community-acquired soft tissue abscesses in children

BACKGROUND

The continually rising incidence of soft tissue abscesses in children has prompted us to seek an alternative to the traditional open incision and drainage (I&D) that would minimize the pain associated with packing during dressing changes and eliminate the need for home nursing care.

STUDY DESIGN

A retrospective review of all patients with soft tissue abscesses from November 2007 to June 2008 was conducted after institutional review board approval. Patients who were treated with open I&D were compared to those treated with placement of subcutaneous drains through the abscess cavities. Both groups received equivalent antibiotic treatment, and all patients were followed in outpatient clinics until infection resolved. The demographics, presenting temperature, culture results, and outcomes were compared between these 2 groups.

RESULTS

A total of 219 patients were identified; 134 of them underwent open I&D, whereas 85 were treated with subcutaneous drains. The demographics, anatomical location of the abscesses, and bacteriology were comparable between the 2 groups. There were equal number of patients in each group who presented with fever initially. Of those treated with open I&D, 4 had metachronous recurring abscesses within the same anatomical region and 1 patient required an additional procedure because of incomplete drainage. There were no recurrences or incomplete drainages in the subcutaneous drain group. The cosmetic appearance of the healed wound from subcutaneous drain placement during the immediate follow-up period is better than that of an open I&D.

CONCLUSIONS

Placement of a subcutaneous drain for community-acquired soft tissue abscesses in children is a safe and equally effective alternative to the traditional I&D.

Management of difficult-to-treat inhibitor patients

The workshop looked at seven scenarios based on fictional and real-life cases of difficult-to-treat patients with haemophilia A or haemophilia B and inhibitors with the aim of sharing clinical opinion and experience from around the world. Delegate opinions on the best treatment option for each scenario are described together with actual treatment given in real-life cases and its outcome.

In non-severe hemophilia A the risk of inhibitor after intensive factor treatment is greater in older patients: a case-control study

BACKGROUND

 Twenty-five percent of new anti-factor VIII (FVIII) antibodies (inhibitors) that complicate hemophilia A occur in those with mild and moderate disease. Although intensive FVIII treatment has long been considered a risk factor for inhibitor development in those with non-severe disease, its strength of association and the influence of other factors have remained undefined.

OBJECTIVE

 To evaluate risk factors for inhibitor development in patients with non-severe hemophilia A.

METHODS

 Information on clinical and demographic variables and FVIII genotype was collected on 36 subjects with mild or moderate hemophilia A and an inhibitor and 62 controls also with mild or moderate hemophilia A but without an inhibitor.

RESULTS

 Treatment with FVIII for six or more consecutive days during the prior year was more strongly associated with inhibitor development in those ≥30years of age compared with those <30years of age [adjusted odds ratio (OR) 12.62; 95% confidence interval (CI), 2.76-57.81 vs. OR 2.54; 95% CI, 0.61-10.68]. Having previously received <50days of FVIII was also not statistically associated with inhibitor development on univariate or multivariate analysis.

CONCLUSIONS

 These findings suggest that inhibitor development in mild and moderate hemophilia A varies with age, but does not vary significantly with lifetime FVIII exposure days: two features distinct from severe hemophilia A.

Thrombin generation and fibrinolysis in anti-factor IX treated blood and plasma spiked with factor VIII inhibitor bypassing activity or recombinant factor VIIa

Activated prothrombin complex concentrates (aPCC) and recombinant activated factor VIIa (rFVIIa) are two important therapies in haemophilia patients with inhibitors and improve clot stability. We hypothesized that potential differences in procoagulant and fibrinolytic actions of aPCC and rFVIIa may lie in the clot stability against fibrinolytic activation. We used thrombin generation, fluorescence detection and thromboelastometry in anti-factor IXa (FIXa) aptamer-treated whole blood (WB) and plasma to evaluate: (i) generation of thrombin and activated factor X (FXa) and (ii) viscoelastic properties of blood clots in the presence of tissue plasminogen activator (tPA) after addition of aPCC (0.4 U mL(-1)) or rFVIIa (60 nm). Peak thrombin generation increased from 85 +/- 19 nm in aptamer-treated plasma to 276 +/- 83 nm and 119 +/- 22 nm after addition of aPCC and rFVIIa respectively (P < 0.001). FXa activity increased within 20 min by 87 +/- 6% and by 660 +/- 97% after addition of aPCC and rFVIIa respectively (P < 0.001). TPA-induced lysis time increased from 458 +/- 378 s in aptamer-treated WB to 1597 +/- 366 s (P = 0.001) and 1132 +/- 214 s (P = 0.075), after addition of aPCC and rFVIIa respectively. In this haemophilia model using the anti-FIXa aptamer, the larger amount of thrombin was generated with aPCC compared with rFVIIa, while FXa generation was more rapidly increased in the presence of rFVIIa. Furthermore, clot formation in anti-FIXa aptamer-treated WB was less susceptible to tPA-induced fibrinolysis after adding aPCC compared with rFVIIa.

Early experience with the use of rhomboid excision and Limberg flap in 16 adolescents with pilonidal disease

BACKGROUND

Rhomboid excision with Limberg flap (RELF) repair has been shown to be effective in the management of pilonidal disease (PD) in adults. Wide excision allows complete removal of diseased tissue, and the rotational flap allows tensionless coverage as well as helps flatten the natal crease, which is believed to contribute to the recurrence of PD.

METHODS

This study is a retrospective review of all adolescents who underwent excision of pilonidal disease using RELF at a single institution for a period of 18 months.

RESULTS

Sixteen adolescents with PD were treated with RELF during this period. All procedures were completed with no intraoperative complications. Mean operative time and hospital stay were 92 +/- 30 minutes and 1.8 +/- 0.29 days, respectively. Mean follow-up was 11 +/- 6.0 months. One patient had recurrence of his disease, and one needed prolonged wound care after wound breakdown. Six others had minor complications including 4 patients (25%) who had superficial wound separation that resolved promptly with dressing change. One patient had a superficial wound infection. One patient had residual pain.

CONCLUSION

Rhomboid excision with Limberg flap is effective in the management of PD in adolescents. The 6% recurrence rate is similar to that reported in the adult literature. Despite the limitations of this study, the low morbidity, hospital stay, and recurrence rate noted with our initial experience are very encouraging.

Lawn mower-related projectile injury

Lawn mower injuries are a potentially devastating, yet preventable cause of morbidity and mortality in the pediatric population. The sequelae to these injuries can become even worse if the initial presentation goes unsuspected by medical staff, leading to a delay in treatment. The authors report the case of a lawn mower-related penetrating missile injury, where the extent of injury was not appreciated by the patient until signs and symptoms of a soft-tissue infection developed, prompting the patient to seek medical attention the next day.

Stapled tapering coloplasty to manage colon interposition graft redundancy for long-gap esophageal atresia

Long gap esophageal atresia continues to be a therapeutic challenge for the pediatric surgeon. Although numerous methods have been described to achieve esophageal continuity in infants with esophageal atresia, esophageal replacement is often required if these methods fail. A common method of esophageal replacement in children is the use of a colon graft. Complications include cervical anastomotic leak, stricture, redundant intrathoracic colon with stasis, and cologastric reflux. We present an 11-year-old male with swallowing difficulties because of redundancy of the colon after undergoing colon interposition for long gap atresia. The patient underwent a successful transhiatal mobilization of the intrathoracic colon and stapled tapering coloplasty. The patient currently remains symptom-free.

Laparoscopic excision of a newborn rectal duplication cyst

Congenital rectal duplication cyst is a rare entity treated with surgical excision. Without treatment, a rectal duplication cyst may cause a variety of complications, most notably, transforming into a malignancy. We report on a 7-week-old girl who was found to have a rectal duplication cyst. The rectal duplication cyst was successfully excised laparoscopically. Rectal duplication cysts are rare alimentary tract anomalies generally discovered during childhood. Complications include symptoms arising from the cyst and the possibility of malignant degeneration. They are typically managed by surgical excision.

Congenital bilateral absence of the vas deferens

A 10-year-old boy with cystic fibrosis (CF) (DeltaF508/G551D mutation) underwent an uneventful elective interval laparoscopic appendectomy. During routine laparoscopic inspection of the abdomen and groins, congenital bilateral absence of the vas deferens was noted. Pictures of the patient's internal inguinal ring noted at time of laparoscopy are presented and compared with a similar-aged patient's internal ring with a normal vas deferens. The genetics of CF patients associated with congenital bilateral absence of the vas deferens is reviewed. The pediatric or general surgeon performing a herniorrhaphy should be aware of this anomaly in CF patients.

Long-term outcomes in patients with stage IV neuroblastoma

AIM OF STUDY

Long-term outcome studies in survivors with stage IV neuroblastoma (NB) are sparse. This review evaluates late complications and long-term outcomes in stage IV NB survivors.

METHODS

A retrospective review of stage IV NB survivors was performed to analyze outcomes, including long-term morbidity, recurrence, and survival.

MAIN RESULTS

Of 153 patients with stage IV NB, 52 (34%) survived (male-female, 26:26). Age at diagnosis was 29.1 +/- 31.7 months in survivors. Eighteen were 1 year or younger and 34 were older than 1 year compared with 10 nonsurvivors 1 year or younger and 91 older than 1 year (P = .0003, Fisher's Exact test). Primary tumor sites were adrenal (35), retroperitoneal (11), mediastinal (3), pelvic (2), and no primary with tumor metastases identified (1). Ten survivors had favorable and 16 had unfavorable histology compared with 1 favorable and 18 unfavorable in nonsurvivors (P = .01). Four survivors had MYCN amplification (> or = 10 copies) and 2 deletions of 1p and 11q. Sites of metastasis in survivors and nonsurvivors were similar. Treatment in survivors included surgery in 51 (75% [39/51] complete tumor resection [CTR]); chemotherapy, 50; radiation, 17; stem cell transplantation, 20; and bone marrow transplant, 1. In nonsurvivors, 13 (25%) of 53 (P < < .0001) had CTR, 18 stem cell transplantation, and 12 bone marrow transplant. Six patients had tumor recurrence but survived (mean, 9.3 +/- 8.3 years; range, 6 months-24 years). Recurrence was local (1), distant (2), and both (3) and was treated by resection, chemotherapy, and radiation. The mean age of survivors was 12.4 +/- 8.3 years (range, 2-34 years). In all stage IV cases, event-free survival was 30% and overall survival was 34%. Long-term complications occurred in 23 (44%) survivors, including endocrine disturbances (7), orthopedic (5), cataracts (2), adhesive bowel obstruction (2), hypertension (1), bronchiolitis (1), blindness (1), peripheral neuropathy (1), nonfunctioning kidney (1), cholelithiasis (1), and thyroid nodule (1).

CONCLUSION

Only 34% of patients with stage IV NB survived despite aggressive multimodal therapy. Age of younger than 1 year, favorable pathology, CTR, and no recurrence were the only statistically significant factors that favored survival. Forty-four percent of survivors experienced late morbidity, and tumor recurred in 6 (11.5%) of 52. Patients should be monitored for tumor recurrence and long-term sequelae. New methods of treatment are required to achieve better outcomes.

Effect of corticosteroid therapy on outcomes in biliary atresia after Kasai portoenterostomy

PURPOSE

This study tests the hypothesis that steroid administration improves the outcome of biliary atresia (BA) by evaluating the efficacy of postoperative steroid use on surgical outcomes in infants with BA.

METHODS

Steroid use and outcomes in patients with BA were retrospectively analyzed at a tertiary pediatric hospital. Institutional review board approval was obtained.

RESULTS

Kasai portoenterostomy (PE) was performed in 43 patients with BA treated from 1992 to 2004 (16 boys and 27 girls). Twenty-one PE patients received steroids and 22 did not. Portoenterostomy was successful in 24 patients (55.8%) with consistent serum bilirubin less than 2 mg/dL. Sixteen (66%) received postoperative steroids. A normal postoperative bilirubin was achieved at 6 months in 16 (76%) of 21 patients with steroids compared with 8 (37%) of 22 in untreated controls (Fisher's Exact test, P = .01). Of the 43 patients, 19 (44%) required liver transplantation, including 7 (37%) of 19 with steroids vs 12 (63%) of 19 without (P = .2). Twenty-eight infants developed cholangitis (fever with and without changes in hepatic function): 25 after PE and 3 after transplant. Of the 25, 12 (48%) received steroids. Seven died (16%) (range, 7 months to 4 years): 2 while awaiting transplantation (received steroids) and 5 after transplantation (1 received steroids and 4 were untreated). Survival was 86% (18/21) in patients with steroids and 82% (18/22) in those without. Transplant survival (74%) was comparable to previously reported historical controls (82%).

CONCLUSIONS

The Kasai PE continues to be the procedure of choice in infants with BA younger than 3 months. A significantly improved clearance of postoperative jaundice and lower serum bilirubin levels were observed in patients receiving steroids. However, steroids had no effect on the incidence of cholangitis, need for liver transplantation, and overall survival. A prospective study with standardized dose and length of steroid administration and longer period of follow-up is necessary to more accurately assess the effectiveness of steroids after PE.

Surgical considerations in cystic fibrosis: a 32-year evaluation of outcomes

BACKGROUND

Information concerning long-term operative outcomes in patients with cystic fibrosis (CF) is relatively sparse in the operative literature.

METHODS

A retrospective review of CF patients with operative conditions was performed (1972-2004) at a tertiary children's hospital to analyze outcomes including long-term morbidity and survival.

RESULTS

A total of 226 patients with CF presented with an operative diagnosis (113 men, 113 women). A total of 422 operations were performed in 213 patients (94%). The mean age at operation was 4.1 +/- 6.2 years (range, 1 d to 26 y) and 109 were neonates. Fifteen of 42 (36%) babies with simple meconium ileus (MI) were treated nonoperatively with hypertonic enemas, 27 of 42 and all 45 patients with complicated MI required operation, including 15 with jejunoileal atresia (17%). Seventeen of 27 (63%) patients with meconium ileus equivalent had MI as neonates; 7 of 27 (26%) required operation. Eight of 9 (89%) with fibrosing colonopathy required operation. Organ transplantation was required in 21 patients. Follow-up evaluation was possible in 204 of 213 (96%) patients. The duration of follow-up evaluation was 14.9 +/- 8.5 years (range, 2 mo to 35 y). Operative morbidity was 11% at 1 year, 2% at 2 to 4 years, 1% at 5 to 10 years, and less than 1% at more than 10 years. There were 24 deaths (11%); 22 followed CF-related pulmonary complications and included 8 of 16 (50%) children with pneumothorax.

CONCLUSIONS

Long-term survival in CF patients has improved significantly (89%), with many surviving into the fourth decade. MI may predispose to late complications including meconium ileus equivalent and fibrosing colonopathy. Pneumothorax in CF patients is an ominous predictor of mortality. Children with CF are living longer and are good candidates for operation, but require long-term follow-up evaluation because of ongoing exocrine dysfunction.

Long-term outcomes in total colonic aganglionosis: a 32-year experience

BACKGROUND/METHODS

A 32-year retrospective review from 1972 to 2004 analyzed complications and long-term outcomes in children with total colonic aganglionosis (TCA) as they relate to the procedure performed.

RESULTS

Thirty-six patients (27 boys, 9 girls) had TCA. The level of aganglionosis was distal ileum (26), mid-small bowel (8), midjejunum (1), and entire bowel (1). Enterostomy was performed in 35 of 36. Eight developed short bowel syndrome. Twenty-nine (81%) had a pull-through at 15 +/- 6 months (modified Duhamel 20, Martin long Duhamel 4, and Soave 5). Six had a Kimura patch. Postoperative complications (including enterocolitis) were more common after long Duhamel and Soave procedures. Seven (19%; 2 with Down's syndrome) died (3 early, 4 late) from pulmonary emboli (1), sepsis (1), fluid overload (1), viral illness (1), liver failure (1), arrhythmia (1), and total bowel aganglionosis (1). Mean follow-up was 11 +/- 9 years (range, 6 months-29 years). Twenty-four (83%) of 29 patients exhibited growth by weight of 25% or more, 21 (91%) of 23 older than toddler age had 4 to 6 bowel movements per day, and 17 (81%) of 21 were continent. In 5 of 6, the Kimura patch provided functional benefit with proximal disease.

CONCLUSION

Long-term survival was 81%. The highest morbidity occurred with long Duhamel or Soave procedures. The modified Duhamel is our procedure of choice in TCA. Bowel transplantation is an option for TCA with unadapted short bowel syndrome.

Profiling of nuclear extract proteins from human neuroblastoma cell lines: the search for fingerprints

PURPOSE

Neuroblastoma (NB) commonly presents with advanced disease at diagnosis and is associated with poor survival. If identified early, however, survival is improved suggesting a benefit of early detection. The authors have used proteomics technology in an attempt to identify novel markers that permit early detection of NB and characterize its molecular makeup.

METHODS

Three different human NB cell lines SK-N-AS, SK-N-DZ, and SK-N-FI were subjected to series of biochemical fractionation steps to extract nuclear proteins. These proteins were analyzed for differential expression by 2-dimensional polyacrylamide gel electrophoresis. Polypeptides of interest were subsequently identified by liquid chromatography-linked tandem mass spectrometry.

RESULTS

Multiple proteins were identified in these human NB cell lines including SET (a ubiquitous nuclear protein), stathmin (a cytosolic signal transduction protein), and grp94 (a heat shock protein). SET is a putative oncogene associated with the chromosomal translocation (6;9) leading to acute undifferentiated leukemia. Stathmin is an oncogene found in greater abundance in leukemic cells compared to nonleukemic cells. A total of 94-kDa glucose-regulated protein has been shown to be protective in human breast cancer cells in vitro and related with the occurrence, differentiation, and progression of human lung cancer. The first protein has not been previously associated with NB.

CONCLUSIONS

The identification of these 3 previously unrecognized cancer-related potential biomarkers in human NB cell lines may prove useful in developing diagnostic tests. The proteomic methodology of 2-dimensional polyacrylamide gel electrophoresis/mass spectrometry also provides an improved opportunity to understand the natural history of NB and develop novel chemotherapeutic agents for this prevalent childhood malignancy with a dismal outcome.

Duodenal atresia and stenosis: long-term follow-up over 30 years

BACKGROUND

Duodenal atresia and stenosis is a frequent cause of congenital, intestinal obstruction. Current operative techniques and contemporary neonatal critical care result in a 5% morbidity and mortality rate, with late complications not uncommon, but unknown to short-term follow-up.

METHODS

A retrospective review of patients with duodenal anomalies was performed from 1972 to 2001 at a tertiary, children's hospital to identify late morbidity and mortality.

RESULTS

Duodenal atresia or stenosis was identified in 169 patients. Twenty children required additional abdominal operations after their initial repair with average follow-up of 6 years (range, 1 month to 18 years) including fundoplication (13), operation for complicated peptic ulcer disease (4), and adhesiolysis (4). Sixteen children underwent revision of their initial repair: tapering duodenoplasty or duodenal plication (7), conversion of duodenojejunostomy to duodenoduodenostomy (3), redo duodenojejunostomy (3), redo duodenoduodenostomy (2), and conversion of gastrojejunostomy to duodenoduodenostomy (1). There were 10 late deaths (range, 3 months to 14 years) attributable to complex cardiac malformations (5), central nervous system bleeding (1), pneumonia (1), anastomotic leak (1), and multisystem organ failure (2).

CONCLUSIONS

Late complications occur in 12% of patients with congenital duodenal anomalies, and the associated late mortality rate is 6%, which is low but not negligible. Follow-up of these patients into adulthood is recommended to identify and address these late occurrences.

Treatment on demand--in vivo dose finding studies

Since the discovery of replacement therapy the goal of treatment for haemophilia patients has always been the prevention of haemorrhagic episodes. However, the "ideal"" plasma level needed to prevent hemathrosis or treat haemorrhages is still unknown. It seems that the doses of treatment have been arrived at by trial and error based in the pharmacokinetics of the factors and the characteristics of the replacement product. This review provides some guidelines for the treatment of haemophilia, however the doses are not based in randomized trials.

Characterization of oncogene-silenced transgenic plants: implications for Agrobacterium biology and post-transcriptional gene silencing

SUMMARY Agrobacterium tumefaciens tumorigenesis is initiated by the horizontal transfer of a suite of oncogenes that alter hormone synthesis and sensitivity in infected plant cells. Transgenic plants silenced for the iaaM and ipt oncogenes are highly recalcitrant to tumorigenesis, and present a unique resource to elucidate fundamental questions related to Agrobacterium biology and post-transcriptional gene silencing (PTGS). The oncogene-silenced transgenic tomato line 01/6 was used to characterize A. tumefaciens growth in planta and to screen for iaaM and ipt sequence variants. Even in the absence of macroscopic and microscopic indications of tumorigenesis, A. tumefaciens is capable of long-term survival in the hypocotyl tissues of the 01/6 line. A. tumefaciens growth, however, is significantly reduced in the 01/6 line, with populations decreased by 96% relative to wild-type at 52 days post-inoculation. In addition, the 01/6 line displayed suppression of tumorigenesis against all 35 tested strains of A. tumefaciens. High target homology is an absolute requirement of PTGS, therefore this result suggests that regions of the iaaM and ipt oncogenes are very highly conserved across most A. tumefaciens strains. Finally, graft transmissibility of oncogene silencing was assessed by grafting various non-silenced tomato genotypes on to the 01/6 line. Phenotypic and molecular evidence (tumorigenesis and absence of small interfering RNAs, respectively) suggest that oncogene silencing is not graft-transmissible, at least to wild-type and antisense iaaM-over-expressing genotypes.

RNAi-mediated oncogene silencing confers resistance to crown gall tumorigenesis

Crown gall disease, caused by the soil bacterium Agrobacterium tumefaciens, results in significant economic losses in perennial crops worldwide. A. tumefaciens is one of the few organisms with a well characterized horizontal gene transfer system, possessing a suite of oncogenes that, when integrated into the plant genome, orchestrate de novo auxin and cytokinin biosynthesis to generate tumors. Specifically, the iaaM and ipt oncogenes, which show approximately 90% DNA sequence identity across studied A. tumefaciens strains, are required for tumor formation. By expressing two self-complementary RNA constructions designed to initiate RNA interference (RNAi) of iaaM and ipt, we generated transgenic Arabidopsis thaliana and Lycopersicon esculentum plants that are highly resistant to crown gall disease development. In in vitro root inoculation bioassays with two biovar I strains of A. tumefaciens, transgenic Arabidopsis lines averaged 0.0-1.5% tumorigenesis, whereas wild-type controls averaged 97.5% tumorigenesis. Similarly, several transformed tomato lines that were challenged by stem inoculation with three biovar I strains, one biovar II strain, and one biovar III strain of A. tumefaciens displayed between 0.0% and 24.2% tumorigenesis, whereas controls averaged 100% tumorigenesis. This mechanism of resistance, which is based on mRNA sequence homology rather than the highly specific receptor-ligand binding interactions characteristic of traditional plant resistance genes, should be highly durable. If successful and durable under field conditions, RNAi-mediated oncogene silencing may find broad applicability in the improvement of tree crop and ornamental rootstocks.