Use of modern three-dimensional imaging models to guide surgical planning for local control of pediatric extracranial solid tumors

INTRODUCTION

In complex pediatric surgical oncology, surgical planning is contingent upon data gathered from preoperative imaging. Three-dimensional (3D) modeling and printing has been shown to be beneficial for adult presurgical planning, though pediatric literature is less robust. The study reviews our institutional experience with the use of 3D image segmentation and printed models in approaching resection of extracranial solid tumors in children.

METHODS

This is a single institutional series from 2021 to 2023. Models were based on computed tomography and magnetic resonance imaging studies, optimized for 3D imaging. The feasibility and creation of the models is reviewed, including specific techniques, software, and printing materials from our institution. Clinical implications for surgical planning are also described, along with detailed preoperative and intraoperative images.

RESULTS

3D modeling and printing was performed for four pediatric patients diagnosed with extracranial solid tumors. Diagnoses included Ewing sarcoma, hepatoblastoma, synovial sarcoma, and osteosarcoma. No intraoperative complications or discrepancies with the preoperative 3D-printed model were noted. No evidence of local recurrence was identified in any patient thus far.

CONCLUSION

Our institutional series demonstrates a wide spectrum of clinical application for 3D modeling and printing technology within pediatric surgical oncology. This technology may aid in surgical planning for both resection and reconstruction, can be applied to a diverse breadth of diagnoses, and may potentially augment patient and/or family education about their condition.

Limited English Proficiency can Negatively Impact Disease/Treatment in Children With Cancer Compared to Those Who are English Proficient-an Institutional Study

BACKGROUND

In 2013, 25.5 million people in the United States self-identified as having limited English proficiency (LEP). LEP in adults has been associated with longer hospital stays, increased adverse events, increased emergency room visits, and decreased understanding of medications prescribed. This study aims to define the relationship between LEP and outcomes in a pediatric oncologic population.

METHODS

We performed a matched case-control study utilizing data from our institutional cancer database (children

RESULTS

Twenty-four LEP children were identified and matched with 77 EP children. LEP children represented 11 languages, with the most common being Spanish (42%). Statistical regression demonstrated a clinically significant trend for LEP children to have an increased mean number of unexpected hospital admissions (p = 0.04), increased number of clinic cancellations (n = 0.003), and increased emergency department visits (p = 0.05). LEP children were more likely to have Medicaid than commercial insurance (p < 0.001). There was no difference in 2-year event free or overall survival.

CONCLUSION

In our study cohort, LEP families are at risk for more negative treatment experiences than EP families. Further studies are needed to delineate specific causes and interventions.

TYPE OF STUDY

Retrospective comparative cohort study.

LEVEL OF EVIDENCE

Level III.

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Key Words

• Healthcare disparities
• Limited English proficiency
• Pediatric oncology

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MESH Headings

• Child
• Adult
• Humans
• United States/epidemiology
• Limited English Proficiency
• Cohort Studies
• Retrospective Studies
• Communication Barriers
• Case-Control Studies
• Neoplasms/therapy

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Affiliation(s)

Keyonna M Williams University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Ann Arbor, MI, USA.
Danielle Dougherty University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Ann Arbor, MI, USA
Connor Plagens University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Ann Arbor, MI, USA
Nikhil R Shah University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Ann Arbor, MI, USA
Darrell Tubbs University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Ann Arbor, MI, USA
Peter F Ehrlich University of Michigan, Michigan Medicine, Department of Surgery, Section of Pediatric Surgery, Ann Arbor, MI, USA

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Temporal Trends of Neonatal Surgical Conditions in Texas and Accessibility to Pediatric Surgical Care

INTRODUCTION

Texas consistently accounts for approximately 10% of annual national births, the second highest of all US states. This temporal study aimed to evaluate incidences of neonatal surgical conditions across Texas and to delineate regional pediatric surgeon accessibility.

METHODS

The Texas Birth Defects Registry was queried from 1999 to 2018, based on 11 well-established regions. Nine disorders (30,476 patients) were identified as being within the operative scope of pediatric surgeons: biliary atresia (BA), pyloric stenosis (PS), Hirschsprung's disease, stenosis/atresia of large intestine/rectum/anus, stenosis/atresia of small intestine, tracheoesophageal fistula/esophageal atresia, gastroschisis, omphalocele, and congenital diaphragmatic hernia. Annual and regional incidences were compared (/10,000 births). Statewide pediatric surgeons were identified through the American Pediatric Surgical Association directory. Regional incidences of neonatal disorder per surgeon were evaluated from 2010 to 2018 as a surrogate for provider disparity.

RESULTS

PS demonstrated the highest incidence (14.405/10,000), while BA had the lowest (0.707/10,000). Overall, incidences of PS and BA decreased significantly, while incidences of Hirschsprung's disease and small intestine increased. Other diagnoses remained stable. Regions 2 (48.24/10,000) and 11 (47.79/10,000) had the highest incidence of neonatal conditions; Region 6 had the lowest (34.68/10,000). Three rural regions (#2, 4, 9) lacked pediatric surgeons from 2010 to 2018. Of regions with at least one surgeon, historically underserved regions (#10, 11) along the Texas-Mexico border consistently had the highest defect per surgeon rates.

CONCLUSIONS

There are temporal and regional differences in incidences of neonatal conditions treated by pediatric surgeons across Texas. Improving access to neonatal care is a complex issue that necessitates collaborative efforts between state legislatures, health systems, and providers.

Palliative Care Training During Surgical Critical Care Fellowship: A Preliminary Needs Assessment at a Major Academic Center

Surgical palliative care (PC) facilitates communication between surgeons and patients/family about prognosis, symptom control, and therapeutic goals. Surgical critical care (SCC) fellows are at the forefront of the intensive care team; thus, we aim to assess previous and ongoing experiences in delivering PC by surveying fellows at a large academic center. Seventeen surveys were completed in which 59% of fellows reported no previous PC education. Six fellows (35%) reported participating in goals of care/end-of-life (GOC/EOL) discussions "a few times a year" during residency, while 41% responded the same for transitioning patients to comfort-focused care (CFC). When asked if respondents felt comfortable facilitating GOC/EOL discussions prior to fellowship, 7 (41%) answered "disagree" or "strongly disagree." Most fellows reported that more training in navigating GOC/EOL discussions (88%) and transitioning patients to CFC (76%) is needed. This assessment demonstrates variability in fellows' prior PC exposure and a strong desire for more structured training.

Identifying Community Safety and Policy-Based Injury Prevention Opportunities to Reduce Golf Cart Injuries

BACKGROUND

In small US communities, golf cart utilization has become increasingly more common. In the past 3 years, the incidence and severity of pediatric golf cart-related trauma evaluated at our trauma center has noticeably increased. Thus, the aim of this study was to analyze trends, identify risk and protective factors, and provide community-level recommendations to improve golf cart safety for children in a coastal community.

METHODS

A retrospective cross-sectional study of our institutional trauma registry was performed. The registry was queried for golf cart injuries between 2012 -2022. Demographics, accident details, hospital course and outcomes were reviewed. Data analysis involved quantitative statistics. Incident locations were mapped, including additional data from the County emergency medical service. Additionally, customer education at four prominent golf rental shops was observed.

RESULTS

Annual golf cart-related traumas doubled starting in 2020. Of 235 total patients, 105 (46%) were children. Median age was 11.5 years (range 2-17). 55% were female and 67% were non-Hispanic White. 80% were out-of-county residents. The most common injury location was extremity (56%). Median ISS was 4, and 3% died. Only 10% of children were restrained. 41% were ejected and most (84%) were front-facing passengers. Ejection was associated with more severe injury (OR 4.13, p = 0.01). Most injuries occurred during 5-10 pm (47%), weekends and summertime. Nighttime injuries were more severe than daytime (p = 0.04). A hotspot of crashes was identified in a zone where golf carts were restricted. Rental stores provided education on seat belt use, car seat use for infants, and off-limit zones. However, rules were not enforced.

CONCLUSION

Our results inform the following golf cart injury prevention opportunities: raising awareness of injury risks to children in high-tourist areas, partnering with rental stores to enforce rules, improving signage, adding protected lanes, and adopting a no nighttime operation policy.

LEVEL OF EVIDENCE

IV.

Prenatal Measurements of Congenital Lung Malformations: Can They Predict Postnatal Size?

INTRODUCTION

Prenatally diagnosed congenital lung malformations (CLMs) are monitored via ultrasound and measured by congenital pulmonary airway malformation volume ratios (CVRs) which can predict postnatal respiratory symptoms. This study compared CVR to postnatal lesion size to help guide prenatal counseling.

METHODS

A retrospective chart review evaluated the prenatal imaging and postnatal outcomes for patients who were prenatally diagnosed with CLMs and had a postnatal computed tomography (CT) scan at one institution.

RESULTS

Fifty-seven patients were included. Four had symptoms requiring urgent resection. The remaining were discharged and had clinic follow-up with CT scan to determine next steps: five had no identified lesions, eight had lesions whose diagnosis did not warrant an operation, and 40 had lesions whose diagnosis rendered size a factor in operative decision-making. Of these 40, 26/40 patients (65%) underwent elective resection (median maximum CVR 0.97; median lesion size 4 cm) and 14/40 patients (35%) were observed without resection (median maximum CVR 0.5; median lesion size 3 cm). There was a positive correlation between prenatal CVR and postnatal lesion size, with R-squared = 0.46. Maximum CVRs were better than last CVRs when predicting whether postnatal CT size would fall above or below our institution's level of recommended resection, with an area under the curve of 0.85 and a CVR cut-point of 0.61.

CONCLUSIONS

For newborns with asymptomatic CLMs, higher maximum CVRs correlated with larger size on postnatal CT. A maximum CVR ≤0.6 was correlated with a smaller postnatal CT size that may be eligible for nonoperative management. While these results are not intended to recommend surgery based on higher CVRs alone, this information could potentially be used to reassure expectant parents whose babies' prenatal imaging demonstrate lower maximum CVRs.

Sagittal Craniosynostosis: Treatment and Outcomes According to Age at Intervention

The purpose of this study is to describe the treatment strategies and outcomes of nonsyndromic single-suture sagittal craniosynostosis based on the patient's age at intervention. Studies from MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched for patients with nonsyndromic single-suture sagittal craniosynostosis. Inclusion criteria encompassed studies with follow-up of at least 12 months, minimum of 25 patients per cohort, and first-time surgical intervention. The risk of bias in nonrandomized studies of intervention tool [Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-I)] was applied. A total of 49 manuscripts with 3316 patients met criteria. Articles were categorized based on age at intervention; 0 to 6, older than 6 to 12, and older than 12 months. Fifteen of the manuscripts described interventions in more than 1 age group. From the 49 articles, 39 (n=2141) included patients 0 to 6 months old, 15 (n=669) discussed patients older than 6 to 12 months old, and 9 (n=506) evaluated patients older than 12 months old. Follow-up ranged from 12 to 144 months. Over 8 types of open surgical techniques were identified and 5 different minimally invasive procedures were described. Minimally invasive procedures were exclusively seen in the youngest patient cohort, while open cranial vault reconstructions were often seen in the 2 older cohorts. Endoscopic surgery and open conservative procedures are indicated for younger patients, while complex open cranial vault reconstructions are common in older patients. However, there is no consensus on one approach over the other. Even with the analysis of this review, we cannot factor a strong conclusion on a specific technique.

The impact of COVID-19 on clinical outcomes of burn patients

Background

Multiple studies have shown the SARS-CoV-2 virus (COVID-19) to be associated with deleterious outcomes in a wide range of patients. The impact of COVID-19 has not been well investigated among burned patients. We suspect that patients will have worsened respiratory and thrombotic complications, ultimately leading to increased mortality. The objective of this study is to determine the impact a concurrent infection of COVID-19 has on clinical outcomes after a burn injury.

Methods

This is a retrospective, propensity matched, cohort study. We examined a de-identified database of electronic medical records of over 75 million patients across 75 health care associations in the United States for patients treated for thermal burns from 1 January 2020, to 31 July 2021, and those who also were diagnosed with COVID-19 infection within one day before or after injury based on International Classification of Disease, tenth revision (ICD-10) codes. Study participants included adults who were treated for a burn injury during the study period.

Results

We included 736 patients with burn injury and concomitant COVID-19 infection matched to 736 patients with burn injury and no concurrent COVID-19 infection (total 1472 patients, mean age 36.3 ± 24.3). We found no significant increase in mortality observed for patients with concurrent COVID-19 (OR 1.203, 95% CI 0.517-2.803; p = 0.6675). We did observe significant increase in infections (OR 3.537, 95% CI 2.798-4.471; p = 0.0001), thrombotic complications (OR 2.342, 95% CI 1.351-4.058; p = 0.0018), as was the incidence of hypertrophic scarring (OR 3.368, 95% CI 2.326-4.877; p = 0.0001).

Conclusions

We observed that concurrent COVID-19 infection was associated with an increase in infections, thrombosis and hypertrophic scarring but no increase in mortality in our cohort of burn patients.

Debunking Myths of Gender Informed Care: What Every Pediatric Surgeon Should Know

As the transgender population in the United States grows, gender-affirming care is becoming increasingly relevant to the practice of pediatric surgery. Medical care for the transgender and gender diverse population is a politically charged topic with significant complexity and opportunities for clarification. It is important for providers to better understand this population's unique health and social needs. This review aims to debunk long-standing myths regarding gender-affirming care and highlight the current therapeutic and legislative landscapes within the scope of pediatric surgical practice. LEVEL OF EVIDENCE: IV.

Remote Instruction in Focused Assessment With Sonography in Trauma (FAST) Exams for Surgery Residents: A Pilot Study

BACKGROUND

The Focused Assessment with Sonography in Trauma (FAST) exam is an important component to the evaluation of trauma patients. With advances in technology and meeting limitations due to COVID-19, remote instruction and learning have gained popularity. We sought to determine whether remote instruction of FAST exams was feasible as sustainable surgical education and a possible alternative to traditional in-person teaching.

METHODS

General surgery residents completed a baseline survey and skills assessment on FAST exams and were then randomized to remote or in-person instruction. The remote group participated in an instructional session with a content expert through video conference and then practiced on a simulated mannequin while the expert remotely provided feedback. The in-person group received the experience with the content expert in the room. Both groups completed a post-course survey immediately after the session and a follow-up survey and objective assessment at six-months. Results were compared with two-way analysis of variance (ANOVA).

RESULTS

14 residents underwent the curriculum, seven in each group. There was a significant increase in self-reported confidence when comparing pre- and immediate post-course results for both the remote and in-person groups. At six months, confidence scores remained elevated and skill assessment scores improved, although the latter did not reach significance. There was no significant difference in post-course results between the groups.

CONCLUSIONS

Remote instruction of FAST exams was feasible. Pilot data demonstrated an increase in confidence and suggest outcomes that are similar to in-person instruction, which has positive implications for future remote educational and potentially clinical initiatives.

Outcomes of Complex Abdominal Wall Reconstruction with Biologic Mesh in Patients with 8 Years of Follow-Up

BACKGROUND

While many studies evaluated outcomes of abdominal wall reconstruction with biologic mesh, long-term data is lacking. In this study, we sought to analyze the outcomes of complex AWR with biologic mesh in a robust cohort of patients with a mean follow up of 8 years.

METHODS

We conducted a longitudinal study of AWR patients from 2005 to 2019. Hernia recurrence was the primary outcome, and surgical site occurrence was the secondary outcome. Predictive/protective factors were identified using a Cox proportional hazards regression models.

RESULTS

We identified 109 consecutive patients who met the inclusion criteria. Patient's mean (± SD) age was 57.5 ± 11.8 years, mean body mass index was 30.7 ± 7.2 kg/m2, and mean follow-up time was 96.2 ± 15.9 months. Fifty-six percent had clean defects, 34% had clean-contaminated defects, and 10% had contaminated/infected defects. Patients had a mean defect size of 261 ± 199.6 cm2 and mean mesh size of 391.3 ± 160.2 cm2. Nineteen patients (17.4%) developed HR at the final follow-up date. Obesity was independently associated with a four-fold higher risk of HR (hazard ratio, 3.98; 95%CI, 1.34 to 14.60, p = 0.02). SSOs were identified in 24.8% of patients. A prior hernia repair was associated with a three-fold higher risk of SSOs (Odds ratio, 3.13; 95%CI, 1.10 to 8.94, p = 0.03). No patient developed mesh infection.

CONCLUSION

These longitudinal data demonstrate that complex AWR with biologic mesh provides long-term durable outcomes with acceptable HR and SSO rates despite high contamination levels, patients complexity, and large defect size.

The Social Media Footprint of Pediatric Surgery Fellowship Programs: Where Do We Stand?

INTRODUCTION

Social media utilization is expanding within graduate medical education and academic surgery. This study aims to quantify the current social media footprint of pediatric surgery (PS) fellowship training programs.

METHODS

United States PS fellowship programs from the American Pediatric Surgical Association website and social media accounts on three platforms (Facebook, Instagram, Twitter) were identified. Authors quantified subject matter within public program content and compared PS social media utilization to other surgical training programs. A public Twitter survey was disseminated to evaluate recent PS applicant Twitter use and perceptions about content posted by programs.

RESULTS

Of 51 PS fellowship programs, 23 (45.1%) had active Twitter accounts, 2 (3.9%) had active Facebook accounts, and 1 (2.0%) had an active Instagram account. Cumulatively, 5162 organic posts were published across all 26 accounts (90.4% on Twitter). Most commonly posted content included research/conference presentations (31.3%) and faculty accolades (15.1%), while clinical/OR experience (3.6%), gender/ethnic diversity (2.4%) had the least content. Compared to other training programs, PS has lower utilization of Facebook (p < 0.001) and Instagram (p < 0.001), but similar Twitter utilization (p = 0.09). Twenty-four recent applicants responded to the public Twitter survey. Most (62.5%) used Twitter intentionally for recruitment and networking purposes when applying to fellowship. They expressed desire for increased content related to clinical/OR experiences, program ethnic/gender diversity and recruitment information.

CONCLUSION

Amongst PS training programs, Twitter is the most commonly utilized platform. Expanding Twitter usage to more programs and posting more varied content may facilitate opportunities for diverse applicant recruitment and serve as a platform to share clinical knowledge, which will ultimately move the needle towards growth and equity.

LEVEL OF EVIDENCE

IV.

Lower extremity complications in children following femoral cannulation for extracorporeal membrane oxygenation

INTRODUCTION

Extracorporeal membrane oxygenation cannulation strategies vary between adults and children. Femoral approach is common in adults and extremity morbidity is well-documented. Aside from limb ischemia, complications in children are theorized and have yet to be studied. This study aims to comprehensively evaluate implications of pediatric femoral cannulation.

METHODS

This is a single-center retrospective review of children <21 years, undergoing femoral venoarterial (VA) or venovenous (VV) cannulation between 2015 and 2022. The primary outcome was incidence of lower extremity complications on ECMO (groin hematoma/hemorrhage, vascular thrombosis, North-South syndrome, compartment syndrome, limb loss). Secondary outcome was incidence of post-decannulation extremity complications (pseudoaneurysm, surgical site infection, vascular thrombosis, motor/sensory deficits).

RESULTS

29 children were cannulated via femoral approach. Most required VA support (89%). Common sites were right femoral artery (70.8%) and right femoral vein (56%). 18 patients (75%) had distal reperfusion cannulas (DPC) placed. Short-term lower extremity complication rate was 59%, most frequently groin hematoma/hemorrhage (30%) and North-South syndrome (19%). Compartment syndrome occurred in 3 patients (11%), though none suffered digit/limb loss. There were no significant differences in complications between cannulation approach (open vs percutaneous) or vessel laterality (ipsilateral vs contralateral). Of those decannulated (n = 15), median ECMO duration was 8 days. Following decannulation, 20% suffered pseudoaneurysm. Ten (63%) experienced ipsilateral motor weakness which resolved in 50% of patients at 1-month follow-up; 20% suffered sensory deficits all resolving by discharge.

CONCLUSION

Approximately one third of children who underwent femoral cannulation suffered groin hematoma/hemorrhage and nearly 20% experienced North-South syndrome. Following decannulation, most had extremity weakness while sensory deficits were rarer. This marked risk of extremity morbidity prompts proactive inpatient monitoring and close surveillance after discharge.

Beyond Parity: Gender Diversity of National and International Pediatric Surgery Societal Leadership

PURPOSE

Despite trends toward equal gender representation among medical school graduates, surgical trainees and fellows, diversity in higher levels of pediatric surgery is largely unstudied. This study aims to quantify gender diversity among leadership of pediatric surgical associations and societies across the globe.

METHODS

National and international pediatric surgical organizations were identified from the websites of the American Pediatric Surgical Association (APSA) and World Federation of Associations of Pediatric Surgery (WOFAPS). Compositional gender data of current and past organizational leadership was collected by examining publicly available archives of executive membership rosters. If roster pictures were not available, member names were input into social media sites and other search engines to ensure accurate gender denotation. Univariate analyses of organizational metrics and aggregate data of 5-year time intervals were performed via Fischer's Exact Test with significance of p < 0.05.

RESULTS

Nineteen pediatric surgical organizations were included for study analysis. Of 189 current organizational leaders, 50 (26.4%) are women. Eight organizations (42.1%) have less than 20% of leadership positions filled by women members, while two executive boards have no women members. Four organizations (22.2%) have a current woman seated as president/chairperson. Historical gender distribution stratified by organization demonstrates a range of 0-7.8% (p = 0.99), with one organization having yet to elect a woman president/chairperson. Longitudinally, women presidential representation remained consistently low (5-11%) across all time intervals from 1993 to 2022 (p = 0.35).

CONCLUSIONS

Despite advances in diversity in medical school graduates, surgical training, and workforce recruitment, there are still significant disparities in gender representation within pediatric surgery societal leadership.

LEVEL OF EVIDENCE

IV.

Outcomes of Abdominal Wall Reconstruction with a Bovine versus a Porcine Acellular Dermal Matrix: A Propensity Score-Matched Analysis

BACKGROUND

Abdominal wall reconstruction (AWR) is one of the most commonly performed procedures, yet large comparative studies comparing outcomes of AWR using bovine acellular dermal matrix (BADM) and porcine acellular dermal matrix (PADM) are lacking.

METHODS

In this retrospective cohort study of patients who underwent AWR from March of 2005 to June of 2019, the primary comparative outcome measure was hernia recurrence with BADM versus PADM. The secondary outcome was the incidence of surgical-site occurrence (SSO) and surgical-site infection. A propensity score matching approach was applied to compare the clinical outcomes between the two study groups.

RESULTS

The authors identified 725 patients who underwent AWR using BADM (50.5%) or PADM (49.5%). Their mean ± SD age was 59.8 ± 11.5 years, mean body mass index was 31.4 ± 6.7 kg/m 2 , and mean follow-up time was 42 ± 29 months. With propensity score matching, 219 matched pairs were identified. Hernia recurrence rates in BADM (11.4%) and PADM (13.7%) groups did not differ significantly ( P = 0.793). SSO (26.5% versus 29.2%; P = 0.518) and SSI (13.2% versus 11%; P = 0.456) rates did not differ significantly in the PADM and BADM groups, respectively. Conditional logistic regression model and marginal Cox proportional hazards regression model determined that type of acellular dermal matrix was not significantly associated with SSOs (adjusted OR, 1.11; 95% CI, 0.74 to 1.70; P = 0.589) or hernia recurrence (adjusted hazard ratio, 0.85; 95% CI, 0.50 to 1.42; P = 0.52).

CONCLUSIONS

Both BADMs and PADMs provide durable, long-term outcomes. The hernia recurrence and postoperative surgical complication rates were not significantly different between BADM and PADM.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Implications of COVID-19 Infection on Arteriovenous Fistula Thrombosis

Objective: This study aims to identify and analyze implications of COVID-19 positivity on AVF occlusion, subsequent treatment patterns, and ESRD patient outcomes. Our aim is to provide a quantitative context for vascular access surgeons in order to optimize surgical decision making and minimize patient morbidity. Methods: The de-identified national TriNetX database was queried to extracted all adult patients who had a known AVF between January 1, 2020 and December 31, 2021. From this cohort individuals who also were diagnosed with COVID-19 prior to creation of their AVF were identified. Cohorts were propensity score matched according to age at AVF surgery, gender, ethnicity, diabetes mellitus, nicotine dependence, tobacco use, use of anticoagulant medications, and use of platelet aggregation inhibitors, hypertensive diseases, hyperlipidemia, and prothrombotic states. Results: After propensity score matching there were 5170 patients; 2585 patients in each group. The total patient population had 3023 (58.5%) males and 2147 (41.5%) females. The overall rate of thrombosis of AV fistulas was 300 (11.6%) in the cohort with COVID-19 and 256 (9.9%) in the control group (OR 1.199, CI 1.005-1.43, P =.0453). Open revisions of AVF with thrombectomy were significantly higher in the COVID-19 cohort compared to the non-COVID-19 group (1.5% vs .5% P = .0002, OR 3.199, CI 1.668-6.136). Regarding the time from AVF creation to intervention, the median days for open thrombectomy in COVID-19 patients was 72 vs 105 days in controls. For endovascular thrombectomy, the median was 175 vs 168 days for the COVID-19 and control cohorts respectively. Conclusion: As for this study, there were significant differences in rates of thrombosis and open revisions of recent created AVF, however endovascular interventions remained remarkably low. As noted in this study, the persistent prothrombotic state of patients with a history of COVID-19 may persist beyond the acute infectious period of the disease.

Thoracoscopic Patch Repair of Congenital Diaphragmatic Hernia: Can Smaller Incisions Treat Larger Defects?

INTRODUCTION

Thoracoscopic CDH repair is increasingly performed for Type A and small Type B defects that are amenable to primary repair. However, the thoracoscopic approach is controversial for larger defects necessitating a patch due to technical complexity, intraoperative acidosis, and recurrence risk. We aim to compare clinical outcomes between thoracoscopic and open patch repair of Type B/C defects, using a standardized technique.

METHODS

This is a single-center retrospective review of thoracoscopic and open CDH patch repairs January 2017-December 2021. We excluded primary repairs, Type D hernias, repairs on ECMO, recurrent repairs. Various preoperative, intraoperative, and postoperative variables were compared. Primary outcome was recurrence rate. Secondary outcomes included intraoperative pH and pCO2, operative time, and complication rates.

RESULTS

Twenty-nine patients met inclusion criteria (open = 13, thoracoscopic = 16). The open cohort had lower o/e total fetal lung volume (29 vs 41.2%, p = 0.042), higher preoperative peak inspiratory pressures (24 vs 20 cm H2O, p = 0.007), were more frequently Type C defects (92.3 vs 31%, p = 0.002) and had liver "up" in left-sided hernias (46 vs 0%, p < 0.0001). Intraoperatively, median lowest pH and highest pCO2 did not differ; neither did overall median pH or pCO2. Operative times were similar (153 vs 194 min, p = 0.113). No difference in recurrence rates was identified, however postoperative complications were higher in the open group. There were no mortalities.

CONCLUSIONS

Although we demonstrate higher disease severity of patients undergoing open repair, thoracoscopic patch repair for Type B/C defects is safe and effective in patients with favorable physiologic status, alleviating concerns for intraoperative acidosis, operative length, and risk of recurrence.

LEVEL OF EVIDENCE

II.

Implications of pediatric extracorporeal cardiopulmonary resuscitation simulation for intensive care team confidence and coordination: A pilot study

INTRODUCTION

Extracorporeal cardiopulmonary resuscitation (ECPR) is associated with improved outcomes in select populations, however, crisis resource management (CRM) in this setting is logistically challenging. This study evaluates the impact of ECPR simulation on self-perceived confidence and collaboration of intensive care unit team members.

METHODS

This is a prospective observational study analyzing data obtained between July 2018-December 2019. This study focused on non-surgical members of critical care team consisting of pediatric intensivists, resident physicians, registered nurses, respiratory therapists. Participants were expected to perform cardiopulmonary resuscitation (CPR) during the ECPR event, participate in code-team responsibilities and provide ancillary support during cannulation. Pre- and post-simulation surveys employed the Likert scale (1 = not at all confident, 5 = highly confident) to assess self-perceived scores in specified clinical competencies.

RESULTS

Twenty-nine providers participated in the simulation; 38% had prior ECPR experience. Compared to mean pre-study Likert scores (2.4, 2.4, 2.5), post-simulation scores increased (4.2, 4.4, 4.3) when self-evaluating: confidence in assessing patients needing ECPR, confidence in participating in ECPR workflow and confidence in performing high-quality CPR, respectively. Post-simulation values of >3 were reported by 100% of participants in all domains (p < .0001). All participants indicated the clinical scenario and procedural environment to be realistic and appropriately reflective of situational stress. Additionally, 100% of participants reported the simulation to improve perceived team communication and teamwork skills.

CONCLUSION

This study demonstrated preliminary feasibility of pediatric ECPR simulation in enhancing independent provider confidence and team communication. This self-perceived improvement may establish a foundation for cohesive CRM, in preparation for a real life ECPR encounter.

The new frontier in ECLS: Artificial placenta and artificial womb for premature infants

Outcomes for extremely low gestational age newborns (ELGANs), defined as <28 weeks estimated gestational age (EGA), remain disproportionately poor. A radical paradigm shift in the treatment of prematurity is to recreate the fetal environment with extracorporeal support and provide an environment for organ maturation using an extracorporeal VV-ECLS artificial placenta (AP) or an AV-ECLS artificial womb (AW). In this article, we will review clinical indications, current approaches in development, ongoing challenges, remaining milestones and ethical considerations prior to clinical translation.

The Burn Wound

Skin serves as a protective barrier against infection, prevents excessive fluid and electrolyte losses, performs crucial thermoregulation, and provides tactile feedback of surroundings. The skin also plays an essential role in human perception of body image, personal appearance, and self-confidence. With these many diverse functions, understanding normal anatomic composition of skin is pivotal to evaluating the extent of its disruption from burn injury. This article discusses the pathophysiology, initial evaluation, subsequent progression, and healing of burn wounds. By delineating the various microcellular and macrocellular alterations of burn injury, this review also augments providers' capacity to deliver patient-centered, evidence-based burn care.

Prevalence and Impact of Infection during Extracorporeal Membrane Oxygenation in Oncologic Patients: A Retrospective Analysis of the Extracorporeal Life Support Organization (ELSO) Registry

Background: Extracorporeal membrane oxygenation (ECMO) is widely utilized for severe cardiopulmonary insufficiency, but its application to the oncologic population has been debated given concern for increased risk of infection. This study aims to analyze the implications of infections acquired during ECMO runs in patients with malignancy. Methods: The Extracorporeal Life Support Organization (ELSO) database was queried for patients with an International Classification of Diseases code of neoplasms over the last two decades (2000-2019). Culture-proven infections during ECMO runs were analyzed and compared to previously reported data for all ECMO runs. Results: Two thousand, seven hundred and fifty-seven patients met inclusion criteria. Infection acquired during ECMO run was found in 687 patients, a significantly greater proportion compared to all ECMO runs (24.9% vs 11.7%; P = .001). Adult patients had a significantly higher rate of infection (27.0%; P < .001) compared to neonatal (11.0%) and pediatric (21.4%) patients. Prevalence of infection was highest in pulmonary ECMO (29.0%), while the infection rate standardized with ECMO duration was highest in extracorporeal cardiopulmonary resuscitation (55.03/1000-day ECMO run). Compared with ECMO for all diagnoses, the prevalence of Candida and Klebsiella infection was significantly higher in adult and pediatric oncologic patients. Regardless of the pathogen, the presence of infection was not associated with lower survival (38.6% vs 40.0%; P = .522). Conclusions: Oncologic patients had a significantly higher infection rate while on ECMO compared with the general ECMO population. However, the prognostic impact of these infections was minimal, thus ECMO should not be withheld in oncologic patients solely with concern for infection.

Risk factors for opioid use disorder after severe burns in adults

INTRODUCTION

Risk factors for opioid dependence amongst burn patients have not been well-explored compared to other surgical fields.

METHODS

The TrinetX database was queried for patients diagnosed with opioid use disorder (OUD) after thermal or chemical burn. Propensity score matching was performed. Opioid and non-opioid analgesia use, ICU care, surgery, and comparative risks among common opiates were examined using descriptive and univariate regression models, including odds ratios. Subgroup analysis evaluated the impact of multimodal analgesia.

RESULTS

Odds of receiving IV opioids for acute analgesia (p = <0.0001, OR = 1.80, CI = 1.45-2.25), undergoing surgery (p = <0.0001, OR = 1.58, CI = 1.26-1.98), and ICU care (p = <0.0001, OR = 3.60, CI = 2.00-3.83) after burn injury were higher in patients who developed OUD. Patients receiving multimodal therapy within 24 hours of admission had lower odds of developing OUD (OR = 0.74, CI = 2.76-4.68, p = 0.0001) and chronic pain (OR = 0.89, CI = 0.78-1.00, p = 0.05) regardless of TBSA.

CONCLUSION

Patients who developed opioid use disorder following burn injury had higher odds of receiving opioid exclusive pain management, more frequent surgery, ICU care.

Outcomes of Complex Abdominal Wall Reconstruction After Oncologic Resection: 14-Year Experience at an NCI-Designated Cancer Center

BACKGROUND

Outcomes studies for abdominal wall reconstruction (AWR) in the setting of previous oncologic extirpation are lacking. We sought to evaluate long-term outcomes of AWR using acellular dermal matrix (ADM) after extirpative resection, compare them to primary herniorrhaphy, and report the rates and predictors of postoperative complications.

METHODS

We conducted a retrospective cohort study of patients who underwent AWR after oncologic resection from March 2005 to June 2019 at a tertiary cancer center. The primary outcome was hernia recurrence (HR). Secondary outcomes included surgical site occurrences (SSOs), surgical site infection (SSIs), length of hospital stay (LOS), reoperation, and 30-day readmission.

RESULTS

Of 720 consecutive patients who underwent AWR during the study period, 194 (26.9%) underwent AWR following resection of abdominal wall tumors. In adjusted analyses, patients who had AWR after extirpative resection were more likely to have longer LOS (β, 2.57; 95%CI, 1.27 to 3.86, p < 0.001) than those with primary herniorrhaphy, but the risk of HR, SSO, SSI, 30-day readmission, and reoperation did not differ significantly. In the extirpative cohort, obesity (Hazard ratio, 6.48; p = 0.003), and bridged repair (Hazard ratio, 3.50; p = 0.004) were predictors of HR. Radiotherapy (OR, 2.23; p = 0.017) and diabetes mellites (OR, 3.70; p = 0.005) were predictors of SSOs. Defect width (OR, 2.30; p < 0.001) and mesh length (OR, 3.32; p = 0.046) were predictors of SSIs. Concomitant intra-abdominal surgery for active disease was not associated with worse outcomes.

CONCLUSIONS

AWR with ADM following extirpative resection demonstrated outcomes comparable with primary herniorrhaphy. Preoperative risk assessment and optimization are imperative for improving outcomes.

Spinophilin Limits Metabotropic Glutamate Receptor 5 Scaffolding to the Postsynaptic Density and Cell Type Specifically Mediates Excessive Grooming

BACKGROUND

Grooming dysfunction is a hallmark of the obsessive-compulsive spectrum disorder trichotillomania. Numerous preclinical studies have utilized SAPAP3-deficient mice for understanding the neurobiology of repetitive grooming, suggesting that excessive grooming is caused by increased metabotropic glutamate receptor 5 (mGluR5) activity in striatal direct- and indirect-pathway medium spiny neurons (MSNs). However, the MSN subtype-specific signaling mechanisms that mediate mGluR5-dependent adaptations underlying excessive grooming are not fully understood. Here, we investigated the MSN subtype-specific roles of the striatal signaling hub protein spinophilin in mediating repetitive motor dysfunction associated with mGluR5 function.

METHODS

Quantitative proteomics and immunoblotting were utilized to identify how spinophilin impacts mGluR5 phosphorylation and protein interaction changes. Plasticity and repetitive motor dysfunction associated with mGluR5 action were measured using our novel conditional spinophilin mouse model in which spinophilin was knocked out from striatal direct-pathway MSNs and/or indirect-pathway MSNs.

RESULTS

Loss of spinophilin only in indirect-pathway MSNs decreased performance of a novel motor repertoire, but loss of spinophilin in either MSN subtype abrogated striatal plasticity associated with mGluR5 function and prevented excessive grooming caused by SAPAP3 knockout mice or treatment with the mGluR5-specific positive allosteric modulator VU0360172 without impacting locomotion-relevant behavior. Biochemically, we determined that the spinophilin-mGluR5 interaction correlates with grooming behavior and that loss of spinophilin shifts mGluR5 interactions from lipid raft-associated proteins toward postsynaptic density proteins implicated in psychiatric disorders.

CONCLUSIONS

These results identify spinophilin as a novel striatal signaling hub molecule in MSNs that cell subtype specifically mediates behavioral, functional, and molecular adaptations associated with repetitive motor dysfunction in psychiatric disorders.

Emergent Bedside Resternotomy: An Innovative Simulation Model for Training Pediatric Cardiac Intensive Care Teams

Cardiac tamponade after cardiac surgery is a life-threatening event that requires simultaneous resuscitation and emergent resternotomy by the intensive care team. A simulated scenario using an innovative mannequin with sternotomy wound has the capability of reproducing cardiac arrest associated with postoperative tamponade. We evaluated the validity of this mannequin to investigate the confidence level and crisis resource management skills of the team during bedside resternotomy to manage postoperative cardiac tamponade. The simulation scenario was developed using the sternotomy mannequin for a pediatric cardiac intensive care unit (CICU) team. The case involved a 3-year-old male, intubated, and mechanically ventilated after surgical repair of congenital heart disease, progressing to cardiac arrest due to cardiac tamponade. We conducted a formative learner assessment before and after each scenario as well as a structured, video debriefing following each encounter. The simulation was repeated in a 6-month interval to assess knowledge retention and improvement in clinical workflow. The data were analyzed using student t-test and chi-square test, when appropriate. Of the 72 CICU providers, a significant proportion of providers (p < 0.0001) showed improved confidence in assessing and managing cardiac arrest associated with postoperative cardiac tamponade. All providers scored ≥3 for the impact of the scenario on practice, teamwork, communication, assessment skills, improvement in cardiopulmonary resuscitation, and opening the chest and their confidence in attending similar clinical situations in future. Most (96–100%) scored ≥3 for the perception on the realism of mannequin, the scenario, reopening the sternotomy, and level of stress. Time to diagnosis of cardiac tamponade (p = 0.004), time to the first dose of epinephrine (p = 0.045), and median number of interruptions to chest compressions (p = 0.006) all significantly decreased between the two sessions. Time to completion of resternotomy improved by 81.4 seconds; however, this decrease was not statistically significant. Implementation of a high-fidelity mannequin for postoperative cardiac tamponade simulation can achieve a realistic and reproducible training model with positive impacts on multidisciplinary team education.

Comparison of Outcomes of Abdominal Wall Reconstruction Performed by Surgical Fellows vs Faculty

Importance

Concern regarding surgical trainees' operative autonomy has increased in recent years, emphasizing patient safety and preparation for independent practice. Regarding abdominal wall reconstruction (AWR), long-term outcomes of fellow autonomy have yet to be delineated.

Objectives

To evaluate the long-term outcomes of AWRs performed by fellows and compare them with those of AWRs performed by assistant, associate, and senior-level professors.

Design, Setting, and Participants

This retrospective cohort study included patients who underwent AWR for ventral hernias or repair of tumor resection defects at a 710-bed tertiary cancer center between March 1, 2005, and June 30, 2019. The analysis was conducted between January 2020 and December 2021.

Exposure

Academic rank of primary surgeon.

Main Outcomes and Measures

The primary outcome was hernia recurrence. Secondary outcomes were surgical site occurrence, surgical site infection, length of hospital stay, unplanned return to the operating room, and 30-day readmission. Multivariable hierarchical models were constructed to identify predictive factors.

Results

Of 810 consecutive patients, 720 (mean [SD] age, 59.8 [11.5] years; 375 female [52.1%]) met the inclusion criteria. Mean (SD) body mass index was 31.4 (6.7), and mean (SD) follow-up time was 42 (29) months. Assistant professors performed the most AWRs (276 [38.3%]), followed by associate professors (169 [23.5%]), senior-level professors (157 [21.8%]), and microsurgical fellows (118 [16.4%]). Compared with fellows and more junior surgeons, senior-level professors tended to operate on significantly older patients (mean [SD] age, 59.9 [10.9] years; P = .03), more patients with obesity (103 [65.6%]; P = .003), and patients with larger defects (247.9 [216.0] cm; P < .001), parastomal hernias (27 [17.2%]; P = .001), or rectus muscle violation (53 [33.8%]; P = .03). No significant differences were found for hernia recurrence, surgical site occurrence, surgical site infection, 30-day readmission rates, or length of stay among the fellows and assistant, associate, and senior-level professors in adjusted models. Compared with fellows, assistant professors (OR, 0.22; 95% CI, 0.08-0.64) and senior-level professors (OR, 0.20; 95% CI, 0.06-0.69) had lower rates of unplanned return to the operating room.

Conclusions and Relevance

This cohort study provides evidence-based reassurance that providing fellows with autonomy in performing AWRs does not compromise long-term patient outcomes. These findings may incite efforts to increase appropriate surgical trainee autonomy, thereby empowering future generations of competent, independent surgeons.

Oncoplastic reconstruction of a large chest wall defect using dual fasciocutaneous flaps: A case report

Introduction and importance

Large chest wall defects in the context of breast cancer or its sequelae can be challenging to address. Oncoplastic techniques have been demonstrated to be safe and feasible options for immediate reconstruction. We describe the use of dual fasciocutaneous flaps for coverage following resection of a large chest wall mass in an area with a remote history of radiation therapy.

Case presentation

A 67-year-old woman with a distant history of bilateral mastectomies and adjuvant chemoradiation for Stage IIB triple negative invasive ductal carcinoma presented with an enlarging left chest wall mass and chronic wound. The mass was excised with adequate margins, and the resulting defect was reconstructed with two locoregional fasciocutaneous flaps. Pathology returned negative for malignancy and follow-up demonstrated viable flaps that were healing well.

Clinical discussion

Fasciocutaneous flaps are one of many techniques for breast reconstruction and offer advantages of a relatively superficial dissection, shorter operative time, and decreased risk of functional impairment. They are consequently an attractive option for patients with multiple comorbidities and high risk of perioperative complications. Historically used for immediate reconstruction at the time of oncologic resection, we present its successful use decades after the index cancer operation to manage a chest wall defect secondary to radiation injury.

Conclusions

Oncoplastic reconstruction with dual fasciocutaneous flaps is a feasible option for a large chest wall defect in the setting of previous radiation.

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Radiation necrosis may present late with an enlarging mass and draining wound.

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Excision is indicated to rule out malignancy.

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Oncoplastic fasciocutaneous flaps are a feasible option for wound coverage.

Pancreatic pseudocyst extending into psoas muscle mimicking acute complicated diverticulitis: A case report

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Pancreatic pseudocysts (PP) are known sequelae of acute and chronic pancreatitis.

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Pseudocyst extension into the psoas muscles have been rarely described.

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Pancreatic pseudocyst can also masquerade as complicated diverticulitis.

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This is a rare case of PP successfully managed with percutaneous drainage.

Introduction and importance

Pancreatic pseudocysts (PP) are known sequelae of pancreatitis. In this case, we present a patient with a pancreatic pseudocyst extending to the left psoas muscle, initially masquerading as acute complicated diverticulitis.

Case presentation

A 43-year-old male with previous episode of pancreatitis presented with a one-week history of abdominal pain. Physical examination revealed left lower quadrant tenderness. A computed tomography (CT) showed a large intraperitoneal fluid collection extending to the left psoas muscle with segmental inflammation of the descending colon. The patient was managed medically with empiric antibiotic therapy for concern of complicated diverticulitis. Ultrasound-guided percutaneous drainage was performed and fluid analysis showed lipase >20,000 U/L. The patient was discharged home with the drain. At one month follow up a repeat CT showed resolution of the left psoas fluid collection. The drain was removed and the patient remained asymptomatic at two month follow-up.

Clinical discussion

Pancreatic pseudocysts are well-known complications of pancreatitis. In this case, we describe extension of a pseudocyst to the left psoas muscle. We identified twelve previously reported patients diagnosed with PP involving the psoas muscles. Our case is unique as there is no previously published case in which a pseudocyst masqueraded as complicated diverticulitis. In analysis of the literature, most patients were managed with percutaneous drainage. Only 50% had documented complete resolution on follow up; of those 75% had undergone percutaneous drainage.

Conclusion

Pancreatic pseudocysts that extend to the psoas muscle can mimic acute complicated diverticulitis upon presentation. These may be effectively managed with percutaneous drainage.

Outcomes in Chest Wall Reconstruction Using Methyl Methacrylate Prostheses: A Review of the Literature and Case Series Utilizing a Novel Approach with Biologic Mesh

Background Composite defects after chest wall resection may leave patients at risk with lack of protection of vital structures and potentially respiratory compromise secondary to flail segments. Reconstruction of the chest wall with various alloplastic materials is possible and well described. Here, the authors present a novel technique in chest wall reconstruction utilizing a methyl methacrylate (MMA) “sandwich” with biologic mesh. The authors also sought to determine outcomes in chest wall reconstruction with MMA to optimize surgical decision making and minimize patient morbidity.

Methods A literature review was conducted using MEDLINE and the Cochrane Collaboration Library for primary research articles on chest wall reconstruction using MMA. Data related to surgical techniques and patient outcomes were extracted and analyzed. The authors also present their case series and outcomes utilizing a novel technique with biologic mesh.

Results Seventy-four articles met inclusion criteria, which included a total of 562 patients. Reconstruction methods included three main variations of the MMA prosthesis and six institution-specific variations. Complications were reported in 13.7% of patients; the most common complications included infection (5.6%), respiratory failure (3.3%), and atelectasis (1.7%). Less commonly reported complications included prosthesis dislocation (1.2%), pneumonia (1.0%), and lung collapse (0.4%). Overall mortality due to respiratory causes was observed in nine patients (1.6%). In our case series, complications included respiratory failure and seroma was reported in one patient, with no complications at long-term follow-up.

Conclusion There are a variety of options available for rigid and nonrigid prosthetic repair of the chest wall. We present the first successful reported case series of reconstruction using biologic mesh as a component of the MMA sandwich prosthesis. MMA appears to be a safe and effective choice for rigid reconstruction when used alone or in conjunction with synthetic or biologic mesh.

Study on effectiveness of transfusion program in thalassemia major patients receiving multiple blood transfusions at a transfusion centre in Western India

Background:

Children suffering from beta-thalassemia major require repeated blood transfusions which may be associated with dangers like iron overload and contraction of infections such as HIV, HCV, and HBsAg which ultimately curtail their life span. On the other hand, inadequate transfusions lead to severe anemia and general fatigue and debility.

Materials and Methods:

Data were obtained from 142 beta-thalassemia major patients aged 3 years or more receiving regular blood transfusions at a transfusion centre in Western India from 1 April 2009 to 30 June 2009. The clinical data and laboratory results were subsequently analyzed.

Results:

Of the 142 patients, 76 (53.5%) were undertransfused (mean Hb <10 gm%). 96 (67%) of the patients were taking some form of chelation therapy but out of them only 2 (2%) were adequately chelated (S. ferritin <1000 ng/ml). 5 (3.5%) of the patients were known diabetics on insulin therapy. 103 (72%) of the patients were retarded in terms of growth. The prevalence of transfusion-transmitted infections (TTIs) such as HCV, HIV, and HBsAg was respectively 45%, 2%, and 2%, with the prevalence of HCV being significantly more than the general population. The HCV prevalence showed positive correlation with the age of the patients and with the total no of blood transfusions received. As many as 15% (6 out of 40) children who were born on or after 2002 were HCV positive despite the blood they received being subjected to screening for HCV.

Conclusions:

The study suggests the need to step up the transfusions to achieve hemoglobin goal of 10 gm% (as per the moderate transfusion regimen) and also to institute urgent and effective chelation measures with the aim of keeping serum ferritin levels below 1000 ng/ml to avoid the systemic effects of iron overload. In addition, strict monitoring of the children for endocrinopathy and other systemic effects of iron overload should be done. Rigid implementation of quality control measures for the ELISA kits used to detect HCV in donor blood needs to be done urgently. Alternately, more sensitive and specific measures (like NAT testing) should be employed for detection of HCV. In the absence of a definitive cure accessible and available to all patients, strict implementation of the above suggested measures will go a long way in improving the quality (and quantity) of life in patients of beta-thalassemia major.

Ventricular fibrillation as a likely consequence of capecitabine-induced coronary vasospasm

Capecitabine is a member of the fluoropyrimidine family of chemotherapeutic agents that selectively delivers 5-fluorouracil (5-FU) to tumors. It is increasingly used as part of combined modality treatment for gastrointestinal malignancies. Cardiotoxicity has been documented to occur with 5-FU, but due to an expansion in capecitabine use, reports exist of its propensity to coronary vasospasm. We report the case of a 28-year-old man, with no preceding angina, presenting with a reversible episode of ventricular fibrillation (VF) at rest in his fifth course of capecitabine chemotherapy for metastatic colorectal cancer. Emergency resuscitation successfully restored spontaneous circulation, with initial ST segment elevation in the inferolateral leads on electrocardiogram prompting emergency coronary angiography. This demonstrated normal coronary arteries. ST segments normalized post-angiography and the patient rapidly recovered with no myocardial damage sustained. An implantable cardioverter-defibrillator was placed for secondary prevention of sudden death, and capecitabine was implicated as the cause of coronary vasospasm which resulted in his presentation of VF. To our knowledge, this is the first episode of VF as a consequence of suspected capecitabine-induced coronary vasospasm occurring at rest. Our case highlights the potential for severe cardiotoxic consequences of capecitabine including sudden death from VF, and given the multi-disciplinary approach to managing oncology patients, health professionals should be aware of this.

Takotsubo cardiomyopathy presenting as postoperative atrial fibrillation

Takotsubo cardiomyopathy (TC) is a condition which was first acknowledged in Japan and is characterized by a reversible systolic dysfunction of the apical or mid segments of the left ventricle. Typically affecting women in the post-menopausal population, it is triggered by intense emotional, physical or medical stress. Also known as apical ballooning syndrome or stress cardiomyopathy, TC derives its name from the left ventricular angiographic appearance of a 'Takotsubo', literally translated as an 'octopus fishing trap' in Japanese. Patients often describe chest pain, have ischemic electrocardiogram (ECG) changes and positive cardiac enzymes mimicking an acute coronary syndrome. Obstructive coronary artery disease is excluded with prompt cardiac catheterization. We present the case of a 78-year-old lady, post gynecological surgery, presenting with palpitations and ECG confirming fast atrial fibrillation. Despite spontaneous cardioversion, she went on to develop ECG changes and cardiac enzyme elevations suggestive of an acute myocardial infarction. Cardiac catheterization was performed and confirmed the diagnosis of TC. It highlights an atypical presentation of TC, which can present initially as an arrhythmia in the postoperative phase as a consequence of the supraphysiological effects of elevated circulating plasma catecholamines. It reiterates the importance of prompt diagnosis and treatment to prevent cardiac decompensation in a condition poorly understood.

An unusual presentation of myxoid liposarcoma: a case report

A 50 year old female had a myxoid liposarcoma of left thigh that was widely excised. After three years, she presented with a soft tissue mass in right hypochondriac region, which was diagnosed as myxoid liposarcoma on fine needle aspiration cytology (FNAC) and was confirmed histologically.

Outcomes of treatment of children and adolescents with recurrent non-Hodgkin's lymphoma and Hodgkin's disease with dexamethasone, etoposide, cisplatin, cytarabine, and l-asparaginase, maintenance chemotherapy, and transplantation: Children's Cancer Group Study CCG-5912

PURPOSE

To determine the toxicity and response rate in children treated with dexamethasone, etoposide, cisplatin, high-dose cytarabine, and L-asparaginase (DECAL) for recurrent non-Hodgkin's lymphoma (NHL) and Hodgkin's disease (HD).

PATIENTS AND METHODS

Ninety-seven children with recurrent NHL (n = 68) or HD (n = 29) were enrolled. Treatment consisted of two cycles of DECAL, then bone marrow transplantation or up to four cycles of ifosfamide, mesna, and etoposide alternating with DECAL maintenance therapy.

RESULTS

After two cycles of DECAL induction therapy, complete response (CR) or partial response (PR) was reported in 19 (65.5%; 10 CRs and nine PRs) of 29 patients with HD and 29 (41.6%; 23 CRs and six PRs) of 68 patients with NHL. When only 24 patients with HD and 58 patients with NHL who were assessable for response were considered, the response rates were 79.2% (19 of 24 patients) and 50.0% (29 of 58 patients), respectively. Five-year event-free survival was 26% +/- 9% and 23% +/- 5% in patients with HD and NHL, respectively. Five-year survival was 31% +/- 14% and 30% +/- 6%, respectively. Although median time to treatment failure was significantly longer in patients with HD (EFS, P =.002; survival, P =.011), this difference did not translate into a higher long-term survival. Grade 3 or 4 toxic effects were observed during induction in 70 (72%) of 97 patients and during maintenance in 45 (70%) of 64 courses of DECAL therapy. Pancytopenia and systemic infections in particular were frequently observed. Other toxic effects were uncommon. Although not a formal part of the therapy or the study design, 42 patients who responded to therapy who underwent bone marrow transplant did not show any benefit from this approach.

CONCLUSION

DECAL is an effective and tolerable salvage regimen for treating patients with recurrent NHL and HD.

Parental smoking and alcohol consumption and risk of neuroblastoma

Previous studies and animal evidence have suggested a relationship between parental tobacco or alcohol use and the risk of some childhood cancers, including neuroblastoma. A case-control study was conducted to investigate the relationship between parental tobacco smoking, alcohol consumption, and risk of neuroblastoma. Cases were children diagnosed with neuroblastoma over the period 1992-1994 at Children's Cancer Group and Pediatric Oncology Group institutions throughout the United States and Canada. One matched control was selected using random-digit dialing. Information on parental smoking and drinking history was obtained from 504 case and 504 control parents by telephone interview. Overall, there was no consistent pattern of association with parental smoking and alcohol consumption. For example, both maternal smoking and drinking during the period from 1 month before pregnancy through breastfeeding had adjusted odds ratios (ORs) of 1.1 [95% confidence interval (CI), 0.8-1.4]. There was no association with paternal smoking (OR, 1.2; 95% CI, 0.8-1.6) or paternal drinking 1 month before conception (OR, 1.0; 95% CI, 0.7-1.4). There was no consistent increase in risk by the amount of smoking or drinking during any time period relative to pregnancy. There was no suggestion of an increased risk when only one parent smoked. Smoking or drinking among both parents did not jointly increase the risk of neuroblastoma in their offspring. The child's age at diagnosis, stage, or MYCN oncogene amplification status did not materially alter the OR estimates. It is concluded that the results from this study do not indicate any evidence for a relationship between neuroblastoma and parental tobacco or alcohol use.

A systematic review and meta-analysis of prospective studies on the association between maternal cigarette smoking and preterm delivery

We have attempted to quantify the most up-to-date estimate of the association between cigarette smoking by the mother and preterm delivery. Studies were selected for inclusion in this review if they were prospective, reported data stratified across at least two levels of maternal smoking, and defined preterm delivery on the basis of gestational age. In a meta-analysis we combined results from multiple studies that reported on preterm delivery and maternal smoking during pregnancy. Pooled odds ratios were computed for various strata of smoking intensity with the Mantel-Haenszel fixed-effects model. Twenty studies met all inclusion criteria and were included in meta-analysis. The pooled point estimate from 20 prospective studies on any maternal smoking versus no maternal smoking was 1.27 (95% confidence interval, 1.21-1.33). Subgroup analyses stratifying maternal smoking on number of cigarettes per day suggest a dose-response relationship at low to moderate levels of smoking, which was not further increased at high levels of smoking. A nonsignificant level of publication bias appears to exist in the smoking-preterm delivery literature. Cigarette smoking is a preventable risk factor that is associated with preterm delivery. Consistent results across many study populations and research designs and evidence of a dose-response relationship support its causal role in preterm delivery.

Resolution enhancement of color video sequences

We propose a new multiframe algorithm to enhance the spatial resolution of frames in video sequences. Our technique specifically accounts for the possibility that motion estimation will be inaccurate and compensates for these inaccuracies. Experiments show that our multiframe enhancement algorithm yields perceptibly sharper enhanced images with significant signal-to-noise ratio (SNR) improvement over bilinear and cubic B-spline interpolation.

New frontiers for diagnostic testing: taking advantage of forces changing health care

The transformation of the health-care industry holds great economic potential for laboratory diagnostic testing providers who understand the five market forces driving change and who are shaping their own roles in the emerging market. Because of these trends, provider-based laboratories (PBLs) are competing with independent laboratories (ILs) for the latter's traditional client base--outpatients and nonpatients. PBLs will continue to service acute care patients while becoming more IL-like in logistics, sales, customer service, and marketing. Forced to compete on price, ILs have engaged in mega-mergers and will try to break into acute care via joint ventures. The ILs will need to choose their markets carefully, solidly integrate with parent organizations, and find ways to be profit centers. Consumers' demands also are forcing change. Consumers want accurate, legible bills and simplified eligibility determination and registration. They want an emphasis on prevention and wellness, which means that diagnostic testing must address early identification and monitoring of high-risk groups. To realize cost-efficiencies under whole-life capitation, laboratory networks must be part of a completely integrated health-care system. The laboratory of the future will be multicentered, without walls, and with quick access to information through technology.

Interleukin-6-associated laboratory parameters and immunohistochemistry in symptomatic stage A and B nodular sclerosing Hodgkin's disease in children

Interleukin (IL)-6-associated laboratory parameters obtained at diagnosis on 17 children with histologically confirmed nodular sclerosing Hodgkin's disease (NSHD) are reported. When these patients were grouped as either symptomatic stage A or B, they were found to be similar in extent of disease, age, and gender. However, statistically significant differences between these two groups were observed for the means of the following IL-6-associated laboratory parameters: hematocrit (p = 0.019), platelet count (p = 0.009), serum albumin (p = 0.001), and ferritin (p = 0.037) concentrations. Moreover, trend analysis of abnormalcy revealed an increasing frequency of anemia, thrombocytosis, hypoalbuminemia, and hyperferritinemia between stage A and B patients and, when available, febrile controls (p values = 0.0012, 0.0009, 0.0406, and 0.0011, respectively). Correspondingly, IL-6 immunohistochemistry performed on archival material from representative cases in each group showed greater overall reactivity in specimens from stage B patients. A variety of cells accounted for this positivity for IL-6 antigen including Reed-Sternberg cells and their variants, lacunar cells, dendritic interdigitating cells, endothelial cells, fibroblasts, and vascular smooth muscle cells. In summary, greater and more frequent abnormalities in IL-6-associated laboratory parameters and increased immunohistochemical reactivity for IL-6 antigen coincide with the presence of fever in helping to identify children with clinical stage B NSHD.

Total quality management in action: pharmacy system changes to decrease medication incidents and increase clinical services

During a monitoring of risk management indicators (incident report analysis), a trend of increasing medication incidents was noted from 1987 to 1990. The medication ordering process was tracked using a flow chart, and, using an interdisciplinary team, the transcription system was targeted for corrective action. A "roving pharmacist" system was devised, with a resultant 63% decrease in the reported medication incident rate from 1990 to 1993.

Epidemiologic features of pain in pediatric cancer patients: a co-operative community-based study. North Central Cancer Treatment Group and Mayo Clinic)

The prevalence, etiology, and management of pain in pediatric cancer patients seen at the Mayo Clinic and member institutions of the North Central Cancer Treatment Group were assessed. Participating centers, including both primary care and referral institutions, surveyed all patients seen during a 1-week period (Monday through Friday); procedure-related pain was excluded. Of the 160 children surveyed, 28 reported pain of which 57.8% was related to a side effect of anticancer treatment, 21.1% was unrelated to the malignancy, and 21.1% arose directly from the cancer. Pain intensity assessment was performed by both health-care professional and patient using a variety of measurement tools. Correlation between assessors was close except in young children. The predominance of treatment-related rather than cancer-related pain differs from results in series in adult cancer patients.

Aluminum-induced microcytosis in a child with moderate renal insufficiency

A child with moderate renal failure, on high doses of aluminum compounds for treatment for hyperphosphatasemia, presented with unexplained microcytosis. The patient also had psychomotor delay. On discontinuation of aluminum, microcytosis reversed in 2 months. Four months later, psychomotor development improved. Children with renal failure, on aluminum supplementation, should be carefully monitored for toxicity. Microcytosis may be a clue to aluminum toxicity in such patients.