[Show abstract][Hide abstract] ABSTRACT: Background:
Despite randomized controlled trials and meta-analyses, it remains unclear whether laparoscopic pyloromyotomy (LP) carries a higher risk of incomplete pyloromyotomy and mucosal perforation compared with open pyloromyotomy (OP).
Multicenter study of all pyloromyotomies (May 2007-December 2010) at nine high-volume institutions. The effect of laparoscopy on the procedure-related complications of incomplete pyloromyotomy and mucosal perforation was determined using binomial logistic regression adjusting for differences among centers.
Data relating to 2830 pyloromyotomies (1802 [64%] LP) were analyzed. There were 24 cases of incomplete pyloromyotomy; 3 in the open group (0.29%) and 21 in the laparoscopic group (1.16%). There were 18 cases of mucosal perforation; 3 in the open group (0.29%) and 15 in the laparoscopic group (0.83%). The regression model demonstrated that LP was a marginally significant predictor of incomplete pyloromyotomy (adjusted difference 0.87% [95% CI 0.006-4.083]; P=0.046) but not of mucosal perforation (adjusted difference 0.56% [95% CI -0.096 to 3.365]; P=0.153). Trainees performed a similar proportion of each procedure (laparoscopic 82.6% vs. open 80.3%; P=0.2) and grade of primary operator did not affect the rate of either complication.
This is one of the largest series of pyloromyotomy ever reported. Although laparoscopy is associated with a statistically significant increase in the risk of incomplete pyloromyotomy, the effect size is small and of questionable clinical relevance. Both OP and LP are associated with low rates of mucosal perforation and incomplete pyloromyotomy in specialist centers, whether trainee or consultant surgeons perform the procedure.
Journal of Pediatric Surgery 07/2014; 49(7):1083-6. DOI:10.1016/j.jpedsurg.2013.10.014 · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although physician-reported complications following circumcision are very low, parental satisfaction is not well documented. This study examined parental opinions and compared these with those of the medical professional.
Physicians independently assessed complications and cosmetic outcome following the circumcision. Six weeks post-circumcision, parental report of complications, cosmetic outcome, and overall satisfaction were assessed.
Newborn infants (n = 710) were prospectively recruited and underwent either a Gomco [n = 552 (78 %)] or Plastibell(®) [n = 158 (22 %)] circumcision. Physician assessed complication rates were equivalent (Gomco 4.3 % versus Plastibell 5.1 %; p = 0.67), however, parental assessment found a much lower complication rate for Gomco 5.6 % versus Plastibell 12.0 % (p < 0.001). There was no difference between who performed the procedure nor between the techniques in regards to parental rating of overall satisfaction (excellent/good: Gomco 96.9 % versus Plastibell 95.6 %, p = 0.45). However, perceived post-operative pain as scored by parents was significantly higher in patients undergoing Plastibell procedure (6.4 % too much pain) versus Gomco (2.7 %; p = 0.05). Gomco accounted for 72.7 % of parental cosmetically unsatisfactory cases.
Clinicians and parents differed considerably in terms of opinion of cosmetic outcome and occurrence of post-operative complications. This study emphasizes the need for clinicians to better understand and address parental concerns before and after circumcision.
Pediatric Surgery International 11/2013; 30(3). DOI:10.1007/s00383-013-3430-5 · 1.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A major determinant of survival in patients with congenital diaphragmatic hernia (CDH) is severity of pulmonary hypoplasia. This study addresses the comparative effectiveness of prenatal methods of lung assessment in predicting mortality, extracorporeal membrane oxygenation (ECMO), and ventilator dependency.
We retrospectively reviewed all patients born with isolated CDH between 2004 and 2008. Lung-to-head ratio (LHR) and observed-to-expected LHR (OELHR) were obtained from prenatal ultrasounds. Percent-predicted lung volume (PPLV) was obtained from fetal MRI (fMRI). Postnatal data included in-hospital mortality, need for ECMO, and ventilator dependency at day-of-life 30.
Thirty-seven patients underwent 81 prenatal ultrasounds, while 26 of this sub-cohort underwent fMRI. Gestational age during imaging study was associated with LHR (p=0.02), but not OELHR (p=0.12) or PPLV (p=0.72). PPLV, min-LHR, and min-OELHR were each associated with mortality (p=0.03, p=0.02, p=0.01), ECMO (p<0.01, p<0.01, p=0.03), and ventilator dependency (p<0.01, p<0.01, p=0.02). For each outcome, PPLV was a more discriminative measure, based on Akaike's information criterion. Using longitudinal analysis techniques for patients with multiple ultrasounds, OELHR remained associated with mortality (p=0.04), ECMO (p=0.03), and ventilator dependency (p=0.02), while LHR was associated with ECMO (p=0.01) and ventilator dependency (p=0.02) but not mortality (p=0.06).
When assessing fetuses with CDH, OELHR and PPLV may be most helpful for counseling regarding postnatal outcomes.
Journal of Pediatric Surgery 06/2013; 48(6):1190-1197. DOI:10.1016/j.jpedsurg.2013.03.033 · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
Hirschsprung-associated enterocolitis (HAEC) is one of the most troublesome problems encountered after a pullthrough. We hypothesized that prophylactic administration of probiotics after a pullthrough procedure would decrease the incidence of HAEC.
A prospective, double-blind, placebo-controlled, randomized trial was conducted at 2 children's hospitals. Infants undergoing pullthrough were randomized to probiotic or placebo for a period of 3 months post-pullthrough. Primary outcome was incidence of post-operative HAEC. Other outcomes included severity of HAEC by clinical grade, number of HAEC episodes and extent of aganglionosis. Pearson Chi Square analysis, as well as logistic regression, was used for statistical analysis.
Sixty-two patients were recruited (Sites: A=40; B=22). One was lost to follow up and one immediate post-op death was not included in final analysis. Probiotics were administered to 32 patients. Distribution of placebo/probiotics was equal between sites (P=0.858). Mean age at pullthrough was 6.5 ± 8.1(± SD) months. The incidence of HAEC was 28.3%. The incidence of HAEC was not statistically different between probiotic and placebo study groups.
Incidence of HAEC was not reduced with prophylactic probiotics. Future studies are needed to better determine the etiology and possible ways of preventing this complex condition.
Journal of Pediatric Surgery 01/2013; 48(1):111-117. DOI:10.1016/j.jpedsurg.2012.10.028 · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
The purpose of this study was to develop a simple and accurate approach for risk stratification of fetal lung lesions that are associated with respiratory compromise at birth.
We conducted a retrospective review of 64 prenatal lung lesions that were managed at a single fetal care referral center (2001-2011). Sonographic data were analyzed and correlated with perinatal outcomes.
Hydrops occurred in only 4 cases (6.3%). Among fetuses without hydrops, the congenital pulmonary airway malformation volume ratio (CVR) was the only variable that was associated significantly with respiratory compromise and the need for lung resection at birth (P < .01). Based on a maximum CVR >1.0, the sensitivity, specificity, positive predictive value, and negative predictive value for respiratory morbidity were 90%, 93%, 75%, and 98%, respectively.
Nonhydropic fetuses with a maximum CVR >1.0 are a subgroup of patients who are at increased risk for respiratory morbidity and the need for surgical intervention. These patients should be delivered at a tertiary care center with pediatric surgery expertise to ensure optimal clinical outcomes.
American journal of obstetrics and gynecology 11/2012; 208(2). DOI:10.1016/j.ajog.2012.11.012 · 4.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose: A major determinant of survival in patients with CDH is the degree of pulmonary hypoplasia. Prenatal methods of lung assessment include lung-to-head ratio (LHR) by ultrasound, observed-to-expected LHR (o:eLHR) by ultrasound, and percent-predicted lung volume (PPLV) by fetal MRI (fMRI). This study addresses the comparative effectiveness of LHR, o:eLHR, and PPLV in predicting mortality and ventilator-dependency.
Methods: We retrospectively reviewed 67 patients born with CDH between 2004-2008. Prenatal ultrasounds were assessed to determine LHR and o:eLHR. PPLV was obtained from imaging reports of patients who also underwent fMRI. Postnatal data included discharge mortality and ventilator-dependency at day-of-life (DOL) 30 for survivors. Univariate generalized linear mixed modeling (GLMM), a longitudinal analysis random-effects technique that accounts for patient-specific repeated measures, was utilized to assess variation of LHR and o:eLHR with estimated gestational age (EGA). Simple linear regression modeling was used to predict PPLV with EGA. Next, repeated measures of LHR and o:eLHR for a given patient were summarized using the minimum value and simple logistic regression was used to model minimum-LHR (min-LHR), minimum-o:eLHR (min-o:eLHR), and PPLV as predictors of mortality and ventilator-dependency. Log-transformation was employed to stabilize the variance of the logistic regression models. Models were compared using Akaike's information criterion (AIC), with lower AIC indicating better fit. To further quantify the effect on mortality and ventilator-dependency of LHR and o:eLHR without requiring a summary statistic (i.e. minimum value), simple GLMM was again utilized. All analysis was conducted using SAS, with alpha-level=0.05.
Results: Thirty-seven patients underwent 82 prenatal ultrasounds, while 26 of this sub-cohort underwent an fMRI study. Survival-to-discharge was 78.4% (29/37) and 76.9% (20/26) in the ultrasound and fMRI cohorts, respectively. Median EGA at ultrasound and fMRI were 30.2 (range=18.1-38.5) and 23.0 weeks (range=20.0-38.0), respectively. Using GLMM to account for repeated measures, EGA predicted LHR (p=0.02), but not o:eLHR (p=0.12). Using linear regression, EGA did not predict PPLV (p=0.72). Univariate logistic regression revealed min-LHR, min-o:eLHR, and PPLV as significant predictors of mortality and ventilator-dependency. The PPLV models had the best fits, based on AIC.[Figure 1] Receiver-operating-characteristic (ROC) analysis illustrated highest area-under-the-curve for the PPLV mortality-prediction model.[Figure 2] Univariate GLMM for repeated ultrasound measures showed o:eLHR (p=0.04) but not LHR (p=0.06) predicted mortality. Both LHR (p=0.02) and o:eLHR (p=0.02) predicted ventilator-dependency at DOL30.
Conclusion: PPLV and o:eLHR were independent of EGA, in contrast to LHR. Min-LHR, min-o:eLHR, and PPLV each independently predicted mortality and ventilator-dependency. PPLV was a slightly more predictive and discriminative measure for these outcomes. Given that PPLV and o:eLHR were independent of EGA and predictive of both mortality and ventilator dependency, these measures were found to be superior to LHR. When assessing fetuses with CDH, o:eLHR using ultrasound or PPLV utilizing fetal MRI may be most helpful for counseling regarding postnatal outcomes.
2012 American Academy of Pediatrics National Conference and Exhibition; 10/2012
[Show abstract][Hide abstract] ABSTRACT: Background:
Fifteen percent of infants with congenital diaphragmatic hernia (CDH) are born with a coexisting cardiac anomaly. The purpose of this study was to evaluate contemporary outcomes in this patient population and to identify potential risk factors for in-hospital mortality.
Data from all CDH neonates with congenital heart disease managed at a single pediatric tertiary care referral center between 1997 and 2011 were retrospectively analyzed.
Forty (18%) of 216 CDH patients had a cardiac anomaly. This group was associated with a significant decrease in overall survival when compared with patients without cardiac anomaly (55% versus 81%; p = 0.001). There was no association between type of cardiac anomaly and mortality based on risk stratification according to the Risk Adjustment for Congenital Heart Surgery and The Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery scoring systems (p = 0.86 and p = 0.87, respectively). Birth weight was similarly no different between survivors and nonsurvivors (2.8 ± 0.6 kg versus 2.8 ± 0.9 kg, respectively; p = 0.98). There was a trend toward increased extracorporeal membrane oxygenation use among nonsurvivors (p = 0.13). Infants with hemodynamic stability enabling subsequent cardiac repair were associated with lower mortality (p = 0.04). Survivors had a wide spectrum of long-term morbidity, but most had some evidence of neurodevelopmental impairment.
This large single-institution series suggests that the overall prognosis of infants with concomitant CDH and congenital heart disease can be quite variable, regardless of the type of heart anomaly. Hemodynamic instability and need for extracorporeal membrane oxygenation correlate with higher mortality. Although some long-term survivors have excellent outcomes, most suffer from chronic, long-term morbidities.
The Annals of thoracic surgery 08/2012; 95(3). DOI:10.1016/j.athoracsur.2012.07.010 · 3.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Deep venous thrombosis (DVT) is a frequent complication in infants with central venous catheters (CVCs). We performed this study to identify risk factors and risk-reduction strategies of CVC-associated DVT in infants.
Infants younger than 1 year who had a CVC placed at our center from 2005 to 2009 were reviewed. Patients with ultrasonically diagnosed DVT were compared to those without radiographic evidence.
Of 333 patients, 47% (155/333) had femoral, 33% (111/333) had jugular, and 19% (64/333) had subclavian CVCs. Deep venous thromboses occurred in 18% (60/333) of patients. Sixty percent (36/60) of DVTs were in femoral veins. Femoral CVCs were associated with greater DVT rates (27%; 42/155) than jugular (11%; 12/111) or subclavian CVCs (9%; 6/64; P < .01). There was a 16% DVT rate in those with saphenofemoral Broviac CVCs vs 83% (20/24) in those with percutaneous femoral lines (P < .01). Multilumen CVCs had higher DVT rates than did single-lumen CVCs (54% vs 6%, P < .01), and mean catheter days before DVT diagnosis was shorter for percutaneous lines than Broviacs (13 ± 17 days vs 30 ± 37 days, P = .02). Patients with +DVT had longer length of stay (86 ± 88 days vs 48 ± 48 days, P < .01) and higher percentage of intensive care unit admission (82% vs 70%, P = .02).
Deep venous thrombosis reduction strategies in infants with CVCs include avoiding percutaneous femoral and multilumen CVCs, screening percutaneous lines, and early catheter removal.
Journal of Pediatric Surgery 06/2012; 47(6):1159-66. DOI:10.1016/j.jpedsurg.2012.03.043 · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The safety of performing a restorative proctocolectomy (RP) and J-pouch ileoanal anastomosis (IPAA) without diverting ileostomy for children with ulcerative colitis (UC) is a subject of extensive debate. Our goal was to examine pediatric outcomes of RP and IPAA without ileostomy.
We performed a single-institution review of UC patients who had RP and IPAA with (+Ostomy) or without (-Ostomy) diverting ileostomy from 2002 to 2010. Surgeon and patient preference determined ileostomy decision. The study included 50 patients (28 +Ostomy, 22 -Ostomy).
Preoperative demographics were similar between 2 groups in age (13.5 ± 3.5 years -Ostomy, 14.3 ± 3 years +Ostomy), serum albumin (3.6 ± 0.7 -Ostomy, 3.6 ± 0.7 +Ostomy), body mass index (20.8 ± 6.9 -Ostomy, 21.3 ± 8.6 +Ostomy), and daily corticosteroid dose (22.4 ± 17.7 mg -Ostomy, 23.5 ± 13.7 mg +Ostomy). Operating time was less in -Ostomy with mean times of 6:22 ± 2:04 vs 9:07 ± 2:57. The -Ostomy group required fewer ileoanal anastomotic dilations per patient (0.4 ± 0.8 vs 1.4 ± 1.9). Functional outcomes were not significantly different regarding pouchitis episodes per patient (0.6 ± 1.1 -Ostomy, 0.6 ± 1.1 +Ostomy), daily bowel movements (5.5 ± 1.9 -Ostomy, 6.7 ± 4.0 +Ostomy), and daily postoperative loperamide dose (8.4 ± 4.3 mg -Ostomy, 6.8 ± 4.0 mg +Ostomy).
Short- and long-term outcomes can be equivalent in patients with and without diverting ileostomy, but questions remain regarding patient selection and quality of life impact.
Journal of Pediatric Surgery 01/2012; 47(1):204-8. DOI:10.1016/j.jpedsurg.2011.10.041 · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose: Data from the Congenital Diaphragmatic Study Group has shown that neonates born with a congenital diaphragmatic hernia (CDH) and a major cardiac anomaly have significantly higher mortality compared to CDH neonates with normal cardiac anatomy. However, little is known about the actual short- and long-term morbidities in CDH patients with major cardiac anomalies. The purpose of this study was to evaluate contemporary outcomes in a cohort of CDH patients with major congenital heart disease (CHD) treated at a pediatric tertiary care referral center.
Methods: A retrospective review of all CDH patients managed at the University of Michigan C.S. Mott Children’s Hospital between 1997 and 2011 was performed. Infants with and without cardiac anomalies were stratified, and those with major CHD were determined based on the hemodynamic significance of the heart defect on initial postnatal echocardiography reports. Statistical analyses were performed by the t-test for equality of means, the Pearson’s chi-square test, and logistic regression.
Results: Of 216 infants diagnosed with CDH, 164 (76%) had normal cardiac anatomy, 30 (14%) had minor CHD, and 22 (10%) had major CHD. Of the major CHD group, 8 had a ventricular septal defect, 3 had aortic arch disruption, 3 had double outlet right ventricle, 3 had anomalous pulmonary venous return, and 1 had Tetrology of Fallot. Neonates with major CHD were found to have similar Apgar scores but slightly lower birthweights (2.7 vs. 3.0 kg; p=0.03) and estimated gestational ages (36.6 vs. 37.7 weeks, p=0.02) when compared to neonates without CHD. Fifty-five percent of major CHD patients required ECMO but this was not statistically significant when compared with non-CHD patients (38%). Major CHD was associated with longer time on the ventilator (36.0 vs. 18.7 days; p<0.01) and hospital length of stay (85.3 vs. 37.8 days, p<0.01). There was a significant decrease in the overall survival rate of patients with major CHD when compared to non-CHD patients (46% vs. 81%; p<0.01). Liver herniation into the chest was associated with decreased survival in infants with major CHD (43% vs. 70% survival without liver herniation) but this did not reach statistical significance. Based on a mean follow-up period of 6.4 years, all survivors eventually weaned off of supplemental oxygen and were tolerating an oral diet. There was a wide spectrum of neurodevelopmental outcomes in the survivors with severe CHD (33% normal, 44% delayed, 22% autistic, 38% hearing impaired). Fifty-percent were enrolled in special education classes.
Conclusion: An aggressive postnatal management strategy in infants with CDH and major cardiac anomalies is associated with high resource utilization and increased mortality when compared to CDH infants without heart disease. Nevertheless, almost half of all CDH infants with major CHD survive with varying degrees of chronic, long-term morbidity.
2011 American Academy of Pediatrics National Conference and Exhibition; 10/2011
[Show abstract][Hide abstract] ABSTRACT: Patients with congenital diaphragmatic hernia (CDH) requiring extracorporeal life support (ECLS) are at increased risk for acute kidney injury (AKI). We hypothesized that AKI would be associated with increased mortality. We further hypothesized that vasopressor requirement, nephrotoxic medications, and infections would be associated with AKI.
We performed a retrospective chart review in all patients with CDH requiring ECLS from 1999 to 2009 (n = 68). Patient variables that could potentiate renal failure were collected. We used a rise in creatinine from baseline by the RIFLE (risk, 1.5×; injury, 2×; failure, 3×; loss; and end-stage renal disease) criteria to define AKI. Statistical analysis was performed via SPSS (SPSS, Chicago, IL) using Student t test and χ(2) analysis, with P < .05 being considered significant.
Survival to hospital discharge was 37 (54.4%) of 68. Acute kidney injury was identified in 48 (71%) of 68 patients, with 15 (22% of all patients) qualifying as injury and 33 (49% of all patients) qualifying as failure by the RIFLE criteria. Patients who qualified as failure by the RIFLE criteria had a significant decrease in survival (27.3% with failure vs 80% without failure; P = .001). Patients who qualified as failure also had increased length of ECLS (314 ± 145 vs 197 ± 115 hours; P = .001) and decreased ventilator-free days in the first 60 days (1.39 ± 5.3 vs 20.17 ± 17.4 days; P = .001). There was no significant difference in survival when patients qualified as risk or injury.
This is the first report using a systematic definition of AKI in patients with CDH on ECLS. There is a high incidence of AKI in these patients, and when it progresses to failure, it is associated with higher mortality, increased ECLS duration, and increased ventilator days. This highlights the importance of recognizing AKI in patients with CDH requiring ECLS and the potential benefit of preventing progression of AKI or early intervention.
Journal of Pediatric Surgery 04/2011; 46(4):630-5. DOI:10.1016/j.jpedsurg.2010.11.031 · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Vertical expandable prosthetic titanium rib (VEPTR) insertion and expansion has been advocated to increase thoracic volume and pulmonary function in patients with thoracic insufficiency syndrome. We reviewed our experience with VEPTR implantation to determine if lung function and growth is augmented, to determine the children's functional status, and if the scoliosis is controlled.
From 2006 to 2010, 29 insertions and 57 expansions were performed in 26 patients at our institution. Demographic data were reviewed in conjunction with complications, scoliosis angles, pulmonary function tests (PFTs), and computed tomography-guided 3D reconstructions to determine lung volumes; and quality of life scores were determined using a modified Scoliosis Research Society (SRS) questionnaire preoperatively and postoperatively. The groups were also stratified by age (because of lung growth potential), disease (congenital or infantile scoliosis, Jeune syndrome, neuromuscular, other structural thoracic disorders), and sex. Analyses using SPSS (SPSS, Chicago, Ill) were performed with P < .05 considered significant.
Each patient underwent 3.03 ± 1.8 surgeries, spending 0.97 ± 1.8 days in the intensive care unit and 4.41 ± 6 days in the hospital for each procedure. Mean age was 90.7 ± 41 months. Of the 36 complications, most were because of infection (12), half requiring operative repair (hardware removal). The average PFT percent predicted values for forced expiratory volume in 1 second, forced vital capacity, and RV were 54.6 ± 22, 58.1 ± 24, and 145.3 ± 112, respectively, preoperatively and 51.8 ± 20, 55.9 ± 20, and 105.6 ± 31, respectively, postoperatively. The lung volumes measured by computed tomography when corrected for age do not increase significantly postoperatively. The mean Cobb measurement for the preoperative major curves was 64.7° and postoperatively was 46.1° for those curves measured preoperatively, for a 29% curve improvement. All postoperative curves had a mean of 56.4° and 58.1° at final follow-up, a 3% curve increase. The SRS scores for patients remained unchanged and no statistical difference was seen from preoperative to postoperative values. No statistically significant difference was seen in complications, PFT (forced expiratory volume in 1 second, forced vital capacity, RV), lung volumes, scoliosis angles, and SRS scores between sex, age, and disease categories.
There was mild improvement in scoliosis angles but no improvement in lung function and volume. Scoliosis Research Society scores indicate that the children have near normal function both before and after VEPTR placement. Pulmonary function, lung volume, and patient subjective assessments did not increase dramatically after VEPTR placement, although scoliosis angles improved.
Journal of Pediatric Surgery 01/2011; 46(1):77-80. DOI:10.1016/j.jpedsurg.2010.09.070 · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: PulmonaryHypertension in Patients with Congenital Diaphragmatic Hernia:
Does Lung SizeMatter?
The relationship betweenpulmonary parenchymal hypoplasia and pulmonary arterial hypertension (PHTN) inpatients with congenital diaphragmatic hernia (CDH) remains unknown. Thepurpose of this study was to compare pre- and postnatal lung measurements withclinical course and degree of postnatal PHTN.
We retrospectively reviewed67 patients born with CDH between 2004-2008. Measurements of lung-to-head ratio(LHR) and %-predicted lung volumes (PPLV=observed/predicted volumes) wereobtained from prenatal ultrasound and fetal MRI imaging, respectively.Postnatal data included serial pCO2s and tidal volumes (TV)/kg, need formechanical ventilation or ECMO, and outcome. Blinded cardiology review ofechocardiograms was performed to determine the degree of PHTN. Data wereanalyzed using χ2 and unpaired t–testing with significance at p-values £ 0.05.
Of the 67 patients, 54 (81%) had a left and 13 (19%) had a rightCDH, and overall 53 (79%) survived. The prenatal (LHR, PPLV) andpostnatal (pCO2, TV/kg) lung measures correlated with one another. No correlation was found between grade ofecho-assessed PHTN over the first six months of life and early measures of pre-and post-natal lung volumes. PHTN on echo done within the first three days oflife (DOL) predicted need for mechanical ventilation at DOL 30 (p=0.04). LHR,PPLV, TV/kg and pCO2 (on DOL1) all correlated with need for ECMO and mechanicalventilation at DOL30. In table 1, echo-measured PHTN was graded as: 0=no PHTN,1=<½ systemic, 2= ½ systemic-systemic, 3=suprasystemic. Echo-assessedimprovement or deterioration over time in PHTN did correlate with pre-natalmeasures of lung volume (table 1).
ΔPHTN: Grade of PHTN on ECHO between DOL8-28 minus
Grade of PHTN on ECHO between DOL0-3
2 grades of improvement
1 grade of improvement
1 grade of deterioration
LHR (mean SD)*
PPLV (mean SD)**
*1 grade deterioration vs. [2grades improvement (p=0.04) or no change (p=0.02)].
**2 grades of improvement vs.[no change (p=0.03) or 1 grade deterioration (p=0.04)].
The pre- and post-natalmeasurements of lung size did not correlate with echo-measured degree of PHTNbut did correlate with severity of disease assessed by need for ECMO andmechanical ventilation. LHR and PPLV correlated with improvement ordeterioration in PHTN over the first 30 days of life. These findings suggestthat lung size alone cannot predict severity of PHTN but may predict theclinical course of patients in whom PHTN develops.
2010 American Academy of Pediatrics National Conference and Exhibition; 10/2010
[Show abstract][Hide abstract] ABSTRACT: Research on the rates of alcohol and drug misuse as well as developmentally appropriate screening and intervention approaches in a hospitalized pediatric trauma population are lacking. The purpose of this study was to identify the rate of alcohol misuse in an admitted trauma population of adolescents aged 11 years to 17 years and to identify key correlates of alcohol misuse in this population including age, gender, and injury severity.
A prospective clinical study of 230 injured youth (aged 11-17 years) comprising both hospitalized and emergency department (ED) population was performed, and the patients were screened for the Alcohol Use Disorders Identification Test (AUDIT), blood alcohol levels (BALs), and drinking and driving index. The main outcome measures were rates of alcohol misuse characterized by a positive BAL or a positive AUDIT.
Thirty percent hospitalized trauma patients screened positive for alcohol misuse. Five patients had a positive BAL without a positive AUDIT score. Binge drinking was the most commonly positive domain of the AUDIT tool. In hospitalized trauma patients who are older than 14 years (p = 0.005), it was significantly associated with a positive AUDIT score, but the injury severity score, gender, mechanism of injury, or positive BAL were not significant predictors. In the ED sample, 15.8% of patients had a positive AUDIT score. One-way analysis of variance among the ED group showed that age >or=14 was the single predictor of a positive AUDIT score. Twenty-three percent of hospitalized patients had been in a car, where the driver had been drinking. The average AUDIT scores in this group was 5.3 versus 1.0 (p < 0.001), compared with those who had not ridden in a car with a driver who had been drinking.
Injured youth admitted to a pediatric trauma center are a high-risk population. Alcohol misuse is a significant cofactor for trauma for these patients, and effective developmentally appropriate interventions are justified and needed.
The Journal of trauma 07/2010; 69(1):202-10. DOI:10.1097/TA.0b013e3181df646a · 2.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Advances in percutaneous endoscopic gastrostomy (PEG) and laparoscopic (LAP) techniques, including LAP-assisted PEG, offer alternatives to the standard open gastrostomy technique. This study compares the outcomes of the PEG and LAP techniques.
All gastrostomy tube placements were reviewed at our institution from January 2004 to October 2008. Demographic, procedural, and outcome data were collected. Univariate and logistic regression statistical analysis was performed with SPSS (SPSS, Chicago, IL), and P < or = .05 considered significant.
Of 238 gastrostomy tubes placed, 134 were PEG (56.3%) and 104 were LAP (43.7%). Most tubes were inserted for failure to thrive (74.4%) and feeding difficulties (52.1%). Patient weight and age were increased and operative time decreased for PEG compared with other methods. Percutaneous endoscopic gastrostomy patients also had a statistically higher number of postoperative complications, requiring a return trip to the operating room (P = .02).
Minimally invasive PEG and LAP techniques have supplanted the open technique for most patients. Operative time for PEG placement is shorter than other methods, and patients chosen for the PEG method of placement are older and of greater weight. However, there were significant and more serious postoperative complications requiring a second operation in the PEG group when compared with the LAP group.
Journal of Pediatric Surgery 06/2010; 45(6):1147-52. DOI:10.1016/j.jpedsurg.2010.02.079 · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Guidelines for termination of resuscitation in prehospital traumatic cardiopulmonary arrest (TCPA) have recently been published for adults. Clinical criteria for termination of care include absent pulse, unorganized electrocardiogram (ECG), fixed pupils (all at the scene), and cardiopulmonary resuscitation (CPR) greater than 15 minutes. The goal of this study was to evaluate these guidelines in a pediatric trauma population.
Pediatric trauma patients with documented arrest were included in the study. Data assessed were duration of CPR, ECG rhythm, pulse assessment, pupil response, transport times, and standard injury criteria (eg, mechanism of injury). Survivors were compared to nonsurvivors using descriptive statistics, chi(2), and Pearson correlation.
Between 2000 and 2009, 30 patients were identified as having had a TCPA. Of the 30 with a prehospital TCPA, there were 9 females and 21 males (0.2-18 years old). The average (SD) injury severity score was 35.4 (20.6). Twenty-four patients (80%) did not survive. Severe traumatic brain injury was associated with nonsurvivors in 78%. One-way analysis of variances demonstrated that CPR greater than 15 minutes (P = .011) and fixed pupils (P = .022) were significant variables to distinguish between survivors and nonsurvivors, whereas ECG rhythm (P = .34) and absent pulse (P = .056) did not, 42 +/- 28 minutes for nonsurvivors and 7 +/- 3 minutes for survivors.
Criteria for termination of resuscitation correctly predicted 100% of those who died when all the criteria were met. More importantly, no survivors would have had resuscitation stopped. Duration of CPR seems to be a strong predictor of mortality in this study.
Journal of Pediatric Surgery 05/2010; 45(5):903-7. DOI:10.1016/j.jpedsurg.2010.02.014 · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Anorectal malformations (ARMs) are associated with a large number of functional sequale that may affect a child's long-term quality of life (QOL). The purposes of this study were to better quantify patient functional stooling outcome and to identify how these outcomes related to the QOL in patients with high imperforate anus.
Forty-eight patients from 2 children's hospitals underwent scoring of stooling after 4 years of life. Scoring consisted of a 13-item questionnaire to assess long-term stooling habits (score range: 0-30, worst to best). These results were then correlated with a QOL survey as judged by a parent or guardian.
Mean (SD) age at survey was 6.5 (1.6) years. Comparison of QOL and clinical scoring showed no signficant difference between the 2 institutions (P > .05). There was a direct correlation between the QOL and stooling score (Pearson r(2) = 0.827; beta coefficient = 24.7, P < .001). Interestingly, functional stooling scores worsened with increasing age (Pearson r(2) = 0.318, P = .02). Patients with associated congenital anomalies had a high rate of poor QOL (44% in poor range; P = .001). Stooling scores decreased significantly with increasing severity/complexity of the ARM (P = .001).
A large number of children experience functional stooling problems, and these were directly associated with poor QOL. In contrast to previous perceptions, our study showed that stooling patterns are perceived to worsen with age. This suggests that children with ARMs need long-term follow-up and counseling.
Journal of Pediatric Surgery 01/2010; 45(1):224-30. DOI:10.1016/j.jpedsurg.2009.10.041 · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose: The implementation of medical information technologies such as CPOE in the intensive care setting has had mixed effects. While some studies report an increased mortality, others have shown no association. Moreover, to our knowledge, there are no studies addressing the effect of CPOE in the NICU. Our aim was to analyze medical errors, length of stay (LOS), and mortality in the NICU and PICU before and after the implementation of CPOE.
Methods: A retrospective analysis of ICU admissions at our institution was conducted from 2006-2008, which included a 12-month period prior to (NICU n=1274, PICU n=1176) and following (NICU n=1229, PICU n=1252) implementation of CPOE. Patient demographics, admission/birth data, LOS, mortality, as well as all self-reported medical (medication, specimen and diagnostic testing) errors were statistically analyzed using SPSS.
Results: Medication errors were increased in the NICU (Pre-CPOE = 75, Post-CPOE= 97, +21%) and PICU (Pre-CPOE= 31 , Post-CPOE: 40, +4%) prior to CPOE implementation. However, specimen errors were decreased in the NICU (Pre-CPOE = 133, Post-CPOE: 70, -20%) and PICU (Pre-CPOE= 151 , Post-CPOE: 141, -5%). Overall, LOS remained unchanged in the PICU (Pre CPOE = 11.7 ± 21.1 days, Post CPOE = 8.7 ± 9.3 days, P = 0.06), but decreased in the NICU after CPOE implementation (Pre CPOE = 34.2 ± 37.0 days, Post CPOE = 49.4 ± 57.2 days, P =0.01). There was no difference in mortality in the NICU (Pre CPOE = 5.1%, Post CPOE = 6.4%, P =0.21), nor in the PICU (Pre-CPOE= 3.1% Post-CPOE = 1.9% P=0.11). Logistic regression analysis revealed that predictors of errors in the NICU with CPOE were: increased gestational age, Apgar score, and length of stay (LOS) (P < 0.05), whereas increased Pediatric Risk of Mortality Score (PRISM) and LOS were predictors of errors in the PICU (P < 0.05).
Conclusion: Surprisingly, medication error rates appeared to increase in the NICU & PICU in the first 12 months following CPOE implementation. However, LOS decreased in the NICU, although it remained unchanged in the PICU. Mortality in the NICU and PICU remained unaffected. Gestational age, Apgar, PRISM score, and LOS were all predictors of increased errors in the ICUs.
2009 American Academy of Pediatrics National Conference and Exhibition; 10/2009
[Show abstract][Hide abstract] ABSTRACT: Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years.
The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third.
Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study.
CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.
The Journal of trauma 09/2009; 67(3):543-9; discussion 549-50. DOI:10.1097/TA.0b013e3181b57aa1 · 2.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In this study, we compared the skin adhesive 2-octylcyanoacrylate to subcuticular suture for closure of pediatric inguinal hernia incisions to determine if skin adhesive improves wound cosmesis, shortens skin closure time, and lowers operative costs.
We prospectively randomized 134 children undergoing inguinal herniorrhaphy at our institution to have skin closure with either skin adhesive (n = 64) or subcuticular closure (n = 70). Data collected included age, sex, weight, type of operation, total operative time, and skin closure time. Digital photographs of healing incisions were taken at the 6-week postoperative visit. The operating surgeon assessed cosmetic outcome of incisions using a previously validated visual analog scale, as well as an ordinate scale. A blinded assessment of cosmetic outcome was then performed by an independent surgeon comparing these photographs to the visual analog scale. Operating room time and resource use (ie, costs) relative to the skin closure were assessed. Comparisons between groups were done using Student's t tests and chi(2) tests.
Children enrolled in the study had a mean +/- SE age of 3.7 +/- 0.3 years and weighed 16 +/- 0.8 kg. Patients were predominantly male (82%). Patients underwent 1 of 3 types of open hernia repair as follows: unilateral herniorrhaphy without peritoneoscopy (n = 41; 31%), unilateral herniorrhaphy with peritoneoscopy (n = 55; 41%), and bilateral herniorrhaphy (n = 38; 28%). Skin closure time was significantly shorter in the skin adhesive group (adhesive = 1.4 +/- 0.8 minutes vs suture = 2.4 +/- 1.1 minutes; P = .001). Mean wound cosmesis scores based on the visual analog scale were similar between groups (adhesive = 78 +/- 21; suture=78 +/- 18; P = .50). Material costs related to herniorrhaphy were higher for skin adhesive (adhesive = $22.63 vs suture = $11.70; P < .001), whereas operating room time costs for adhesive skin closure were lower (adhesive = $9.33 +/- 5.33 vs suture = $16.00 +/- 7.33; P < .001). Except for a 7% incidence of erythema in both groups, there were no complications encountered.
There is no difference in cosmetic outcome between skin adhesive and suture closure in pediatric inguinal herniorrhaphy. Material costs are increased because of the high cost of adhesive relative to suture. This is partially offset, however, by the cost savings from reduction in operating room time.
Journal of Pediatric Surgery 08/2009; 44(7):1418-22. DOI:10.1016/j.jpedsurg.2009.02.051 · 1.39 Impact Factor