Faculty Bibliography

INTRODUCTION/BACKGROUND:Maxillary fractures are frequently managed depending on the surgeon's preferences, nature of the injury, presence of associated injuries, and comorbidities. Current literature advocates open reduction with plating versus closed techniques. However, data defining associated costs and complications comparing the 2 approaches remains lacking. METHODS:National Inpatient Sample (2006-2011) was examined for patients undergoing closed or open (76.73-76.74) reduction of maxillary fractures. Treatment-related complications were regarded as re-exploration of surgical site, hemorrhage, hematoma, seroma, wound infection, and dehiscence. RESULTS:Overall, 22,157 patients were identified. There were 18,874 closed and 3283 open procedures. Median age was 35 (interquartile range 27). Median length of stay (LOS) was 4 days. Median total charges were reported as 51486.80 USD. Males comprised 77% of the cohort. 68% of patients were Caucasian. Private payer/HMO accounted for the largest source of health care coverage (43.5%). On risk-adjusted multivariate analysis, there was no difference in surgical approach regarding incidence of postoperative complications. Males (2.73), nonprivate insurer payer (P = 0.002), South region (2.49), and transferred patients (2.55) had higher incidence of complications. Presence of chronic pulmonary disease (2.87) and coagulopathy (6.62) also increased risk of complications. Length of stay was shorter for open reduction (0.68) versus closed. Total charges were also less for open approach (0.37). CONCLUSION/CONCLUSIONS:While surgical approach did not affect complications, open approach favorably affected LOS and total charges. Future studies should focus on comorbidities, demographics, and associated injuries in relation to resource utilization for maxillary fractures. In current economic environment, such information might further dictate management options.

PURPOSE/OBJECTIVE:Despite its diagnostic and therapeutic utility, endoscopic retrograde cholangiopancreatography (ERCP) is underutilized in children. METHODS:Patients younger than 18years undergoing ERCP from 2000 to 2014 at a children's hospital were identified. Patient characteristics and outcomes were evaluated. RESULTS:Overall, 215 ERCPs (78% therapeutic) were performed in 184 patients. Our cohort was 67% female, with a median age (IQR) of 14 (8) years. Common indications were choledocholithiasis, pancreatitis, sclerosing cholangitis, and postoperative complication. ERCP was performed with an adult duodenoscope in 96% of cases and with a pediatric duodenoscope in the remainder. Patients requiring a pediatric scope ranged in weight from 4.3 to 22.8kg, with ages from 2months to 6years. Cannulation was successful in 97% of cases. Findings included bile duct (BD) stones, BD dilatation, sclerosing cholangitis, BD stricture, pancreatic duct (PD) disruption, choledochal cyst, pancreas divisum, and BD leak. The most common therapeutic techniques were sphincterotomy, stone extraction, and stent. Complication rate was overall 10% with no deaths. On multivariate analysis, PD cannulation was associated with pancreatitis (OR 3.48), while age<4years (10.7), male gender (12.8), and precut sphincterotomy (31.3) were associated with hemorrhage (all p<0.05). CONCLUSION/CONCLUSIONS:ERCP can be performed successfully and safely in children with complication rates comparable to those in adults. The type of cannulation and patient age are independent risk factors for complications. LEVEL OF EVIDENCE/METHODS:Treatment study-IV.

BACKGROUND:Firearm injuries related to legal intervention have come under scrutiny because of recent events. METHODS:The Kids' Inpatient Database (1997-2012) was searched for firearm injuries due to legal interventions (International Classification of Diseases, ninth revision, Clinical Modification E970) requiring inpatient admission in children aged <20 y. Cases were weighted to provide national estimates. The Brady Campaign criteria were used to identify lenient versus strict gun law states. RESULTS:Overall, 275 cases were identified, with a 7.5% mortality rate. Incidence peaked at 1.0 per 100,000 admissions in 2006, significantly increased from a low 0.2 per 100,000 admissions in 1997, P < 0.001. Patients were predominantly male (97%). African Americans (44%) represented the largest racial group, followed by Hispanics (30%) and Caucasians (20%). Mean age was 17.5 ± 2.08 y. Patients were insured by Medicaid (33%) or a private payer (24%); the remainder (43%) was uninsured. Admissions most frequently occurred at urban teaching hospitals (81%). Cases occurred most frequently in the Southern United States (44%), followed by the Western United States (35%). Most patients presented to non-children's hospitals (97%). Mean hospital admission cost was 27,507 ± 40,197 USD, whereas mean charges amounted to 75,905 ± 116,622 USD. Cases mostly occurred in lenient (56%) gun law states, whereas the remainder occurred in strict (41%) and neutral (3%) states. When analyzed by race, Caucasians (16%) had a significantly higher mortality rate when compared with African Americans (5%), P = 0.03. CONCLUSIONS:An analysis of this very specific injury mechanism demonstrates important findings, which are difficult to collect from conventional data sources. Future research will contribute to the objective analysis of this politically charged subject.

INTRODUCTION/BACKGROUND:Abdominal based breast reconstruction exists in a continuum from pedicled transverse rectus abdominis myocutaneous (TRAM) flap to deep inferior epigastric perforator (DIEP) free flap. DIEP flap has the advantage of complete rectus abdominis sparing during harvest, thus decreasing donor site morbidity. Aim of this study is to determine whether the surgical advantages of the DIEP flap impact postoperative outcomes versus the free TRAM flap (fTRAM). METHODS:We reviewed the Nationwide Inpatient Sample database (2010-2011) for all cases of DIEP and fTRAM breast reconstruction. Inclusion criteria were: female sex and patients undergoing DIEP or fTRAM total breast reconstruction. Male sex was excluded from the analysis. We examined demographic characteristics, hospital setting, insurance information, patient income, comorbidities, postoperative complications (including reoperation, hemorrhage, hematoma, seroma, myocardial infarction, pulmonary embolus, wound infection, and flap loss), length of stay, and total charges (TCs). Bivariate and multivariate analyses were performed to identify independent risk factors of increased length of stay and TCs. RESULTS:Fifteen thousand eight hundred thirty-six cases were identified. Seventy percent were white, 97% were insured, and 83% of patients were treated in an academic teaching hospital setting. No mortalities were recorded. The DIEP cohort was more likely to be obese (P = 0.001). Free TRAM cohort was more likely to suffer pneumonia (P < 0.001; odds ratio [OR], 3.7), wound infection (P = 0.001; OR, 1.7), and wound dehiscence (P < 0.001; OR, 4.3). Type of reconstruction did not appear to affect risk of revision, hemorrhage, hematoma, seroma, or flap loss. Total charges were higher in the DIEP group (P < 0.001). Multivariate analysis demonstrated that fTRAM was an independent risk factor for increased length of stay (P < 0.001; OR, 1.6), and DIEP was an independent risk factor for increased TCs (P < 0.01; OR, 1.5). There was no significant difference in postoperative complications. CONCLUSIONS:The fTRAM cohort was more likely to develop surgical site complications and have an increased length of stay, but TCs were higher for the DIEP group.

BACKGROUND/PURPOSE/OBJECTIVE:In pediatric cases of ingested foreign bodies, gastrointestinal foreign bodies (GIFB) have distinct factors contributing to longer and more costly hospitalizations. METHODS:Patients admitted with ingested foreign bodies were identified in the Kids' Inpatient Database (1997-2009). RESULTS:Overall, 7480 cases were identified. Patients were most commonly <5years of age (44%), male (54%), and Caucasian (57%). A total of 2506 procedures were performed, GI surgical procedures (57%) most frequently, followed by GI endoscopy (24%), esophagoscopy (11%), and bronchoscopy - in cases of inhaled objects (9%). On multivariate analysis, length of stay increased when cases were associated with intestinal obstruction (OR=1.7), esophageal perforation (OR=40.0), intestinal perforation (OR=4.4), exploratory laparotomy (OR=1.9), and gastric (OR=2.9), small bowel (OR=1.5), or colon surgery (OR=2.5), all p<0.02. Higher total charges (TC) were associated with intestinal obstruction (OR=2.0), endoscopy of esophagus (OR=1.8), stomach (OR=2.1), or colon (OR=3.3), and exploratory laparotomy (OR=3.6) or surgery of stomach (OR=5.6), small bowel (OR=6.4), or colon (OR=3.4), all p<0.001. CONCLUSIONS:Surgical or endoscopic procedures are performed in approximately one third of GIFB cases. Associated psychiatric disorder or self-inflicted injury is seen in more than 20% of GIFB patients. Resource utilization is determined heavily by associated diagnoses and treatment procedures.

Thoracic outlet syndrome (TOS) refers to the compression of the neurovascular bundle within the thoracic outlet. Cases are classified by primary etiology-arterial, neurogenic, or venous. In addition to the typical symptoms of arm swelling and paresthesias, headaches have been reported as a potential symptom of TOS. In this report, we describe a patient with debilitating migraines, which were consistently preceded by unilateral arm swelling. Resolution of symptoms occurred only after thoracic outlet decompression. Patients with migraines and concomitant swelling and/or paresthesias, especially related to provocative arm maneuvers, should be considered a possible atypical presentation of TOS and evaluated in more detail.

BACKGROUND:Dermatofibrosarcoma protuberans (DFSP) is a low-grade soft tissue sarcoma. In the pediatric population, DFSP is exceedingly rare. Aim of this study was to describe the epidemiology and clinical outcomes in a large pediatric cohort. METHODS:Surveillance, Epidemiology, and End Results (SEER) database (1973-2010) was analyzed for all patients with dermatofibrosarcoma occurring in patients <20 years of age. Data were extracted based on age, gender, race, anatomic site, histology, stage, treatment modalities, and survival. Incidence rates were standardized to the 2000 US population. RESULTS:A total of 451 patients were identified. Overall annual incidence was 0.10 per 100,000. Incidence was highest among black children and adolescents (ages 15 to 19 years). Trunk was most common site, followed by extremities. Head and neck region was least common site (P < 0.05). Majority (54%) of patients presented with localized disease. Overall, 95% underwent surgery. Only 2.2% were treated with perioperative radiation therapy. Overall prognosis was favorable with 5-year overall survival (OS) of 100%, 15-year OS of 98%, and 30-year OS of 97%. Median survival was 117 months. Male patients had lower 15- and 30-year OS compared with females (P < 0.05). CONCLUSION/CONCLUSIONS:Pediatric DFSP has lower incidence but similar clinical characteristics to adults. Incidence is higher in black children and in the trunk region. While prognosis is favorable, male sex is associated with decreased OS.

BACKGROUND:Although firearms account for less than 5 % of all pediatric injuries, they have the highest associated case fatality rate. METHODS:The registry at a Level-1 trauma center was used to identify firearm injuries (<18 years of age) from 1991 to 2011. Descriptive statistics and risk-adjusted multivariate analyses (MVA) were performed. RESULTS:Overall, 1085 patients were identified. Immediate operations were performed in 33 % (n = 358) of patients with most having abdominal surgery (n = 214). Survival was 86 %, but higher for African Americans (OR = 1.92) than for Hispanics (p = 0.006). African Americans were more likely to sustain extremity (OR = 2.26) and less head (OR = 0.36) injuries than Hispanics (p < 0.001). Analysis by injury location showed that head (OR = 14.1) had the highest associated mortality. Other significant predictors included multiple major injury (defined by Abbreviated Injury Scale) with central nervous system involvement (OR = 7.30) and single injuries to the chest (OR = 2.68). These findings were compared to abdominal injuries as the baseline (p < 0.02). MVA demonstrated that Caucasian children had higher mortality (OR = 6.12) vs. Hispanics (p = 0.031). Children admitted with initial pH ≤ 7.15 (OR = 14.8), initial hematocrit ≤30 (OR = 3.24), or Injury Severity Score (ISS) > 15 (OR = 1.08) had higher mortality rates (p < 0.05). CONCLUSION/CONCLUSIONS:Independent significant indicators of mortality include low initial pH or hematocrit, Caucasian race, high ISS, and those who sustain head injuries.

Large multicenter clinical trials have led to two recently approved drugs for patients with idiopathic pulmonary fibrosis (IPF); yet, both of these therapies only slow disease progression and do not provide a definitive cure. Traditionally, preclinical trials have utilized mouse models of bleomycin (BLM)-induced pulmonary fibrosis-though several limitations prevent direct translation to human IPF. Spontaneous pulmonary fibrosis occurs in other animal species, including dogs, horses, donkeys, and cats. While the fibrotic lungs of these animals share many characteristics with lungs of patients with IPF, current veterinary classifications of fibrotic lung disease are not entirely equivalent. Additional studies that profile these examples of spontaneous fibroses in animals for similarities to human IPF should prove useful for both human and animal investigators. In the meantime, studies of BLM-induced fibrosis in aged male mice remain the most clinically relevant model for preclinical study for human IPF. Addressing issues such as time course of treatment, animal size and characteristics, clinically irrelevant treatment endpoints, and reproducibility of therapeutic outcomes will improve the current status of preclinical studies. Elucidating the mechanisms responsible for the development of fibrosis and disrepair associated with aging through a collaborative approach between researchers will promote the development of models that more accurately represent the realm of interstitial lung diseases in humans.

Introduction This study aims to update outcomes and predictors of survival on pediatric thyroid carcinoma, specifically examining pediatric patients with nonpapillary thyroid carcinoma who underwent surgical resection. Methods Surveillance, epidemiology, and end results database were searched for pediatric cases (< 20 years old) of surgically treated nonpapillary thyroid carcinoma diagnosed from 1973 to 2011. Demographics, clinical characteristics, and survival outcomes were analyzed using standard statistical methods. All follicular, medullary, Hürthle-cell, and nonencapsulated sclerosing carcinoma types were included. Results A total of 493 cases were identified. The overall incidence was 0.096/100,000 persons per year. The mean age at diagnosis was 15 years and highest incidence was found in whites, females, and patients aged 15 to 19 years. Most patients had localized (60%) or regional disease (35%) and only 38% received radiation (any type). Subtotal/total thyroidectomy was the most common procedure performed (83%) and 47% had lymph node sampling. The most common histologies were follicular (54%) and medullary (28%). Most tumors were > 2cm in size (63%). Overall 30-year survival was 91% but higher for females (94%, p = 0.02) and for local disease (92%). Disease-specific survival was highest for those with no lymph node sampling and negative lymph nodes. On multivariate analysis for medullary type only stage was an independent prognostic indicator of survival. Gender, age, tumor size, histology, and disease extent were not associated with an increased risk of mortality. Conclusions Incidence of pediatric nonpapillary thyroid cancer is low. Females have a higher incidence but similar survival to males. Stage is the only independent prognostic indicator of survival for patients with medullary thyroid cancer.