Faculty Bibliography

OBJECTIVES/OBJECTIVE:To evaluate outcomes after surgical ligation (SL) of patent ductus arteriosus (PDA) in premature, extremely low birth weight (ELBW) infants. BACKGROUND:Optimal management of PDA in this specialized population remains undefined. Currently, surgical therapy is largely reserved for infants failing medical management. To date, a large-scale, risk-matched population-based study has not been performed to evaluate differences in mortality and resource utilization. METHODS:Data on identified premature (<37 weeks) and ELBW (<1000  g) infants with PDA (International Classification of Diseases, 9th revision, Clinical Modification, 747.0) and respiratory distress (769) were obtained from Kids' Inpatient Database (2003-2009). RESULTS:Overall, 12,470 cases were identified, with 3008 undergoing SL. Propensity score-matched analysis of 1620 SL versus 1584 non-SL found reduced mortality (15% vs 26%) and more routine disposition (48% vs 41%) for SL (P < 0.001). SL had longer length of stay and higher total cost (P < 0.001). On multivariate analysis, SL mortality predictors were necrotizing enterocolitis (NEC; surgical odds ratio, 5.95; medical odds ratio, 4.42) and sepsis (3.43) (P < 0.006). Length of stay increased with bronchopulmonary dysplasia (BPD; 1.77), whereas total cost increased with surgical NEC (1.82) and sepsis (1.26) (P < 0.04). Non-SL mortality predictors were NEC (surgical, 76.3; medical, 6.17), sepsis (2.66), and intraventricular hemorrhage (1.97) (P < 0.005). Length of stay increased with BPD (2.92) and NEC (surgical, 2.04; medical, 1.28) (P < 0.03). Total cost increased with surgical NEC (2.06), medical NEC (1.57), sepsis (1.43), and BPD (1.30) (P < 0.001). CONCLUSIONS:Propensity score-matched analysis demonstrates reduced mortality in premature/ELBW infants with SL for PDA. NEC and sepsis are predictors of mortality and resource utilization.

Enlarging aneurysms in the thoracic aorta frequently remain asymptomatic. Fistulization of thoracic aortic aneurysms (TAA) to adjacent structures or the presence of a patent ductus arteriosus and TAA may lead to irreversible cardiopulmonary sequelae. This article reports on a large aneurysm of the thoracic aorta with communication to the pulmonary artery causing pulmonary edema and cardiorespiratory failure. The communication was ultimately closed after thoracic endovascular aortic aneurysm repair allowing rapid symptom resolution. Early diagnosis and closure of such communication in the presence of TAA are critical for prevention of permanent cardiopulmonary damage.

The observation that pulmonary inflammatory lesions and bleomycin (BLM)-induced pulmonary fibrosis spontaneously resolve in young mice, whereas remaining irreversible in aged mice suggests that impairment of pulmonary regeneration and repair is associated with aging. Because mesenchymal stem cells (MSCs) may promote repair after injury, we postulated that differences in MSCs from aged mice may underlie postinjury fibrosis in aging. The potential for young-donor MSCs to inhibit BLM-induced pulmonary fibrosis in aged male mice (>22 months) has not been studied. Adipose-derived MSCs (ASCs) from young (4 months) and old (22 months) male mice were infused 1 day after intratracheal BLM administration. At 21-day sacrifice, aged BLM mice demonstrated lung fibrosis by Ashcroft score, collagen content, and α(v)-integrin messenger RNA (mRNA) expression. Lung tissue from aged BLM mice receiving young ASCs exhibited decreased fibrosis, matrix metalloproteinase (MMP)-2 activity, oxidative stress, and markers of apoptosis vs BLM controls. Lung mRNA expression of tumor necrosis factor-alpha was also decreased in aged BLM mice receiving young-donor ASCs vs BLM controls. In contrast, old-donor ASC treatment in aged BLM mice did not reduce fibrosis and related markers. On examination of the cells, young-donor ASCs had decreased mRNA expression of MMP-2, insulin-like growth factor (IGF) receptor, and protein kinase B (AKT) activation compared with old-donor ASCs. These results show that the BLM-induced pulmonary fibrosis in aged mice could be blocked by young-donor ASCs and that the mechanisms involve changes in collagen turnover and markers of inflammation.

OBJECTIVES/OBJECTIVE:Other than automobiles, bicycles are connected to more pediatric injuries than any other consumer product. Whereas characterization of injury patterns following motor vehicle accidents has led to safety initiatives and treatment guidelines, knowledge related to bicyclist injuries is lacking. Our purpose is to identify major injury patterns and outcomes associated with pediatric bicycle accidents. METHODS:From January 2000 to December 2012, 1934 consecutive pediatric admissions (≤17 years) at a level I trauma center were retrospectively reviewed for mechanism injury, demographics, and outcomes. Parametric data were analyzed with student's t test and are presented as mean ± standard deviation. Nonparametric data were analyzed with Mann-Whitney-U test and are presented as median (interquartile range). Analysis was performed to recognize injury patterns and outcomes significantly associated with bicycle related accidents. RESULTS:80 pediatric patients were admitted following bicycle related trauma (4% of all pediatric trauma admissions). The cohort was age 11 ± 4 years, ISS 11 ± 10, 48% black, and 81% male. Injury patterns included 21% isolated head, 21% isolated abdominal, 13% isolated extremity, and 34% multiple injuries. 5% were age 0-4 years, 35% were age 5-9 years, 45% were 10-14 years, and 15% were 15-17 years (p < 0.001). 16% required operative intervention (6% abdominal, 9% orthopedic, 1% vascular). Children under age 6 required an abdominal operation 20% of the time. Length of stay was 2 (4) days with a mortality of 2.5%. CONCLUSIONS:Pediatric bicycle accidents more commonly occur in male children aged 10-14 years. Orthopedic injury is the most frequent overall indication for surgery, yet the youngest children more often required an abdominal operation. LEVEL OF EVIDENCE/METHODS:Level III.

Thoracic aortic aneurysm is a rare condition that carries a critical risk of rupture and mortality. These risks are increased during pregnancy because of a progressively hyperdynamic pattern of circulation. Simultaneously, pregnancy-imposed limitations on the use of ionized radiation and intravenous contrast agents may render conventional techniques for imaging and repair confirmation less acceptable. We describe a novel approach to intraoperative management of an endovascular repair for symptomatic thoracic saccular aneurysm in a pregnant patient, based on intravascular ultrasound and transesophageal echocardiography, with maintenance of uterine perfusion. The patient recovered well and proceeded to a normal delivery. Despite a favorable outcome in this case, further studies of perioperative management of aortic disease in pregnancy are needed.

BACKGROUND:Pedicled breast reconstruction is a mainstay treatment for plastic surgeons. Although indications vary for each breast reconstruction technique, there exist some overlapping characteristics that may determine a successful outcome. We aimed to determine the impact flap selection has on postoperative outcomes and resource utilization. MATERIALS AND METHODS/METHODS:Nationwide Inpatient Sample database (2010-2011) was reviewed for cases of latissimus dorsi (LD; International Classification of Diseases, Ninth Revision, Clinical Modification, 85.71) and pedicled transverse rectus abdominis myocutaneous (pTRAM; 85.72) breast reconstruction. Males were excluded. Demographic, socioeconomic, clinical factors, postoperative complications, length of stay (LOS), and total charges (TC) were assessed. Chi-squared and multivariate analyses were performed to identify independent risk factors of resource utilization and postoperative complications. RESULTS:A total of 29,074 cases were identified; 17,670 (61%) LD and 11,405 (39%) pTRAM. 74% percent were Caucasian, 94% insured, and 66% were treated in teaching hospitals. There were 24 mortalities (15 LD, 9 pTRAM). LD patients were more likely to be obese (odds ratio [OR] = 1.3), suffer from flap loss (OR = 1.4), wound infection (OR = 1.6), wound dehiscence (OR = 2.2), and hematoma (OR = 1.3), P < 0.05. Patients undergoing pTRAM were more likely to undergo surgical revision (OR = 6.9), suffer from systemic infection (OR = 1.8), pneumonia (OR = 5.0), or pulmonary embolism (OR = 29.2), P < 0.05. Risk-adjusted multivariate analysis demonstrated LD was an independent risk factor for postoperative complication (OR = 1.4) and increased TC (OR = 1.3), P < 0.001. Conversely, undergoing pTRAM was an independent risk factor for increased LOS (OR = 6.3), P < 0.001. CONCLUSIONS:Analysis of a national database found LD breast reconstruction to have higher TC and increased risk for surgical site complications. Patients undergoing pTRAM had increased risk for pulmonary complications and LOS. Procedure selection may be refined as additional characteristics are discovered using outcomes-based research.

BACKGROUND:Despite radiation concerns, computed tomography (CT) remains the favored imaging modality at many children's hospitals for appendicitis. We sought to reduce CT utilization for appendicitis in a children's hospital with an algorithm relying on 24-h ultrasound (US) as the primary imaging study. MATERIALS AND METHODS/METHODS:An US-based protocol for suspected appendicitis was adopted at the end of the fiscal year (FY) 2011. Data were collected for 12 mo before and 24 mo after implementation. Imaging test usage and charges were adjusted per annual number of appendectomies. Training of emergency department staff continued over 1 y after protocol implementation. RESULTS:For FY 2011, 644 abdominal CT and 1088 appendix US were ordered, and 249 laparoscopic appendectomies (LAs) were performed. After protocol implementation, FY 2012: 535 CT, 1285 US, and 265 LA were performed; and FY 2013: 330 CT, 1235 US, and 236 LA were performed. Length of stay decreased from before to after protocol (2.57 ± 0.29 versus 2.15 ± 0.11 d), P < 0.001. CTs per appendectomy decreased 42% from FY 2011 to FY 2013 (2.43 versus 1.40, P < 0.001) and 30% from before to after protocol (2.43 versus 1.70, P < 0.001). A corresponding 27% increase in number of US before to after protocol (4.11 versus 5.20 US/appendectomy, P = 0.004) occurred. CT and US charges decreased $2253 and $6633 per appendectomy for FY 2012 and 2013, respectively. CONCLUSIONS:Protocol-driven workup with US significantly reduced CT utilization, radiation exposure, and imaging-related charges in children with suspected appendicitis. Ongoing training of emergency department staff is required to ensure protocol compliance.

BACKGROUND:Bronchopulmonary malformations (BPM) are rare conditions, which typically arise below the carina and can result in significant morbidity (infection and/or hemorrhage) and mortality (respiratory failure). MATERIALS AND METHODS/METHODS:All children with BPM surgically treated from 2001-2014 at a tertiary care children's hospital were identified. Patient demographics, surgical indications, procedure type, estimated blood loss, pathology, perioperative complications, length of stay, and outcomes were analyzed. RESULTS:A total of 41 BPM patients underwent surgery with 98% overall survival (one abdominal BPM expired) but 100% for thoracic lesions. Resections were performed thoracoscopically (37%), thoracoscopy converted to open (22%), and via thoracotomy (37%). Poor visualization (67%) or inability to tolerate single lung ventilation (33%) led to conversions. No conversions resulted from hemorrhage or received blood transfusions. Patients with prenatally diagnosed BPM were more likely to undergo thoracoscopic surgery (odds ratio [OR], 18.2) versus nonprenatally diagnosed, P = 0.002. Open/converted patients had longer chest tube days (6.2) versus thoracoscopic (2.9), P = 0.048. Additionally, respiratory distress was a more common indication in patients aged <4 mo (OR, 28.0) versus ≥4 mo and <6 kg (OR, 40.5) versus ≥6 kg, P < 0.001. Open resections were more common in patients aged <4 mo (OR, 26.3) versus ≥4 mo, P = 0.002. Operative time was shorter and estimated blood loss (mL/kg) was greater for <6 versus ≥6 kg, P < 0.05. CONCLUSIONS:BPM resections have high overall survival. Chest tube days are shorter among thoracoscopic patients, but conversion to thoracotomy can avoid hemorrhage and need for transfusion. Size and respiratory distress limit use of thoracoscopy in young infants with BPM.

BACKGROUND:Aortic injuries are rare, but have a high mortality rate in children and adolescents. We sought to investigate mechanisms of injury and predictors of survival. MATERIALS AND METHODS/METHODS:The Kids' Inpatient Database (1997-2009) was used to identify cases of thoracic and abdominal aortic injury (International Classification of Diseases, ninth Revision, Clinical Modification codes 901.0, 902.0) occurring in children aged <20 y. Bivariate and risk-adjusted multivariate analyses were used to reveal associated diagnoses and procedures and to identify predictors of in-hospital mortality, respectively. Cases were limited to emergent or urgent admissions. RESULTS:A total of 468 cases were identified. Survival was 65% overall, 63% for boys and 68% for girls. The most common mechanism of injury was motor vehicle-related (77%), followed by other penetrating trauma (10%) and firearm injury (8%). On multivariate modeling, boys (odds ratio, 0.15 [95% confidence interval, 0.05, 0.45]) and Hispanic children (0.17 [0.05, 0.60]) had lower associated mortality versus girls and Caucasians, respectively. Self-pay patients (6.47 [1.94, 21.6]) had higher mortality versus privately insured patients. Children in the fourth income quartile had lower mortality versus all income quartile patients. Patients admitted to urban nonteaching hospitals (0.15 [0.04, 0.59]) had lower mortality versus those admitted to urban teaching hospitals. Patients with traumatic shock (47.9 [12.3, 187]) or necessitating exploratory laparotomy (13.7 [2.06, 91.4]) had the highest associated mortality overall. Survival increased over the study period between 1997 and 2009. CONCLUSIONS:Motor vehicle-related injuries are the predominant mechanisms of aortic injury in the pediatric population. Gender, race, payer status, income quartile, and hospital type, along with associated procedures and diagnoses, are significant determinants of mortality on multivariate analysis.