Faculty Bibliography

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: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.

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.

Papillary thyroid cancer (PTC) is the most prevalent of all endocrine cancers. In recent studies, the presence of receptors for pituitary-type growth hormone-releasing hormone (pGHRH-R) has been demonstrated in various human cancers, including human prostate, brain, and other cancer lines. Thyroid malignancies, however, have not yet been investigated in this regard. In this study, we found that pGHRH-R and its functional splice variant, SV1, are present in normal thyroid and PTC cells. We also treated seven normal and PTC tumor thyroid cells in vitro with a GHRH antagonist, MIA-602, to compare its anti-proliferation and anti-invasion potential against vehicle-treated cells. We found that treatment with GHRH antagonist increases the expression of SV1 and pGHRH-R in tumor cells compared to tumor cells exposed to vehicle only, a response which may alter the sensitivity of signaling kinases within the cells. GHRH antagonist treatment of tumor cells also reduced activity of the tumor invasion marker, matrix metalloproteinase (MMP)-2, compared to tumor cells exposed to vehicle only. The expression of pGHRH-R and SV1, as well as MMP-2 activity, in normal thyroid cells remained unaffected by GHRH antagonist treatment. Similarly, cell proliferation rates for tumor or normal thyroid cells were not affected by GHRH antagonist treatment. Our findings have important implications for the therapeutic use of GHRH antagonist in cases of aggressive PTC refractory to conventional treatment modalities, and in which protein expression and MMP-2 activity in normal thyroid tissue is left unaltered.

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.

PURPOSE/OBJECTIVE:This study aims to review the incidence and outcomes for children with superficial spreading melanomas (SSM) using population-based data. METHODS:The Surveillance, Epidemiology, and End Results database (1974-2009) was analyzed for all patients less than 20 years of age diagnosed with SSM. RESULTS:Overall, 724 patients were identified. The annual age-adjusted incidence was 1.78 cases per 1,000,000 in 2009. Most patients were adolescents (N = 620, 85.6%), girls (N = 478, 66.0%), and Caucasian (N = 670, 92.5%). Most tumors were located on the trunk (N = 308, 42.5%) or lower extremities (N = 160, 22.1%). Overall and disease-specific survivals were 95.6% and 97.6%, respectively. Lymph node positivity decreased disease-specific survival among patients undergoing lymph node dissection (86% vs. 100% for negative lymph nodes, P = 0.001). CONCLUSIONS:Incidence of SSM increased in the early part of the study, but has remained relatively stable over the past 2 decades. Girls are at higher risk of development of the disease. Outcomes for children with SSM are very favorable.

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.

The gold standard of peripheral nerve repair is nerve autograft when tensionless repair is not possible. Use of nerve autograft has several shortcomings, however. These include limited availability of donor tissue, sacrifice of a functional nerve, and possible neuroma formation. In order to address these deficiencies, researchers have developed a variety of biomaterials available for repair of peripheral nerve gaps. We review the clinical studies published in the English literature detailing outcomes and reconstructive options. Regardless of the material used or the type of nerve repaired, outcomes are generally similar to nerve autograft in gaps less than 3 cm. New biomaterials currently under preclinical evaluation may provide improvements in outcomes.

BACKGROUND:Extracorporeal membrane oxygenation (ECMO) remains a vital therapy for children requiring cardiopulmonary support. METHODS:The Kids' Inpatient Database (KID) was analyzed for ECMO (ICD-9-CM 39.65) patients between 1997 and 2009. RESULTS:Overall, 8005 cases were identified, consisting of neonatal (ECMO <30days of life; 33%), infant (30days to 1year; 46%), young child (1year to 5years; 9.7%), and older child (>5years; 11%) groups. Patients were most commonly male (56%), Caucasian (49%), and insured by Medicaid (46%). ECMO was indicated for respiratory distress syndrome (RDS; 33%), cardiac and circulatory congenital anomalies (CCCA; 22%), congenital diaphragmatic hernia (CDH; 13%), and persistent pulmonary hypertension of the newborn (PPHN; 10%). On multivariate analysis, length of stay (LOS) decreased over the study period, while total charges (TC) increased over time, p<0.001. Survival was higher for boys and those treated in large or urban teaching hospitals, p<0.05. ECMO for CDH, CCCA, and RDS had the highest associated mortality, p<0.001. Neonatal and infant ECMO had no difference in mortality vs. older children. CONCLUSIONS:While LOS for ECMO has decreased over time, TC has increased steadily. Improved survival is found in boys and patients at large or urban teaching hospitals. CDH, CCCA, and RDS portend poor survival outcomes as indicators for ECMO.

BACKGROUND:Prevention of retained surgical items (RSIs) is the main objective of the World Health Organization "Guidelines for Safe Surgery" (WHO/GSS) 2008 to improve patient safety. METHODS:We analyzed Kids' Inpatient Database 1997-2009 for RSI in patients aged <18 y. Incidence of RSI was calculated by per 100,000 admissions and per 100,000 procedures. The incidence was analyzed based on hospital bedsize, teaching status, region, and ownership and rural versus metropolitan location based on per 100,000 admissions. RESULTS:Overall, 713 cases were identified with a mean (standard deviation) age of 8.31 y (6.62), length of stay of 13 d (20), and total charges of $91,321 (155,054). RSI occurred at a rate of 2.22 per 100,000 admissions and 1.93 per 100,000 procedures; both rates decreased post-WHO/GSS implementation versus pre-WHO/GSS, P < 0.005. On average, public or children's hospitals reported the highest RSI rates (8.89 and 6.07/100,000 admissions, respectively). Small and medium bedsize hospitals had lower rates of RSI post-WHO/GSS, P < 0.05. Nonteaching, non-children's, or public hospitals reported lower rates post-WHO/GSS, P < 0.003. Private (nonprofit) hospitals reported higher rates post-WHO/GSS, P < 0.001. Facilities in the southern United States or in metropolitan areas reported lower rates post-WHO/GSS, P < 0.02. A subanalysis of 107 cases requiring surgical removal demonstrated that fundoplications had the highest rate of RSI, followed by gastric procedures, laparotomy, bile duct procedures, lysis of adhesions, and abdominal wall repair. CONCLUSIONS:RSI rates have decreased overall after the introduction of the WHO/GSS. The largest reductions have occurred in public or nonteaching hospitals. Only private (nonprofit) hospitals reported increases in RSI since 2008. Higher rates of RSI are associated with fundoplications and other gastric procedures.