Faculty Bibliography

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.

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.

BACKGROUND:Thoracic aortic dissection (AD) is a rare occurrence in childhood and mostly associated with connective tissue disorders or congenital abnormalities. We examined the characteristics associated with AD and predictors of survival. METHODS:The Kids' Inpatient Database (1997-2009) was used to identify thoracic ADs occurring in patients <20-y-old. Clinical characteristics, as well as determinants of survival, were analyzed using standard statistical methods. RESULTS:One hundred sixty-eight cases of thoracic AD were identified during the study period. Overall survival was 83%. Average length of stay was 15.9 ± 16.9 d, with charges 181,867.92 ± $211,985.00. Thoracic dissection tended to affect adolescents aged 15-19 y (67%), males (76%), and Caucasians (56%) most frequently. Most patients were privately insured (64%) and treated at urban teaching centers (86%). Commonly associated diagnoses were hypertension (18%), Marfan syndrome (15%), and aortic valve disorders (8%). When repair was performed, open repair was more frequent (88%) than endovascular repair (6%). Hemorrhage was the most common complication (19%). Multiple determinants of survival were found. Girls (mortality odds ratio: 0.21 [0.05-0.91]) fared better than boys, P = 0.023. Patients with Medicaid (2.84 [1.21-6.69]) had higher mortality versus privately insured, P = 0.014. Income, race, and hospital characteristics, and type of repair were not significant predictors, even on sub-analyses of surgical and nonsurgical groups separately. CONCLUSIONS:Dissection of the thoracic aorta is a rare but significant condition affecting the pediatric population. Most repairs are performed using open technique. Payer status and gender are predictors of survival in these cases.

BACKGROUND:Our purpose was to analyze modern major vascular injury (MVI) patterns in pediatric trauma, interventions performed, and outcomes at a level 1 trauma center. MATERIALS AND METHODS/METHODS:From January 2000-December 2012, all pediatric admissions (≤17 y) were reviewed. RESULTS:Of 1928 pediatric admissions, 103 (5.3%) sustained MVI. This cohort was 85% male, age 15 ± 3 y, 55% black, 58% penetrating, injury severity score of 23 ± 15, with a length of stay of 8 (5) days. Firearm-related injury (47%) was the most common mechanism. Location of injuries included the extremities (50.5%), abdomen/pelvis (29.1%), and chest/neck (20.4%). Operative procedures included repair/bypass (71.4%), ligation (12.4%), amputation (10.5%), or temporary shunt (2.9%). Only three injuries (2.9%) were treated endovascularly. MVI patients had a mortality rate of 19.4%, higher than the overall pediatric trauma population of 3.5% (P < 0.001). After logistic regression, independent risk factors of mortality were vascular injury to the neck (odds ratio [OR]: 6.5; confidence interval (CI): 1.1-39.3), abdomen/pelvis (OR: 16.3; CI: 3.13-80.2), and chest (OR: 49.0; CI: 3.0-794.5). CONCLUSIONS:MVI in children more commonly results from firearm-related injury. The mortality rate associated with MVI is profoundly higher than that of the overall pediatric trauma population. These findings underscore the major public health concern of firearm-related injury in children.

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.

BACKGROUND:Severe morbidity and mortality has been reported from chest tube (CT) placement during pediatric extracorporeal membrane oxygenation (ECMO). METHODS:Kids' Inpatient Database (KID) was analyzed for ECMO with CT placed <8days postcannulation (1997-2009). RESULTS:Overall, 5884 patients were identified (213 CT) (56% male, 49% white), with a median (IQR) age at ECMO cannulation 7 (117)days, length of stay (LOS) 26 (35)days, and total charges (TC) 342,116 (409,573) USD. Diagnoses included congenital diaphragmatic hernia (CDH) 16%, meconium aspiration (MA) 2%, pulmonary hypertension (PH) 13%, respiratory distress syndrome (RDS) 41%, and cardiac (C) 29%. Survival was overall 57%, CDH 47%, MA 88%, PH 75%, RDS 57%, and C 52%. There were no differences in survival between CT and non-CT patients compared overall, or by diagnosis, or by age <30days, or by diagnosis and age <30days. Multivariate analysis and propensity score matching for all ages, or <30days of age by diagnosis showed no difference in survival between CT and non-CT patients. CONCLUSION/CONCLUSIONS:Analysis of KID with correlative propensity score matching demonstrates no increased mortality in pediatric ECMO patients requiring CT placement.

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.

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.

A 17-year-old girl presented with episodic vomiting associated with chest pain, a 20-pound weight loss over the past year, and multiple hospitalizations for pneumonia. She was bradycardic, cachectic (<3rd percentile), pale, and had anterior cervical lymphadenopathy. CT angiography suggested an obstructive vascular ring (formed by a right aortic arch with an aberrant left subclavian artery), diverticulum of Kommerell, and a tracheoesophageal fistula (TEF). She underwent left thoracotomy with ligation and division of the ligamentum arteriosum to relieve the vascular ring. Flexible bronchoscopy at the time demonstrated a large H-type TEF. Eight weeks later, she had the TEF closed via a right cervical incision and recovered uneventfully. Our case is unique, with symptomatic presentation of a congenital TEF and vascular ring in a teenager. Such major congenital anomalies are rarely discovered outside of childhood, and TEFs virtually always (>90%) present as neonatal emergencies secondary to esophageal obstruction. They have a high incidence of associated abnormalities, cardiovascular being the most common. Unexplained recurrent respiratory symptoms in an otherwise normal child with dysphagia should prompt the clinician to evaluate patients for foreign bodies, reflux and other more common problems. Unusual etiologies, however, do occur - as in this case - and warrant more complex workup.

PURPOSE/OBJECTIVE:Initial hematocrit (Hct) is generally not considered a marker of acute blood loss because it is assumed that physiologic response of fluid conservation to hemorrhage is delayed. We challenged this idea by theorizing that admission Hct correlates with conventional signs of shock and predicts the use of blood transfusion during resuscitation of pediatric trauma patients. METHODS:Data from 1928 pediatric admissions (<18 years) at a Level I trauma center (2000-2012) were compared using standard statistical analyses and logistic regression modeling to identify factors associated with blood transfusion during initial trauma resuscitation. RESULTS:Overall mortality rate was 3.5%, with a transfusion rate of 10.7%. Factors significantly associated with transfusion were initial Hct, Glasgow Coma Score, base deficit, and injury severity score (all p<0.001). Initial Hct is a stronger predictor for transfusion (area under receiver operator curve (AUC: 0.728) compared to age-specific tachycardia (AUC: 0.689), age-specific hypotension (AUC: 0.673), and altered mental status (AUC: 0.654)). On multivariate analysis, initial Hct was an independent predictor (OR [95% CI]: 2.94 [1.56, 5.52]) along with hypotension (6.37 [2.95, 13.8]), base deficit (4.14 [1.38, 12.4]), and tachycardia (3.07 [1.62, 5.81]). CONCLUSIONS:Initial Hct correlates significantly with conventional signs of shock and is a strong independent predictor for blood transfusion with better predictability than other clinical factors.