Faculty Bibliography

BACKGROUND:Ingested foreign bodies are a frequent presentation in pediatric emergency departments. Although some pass spontaneously through the gastrointestinal tract, the majority of esophageal-ingested foreign bodies (EFB) require removal. MATERIALS AND METHODS/METHODS:Kids' Inpatient Database (1997-2009) was used to identify children (aged <20 y) with EFB (International Classification of Diseases, Ninth Revision, Clinical Modification code 935.1). Multivariate logistic regression analyses were constructed to identify predictors of resource utilization. RESULTS:Overall, 14,767 EFB cases were identified. Most patients were <5 y of age (72%), boys (57%), and non-Caucasian (55%), with a median (interquartile range) length of stay (LOS) of 1 (1) d, and total charges of $11,003 (8503). A total of 11,180 procedures were performed, most commonly esophagoscopy (77%), followed by bronchoscopy (20%), gastroscopy (2%), and rarely surgery (0.8%). By multivariate logistic regression, increased total charges were associated with a diagnosis of esophageal ulceration (odds ratio [OR] = 1.57), esophagoscopy (OR = 1.42), and bronchoscopy (OR = 1.62), all P < 0.001. Total charges also increased with admission to urban nonteaching hospitals (OR = 1.51) versus urban teaching hospitals, P < 0.001. Prolonged LOS (≥1 d) was associated with admission to a hospital in the Midwest (OR = 3.18) and with esophageal ulceration (OR = 2.11) and esophagoscopy (OR = 1.13), P < 0.03. Boys had higher odds of longer hospitalization (OR = 1.21), P < 0.001. Overall hospital mortality was 0.1% (n = 16). CONCLUSIONS:Most EFB occur in children <5 y of age. Esophageal ulceration, esophagoscopy, and bronchoscopy are associated with increased total charges. Esophageal ulceration, esophagoscopy, and boys are associated with an increased LOS. Surgery and hospital mortality are both extremely rare in children with EFB.

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: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.

The chief therapeutic mechanism of fingolimod in multiple sclerosis (MS) is considered to be sequestration of pathogenic lymphocytes into secondary lymphoid tissues. B cells have recently been recognized as important immune regulators in MS. In this study, the effects of fingolimod on B cells in MS patients were analyzed. MS patients treated with fingolimod (MS-F) had a significantly lower number of B cells in the circulation. The remaining B cells in the blood of MS-F had a reduced proportion of memory B cells and an increased proportion of naïve B cells, expressed lower levels of the costimulatory molecule CD80, and produced less tumor necrosis factor-α and more interleukin-10. These observations in MS-F were based on an increased proportion of the transitional B-cell subpopulation within the naïve B-cell compartment. The observed findings in B cells of MS-F might be related to the therapeutic effect of this drug in MS.

BACKGROUND:Histiocytoses are rare disorders affecting the pediatric population. MATERIALS AND METHODS/METHODS:Surveillance, Epidemiology, and End Results database was searched for pediatric cases (<20 y old) of histiocytosis diagnosed between 1973 and 2010. Demographics, clinical characteristics, and survival outcomes were analyzed using standard statistical methods. Class I disease (Langerhans cell histiocytosis) and class III (malignant histiocytosis) were included in the data set. RESULTS:A total of 828 cases were identified. Overall incidence was 0.142/100,000 persons per annum. Incidence was highest in younger children and those of Asian or Native American descent. Class III disease had a higher incidence versus class I. Adolescents tended to present with class III, whereas young children presented with class I. Disseminated disease was present in most cases of class III, whereas class I had more localized cases. Surgical excision was more likely to be performed in class I. Overall median survival was 349 mo. Patients 15-19 y old and children<1 y old had the worst outcomes. Class I had higher survival compared with class III, which had a median survival of 33 mo. Cases with hematologic spread carried the worst prognosis. Surgical excision conferred a survival advantage while radiation had no effect. Survival improved over the study period. Gender and race had no association with survival. CONCLUSIONS:Class I disease had localized cases and showed benefit from surgical intervention. Class III disease had a higher incidence and was associated with disseminated disease and lower survival. Radiation therapy did not affect survival. Overall survival increased over the previous 40 y.

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.

BACKGROUND:Sinonasal tumors in the pediatric population are exceedingly rare. MATERIALS AND METHODS/METHODS:Surveillance, Epidemiology, and End Results database was used to identify 250 cases of sinonasal malignancy in patients aged <20 y (1973-2010). Malignant histology codes were based on the International Classification of Disease for Oncology, third edition coding scheme. Incidence rates were adjusted to the 2000 U.S. population. Survival outcomes were plotted using the Kaplan-Meier method and compared with the log-rank test. All other analyses were performed using standard statistical methods. RESULTS:Overall incidence was 0.052 per 100,000. Rhabdomyosarcoma had the highest incidence among histologic groups. Regional stage was the most common at diagnosis (59%). Overall survival at 5-y follow-up was 62.5%. Patients in age groups 1-4 and 15-19 y had the worst survival rates, as median survival was 205 and 104 mo, respectively. Distant metastases at the time of diagnosis signified a poor prognosis. These were associated with a 39-mo median survival. Survival improved during the study period, P=0.003. Gender, race, site of lesion, or histology did not appear to affect mortality. CONCLUSIONS:Sinonasal tumors are rare in children and adolescents. Long-term survival is dependent on age and clinical stage at the time of diagnosis. Cancer-related surgery confers a survival advantage. Gender, race, and histologic type are not associated with mortality.

Malignant melanomas are the most common skin cancer in the pediatric population. Melanoma incidence is extremely low in infants, and metastatic disease is even less common. We present the case of an 11-month-old girl who presented with a non-pigmented lesion that progressed to an ulcerated lesion. Pathology was found to be Spitzoid melanoma of 7.6-mm thickness. Micrometastases were found on examination of the sentinel lymph node. The family chose expectant observation following the excision procedure. A pediatric melanoma registry may be helpful in developing future analyses of incidence in survival in this specialized population.

A 70-year-old man presented with a contained aortic rupture above the aortic bifurcation in the setting of a chronic type B aortic dissection. The celiac and right iliac arteries were supplied by the false lumen, and the superior mesenteric, left iliac, and bilateral renal arteries were supplied by the true lumen. An open repair was not possible due to right-sided heart failure. The "cheese wire" maneuver is a technique used to fenestrate an intimal flap, alleviating malperfusion in aortic dissection. In our modification, a Glidewire (Terumo Medical, Somerset, NJ) was passed across the intimal flap using a Ross Modified Colapinto needle (Cook Medical, Bloomington, Ind) and pulled downward to shear through the membrane to the aortic bifurcation. The fenestration was followed by a unibody endograft stent repair across the contained rupture.

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.