ABO blood group and procoagulant factors: the hypercoagulation hypothesis ABO and Procoagulant Factors
BACKGROUND:The correlation between procoagulant levels-factor VIII (FVIII), von Willebrand factor (vWF), and fibrinogen-and risk of thrombosis has been well documented in adult populations. We hypothesize that interaction of passively transferred isoagglutinins in premature neonates with a compromised immune system may trigger an immune response that can target the immature gastrointestinal tract. The objective of this study is to evaluate if there are procoagulant level differences in preterm newborns stratified by ABO blood group. METHODS:VWF, FVIII, and fibrinogen levels were analyzed in neonates â‰¤32 weeks and/or birthweight â‰¤1500â€‰g over the first 6 weeks of life. Demographic, blood type, and transfusion data were collected. RESULTS:Elevations in vWF and FVIII were found to be statistically significant in the third week of life in non-O neonates vs. type O neonates. FVIII was also found to be significantly elevated in week 1. Transfused neonates also showed elevations between weeks 0 and 3. CONCLUSION:There appears to be a time-dependent variation in procoagulant factor levels in preterm newborns. Although the clinical significance remains unclear, prothrombotic factors vWF and FVIII are significantly higher in non-O blood-type preterm neonates in the third week of life.
Staged imaging pathway for the evaluation of pediatric appendicitis
PURPOSE/OBJECTIVE:Despite significant radiation exposure involved with computed tomography (CT) in evaluation of pediatric appendicitis, its use is still widespread. The goal of this study was to assess the effect of a staged imaging pathway for appendicitis to significantly decrease CT use while maintaining diagnostic accuracy. METHODS:Chart review was performed for patients evaluated for appendicitis over a 12-month period prior to and after pathway implementation. RESULTS:There was a significant decrease in CT use as initial imaging after implementation of the pathway; 87.1-13.4Â % for evaluations positive for appendicitis (decrease 84.6Â %, pÂ <Â 0.0001) and 82.6-9.2Â % for evaluations negative for appendicitis (decrease 88.9Â %, pÂ <Â 0.0001). Use of CT during any point in the evaluation decreased from 91.7 to 25.1Â % (decrease 72.6Â %, pÂ <Â 0.0001). The negative appendectomy rate was similar; 5.4Â % prior, 4.9Â % post (pÂ =Â 0.955). The missed appendicitis rate did not statistically change; 1.1Â % prior, 3.7Â % post (pÂ =Â 0.523). The perforation rate was not statistically altered; 6.5Â % prior; 9.8Â % post (pÂ =Â 0.421). 350 less patients underwent CT during the year following the pathway. CONCLUSIONS:The staged imaging pathway resulted in a marked decrease in children exposed to CT without compromising diagnostic accuracy.
The relationship between reticulated platelets, intestinal alkaline phosphatase, and necrotizing enterocolitis
BACKGROUND:Necrotizing enterocolitis (NEC) affects up to 10% of extremely-low-birthweight infants, with a 30% mortality rate. Currently, no biomarker reliably facilitates early diagnosis. Since thrombocytopenia and bowel ischemia are consistent findings in advanced NEC, we prospectively investigated two potential biomarkers: reticulated platelets (RP) and intestinal alkaline phosphatase (iAP). METHODS:Infants born â‰¤ 32 weeks and/or â‰¤ 1500 g were prospectively enrolled from 2009 to 2012. Starting within 72 hours of birth, 5 weekly whole blood specimens were collected to measure RP and serum iAP. Additional specimens were obtained at NEC onset (Bell stage II or III) and 24 hours later. Dichotomous cut-points were calculated for both biomarkers. Non-parametric (Mann-Whitney) and Chi-square tests were used to test differences between groups. Differences in Kaplan-Meier curves were examined by log-rank test. The Cox proportional hazards model estimated hazard ratios. RESULTS:A total of 177 infants were enrolled in the study, 15 (8.5%) of which developed NEC (40% required surgery and 20% died). 14 (93%) NEC infants had "low" (â‰¤ 2.3%) reticulated platelets, and 9 (60%) had "high" iAP (>0 U/L) in at least one sample before onset. Infants with "low" RP were significantly more likely to develop NEC [HR=11.0 (1.4-83); P=0.02]. Infants with "high" iAP were at increased risk for NEC, although not significant [HR=5.2 (0.7-42); P=0.12]. Median iAP levels were significantly higher at week 4 preceding the average time to NEC onset by one week (35.7 Â± 17.3 days; P=0.02). CONCLUSION/CONCLUSIONS:Decreased RP serves as a sensitive marker for NEC onset, thereby enabling early preventative strategies. iAP overexpression may signal NEC development.
Splenic torsion after congenital diaphragmatic hernia repair: case report and review of the literature [Case Report]
Wandering spleen with torsion, a rare clinical diagnosis, was found to be the cause of chronic abdominal pain in an 11-year-old female with a history of congenital diaphragmatic hernia repaired at three days of age. Doppler ultrasound revealed patent vessels with splenomegaly, and computed tomography (CT) showed an absence of the spleen in the left subphrenic space with torsion at the splenic hilum. Due to the chronicity of pain and risk of ischemia from torsion, open splenopexy with Vicryl mesh was performed. This case report/review of the literature discusses the rarity of this condition, and the importance of timely diagnosis and intervention.
Outcomes research in pediatric surgery. Part 1: overview and resources
Outcomes research in pediatric surgery can be defined as the analysis of pediatric surgical outcomes and their predictors at different levels in the health care delivery system. The objectives of this article are to understand the differences between outcomes research and clinical trials as well as to gain familiarity with public multispecialty and specialty-specific databases. The utility of outcomes research extends to benchmarking the quality of care, refinement of management strategies, patient education, and marketing. Assessment of the integration of a new surgical technique into the health care system is best determined by examining a population-based registry, whereas comparative efficacy of surgical procedures is best assessed by randomized clinical trials. In the first part of this 2-part series, an overview and brief outline of available resources for outcomes research in pediatric surgery are reviewed. In part 2, a template is presented on how to structure and design an outcomes research question.
Handlebar injuries in children: should we raise the bar of suspicion? [Case Report]
Injury prevention strategies for child bicyclists have focused on helmet use to prevent head trauma. Handlebars are another source of injury. A retrospective review from 2005 identified 385 admissions to a Level 1 pediatric trauma center of which 23 (5.9%) were pedal cyclists. Four cases (<1.0%) of handlebar injuries were identified. Three children (two bicyclists, one riding a scooter) sustained handlebar impact to the neck. All children with neck injuries had subcutaneous emphysema. Two of the children had pneumomediastinum, which after work-up was managed nonoperatively. One child had a tracheal injury requiring operative intervention. Another child was struck in the upper abdomen resulting in a traumatic abdominal wall hernia requiring emergent exploration and hernia repair. Discordance exists between the apparently minor circumstances of handlebar trauma and the severity of injury sustained by bicyclists. Recognizing the mechanism of handlebar-related injuries and maintaining a high index of suspicion for visceral injuries aids in the diagnosis. The incidence of these injuries is underestimated due to insufficient documentation of the circumstances of injury events and a lack of applicable E-codes specific for handlebar injury.
The umbilical mass: a rare neonatal anomaly [Case Report]
Umbilical anomalies are a rare presentation in the pediatric patient. The differential diagnosis includes anomalies resulting from urachal and vitelline duct derivatives such as urachal sinus, urachal cyst, urachal diverticulum, patent urachus, herniated Meckel's diverticulum, umbilico-enteric fistula, or umbilical polyp. In this article, a case presentation of an umbilical anomaly along with the differential diagnosis and management options are discussed. Based upon this review of the literature, the authors propose a management algorithm for treating children with umbilical anomalies.
Sequential linear stapling technique for perineal resection of intractable pediatric rectal prolapse [Case Report]
Rectal prolapse (RP), although most frequently encountered in the frail elderly, may also occur in children. This condition is most troublesome in the premature infant with significant associated comorbidities. Pediatric RP most often can be managed conservatively with expectant and/or judicious use of laxative-based bowel regimens. In rare instances of intractable RP, surgical intervention ranging from simple (sclerotherapy, Thiersch wire) to complex (perineal or transabdominal bowel resection) becomes necessary. We describe a modification of the Altemeier technique using a novel sequential linear stapling technique to treat intractable RP in a 5.0-kg infant with severe coexisting life-threatening comorbidities. The child had resumption of bowel movements on postoperative Day 1 and has had no recurrences. Sequential linear stapling technique for perineal resection of intractable pediatric RP appears to be a safe and potentially attractive alternative.
Ready for the frontline: is early thoracoscopic decortication the new standard of care for advanced pneumonia with empyema?
Video-assisted thoracoscopic decortication (VATD) has been established as an effective and potentially less morbid alternative to open thoracotomy for the management of empyema. However, the timing and role of VATD for advanced pneumonia with empyema is still controversial. In assessing surgical outcome, the authors reviewed their VATD experience in children with empyema or empyema with necrotizing pneumonia. The charts of 42 children who underwent VATD at our institution between July 2001 and July 2005 were retrospectively reviewed for surgical outcome. For purposes of analysis, patients were cohorted into four classes with increasing severity of pneumonia: 1 (-) intraoperative pleural fluid cultures, (-) necrotizing pneumonia, 18 (43%); 2 (+) pleural fluid cultures, (-) necrotizing pneumonia, 10 (24%); 3 (-) pleural fluid cultures, (+) necrotizing pneumonia, 6 (14%); 4 (+) pleural fluid cultures, (+) necrotizing pneumonia, 8 (19%). A P value of < 0.05 via Student's t test or Fischer's exact analysis was considered an indicator of significant difference in the comparison of group outcomes. VATD was successfully completed in all 42 patients with no mortality and without significant morbidity (82% had less than 20 cc blood loss). There was found to be no significant difference (p = NS) in time to surgical discharge (removal of chest tube) among all groups. Hospital length of stay postsurgery was found to be significantly increased between 1 and 4 (6 days vs 9 days; P = 0.038). 14/14 (100%) of children with necrotizing pneumonia were found to have evidence of lung parenchymal preservation with improved aeration on follow-up CT scan and/or chest x-rays. The authors conclude that early VATD in children with advanced pneumonia with empyema is indicated to avoid unnecessarily lengthy hospitalization and prolonged intravenous antibiotic therapy. Furthermore, early VATD can be safely performed in various stages of advanced pneumonia with empyema, promoting lung salvage, and accelerating clinical recovery.
A high prevalence of methicillin-resistant Staphylococcus aureus among surgically drained soft-tissue infections in pediatric patients
Over the past decade, methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a global problem, prompting extensive surveillance efforts. A previous study of S. aureus isolates at our institution revealed alarming increases in the prevalence of MRSA with no sign of plateau. However, evidence of MRSA in pediatric surgical patients remains largely anecdotal, as there are no published reports of institutional MRSA surveillance in the pediatric surgical literature. We conducted a retrospective review of incision and drainage (I and D) procedures at our institution from 1998 through 2004. All I and D procedures performed at the University of Chicago Children's Hospital were identified and the patients' charts reviewed for pertinent information. A total of 99 I and D procedures were performed during the study period, ranging from 5 in 1998 to 32 in 2004. Among cultures with positive growth, 52 (65.8%) were MRSA, 14 (17.7%) were methicillin-sensitive S. aureus, and 13 (16.5%) were miscellaneous species. The number of MRSA isolates increases from 2 in 1998 to 20 in 2004, the largest increase occurring during the last 3 years of the study. A large proportion of MRSA isolates were resistant to antimicrobials from other classes, with over 70% being resistant to both erythromycin and cefazolin. A majority of MRSA isolates (71.4%) were obtained from patients with no record of prior hospitalization. Our analysis confirms a high prevalence of MRSA among soft-tissue infections requiring surgical drainage. In addition, a majority of MRSA isolates were resistant to multiple antimicrobials and were isolated from children without a previous documented exposure to the hospital milieu. Thus, pediatric surgeons should be aware of MRSA prevalence and resistance patterns in the local communities.