Bethany Easterbrook

Cause and Effect versus Confounding—Is There a True Association between Caudal Blocks and Tubularized Incised Plate Repair Complications?

Purpose: We studied the impact of caudal block vs dorsal penile block on the rate of urethrocutaneous fistula and glans dehiscence in children who underwent hypospadias repair. Materials and Methods: We retrospectively reviewed the records of 849 consecutive patients who underwent tubularized incised plate repair between 2004 and 2015. A total of 331 cases with incomplete medical records, other techniques and redo repair were excluded. The preference for caudal block was based on anesthesiologist discretion. Age at surgery, meatal location, preoperative testosterone stimulation, type of regional anesthesia (caudal block vs dorsal penile block), degree of ventral curvature, surgeon expertise and complications (urethrocutaneous fistula/glans dehiscence) were captured. Univariate and multivariable analyses were done of risk factors for complications. Results: Median age at surgery was 18 months and median followup was 6 months. Of 518 patients 405 (78%) had distal and 113 (22%) had mid shaft/proximal defects. Complications developed in 37 cases (7%), including urethrocutaneous fistula in 21 (19 with a caudal block and 2 with a dorsal penile block) and glans dehiscence in 16 (13 with a caudal block and 3 with a dorsal penile block). On univariate analysis preoperative testosterone stimulation vs no preoperative testosterone stimulation (13.0% vs 6.2% of cases, p = 0.04), mid shaft/proximal vs distal defects (15.9% vs 4.7%, p <0.01) and caudal block (8.7% vs 3.3%, p = 0.03) were significantly associated with more complications. However, on multivariable analysis the associations of preoperative testosterone stimulation (OR 1.2, 95% CI 0.4–3.7) and caudal block (OR 2.4, 95% CI 0.9–6.4) with complications did not hold. Only the combination of meatal location/ventral curvature remained as an independent risk factor for urethrocutaneous fistula/glans dehiscence (OR 2.4, 95% CI 1.1–5.7, p = 0.04). Conclusions: Our data indicate that hypospadias severity and not the type of regional anesthesia was the only risk factor significantly associated with postoperative complications. To confirm these findings and provide strong and definitive evidence on this topic a well powered, randomized, controlled trial is clearly required.

From Research Question to Conducting a Randomized Controlled Trial on Continuous Antibiotic Prophylaxis in Prenatal Hydronephrosis: A Rational Stepwise Process

Introduction and objectives Continuous antibiotic prophylaxis (CAP) use to prevent urinary tract infections (UTI) in infants with prenatal hydronephrosis (HN) remains controversial. Lack of consensus guidelines and diverse practice patterns for postnatal management of HN highlight the dire need for higher level of evidence studies. Herein, we aim to describe the steps from developing a well-defined research question to execute a multicentered randomized controlled trial (RCT) to address the issue of CAP use in patients with prenatal HN. Materials and methods The steps involved were (1) choosing the proper research question, (2) survey of practice patterns and establishing clinical equipoise, (3) systematic review of the literature, (4) reviewing own practice, (5) longitudinal prospective study, (6) pilot study, (7) cost-utility analysis, and (8) definitive RCT (clinical trials registry number: NCT01140516). An update of our previous systematic review was conducted using two electronic databases and gray literature from 2010 to 2015. Eligibility criteria included studies of children <2 years old with postnatally confirmed prenatal HN, receiving CAP or not, and reporting on development of UTIs, capturing information on voiding cystourethrogram result and HN grade. Full-text screening was conducted by two independent reviewers. UTI rates in patients with high-grade HN were compared across different study designs. Finally, blinded comparative analysis of UTI rates between placebo and treatment groups was carried out using chi-square test. Results UTI rates in patients with high-grade HN by their respective study design were: 25% for systematic review, 20% for retrospective study, 21% for prospective and pilot studies, and 13% for the definitive RCT thus far. Regardless of the type of study design, patients with hydroureteronephrosis had significantly higher (threefold to sixfold) UTI rates than those with isolated HN. Our updated systematic review yielded 486 citations, of which 9 (n = 1987 infants) observational studies met eligibility criteria. Conclusion UTI rates in patients with high-grade HN dropped from 25% in observational studies to 13% in our RCT. This decline in UTI rate demonstrates that study designs lacking strategies to minimize bias are more prone to overestimate treatment effects. These findings highlight the importance of conducting methodologically sound RCTs to answer clinically meaningful questions, such as the one presented here.

Letter to the editor regarding “The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair”

Sir—As pediatric urologists and active clinical researchers, we enthusiastically read the recent publication by Taicher et al. in Pediatric Anesthesia. This was an interesting, single-center study, which attempted to definitively determine whether caudal block was associated with an increased risk of postoperative surgical complications in boys undergoing hypospadias repair. This retrospective review examined medical records of 395 patients who underwent singlestage repair, with 230 of those receiving caudal anesthesia, and 165 undergoing dorsal penile block. In their series, 326 patients had distal hypospadias. Using multivariable logistic regression to account for confounders, the authors found that proximal hypospadias and caudal anesthesia were independently associated with postoperative complications. While a 13-fold increase in the odds of developing a posthypospadias repair complication when performing a caudal block is undoubtedly alarming, it is essential to examine the precision of such an outcome measure prior to drawing strong conclusions. Following bivariate analysis, caudal anesthesia was shown to have an unadjusted odds ratio (OR) of 16.5 with a 95% confidence interval (CI) of 2.2-123.8. Even after using multivariable analysis and including only two covariates in their model, the adjusted OR for postoperative surgical complications with caudal block was 13.4, with a still very wide 95% CI, spanning from 1.8 to 101.8, which indicates a substantial amount of imprecision for the estimate of the treatment effect. The wider the 95% CI, the less precise our outcome measure typically is, which casts doubt on the true association of the effect. The extremely wide 95% CIs presented in this paper lead us to question whether the strong magnitude of effect is spurious due to low numbers of events, and/or due to selection bias toward the indication of caudal blocks for more severe proximal hypospadias cases. Unfortunately, the authors did not provide the number of patients with proximal hypospadias that were administered dorsal penile block, information that could have explained and shed light on some of the points previously raised. Several studies have been published on this topic in the past 5 years with conflicting results. This paper has fostered an already intriguing debate regarding caudal block for hypospadias repair; however, embarking on a practice change based exclusively on the current low level of evidence would be premature at this stage. Such clinical equipoise in the medical community should be the driving force to design and conduct methodologically sound randomized controlled trials. Although the link between caudal block and surgical complications posthypospadias repair is fascinating, due to currently limited evidence in the literature, this association should be seen simply as hypothesis generating as it presently stands. No concrete conclusions should current be drawn regarding this issue, and a definitive answer can only be obtained once well-powered RCTs are conducted.

Elbow splinting as a method to increase patching compliance in amblyopia therapy

PurposeThe purpose of the study was to evaluate the feasibility and acceptability of utilizing elbow splints as a method of increasing amblyopic patching compliance in pediatric ophthalmology patients who fail to comply with prescribed patching regimens.Patients and methodsPatients <6 years of age who were not adhering to pre-specified patching guidelines were prescribed elbow splints in order to increase patching compliance at the discretion of a pediatric ophthalmologist. If the child was non-compliant (patching <50% of specified time or consistently removing patch), parents were asked to try using the elbow splints until patching compliance was achieved. Non-parametric Wilcoxon signed-rank tests were used to compare patching time pre- and post-splints.Results41/48 children who were prescribed elbow splints to increase patching compliance for amblyopia were included for analysis. Seven children were excluded due to patching and splints being prescribed at the outset (n=4), and for not using the splinting intervention (n=3). Median age at being prescribed elbow splints was 37 (12–68) months. Mean daily patching prior to splints was 1.5±1.7 h, whereas mean prescribed daily patching was 4.95±1.5 h. Following splinting, 34/41 (83%) became compliant with patch alone, and visual acuity increased in 39/41 (95%) patients, with no patients developing amblyopia in the fellow eye. Median amount of time splints was required to improve compliance was 7 (1–240) days.ConclusionElbow splinting seems to be a viable alternative method to increase pediatric amblyopic patching compliance when patching alone fails to achieve satisfactory compliance.

Antibiotic prophylaxis for prevention of urinary tract infections in prenatal hydronephrosis: An updated systematic review

INTRODUCTION While continuous antibiotic prophylaxis (CAP) is currently recommended to prevent urinary tract infections (UTIs) in infants with prenatal hydronephrosis (HN), this recommendation is not evidence-based. The objective of this study was to systematically determine whether CAP reduces UTIs in the HN population. METHODS Applicable trials were identified through an electronic search of MEDLINE (1946-2015), EMBASE (1980-2016), CINAHL (1982-2016), and CENTRAL (1993-2016) and through a hand search of American Urological Association (AUA) (2012-2015) and European Society for Pediatric Urology (ESPU) (2012-2015) abstracts, as well as reference lists of included trials. The search strategy was not limited by language or year of publication. Eligible studies compared CAP to no CAP in patients with antenatal HN, <2 years of age, and reported development of UTI and HN grades. Two independent reviewers performed title and abstract screening, full-text review, and quality appraisal. RESULTS Of 1518 citations screened, 11 were included, contributing 3909 patients for final analysis. Of these, four (36%) were considered high-quality when assessed by the Newcastle Ottawa Scale. Meta-analysis of the non-randomized trials (n=10) provided similar pooled UTI rates, regardless of CAP use: 9.9% (95% confidence interval [CI] 8.4-11.4%) for CAP and 7.5% (95% CI 6.4-8.6%) for no CAP. CONCLUSIONS This systematic review and meta-analysis suggests there may be value in providing CAP to infants with high-grade HN; however, due to the very low-quality data from non-randomized studies, important clinical variables, such as circumcision status, were unable to be assessed.

Understanding paediatric patients’ attitudes toward obesity and expectations prior to entering a weight management program

Objective This qualitative study explored attitudes toward weight management and knowledge of healthy, active living among paediatric patients referred to a weight management program. The objective of this study was to determine the emotional state and attitudes of patients entering into a paediatric weight management program. Methods Study participants (aged 7 to 17 years old) were recruited during clinic orientation. Semistructured interviews were conducted, audiotaped and transcribed verbatim. Qualitative content analysis generated a thematic coding scheme, identifying concepts and linkages in the data. Study rigour was achieved collaboratively through an audit trail, and data triangulation. Results Fifteen patients (median age 11 years) consented to interviews. Three recurring themes emerged: emotions, motivation and learning. A total of nine subthemes were identified. Four key spheres of influence (family, peers, school and health care providers) affected the patients outlook on obesity positively by providing support or negatively by adversely influencing their emotions and motivation. The level of individual motivation to engage in the weight management program varied. A positive outlook toward learning about obesity from school officials and health care providers emerged. Conclusions This study provided insight regarding paediatric attitudes related to entering a weight management program. The negative emotional state and sometimes fear of the program expressed should be considered by the referring physician and by clinicians in weight management programs engaging in their care.

Retinopathy of prematurity practices: a national survey of Canadian Neonatal Intensive Care Units

ObjectiveTo examine current level three Neonatal Intensive Care Unit (NICU) practices related to ROP screening and treatment.Study designA cross-sectional survey was sent to 29 level three NICU’s across Canada to survey current screening inclusion criteria, treatment options, supportive care and post-screening events for ROP.Result22/29 (76%) level three NICU’s responded. Ten different ROP screening inclusion criteria were found to be in use with significant variation in gestational age and birth weight criteria. Many other national variations also exist regarding the supportive and procedural protocols surrounding ROP screening as well as mode of treatment for ROP.ConclusionDespite national guidelines, significant variation in ROP screening inclusion criteria practices exist among neonatal units in Canada. Therefore, there is an urgent need for better evidence-based screening guidelines as well as a need to standardize supportive measures surrounding ROP screening and treatment.

Evaluating complication rates and outcomes among infants less than 5 kg undergoing traditional percutaneous endoscopic gastrostomy insertion: A retrospective chart review

PURPOSE Percutaneous endoscopic gastrostomy (PEG) enables enteral nutrition for patients with inadequate oral intake. Laparoscopic guidance of PEG insertion is used for high-risk populations, including in infants less than 5kg at insertion. This study aimed to assess complication rates with traditional PEG tube insertion in infants less than 5kg at a single tertiary care center. METHODS A retrospective review of patients less than 5kg who underwent PEG insertion was conducted. PEG insertion-related complications, up to four years following insertion, were collected. Outcomes were reported as counts and percentages, or median with minimum and maximum values. RESULTS 480 pediatric gastrostomy procedures between January 1, 2009 and February 1, 2017, were screened, with 129 included for analysis. Median weight at PEG insertion was 3800g. Superficial surgical site infection (SSI) occurred in 6 (4.7%) patients, and 1 (0.8%) required readmission for intravenous antibiotics. One (0.8%) required endoscopic management for retained foreign body, 1 (0.8%) required operative management for gastrocolic fistula, and 1 (0.8%) for persistent gastrocutaneous fistula. No deep space SSI, procedure-related hemorrhage requiring readmission or transfusion, buried bumper syndrome, or procedure-related mortality occurred. CONCLUSION Traditional PEG tube insertion in infants less than 5kg results in complication rates comparable to pediatric literature standards. LEVEL OF EVIDENCE Level II, retrospective prognosis study.

MP61-08 VOIDING CYSTOURETHROGRAM AND ANTIBIOTIC PROPHYLAXIS FOR PRENATAL HYDRONEPHROSIS: SURPRISING RESULTS FROM A SURVEY OF SFU MEMBERS’ PRACTICE PATTERNS

Source of Funding: Data is this study were collected by the Chronic Kidney Disease in children prospective cohort study (CKiD) with clinical coordinating centers (Principal Investigators) at Children’s Mercy Hospital and the University of Missouri Kansas City (Bradley Warady, MD) and Children’s Hospital of Philadelphia (Susan Furth, MD, Ph.D.), Central Biochemistry Laboratory (George Schwartz, MD) at the University of Rochester Medical Center, and data coordinating center (Alvaro MuO1oz, Ph.D). at the Johns Hopkins Bloomberg School of Public Health. The CKiD is funded by the National Institute of Diabetes and Digestive Kidney Diseases, with additional funding from the National Institute of Child Health and Human Development, and the National Heart, Lung, and Blood Institute (U01-DK-66143, U01-DK-66174, U01-DK-082194, U01-DK-66116).

Parental knowledge of pediatric eye health in an ophthalmology clinic setting: validation and delivery of the EYEE questionnaire

OBJECTIVE We aimed to develop and assess the reliability of a questionnaire assessing parental knowledge on core topics in pediatric eye health. METHODS In Phase I, the Evaluate Your Eye Education Questionnaire (EYEE-Q) was developed and distributed to ascertain face validity (n = 20). In Phase II, participants completed EYEE-Q twice to determine test-retest reliability (n = 40). In Phase III, EYEE-Q was administered to parents in a tertiary level pediatric ophthalmology clinic to assess knowledge (n = 193). RESULTS EYEE-Q had good test-retest reliability (Kripendorffs alpha = 0.77). Mean knowledge was 71% on eye physiology, 59% on pediatric vision care, 58% on refractive error, 53% on common childhood eye conditions, and 48% on eye care professional (ECP) roles. Low income, non-Caucasian race, and English as a second language status were associated with poorer scores. CONCLUSION EYEE-Q is a reliable means of assessing parental knowledge on select pediatric eye health-related topics. Knowledge appears to be suboptimal among parents of children attending tertiary level ophthalmology clinics. ECPs should actively provide educational materials in various languages and formats to promote understanding of medical jargon and patient compliance. The influence of educational interventions on knowledge can be assessed using the EYEE-Q.