Casey M. Calkins

The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children

BACKGROUND Rib fractures have a strong association with nonaccidental trauma (NAT) and severe trauma. The purposes of this study were to evaluate rib fractures in children to determine (1) the positive predictive value of a rib fracture in defining NAT and (2) the frequency of rib fractures as the only skeletal manifestation of NAT. METHODS We reviewed the medical records and imaging of all children with rib fractures over a 6-year period. NAT was determined by the Child Advocacy and Protection team. RESULTS In children younger than 3 years of age, the positive predictive value (PPV) of a rib fracture as an indicator of NAT was 95%. The positive predictive value increased to 100% once historical and clinical circumstance excluded all other causes for rib fractures. CONCLUSION In this study, rib fracture(s) were the only skeletal manifestation of NAT in 29% of the children.

Open Versus Laparoscopic Pyloromyotomy for Pyloric Stenosis: A Prospective, Randomized Trial

Background:Pyloric stenosis, the most common surgical condition of infants, is treated by longitudinal myotomy of the pylorus. Comparative studies to date between open and laparoscopic pyloromyotomy have been retrospective and report conflicting results. To scientifically compare the 2 techniques, we conducted the first large prospective, randomized trial between the 2 approaches. Methods:After obtaining IRB approval, subjects with ultrasound-proven pyloric stenosis were randomized to either open or laparoscopic pyloromyotomy. Postoperative pain management, feeding schedule, and discharge criteria were identical for both groups. Operating time, postoperative emesis, analgesia requirements, time to full feeding, length of hospitalization after operation, and complications were compared. Results:From April 2003 through March 2006, 200 patients were enrolled in the study. There were no significant differences in operating time, time to full feeding, or length of stay. There were significantly fewer number of emesis episodes and doses of analgesia given in the laparoscopic group. One mucosal perforation and one incisional hernia occurred in the open group. Late in the study, 1 patient in the laparoscopic group was converted to the open operation. A wound infection occurred in 4 of the open patients compared with 2 of the laparoscopic patients (P = 0.68). Conclusions:There is no difference in operating time or length of recovery between open and laparoscopic pyloromyotomy. However, the laparoscopic approach results in less postoperative pain and reduced postoperative emesis. In addition, there was a fewer number of complications in the laparoscopic group. Finally, patients approached laparoscopically will likely display superior cosmetic outcomes with long-term follow-up.

Parenteral nutrition–associated cholestasis: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review

OBJECTIVE The aim of this study was to review evidence-based data addressing key clinical questions regarding parenteral nutrition-associated cholestasis (PNAC) and parenteral nutrition-associated liver disease (PNALD) in children. DATA SOURCE Data were obtained from PubMed, Medicine databases of the English literature (up to October 2010), and the Cochrane Database of Systematic Reviews. STUDY SELECTION The review of PNAC/PNALD has been divided into 4 areas to simplify ones understanding of the current knowledge regarding the pathogenesis and treatment of this disease: (1) nonnutrient risk factors associated with PNAC, (2) PNAC and lipid emulsions, (3) nutritional (nonlipid) considerations in the prevention of PNAC, and (4) supplemental medications in the prevention and treatment of PNAC. RESULTS The data for each topic area relevant to the clinical practice of pediatric surgery were reviewed, evaluated, graded, and summarized. CONCLUSIONS Although the conditions of PNAC and PNALD have been well recognized for more than 30 years, only a few concrete associations and treatment protocols have been established.

IL-1 regulates in vivo C—X—C chemokine induction and neutrophil sequestration following endotoxemia

The influx of neutrophils into tissues in response to inflammatory stimuli involves C—X—C chemokines. Interleukin-1 (IL-1) stimulates chemokine production in vitro , but its role in vivo on chemokine production is not as clearly understood. We hypothesized that IL-1 mediates in vivo tissue C—X—C chemokine production induced by systemic lipopolysaccharide (LPS). IL-1 activity was blockedbyIL-1 receptor antagonist (IL-1Ra). Rats were injected with Salmonella typhi LPS (0.5 mg/kg) with and without prior administration of IL-1Ra. Cytokine-induced neutrophil chemoattractant-1 (CINC-1) and macrophage inflammatory protein-2 (MIP-2) protein and mRNA levels, tissue neutrophil accumulation, and indices of organ injury were measured. LPS administration resulted in increased plasma, lung, and liver IL-1β that was decreased by IL-1Ra. LPS also induced an increase in plasma, lung, and liver CINC-1 and MIP-2 protein and mRNA. However, IL-1Ra had no effect on LPS-induced plasma or lung tissue CINC-1 levels. In contrast, IL-1Ra pretreatment did significantly decrease CINC-1 protein expression in the liver (45% decrease) and MIP-2 protein expression in plasma (100% decrease), lung (72% decrease) and liver (100% decrease) compared to LPS-treated controls. Steady-state mRNA levels by Northern blot analysis of both CINC-1 and MIP-2 in lung and liver were similar to the protein findings. Pretreatment with IL-1Ra also resulted in a 47% and 59% decrease in lung and liver neutrophil accumulation, respectively, following LPS. In addition, indices of both lung and liver injury were decreased in animals pretreated with IL-1Ra. In summary, LPS induces IL-1β and MIP-2 expression in the lung and liver, both of which are IL-1 dependent. Although lung neutrophil accumulation in both lung and liver after LPS is also IL-1 mediated, lung CINC-1 levels were unaffected by IL-1Ra. These data suggest that IL-1 regulates tissue chemokine expression and neutrophil accumulation after LPS.

The diagnosis and management of empyema in children: a comprehensive review from the APSA Outcomes and Clinical Trials Committee.

The aim of this study is to review the current evidence on the diagnosis and management of empyema. The American Pediatric Surgical Association Outcomes and Clinical Trials Committee compiled 8 questions to address. A comprehensive review was performed on each topic. Topics included the distinction between parapneumonic effusion and empyema, the optimal imaging modality in evaluating pleural space disease, when and how pleural fluid should be managed, the first treatment option and optimal timing in the management of empyema, the optimal chemical debridement agent for empyema, therapeutic options if chemical debridement fails, therapy for parenchymal abscess or necrotizing pneumonia and duration of antibiotic therapy after an intervention. The evidence was graded for each topic to provide grade of recommendation where appropriate.

Strategies for the prevention of central venous catheter infections: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review

PURPOSE The aim of this study is to review the current evidence-based data regarding strategies for prevention of central venous catheter (CVC) infections at the time of catheter insertion and as a part of routine care. METHODS We conducted a PubMed search from January 1990 to November 2010 using the following keywords: central venous catheter, clinical trials, pediatric, infection, prevention, antibiotic, chlorhexidine, dressing, antiseptic impregnated catheters, ethanol lock, impregnated cuff, insertion site infection, and Cochrane systematic review. Seven questions, selected by the American Pediatric Surgical Association Outcomes and Clinical Trials Committee, were addressed. RESULTS Thirty-six studies were selected for detailed review based on the strength of their study design and relevance to our 7 questions. These studies provide evidence that (1) chlorhexidine skin prep and chlorhexidine-impregnated dressing can decrease CVC colonization and bloodstream infection, (2) use of heparin and antibiotic-impregnated CVCs can decrease CVC colonization and bloodstream infection, and (3) ethanol and vancomycin lock therapy can reduce the incidence of catheter-associated bloodstream infections. CONCLUSION Grade A and B recommendations can be made based on available evidence in adult and limited pediatric studies for multiple components of proper CVC insertion practices and subsequent management. These strategies can minimize the risk of CVC infections in pediatric patients.

Cost analysis in the management of esophageal coins: Endoscopy versus bougienage

PURPOSE The aim of this study was to compare the safety, efficiency, and overall cost effectiveness of esophageal bougienage versus endoscopy in the retrieval of ingested coins. METHODS Retrospective review of patients treated for esophageal coin ingestion at Childrens Hospital of Wisconsin over a 1-year period using bougienage or endoscopic retrieval was conducted. (inclusion criterion) RESULTS Twenty-seven patients were evaluated over the 1-year study period. Two patients spontaneously passed the coins before arrival and needed no further treatment. Twelve patients met criteria for bougienage, and this treatment was successful in 10 of the 12 patients. Mean length of hospital stay was 2.15 hours, and the mean cost was

Removal of an intrathoracic migrated fixation pin by thoracoscopy

546. Thirteen patients were treated successfully with endoscopy. The mean length of hospital stay was 22.7 hours, and the mean cost was

Risk of incomplete pyloromyotomy and mucosal perforation in open and laparoscopic pyloromyotomy.

5,230. There were no complications in any of the 25 patients. CONCLUSIONS Bougienage is equally safe, more efficient, and much less expensive than endoscopy for treatment of esophageal coins in properly selected patients. Nearly half of the patients were excluded from bougienage because of delayed presentation alone. Education of parents and physicians regarding symptoms of coin ingestion would allow primary treatment with bougienage in the majority of cases.

Conservative management of giant omphalocele with topical povidone-iodine and its effect on thyroid function

Migration of orthopedic fixation pins into the thoracic cavity can result in perforation of pulmonary vasculature, aorta, bronchus, atrium, or ventricle. Prompt diagnosis and treatment is tantamount in preventing devastating consequences. A patient who had fixation of a right humeral fracture weeks later had intrathoracic migration of a fixation pin, found by routine postoperative radiographic examination. Because the patient was asymptomatic, we removed the pin with a thoracoscopic operation. The foreign body was retrieved successfully without intraoperative or postoperative complication.