David B. Tashjian

Anesthetic management of the exit (ex utero intrapartum treatment) procedure

The EXIT (ex utero intrapartum treatment) procedure is used to maintain fetal-placental circulation during partial delivery of a fetus with a potentially life-threatening upper airway obstruction. We performed the EXIT procedure on a fetus with a large intra-oral cyst. Sevoflurane was used as the anesthetic because of its rapid titratability. Sevoflurane provided excellent maternal and fetal anesthesia. Modifications to previously described monitoring techniques for the EXIT procedure were also used.

Guns and states: pediatric firearm injury.

BACKGROUND A recent report indicates that firearm-related injuries are responsible for 30% of pediatric trauma fatality. The literature is however limited in examining pediatric firearm injuries and variations in state gun control laws. Therefore, we sought to examine the association between pediatric firearm injuries and the Stand-Your-Ground (SYG) and Child Access Protection (CAP) laws. METHODS All pediatric (age, 0–20 years) hospitalizations with firearm injuries were identified from the Kids’ Inpatient Database from 2006 and 2009. States were compared for SYG and CAP laws. RESULTS A total of 19,233 firearm injury hospitalizations were identified, with 64.7% assault, 27.2% accidental, and 3.1% suicide injury. Demographics for assault injury were as follows: mean age of 17.6 years, 88.4% male, 44.4% black, 18.2% Hispanic, 70.5% from metropolitan areas, and 50.1% from the poorest median income neighborhoods. Suicide injury cases were more likely to be white (57.8% vs. 16.6%, p < 0.001) and female (15.1% vs. 9.8%, p < 0.001). States with the SYG law were associated with increased accidental injury (odds ratio [OR], 1.282; p < 0.001). There was no statistical association between CAP law and the incidence of accidental injury or suicide. Multivariate logistic regression analysis found other predictive demographic factors for firearm injury: black (OR, 6.164), urban areas (OR, 1.557), poorest median income neighborhoods (OR, 2.785), male (OR, 28.602), and 16 years or older (OR, 37.308). Total economic burden was estimated at more than

Primary repair of facial dog bite injuries in children

1 billion dollars, with a median length of stay of 3 days, 8.4% discharge to rehabilitation, and 6.2% in-hospital mortality. CONCLUSION Pediatric firearm injuries continue to be a significant source of morbidity, mortality, and economic burden. A significant increase in accidental firearm injuries in states with the SYG law may highlight inadvertent effects of the law. Race, sex, and median income are additional contributing factors. Advocacy and focused educational efforts for specific socioeconomic and racial groups may potentially reduce firearm injuries. LEVEL OF EVIDENCE Prognostic study, level II.

Preoperative chemoembolization for unresectable hepatoblastoma.

Objectives: The management of dog bite wounds is controversial, and current data on risk of infection are variable and inconsistent. Furthermore, the use of prophylactic or empiric antibiotics for the treatment of these wounds is debatable. We investigate the rate of wound infections and other complications after primary repair of pediatric facial dog bite injuries. Methods: We reviewed 87 consecutive patients aged 18 years or younger who had facial dog bite injuries from January 2003 to December 2008. Variables examined were age, sex, setting of repair, number of sutures used for repair, whether surgical drains were used, and antibiotic administration. End points measured were incidence of wound infection, need for scar revision, and any wound complications. Results: The mean age of patients was 6.8 years, and the majority were women (53%). All facial injuries were primarily repaired at the time of presentation either in the emergency department (ED; 46%), operating room (OR; 51%), or an outpatient setting (3%). All patients received an antibiotic course, none of the patients developed wound infection, and no subsequent scar revisions were performed. Three patients repaired in the OR underwent placement of a total of 4 closed-suction drains. The mean (SD) age of patients repaired in the OR was significantly younger than those repaired in the ED (5.7 [3.9] vs 8.0 [4.5] years, respectively; P < 0.01). The number of sutures used were greater for patients repaired in the OR than in the ED (66.4 [39.6] vs 21.7 [12.5], respectively; P < 0.01). Conclusions: Intuitively, younger patients and patients with greater severity injuries are more likely to undergo repair in the OR, and this was supported by our data. Overall, we found that primary repair of pediatric facial dog bite injuries, including complex soft-tissue injuries, is safe when performed in conjunction with antibiotic administration; however, further cross-specialty studies are needed to fully characterize these end points in a larger population.

Occlusion of an Aberrant Right Hepatic Artery, Originating from the Superior Mesenteric Artery, Secondary to Blunt Trauma

Abstract Complete surgical resection offers the only chance for cure in patients with hepatoblastoma (HB). Patients with unresectable lesions are given preoperative chemotherapy in an attempt to create a resectable lesion. We present a case of an 11-month-old with an unresectable stage III HB unresponsive to systemic chemotherapy. Transfemoral hepatic-artery chemoembolization resulted in a surgically resectable tumor. The patient underwent a right trisegmentectomy with complete resection of the tumor and remains tumor-free 24 months postoperatively. Salvage chemoembolization can be an effective preoperative modality to convert an unresectable tumor into a resectable one.

Geographic distribution of community-acquired methicillin-resistant Staphylococcus aureus soft tissue infections

Hepatic arterial injury secondary to both blunt and penetrating traumas is well documented in the literature by case reports and articles regarding management. Penetrating injuries to the hepatic arteries are more common than injuries from blunt trauma. Hepatic arterial injuries secondary to blunt traumas are often associated with injuries to other vital organs or vascular structures, resulting in higher mortality rates. We describe the case of an individual involved in a motor vehicle crash, who sustained blunt traumatic occlusion of an aberrant right hepatic artery, originating from the superior mesenteric artery. No reports describing such an injury exist in the English language literature.

Evaluation of the treatment of pectus carinatum with compressive orthotic bracing using three dimensional body scans

PURPOSE The goal of this study is to look at the geographic growth patterns of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections in our local region and to determine if specific geographic areas are at increased risk. METHODS After Institution Review Board approval (132603-3), a retrospective chart review was conducted of 614 patients who underwent incision and drainage of an abscess by a single pediatric surgical practice from January 2004 to December 2008. In addition, previously published data from 195 patients who underwent incision and drainage of an abscess from January 2000 to December 2003 were reviewed. RESULTS The most commonly cultured organism found in the pediatric population undergoing incision and drainage was S aureus (n = 388), of which 258 (66%) were methicillin resistant. This is a 21% increase from the rate of MRSA cultures identified from 2000 to 2003. Geographic information system space-time analysis showed that a cluster of 14 MRSA cases was located within a 1.44-km radius between 2000 and 2003, and 5 separate clusters of more than 20 MRSA infection cases each were identified in 3 separate cities over the 8-year time span using geographic information system spatial analysis (P value = .001). CONCLUSION Methicillin-resistant S aureus has now become the most prevalent organism isolated from cultures of community-acquired abscesses requiring incision and drainage in the pediatric population in our local region. Significant clustering of MRSA infections has appeared in several different cities within our geographic region.

Endoscopic treatment with Deflux for refluxing duplex systems.

PURPOSE The purpose of this study is to measure the effectiveness of compressive orthotic brace therapy for the treatment of pectus carinatum using an adjusted Haller Index (HI) measurement calculated from 3D body scan (BS) images. METHODS Pediatric patients with pectus carinatum were treated with either compressive orthotic bracing or observation. An adjusted BS Haller index (HI) was calculated from serial 3D BS images obtained on all patients. Medical records were evaluated to determine treatment with bracing and brace compliance more than 12hours daily. Compliant patient measurements were compared to non-compliant and non-brace groups. RESULTS Forty patients underwent compressive orthotic bracing, while ten were observed. Twenty-three patients were compliant with bracing, and seventeen patients were non-compliant. Compliant patients exhibited an 8.2% increase, non-compliant patients had a 1.5% increase, and non-brace patients exhibited a 2.5% increase in BS HI. The change in BS HI of compliant patients was significantly different compared to non-brace patients (p=0.004) and non-compliant patients (p<0.001). CONCLUSIONS Three dimensional BS is an effective, radiation free, and objective means to evaluate patients treated with compressive orthotic bracing.

The Nuss Procedure: Our Experience from the First Fifty

PURPOSE The aim of this study was to review the experience of a single institution with the endoscopic Deflux (Q-Med Scandinavia, Uppsala, Sweden) procedure and assess its effectiveness in the treatment of refluxing duplex systems. MATERIALS AND METHODS A retrospective review of all patients that underwent endoscopic Deflux treatment for vesicoureteral reflux (VUR) in duplex systems between June 2003 and July 2007 was performed. Data collection included: age, gender, side of refluxing ureter, preoperative radiologic grade of VUR on a voiding cystourethrogram (VCUG), presence of VUR on a radionuclide VCUG 3 months postprocedure, volume of Deflux injected, number of Deflux injections performed per patient, and number of patients that underwent reimplantation surgery. RESULTS Sixteen patients with duplex systems, two being bilateral, for a total of 18 duplex ureteral systems, underwent the Deflux procedure. Grades of reflux were as follows: grade II: 4 ureters; grade III: 8 ureters; grade IV: 4 ureters; and grade V: 2 ureters. Deflux injection volume ranged from 0.28 to 1.5 cc (mean, 0.84). Fourteen ureteral systems required one injection, three required two injections, and one required three injections. The overall success rate of the procedure after a maximum of three injections was 94%. One patient with preoperative unilateral grade V reflux had persistent high-grade reflux after two injections and opted to proceed with surgical reimplantation. The mean follow-up was 24 months (mean, 6-48). CONCLUSIONS We conclude that the Deflux procedure is a safe, effective minimally invasive treatment alternative for patients with refluxing duplex systems.

Use of Energy Devices in Thoracoscopy: Quantification of Lung-Sealing Capacity

Purpose: The Nuss procedure for pectus excavatum has rapidly gained acceptance among pediatric surgeons. We present the results and lessons learned from our initial 50 patients undergoing the minimally invasive pectus repair. Patients and methods: After obtaining Internal Review Board approval, we retrospectively reviewed patients undergoing the Nuss procedure from April 1998 to September 2002. Data, including age, operative time, length of hospital stay, and complications, were recorded. Results: Fifty patients whose average age was 13 years underwent the procedure. The mean operative time was 90 minutes, and the average length of stay was 6 days. Eleven immediate postoperative pneumothoraces were detected, none of which required tube thoracostomy or aspiration. One displaced bar was replaced at 6 weeks, and infection necessitated the removal of that bar at 11 months. A second displaced bar lacking a stabilizer was removed at 15 months with a good cosmetic result. Three bar stabilizer complications occur...