Ilan I. Maizlin

Utilization of the NSQIP-Pediatric Database in Development and Validation of a New Predictive Model of Pediatric Postoperative Wound Complications

BACKGROUND Surgical wound classification, introduced in 1964, stratifies the risk of surgical site infection (SSI) based on a clinical estimate of the inoculum of bacteria encountered during the procedure. Recent literature has questioned the accuracy of predicting SSI risk based on wound classification. We hypothesized that a more specific model founded on specific patient and perioperative factors would more accurately predict the risk of SSI. STUDY DESIGN Using all observations from the 2012 to 2014 pediatric National Surgical Quality Improvement Program-Pediatric (NSQIP-P) Participant Use File, patients were randomized into model creation and model validation datasets. Potential perioperative predictive factors were assessed with univariate analysis for each of 4 outcomes: wound dehiscence, superficial wound infection, deep wound infection, and organ space infection. A multiple logistic regression model with a step-wise backwards elimination was performed. A receiver operating characteristic curve with c-statistic was generated to assess the model discrimination for each outcome. RESULTS A total of 183,233 patients were included. All perioperative NSQIP factors were evaluated for clinical pertinence. Of the original 43 perioperative predictive factors selected, 6 to 9 predictors for each outcome were significantly associated with postoperative SSI. The predictive accuracy level of our model compared favorably with the traditional wound classification in each outcome of interest. CONCLUSIONS The proposed model from NSQIP-P demonstrated a significantly improved predictive ability for postoperative SSIs than the current wound classification system. This model will allow providers to more effectively counsel families and patients of these risks, and more accurately reflect true risks for individual surgical patients to hospitals and payers.

Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: A pediatric trauma society collaborative.

BACKGROUND Guidelines for nonoperative management (NOM) of high-grade pancreatic injuries in children have not been established, and wide practice variability exists. The purpose of this study was to evaluate common clinical strategies across multiple pediatric trauma centers to develop a consensus-based standard clinical pathway. METHODS A multicenter, retrospective review was conducted of children with high-grade (American Association of Surgeons for Trauma grade III-V) pancreatic injuries treated with NOM between 2010 and 2015. Data were collected on demographics, clinical management, and outcomes. RESULTS Eighty-six patients were treated at 20 pediatric trauma centers. Median age was 9 years (range, 1–18 years). The majority (73%) of injuries were American Association of Surgeons for Trauma grade III, 24% were grade IV, and 3% were grade V. Median time from injury to presentation was 12 hours and median ISS was 16 (range, 4–66). All patients had computed tomography scan and serum pancreatic enzyme levels at presentation, but serial enzyme level monitoring was variable. Pancreatic enzyme levels did not correlate with injury grade or pseudocyst development. Parenteral nutrition was used in 68% and jejunal feeds in 31%. 3Endoscopic retrograde cholangiopancreatogram was obtained in 25%. An organized peripancreatic fluid collection present for at least 7 days after injury was identified in 59% (42 of 71). Initial management of these included: observation 64%, percutaneous drain 24%, and endoscopic drainage 10% and needle aspiration 2%. Clear liquids were started at a median of 6 days (IQR, 3–13 days) and regular diet at a median of 8 days (IQR 4–20 days). Median hospitalization length was 13 days (IQR, 7–24 days). Injury grade did not account for prolonged time to initiating oral diet or hospital length; indicating that the variability in these outcomes was largely due to different surgeon preferences. CONCLUSION High-grade pancreatic injuries in children are rare and significant variability exists in NOM strategies, which may affect outcomes and effective resource utilization. A standard clinical pathway is proposed. LEVEL OF EVIDENCE Therapeutic/care management, level V (case series).BACKGROUND Guidelines for non-operative management (NOM) of high-grade pancreatic injuries in children have not been established, and wide practice variability exists. The purpose of this study was to evaluate common clinical strategies across multiple pediatric trauma centers in order to develop a consensus-based standard clinical pathway. METHODS A multicenter, retrospective review was conducted of children with high-grade (AAST grade III-V) pancreatic injuries treated with NOM between 2010-15. Data was collected on demographics, clinical management, and outcomes. RESULTS Eighty-six patients were treated at 20 pediatric trauma centers. Median age was 9 years (range 1-18). The majority (73%) of injuries were AAST grade III, 24% were grade IV, and 3% were grade V. Median time from injury to presentation was 12 hours and median ISS was 16 (range 4-66). All patients had computed tomography (CT) scan and serum pancreatic enzyme levels at presentation, but serial enzyme level monitoring was variable. Pancreatic enzyme levels did not correlate with injury grade or pseudocyst development. Parenteral nutrition was used in 68% and jejunal feeds in 31%. Endoscopic retrograde cholangiopancreatogram (ERCP) was obtained in 25%. An organized peri-pancreatic fluid collection present for at least 7 days following injury was identified in 59% (42/71). Initial management of these included: observation 64%, percutaneous drain 24%, and endoscopic drainage 10% and needle aspiration 2%. Clear liquids were started at median 6 days (IQR 3-13) and regular diet at median 8 days (IQR 4-20). Median hospitalization length was 13 days (IQR 7-24). Injury grade did not account for prolonged time to initiating oral diet or hospital length; indicating that the variability in these outcomes was largely due to different surgeon preferences. CONCLUSION High-grade pancreatic injuries in children are rare and significant variability exists in NOM strategies, which may affect outcomes and effective resource utilization. A standard clinical pathway is proposed. LEVEL OF EVIDENCE IV (case series). STUDY TYPE Therapeutic/Care Management.

Testicular tumors in prepubescent patients

BACKGROUND/PURPOSE Pediatric testicular tumors are rare, constituting only 1% of all pediatric solid tumors. Single-institution studies addressing pediatric testicular tumors published to date have been limited in the number of patients. METHODS We utilized the National Cancer Data Base (1998-2012) to review all prepubescent patients (≤12 years old) with testicular neoplasms. Demographics, tumor characteristics, treatment modalities, and outcomes were abstracted. RESULTS A total of 479 patients were identified, with a median age of 3 years (IQR 0-4) at diagnosis. 67% of cases were diagnosed by 3 years of age. Yolk sac tumors were the most common histology (202 patients, 42.2%). Most tumors were diagnosed at a low stage. Resection was performed in 465 boys, with 75% having undergone radical orchiectomies. Chemotherapy was utilized in 28% of cases and radiotherapy in 7%. With mean follow-up of 5.6 years, mortality rate was 3%. No difference in mortality was noted based on histology or extent of surgical resection. CONCLUSIONS This series of prepubertal testicular tumors is the largest yet reported and highlights the patient demographics, tumor characteristics, treatment modalities and outcomes for these tumors. TYPE OF STUDY Prognosis study LEVEL OF EVIDENCE: II.

Effects of socioeconomic status on children with well-differentiated thyroid cancer

Background: Well‐differentiated thyroid cancer is the most common endocrine malignancy in children. Adult literature has demonstrated socioeconomic disparities in patients undergoing thyroidectomy, but the effects of socioeconomic status on the management of pediatric well‐differentiated thyroid cancer remains poorly understood. Methods: Patients ≤21 years of age with well‐differentiated thyroid cancer remains were reviewed from the National Cancer Data Base. Three socioeconomic surrogate variables were identified: insurance type, median income, and educational quartile. Tumor characteristics, diagnostic intervals, and clinical outcomes were compared within each socioeconomic surrogate variable. Results: A total of 9,585 children with well‐differentiated thyroid cancer remains were reviewed. In multivariate analysis, lower income, lower educational quartile, and insurance status were associated with higher stage at diagnosis. Furthermore, lower income quartile was associated with a longer time from diagnosis to treatment (P < .002). Similarly, uninsured children had a longer time from diagnosis to treatment (28 days) compared with those with government (19 days) or private (18 days) insurance (P < .001). Despite being diagnosed at a higher stage and having a longer time interval between diagnosis and treatment, there was no significant difference in either overall survival or rates of unplanned readmissions based on any of the socioeconomic surrogate variables. Conclusion: Children from lower income families and those lacking insurance experienced a longer period from diagnosis to treatment of their well‐differentiated thyroid cancer remains. These patients also presented with higher stage disease. These data suggest a delay in care for children from low‐income families. Although these findings did not translate into worse outcomes for well‐differentiated thyroid cancer remains, future efforts should focus on reducing these differences.