Ioana Bratu

Pediatric appendicitis rupture rate: disparities despite universal health care

BACKGROUND/PURPOSE Significant socioeconomic disparities have been observed in the rates of perforated appendicitis among children in private health care. We seek to explore if, in the Canadian system of public, universal health care access, pediatric appendicitis rupture rates are an indicator of health disparities. METHODS Using the Population Health Research Data Repository housed at Manitoba Centre for Health Policy, a retrospective analysis over a 20-year period (1983-2003) examined all patients aged less than 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes for appendicitis (N = 7475). Multivariate logistic regression analysis was used to calculate odds ratios in the association between appendiceal rupture rates and the patients socioeconomic status (SES) based upon average household income of the census area adjusted for age, sex, area of residence, and treating hospital. RESULTS The overall appendiceal rupture rate was 28.8%. Significant positive predictors of appendiceal rupture were lower rural SES, lower urban SES, younger age, northern area of residence, and receiving treatment at the provinces only pediatric tertiary care hospital. CONCLUSION Despite free, universal access health care, children from lower SES areas have increased appendiceal rupture rates. Seeking and accessing medical attention can be complicated by social, behavioral, and geographical problems.

Attention to small details: big deal for gastrostomies

Gastrostomy tubes are used in the pediatric population when long-term enteral feeding is needed. A common method of placement is percutaneously with endoscopy (PEG, percutaneous endoscopic gastrostomy). Although PEG placement is a straightforward procedure most of the time, it can be associated with a significant rate of minor complications and a smaller but significantly important rate of major complications. Some of these complications may also occur after any type of gastrostomy. We will present representative case studies outlining major complications and discuss how we may be able to prevent them at the time of PEG insertion or during PEG to low-profile button gastrostomy exchange. The proposed guidelines apply to all types of gastrostomies.

Incidence and Predictors of Gastrocutaneous Fistula in the Pediatric Patient

Background/Purpose. To determine the incidence, predictors, and outcomes of repair of gastrocutaneous fistulae (GCF) in pediatric patients. Methods. Patients were identified through a medical records search of all gastrostomy insertions performed from 1997–2007. Results. Of 1083 gastrostomies, 49 had GCF closure. Gastrostomy indications were reflux/aspiration (30/43 [70%]) and feeding intolerance/failure to thrive (7/43 [16%]). Gastrostomies were performed as open surgical procedures (84%) with fundoplication (66% of all cases) at an age of 0.5 ± 0.57 (median ± inter-quartile range) years. Gastrostomies were removed in outpatient settings when no longer used and were present for 2.3 ± 2.2 years, and GCF persisted for 2.0 ± 3.0 months. GCF were closed by laparotomy and stapling. GCF closure length of stay was 2.0 ± 3.3 days. Complications occurred in 6/49 patients and included infection/fever (4/6) and localized skin redness/breakdown (2/6). Conclusions. From our collected data, GCFs occur at a frequency of 4.5% and persist for 2.0 ± 3.0 months until closed. Given the complicated medical histories of patients and relatively high rate of postoperative infection/reaction (12.2%), GCF closure is not a benign, “uncomplicated” procedure. Further information describing factors determining which patients develop GCF requiring closure is needed.

Focus on pediatric intentional trauma.

BACKGROUND: Based on our previous study, pediatric intentional trauma injuries with Injury Severity Scores (ISS) ≥12 were more commonly observed in the urban than the rural setting (15.2% vs. 5.5%) in Alberta from 1996 to 2006. We wish to understand differences between urban and rural pediatric intentional trauma to plan for prevention and supportive strategies. METHODS: Data were extracted from the Alberta Trauma Registry on pediatric patients (0–17 years) with ISS ≥12, treated from 1996 to 2010 at the Stollery Childrens Hospital. Statistical analysis was made comparing urban versus rural groups using t test and &khgr;2 with p < 0.05 considered significant. RESULTS: There were 170 pediatric patients who suffered intentional injury (urban = 58.3%; rural = 41.8%; not significant), with a majority of males (72.4%). Two groups were predominant: the very young (<1 year) at 17.1% of all injuries and the teens (≥15 years) at 54.1%. The cause of intent injury was child abuse (31.2%), assault with blunt object (24.6%), assault with a sharp object (22.9%), and suicide (18.2%). The mean ISS was 22.9 ± 7.8 standard deviation. Tragically, 29 patients (17.1%) died. There were no differences between urban and rural pediatric trauma in terms of age, gender, cause of injury, ISS, survival, length of stay, pediatric intensive care unit length of stay, number of operations needed, or alcohol. CONCLUSION: An important pattern of intentional injuries can be seen where preventative efforts can be strengthened regardless of urban or rural area: the very young as shaken baby cases and the teens, who unfortunately, accounted for the majority of suicidal attempts. LEVEL OF EVIDENCE: II.

Urban vs rural pediatric trauma in Alberta: where can we focus on prevention?

PURPOSE Understanding differences between rural and urban pediatric trauma is important in establishing preventative strategies specific to each setting. METHODS Data were extracted from a Provincial Pediatric Trauma Registry on pediatric patients (0-17 years) with Injury Severity Scores (ISS) 12 or more, treated from 1996 to 2006 at 5 major trauma centers in the province. Urban and rural patients were compared with respect to demographic data, as well as injury type and severity. Statistical analysis was made using SPSS software (SPSS Inc, Chicago, Ill) by chi(2), Fishers Exact test, or t test with P < .05 considered significant. RESULTS Of n = 2660, 63.3% rural patients predominate; mean ISS was 22.5. However, rural patients had more severe injuries (ISS, 23.2 vs 21.8; P < .0001). Blunt trauma was the most common mechanism overall (urban, 89.6%; rural, 93.2%), with most being motor vehicle accidents (MVAs). Significantly, more penetrating trauma occurred in the urban setting (5.4% vs 2.6%; P < .0001). Intent injuries were more common in the urban setting (15.2% vs 5.5%). Of the patients, 89.2% survived the trauma. However, urban patients had a higher rate of death than rural ones (13.0% vs 10.5%; P < .05). CONCLUSION Despite the finding that rural patients sustained more severe injuries, overall survival was actually better when compared with urban patients. Most injuries were blunt trauma, suggesting road safety should be the main target in prevention strategies. Intent injuries were much higher in the urban group, thus, a need to target violence in urban prevention strategies.

Serious Impact of Handlebar Injuries

Background. Injuries from bicycles is a leading cause of trauma in children. We sought to investigate the epidemiology of bicycle handlebar injuries. Methods. A retrospective analysis of bicycle trauma treated at our institution was preformed. Results. A total of 462 children younger than 17 years had bicycle trauma. Abdominal handlebar injuries, representing 9% of bicycle injuries, contributed to 19% of all internal organ injuries, and 45.4% of solid, 87.5% of hollow, 66.6% of vascular or lymphatic, and 100% of pancreatic injuries. Handlebar injuries were 10 times more likely to cause severe injury, yet more than half of the children were misdiagnosed at their initial presentation. Delayed diagnosis and longer hospital stays were observed in handlebar injuries to the abdomen. Conclusion. Physicians should be aware of the serious impact of bicycle handlebar injury to the abdomen. The mechanism alone should raise the suspicion of internal organ injury, and timely imaging and surgical consultation.

Use of Paralysis in Silo-Assisted Closure of Gastroschisis

OBJECTIVE To examine the association between pre-closure neuromuscular paralysis and time to final surgical closure for infants with gastroschisis undergoing silo reduction. STUDY DESIGN This study was an exploratory review of observational variables obtained from the Canadian Pediatric Surgery Network database. The focus was on the subset of infants with gastroschisis undergoing silo reduction between May 2005 and March 2009. Of the 186 infants, paralysis use could be ascertained for 167 infants (79 received pre-closure paralysis and 88 received none). Groups were compared by using statistical tests, with relationships explored using regression analysis. RESULTS Infants receiving paralysis took longer to achieve closure by an average of 3 days (8 versus 5 days; P < .001) and had greater mean number of ventilation days (12 versus 7 days; P < .001). The relationship between paralysis and days to closure remained after adjusting for other variables. CONCLUSIONS In infants with gastroschisis undergoing silo reduction, use of paralysis was associated with longer time to closure. Pre-closure paralysis should be carefully weighed in this population.

The impact of fatal pediatric trauma on aboriginal children

BACKGROUND/PURPOSE Injuries are the leading cause of death in young people. Our aim is to examine the differences between aboriginal and non-aboriginal pediatric trauma mortality as a means to focus on prevention strategies. METHODS The records for all traumatic pediatric (0-18 years) deaths between 1996 and 2010 were reviewed from the regional Medical Examiners office. RESULTS The majority of the total 932 pediatric deaths were the result of non-intentional injuries (640) followed by suicide (195), homicide (65), child abuse (15), and undetermined (17). Despite being only 3.3% of the provincial population, Aboriginals represented 30.9% of pediatric trauma fatalities. Aboriginal fatalities occurred most commonly in the home, with males and females equally affected. Road related events were the main causes of injury overall. Up to three-quarters of Aboriginal children who died in a non-pedestrian road related event did not wear an indicated protective device. Pedestrian deaths were over-represented in Aboriginal children. The second most common cause of death was suicide for both non-Aboriginal and Aboriginal children. Almost half of all of the suicides were Aboriginal. Homicide and child abuse had similar proportions for both non-Aboriginal and Aboriginal children. CONCLUSION Pediatric Aboriginal injury prevention should be a priority and tailored for Aboriginal communities.

The Process of Treating Pediatric Appendicitis

Background. A large service and distant geographical area can make the process of diagnosing and treating appendicitis a challenge. Methods. Hospital records of children treated for appendicitis between 2007 and 2009 were retrospectively analyzed, including time from emergency (ER) to operating room (OR), diagnostic imaging (DI) utilization, preoperative antibiotic usage, operating time, length of stay (LOS), and perforation rate. Results. The perforation rate was 34%, with longer LOS. Transfer time to the children’s hospital between ER inside and outside the city was not different. ER to OR time was significantly shorter for patients assessed at the children’s hospital directly. Ultrasound remained the most used DI modality (55%). Preoperative antibiotics were only fully administered in 42% of the cases. Conclusion. A clinical pathway for pediatric appendicitis may address the challenges of the process of pre-ER, ER to OR, and OR care to maintain an acceptable perforation rate.

Pediatric Fundoplications: Too Much of a Good Thing?

Children with gastroesophageal reflux disease (GERD) refractory to medical treatment may benefit from a fundoplication. Unfortunately, postoperative complications are not uncommon and may result in failure of the fundoplication in up to 25% to 40% of all cases. Many children respond positively to proton pump inhibitors, and surgery may be associated with a failure rate and complications. On closer inspection, the benefit of surgery for GERD, in children, is debated. For pediatric patients, there have been no prospective randomized trials comparing fundoplication with proton pump inhibitors. In addition, there have been no prospective randomized control trials evaluating open versus laparoscopic fundoplications in children. However, in the adult population, there have been several prospective trials including the Nordic Gord study group, a randomized clinical trial comparing proton pump inhibitors with surgical therapy for reflux esophagitis, showing that both treatment arms after 7 years (antireflux surgery or omeprazole groups) were equivalent for treating GERD. Despite surgery being more effective in controlling overall disease symptoms, surgery did have specific postfundoplication complaints that remained a problem. Similarly, another prospective trial of laparoscopic Nissen fundoplication versus proton pump inhibitor therapy for GERD at 7-year follow-up found that both optimal proton pump inhibitor therapy and laparoscopic Nissen fundoplication were effective treatment for GERD. The difference was that surgery did add additional benefit for those who had only partial symptom relief while on proton pump inhibitors. The Lotus trial from Europe, comparing the laparoscopic antireflux surgery with esomeprazole in the management of patients with GERD, shows, at the 3-year interim analysis, that both laparoscopic fundoplication and continuous esomeprazole therapy are similarly effective and well-tolerated therapeutic strategies, providing effective control of GERD. Thus, it appears, in adult literature, that proton pump inhibitors are equivalent to fundoplication in the randomized control trials in a prospective fashion. Unfortunately, for children we have no such trials. Perhaps we can rely on the adult literature and look back at our own children’s hospital series to evaluate truly the effectiveness of fundoplication over the years and see if we need to have a paradigm shift in our way of evaluating for GERD as well as offering possible management therapies that provide the most effective solution for some of these complex children with GERD. We wanted to review at our institution the evolution of evaluating children with GERD, their treatment, and their outcomes with an emphasis on the changing views as new evidence builds throughout the years for GERD outcomes. The purpose of this study is thus to elucidate the outcomes of fundoplication including identification of risk factors for abdominal reoperations at our institution. Other articles have looked at the outcomes of fundoplications as a need for reoperation with a redo fundoplication. However, we feel that the redo fundoplication only tells a portion of the entire story, and thus, we wanted to look at all surgical readmissions requiring abdominal surgery for children having had a fundoplication.