Julia Pemberton

Sclerotherapy for lymphatic malformations in children: a scoping review

PURPOSE This scoping review assesses the literature and summarizes the current evidence on sclerotherapy for the treatment of lymphatic malformations in pediatric patients. METHODS A comprehensive search of published and unpublished literature was conducted using multiple databases. Title, abstract, and full-text screening was conducted by 2 independent clinicians. All discrepancies were resolved during consensus meetings. RESULTS A total of 182 articles were retrieved. Forty-four articles were removed as duplicates, and 11 articles were added after reviewing prominent studies. After full-text abstraction, 44 articles and 2 conference proceedings (N = 882 patients) were included in the final results. Twelve articles were classified as level II and 34 articles as level IV evidence. Picibanil (OK-432) was the primary agent used in most included studies. Postinjection symptoms with OK-432 were primarily fever, swelling, and erythema at the site. Life-threatening complications were uncommon and involved postinjection swelling of cervical lesions causing airway compromise. CONCLUSIONS The literature regarding sclerotherapy for lymphatic malformations is of a low level of evidence and suffers from a lack of standardization. Randomized clinical trials focused on OK-432, bleomycin, or alcoholic solution of zein; standardized dosing protocols; and consistent and reliable outcome reporting will be necessary for further development of treatment guidelines.

Effect of preoperative hormonal stimulation on postoperative complication rates after proximal hypospadias repair: a systematic review.

PURPOSE We conducted a systematic review and meta-analysis to summarize the effect of preoperative hormonal stimulation on complication rates following proximal hypospadias repair. MATERIALS AND METHODS We comprehensively searched the published and unpublished literature between 1990 and 2010. Eligibility criteria were applied. Title, abstract and full text screening was carried out by 2 independent authors, and discrepancies were resolved by consensus. Heterogeneity between studies was tested using Cochran chi-square Q test and quantified by calculating I(2). Quality appraisal of included studies was performed. Meta-analysis was conducted when appropriate using a random effects model. RESULTS Our search yielded 288 citations, of which 11 (622 patients) met inclusion criteria and were incorporated into the systematic review. Most series were retrospective observational studies of moderate or low methodological quality. Of the patients 45% underwent administration of preoperative hormonal stimulation, with intramuscular testosterone being the most commonly prescribed formulation. Four studies addressed postoperative complication rate stratified by preoperative hormonal stimulation use and were included in a meta-analysis. The odds ratio for a complication occurring with preoperative hormonal stimulation use was 1.67 (CI 0.96-2.91, p = 0.07, I(2) = 0%). No persistent side effects due to preoperative hormonal stimulation were reported. CONCLUSIONS To our knowledge this is the only systematic review and meta-analysis thus far that has critically assessed the effect of preoperative hormonal stimulation on operative outcomes after hypospadias repair. The published literature is of low quality and lacks standardized reporting of important patient and surgical details. The effect of preoperative hormonal stimulation on operative outcomes after hypospadias repair remains unclear and requires further investigation.

Methodological Concerns and Quality Appraisal of Contemporary Systematic Reviews and Meta-Analyses in Pediatric Urology

PURPOSE The usefulness of systematic reviews and meta-analyses in influencing clinical practice depends on their quality. We sought to analyze the quality of published systematic reviews and meta-analyses in pediatric urology. MATERIALS AND METHODS We searched PubMed (MEDLINE) and Embase for all systematic reviews and meta-analyses published in the top 5 pediatric urology journals between January 2000 and November 2009. Two reviewers independently selected articles for full text review. Scientific methodological quality was evaluated using the Assessment of Multiple Systematic Reviews 11-item tool. RESULTS Of 267 initial results 220 articles were excluded because they were surveys, case reports or narrative reviews. Full text evaluation of the remaining 47 articles further excluded 32 series of exclusively adult patients, leaving 15 for final analysis. Seven articles (47%) were published in 2009 (p <0.01). Only 1 review (7%) described a full search strategy and 3 (20%) allowed inclusion of non-English studies. In 8 reviews (53%) selection of studies was performed by 2 reviewers. Five systematic reviews (33%) described some form of quality assessment. Only 5 reviews (33%) described assessment of publication bias, while 8 (53%) checked for heterogeneity among studies. According to AMSTAR criteria, 7 systematic reviews (47%) were considered of less than fair methodological quality, 5 (33%) fair to good quality and 3 (20%) good quality. CONCLUSIONS Despite a recent increase in the number of systematic reviews and meta-analyses published in pediatric urology journals, almost half of these reviews lack good scientific quality, raising concerns about their role in influencing clinical practice. Efforts should be made to improve the methodological quality of systematic reviews and meta-analyses in the pediatric urology literature.

Nonleg Venous Thrombosis in Critically Ill Adults: A Nested Prospective Cohort Study

IMPORTANCE Critically ill patients are at risk of venous thrombosis, and therefore guidelines recommend daily thromboprophylaxis. Deep vein thrombosis (DVT) commonly occurs in the lower extremities but can occur in other sites including the head and neck, trunk, and upper extremities. The risk of nonleg deep venous thromboses (NLDVTs), predisposing factors, and the association between NLDVTs and pulmonary embolism (PE) or death are unclear. OBJECTIVE To describe the frequency, anatomical location, risk factors, management, and consequences of NLDVTs in a large cohort of medical-surgical critically ill adults. DESIGN, SETTING, AND PARTICIPANTS A nested prospective cohort study in the setting of secondary and tertiary care intensive care units (ICUs). The study population comprised 3746 patients, who were expected to remain in the ICU for at least 3 days and were enrolled in a randomized clinical trial of dalteparin vs standard heparin for thromboprophylaxis. MAIN OUTCOMES AND MEASURES The proportion of patients who had NLDVTs, the mean number per patient, and the anatomical location. We characterized NLDVTs as prevalent or incident (identified within 72 hours of ICU admission or thereafter) and whether they were catheter related or not. We used multivariable regression models to evaluate risk factors for NLDVT and to examine subsequent anticoagulant therapy, associated PE, and death. RESULTS Of 3746 trial patients, 84 (2.2%) developed 1 or more non-leg vein thromboses (superficial or deep, proximal or distal). Thromboses were more commonly incident (n = 75 [2.0%]) than prevalent (n = 9 [0.2%]) (P < .001) and more often deep (n = 67 [1.8%]) than superficial (n = 31 [0.8%]) (P < .001). Cancer was the only independent predictor of incident NLDVT (hazard ratio [HR], 2.22; 95% CI, 1.06-4.65). After adjusting for Acute Physiology and Chronic Health Evaluation (APACHE) II scores, personal or family history of venous thromboembolism, body mass index, vasopressor use, type of thromboprophylaxis, and presence of leg DVT, NLDVTs were associated with an increased risk of PE (HR, 11.83; 95% CI, 4.80-29.18). Nonleg DVTs were not associated with ICU mortality (HR, 1.09; 95% CI, 0.62-1.92) in a model adjusting for age, APACHE II, vasopressor use, mechanical ventilation, renal replacement therapy, and platelet count below 50 × 10(9)/L. CONCLUSIONS AND RELEVANCE Despite universal heparin thromboprophylaxis, nonleg thromboses are found in 2.2% of medical-surgical critically ill patients, primarily in deep veins and proximal veins. Patients who have a malignant condition may have a significantly higher risk of developing NLDVT, and patients with NLDVT, compared with those without, appeared to be at higher risk of PE but not higher risk of death. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00182143.

Parent health literacy and satisfaction with plain language education materials in a pediatric surgery outpatient clinic: a pilot study

BACKGROUND Although significant, the issue of health literacy (HL) among parents attending pediatric surgery outpatient clinics has received little attention. PURPOSE The objectives of this study are to determine the HL skills of parents attending the pediatric surgery outpatient clinic at McMaster Childrens Hospital and to describe parent satisfaction with plain language materials. METHODS This cross-sectional study was conducted at the pediatric surgery outpatient clinic at McMaster Childrens Hospital. Using convenience sampling for 4 months, parents were recruited and interviewed regarding their demographic status. The Newest Vital Sign tool was used to assess HL. Feedback on the plain language education material was received. RESULTS Seventy-nine individuals were recruited, with a recruitment rate of 62%. Seventy-one percent had adequate HL. English as a first language and Canada as the place of birth were significantly correlated with adequate HL (r = 0.367, P < .001; r = 0.259, P < .05). Parents reported satisfaction with the plain language material, regardless of their HL level. CONCLUSION Twenty-nine percent of parents showed inadequate HL, likely an underestimate owing to study limitations. Parents expressed satisfaction with the plain language material, emphasizing the need for clear, effective communication with patients and families. Future directions include evaluating staff knowledge of a universal precautions approach to health communication and the accessibility of plain language materials.

Pilot Randomized, Placebo Controlled Trial to Investigate the Effect of Antibiotic Prophylaxis on the Rate of Urinary Tract Infection in Infants with Prenatal Hydronephrosis

PURPOSE We determined the feasibility of a clinical trial of continuous antibiotic prophylaxis to prevent urinary tract infections in children with prenatal hydronephrosis. MATERIALS AND METHODS We piloted a blinded, randomized, placebo controlled study of the urinary tract infection rate in infants with grades III-IV prenatal hydronephrosis at our institution between August 2010 and June 2013. Study exclusion criteria were grades I/II prenatal hydronephrosis, vesicoureteral reflux, duplication anomalies and age at randomization greater than 5 months. Prospectively collected feasibility data were obtained on eligibility, enrollment status, adherence to followup schedule, and medication and protocol compliance. RESULTS Of 301 screened patients 220 (73.1%) were ineligible for analysis and 2 (1%) missed the randomization window. Of the remaining 81 (26.9%) eligible patients 46 were enrolled (56.8%), 29 refused (39.5%) and consent is pending in 1 (1.2%). Reasons for declining participation included parental preference for or against continuous antibiotic prophylaxis and a lack of interest in participating in clinical research. Of 46 enrolled patients 29 (63%) completed the trial, 12 (26.1%) are still in followup and 5 (10.9%) withdrew. Of the 314 medication logs dispensed 263 were returned for a 95% mean medication compliance rate. CONCLUSIONS Based on the results of our pilot study a realistic recruitment rate for this group of patients is established, making a definitive trial of this topic feasible. However, due to the low number of eligible patients multicenter collaboration is critical to address the effect of continuous antibiotic prophylaxis on the urinary tract infection rate in this population. After study enrollment high medication and followup compliance can be expected.

Mortality of pediatric surgical conditions in low and middle income countries in Africa

BACKGROUND There are ongoing efforts to improve the quality of surgical care for children in low and middle-income countries (LMICs) in Africa. The purpose of this study was to review the recent literature and estimate the mortality associated with pediatric surgical conditions in this setting. METHODS We completed a comprehensive search for studies that: (1) reported outcomes associated with pediatric surgical conditions; (2) were conducted in LMICs in Africa; and (3) were published between 2007 and 2012. Abstract screening, full-text review, and data abstraction were completed in duplicate. Mortality rates were pooled using a random effects model. RESULTS Out of 2085 abstracts, 292 were selected for textual review, and 107 underwent complete data abstraction. Only 74 (68%) of these reported mortality explicitly. The highest pooled mortality rates were seen with esophageal atresia (72%), midgut volvulus (36%), and jejunoileal atresia (35%). Pooled mortality was 17% for congenital conditions and 9% for acquired disease. The overall mortality rate for all conditions was 12%. CONCLUSIONS Mortality following pediatric surgical conditions in LMICs in Africa remains high, especially for congenital conditions in neonates. Future studies should report mortality explicitly and provide accurate follow-up data whenever possible.

Evaluating Practice Patterns in Postnatal Management of Antenatal Hydronephrosis: A National Survey of Canadian Pediatric Urologists and Nephrologists

OBJECTIVE To ascertain practice patterns of prescribing continuous antibiotic prophylaxis (CAP) and obtaining a voiding cystourethrogram for infants with antenatal hydronephrosis (AHN) by pediatric nephrologists and urologists across Canada. METHODS A previously piloted online survey was distributed to members of the Canadian pediatric nephrology and urology associations. Summarized confidential responses were stratified by specialty, AHN grade, and laterality. RESULTS A total of 88 of 139 responses were received (response rate, 63.3%; 95% confidence interval, 55.0%-71.0%): 46 nephrologists, 39 urologists, and 3 undisclosed. Only 17 of 88 (19.32%; 95% confidence interval, 12.4%-28.8%) reported following standardized AHN protocols. Concern surrounding the development of urinary tract infections was the main deciding factor for prescribing CAP (nephrology, 65.4%; urology, 71.4%). Almost a third of nephrologists (29.6%) recommend CAP for bilateral low-grade AHN compared with 11.4% of urologists (P = .02); in contrast, 73% of nephrologists and 38.2% of urologists (P = .02) offer CAP in the presence of isolated high-grade AHN. In regards to indications for voiding cystourethrogram, 31% of pediatric nephrologists would recommend this test for patients with unilateral low-grade AHN compared with 7.7% of urologists (P < .01), although almost all nephrologists (96.6%) and 69.2% of urologists (P = .02) would obtain this test for patients with unilateral high-grade isolated AHN. CONCLUSION Our results show important practice variability between pediatric nephrologists and urologists in the management of children with AHN, which are partially explained by laterality and degree of dilation. This survey reflects the lack of treatment guidelines and supports efforts to obtain high-level evidence to develop management protocols for this common condition.

Post-operative management of esophageal atresia–tracheoesophageal fistula and gastroesophageal reflux: A Canadian Association of Pediatric Surgeons annual meeting survey

BACKGROUND Esophageal atresia (EA), with or without tracheoesophageal fistula (TEF), is commonly associated with gastroesophageal reflux (GER) after surgical repair. One risk factor for anastomotic stricture is post-operative GER. This survey assessed practice patterns among attendees at the Canadian Association of Pediatric Surgeons (CAPS) annual meeting with respect to management of GER post EA-TEF repair. METHODS A pre-piloted survey was handed out and collected at the 2012 CAPS annual meeting. Data were entered and coded, and descriptive statistics were calculated. RESULTS We distributed 70 surveys, and 57 (81.4%) surveys were returned. On average, the incidence of EA-TEF is 8-10 cases per institution, per year. Anti-reflux medication is started immediately post-operatively in 74% of patients at institution of feeds (11%), or if symptoms of reflux develop (14%). Proton pump inhibitors and H2-receptor antagonists are used in approximately equal proportion. Patients are typically kept on anti-reflux medication for 3-6 months (37%) or 6-12 months (35%). CONCLUSIONS Most CAPS attendees treat postoperative GER prophylactically. However, there is no consistency in management strategy regarding which anti-reflux agent to use or for how long. A multi-centered study is required to establish a standardized protocol for the post-operative management of EA-TEF to prevent reflux and its effect on anastomotic strictures.

Gastrostomy matters—The impact of pediatric surgery on caregiver quality of life

INTRODUCTION While pediatric surgeons consider gastrostomy to be routine treatment for children with feeding difficulties, the impact on the family is not fully understood. This study focuses on Quality of Life (QoL) of parents of children who require a gastrostomy tube. METHODS A prospective repeated measures cohort study was conducted between November 2009 and March 2012. Demographic, surgical, and QoL data were collected at Baseline, 2 weeks, 3, 6, 9, and 12 months after surgery. At each time-point parents completed three QoL measures: Short Form 36v2 (SF-36), Caregiver Strain Index (CSI), and Parent Experience of Childhood Illness (PECI). RESULTS A total of 31 caregivers were recruited with a mean age of 32.6 years (SD=7.0). Overall, a 38% increased risk of depression was seen in the SF-36 when compared to population norms, and a moderate effect was seen in mental health at 12 months (ES=0.56). The CSI demonstrated a decrease in caregiver burden (8.72 to 7.05, p=0.007, 95% CI (0.57-3.18)), while the PECI revealed a decrease in frequency of feelings of guilt, worry, sorrow, anger, and long term uncertainty over 12 months. CONCLUSION Gastrostomy not only improves the childs physical health, but also improves the mental health of the childs caregivers, especially at (or after) one year.