Lorraine I. Kelley-Quon

The vulnerable elders survey-13 predicts hospital complications and mortality in older adults with traumatic injury: a pilot study.

OBJECTIVES: To determine whether the Vulnerable Elders Survey (VES)‐13, a survey based on functional status that has been validated in uninjured older populations, will predict complications and mortality in injured older adults.

Outcomes and Costs of Surgical Treatments of Necrotizing Enterocolitis

BACKGROUND AND OBJECTIVES: Despite previous studies demonstrating no difference in mortality or morbidity, the various surgical approaches for necrotizing enterocolitis (NEC) in infants have not been evaluated economically. Our goal was to compare total in-hospital cost and mortality by using propensity score–matched infants treated with peritoneal drainage alone, peritoneal drainage followed by laparotomy, or laparotomy alone for surgical NEC. METHODS: Utilizing the California OSHPD Linked Birth File Dataset, 1375 infants with surgical NEC between 1999 and 2007 were retrospectively propensity score matched according to intervention type. Total in-hospital costs were converted from longitudinal patient charges. A multivariate mixed effects model compared adjusted costs and mortality between groups. RESULTS: Successful propensity score matching was performed with 699 infants (peritoneal drainage, n = 101; peritoneal drainage followed by laparotomy, n = 172; and laparotomy, n = 426). Average adjusted cost for peritoneal drainage followed by laparotomy was

Long-term Postinjury Functional Recovery: Outcomes of Geriatric Consultation

398 173 (95% confidence interval [CI]: 287 784–550 907), which was more than for peritoneal drainage (

Congenital malformations associated with assisted reproductive technology: a California statewide analysis.

276 076 [95% CI: 196 238–388 394]; P = .004) and similar to laparotomy (

Complications of Pediatric Cholecystectomy: Impact from Hospital Experience and Use of Cholangiography

341 911 [95% CI: 251 304–465 186]; P = .08). Adjusted mortality was highest after peritoneal drainage (56% [95% CI: 34–75]) versus peritoneal drainage followed by laparotomy (35% [95% CI: 19–56]; P = .01) and laparotomy (29% [95% CI: 19–56]; P < .001). Mortality for peritoneal drainage was similar to laparotomy. CONCLUSIONS: Propensity score–matched analysis of surgical NEC treatment found that peritoneal drainage followed by laparotomy was associated with decreased mortality compared with peritoneal drainage alone but at significantly increased costs.

Low-Dose Intravenous Soybean Oil Emulsion for Prevention of Cholestasis in Preterm Neonates

IMPORTANCE Functional recovery is an important outcome following injury. Functional impairment is persistent in the year following injury for older trauma patients. OBJECTIVE To measure the impact of routine geriatric consultation on functional outcomes in older trauma patients. DESIGN, SETTING, AND PARTICIPANTS In this pretest-posttest study, the pretest control group (n = 37) was retrospectively identified (December 2006-November 2007). The posttest geriatric consultation (GC) group (n = 85) was prospectively enrolled (December 2007-June 2010). We then followed up both groups for 1 year after enrollment. This study was conducted at an academic level 1 trauma center with adults 65 years of age and older admitted as an activated code trauma. INTERVENTION Routine GC. MAIN OUTCOMES AND MEASURES The Short Functional Status survey of 5 activities of daily living (ADLs) at hospital admission and 3, 6, and 12 months postinjury. RESULTS The unadjusted Short Functional Status score (GC group only) declined from 4.6 preinjury to 3.7 at 12 months postinjury, a decline of nearly 1 full ADL (P < .05). The ability to shop for personal items was the specific ADL more commonly retained by the GC group compared with the control group. The GC group had a better recovery of function in the year following injury than the GC group, controlling for age, sex, race/ethnicity, length of stay, comorbidity, injury severity, postdischarge rehabilitation, complication, and whether surgery was performed (P < .01), a difference of 0.67 ADL abilities retained by the GC group compared with the control group (95% CI, 0.06-1.4). CONCLUSIONS AND RELEVANCE Functional recovery for older adults following injury may be improved by GC. Early introduction of multidisciplinary care in geriatric trauma patients warrants further investigation.

Predictors of proctocolectomy in children with ulcerative colitis.

BACKGROUND Management of congenital malformations comprises a large part of pediatric surgical care. Despite increasing utilization of assisted reproductive technology (ART) and fertility-related services (FRS), associations with birth defects are poorly understood. METHODS Infants born after ART or FRS were identified from the California Linked Birth Cohort Dataset from 2006 to 2007 and compared to propensity matched infants conceived naturally. Factors associated with major congenital malformations were evaluated using Firth logistic regression. RESULTS With a cohort of 4,795 infants born after ART and 46,025 naturally conceived matched controls, major congenital malformations were identified in 3,463 infants. Malformations were increased for ART infants (9.0% vs. 6.6%, p<0.001). After adjusting for infant and maternal factors, ART infants exhibited increased odds of major malformations overall (OR 1.25, 95% CI 1.12-1.39), specifically defects of the eye (OR 1.81, 95% CI 1.04-3.16), head and neck (OR 1.37, 95% CI 1.00-1.86), heart (OR 1.41, 95% CI 1.22-1.64), and genitourinary system (OR 1.40, 95% CI 1.09-1.82). The likelihood of birth defects was increased for multiples (OR 1.35, 95% CI 1.18-1.54) and not singletons. Odds of congenital malformation after FRS alone (n=1,749) were non-significant. CONCLUSION ART contributes a significant risk of congenital malformation and may be more pronounced for multiples. Accurate counseling for parents considering ART and multidisciplinary coordination of care prior to delivery are warranted.

Postoperative complications and health care use in children undergoing surgery for ulcerative colitis

BACKGROUND Complications after cholecystectomy in children are poorly characterized. The aim of this study was to assess risk factors for major surgical complications for children undergoing cholecystectomy. STUDY DESIGN All children 4 to 18 years old with gallbladder disease who underwent cholecystectomy from 1999 to 2006 were identified from the California Patient Discharge Database. Patient, hospital, and surgical factors were analyzed using multivariate logistic regression analysis to identify factors predictive of bile duct injury (BDI) and postoperative ERCP. RESULTS A cohort of 6,931 children treated at 360 hospitals was evaluated. Most children underwent cholecystectomy at a non-childrens hospital (84%). Intraoperative cholangiogram (IOC) was performed in 2,053 (30%) children. Of 5,101 children tracked through the year after cholecystectomy, 153 (3%) required readmission for surgical complications. Bile duct injury occurred in 25 (0.36%) children, and postoperative ERCP was performed in 711 (10%) children. Older age (odds ratio = 0.80; 99% CI, 0.67-0.95) was associated with decreased risk of BDI. Increased hospital tendency for routine IOC use was associated with increased likelihood of BDI (odds ratio = 12.92; 99% CI, 1.31-127.15). Receiving surgical care at a childrens hospital was associated with a decreased likelihood of postoperative ERCP (odds ratio = 0.39; 99% CI, 0.23-0.66). As anticipated, choledocholithiasis, cholecystitis, IOC, and laparoscopic cholecystectomy were associated with increased risk of postoperative ERCP (p < 0.01). CONCLUSIONS Serious complications and readmissions from pediatric cholecystectomy are uncommon. Surgeons performing cholecystectomy in young children must have an elevated concern about BDI. Routine IOC or surgical volume might not be helpful in lowering BDI rates.

Hospital type as a metric for racial disparities in pediatric appendicitis.

BACKGROUND Premature infants depend on intravenous fat emulsions to supply essential fatty acids and calories. The dose of soybean-based intravenous fat emulsions (S-IFE) has been associated with parenteral nutrition (PN)-associated liver disease. This studys purpose was to determine if low-dose S-IFE is a safe and effective preventive strategy for cholestasis in preterm neonates. MATERIALS AND METHODS This is a multicenter randomized controlled trial in infants with a gestational age (GA) ≤29 weeks. Patients <48 hours of life were randomized to receive a low (1 g/kg/d) or control dose (approximately 3 g/kg/d) of S-IFE. The primary outcome was cholestasis, defined as a direct bilirubin ≥15% of the total bilirubin at 28 days of life (DOL) or full enteral feeds, whichever was later, after 14 days of PN. Secondary outcomes included growth, length of hospital stay, death, and major neonatal morbidities. RESULTS In total, 136 neonates (67 and 69 in the low and control groups, respectively) were enrolled. Baseline characteristics were similar for the 2 groups. When the low group was compared with the control group, there was no difference in the primary outcome (69% vs 63%; 95% confidence interval, -0.1 to 0.22; P = .45). While the low group received less S-IFE and total calories over time compared with the control group (P < .001 and P = .03, respectively), weight, length, and head circumference at 28 DOL, discharge, and over time were not different (P > .2 for all). CONCLUSION Compared with the control dose, low-dose S-IFE was not associated with a reduction in cholestasis or growth.

Does hospital transfer predict mortality in very low birth weight infants requiring surgery for necrotizing enterocolitis

Objectives: Few clinical predictors are associated with definitive proctocolectomy in children with ulcerative colitis (UC). The purpose of the present study was to identify clinical predictors associated with surgery in children with UC using a disease-specific database. Methods: Children diagnosed with UC at age <18 years were identified using the Pediatric Inflammatory Bowel Disease Consortium (PediIBDC) database. Demographic and clinical variables from January 1999 to November 2003 were extracted alongside incidence and surgical staging. Results: Review of the PediIBDC database identified 406 children with UC. Approximately half were girls (51%) with an average age at diagnosis of 10.6 ± 4.4 years in both boys and girls. Average follow-up was 6.8 (±4.0) years. Of the 57 (14%) who underwent surgery, median time to surgery was 3.8 (interquartile range 4.9) years after initial diagnosis. Children presenting with weight loss (hazard ratio [HR] 2.55, 99% confidence interval [CI] 1.21–5.35) or serum albumin <3.5 g/dL (HR 6.05, 99% CI 2.15–17.04) at time of diagnosis and children with a first-degree relative with UC (HR 1.81, 99% CI 1.25–2.61) required earlier surgical intervention. Furthermore, children treated with cyclosporine (HR 6.11, 99% CI 3.90–9.57) or tacrolimus (HR 3.66, 99% CI 1.60–8.39) also required earlier surgical management. Other symptoms, laboratory tests, and medical therapies were not predictive for need of surgery. Conclusion: Children with UC presenting with hypoalbuminemia, weight loss, a family history of UC, and those treated with calcineurin inhibitors frequently require restorative proctocolectomy for definitive treatment. Early identification and recognition of these factors should be used to shape treatment goals and initiate multidisciplinary care at the time of diagnosis.