Richard J. Scriven

Diagnosis and treatment of urethral prolapse in children

OBJECTIVES To review published reports on urethral prolapse in the pediatric population, with a focus on diagnosis and management, and to do a retrospective review of 20 cases of urethral prolapse at an urban hospital. METHODS A retrospective chart review of 20 consecutive cases of urethral prolapse in the pediatric population at Kings County Hospital was done. A review of the published reports on urethral prolapse from 1937 to the present was included in this study. RESULTS Twenty patients with urethral prolapse were treated at Kings County Hospital during a 10-year period. Patients were identified by perineal bleeding and diagnosed by physical examination. All patients were successfully treated by excision of the prolapsed urethral mucosa and suturing of the remaining mucosa to the vestibule. CONCLUSIONS Urethral prolapse is an uncommon entity that occurs primarily in prepubertal black girls. Patients may be successfully treated by excision of the prolapsed mucosa and suturing of the proximal urethra to the vestibule.

Pediatric venous thromboembolism in relation to adults

OBJECTIVE This review was performed to analyze the current knowledge and controversies in the pathophysiology, diagnosis, treatment, and outcomes of pediatric venous thromboembolism (VTE) compared with adults. METHODS Searches of the MEDLINE database and manual searches of the references of selected articles were performed to select reports for their relevance and quality of information on the similarities and differences in pathophysiology, diagnosis, and treatment of VTE in children and adults. RESULTS Symptomatic VTE incidence is reported at a rate of 0.07 in every 10,000 children, which is significantly lower than the rate in adults. Pulmonary emboli in adolescents are rarely fatal, unlike in adults. VTE recurrence is also much lower in children. Young age has been shown to be protective of VTE, whereas central venous catheters are very important in pediatric venous thrombosis. The incidence of postthrombotic syndrome varies from 20% to 65%, with mild symptoms in most children. Cerebral and visceral vein thrombosis may lead to severe morbidity and death. Some factors of thrombophilia have a significant effect in the pediatric population; however, its overall significance is controversial. Most data on VTE treatment are extrapolated from studies in adults. Children with acute VTE should be treated with anticoagulation therapy. Treatment duration depends on the nature of the thrombosis and previous VTE events. CONCLUSIONS There is a paucity of prospective randomized studies with data determining not only the effect of VTE but also the treatment options in children. Thrombophilia is a risk factor for pediatric VTE, but its significance has not been thoroughly investigated. Guidelines specific to children for antithrombotic therapy, prophylaxis, and optimal duration need re-evaluation and support by strong evidence.

Ventilator-associated pneumonia in pediatric trauma patients.

Background: Ventilator-associated pneumonia (VAP) is a significant cause of secondary morbidity and mortality in adult trauma patients. No study has characterized VAP in pediatric trauma patients. We determined the rates of and potential risk factors for VAP in pediatric trauma patients. Methods: A countywide trauma registry identified all pediatric trauma patients with potential VAP treated at a Regional Trauma Center. After a structured chart review, descriptive statistics were used to characterize the population. Results: One hundred fifty-eight trauma patients younger than 16 years requiring intubation and mechanical ventilation were identified in 3388 pediatric trauma admissions from the period 1995-2006. Drownings and poisonings were excluded. The registry identified 14 potential VAPs, of which, on detailed review, 7 were true cases. The VAP rate for pediatric trauma patients was 0.2% overall or 4.4% of those mechanically ventilated. In addition, ventilator days were available in the registry from 2003 forward and the rate in ventilator days was found to be 13.83/1000. Although higher than the overall pediatric intensive care unit VAP rate (5.93/1000 ventilator days), the pediatric trauma VAP rate was substantially lower than the VAP rate in adult trauma patients (58.25/1000 ventilator days). On chart review, six of the seven patients were male and older than 10 years (mean age, 11.9 years). All seven patients with VAP were blunt trauma victims with head injury (mean initial Glasgow Coma Score, 5.6) with Injury Severity Scores over 25 (mean, 32.1). Pulmonary contusion was present in four of the seven. Although the in-hospital mortality rate of ventilated pediatric trauma patients was 17.1%, there was no mortality in those with VAP. Conclusions: The rate of VAP in pediatric trauma patients is substantially lower than in similar adults. Age older than 10 years, blunt trauma, head injury, and Injury Severity Score >25 may be risk factors. VAP is not associated with increased mortality in pediatric trauma patients.

Simulated laparoscopic sigmoidectomy training: responsiveness of surgery residents.

PURPOSE: This study aimed to evaluate the responsiveness of surgery residents to simulated laparoscopic sigmoidectomy training. METHODS: Residents underwent simulated laparoscopic sigmoidectomy training for previously tattooed sigmoid cancer with use of disposable abdominal trays in a hybrid simulator to perform a seven-step standardized technique. After baseline testing and training, residents were tested with predetermined proficiency criteria. Content validity was defined as the extent to which outcome measures departed from clinical reality. Content-valid measures of trays were evaluated by two blinded raters. Simulator-generated metrics included path length and smoothness of instrument movements. Responsiveness was defined as change in performance over time and was assessed by comparing baseline testing with unmentored final testing. RESULTS: For eight weeks, eight postgraduate year 3/4 residents performed 34 resections. Overall operating time (67 vs. 37 min; P = 0.005), flexure (10 vs. 5 min; P = 0.005), inferior mesenteric vessel (8 vs. 5 min; P = 0.04), and ureter (7 vs. 1 min; P = 0.003) times improved significantly. Content-valid measures from trays remained unchanged. Path length (27,155.2 mm) and smoothness (3,575.5 cm/s3) of instrument movement remained unchanged. There were two bowel perforations and 19 anastomotic leaks. Leak rate decreased from 87% to 12.5%. Strong correlation was found between path length and smoothness of instrument movements (r = 0.9; P < 0.001). There was no correlation between simulator-generated metrics and content-valid outcome measures. Interrater reliability was 1.0 for all measures except anastomotic leak (k = 0.56). There was a linear relationship between residents’ clinical advanced laparoscopic case volume and responsiveness (r = −0.7; P = 0.04). CONCLUSIONS: Simulated laparoscopic sigmoidectomy training affected responsiveness in surgery residents with significantly decreased operating time and anastomotic leak rate.

The vomiting neonate: a review of the ACR appropriateness criteria and ultrasound's role in the workup of such patients.

Ultrasound (US) plays a central role in the diagnostic imaging workup for infantile vomiting. This paper reviews the major causes of vomiting in the first months of life and the use of US and other modalities for their imaging assessment. The differential diagnostic possibilities are reviewed by examining 3 clinical scenarios of bilious vomiting during the first days of life, nonbilious vomiting since birth, and projectile vomiting first occurring after several weeks of life. These are the 3 scenarios that were used for the American College of Radiology (ACR) Appropriateness Criteria for Vomiting in Infants up to 3 Months of Age.

Natural history of deep vein thrombosis in children

Objective To determine the natural history of deep vein thrombosis in children presented with a first episode in the lower extremity veins. Methods Children with objective diagnosis of acute deep vein thrombosis were followed up with ultrasound and clinical examination. Risk factors and clinical presentation were prospectively collected. The prevalence of recurrent deep vein thrombosis and the development of signs and symptoms of chronic venous disease were recorded. Results There were 27 children, 15 males and 12 females, with acute deep vein thrombosis, with a mean age of 4 years, range 0.1–16 years. The median follow-up was 23 months, range 8–62 months. The location of thrombosis involved the iliac and common femoral vein in 18 patients and the femoral and popliteal veins in 9. Only one vein was affected in 7 children, two veins in 14 and more than two veins in 6. Recurrent deep vein thrombosis occurred in two patients, while no patient had a clinically significant pulmonary embolism. Signs and symptoms of chronic venous disease were present at last follow-up in 11 patients. There were nine patients with vein collaterals, but no patient developed varicose veins. Reflux was found in 18 veins of 11 patients. Failure of recanalization was seen in 7 patients and partial recanalization in 11. Iliofemoral thrombosis (p = 0.012) and failure to recanalize (p = 0.036) increased significantly the risk for developing signs and symptoms. Conclusions Children with acute proximal deep vein thrombosis develop mild chronic venous disease signs and symptoms at mid-term follow-up and are closely related with iliofemoral thrombosis and failure to recanalization.

Bronchial anomalies in VACTERL association.

VACTERL association is an acronym made of associated defects including vertebral anomalies, anal atresia, cardiac, tracheal–esophageal fistula, and renal/radial limb anomalies. Tracheal bronchus is a condition characterized by ectopic location of the right upper lobe bronchus at the mid to distal trachea. This condition is associated with congenital anomalies and has been reported in one previous case of VACTERL. We report another infant with VACTERL presenting with respiratory complications due to presence of tracheal bronchus. She also had a narrowed segment of her right main stem bronchus. Pediatr Pulmonol. 2008; 43:930–932.

Simulated colonoscopy training using a low‐cost physical model improves responsiveness of surgery interns

Surgery residents are required to become proficient in colonoscopy before completing training. The aim of this study was to evaluate the responsiveness of surgery interns to simulated colonoscopy training.

Single-shot thoracic epidural: an aid to earlier discharge for pediatric laparoscopic cholecystectomy.

SIR—Laparoscopic surgery has become the standard of care for many operations and has been associated with decreased pain, shortened hospital stays, and faster recovery (1). Ambulatory laparoscopic cholecystectomy has become an accepted practice in adults, but is not yet widely practiced in pediatric medicine. Two recent studies have demonstrated that the use of appropriate clinical pathways, utilizing regional anesthesia, can allow for safe same-day discharge (SDD) following laparoscopic cholecystectomy in pediatric patients (2,3). Epidural anesthesia, for pain management, has been used effectively in adult laparoscopic cholecystectomy but currently there are limited data for its use in pediatric laparoscopic cholecystectomy. We retrospectively studied elective pediatric laparoscopic cholecystectomies from 2007 to 2012. All patients were offered a single shot thoracic epidural (SSTE) vs narcotics for pain control and the option of SDD. SSTE use was based on parental preference. Our purpose was to better understand if SSTE for pediatric laparoscopic cholecystectomies could reduce length of stay, facilitate SDD, and improve postoperative pain control. Statistical analysis was conducted using SAS Software (version 9.3, SAS Institute Inc., Cary, NC, USA) and JMP (Version 11. SAS Institute Inc., Cary, NC, 1989-2007). All statistical tests were two-tailed tests. We identified 26 patients receiving SSTE and compared age-matched controls that only received standard intravenous opioid analgesia. SSTE was administered at T6–T8 spinal level after induction of general anesthesia in a lateral position with a standard loss of resistance technique to confirm placement. Approximately, 7–10 ml of 0.25% bupivicaine clonidine (1 lg/kg) was used based on the anesthesiologist assessment. No epidural catheters were placed. All analgesic dosing, for purpose of analysis, were reported as morphine equivalents. We found that SDD was more common in SSTE patients (65% vs 35%, P = 0.027) along with decreased length of stay (14.3 vs 22 h, P = 0.03) when compared to age-matched controls receiving only standard intravenous opioid analgesia. Intraoperative and postoperative intravenous analgesic use was greater in the non-SSTE group (both total intraoperative morphine equivalents [27 vs 9 mg, P = 0.001], and weight-based morphine equivalents [0.39 vs 0.14 mg kg , P < 0.001]). There was no significant difference in postoperative nausea or postoperative opiate use within 2 h of surgery between the two groups. There was a decreased time to first PO intake in the SSTE compared to the non-SSTE. There were no reported complications related to SSTE (Table 1). Our goal was to show that SDD for pediatric laparoscopic cholecystectomy can be safely achieved in adolescents. SSTE showed decreased intraoperative opiate usage suggesting improved pain control and a significant increase in successful SDD. With proper patient selection, SSTE can be used to aid SDD. There are inherent limitations due to the small population and retrospective study. This illustrates the need for future prospective studies that could be directed at minimizing the biases of small retrospective studies and further delineating the role of regional anesthetic