Debunking Myths of Gender Informed Care: What Every Pediatric Surgeon Should Know.

As the transgender population in the United States grows, gender-affirming care is becoming increasingly relevant to the practice of pediatric surgery. Medical care for the transgender and gender diverse population is a politically charged topic with significant complexity and opportunities for clarification. It is important for providers to better understand this population's unique health and social needs. This review aims to debunk long-standing myths regarding gender-affirming care and highlight the current therapeutic and legislative landscapes within the scope of pediatric surgical practice. LEVEL OF EVIDENCE: IV.

Osseointegration reduces aseptic loosening of primary distal femoral implants in pediatric and adolescent osteosarcoma patients: a retrospective clinical and radiographic study.

AIM: The challenge of distal femoral replacement (DFR) longevity remains a priority for orthopaedic oncologists as the overall survival and activity level of young patients with osteosarcoma continues to improve. This study hypothesized that increased extracortical osseointegration at the bone-implant shoulder (i.e., where the metal implant shaft abuts the femur) will improve stress transfer adjacent to the implant, as evidenced by reduced cortical bone loss, radiolucent line progression and implant failure in young patients (< 20 years) following DFR surgery. METHODS: Twenty-nine patients of mean age 13.09 ± 0.56 years received a primary DFR. The clinical outcome of 11 CPS®, 10 GMRS®, 5 Stanmore® and 3 Repiphysis® implants was evaluated over a mean follow-up period of 4.25 ± 0.55 years. The osseous response to a bone-implant shoulder composed of either a hydroxyapatite-coated grooved ingrowth collar (Stanmore®), a porous metal coating (GMRS®) or a polished metal surface (Repiphysis®) was quantified radiographically. RESULTS: All (100.0%) of the Stanmore® implants, 90.0% of GMRS®, 81.8% of CPS® and 33.3% of the Repiphysis® implants survived. Significantly increased extracortical bone and osseointegration were measured adjacent to the Stanmore® bone-implant shoulder when compared with the GMRS® and Repiphysis® implants (p < 0.0001 in both cases). Significantly decreased cortical loss was identified in the Stanmore® group (p = 0.005, GMRS® and p < 0.0001, Repiphysis®) and at 3 years, the progression of radiolucent lines adjacent to the intramedullarly stem was reduced when compared with the GMRS® and Repiphysis® implants (p = 0.012 and 0.026, respectively). CONCLUSIONS: Implants designed to augment osseointegration at the bone-implant shoulder may be critical in reducing short- (≤ 2 years) to mid- (≤ 5 years) term aseptic loosening in this vulnerable DFR patient group. Further longer-term studies are required to confirm these preliminary findings.

The Effect of Omega-9 on Bone Viscoelasticity and Strength in an Ovariectomized Diet-Fed Murine Model.

Few studies have investigated the effect of a monosaturated diet high in ω-9 on osteoporosis. We hypothesized that omega-9 (ω-9) protects ovariectomized (OVX) mice from a decline in bone microarchitecture, tissue loss, and mechanical strength, thereby serving as a modifiable dietary intervention against osteoporotic deterioration. Female C57BL/6J mice were assigned to sham-ovariectomy, ovariectomy, or ovariectomy + estradiol treatment prior to switching their feed to a diet high in ω-9 for 12 weeks. Tibiae were evaluated using DMA, 3-point-bending, histomorphometry, and microCT. A significant decrease in lean mass (p = 0.05), tibial area (p = 0.009), and cross-sectional moment of inertia (p = 0.028) was measured in OVX mice compared to the control. A trend was seen where OVX bone displayed increased elastic modulus, ductility, storage modulus, and loss modulus, suggesting the ω-9 diet paradoxically increased both stiffness and viscosity. This implies beneficial alterations on the macro-structural, and micro-tissue level in OVX bone, potentially decreasing the fracture risk. Supporting this, no significant differences in ultimate, fracture, and yield stresses were measured. A diet high in ω-9 did not prevent microarchitectural deterioration, nevertheless, healthy tibial strength and resistance to fracture was maintained via mechanisms independent of bone structure/shape. Further investigation of ω-9 as a therapeutic in osteoporosis is warranted.

APSA Members experience bias and discrimination in training and practice.

INTRODUCTION: Bias and discrimination remain pervasive in the medical field and increase the risk of burnout, mental health disorders, and medical errors. The experiences of APSA members with bias and discrimination are unknown, therefore the APSA committee on Diversity, Equity and Inclusion conducted a survey to characterize the prevalence of bias and discrimination. METHODS: 1558 APSA members were sent an anonymous survey, of which 423 (27%) responded. Respondents were asked about their demographics, knowledge of implicit bias, and experience of bias and discrimination within their primary workplace, APSA, and APSA committees. Data were analyzed using Fisher's Exact test, Kruskal-Wallis test, and multivariable logistic regression as appropriate with significance defined as p<0.05. RESULTS: Discrimination was reported across all levels of practice, academic appointments, race, ethnicity, and gender identities. On multivariable analysis, surgical trainees (OR 3.6) as well as Asian American and Pacific Islander (OR 4.8), Black (OR 5.2), Hispanic (OR 8.2) and women (OR 8.7) surgeons were more likely to experience bias and discrimination in the workplace. Community practice surgeons were more likely to experience discrimination within APSA committees (OR 3.6). Members identifying as Asian (OR 0.4), or women (OR 0.6) were less likely to express comfort reporting instances of bias and discrimination. CONCLUSION: Workplace discrimination exists across all training levels, academic appointments, and racial and gender identities. Trainees and racial- and gender-minority surgeons report disproportionately high prevalence of bias and discrimination. Improving reporting mechanisms and implicit bias training are possible initiatives in addressing these findings.

Diversity and demographics of APSA members: Understanding our identity.

INTRODUCTION: There are existing healthcare disparities in pediatric surgery today. Identity and racial incongruity between patients and providers contribute to systemic healthcare inequities and negatively impacts health outcomes of minoritized populations. Understanding the current demographics of the American Pediatric Surgical Association and therefore the cognitive diversity represented will help inform how best to strategically build the organization to optimize disparity solutions and improve patient care. METHODS: 1558 APSA members were sent an anonymous electronic survey. Comparative data was collected from the US Census Bureau and the Association of American Medical Colleges. Results were analyzed using standard statistical tests. RESULTS: Of 423 respondents (response rate 27%), the race and ethnicity composition were 68% non Hispanic White, 12% Asian American and Pacific Islander, 6% Hispanic, 5% multiracial, and 4% Black/African American. Respondents were 35% women, 63% men, and 1% transgender, androgyne, or uncertain. Distribution of sexual identity was 97% heterosexual and 3% LGBTQIA. Religious identity was 50% Christian, 22% Agnostic/Atheist, 11% Jewish, 3% Hindu, and 2% Muslim. 32% of respondents were first-generation Americans. Twenty-four different primary languages were spoken, and 46% of respondents were conversational in a second language. These findings differ in meaningful ways from the overall American population and from the population of matriculants in American medical schools. CONCLUSION: There are substantial differences in the racial, gender, and sexual identity composition of APSA members compared with the overall population in the United States. To achieve excellence in patient care and innovate solutions to existing disparities, representation, particularly in leadership is essential. TYPE OF STUDY: Survey; original research. LEVEL OF EVIDENCE: Level IV.

Concurrent Acute Appendicitis and Type III Appendiceal Intussusception: A Case Report.

Appendiceal intussusception is exceedingly rare. Although there are few case reports of concurrent ileocecal intussusception and acute appendicitis, to our knowledge, this is the first reported case of concurrent Type III appendiceal intussusception and acute appendicitis. We present the case of an 11-year-old male who underwent appendectomy with partial cecectomy for a Type III appendiceal intussusception with concurrent acute appendicitis.

Omega-9 Modifies Viscoelasticity and Augments Bone Strength and Architecture in a High-Fat Diet-Fed Murine Model.

The influence of diet on the development of osteoporosis is significant and not fully understood. This study investigated the effect of diets of varying lipid profiles and ω-3, ω-6 and ω-9 composition on the structural and mechanical properties of bone. The hypothesis studied was that a diet high in saturated fat would induce osteoporosis and produce an overall increased detrimental bony response when compared with a diet high in unsaturated ω-6, or ω-9. Male C57BL/6J mice were fed either a control diet, 50:50 mix (saturated:unsaturated) high in ω-9 (HFD50:50), a diet high in saturated fat (HSF) or a polyunsaturated fat diet high in ω-6 (PUFA) over an 8-week duration. Tibiae were retrieved and evaluated using DMA, 3-point-bending, histomorphometry, and microCT. Mice fed a HSF diet displayed key features characteristic of osteoporosis. The loss tangent was significantly increased in the HFD50:50 diet group compared with control (p = 0.016) and PUFA-fed animals (p = 0.049). HFD50:50-fed mice presented with an increased viscous component, longer tibiae, increased loss modulus (p = 0.009), and ultimate stress, smaller microcracks (p < 0.001), and increased trabecular width (p = 0.002) compared with control animals. A diet high in ω-9 resulted in an overall superior bone response and further analysis of its role in bone health is warranted.

Delayed Presentation of Duodenal Atresia in a Male With Trisomy 21.

The duodenum is the secondmost common site of congenital intestinal obstruction. There are three types of congenital duodenal atresia according to the severity of obstruction. Duodenal atresia is thought to develop due to the failure of recanalization of the gut lumen during embryonic development. This congenital abnormality usually presents in utero or shortly after birth with signs of intestinal obstruction. However, rare cases can present later in life. In this case report, we will discuss a two-year-old male with trisomy 21 who presented with intractable vomiting and failure-to-thrive. He did not have the classic clinical or diagnostic signs of duodenal atresia, but on exploratory laparotomy, he was found to have severe duodenal stenosis. Diamond-shaped duodenoduodenostomy was performed to bypass the stenosed intestine. The patient recovered well from surgery and was able to tolerate a soft mechanical diet without vomiting one week postoperatively. This case exhibits a particularly delayed and atypical presentation of duodenal stenosis. Yet, it is imperative to recognize this presentation from an educational and clinical standpoint for surgical intervention.

Lactobacillus cell-free supernatant as a novel bioagent and biosurfactant against Pseudomonas aeruginosa in the prevention and treatment of orthopedic implant infection.

The hypothesis was that probiotic Lactobacillus species (spp.) or their cell-free supernatant (CFS) are effective in inhibiting (a) planktonic growth of Pseudomonas aeruginosa (PA), (b) its adhesion to a Ti6Al4V-alloy surface, and (c) in dispersing biofilm once formed. (a) A planktonic co-culture containing PA(104 colony-forming unit [CFU]/ml) was combined with either Lactobacillus acidophilus, Lactobacillus plantarum (LP), or Lactobacillus fermentum (LF) at a suspension of 104 (1:1) or 108 CFU/ml (1:2). Lactobacillus and PA CFUs were then quantified. (b) Ti-6Al-4V discs were inoculated with PA followed by supplementation with CFS and adherent PA quantified. (c) Biofilm covered discs were supplemented with Lactobacillus CFS and remaining PA activity quantified. Results showed that whole-cell cultures were ineffective in preventing PA growth; however, the addition of CFS resulted in a 99.99 ± 0.003% reduction in adherent PA in all Lactobacillus groups (p < .05 in all groups) with no viable PA growth measured in the LF and LP groups. Following PA biofilm formation, CFS resulted in a significant reduction in PA activity in all Lactobacillus groups (p ≤ .05 in all groups) with a 29.75 ± 15.98% increase measured in control samples. Supplementation with CFS demonstrated antiadhesive, antibiofilm, and toxic properties to PA.

Incidence of Osteolysis and Aseptic Loosening Following Metal-on-Highly Cross-Linked Polyethylene Hip Arthroplasty: A Systematic Review of Studies with Up to 15-Year Follow-up.

BACKGROUND: This study compared the incidence of osteolysis, aseptic loosening, and revision following use of highly cross-linked polyethylene (HXLPE) or conventional polyethylene (CPE) at medium to long-term (>5 to 15 years) follow-up in primary total hip arthroplasty (THA). Incidences were quantified and compared with regard to age and method of implant fixation. METHODS: Using the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines, 12 randomized controlled trials and 18 cohort studies were investigated for evidence-based outcomes following HXPLE and CPE use in 2,539 hips over a 5 to 15-year follow-up. RESULTS: Lower rates of osteolysis, aseptic loosening, and implant revision were reported following use of HXLPE liners. Osteolysis was reduced from 25.4% with CPE to 4.05% with HXLPE in young patients, and from 29.7% to 6.6% in the older patient cohort. Similarities in osteolysis rates were observed when cemented (24.9% for CPE and 6.5% for HXLPE) and uncemented components (32.8% for CPE and 7.1% for HXLPE) were compared. No clear advantage in the type of HXLPE used was observed. CONCLUSIONS: Over a follow-up period of up to 15 years, when compared with CPE, use of HXLPE liners reduced the incidence of osteolysis, aseptic loosening, and implant revision, regardless of the fixation method and including in younger and potentially more active patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Standardized Protocol for Nonoperative Management of Complicated Appendicitis in Children Reduces Resource Utilization.

INTRODUCTION: To standardize care and reduce resource utilization, we implemented a standardized protocol (SP) for the nonoperative treatment of complicated appendicitis. MATERIALS AND METHODS: We conducted a prospective, historically controlled, study of patients <21 years with complicated appendicitis managed nonoperatively using an SP from January 2017 to November 2018. The primary outcomes included length of stay (LOS), antibiotic days, peripheral inserted central catheter (PICC) utilization, discharge on intravenous antibiotics, and predischarge imaging. Secondary outcomes were protocol adherence and the rates of adverse events (AE) including return to emergency department (ED), readmission, failure of nonoperative treatment, and interval appendectomy complications. RESULTS: Protocol adherence was 67.9%. In total, 741 children were treated for appendicitis of which 58 (30 pre-SP and 28 post-SP) were treated nonoperatively for complicated appendicitis at presentation. Patients were well matched for age, admission white blood cell, sex, body mass index, race, and the proportion requiring percutaneous drainage. After implementing the SP, fewer children had PICCs (100.0 vs. 57.1%, p ≤ 0.001), fewer were discharged on intravenous antibiotics (90.0 vs. 42.9%, p < 0.001), and total antibiotic days were reduced (14.0 vs. 10.0, p = 0.006). There was no difference in LOS (5.5 vs. 6.0 days, p = 0.790) or the proportion undergoing ultrasound (36.7 vs. 39.3%, p = 0.837) or computed tomography scan (16.7 vs. 3.6%, p = 0.195) prior to discharge. There were nonsignificant trends toward reduced AEs (46.7 vs. 35.7%, p = 0.397), returns to ED (40.0 vs. 28.6%, p = 0.360), and readmissions (26.7 vs. 17.9%, p = 0.421). The proportion failing nonoperative treatment (10.0 vs. 3.6%, p = 0.612) and experiencing complications of interval appendectomy (3.3 vs. 3.6%, p = 0.918) were not significantly different. CONCLUSION: Implementing an SP for treating complicated appendicitis nonoperatively reduced resource utilization without negatively affecting clinical outcomes.

Do polyunsaturated fatty acids protect against bone loss in our aging and osteoporotic population?

Age-related bone loss is inevitable in both men and women and there will soon be more people of extreme old age than ever before. Osteoporosis is a common chronic disease and as the proportion of older people, rate of obesity and the length of life increases, a rise in age-related degenerating bone diseases, disability, and prolonged dependency is projected. Fragility fractures are one of the most severe complications associated with both primary and secondary osteoporosis and current treatment strategies target weight-bearing exercise and pharmacological intervention, both with limited long-term success. Obesity and osteoporosis are intimately interrelated, and diet is a variable that plays a significant role in bone regeneration and repair. The Western Diet is characterized by its unhealthy components, specifically excess amounts of saturated fat intake. This review examines the impact of saturated and polyunsaturated fatty acid consumption on chronic inflammation, osteogenesis, bone architecture, and strength and explores the hypothesis that dietary polyunsaturated fats have a beneficial effect on osteogenesis, reducing bone loss by decreasing chronic inflammation, and activating bone resorption through key cellular and molecular mechanisms in our aging population. We conclude that aging, obesity and a diet high in saturated fatty acids significantly impairs bone regeneration and repair and that consumption of ω-3 polyunsaturated fatty acids is associated with significantly increased bone regeneration, improved microarchitecture and structural strength. However, ω-6 polyunsaturated fatty acids were typically pro-inflammatory and have been associated with an increased fracture risk. This review suggests a potential role for ω-3 fatty acids as a non-pharmacological dietary method of reducing bone loss in our aging population. We also conclude that contemporary amendments to the formal nutritional recommendations made by the Food and Nutrition Board may be necessary such that our aging population is directly considered.

Not Just for Urine: A Versatile Tool for Foreign Body Removal.

The swallowed or aspirated foreign body is a common pediatric emergency medicine complaint for which emergency providers must be familiar with the intricacies of management. Most swallowed foreign bodies will harmlessly pass through the GI tract, but children with GI tract abnormalities may have an increased risk of object impaction. There are few reported cases of foreign object ingestion in children with GI tract abnormalities, specifically ostomies. The Foley catheter is a versatile tool that is easily accessible in the ED setting. We present a novel case of foreign body ingestion in an infant with a colostomy secondary to Hirschsprung's disease managed with Foley catheter retrieval through an ileostomy stoma. A 17-month-old infant presented to the ED with a chief complaint of an episode of bloody vomiting. He had a two-day history of increased irritability and intolerance of feeds with emesis after every feed. The child's medical history is pertinent for Hirschsprung's disease, for which the patient had a pull-through procedure shortly after birth and a revision of the pull-through. On physical examination, the patient's ostomy was found to contain brown-green liquid stool. A small ovular mass was visualized at the stoma during crying episodes. Supine posteroanterior radiograph of the abdomen showed an oval-shaped radiolucency consistent with a metallic ingested foreign body at the site of the stoma. The foreign object was removed using a Foley catheter and forceps and was found to be a penny. The patient was observed and discharged without complications later that day. Treatment of a symptomatic ingested foreign object requires careful consideration of the type of object present and its location in the body. In this case report, we discussed the removal of an ingested coin in a symptomatic 17-month-old infant with a history of ileostomy secondary to Hirschsprung's disease using a Foley catheter. In children with ostomies, prompt imaging and non-surgical removal may be an option to manage retrieval of these objects if the patient is stable and symptoms are not severe.

A Standardized Protocol for the Management of Appendicitis in Children Reduces Resource Utilization.

Appendicitis is the most common condition requiring emergency surgery in children. We implemented a standardized protocol (SP) for treating children with appendicitis to provide more uniform care and reduce resource utilization. METHODS: All patients younger than 21 years were managed with the SP beginning in January 2017. We compared data from 22 months before and after implementation. The primary outcomes included the length of stay (LOS), antibiotic days, discharge on intravenous antibiotics, utilization of peripherally inserted central catheters lines, and postoperative imaging. Secondary outcomes were protocol adherence and the rates adverse events, including postoperative abscess, return to emergency department or operating room, surgical site infection, and readmission. RESULTS: Protocol adherence was 92.3%. For uncomplicated cases (n = 412), LOS (P = 0.010) and postoperative antibiotic days (P < 0.001) were significantly reduced. There was no difference in the rates of any adverse event (6.7% versus 2.7%; P = 0.058), postoperative abscess (0.4% versus 0.0%; P = 0.544), return to emergency department (6.3% versus 2.7%; P = 0.084), readmission (1.8% versus 0.5%; P = 0.245), or postoperative ultrasound (0.4% versus 0.5%; P = 0.705) and computed tomography (0.0% versus 0.5%; P = 0.456). For complicated cases (n = 229), the post-SP cohort had a shorter LOS (P = 0.015), fewer peripherally inserted central catheters lines (26.9% versus 2.7%; P < 0.001), fewer postoperative ultrasounds (8.4% versus 1.8%; P = 0.027), and fewer discharges on intravenous antibiotics (17.6% versus 0.9%; P < 0.001). There were no differences in adverse events before and after the SP (16.0% versus 18.3%; P = 0.633). CONCLUSION: Implementing an SP for appendicitis in children reduced resource utilization, and by inference healthcare costs, for both uncomplicated and complicated cases without adversely affecting clinical outcomes.

Laparoscopic Repair of Bilateral Congenital Diaphragmatic Hernia Without Pulmonary Hypoplasia.

We report the case of a 14-month-old female who had a right-sided congenital diaphragmatic hernia (CDH) without pulmonary hypoplasia. The patient was preoperatively diagnosed with a Morgagni hernia due to the size and location of the hernia seen on imaging. However, the patient was found to have bilateral diaphragmatic defects intraoperatively, and her right diaphragm was almost completely absent. Our patient did not have pulmonary hypoplasia or any of the respiratory comorbidities that CDH patients typically present with, though she did have repeated respiratory infections and cough. This case demonstrates that CDH is not always diagnosed in an accurate or timely manner radiographically and that the surgeon should be prepared to potentially repair more of the diaphragm than expected. Additionally, there is a need to study the pathophysiology and genetics of CDHs further.

Admission of Pediatric Concussion Injury Patients: Is It Necessary?

BACKGROUND: Currently there is no consensus on the management of patients with a concussion and negative computed tomography (CT) of the head. This study examined the necessity of admitting pediatric patients with concussive symptoms. The purpose of this study was to determine if pediatric patients evaluated in the emergency department (ED) for concussion with a negative head CT scan require routine hospital admission. MATERIALS AND METHODS: A retrospective chart review of pediatric trauma patients admitted to the hospital for a concussion from 2010 to 2017 was conducted after IRB approval (1709005621). Only patients with a negative head CT were included. Demographic information, ED evaluation, and hospital course were reviewed. RESULTS: A total of 90 patients (Mage = 10 y; 72.2% male) were included in the analysis. The average Glasgow coma scale was 14.6 (range 9-15). Loss of consciousness was reported by 36.7% (n = 33) of patients. Reported symptoms included nausea/emesis in 35.5% (n = 32) and altered mental status in 40% (n = 36). Following admission, 94.4% of patients were discharged within 24 h of admission. Of the four patients (4.4%) that stayed longer than 24 h, only two hospitalizations were related to the concussion (inability to tolerate diet). One patient had a fever unrelated to the concussion and one stayed because of social issues. Average length of stay for these patients was 2.75 d (range 2-4 d). There was no difference in Glasgow coma scale in comparison to patients who were discharged within 24 h. CONCLUSIONS: Although there are a large number of pediatric patients evaluated in the ED for concussion injuries, very few of these patients require any further care. Our study suggests that patients with concussion and a negative head CT who tolerate a diet can be safely discharged home.

Standardization of common bile duct size using ultrasound in pediatric patients.

BACKGROUND/PURPOSE: The incidence of choledocholithiasis is increasing. The diagnosis of common bile duct (CBD) obstruction is based on abnormal CBD size. Establishing norms for CBD size in children would improve diagnostic accuracy. We analyzed ultrasounds (US) to determine normal pediatric CBD size based on age and then validated this against patients with choledocholithiasis. METHODS: A retrospective review was conducted for children less than 21 years of age with US defined CBD size. Patients were stratified into age groups by ANOVA statistical analysis. Secondary analysis included patients with confirmed choledocholithiasis in comparison to the normal cohort. RESULTS: A total of 778 patients had US without pathology. Group 1 (<1 year) had a mean CBD of 1.24±0.54 mm, group 2 (1-10 years) 1.97±0.71 mm, and group 3 (>10 years) 2.98±1.17 mm, p<0.05. Fourteen additional patients were found to have choledocholithiasis with a mean CBD size of 8.1 mm. All patients with choledocholithiasis had CBD sizes outside of our normal range, but only 50% of patients had enlarged CBD size based on adult normal range of values. CONCLUSION: Normal CBD size in children is less than a normal adult patient. More accurate normal values will aid in determining if a child needs further evaluation for possible obstruction of the CBD. TYPE OF STUDY: diagnostic Level of evidence: III.

Pain Control in a Pediatric Patient With Sickle Cell Disease Using Regional Nerve Blocks for Laparoscopic Cholecystectomy: A Case Report.

The sickle cell patient population continues to provide challenges in pain control. Current therapies include narcotic usage with adjuvant therapies such as anti-inflammatories and nonpharmacological interventions. Poor pain management in the sickle cell patient population, especially postoperatively, can lead to hypoventilation, escalating opioid requirements, poor recovery, and longer hospital stays. This case report addresses a novel addition of ultrasound-guided paravertebral and rectus sheath blocks postinduction of general anesthesia and before surgical incision to assist with the intravenous postoperative pain management regimen after laparoscopic cholecystectomy in a 10-year-old boy with sickle cell disease.

Hidden morbidity of ethanol lock therapy.

AIMS: Long-term central venous catheters are essential in sustaining growth and development in patients with intestinal failure (IF). Several strategies have been developed to prevent and treat catheter-related blood stream infections (CRBSIs), including ethanol lock therapy. We sought to evaluate the efficacy of ethanol lock therapy in our IF population. METHOD: This is a retrospective review of IF patients treated with ethanol lock therapy at a single institution from 2006 to 2013. We evaluated the number of catheter days, rate of CRBSI per 1000 catheter days, rate of central venous catheter (CVC) thrombosis, rate of CVC breakage, total number of CVC replacements, total number of hospital admissions, and total number days in the hospital. RESULT: We identified 19 patients who underwent ethanol lock therapy for CRBSI. There was no difference in CRBSI rate prior to (5.6 per 1000 catheter days) and after (7 per 1000 catheter days) initiation of ethanol lock therapy. The mean rate of thrombosis increased from 0 to 3 per 1000 catheter days with ethanol lock therapy (p < 0.05). In addition, the CVC breakage rate increased from 0 to 13.7 per 1000 catheter days with ethanol lock therapy (p < 0.001). Hospital admissions and catheter-related ER visits increased following the initiation of ethanol lock therapy. CONCLUSIONS: Contrary to other studies, there was no difference in CRBSI rate prior to and after initiation of ethanol lock therapy. Factors in the methodology of ethanol lock therapy may influence the effectiveness of infection prevention associated with ethanol lock therapy, as well as the rate of line breakage, line thrombosis, and the need for line replacement.

Vacuum-assisted closure: a novel method of managing surgical necrotizing enterocolitis.

PURPOSE: Necrotizing enterocolitis (NEC) requiring surgical intervention is associated with mortality rates approaching 50%. We evaluated outcomes of patients that underwent surgical treatment for NEC with vacuum-assisted closure (VAC) of the abdomen as compared with traditional laparotomy, bowel resection, and ostomy creation. METHODS: A retrospective review identified 26 patients from 2007 to 2012 with NEC. Overall, 17 patients were treated with laparotomy, and 9 were treated with laparotomy and VAC (LapVac). Age, weight, preoperative and postoperative mean airway pressure, length of bowel resected, duration on total peripheral nutrition, time until initiation of feeds, and length of stay were assessed. A Student's t-test was used for statistical analysis. RESULTS: Nine LapVac patients underwent a total of 1.2 ± 1.3 VAC changes and had open abdomens for 13.1 ± 19.1 days. LapVac and traditional laparotomy patients had similar outcomes with respect to amount of bowel resected, time on a ventilator, time to initiation of feeds, and length of hospital stay. Two of nine patients (22%) in the LapVac group were placed in continuity without the need for an ostomy. We identified a subset of patients in the LapVac group that demonstrated signs of abdominal compartment syndrome (ACS), exhibiting mean airway pressures greater than 15 cm H2O preoperatively. Patients with ACS treated with VAC therapy had shorter time to initiation of feeds (p=0.047) and shorter lengths of stay (p=0.0395) as compared with traditional laparotomy. CONCLUSION: Our data demonstrate that use of the wound VAC is a safe approach in the management of premature infants with NEC requiring surgical intervention with outcomes comparable to standard surgical management. Use of the wound VAC may allow the establishment of bowel continuity and abdominal closure without the need for an ostomy. VAC therapy may also hasten the recovery of NEC patients with concomitant ACS by eliminating the compartment syndrome. Larger studies are required to confirm this theory.