Opioid prescribing to preteen children undergoing ambulatory surgery in the United States.

BACKGROUND: Overuse and misuse of opioids is a continuing crisis. The most common reason for children to receive opioids is postoperative pain, and they are often prescribed more than needed. The amount of opioids prescribed varies widely, even for minor ambulatory procedures. This study uses a large national sample to describe filled opioid prescriptions to preteen patients after all ambulatory surgical procedures and common standard procedures. METHODS: We analyzed Truven Health MarketScan data for July 2012 through December 2016 to perform descriptive analyses of opioid fills by age and geographic area, change over time, second opioid fills in opioid-naïve patients, and variation in the types and amount of medication prescribed for 18 common and standard procedures in otolaryngology, urology, general surgery, ophthalmology, and orthopedics. RESULTS: Over 10% of preteen children filled perioperative opioid prescriptions for ambulatory surgery in the period 2012 to 2016. The amount prescribed varied widely (median 5 days' supply, IQR 3-8, range 1-90), even for the most minor procedures, for example, frenotomy (median 4 days' supply, IQR 2-5, range 1-60). Codeine fills were common despite safety concerns. Second opioid prescriptions were filled by opioid-naïve patients after almost all procedures studied. The rate of prescribing declined significantly over time and varied substantially by age and across census regions. CONCLUSIONS: We identified opioid prescribing outside of the norms of standard practice in all of the specialties studied. Standardizing perioperative opioid prescribing and developing guidelines on appropriate prescribing for children may reduce the opioids available for misuse and diversion.

Pyuria as a Marker of Urinary Tract Infection in Neurogenic Bladder: Is It Reliable?

OBJECTIVE: The utility of the urinalysis as a potential marker to diagnose urinary tract infection (UTI) in patients with neurogenic bladder is controversial. We assessed the baseline urine characteristics and intraindividual variance of pyuria in a cohort of asymptomatic children with neurogenic bladder followed longitudinally. STUDY DESIGN: A cohort of 54 children with neurogenic bladder was followed from 2004 to 2015 at a single institution's multidisciplinary clinic. Urine data obtained from 529 routine urology visits were reviewed. Urine obtained within 2 weeks before or after treatment for UTI were excluded. Bladder surgery was defined as any operation that altered the bladder as a closed or sterile system. The effects of age, gender, catheterization, and bladder surgery on pyuria were evaluated using mixed-model regression analysis. RESULTS: Fifty patients with 305 urine samples had a mean length of follow-up of 3.2 years. Only 16/50 patients (32%) never had pyuria, and these patients had shorter follow-up compared with the group who ever had pyuria (≥5 white blood cells per high powered field) (1.7 vs. 3.8 years; P = 0.008). Catheterization was associated with a 15% increase in pyuria (P = 0.21). Surgery was associated with a 120% increase in pyuria (P < 0.001). The test-to-test variance of pyuria within an individual was consistently greater than between individuals (P < 0.001). CONCLUSIONS: Bladder surgery is associated with significant increases in pyuria among children with neurogenic bladder. The substantial test-to-test variation in pyuria in asymptomatic individuals indicates the low reliability of pyuria, when positive, as a marker for UTI in neurogenic bladder and the need to search for either methods to reduce this variability or alternative biomarkers of UTI in this population.

Differential renal function estimation using computerized tomography based renal parenchymal volume measurement.

PURPOSE: Nuclear renal scan is currently the gold standard imaging study to determine differential renal function. We propose helical computerized tomography as a more efficient way to gain renal function information. Renal parenchymal volume is measured and percent total renal volume is used as a surrogate marker for differential renal function. MATERIALS AND METHODS: Computerized tomography and diuretic enhanced nuclear renal scan were performed in 33 patients with chronic obstruction. Computerized tomography was contrast enhanced in 23 cases and nonenhanced in 10. Diagnoses included ureteropelvic junction obstruction, ureteral stricture and extrinsic compression. Using semiautomated boundary delineation with manual editing method the parenchymal volume of each kidney was measured and percent renal volume was calculated. Percent renal volume was compared with percent renal function, as determined by nuclear renal scan. Correlations between the 2 measures were evaluated using the Spearman or Pearson coefficient. RESULTS: Strong correlations were observed between percent renal function and percent renal volume in all cases (r = 0.90, p <0.001), including the enhanced (r = 0.87, p <0.001) and nonenhanced (r = 0.95, p <0.001) groups. Moderately strong correlations were noted in the less than 40% (r = 0.76, p <0.001) and less than 30% (r = 0.64, p = 0.015) renal function subgroups. CONCLUSIONS: Differential renal volume measured from computerized tomography strongly correlates with differential renal function on nuclear renal scan for normal and chronically obstructed kidneys. Computerized tomography may serve as a single radiological diagnostic study for anatomical and functional assessment in patients in whom a poorly functioning kidney is suspected.

Single-site laparoscopic orchidopexy in an infant.

We describe a laparoscopic orchidopexy performed on an 18-month-old child through a single infraumbilical site.