Long-term Outcomes Following Thoracoscopic Division of Vascular Rings.

OBJECTIVES: We evaluate long-term symptomatic improvement in vascular ring patients who underwent thoracoscopic division at a single quaternary pediatric surgery center. METHODS: All pediatric patients who underwent vascular ring division without Kommerell's diverticulum resection between 01/2007-12/2022 were included. Surgeries were performed by pediatric general and thoracic surgeons. Patient demographic and clinical characteristics were obtained from retrospective chart review. Data on long-term symptomatic improvement were collected with structured telephone interviews. RESULTS: 60% of patients were male. Median age at operation was 24 months (IQR: 11, 60 months) with a median weight of 11.3 kg (IQR: 8.7, 19.8 kg). All patients were symptomatic preoperatively with dysphagia being the most frequent complaint (42%), followed by chronic cough (21%). Of 41 patients eligible for the long-term follow-up survey, 8 patients with a primary diagnosis of a double arch with an atretic segment in the non-dominant arch and 9 with a right dominant arch with left ligamentum arteriosum and aberrant left subclavian artery (LSCA) were contacted and consented for participation. Median interval from surgery to survey completion was 95 months (IQR 28, 135 months). Most patients had no, or only minor, symptoms related to breathing and swallowing at the time of long-term follow-up. 88% of patients experienced postoperative symptom improvement, and only one patient reported worsening of symptoms over time. CONCLUSION: Division of an atretic arch and/or ligamentum for patients with an aberrant LSCA without Kommerell's resection may be adequate to ensure long-term improvement of breathing and swallowing problems attributable to vascular rings. LEVEL OF EVIDENCE: Level IV.

Esophagogastric Fistula: The Consequence of High-Powered Magnets Ingestion.

A 17-month-old female had an unwitnessed ingestion of 26 high-powered magnets, resulting in the creation of an esophagogastric fistula via the left crus of the diaphragm. This case highlights a rare injury to the stomach and esophagus caused by high-powered magnets requiring surgical intervention. Furthermore, this case report illustrates the risks that high-powered magnets pose to young children. Additionally, this case highlights the importance of maintaining a high level of suspicion for ingestion in young patients along with a multidisciplinary team to manage sequelae of injury.

A thirty-year contaminant trend analysis in great lakes Native American fish harvests 1991-2021.

The Chippewa Ottawa Resource Authority (CORA) in Sault Ste. Marie, Michigan has been monitoring contaminant concentrations of mercury (Hg) and polychorinated biphenyls (PCBs) in the fillet portions of lake trout (Salvelinus namaycush) and lake whitefish (Coregonus clupeaformus) from waters of lakes Superior, Huron, and Michigan since 1991. This contaminant monitoring program is essential to supporting the fisheries interests and consumption advice for five Ojibwa and Ottawa tribes (collectively called Anishinaabe) whose ancestors ceded lands through the 1836 Treaty of Washingtonbut retained the rights to hunt and fish on those lands and waters. This manuscript presents an updated contaminant trend analysis covering the past three decades in which we observed a significant decreasing trend of median PCBs in both whitefish and lake trout harvested by tribal fishermen across all lakes. Median Hg tissue burdens significantly increased in whitefish harvests across all lakes and lake trout harvested from lake Michigan relative to earlier decades. Linear regression of fish fillets, adjusted for length, also conform to these trends. In 2021, per- and polyfluoroalkyl substances (PFAS) were detected in all Lake Michigan samples of lake trout (median 6.81pbb total PFAS) and in white fish (median 7.18 ppb total PFAS). Both decreasing and increasing trends of these key contaminants can alter fish consumption advice and risk calculations relative to advice presented in earlier decades.

A Culture and Wellness Pilot to Guide Community Engaged Public Health Research in Native American Populations.

BACKGROUND: Alaskan Native/American Indian (AI/AN) participation in biomedical sciences is often hindered by cultural miscommunication regarding concepts and definitions of health. Identifying culturally contextualized health priorities is crucial to building research collaborations between academic institutions and AI/AN consortia. METHODS: This article describes pilot data from the development of a culture and wellness questionnaire deployed by the Great Lakes Native American Research Center for Health at cultural events and community engagement meetings. The questionnaire was designed in collaboration with AI/AN members to assess performance indicators of public health promotion in AI/AN populations who are culturally inclined to interpret health holistically. RESULTS: There were 25 completed questionnaires. Connection to the land (88%) and "giving thanks" (96%) were the most prominently affirmed health and wellness concepts. Participants were least confident (33%) in the ability to support the next generation culturally (language, stories, etc). These results comport with anecdotal data that AI/AN concepts of health and wellness should be co-developed with AI/AN cultural leaders and community members. Future implications for academic partnerships are discussed.

Associations between extreme precipitation, drinking water, and protozoan acute gastrointestinal illnesses in four North American Great Lakes cities (2009-2014).

Climate change is already impacting the North American Great Lakes ecosystem and understanding the relationship between climate events and public health, such as waterborne acute gastrointestinal illnesses (AGIs), can help inform needed adaptive capacity for drinking water systems (DWSs). In this study, we assessed a harmonized binational dataset for the effects of extreme precipitation events (≥90th percentile) and preceding dry periods, source water turbidity, total coliforms, and protozoan AGIs - cryptosporidiosis and giardiasis - in the populations served by four DWSs that source surface water from Lake Ontario (Hamilton and Toronto, Ontario, Canada) and Lake Michigan (Green Bay and Milwaukee, Wisconsin, USA) from January 2009 through August 2014. We used distributed lag non-linear Poisson regression models adjusted for seasonality and found extreme precipitation weeks preceded by dry periods increased the relative risk of protozoan AGI after 1 and 3-5 weeks in three of the four cities, although only statistically significant in two. Our results suggest that the risk of protozoan AGI increases with extreme precipitation preceded by a dry period. As extreme precipitation patterns become more frequent with climate change, the ability to detect changes in water quality and effectively treat source water of varying quality is increasingly important for adaptive capacity and protection of public health.

Environmental health literacy for Anishinaabe (Great Lakes Native American) fish consumers: A randomized control trial.

BACKGROUND: Fish consumption comprises an important part of what the Anishinaabe (Great Lakes Native Americans) call "minobimaadiziiwin" which translates roughly to "living in a good way". Industrial activity leading to the accumulation of persistent contaminants in fish disrupts minobimaadiziiwin. Our team of academic and Anishinaabe scientists co-developed a fish consumption advisory for the Anishinaabe using software that can be accessed via mobile phones and/or the internet. OBJECTIVES: The software, Gigiigoo'inaan ("our fish") is designed to improve environmental health literacy using culturally congruent messaging and aesthetics. We tested the following hypotheses: 1) the Gigiigoo'inaan would encourage consumption of fish high in Polyunsaturated Omega-3 fatty acids (PFUA-3) whilst minimizing contaminant intake (methylmercury (MeHg) and Polychorinated Biphenyls (PCBs)); and 2) intervention participants will be more likely than controls to achieve a favorable n-3 PUFA/MeHg consumption ratios. METHODS: We conducted a randomized controlled trial with prospective self-reported fish consumption using automated email surveys. One-month pre and one month post, control and intervention outcome variables were calculated per participant as µg/kg/day of MeHg, µg/kg/day of PCB, g of fish, and mg/day of EPA+DHA. These were modeled using an analysis of covariance (ANCOVA) with a-priori covariates: age, sex, and tribal affiliation. RESULTS: Most participants in both trial arms reported eating relatively elevated amounts of fish yet remained within advisory guidelines for contaminants. EPA+DHA:MeHg ratios were also favorable in most participants. Advisory limits for contaminants were exceeded by relatively few participants in the study. DISCUSSION: Gigiigoo'inaan was previously reported to increase confidence, the current user feedback confirms this. Most participants ate fish but did not exceed the advisory limits, which demonstrates Environmental Health Literacy progress in the region despite a lack of observed behavior change during the trial. A small number of participants exceeded contaminant intake guidelines which matches the pilot work for this study.

The need for early Kasai portoenterostomy: a Western Pediatric Surgery Research Consortium study.

PURPOSE: The purpose of this study was to investigate factors impacting transplant-free survival among infants with biliary atresia. METHODS: A multi-institutional, retrospective cohort study was performed at nine tertiary-level children's hospitals in the United States. Infants who underwent Kasai portoenterostomy (KP) from January 2009 to May 2017 were identified. Clinical characteristics included age at time of KP, steroid use, surgical approach, liver pathology, and surgeon experience. Likelihood of transplant-free survival (TFS) was evaluated using logistic regression, adjusting for patient and surgeon-level factors. Secondary outcomes at 1 year included readmission, cholangitis, reoperation, mortality, and biliary clearance. RESULTS: Overall, 223 infants underwent KP, and 91 (40.8%) survived with their native liver. Mean age at surgery was 63.9 days (± 24.7 days). At 1 year, 78.5% experienced readmission, 56.9% developed cholangitis, 3.8% had a surgical revision, and 5 died. Biliary clearance at 3 months was achieved in 76.6%. Controlling for patient and surgeon-level factors, each additional day of age toward operation was associated with a 2% decrease in likelihood of TFS (OR 0.98, 95% CI 0.97-0.99). CONCLUSION: Earlier surgical intervention by Kasai portoenterostomy at tertiary-level centers significantly increases likelihood for TFS. Policy-level interventions to facilitate early screening and surgical referral for infants with biliary atresia are warranted to improve outcomes.

Management of intussusception in children: A systematic review.

OBJECTIVE: The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations for the management of ileocolic intussusception in children. METHODS: The ClinicalTrials.gov, Embase, PubMed, and Scopus databases were queried for literature from January 1988 through December 2018. Search terms were designed to address the following topics in intussusception: prophylactic antibiotic use, repeated enema reductions, outpatient management, and use of minimally invasive techniques for children with intussusception. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available evidence. RESULTS: A total of 83 articles were analyzed and included for review. Prophylactic antibiotic use does not decrease complications after radiologic reduction. Repeated enema reductions may be attempted when clinically appropriate. Patients can be safely observed in the emergency department following enema reduction of ileocolic intussusception, avoiding hospital admission. Laparoscopic reduction is often successful. CONCLUSIONS: Regarding intussusception in hemodynamically stable children without critical illness, pre-reduction antibiotics are unnecessary, non-operative outpatient management should be maximized, and minimally invasive techniques may be used to avoid laparotomy. LEVEL OF EVIDENCE: Level 3-5 (mainly level 3-4) TYPE OF STUDY: Systematic Review of level 1-4 studies.

Risk-Benefit Modeling to Guide Health Research in Collaboration with Great Lakes Fish Consuming Native American Communities.

It is well documented that fish consumption imparts both health risks and benefits. Furthermore, fish harvest and consumption are an essential part of Great Lakes Native American cultures. Quantitative models that compare risk and benefits to potential consumption scenarios can help guide future health research as well as consumption advice for potentially sensitive populations. This article presents fish consumption scenarios based on self-reported meal plans constructed by tribal members in eastern upper peninsula and northern lower Michigan Anishinaabe. Two risk-benefit models were applied to these scenarios to estimate the potential neurodevelopmental and cardiovascular risks (either increased or reduced risk) from dioxin-like polychlorinated biphenyls (DL-PCBs), methylmercury (MeHg), and omega-3 polyunsaturated fatty acids (n3-PUFA). All scenarios except maximum exposure estimates (i.e. 25th-75th percentile MeHg, DL-PCB, and n3-PUFA intakes) predicted reduced cardiovascular risk and improved neurodevelopmental outcomes. The greatest predicted benefits (adjusted for risks) occurred at the 75th percentile intake of MeHg, DL-PCB, and n3-PUFA scenarios: 5.0 visual recall memory (VRM) and 4.41 Intelligence Quotient (IQ) benefits, and 28% reduced risk of cardio-vascular disease. Scenarios based on maximum self-reported intake, however, predicted health detriments. These results suggest that most fish consumption scenarios as constructed in collaboration with Native American communities could impart health benefits despite the presence of contaminants. However, high-end consumption estimates warrant caution as well as the need for well-crafted advice. Potential benefits further underscore the value of reducing contamination burdens in Great Lakes fisheries. Future priorities of ongoing contamination monitoring and health research are discussed.

Pancreatic islet cell tumors in adolescents and young adults.

BACKGROUND: Pancreatic islet cell tumors are rare in adolescents, and most studies published to date focus on older patients. We utilized a national database to describe the histology and clinical pattern of pancreatic islet cell tumors in adolescent and young adult (AYA) patients, and to compare AYAs to older adults. We hypothesized that AYAs with pancreatic islet cell tumors would have better overall survival. METHODS: The National Cancer Data Base (NCDB, 1998-2012) was queried for AYA patients (15-39 years) with a pancreatic islet cell tumor diagnosis. Demographics, tumor characteristics, treatment modalities, and outcomes were abstracted and compared to adults (≥40 years). RESULTS: 383 patients (56.4% female, 65% non-Hispanic Whites) were identified, with a median age of 27 (IQR 16-34) years. Islet cell carcinoma was the most common histology. Of patients with known stage of disease, 49% presented with early stage (I or II). Seventy percent of patients underwent surgical resection, including local excision 44%, Whipple procedure 37.5%, or total pancreatectomy 19%. Chemotherapy was utilized in 27% and radiotherapy in 7%. All-cause mortality was 36%. AYA patients underwent more extensive resections (p = 0.001) and had lower mortality rates (p < 0.001), with no differences in tumor stage or use of adjuvant therapies, when compared to adults. CONCLUSIONS: AYA patients with pancreatic islet cell tumors had comparable utilization of adjuvant therapies but underwent more extensive resections and demonstrated a higher overall survival rate than adult counterparts. Further investigation into approaches to earlier diagnosis and tailoring of multimodality therapy of these neoplasms in the AYA population is needed. LEVELS OF EVIDENCE: Prognostic Study, Level II - retrospective study.

Pediatric gastric adenocarcinoma: A National Cancer Data Base review.

PURPOSE: We sought to compare the presentation, management, and outcomes in gastric adenocarcinoma cancer for pediatric and adult patients. METHODS: Using the 2004 to 2014 National Cancer Database (NCDB), patients ≤21 years (pediatric) were retrospectively compared to >21 years (adult). Chi-squared tests were used to compare categorical variables, and Cox regression was used to estimate hazard ratios (HR) for survival differences. RESULTS: Of the 129,024 gastric adenocarcinoma cases identified, 129 (0.10%) occurred in pediatric patients. Pediatric cases presented with more advanced disease, including poorly differentiated tumors (81% vs 65%, p = 0.006) and stage 4 disease (56% vs 41%, p = 0.002). Signet ring adenocarcinoma comprised 45% of cases in the pediatric group as compared to 20% of cases in the adults (P < 0.001). Similar proportions in both groups underwent surgery. However, near-total gastrectomy was more common in the pediatric group (16% vs 6%, p < 0.001). The proportions of patients with negative margins, nodal examination, and presence of positive nodes were similar. There was no overall survival difference between the two age groups (HR 0.92, 95% Confidence interval 0.73-1.15). CONCLUSION: While gastric adenocarcinoma in pediatric patients present with a more advanced stage and poorly differentiated tumors compared to adults, survival appears to be comparable. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: III.

Culturally Adapted Mobile Technology Improves Environmental Health Literacy in Laurentian, Great Lakes Native Americans (Anishinaabeg).

The presence of persistent bioaccumulative toxics (PBT) in aquatic food chains complicates decision processes of people with a strong culture of fish consumption. This environmental contamination is especially problematic for Native American populations in the Laurentian Great Lakes region (Anishinaabeg). Pursuing the growing discipline of environmental health literacy (EHL) may help reduce toxic exposures, support healthy decision-making, and combat health deficits. Our goals for this research were first to improve environmental health literacy using novel technologies and second to help define environmental health literacy metrics that can be tracked over time, especially regarding culturally-contextualized health interests. We recently reported that a mobile app (Gigiigoo'inaan App) presenting personalized, culturally-contextualized fish consumption advice may improve EHL for the Anishinaabeg. Gigiigoo'inaan App safely supports desired fish consumption rates by putting local data into the hands of the Anishinaabeg. We conducted a pre-test post-test evaluation with 103 Aninishinaabe adults. Participants estimated their current fish meal consumption over a hypothetical month before exposure to the software and then planned their future consumption of fish meals in a month after using the mobile app. Significantly more monthly traditional fish meals on average (Median: 4 vs 2, p=0.0005) were selected when using the app versus pre-exposure to the app. Significantly more traditional grams of fish were also selected during use of the app relative to the pretest (Median: 680.39g vs 453.59g, p=0.0007). These increases were accompanied by widespread (97%) adherence to conventional advice that minimizes PBT exposure health effects (ATSDR minimum risk levels).

Fatty Acids in Ten Species of Fish Commonly Consumed by the Anishinaabe of the Upper Great Lakes.

The Chippewa Ottawa Resource Authority (CORA) in Sault Ste. Marie, Michigan, has been monitoring contaminant concentrations in the fillet portions of fish from the 1836 treaty-ceded waters of lakes Superior, Huron, and Michigan since 1991. The goal is to provide up to date consumption advice for their CORA member tribes. For the first time since the program started, CORA has included fatty acid analysis in 2016 monitoring of fish in Lake Superior. Ten species were targeted by CORA based on 25 years of experience and regular discussions with Anishinaabe fish consumers. This paper reports these results and presents some preliminary discussion of the consequences for consumption advice for the CORA member tribes who inhabit the Great Lakes region. Six of the species were sampled from Lake Huron and Lake Superior and four were sampled from supermarkets. Wild caught fish are an important link to the culture of Great Lakes Native American tribes and important sources of food and omega-3 polyunsaturated fatty acids (PUFA N-3). While some PUFA N-3 data from the Great Lakes is available, this dataset provides an important supplement and is specific to the 1836-treaty ceded waters of CORA. This paper confirms the presence of PUFA N-3s in Great Lakes fish traditionally harvested by the CORA tribes.

Mercury, Polychlorinated Biphenyls, Selenium, and Fatty Acids in Tribal Fish Harvests of the Upper Great Lakes.

The Chippewa Ottawa Resource Authority monitors fish contaminants in Anishinaabe (Great Lake Native American) tribal fisheries. This article updates previously reported trends in two persistent bioaccumulative toxic (PBT) substances that are the primary contributors to consumption advisory limits for these fish: methylmercury (MeHg) and polychlorinated biphenyls (PCBs). Also, we report, for the first time, an analysis of nutritional benefit bioindicators and metrics in these same Upper Great Lakes fish harvests: selenium (Se) and omega-3 fatty acids (PUFA-3s). A novel risk/benefit quantification originally presented by Ginsberg et al. is reported here to characterize the tradeoffs between fatty acid benefits and toxic MeHg health outcomes. We also report a Se benefit metric to characterize the possible protective value against MeHg neurotoxicity based on Ralston et al. Congruent with Anishinaabe cultural motivations to consume fish from their ancestral fisheries, nutritional content was high in locally caught fish and, in some respects, superior to farmed/store-bought fish. These Great Lakes fish still contained levels of PBTs that require careful education and guidance for consumers. However, the contaminant trends suggest that these fish need not be abandoned as important (both culturally and nutritionally) food sources for the Anishinaabe who harvested them.

Disparities in fertility-sparing surgery in adolescent and young women with stage I ovarian dysgerminoma.

BACKGROUND: In many cancers, racial and socioeconomic disparities exist regarding the extent of surgery. For ovarian dysgerminoma, fertility-sparing (FS) surgery is recommended whenever possible. The aim of this study was to investigate rates of FS versus non-fertility-sparing (NFS) procedures for stage I ovarian dysgerminoma in adolescents and young adults (AYAs) by ethnicity/race and socioeconomic status. MATERIALS AND METHODS: The National Cancer Data Base was queried for patients with ovarian dysgerminoma from 1998 to 2012. After selecting patients aged 15-39 y with stage I disease, a multivariate regression analysis was performed, and rates of FS and NFS procedures were compared, first according to ethnicity/race, and then by socioeconomic surrogate variables. RESULTS: Among the 687 AYAs with stage I ovarian dysgerminoma, there was no significant difference in rates of FS and NFS procedures based on ethnicity/race alone (P = 0.17), but there was a significant difference in procedure type for all three socioeconomic surrogates. The uninsured had higher NFS rates (30%) than those with government (21%) or private (19%) insurance (P = 0.036). Those in the poorest ZIP codes had almost twice the rate of NFS procedures (31%) compared with those in the most affluent ZIP codes (17%). For those in the least-educated regions, 24% underwent NFS procedures compared to 14% in the most-educated areas (P = 0.027). CONCLUSIONS: AYAs with stage I ovarian dysgerminoma in lower socioeconomic groups were more likely to undergo NFS procedures than those in higher socioeconomic groups, but there was no difference in rates of FS versus NFS procedures by ethnicity/race. Approaches aimed at reducing socioeconomic disparities require further examination.

Testicular tumors in prepubescent patients.

BACKGROUND/PURPOSE: Pediatric testicular tumors are rare, constituting only 1% of all pediatric solid tumors. Single-institution studies addressing pediatric testicular tumors published to date have been limited in the number of patients. METHODS: We utilized the National Cancer Data Base (1998-2012) to review all prepubescent patients (≤12 years old) with testicular neoplasms. Demographics, tumor characteristics, treatment modalities, and outcomes were abstracted. RESULTS: A total of 479 patients were identified, with a median age of 3 years (IQR 0-4) at diagnosis. 67% of cases were diagnosed by 3 years of age. Yolk sac tumors were the most common histology (202 patients, 42.2%). Most tumors were diagnosed at a low stage. Resection was performed in 465 boys, with 75% having undergone radical orchiectomies. Chemotherapy was utilized in 28% of cases and radiotherapy in 7%. With mean follow-up of 5.6 years, mortality rate was 3%. No difference in mortality was noted based on histology or extent of surgical resection. CONCLUSIONS: This series of prepubertal testicular tumors is the largest yet reported and highlights the patient demographics, tumor characteristics, treatment modalities and outcomes for these tumors. TYPE OF STUDY: Prognosis study LEVEL OF EVIDENCE: II.

Socioeconomic disparities affect survival in malignant ovarian germ cell tumors in AYA population.

BACKGROUND: Malignant ovarian germ cell tumors (MOGCTs) are a rare form of ovarian malignancy. Socioeconomic status (SES) has been shown to affect survival in several gynecologic cancers. We examined whether SES impacted survival in adolescent and young adults (AYAs) with MOGCT. MATERIALS AND METHODS: The National Cancer Data Base was used to identify AYAs (aged 15-39 years) with MOGCT from 1998 to 2012. Three SES surrogate variables identified were as follows: insurance type, income quartile, and education quartile. Pooled variance t-tests and chi-square tests were used to compare tumor characteristics, the time from diagnosis to staging/treatment, and clinical outcome variables for each SES surrogate variable, while controlling for age and race/ethnicity in a multivariate model. Kaplan-Meier survival estimates were calculated using the log-rank test. RESULTS: A total of 3125 AYAs with MOGCT were identified. Subjects with lower SES measures had higher overall stage and T-stage MOGCTs at presentation. There was no significant difference in the time to staging/treatment, extent of surgery, or use of chemotherapy by SES. Subjects from a lower education background, from a lower income quartile, and without insurance had decreased survival (P ≤ 0.02 for all). Controlling for overall stage and T-stage, the difference in survival was no longer significant. CONCLUSIONS: AYAs with MOGCT from lower SES backgrounds presented with more advanced stage disease. Further studies that focus on the underlying reasons for this difference are needed to address these disparities.