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PURPOSE: Recent studies demonstrate the success of Kasai portoenterostomy for biliary atresia (BA) is linearly related to infant age at time of Kasai. We sought to review the feasibility and safety of laparoscopic needle micropuncture cholangiogram with concurrent core liver biopsy (if needed) for expedited exclusion of BA in patients with direct conjugated hyperbilirubinemia. METHODS: Expedited laparoscopic cholangiogram and liver biopsy were instituted at our facility for infants with direct hyperbilirubinemia for whom clinical exam and laboratory workup failed to diagnose. A retrospective chart review was performed in infants <1 year with hyperbilirubinemia from 2016 to 2021. Demographics, preoperative evaluation, procedure details, and complications were reviewed. RESULTS: Two hundred ninety-seven infants with unspecified jaundice were identified, of which, 86 (29%) required liver biopsy. Forty-seven percutaneous liver biopsies were obtained including 8 (17%) in whom BA could not be excluded. Laparoscopic cholangiogram was attempted in 47 infants following basic workup; BA was diagnosed in 22 infants (47%) of which 3 were <18 days old. Biliary patency was demonstrated laparoscopically in 22 of 25 (88%); 3 (12%) required conversion to open cholangiogram. Infants with percutaneous liver biopsy had an average delay of 3 days (range: 2-36) to cholangiogram. Preoperative studies and liver biopsy alone did not reliably exclude the diagnosis of BA. CONCLUSION: Laparoscopic cholangiogram with liver biopsy is a safe procedure resulting in the confirmation or exclusion of BA in infants. Forty-seven percent of infants who underwent laparoscopic cholangiogram were found to have BA; those who were surgical candidates underwent Kasai during the same operation.
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Atresia Biliar , Laparoscopía , Humanos , Lactante , Atresia Biliar/diagnóstico , Atresia Biliar/cirugía , Atresia Biliar/complicaciones , Biopsia/efectos adversos , Hiperbilirrubinemia/diagnóstico , Laparoscopía/métodos , Hígado/patología , Portoenterostomía Hepática/métodos , Estudios Retrospectivos , Resultado del Tratamiento , Estudios de FactibilidadRESUMEN
PURPOSE: Thyroid cancer is a common subsequent malignant neoplasm in childhood cancer survivors (CCS). Patients who received radiotherapy (RT) to the head, neck, upper thorax, or total body irradiation (TBI) are considered to be at risk for subsequent thyroid cancer. Current Children's Oncology Group screening guidelines recommend annual neck palpation. Our objective was to determine if ultrasound (US) is more sensitive and specific than palpation to detect thyroid cancer in high-risk CCS and bone marrow transplant (BMT) survivors. METHODS: Electronic medical records of patients followed in a longitudinal survivorship clinic from January 1, 2010 to December 31, 2017 were reviewed. Inclusion criteria included history of RT to the head, neck, upper thorax, or TBI for primary therapy or preparation for BMT prior to the age of 20 years. RESULTS: Two hundred and twenty-five patients had documented palpation and 144 (64%) also had US evaluation. Mean radiation dose was 28.6 Gy. Sixteen of 225 patients (7.1%) developed a subsequent thyroid cancer at a mean of 9.7 years from the completion of RT. Sensitivity of US was 100% compared with 12.5% for palpation. US demonstrated higher accuracy, with a receiver operating characteristic (ROC) area under the curve (AUC) of 0.87 versus 0.56 for palpation (P < 0.0001). CONCLUSION: Routine screening with US was more sensitive than palpation for detection of subsequent thyroid cancer after high-risk RT in CCS and BMT survivors. Screening US may lead to earlier detection of thyroid cancer in this population. Earlier diagnosis has the potential to decrease operative complexity, and earlier definitive therapy reduces the likelihood of metastatic disease.
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Supervivientes de Cáncer/estadística & datos numéricos , Neoplasias Primarias Secundarias/diagnóstico , Neoplasias Primarias Secundarias/epidemiología , Neoplasias de la Tiroides/diagnóstico , Neoplasias de la Tiroides/epidemiología , Adolescente , Adulto , Trasplante de Médula Ósea/efectos adversos , Trasplante de Médula Ósea/estadística & datos numéricos , Niño , Detección Precoz del Cáncer , Registros Electrónicos de Salud , Femenino , Humanos , Masculino , Neoplasias Primarias Secundarias/diagnóstico por imagen , Neoplasias Primarias Secundarias/etiología , Palpación , Estudios Retrospectivos , Factores de Riesgo , Neoplasias de la Tiroides/diagnóstico por imagen , Neoplasias de la Tiroides/etiología , Ultrasonografía/métodos , Irradiación Corporal Total/efectos adversos , Irradiación Corporal Total/estadística & datos numéricos , Adulto JovenRESUMEN
PURPOSE: Sickle cell patients receiving chronic RBC exchange require a form of long-term central venous access if peripheral access is inadequate. In adults, dual lumen (DL) ports have been utilized but associated with greater procedure complications and duration when compared to other forms of access. In the pediatric sickle cell population, the use of DL ports for RBC exchange has not been well described. In this retrospective cohort study, RBC exchange procedures utilizing DL ports in the pediatric vs adult sickle cell population were compared. METHODS: Medical records were reviewed for 685 RBC exchange procedures performed on 25 patients (11 pediatric and 14 adult) between November 2014 to November 2018. Patient-level characteristics and outcomes were compared between pediatric and adult patients using the Fisher-exact and Wilcoxon-rank sum test. Linear/logistic regression models examined procedure-level parameters and port characteristics with adjustment for clustering. RESULTS: Compared to adults, pediatric patients had slower average maximum inlet speed (42 vs 53 mL/min, P < .01), but shorter procedure time (60 vs 75 minutes, P < .01) and lower rate of access alarms (1% vs 11%, P < .01). Overall, 0.29 thrombotic events per 1000 port days and 0.04 infections per 1000 port days were observed. CONCLUSION: For adult and pediatric sickle cell patients, a DL port provides a viable option for RBC exchange. In comparison to adults, pediatric procedures with a DL port will typically be shorter and with less procedural complications due to smaller blood volumes and lower flow requirements.
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Anemia de Células Falciformes/terapia , Eritrocitos/citología , Pediatría/métodos , Plasmaféresis/métodos , Adolescente , Adulto , Niño , Preescolar , Estudios de Cohortes , Femenino , Humanos , Lactante , Masculino , Estudios Retrospectivos , Adulto JovenRESUMEN
Anorectal complaints are not uncommon in pediatric care, but the etiology and management can differ significantly from adults. Age is an important factor when considering etiology and management, distinguishing between infants, children, and adolescents. For all ages, malignancy is rarely a consideration, but a thorough examination of infants and children typically requires deep sedation or general anesthesia. Very little primary literature or evidence exists to guide care; so there are many opportunities for careful study to enhance our understanding beyond personal experience and historical practice patterns.
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INTRODUCTION: Clinical clearance of a child's cervical spine after trauma is often challenging because of impaired mental status or an unreliable neurologic examination. Magnetic resonance imaging (MRI) is the criterion standard for excluding ligamentous injury in children but is constrained by long image acquisition times and frequent need for anesthesia. Limited-sequence magnetic resonance imaging (LSMRI) is used in evaluating the evolution of traumatic brain injury and may also be useful for cervical spine clearance while potentially avoiding the need for anesthesia. The purpose of this study was to assess the sensitivity and negative predictive value of LSMRI as compared with criterion standard full-sequence MRI as a screening tool to rule out clinically significant ligamentous cervical spine injury. METHODS: We conducted a 10-center, 5-year retrospective cohort study (2017-2021) of all children (0-18 years) with a cervical spine MRI after blunt trauma. Magnetic resonance imaging images were rereviewed by a study pediatric radiologist at each site to determine if the presence of an injury could be identified on limited sequences alone. Unstable cervical spine injury was determined by study neurosurgeon review at each site. RESULTS: We identified 2,663 children younger than 18 years who underwent an MRI of the cervical spine with 1,008 injuries detected on full-sequence studies. The sensitivity and negative predictive value of LSMRI were both >99% for detecting any injury and 100% for detecting any unstable injury. Young children (younger than 5 years) were more likely to be electively intubated or sedated for cervical spine MRI. CONCLUSION: Limited-sequence magnetic resonance imaging is reliably detects clinically significant ligamentous injury in children after blunt trauma. To decrease anesthesia use and minimize MRI time, trauma centers should develop LSMRI screening protocols for children without a reliable neurologic examination. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level III.
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Vértebras Cervicales , Imagen por Resonancia Magnética , Sensibilidad y Especificidad , Traumatismos Vertebrales , Humanos , Imagen por Resonancia Magnética/métodos , Estudios Retrospectivos , Niño , Preescolar , Vértebras Cervicales/lesiones , Vértebras Cervicales/diagnóstico por imagen , Adolescente , Femenino , Lactante , Masculino , Traumatismos Vertebrales/diagnóstico por imagen , Traumatismos Vertebrales/cirugía , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/cirugía , Valor Predictivo de las Pruebas , Recién NacidoRESUMEN
Hair tourniquet syndrome has been recognized as a medical entity since the 1600 s. Appendages develop acute ischemia from tightening of hair strands circumferentially wrapped around them. Most commonly affected sites are fingers, toes, and penis, but limited reports have described involvement of the female genitalia. Although hair strangulation involving the labia minora or clitoris has been described, it typically occurs in young children. We present a case of an adolescent girl with a labial appendage hair tourniquet resulting from a previous unrepaired genital laceration. This is one of the oldest patients in whom a genital hair tourniquet has been reported, as well as description of a posttraumatic genital appendage. Genital hair tourniquets are medical emergencies that require prompt diagnosis and treatment to avoid tissue necrosis and possible amputation. Genital trauma in general requires surgical evaluation.
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Cabello , Isquemia/etiología , Vulva/irrigación sanguínea , Accidentes por Caídas , Niño , Femenino , Humanos , Laceraciones/complicaciones , Vulva/lesiones , Vulva/cirugía , Cicatrización de HeridasRESUMEN
BACKGROUND: Non-operative management of blunt liver and spleen injuries was championed initially in children with the first management guideline published in 2000 by the American Pediatric Surgical Association (APSA). Multiple articles have expanded on the original guidelines and additional therapy has been investigated to improve care for these patients. Based on a literature review and current consensus, the management guidelines for the treatment of blunt liver and spleen injuries are presented. METHODS: A recent literature review by the APSA Outcomes committee [2] was utilized as the basis for the guideline recommendations. A task force was assembled from the APSA Committee on Trauma to review the original guidelines, the literature reported by the Outcomes Committee and then to develop an easy to implement guideline. RESULTS: The updated guidelines for the management of blunt liver and spleen injuries are divided into 4 sections: Admission, Procedures, Set Free and Aftercare. Admission to the intensive care unit is based on abnormal vital signs after resuscitation with stable patients admitted to the ward with minimal restrictions. Procedure recommendations include transfusions for low hemoglobin (<7 mg/dL) or signs of ongoing bleeding. Angioembolization and operative exploration is limited to those patients with clinical signs of continued bleeding after resuscitation. Discharge is based on clinical condition and not grade of injury. Activity restrictions remain the same while follow-up imaging is only indicated for symptomatic patients. CONCLUSION: The updated APSA guidelines for the management of blunt liver and spleen injuries present an easy-to-follow management strategy for children. LEVEL OF EVIDENCE: Level 5.
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Traumatismos Abdominales , Heridas no Penetrantes , Niño , Humanos , Bazo/lesiones , Heridas no Penetrantes/terapia , Heridas no Penetrantes/cirugía , Hígado/cirugía , Hospitalización , Alta del Paciente , Estudios RetrospectivosRESUMEN
BACKGROUND/PURPOSE: Breast masses in the pediatric population cause patient and family concern, partially driven by public awareness of adult breast cancer. However, the spectrum of breast masses in children differs greatly from that in adults, and malignancy is exceedingly rare. The American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) ultrasound-based classification system is the diagnostic standard, yet no study has validated BI-RADS in pediatric patients. This study compares BI-RADS classification with histologic diagnoses to evaluate BI-RADS validity in pediatric patients. METHODS: Multicenter retrospective evaluation of breast masses in patients under 21 years. Ultrasound reports were compared with histologic diagnoses. RESULTS: There were 283 patients with breast pathology results after excluding clinical diagnoses of gynecomastia. Mean age was 16.9 (SD 2.3), ranging 10-20 years. 227 had pre-operative ultrasounds, and 84% (191/227) were assigned a BI-RADS category. BI-RADS 4 was the most frequent category (55%, n = 124), by definition predicting 2 - 95% likelihood of malignancy. However, pathology was benign in all patients. CONCLUSIONS: The current BI-RADS categorization system overestimates cancer risk when applied to pediatric patients. BI-RADS scores should not be assigned to pediatric patients, and BIRADS-defined recommendations for biopsy should be disregarded. A pediatric-specific classification system could be useful.
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Neoplasias de la Mama , Ultrasonografía Mamaria , Adolescente , Adulto , Mama/diagnóstico por imagen , Neoplasias de la Mama/diagnóstico por imagen , Niño , Femenino , Humanos , Estudios Retrospectivos , UltrasonografíaRESUMEN
Parathyroid glands are critical for calcium and phosphate homeostasis. Parathyroid disease is relatively rare in the pediatric population, but there are some important pediatric-specific considerations and conditions. This article reviews parathyroid physiology, disorders of hyper- and hypo- function, operative management, and uniquely pediatric diagnoses such as neonatal severe hyperparathyroidism. Advances in preoperative imaging, intra-operative gland identification, and management of post-thyroidectomy hypocalcemia are also presented in detail. This article combines a review of fundamentals with recent advances in care, emphasizing pediatric-specific publications.
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Enfermedades de las Paratiroides/cirugía , Paratiroidectomía , Adolescente , Biomarcadores/metabolismo , Niño , Preescolar , Humanos , Lactante , Recién Nacido , Enfermedades de las Paratiroides/diagnóstico , Enfermedades de las Paratiroides/metabolismo , Enfermedades de las Paratiroides/fisiopatología , Glándulas Paratiroides/metabolismo , Glándulas Paratiroides/fisiología , Glándulas Paratiroides/fisiopatología , Glándulas Paratiroides/cirugía , Hormona Paratiroidea/metabolismo , Atención Perioperativa/métodos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/terapiaRESUMEN
BACKGROUND: Atlanto-occipital transarticular screw fixation (AOTSF) has rarely been reported for fixation of the craniovertebral junction (CVJ). METHODS: A retrospective chart review of all pediatric patients (less than 18 years of age) with an attempt of AOTSF for fixation of traumatic CVJ instability was conducted. RESULTS: A total of 4 patients (2 boys and 2 girls; ages 2, 3, 5, and 8 years) who suffered from acute traumatic CVJ instability managed during 2007-2018 underwent an attempted AOTSF. In 2 patients, this method was technically successful. In the other 2 instances, we were not able to engage the screw into the occipital condyle. These were converted to standard occipital plate, rod, and screw fixation. All were placed in a halo subsequently for a minimum of 3 months. Three patients were fused at last follow-up (range, 17-48 months). One patient after successful AOTSF did not fuse. There were no surgical complications or revision procedures. CONCLUSIONS: AOTSF was feasible in half of pediatric patients suffering from traumatic CVJ instability. Therefore, intraoperative salvage options and strategies should be on hand readily. In the pediatric population, where bony anatomy may pose challenges to fixation, this technique may offer a viable first-line option in selected cases, despite the overall modest success rate.
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Articulación Atlantooccipital/cirugía , Tornillos Óseos , Vértebras Cervicales/cirugía , Inestabilidad de la Articulación/cirugía , Hueso Occipital/cirugía , Fusión Vertebral/métodos , Adolescente , Articulación Atlantooccipital/diagnóstico por imagen , Vértebras Cervicales/diagnóstico por imagen , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Fijadores Internos , Inestabilidad de la Articulación/diagnóstico por imagen , Masculino , Hueso Occipital/diagnóstico por imagen , Estudios Retrospectivos , Fusión Vertebral/instrumentaciónRESUMEN
Objectives Hypocalcemia following total thyroidectomy (TT) is relatively common. It may result in significant morbidity, prolonged hospital stay, and increased costs. Treatment with intravenous (IV) calcium gluconate may also carry significant risks. In pediatrics, management consensus guidelines are lacking. Methods At Phoenix Children's Hospital, a team of pediatric endocrinologists, surgeons and otolaryngologists developed a clinical pathway for patients undergoing TT. It was a Quality Improvement (QI) project with the primary aim of decreasing IV calcium gluconate use from a baseline of 68% to less than 40% over 15 months. Secondary aims included reducing hypocalcemia and length of hospitalization. Interventions included sending weekly pathway reminder emails, starting pre-operative calcium, and pathway implementation into the electronic health record. Results Twenty-seven patients underwent TT over 15 months. IV calcium gluconate use dropped to 48%. Hypocalcemia and length of hospitalization were 96% and 52.7 h (range 21.1-115.7) respectively. Pathway adherence improved after targeted interventions. Eleven (73%) of the 15 patients whose post-operative parathyroid hormone (PTH) nadir was below 15 pg/mL required IV calcium gluconate vs. two (17%) out of 12 with levels above this threshold. Conclusions Standardizing care allowed for objective outcome analysis. We learned that post-operative serum PTH level was the main risk factor for requiring IV calcium gluconate. Implementing the pathway as a QI project allows for revisions based on outcomes, ultimately resulting in a pathway that best utilizes our infrastructure to optimize care. Other pediatric institutions may face similar challenges and can potentially learn from our experience.
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Hipocalcemia/terapia , Complicaciones Posoperatorias/terapia , Mejoramiento de la Calidad/organización & administración , Enfermedades de la Tiroides/cirugía , Tiroidectomía/efectos adversos , Adolescente , Edad de Inicio , Calcio/sangre , Niño , Vías Clínicas/organización & administración , Vías Clínicas/normas , Vías Clínicas/estadística & datos numéricos , Femenino , Humanos , Hipocalcemia/sangre , Hipocalcemia/epidemiología , Hipocalcemia/etiología , Ciencia de la Implementación , Tiempo de Internación/estadística & datos numéricos , Masculino , Disección del Cuello/efectos adversos , Disección del Cuello/métodos , Disección del Cuello/normas , Disección del Cuello/estadística & datos numéricos , Hormona Paratiroidea/sangre , Complicaciones Posoperatorias/sangre , Complicaciones Posoperatorias/epidemiología , Evaluación de Programas y Proyectos de Salud , Mejoramiento de la Calidad/normas , Estudios Retrospectivos , Enfermedades de la Tiroides/sangre , Enfermedades de la Tiroides/epidemiología , Tiroidectomía/normas , Tiroidectomía/estadística & datos numéricos , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Helmets are effective in reducing traumatic brain injury. However, population effects of helmet laws have not been well described. This study assesses the impact of helmet laws on the motorcycle (MC) fatality rate in the United States from 1999 to 2015. METHODS: Fatality Analysis Reporting System MC fatalities (aged ≥16 years), crash characteristics, and MC-related laws were collected by year for all 50 states from 1999 to 2015 to create a pooled time series. Generalized linear autoregressive modeling was applied to assess the relative contribution of helmet laws to the MC fatality rate while controlling for other major driver laws and crash characteristics. RESULTS: Universal helmet laws were associated with a 36% to 45% decline in the motorcycle crash mortality rate during the study period across all age cohorts (unstandardized regression coefficients are reported): 16 to 20 years, B = -0.45 (p < 0.05); 21 to 55 years, B = -0.42 (p < 0.001); 56 to 65 years, B = -0.38 (p < 0.04); and older than 65 years, B = -0.36 (p < 0.02). Partial helmet laws were associated with a 1% to 81% increase in the fatality rate compared with states with no helmet laws and a 22% to 45% increase compared with universal laws. Helmet usage did not attenuate the countervailing effect of weaker partial laws for 16 to 20 years (B = 0.01 [p < 0.001]). Other laws associated with a declining motorcycle crash mortality rate included the following: social host/overservice laws, 21 to 55 years (B = -0.38 [p < 0.001]); 56 to 65 years (B = -0.16 [p < 0.002]), and older than 65 years (B = -0.12 [p < 0.003]); laws reducing allowable blood alcohol content, 21 to 55 years (B = -4.9 [p < 0.02]); and laws limiting passengers for new drivers 16 to 20 years (B = -0.06 [p < 0.01]). CONCLUSION: During the period of the study, universal helmet laws were associated with a declining mortality rate, while partial helmet laws were associated with an increasing mortality rate. Other state driver laws were also associated with a declining rate. In addition to universal helmet laws, advocating for strict alcohol control legislation and reevaluation of licenses in older riders could also result in significant reduction in MC-related mortality. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.
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Accidentes de Tránsito/mortalidad , Lesiones Traumáticas del Encéfalo/mortalidad , Dispositivos de Protección de la Cabeza , Motocicletas/legislación & jurisprudencia , Adolescente , Adulto , Anciano , Lesiones Traumáticas del Encéfalo/etiología , Lesiones Traumáticas del Encéfalo/prevención & control , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Motocicletas/estadística & datos numéricos , Estados Unidos/epidemiología , Adulto JovenRESUMEN
Central venous catheters (CVC) are commonplace in the management of critically ill patients and serve a variety of purposes. Venous access is important for the administration of fluid and medications as well as blood procurement needed for lab analyses. However, not every critically ill patient requires a CVC. This article highlights the key considerations, pitfalls and evidence-based practices regarding the use pediatric central venous catheters.
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Cateterismo Venoso Central/métodos , Adolescente , Cateterismo Venoso Central/efectos adversos , Cateterismo Venoso Central/instrumentación , Catéteres Venosos Centrales , Niño , Preescolar , Enfermedad Crítica , HumanosRESUMEN
Background: Esophagojejunostomy is facilitated by use of a circular stapler, particularly when performed laparoscopically. The minimum patient size that will allow use of circular staplers in the small intestine is unknown. Materials and Methods: Retrospective review of esophagogastric dissociations performed at a single tertiary care institution for 48 months. This was combined with a geometric derivation of a size-estimation formula. Results: From the 7 cases identified, patients weighing >16 kg easily accommodated the 21 mm stapler. There was a narrow fit in the patient weighing 13.6 kg, and the 6 kg patient was too small for the stapler. Conclusions: Through a combination of clinical observation and physical reasoning, circular stapler applicability in small intestine is predicted by patient weight or intestinal measurement. Patients weighing >16 kg will accept the stapler, whereas patients <13 kg are likely too small. Alternately, on the basis of a geometric derivation, if the width of the flat intestine is >1.6 × the device diameter, the device will fit. This calculation can be applied broadly (e.g., incision length for laparoscopic ports or single-port access devices).
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Anastomosis Quirúrgica/instrumentación , Esófago/cirugía , Gastrectomía/métodos , Yeyuno/cirugía , Neoplasias Gástricas/cirugía , Engrapadoras Quirúrgicas , Adulto , Niño , Preescolar , Femenino , Humanos , Masculino , Estudios Retrospectivos , Adulto JovenAsunto(s)
Accidentes de Tránsito/prevención & control , Teléfono Celular , Seguridad , Heridas y Lesiones/prevención & control , Accidentes de Tránsito/mortalidad , Niño , Sordera , Equipos y Suministros Eléctricos/efectos adversos , Resultado Fatal , Humanos , Masculino , Índices de Gravedad del Trauma , Heridas y Lesiones/mortalidadAsunto(s)
Quemaduras/diagnóstico , Quemaduras/terapia , Servicios Médicos de Urgencia , Primeros Auxilios , Adolescente , Atención Ambulatoria/métodos , Unidades de Quemados , Quemaduras/clasificación , Quemaduras/mortalidad , Niño , Preescolar , Cuidados Críticos/métodos , Comparación Transcultural , Estudios Transversales , Fluidoterapia/métodos , Humanos , Incidencia , Lactante , Pronóstico , Derivación y Consulta , Trasplante de Piel/métodos , Tasa de SupervivenciaRESUMEN
BACKGROUND: Machine-learning can elucidate complex relationships/provide insight to important variables for large datasets. This study aimed to develop an accurate model to predict neonatal surgical site infections (SSI) using different statistical methods. METHODS: The 2012-2015 National Surgical Quality Improvement Program-Pediatric for neonates was utilized for development and validations models. The primary outcome was any SSI. Models included different algorithms: full multiple logistic regression (LR), a priori clinical LR, random forest classification (RFC), and a hybrid model (combination of clinical knowledge and significant variables from RF) to maximize predictive power. RESULTS: 16,842 patients (median age 18 days, IQR 3-58) were included. 542 SSIs (4%) were identified. Agreement was observed for multiple covariates among significant variables between models. Area under the curve for each model was similar (full model 0.65, clinical model 0.67, RF 0.68, hybrid LR 0.67); however, the hybrid model utilized the fewest variables (18). CONCLUSIONS: The hybrid model had similar predictability as other models with fewer and more clinically relevant variables. Machine-learning algorithms can identify important novel characteristics, which enhance clinical prediction models.
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Algoritmos , Técnicas de Apoyo para la Decisión , Aprendizaje Automático , Infección de la Herida Quirúrgica/etiología , Área Bajo la Curva , Femenino , Humanos , Lactante , Recién Nacido , Modelos Logísticos , Masculino , Curva ROC , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Infección de la Herida Quirúrgica/diagnóstico , Infección de la Herida Quirúrgica/prevención & controlRESUMEN
PURPOSE: Considering the improvements in CT over the past decade, this study aimed to determine whether CT can diagnose HVI in pediatric trauma patients with seatbelt signs (SBS). METHODS: We retrospectively identified pediatric patients with SBS who had abdominopelvic CT performed on initial evaluation over 5 1/2years. Abnormal CT was defined by identification of any intra-abdominal abnormality possibly related to trauma. RESULTS: One hundred twenty patients met inclusion criteria. CT was abnormal in 38/120 (32%) patients: 34 scans had evidence of HVI and 6 showed solid organ injury (SOI). Of the 34 with suspicion for HVI, 15 (44%) had small amounts of isolated pelvic free fluid as the only abnormal CT finding; none required intervention. Ultimately, 16/120 (13%) patients suffered HVI and underwent celiotomy. Three patients initially had a normal CT but required celiotomy for clinical deterioration within 20h of presentation. False negative CT rate was 3.6%. The sensitivity, specificity and accuracy of CT to diagnose significant HVI in the presence of SBS were 81%, 80%, and 80%, respectively. CONCLUSIONS: Despite improvements in CT, pediatric patients with SBS may have HVI not evident on initial CT confirming the need to observation for delayed manifestation of HVI. LEVEL OF EVIDENCE: Level II Study of a Diagnostic Test.
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Traumatismos Abdominales/diagnóstico por imagen , Accidentes de Tránsito , Tomografía Computarizada por Rayos X , Heridas no Penetrantes/diagnóstico por imagen , Traumatismos Abdominales/etiología , Adolescente , Niño , Preescolar , Femenino , Humanos , Masculino , Estudios Retrospectivos , Sensibilidad y Especificidad , Heridas no Penetrantes/etiologíaRESUMEN
HYPOTHESIS: Biological dressings can be effective tools in the management of enteric fistulas, which are the nemesis of exposed viscera. DESIGN: Retrospective review of medical records. SETTING: University-affiliated level I trauma center. PATIENTS: Patients with open abdominal cavities and coexistent intestinal fistulas who were treated between January 1, 1999, and July 1, 2006. INTERVENTIONS: Application of biological dressings to fistula sites within open abdominal cavities during serial fascial closure. Biological dressings included cadaveric skin, human acellular dermal matrix, and fibrin sealant. MAIN OUTCOME MEASURES: Enteric fistula closure and healing of the abdominal wound. RESULTS: During the 6 years under review, there were 69 patients with open abdomens. Of these patients, 7 (10%) developed enteric fistulas and underwent application of biological dressings. In 5 patients, fistulas closed and the abdominal wound healed after application of biological dressings. One additional patient healed after fistula resection. Biological dressing treatment and fistula resection both failed in 1 patient. There was no morbidity or mortality attributable to the intervention. CONCLUSIONS: Intestinal fistulas significantly complicate the management of patients with open abdomens. In this case series, biological dressings were effective in achieving fistula closure. A prospective multi-institutional study is required to confirm these preliminary encouraging results.