Serum Amyloid P Attenuates Hypertrophic Scarring in Large Animal Models.

INTRODUCTION: This study's purpose was to (1)determine the effect of locally administered serum amyloid P (SAP) on the development of hypertrophic scars (HTS) in porcine and rabbit HTS models and (2)determine the pharmacokinetics of systemically administered SAP and its effect on circulating fibrocyte quantities. METHODS: Two large animal (New Zealand White Rabbit and Female Red Duroc Pigs) HTS models were utilized to study the effects of daily local injections of SAP immediately post wounding (x5 d in rabbits; x7 d in pigs) on HTS development as measured by scar elevation index , scar area, wound closure, and molecular expression studies of scar components. For SAP pharmacokinetics, total and human SAP levels in porcine blood were measured at regular intervals following intravenous administration of human SAP. Fibrocyte quantities were determined prior to and 1 h following human SAP intravenous administration. RESULTS: In the rabbit model, local SAP significantly decreased the level of tissue inhibitor of metalloproteinases-1 mRNA expression and maintained matrix mettaloproteinase-9 expression, while control and vehicle groups significantly declined. In the pig model, there was a significant decrease in the trend of scar elevation indexes treated with local SAP versus controls over the study period. This decrease was statistically significant at days 14 and 84. Human SAP administered intravenously is degraded within 24 h and does not influence circulating fibrocyte quantities. CONCLUSIONS: This is the first study to demonstrate attenuation of HTS formation using locally administered SAP in large animal HTS models. Local SAP administration reduces HTS formation by maintaining matrix mettaloproteinase-9 and decreasing tissue inhibitor of metalloproteinases-1. Intravenous administration of SAP is not as effective.

Trends in Management of Index Adhesive Small Bowel Obstruction in Children.

INTRODUCTION: To examine practice patterns and surgical outcomes of nonoperative versus operative management (OPM) of children presenting with an index adhesive small bowel obstruction (ASBO). METHODS: A California statewide health discharge database was used to identify children (<18 y old) with an index ASBO from 2007 to 2020. The primary study outcome was evaluating initial management patterns (nonoperative versus OPM and early [≤3 d] versus late surgery [>3 d]) of ASBO. Secondary outcomes were hospital characteristics, patient demographics, and postoperative complications. RESULTS: Of the 2297 patients identified, 1948 (85%) underwent OPM for ASBO during the index admission. Of these, 14.7% underwent early surgery within 3 d. Teaching hospitals had higher operative intervention than nonteaching centers (87.1% versus 83.7%, P = 0.034). OPM was the highest in 0-5-year-olds compared to other ages (89% versus 82%, P < 0.001). In comparison to early surgery, late surgery was associated with longer length of stay (early 7[interquartile range 5-10], late 9[interquartile range 6-17], P < 0.001), increased infectious complications (16.4% versus 9.8%, P = 0.004), and greater use of total parenteral nutrition (28.0% versus 14.3%, P = 0.001); there was no difference in bowel resection (21% versus 18%, P = 0.102) or mortality (P = 0.423). CONCLUSIONS: Our pediatric study demonstrated a high rate of OPM for index ASBO, especially in newborns and toddlers. Although operative intervention, especially late surgery, was associated with increased length of stay, increased infectious complications, and increased total parenteral nutrition use, the rates of bowel resection and mortality did not differ by management strategy. These trends need to be further evaluated to optimize outcomes.

Bike Helmet Usage in the Most Disadvantaged Neighborhoods: A Focused Area for Trauma Prevention.

INTRODUCTION: There is a paucity of data to describe how neighborhood socioeconomic disadvantage (NSD) correlates with childhood injuries and outcomes. This study assesses the relationship of NSD to bicycle safety and trauma outcomes among pediatric bicycle versus automobile injuries. METHODS: Between 2008 and 2018, patients ≤18 y old with bicycle versus automobile injuries from a Level I pediatric trauma center were evaluated. Area Deprivation Index (ADI) was used to measure NSD. Patient demographics, injury, clinical data characteristics, and bike safety were analyzed. Traffic scene data from the Statewide Integrated Traffic Records System were matched to clinical records. Multivariate logistic regression was used to assess demographic characteristics related to helmet usage. RESULTS: Among 321 patients, 84% were male with a median age of 12 y [interquartile range 9-13], and 44% were of Hispanic ethnicity. Hispanic ethnicity was greater in the most disadvantaged ADI groups (P < 0.001). Mortality occurred in two patients, and most (96%) were discharged home. Of Statewide Integrated Traffic Records System matched traffic records, 81% were at locations without a bike lane. No differences were found in GCS, intensive care unit admission, or length of stay by ADI. Hispanic ethnicity and the highest deprivation group were independently associated with lower odds of wearing a helmet (AOR 0.35, 95% confidence interval 0.1-0.9, P = 0.03; AOR 0.33 95% confidence interval 0.17-0.62; P = 0.001), while patient age and sex were unrelated to helmet usage. CONCLUSIONS: Outcomes for bike versus auto trauma remains similar across ADI groups. However, bike helmet usage is significantly lower among Hispanic children and those from neighborhoods with greater socioeconomic disadvantage.

Just Stick a Scope in: Laparoscopic Ventriculoperitoneal Shunt Placement in the Pediatric Reoperative Abdomen.

BACKGROUND: Ventriculoperitoneal shunt (VPS) placement into the reoperative abdomen can be challenging due to intraperitoneal adhesions. Laparoscopic guidance may provide safe abdominal access and identify an area for optimal cerebrospinal fluid drainage. The study aim was to compare laparoscopic-assisted VPS placement to an "open" approach in patients with prior abdominal surgery. MATERIALS AND METHODS: A retrospective review was performed of children undergoing VPS placement into a reoperative abdomen from 2009-2019. Clinical data were collected, and patients undergoing laparoscopy (LAP) were compared to those undergoing an open approach (OPEN). RESULTS: A total of 120 children underwent 169 VPS placements at a median age of 8 y (IQR 2-15 y), and a mean number of two prior abdominal operations (IQR 1-2). Laparoscopy was used in 24% of cases. Shunt-related complications within 30 d were lower in the LAP group (0% versus 19%, P = 0.001), as were VPS-related postoperative emergency department visits (0% versus 13%, P = 0.003) and readmissions (0% versus 13%, P = 0.013). Shunt malfunction rates were higher (42% OPEN versus 25% LAP, P = 0.03) and occurred sooner in the OPEN group (median 26 versus 78 wk, P = 0.01). The LAP group demonstrated shorter operative times (63 versus 100 min, P < 0.0001), and the only bowel injury. Time to feeds, length of stay, and mortality were similar between groups. CONCLUSIONS: Laparoscopic guidance during VPS placement into the reoperative abdomen is associated with a decrease in shunt-related complications, longer shunt patency, and shorter operative times. Prospective study may clarify the potential benefits of laparoscopy in this setting.

Same Anesthesia Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy: The Pediatric ERCP Database Intiative Experience.

BACKGROUND: Successful combined Laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) in the Same Session (LESS) has been reported in several studies in adult patients with choledocholithiasis. METHODS: This was a retrospective analysis of data collected prospectively in the Pediatric ERCP Database Initiative using REDCAP. Adverse events were recorded separately and were reviewed for this study. The primary outcome was the hospitalization days. Secondary outcomes included total duration of anesthesia, morbidity, time from diagnosis to procedure. RESULTS: Twenty-five patients underwent LESS, and 42 underwent the traditional ERCP followed by laparoscopic cholecystectomy. The groups were similar in age, weight, ASA. The median length of stay in the LESS group was 3 days, compared with 4 days (P = .32). Total procedure time was similar between the 2 groups, but anesthesia time was shorter in the LESS group (P = .0401). Morbidity was similarly low between the 2 groups. CONCLUSIONS: Relative to 2 interventions, a single session combining ERCP and laparoscopic cholecystectomy in pediatric patients is effective with a similar adverse event rate and length of stay. The use of a single sedation and reduced total anesthesia time are potential benefits of this approach. This modality may be considered for pediatric patients with choledocholithiasis with or without hemolytic disease.

Potential of the ovine brain as a model for anesthesia-induced neuroapoptosis.

PURPOSE: This study aimed to determine the feasibility of the fetal ovine model for anesthesia-induced neuroapoptosis detection and effect of dexmedetomidine on neuroapoptosis. METHODS: Brains of fetal lambs that underwent tracheal occlusion for congenital diaphragmatic hernia were studied following anesthetic exposure. The brains of nine fetuses from six pregnant sheep were studied. Seven of these fetuses underwent surgery for tracheal balloon insertion at 118-120 days gestational age (GA) under 1.5-2.0% isoflurane for 2-3 h. Two weeks afterward, at balloon retrieval, a repeat anesthetic: 1.5-2% isoflurane for 6 h was administered. Five of these fetuses were also exposed to dexmedetomidine concurrently. Immunohistochemistry of fetal brains for apoptotic neurons using activated caspase-3 antibodies was compared to that of an unexposed control group at GA 109 and 122 days. RESULTS: Neuroapoptosis was detected in the ovine fetus with GA- dependent variation observed in the hippocampus. Increased neuroapoptosis occurred in the isoflurane-only group. Fetuses with isoflurane-dexmedetomidine exposure exhibited decreased neuroapoptosis compared to isoflurane-only group. CONCLUSION: The fetal ovine model is a suitable option for neuroapoptosis analysis. Isoflurane use appears to be associated with additional neuroapoptosis in ovine fetuses undergoing surgical stimulation. Possible amelioration of isoflurane-induced neuroapoptosis by dexmedetomidine deserves further study. Further studies of the effect of gestational age, dose, duration of anesthesia and surgical stimulation on neuroapoptosis are needed.

Abdominal near-infrared spectroscopy measurements are lower in preterm infants at risk for necrotizing enterocolitis.

OBJECTIVE: Near-infrared spectroscopy is a noninvasive method of measuring local tissue oxygenation (StO2). Abdominal StO2 measurements in preterm piglets are directly correlated with changes in intestinal blood flow and markedly reduced by necrotizing enterocolitis. The objectives of this study were to use near-infrared spectroscopy to establish normal values for abdominal StO2 in preterm infants and test whether these values are reduced in infants who develop necrotizing enterocolitis. DESIGN: We conducted a 2-year prospective cohort study where we prospectively measured abdominal StO2 in preterm infants, to establish reference values for preterm infants, and compared the near-infrared spectroscopy values with preterm infants in the cohort that developed necrotizing enterocolitis. SETTING: Two neonatal ICUs: one at Texas Children's Hospital and the other at Ben Taub General Hospital in Houston, TX. PATIENTS: We enrolled 100 preterm infants (< 32 weeks' gestation and < 1,500 g birth weight) between January 2007 and November 2008. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eight neonates with incomplete data were excluded. Mean abdominal StO2 in normal preterm infants (n = 78) during the first week of life was significantly higher than in those who later developed necrotizing enterocolitis (n = 14) (77.3% ± 14.4% vs 70.7% ± 19.1%, respectively, p = 0.002). An StO2 less than or equal to 56% identified preterm infants progressing to necrotizing enterocolitis with 86% sensitivity, 64% specificity, 96% negative predictive value, and 30% positive predictive value. Using logistic regression, StO2 less than or equal to 56% was independently associated with a significantly increased risk of necrotizing enterocolitis (odds ratio, 14.1; p = 0.01). Furthermore, infants with necrotizing enterocolitis demonstrated significantly more variation in StO2 both during and after feeding in the first 2 weeks of life. CONCLUSIONS: This study establishes normal values for abdominal StO2 in preterm infants and demonstrates decreased values and increased variability in those with necrotizing enterocolitis. Abdominal near-infrared spectroscopy monitoring of preterm infants may be a useful tool for early diagnosis and guiding treatment of necrotizing enterocolitis.

A Comparative Study of Laparoscopic versus Open Management of Index Small Bowel Obstruction in Children.

INTRODUCTION: There is limited literature on the optimal approach to treat adhesive small bowel obstruction (ASBO) in children. We sought to compare rates and outcomes of laparoscopic (LAP) and open (OPEN) surgery for pediatric ASBO. METHODS: A California statewide database was used to identify children (<18 years old) with an index ASBO from 2007 to 2020. The primary outcome was the type of operative management: LAP or OPEN. Secondary outcomes were hospital characteristics, patient demographics, and postoperative complications. We excluded patients treated non-operatively. RESULTS: Our study group had 545 patients. 381 (70%) underwent OPEN and 164 (30%) LAP during the index admission. Over the study period, there was increasing use of laparoscopic surgery, with higher use in older children (p < 0.001). LAP was associated with fewer overall complications (65.2% vs. 81.6%, p < 0.001), with a decreasing trend in complications over time (p < 0.001). The LAP group had significantly lower rates of bowel resection (4.9% vs. 17.1%, p < 0.001), length of stay (LOS) (17 vs. 23 days, p < 0.001), and TPN use (12.2% vs. 29.1%, p < 0.001). Mortality rates were equivalent. Although the LAP group had lower readmission rates (22.6% vs. 37.3%, p < 0.001), the length of time between discharge and readmission was similar (171 vs. 165 days, p = 0.190). DISCUSSION: The use of laparoscopic surgery for index ASBO increased over the study period. However, it was less commonly utilized in younger children. LAP had fewer overall complications as well as shorter LOS, decreased TPN use, and fewer readmissions. The benefits and risks of each approach must be weighed. LEVEL OF EVIDENCE: III.

The use of ECMO for persistent pulmonary hypertension of the newborn: a decade of experience.

PURPOSE: Despite improvements in the management of persistent pulmonary hypertension of the newborn (PPHN), a number of infants with inadequate gas exchange are treated with extracorporeal membrane oxygenation (ECMO). The objectives of this study were to use the Extracorporeal Life Support Organization Registry to review the outcomes of neonates with PPHN receiving ECMO, and to identify pre-ECMO variables that may be associated with increased mortality. MATERIALS AND METHODS: The study is a retrospective analysis of all patients with PPHN supported with ECMO and reported to the Extracorporeal Life Support Organization registry from 2000 to 2010. Prematurity was defined as <37 wk gestation. Univariate analysis was performed using Student's t-test or Fisher's exact test. Variables found to be statistically significant underwent multivariate analysis by logistic regression. Kaplan-Meier survival curves were generated to analyze the relationship between duration of ECMO support and patient survival. RESULTS: A total of 1569 neonates with PPHN received ECMO support during the study period, at an average age of 3.1 d of life and for a duration of 6.9 d. Survival among neonates with PPHN receiving ECMO support was 81%, and those receiving support for 7, 10, 14, and 21 d survived at rates of 88%, 78%, 55%, and 25%, respectively. By logistic regression, prematurity (P < 0.01), pre-ECMO pH ≤7.2 (P = 0.02), pre-ECMO SaO(2) ≤65% (P = 0.01), and duration of ECMO ≥7 d (P < 0.001) were independent predictors of death in this group. An average of 2.2 complications occurred per patient, with cardiovascular, mechanical, and renal complications being the most common. CONCLUSIONS: Neonates with PPHN have high survival rates with ECMO support. Prematurity, acidosis, and profound hypoxemia are independently associated with increased mortality. Furthermore, prolonged ECMO support (>7 d) is associated with a higher risk of mortality in this cohort than in patients supported for <1 wk.

Increased in vitro differentiation of fibrocytes from keloid patients is inhibited by serum amyloid P.

Keloid scarring is a form of fibroproliferative dermal wound healing characterized by growth beyond the confines of the original wound. Fibrocytes, derived from peripheral blood mononuclear cells and inhibited by serum amyloid P (SAP), have been linked to other fibroproliferative diseases. We hypothesized that peripheral blood mononuclear cells of keloid formers have a higher propensity to differentiate into fibrocytes and are more resistant to the effects of SAP. To test this hypothesis, plasma was isolated from peripheral blood samples of keloid (n = 10) and age/sex/race-matched control (n = 10) subjects, and SAP levels were measured by enzyme-linked immunosorbent assay. Equal numbers of peripheral blood mononuclear cells were also isolated from these samples and fibrocytes cultured in serum-free media with increasing concentrations of SAP. No difference in plasma SAP levels was found between keloid and control subjects. In the absence of SAP, keloid patients (n = 7) had almost 20 times more fibrocytes than controls (n = 7) in culture (median: 1,087 cells vs. 60 cells; p < 0.01). SAP inhibited the differentiation of keloid fibrocytes in vitro, although a higher concentration of SAP was needed when compared with controls (20 µg/mL keloid vs. 5 µg/mL control). Fibrocytes may contribute to the pathogenesis of keloids, and SAP has potential as a therapeutic agent in the prevention of these lesions.

Outcomes of neonates requiring extracorporeal membrane oxygenation for irreversible pulmonary dysplasia: the Extracorporeal Life Support Registry experience.

OBJECTIVE: Neonates with an irreversible pulmonary dysplasia such as alveolar capillary dysplasia, surfactant protein deficiency, and pulmonary lymphangiectasis may have a deteriorating clinical course requiring cardiopulmonary support with extracorporeal membrane oxygenation. These neonates are often difficult to distinguish from those with persistent pulmonary hypertension of the newborn. The objective of this study was to identify clinical variables that distinguish infants with irreversible pulmonary dysplasia from those with persistent pulmonary hypertension of the newborn before, and while receiving, extracorporeal membrane oxygenation support. DESIGN: A retrospective analysis of the Extracorporeal Life Support Registry from 2000 to 2010 was performed. SETTING: A total of 114 extracorporeal membrane oxygenation centers providing data to the Extracorporeal Life Support Registry. PATIENTS: All neonates day of life 0-31 reported to the Extracorporeal Life Support Registry with irreversible pulmonary dysplasia and persistent pulmonary hypertension of the newborn were identified. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient demographics, pre-extracorporeal membrane oxygenation variables, and survival were analyzed. Univariate analysis was performed using Student's t test or Fisher's exact test, and variables found to be significant underwent multivariate analysis by logistic regression. Neonates with irreversible pulmonary dysplasia were placed on extracorporeal membrane oxygenation later (day of life 5.3 vs. 3.0, p = .045) and for a longer duration (11.1 vs. 6.8 days, p < .001) than those with persistent pulmonary hypertension of the newborn. Initiation of extracorporeal membrane oxygenation at day of life ≥5 (p = .026) and a duration of extracorporeal membrane oxygenation ≥10 days (p = .003) were independent predictors of irreversible pulmonary dysplasia by multivariate analysis. No differences in demographics, blood gas values, or vascular access were observed. Survival to discharge was significantly lower for neonates with irreversible pulmonary dysplasia (3%) vs. persistent pulmonary hypertension of the newborn (81%, p < .001). CONCLUSION: Although neonates with irreversible pulmonary dysplasia and persistent pulmonary hypertension of the newborn have similar presentations, those with irreversible pulmonary dysplasia require extracorporeal membrane oxygenation support later in the perinatal period and for a longer duration. For neonates with a diagnosis of persistent pulmonary hypertension of the newborn, irreversible pulmonary dysplasia should be considered when extracorporeal membrane oxygenation is initiated on day of life ≥5 and/or the duration of extracorporeal membrane oxygenation ≥10 days.

Modified laparoscopic gastrostomy tube placement in children: Does subcutaneous suture type matter?

BACKGROUND: Laparoscopic gastrostomy tube (GT) placement carries the risk of early tube dislodgement and is often modified with absorbable subcutaneously-tunneled transabdominal tacking sutures that can aid in tube replacement. However, these buried sutures may increase the risk of surgical site infection (SSI). This study sought to evaluate SSI rates associated with different types of transabdominal tacking sutures used in modified laparoscopic GT placement. METHODS: A single-institution, retrospective review was performed of all patients ≤18 years-old undergoing modified laparoscopic GT placement between September 2016 and March 2020. Patients were stratified into three groups by suture type used, and the primary outcome was SSI within six weeks of surgery. Demographic and perioperative data were analyzed by chi-square or Fisher's exact test. RESULTS: A total of 113 modified laparoscopic GT placements were performed at a median age of 9 months (interquartile range 3 months to 3 years). Prophylactic antibiotic use was similar between groups. Eleven patients (10%) developed an SSI, and all were treated with antibiotics alone. No SSIs were observed with the use of poliglecaprone suture (n = 46), and higher SSI rates were observed with use of polyglactin (n = 17) and polydioxanone (n = 51) suture (18% polyglactin vs. 16% polydioxanone vs. 0% poliglecaprone, p<0.05). No differences were observed in rates of early postoperative dislodgement, leakage, or granulation tissue. CONCLUSION: Absorbable braided and long-lasting monofilament transabdominal tacking sutures may increase risk of SSI following modified laparoscopic gastrostomy tube placement. In this cohort, the use of poliglecaprone (Monocryl) suture was associated with no SSIs and similar rates of postoperative dislodgement, leakage, and granulation tissue. LEVEL OF EVIDENCE: Treatment Study, Level III.

Wound healing characteristics of ICAM-1 null mice devoid of all isoforms of ICAM-1.

BACKGROUND: Intercellular adhesion molecule-1 (ICAM-1) permits leukocyte-endothelial adhesion and transmigration during inflammation. Membrane-bound ICAM-1 knockout mice have been used to understand this molecule's role in wound-healing, but expressed spliced isoforms of ICAM-1 that may have impacted results. We aimed to characterize wound-healing in an ICAM-1 null model devoid of all ICAM-1 isoforms. METHODS: Full-thickness 8-mm wounds were created on C57/BL6 wild-type (n = 24) and ICAM-1 null (n = 24) mice. Wound area was calculated using daily photographs. Histologic samples were harvested on postoperative Days 1, 3, 7, and 14. Wound margins were evaluated for mRNA expression of 13 inflammatory cytokines. A separate group of wild-type and ICAM-1 null mice (n = 24) received full-thickness incisions with tensiometry measured at Day 14. Separately, complete blood counts were measured in unwounded wild-type (n = 4) and ICAM-1 null mice (n = 4). RESULTS: Wound-closure was significantly delayed in ICAM-1 null mice through Day 7 by gross and histologic measurement. mRNA expression of VEGF-A was increased in ICAM-1 null mice on Day 3, although no increase in VEGF-A was observed in the wound bed by immunohistochemistry. ICAM-1 null wounds demonstrated higher stiffness by tensiometry on Day 14 compared to the wild-type (1880 ± 926 kPa versus 478 ± 117 kPa; P < 0.01), and had higher counts of white blood cells (10,009 versus 5720 cells/µL, P < 0.05), neutrophils (2130 versus 630 cells/µL, P < 0.01), and lymphocytes (7130 versus 4,740 cells/µL, P < 0.05). CONCLUSIONS: ICAM-1 null mice demonstrate delayed wound-healing and decreased wound elasticity compared to wild-type controls. This lag, however, was less than observed in earlier membrane-bound ICAM-1 knockouts, suggesting that other ICAM-1 isoforms may promote delayed wound-healing.

Identifying risk factors for enteral access procedures in neonates with congenital diaphragmatic hernia: A novel risk-assessment score.

BACKGROUND/PURPOSE: The purpose of this study was to evaluate the characteristics of neonates with congenital diaphragmatic hernia (CDH) undergoing enteral access procedures (gastrostomy or jejunostomy) during their initial hospitalization, and establish a clinical scoring system based on these characteristics. METHODS: Data were obtained from the multicenter, multinational CDH Study Group database (CDHSG Registry) between 2007 and 2019. Patients were randomly partitioned into model-derivation and validation subsets. Weighted scores were assigned to risk factors based on their calculated ß-coefficients after logistic regression. RESULTS: Of 4537 total patients, 597 (13%) underwent gastrostomy or jejunostomy tube placement. In the derivation subset, factors independently associated with an increased risk for enteral access included oxygen requirement at 30-days, chromosomal abnormalities, gastroesophageal reflux, major cardiac anomalies, ECMO requirement, liver herniation, and increased defect size. Based on the devised scoring system, patients could be stratified into very low (0-4 points; <10% risk), low (5-6 points; 10-20% risk), intermediate (7-9 points; 30-60% risk), and high risk (≥10 points; 70% risk) groups for enteral access. CONCLUSION: This study identifies risk factors associated with enteral access procedures in neonates with congenital diaphragmatic hernia and establishes a novel scoring system that may be used to guide clinical decision making in those with poor oral feeding. TYPE OF STUDY: Prognosis study.

Patience is a virtue: Multiple preoperative visits are associated with decreased recurrence in pediatric pilonidal disease.

BACKGROUND/PURPOSE: This study aimed to compare preoperative management strategies for patients undergoing trephination for pilonidal disease and evaluate risk factors for recurrence. METHODS: A retrospective review was performed of children undergoing index surgical treatment with trephination for pilonidal disease between September 2017 and April 2019. Intraoperative and postoperative management were standardized. Demographic and perioperative data were collected and analyzed. RESULTS: One-hundred twenty patients were identified with a median follow-up time of 7.5 months (interquartile range 4.1-13.2 months). Overall, 24 (20%) patients had a postoperative recurrence of pilonidal disease. Patients with multiple preoperative surgery clinic visits were less likely to have recurrent disease compared to those seen only once preoperatively (11% vs 26%, p = 0.040). Compared to patients without recurrence, those who recurred went to the operating room sooner from the time of initial surgical consultation (32 days vs 54 days, p < 0.001). Perioperative antibiotics, history of acute infection, and prior drainage procedures were not risk factors for recurrence. CONCLUSIONS: Multiple preoperative clinic visits are associated with a lower recurrence rate in children undergoing trephination for pilonidal disease. An increased duration of preoperative medical management may be responsible for this finding. Prospective study is needed to confirm these findings and identify additional factors that influence recurrence. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: III (Retrospective Comparative).

Ovarian volume ratio is a reliable predictor of ovarian torsion in girls without an adnexal mass.

PURPOSE: The aims of this study were to identify ultrasound-based predictors of ovarian torsion in girls without an adnexal mass and establish a set of normal values for ovarian volume ratio (OVR). METHODS: A retrospective review was performed of all premenarchal patients ≥3 years of age with a normal pelvic ultrasound between January 2016 and January 2019. A comparison group of premenarchal girls presenting between 2011 and 2019 with torsion in the absence of an adnexal mass was utilized. RESULTS: Five-hundred and four premenarchal girls underwent pelvic ultrasound evaluation with a normal examination. The mean OVR was 1.6 ±â€¯0.7 (range 1.0-6.5). OVR did not vary with age (r = -0.06) as compared to ovarian width which increased steadily with age (r = 0.53, p < 0.001). OVR was increased in girls with torsion (7.6 vs 1.4, p < 0.0001), and by receiver operating characteristic (ROC) analysis a cutoff value of >2.5 demonstrated the best diagnostic accuracy of any predictive variable (sensitivity 100%, specificity 94%, AUC 0.991, p < 0.001). CONCLUSIONS: OVR is an excellent predictor of ovarian torsion in premenarchal girls without an adnexal mass. Unlike ovarian width, OVR does not increase with age, and a cutoff OVR > 2.5 demonstrates high sensitivity and specificity for identifying ovarian torsion in this population. TYPE OF STUDY: Study of diagnostic test. LEVEL OF EVIDENCE: Level III.

Extremes of age are associated with differences in the expression of selected pattern recognition receptor genes and ACE2, the receptor for SARS-CoV-2: implications for the epidemiology of COVID-19 disease.

BACKGROUND: Older aged adults and those with pre-existing conditions are at highest risk for severe COVID-19 associated outcomes. METHODS: Using a large dataset of genome-wide RNA-seq profiles derived from human dermal fibroblasts (GSE113957) we investigated whether age affects the expression of pattern recognition receptor (PRR) genes and ACE2, the receptor for SARS-CoV-2. RESULTS: Extremes of age are associated with increased expression of selected PRR genes, ACE2 and four genes that encode proteins that have been shown to interact with SAR2-CoV-2 proteins. CONCLUSIONS: Assessment of PRR expression might provide a strategy for stratifying the risk of severe COVID-19 disease at both the individual and population levels.

Nationwide analysis of resuscitative thoracotomy in pediatric trauma: Time to differentiate from adult guidelines?

BACKGROUND: Emergency department thoracotomy (EDT) for pediatric patients is uncommon, and practice patterns have not been evaluated. We examined the indications and outcomes for EDT by trauma center designation using a nationwide database. METHODS: Patients 16 years or younger who underwent EDT within 30 minutes of arrival from 2013 to 2016 were identified in the American College of Surgeons National Trauma Data Bank. Patient demographic information, indications for EDT, and outcomes were analyzed. Outcomes were compared between centers with and without pediatric trauma center designation. RESULTS: A total of 114 patients were identified for analysis with a mean ± SD age of 10.3 ± 4.7 years. Patients were predominantly male (69%) with a median Injury Severity Score of 26 (interquartile range, 18-42). Penetrating trauma occurred in 56%. Overall, mortality was 90% and was similar in penetrating and blunt trauma (88% vs. 94%; p = 0.34). There were no survivors among the 53 patients (46%) who arrived with no signs of life. Among the 11 patients (10%) who survived, median length of stay was 26 days (interquartile range, 6-28 days). Overall, 8% of EDT was performed at free-standing pediatric trauma centers, 45% at adult centers, and 47% at combined trauma centers. Mortality rates and indications were similar among trauma centers regardless of designation status. CONCLUSION: In a national population-based data set, the mortality after pediatric EDT is high, and many of these procedures are performed at nonpediatric trauma centers. Regardless of injury mechanism, EDT is not appropriate in children without signs of life on arrival. Pediatric guidelines are needed to increase awareness of the poor outcomes and limited indications for EDT. LEVEL OF EVIDENCE: Therapeutic, level IV.

Trephination versus wide excision for the treatment of pediatric pilonidal disease.

BACKGROUND/PURPOSE: To evaluate outcomes of trephination compared to wide excision in children undergoing initial surgical treatment of pilonidal disease. METHODS: A retrospective review was conducted of patients undergoing initial pilonidal excision between September 2017 and September 2018. Operations were categorized as either trephination or wide excision via an open or closed-wound technique. Outcomes were evaluated and data analyzed by chi-squared and one-way ANOVA tests. RESULTS: One-hundred and five patients were identified, with a mean follow-up of 4.6 months. Trephination was performed in 57% of patients, and of the remaining patients undergoing wide excision, 62% of wounds were left open. There were no demographic differences among the three groups. Compared to both the open and closed techniques, trephination was associated with fewer wound complications (17% vs 29% vs 3%, respectively, p = 0.006), and postoperative visits (4.4 vs 2.4 vs 1.4, respectively, p < 0.001). There was no difference in recurrence rates among groups. CONCLUSION: Trephination for pilonidal disease in pediatric patients is associated with a lower wound complication rate and fewer postoperative visits compared to wide excision. Recurrence rates are similar among the various surgical methods. Further prospective study would be useful to describe long-term outcomes of patients undergoing trephination for pilonidal disease. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: III (retrospective comparative).

Patient-oriented online resources in pediatric surgery: Are we failing the readability test?

BACKGROUND: The study aim was to evaluate the readability of patient-oriented resources in pediatric surgery from children's hospitals in the US. METHODS: The websites of 30 children's hospitals were evaluated for information on 10 common pediatric surgical procedures. Hospitals of varying characteristics including bed number, geographic location and ACS Children's Surgery Verification (CSV) were selected for the study. Readability scores were calculated using validated algorithms, and text was assigned an overall grade level. RESULTS: Of 195 patient-oriented resources identified, only three (2%) were written at or below the recommended sixth grade level. Larger hospitals provided patient information at a higher grade level than medium and smaller sized centers (10.7 vs 9.3 vs 9.0 respectively, p < 0.001). Hospital size also correlated with availability of information, with large and medium sized hospitals having information more often. Hospitals with ACS CSV had information available more often, and written at a lower grade level, compared to nonverified centers (78% vs 62%, p = 0.023; 9.0 vs 10.0, p = 0.013). CONCLUSION: Most hospital provided patient-oriented resources in pediatric surgery are written at a grade level well above the national guidelines. Centers with ACS CSV status have improved availability and readability of this material, while larger hospitals have improved availability, but decreased readability. TYPE OF STUDY: Modeling study. LEVEL OF EVIDENCE: III.