Dynamic ultrasound in the evaluation of patients with suspected slipping rib syndrome.

OBJECTIVE: Slipping rib syndrome (SRS) affects adolescents and young adults. Dynamic ultrasound plays a potential and likely significant role; however, limited data exist describing the protocol and techniques available. It is our intent to describe the development of a reproducible protocol for imaging in patients with SRS. MATERIALS AND METHODS: Retrospective review of suspected SRS patients from March 2017 to April 2018. A total of 46 patients were evaluated. Focused history and imaging was performed at the site of pain. Images of the ribs were obtained in the parasagittal plane at rest and with dynamic maneuvers. Dynamic maneuvers included Valsalva, crunch, rib push maneuver, and any provocative movement that elicited pain. Imaging was compared with records from the pediatric surgeon specializing in slipping ribs. Statistical analysis was performed. RESULTS: Thirty-six of the 46 patients had a diagnosis of SRS, and had an average age of 17 years. Thirty-one patients were female, 15 were male. Thirty-one out of 46 (67%) were athletes. Average BMI was 22.6. Dynamic ultrasound correctly detected SRS in 89% of patients (32 out of 36) and correctly detected the absence in 100% (10 out of 10). Push maneuver had the highest sensitivity (87%; 0.70, 0.96) followed by morphology (68%; 0.51, 0.81) and crunch maneuver (54%; 0.37, 0.71). Valsalva was the least sensitive (13%; 0.04, 0.29). CONCLUSION: Dynamic ultrasound of the ribs, particularly with crunch and push maneuvers, is an effective and reproducible tool for diagnosing SRS. Valsalva plays a limited role. In addition to diagnosing SRS, ultrasound can give the surgeon morphological data and information on additional ribs at risk, thereby assisting in surgical planning.

Recurrent Crohn's disease.

Although surgical management of the ileocolic segment in pediatric Crohn's disease is not curative, the main goal of therapy is to allow for growth, adequate nutrition, and age-appropriate development. Recurrent disease at the site of anastomosis presents as a major morbidity. Several factors have been implicated in the development of surgical recurrence though data in the literature is scarce. This review explores the epidemiology of recurrent ileocolic disease following primary surgery, indications for surgical intervention, and techniques reported in the literature. Pediatric data is scarce, and therefore, much of it is extrapolated from adult literature.

Pectus Disorders: Excavatum, Carinatum and Arcuatum.

This article reviews pectus excavatum, carinatum, and arcuatum. Topics covered include etiology, epidemiology, associated syndromes, physiologic impact, workup, indications for treatment, surgical and nonsurgical therapy, results, complications, and emerging therapies. Pectus excavatum is an inward deformation of the sternum and/or anterior chest wall. Pectus carinatum is ether an outward protrusion or tilt of the sternum with potential psychological impact, but no demonstrated physiologic impact. Nonoperative compression bracing is successful in carinatum patients with chest wall flexibility who are compliant with a bracing program. Pectus arcuatum is an abnormally short, fully fused sternum with a high anterior protrusion.

Preoperative Metal Allergy Testing for Pectus Excavatum Repair Does Not Effectively Identify Patients Who Develop Metal bar Allergy.

BACKGROUND: Metal allergy following placement of a metal pectus bar for minimally invasive repair of pectus excavatum (MIRPE) is a rare complication with potentially significant morbidity. There is no consensus regarding preoperative metal allergy testing (MAT). This study aims to assess incidence of metal allergy and titanium bar use in tested and untested patients and trends in MAT with different approaches to MAT. METHODS: A retrospective chart review was performed on patients who underwent MIRPE from July 2009 to June 2022 at a single institution. During this time, MAT was performed routinely (RT; routine testing) and selectively (ST; selective testing). RESULTS: The cohort included 741 patients for analysis. Metal bar allergy was documented in 1.3 % of all patients; the incidence was 1.3 % in patients with MAT and 1.4 % without MAT. The incidence of bar allergy was 1.1 % in the RT group and 1.6 % in the ST group. In the RT group, bar allergy occurred in 1.4 % (3/216) of patients with a negative MAT. In the ST group, bar allergy occurred in 1.2 % (2/164) of patients with a negative MAT and in 1.9 % (3/162) of untested patients with a stainless-steel bar. Titanium bar use was not significantly different between the RT and ST groups (18.3 % vs 16.3 %, p > 0.05). CONCLUSION: The incidence of metal bar allergy after MIRPE was less than 2 %, and titanium bar use was not significantly different in routine and selective testing groups. MAT was not associated with a reduction in bar allergy, and its use remains unsupported. LEVEL OF EVIDENCE: III.

Initial Outcomes Using Cryoablation in Surgical Management of Slipping Rib Syndrome.

INTRODUCTION: Minimally invasive repair of pectus excavatum (MIRPE) and cartilaginous rib excision (CRE) for slipping rib syndrome (SRS) are painful procedures. Intercostal nerve cryoablation (Cryo) controls pain and decreases opioid use in MIRPE. Herein, we describe our experience with cryoablation in CRE. METHODS: A retrospective chart review was performed of all patients undergoing CRE between 2018 and 2022. Data on demographics, clinical characteristics, operative details, and hospital course were collected. RESULTS: A total of 98 patients underwent CRE: 68 CRE without cryo, 22 CRE + Cryo, and 8 combined MIRPE + CRE + Cryo. Ninety percent of patients underwent bioabsorbable rib plating. Patients were predominantly female (79%, 73%, 50% respectively) with median ages 17.6, 16.9, and 14.2 years respectively. CRE + Cryo patients used significantly less opioids in hospital (0.6 OME/kg [0.1,1.2]) compared to CRE without cryo (1.0 OME/kg [0.6,2.1]), p < 0.05. The median length of stay (LOS) in CRE + Cryo was 1 day [1,2] compared to 2 days in CRE without cryo [1,2], p = 0.09. MIRPE + CRE + Cryo patients used 0.6 OME/kg [0.2,8.0] with a 2 day [1,5.5] LOS. Ninety-one percent of Cryo patients had cryoablation of T9 and/or T10 intercostal nerves, with no documented abdominal wall laxity at median follow-up of 16 days. Cryo was applied extra-thoracically in CRE + cryo without thoracoscopy or lung isolation, while MIRPE + CRE + Cryo used a combination extra-/intra-thoracic cryoablation in with thoracoscopy. CONCLUSION: Intercostal nerve cryoablation reduces opioid use and LOS in patients undergoing cartilaginous rib excision for slipping rib syndrome. Cryotherapy to as low as T10 did not result in abdominal wall laxity and can be applied extra-thoracically without the need for thoracoscopy. Ongoing prospective studies are required to assess the long-term outcomes. LEVEL OF EVIDENCE: III.

Cryoablation in 350 Nuss Procedures: Evolution of Hospital Length of Stay and Opioid Use.

INTRODUCTION: Current studies show cryoablation decreases opioid requirements and lengths of stay (LOS) in patients undergoing the Nuss procedure for pectus excavatum. This study evaluated the relationship between cryoablation and clinical outcomes for the Nuss procedure. METHODS: A retrospective single-center chart review was performed on patients undergoing the Nuss procedure with intercostal cryoablation from December 2017-August 2021. Demographics, hospital course, and postoperative complications were abstracted. To evaluate the evolution of outcomes over time, the earliest quarter (Q1) of cryoablation patients was compared to the last quarter (Q4). RESULTS: Over 45 months, 350 Nuss procedures with cryoablation were performed. The mean age at operation was 15.7 ± 2.3 years with an average Haller Index of 5.4 ± 4.2. The mean operative time was 136 ± 40.5 minutes. On average, patients used 2.8 ± 2.5 OME/kg of opioid in hospital with a LOS of 2.7 ± 1.1 days. The Q4 patients were discharged 1.3 days earlier (p<0.05) than Q1 patients, with 80% of Q4 discharged by postoperative day #2 vs. 23% in Q1 (p<0.05). Q4 patients received 74% (p<0.05) less opioid in hospital and 21% (p<0.05) less on discharge. Within 90 days postoperatively, complication rates (chest tube placement, wound infection, readmission, neuropathic pain) were similar. Only two patients (0.6%) required reoperation for bar migration/slippage. CONCLUSION: With increased experience, cryoablation for the Nuss procedure decreased opioid use by 74% and was associated with 80% of patients achieving early discharge. Major complication rates were not increased. Cryoablation can be successfully implemented as an effective method of postoperative analgesia. LEVEL OF EVIDENCE: Level III.

Intercostal Nerve Cryoablation in Minimally Invasive Repair of Pectus Excavatum: Effect on Pulmonary Function.

Introduction: Cryoablation of intercostal nerves is performed for pain control after minimally invasive repair of pectus excavatum (MIRPE). Cryoablation affects both sensory and motor neurons, resulting in temporary anesthesia to the chest wall and loss of intercostal motor function. The study objective is to determine the effect of cryoablation on incentive spirometry (IS) volumes, as a measure of pulmonary function, after MIRPE. Materials and Methods: A single-institution retrospective review of pediatric patients undergoing MIRPE was performed. All patients received a multimodal regimen (MMR) of analgesics postoperatively. Three groups were compared-cryoablation (CRYO), elastomeric pain pump (EPP), and MMR alone. The primary outcomes were postoperative IS volumes and IS volumes as a ratio of preoperative forced vital capacity (FVC). Secondary outcomes included pain scores, opioid use, length of stay (LOS), and infectious complications. Results: MIRPE was performed in 115 patients: 50 CRYO, 50 EPP, and 15 MMR alone. Groups were similar for demographics and pectus excavatum severity. Postoperative spirometry measurements were similar across groups: IS (CRYO 750 mL [500,961] versus EPP 750 mL [590,1019] versus MMR 696 mL [500,1037], P = .77); IS/FVC (CRYO 0.19 [0.14,0.26] versus EPP 0.20 [0.16,0.26] versus MMR 0.16 [0.15,0.24], P = .69). Although pain scores were also similar across groups, CRYO patients used less opioid (P < .05) and had shorter LOS (P < .05). Postoperative pneumonia was rare and similar across groups (P = 1.00). Conclusion: Intercostal nerve cryoablation during MIRPE does not adversely affect postoperative IS volumes or increase pneumonia rate, despite the temporary loss of motor innervation to intercostal muscles. Cryoablation provides effective pain control with less opioid use.

Vertical rib plating for the treatment of slipping rib syndrome.

BACKGROUND: Slipping rib syndrome (SRS) is a painful condition of hypermobile, detached lower costal cartilages impinging the intercostal nerves. While surgical resection of the cartilaginous rib is reported as definitive treatment, recurrent symptoms are common. We describe the addition of vertical bioabsorbable rib plating to decrease recurrence. METHODS: An IRB-approved (#17-098), single institution, retrospective chart review was performed for patients who presented with SRS from 2009 to 2019 at a single institution. Descriptive statistics were used to compare patients with and without bioabsorbable vertical plating. RESULTS: A total of 85 patients (71.8% female, mean age 17.7 years) underwent evaluation for SRS. Of the 70 who underwent surgery solely for SRS, 29 (41%) underwent vertical rib plating at initial surgery while 41 (58.6%) did not. Recurrent symptoms developed in 7 (17.1%) unplated patients, while only 1 (3.4%) plated patient had recurrent SRS (which occurred after a motor vehicle crash) (p = 0.0116). Of the 8 with recurrent symptoms, 3 underwent vertical plating at a subsequent operation. CONCLUSION: Rate of recurrent symptoms after cartilage resection alone for SRS was 17.1%. The addition of vertical rib plating with bioabsorbable plates decreased recurrent symptoms and improved outcomes. LEVEL OF EVIDENCE: II.

Elastomeric Pain Pumps as an Adjunct for Postoperative Pain Control After Minimally Invasive Repair of Pectus Excavatum.

Introduction: Pectus excavatum is a common congenital anomaly in the pediatric population. During the postoperative period, pain control is one of the top priorities. As a result, multiple techniques for pain control have been developed, including thoracic epidural analgesia, multimodal analgesia (MM), and elastomeric pain pump (EPP) placement. The purpose of this study was to evaluate the effectiveness of pain control using EPP as an adjunct to MM after the minimally invasive repair of pectus excavatum (MIRPE). Methods: We identified all pediatric patients undergoing MIRPE from June 2017 to July 2018. MM was employed in all patients; some patients additionally received subpleural EPP as adjuncts to postoperative analgesia. We reviewed pain scores, length of stay, opioid use, and complications. Results: During the study period, a total of 62 patients were included. The study cohort was divided into 15 patients undergoing MM alone versus 47 patients undergoing subpleural EPP placement plus MM (EPP + MM). Median pain scores were lower in the EPP + MM group (2.9 versus 4.2, P < .05). There was a significant reduction of total inpatient opioid use in the EPP + MM group (357.6 mg versus 466.9 mg, P = .03). There was no difference in median length of stay or complications. We found no significant difference between subpleural versus subcutaneous placement of the infusion catheters. Conclusion: The use of subpleural EPP as an adjunct to MM is an effective way to reduce pain and opioid use after MIRPE without increased risk of complications. Type of Study: Retrospective study with comparison group.

Recurrent Slipping Rib Syndrome: Initial Experience with Vertical Rib Stabilization Using Bioabsorbable Plating.

Background: Slipping rib syndrome (SRS) is an often underdiagnosed cause of lower chest wall and abdominal pain. The diagnosis of SRS is established by physical examination with or without dynamic ultrasound. The pain can be debilitating and surgical excision of the nonattached, subluxing cartilages is curative for most patients, but frustratingly, up to a quarter of patients have transient or limited relief and require reoperation. Some of these patients were found to have subluxation of the remaining bony ribs, suggesting that excision of rib cartilage alone may not be curative in a subset of patients. Materials and Methods: A retrospective review was performed of 3 patients with recurrent slipping rib pain and hypermobile bony ribs on reoperation. In an effort to stabilize the hypermobile ribs, vertical bioabsorbable plating across their ribs was performed. The plates secure the ribs apart from each other, preventing the movement of ribs against each other and therefore the pain. Results: All patients tolerated the procedure well. Mean length of stay was 2.6 days. Mean follow-up is 7 months and all report significant improvement in pain. Conclusions: Rib plating allows stabilization of hypermobile ribs, while preserving the patient's anatomical rib cage, and is a safe treatment for recurrent pain after the initial procedure. This is a novel approach in patients with recurrent slipping rib symptoms.

The impact of state laws on motor vehicle fatality rates, 1999-2015.

BACKGROUND: Motor vehicle crash (MVC) fatalities have been declining while states passed various legislation targeting driver behaviors. This study assesses the impact of state laws on MVC fatality rates to determine which laws were effective. METHODS: Publically available data were collected on driver-related motor vehicle laws, law strengths, enactment years, and numbers of verified-trauma centers. Prospective data on crash characteristics and MVC fatalities 16 years or older from Fatality Analysis Reporting System 1999 to 2015 (n = 850) were obtained. Generalize Linear Autoregressive Modeling was used to assess the relative contribution of state laws to the crude MVC fatality rate while controlling for other factors. RESULTS: Lowering the minimum blood alcohol content (BAC) was associated with largest declines for all ages, especially the older cohorts: 16 years to 20 years (B = 0.23; p < 0.001), 21 years to 55 years (B = 1.7; p < 0.001); 56 years to 65 years (B = 3.2; p < 0.001); older than 65 years (B = 4.1; p < 0.001). Other driving under the influence laws were also significant. Per se BAC laws accompanying a reduced BAC further contributed to declines in crude fatality rates: 21 years to 55 years (B = -0.13; p < 0.001); older than 65 years (B = -0.17; p < 0.05). Driving under the influence laws enhancing the penalties, making revocation automatic, or targeting social hosts had mixed effects by age. Increased enforcement, mandatory education, vehicle impoundment, interlock devices, and underage alcohol laws showed no association with declining mortality rates. Red light camera and seatbelt laws were associated with declines in mortality rates for all ages except for older than 65 years cohort, but speed camera laws had no effect. Graduated Driver License laws were associated with declines for 16 years to 21 years (B = -0.06; p < 0.001) only. Laws targeting specific risks (elderly, motorcycles, marijuana) showed no effect on declining MVC mortality rates during the study period. CONCLUSION: States have passed a wide variety of laws with varying effectiveness. A few key laws, specifically laws lowering allowable BAC, implementing red light cameras, and mandating seatbelt use significantly reduced MVC mortality rates from 1999 to 2015. Simply adding more laws/penalties may not equate directly to lives saved. Continued research on state laws will better inform policy makers to meet evolving public health needs in the management of MVC fatalities. LEVEL OF EVIDENCE: Epidemiological, Level III.

The Use of Cryoanalgesia in Minimally Invasive Repair of Pectus Excavatum: Lessons Learned.

Introduction: Cryoanalgesia has been applied to minimally invasive repair of pectus excavatum (MIRPE). After implementation of cryoanalgesia at our institution, we had several cases of delayed postoperative pneumothorax. The purpose of this study was to critically evaluate the complications and efficacy of cryoanalgesia in MIRPE. Materials and Methods: We performed a single institution retrospective review of pediatric patients undergoing MIRPE from June 2017 to July 2018. Multimodal (MM) analgesia was used in all patients. In addition, most patients received either cryoanalgesia or elastomeric pain pumps (EPPs) as adjuncts to postoperative analgesia. Primary outcome was clinically significant late pneumothorax. Secondary outcomes included length of stay, pain scores, opiate use, and bar displacement requiring reoperation. Results: A total of 101 patients undergoing MIRPE were included: 45 had cryoanalgesia + MM, 45 EPP + MM, and 11 MM alone. Postoperative tube thoracostomy was placed in 5 patients with cryoanalgesia (4 pneumothorax; 1 effusion), 1 patient with EPP (1 pneumothorax), and none in MM alone (P = .25). Pain scores at discharge were similar in all groups. Cryoanalgesia patients received less overall inpatient opioids than other groups (P < .05). No patient required reoperation for bar displacement. Conclusion: Cryoanalgesia is an effective therapy for pain control in MIRPE. Because thermal injury can occur on the lung and chest wall with cryoanalgesia, we implemented techniques to limit and prevent this injury. Cryoanalgesia offers a safe alternative for postoperative analgesia with significant reduction in inpatient opioid requirement. Larger prospective studies are required to assess the long-term impact and complications of cryoanalgesia.

Slipping Rib Syndrome: A review of evaluation, diagnosis and treatment.

Slipping rib syndrome (SRS) is an under-diagnosed cause of intermittent, yet often debilitating lower rib and abdominal pain. SRS is caused by a hypermobility of the anterior false ribs that allows the 8th-10th ribs to slip or click as the cartilaginous rib tip abuts or slips under the rib above. Pain occurs from impingement of the intercostal nerve passing along the undersurface of the adjacent rib. Studies consistently find patients reporting months to years of typical pain symptoms, unnecessary tests and procedures prior to diagnosis. SRS is a clinical diagnosis, but dynamic ultrasound can be helpful for confirmation or diagnosis in difficult cases. Resection of the slipping rib cartilages is the mainstay of treatment, with good results for pain relief. Rib stabilization is an emerging option for recurrent symptoms.

Success of Minimally Invasive Pectus Excavatum Procedures (Modified Nuss) in Adult Patients (≥30 Years).

BACKGROUND: Minimally invasive repair of pectus excavatum (MIRPE) has become standard for pediatric and young adult patients, but its use for older adults is controversial. METHODS: We retrospectively reviewed electronic medical records of adults (≥18 years of age) who underwent MIRPE from January 1, 2010, through April 30, 2015, and collected demographic data, operative details, and information about outcomes. Cardiac function was measured before and after repair by intraoperative transesophageal echocardiography. We divided patients by age: 18 to 29 years of age and 30 years of age and older. RESULTS: Of 361 patients, 207 were 30 or older (mean, 40 years; range, 30 to 72 years; 71.5% men). Of the older patients, 151 had primary repairs. MIRPE was successfully used in 88.7% of patients older than 30 years of age versus 96.5% of those 18 to 29 years of age. For patients 30 years of age and older, open-cartilage resection, sternal osteotomy, or both was more common with increasing age (mean, 47.8 years versus 39.5 years; p = 0.0003) and higher mean Haller index (7.7 versus 5.5; p = 0.0254). Mean operative time for MIRPE was significantly longer for older patients (≥30 years of age) compared with younger adults (121 [60 to 224] minutes versus 111 [62 to 178] minutes; p = 0.0154). Right ventricular output increased 65.2% after repair in older adults. Although greater, the frequency of bar rotation requiring reoperation was not significantly increased in the older patients (p = 0.74). CONCLUSIONS: The majority of adult patients with PE can have successful repair with modified MIRPE. The use of cartilage or sternal osteotomy, or both, increased with patient age and defect severity.

Small-bowel diaphragm disease: seven surgical cases.

HYPOTHESIS: Small-bowel diaphragm disease is an important source of gastrointestinal tract bleeding and subacute intestinal obstruction that may require surgical intervention. DESIGN: Case series. SETTING: Tertiary-care academic medical center. PATIENTS: Seven consecutive patients with histologically confirmed enteropathy induced by use of nonsteroidal anti-inflammatory drugs received treatment at our institution from February 2001 to February 2004. INTERVENTIONS: Laparotomy with small-bowel resection. MAIN OUTCOME MEASURES: Initial symptoms and signs, findings at diagnostic workup, type of medication and duration of use, operation performed, and intraoperative findings were evaluated. RESULTS: Patients were identified who had symptoms of subacute intestinal obstruction or signs of gastrointestinal tract bleeding and were determined to have used nonsteroidal anti-inflammatory drugs for differing periods. All 7 patients underwent extensive nondiagnostic radiologic and endoscopic examinations. The diagnosis of diaphragm disease was ultimately made at either video capsule endoscopy or laparotomy. Randomly distributed diaphragms throughout the jejunum and ileum necessitated resection in all cases. No patient has had a documented recurrence, although follow-up is short (range, 0-20 months). CONCLUSIONS: Nonsteroidal anti-inflammatory drugs are clearly linked to pathologic findings of diaphragm disease in both the upper and lower gastrointestinal tracts. Although rarely reported in the surgical literature, small-bowel diaphragm disease may be more common than thought and can manifest as gastrointestinal tract bleeding or obstruction. Diagnosis is difficult and may require laparotomy and small-bowel resection.

Is breast cancer sentinel lymph node mapping valuable for patients in their seventies and beyond?

BACKGROUND: Axillary lymph node dissection (ALND) is performed less commonly for the axillary staging of elderly patients because it is felt to uncommonly alter therapy. Sentinel lymph node (SLN) dissection can accomplish axillary staging with less morbidity, but it is unclear if it alters subsequent therapy. METHODS: Review of a prospectively collected breast cancer SLN mapping database. Medical records were reviewed to supplement the database. RESULTS: Among 730 breast cancer SLN mapping patients, 261 (35.8%) were >or=70 years of age (range 70 to 95). The overall SLN identification rate was 98.8% among those <70 and 97.1% for those >or=70 (P=.11) and 100% and 99.4%, respectively (P=.25), among the most recent 500 patients. SLN metastases were detected by hematoxalin and eosin staining (H&E) in 24.2% of those <70 and 13.4% of those >/=70 (P<.01) and by immunohistochemistry staining (IHC) only in 4.6% and 5.0% of patients, respectively. No elderly patients with histologically negative SLNs underwent ALND, but 88.9% of patients with H&E metastases and 84.6% with IHC metastases underwent ALND. Of the H&E-positive women, 88% underwent adjuvant systemic therapy versus 55% of H&E-negative women (P<.01). Hormonal therapy was administered to 86.9% of SLN-positive women and 54.3% of SLN-negative women (P<.01) and cytotoxic chemotherapy was administered to 24% of SLN-positive patients versus 2.8% of SLN-negative patients (P<.01). SLN status was associated with significantly different rates of systemic therapy for patients with tumors <1 cm and 1 to 2 cm, but not with tumors >2 cm. Mean follow-up was 15.4 months. No patient experienced local or regional recurrence. Distant metastases occurred in 8.2% of patients with SLN metastases and in no patients with negative SLNs (P<.01). CONCLUSIONS: The results of SLN mapping and biopsy in elderly patients significantly influences subsequent therapy decisions, including ALND, hormonal therapy, and cytotoxic chemotherapy. SLN biopsy should be recommended to elderly breast cancer patients.

Successful Singleton and Twin Pregnancies With the Nuss Bars in Place.

Pectus excavatum (PE) occurs less commonly in women, and the implications on a pregnancy after repair during the period when support bars are in place are unknown. We present 2 cases: 1 with a successful twin gestation and another with a successful singleton gestation. These women carried the pregnancies to term and delivered their infants with the Nuss bars in place.

Pectus excavatum in adult women: repair and the impact of prior or concurrent breast augmentation.

BACKGROUND: Women present with pectus excavatum five times less frequently than men. Adult women may have additional, associated cosmetic factors, including hypoplastic or asymmetric breasts, or prior augmentation. The authors evaluated the impact of prior or concurrent cosmetic breast surgery in an adult female cohort undergoing repair of pectus excavatum deformity. METHODS: A retrospective review was performed of women (≥18 years old) who underwent pectus excavatum repair at a single institution from January of 2010 to September of 2013. RESULTS: Pectus excavatum repair was performed on 47 women with a median age of 35 years (range, 18 to 63 years). Mean pectus severity index was 6.2 (range, 3.1 to 16). All patients had physiologic symptoms as the primary purpose for seeking repair. Twenty patients (43 percent) presented with existing implants or the desire for implants at the time of repair. Fifteen patients (32 percent) had a history of implant placement including prior breast augmentation (n = 14) and/or pectus implant (n = 4). Concurrent augmentation (n = 5), breast implant exchange (n = 8), and/or removal of chest wall implants (n = 4) was performed during repair. Morbidity included one implant-related hematoma. Complications and hospital stay were not significantly different for patients undergoing primary repair alone versus those with prior or concurrent augmentation. CONCLUSIONS: Breast cosmesis was a concern in nearly half of adult women presenting for pectus excavatum repair. The authors' experience suggests neither prior nor concurrent breast augmentation increases the risk of complications in repair. The authors recommend that cosmetic breast surgery be performed concurrently with pectus excavatum repair. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Pediatric trauma patient alcohol screening: a 3 year review of screening at a Level I pediatric trauma center using the CRAFFT tool.

INTRODUCTION: Alcohol use is a risk factor for adult trauma. Alcohol may significantly influence pediatric trauma risk, but literature is sparse. The aim of this study was to examine the impact of alcohol use screening in pediatric trauma patients. METHODS: A retrospective review was performed of all trauma patients to identify those undergoing CRAFFT alcohol screening assessment between July 1, 2009, and January 31, 2011. Inclusion criteria involved screening of level 1 or 2 trauma activations for patients greater than 12 years. RESULTS: During the study period, 232 patients were eligible for screening, of which 51% (n=118) were screened. Among the patients screened, 21 (18%) had a positive screen (mean age 14.6 years, range 13-16). Twenty patients were referred for further counseling. Sixteen males and 5 females screened positive during the study. The most common mechanism of injury in the positive screen patients was motor vehicle or ATV accident (n=9), followed by assault (n=6), and motor versus pedestrian collision (n=2). Of the 21 patients who screened positive, 10 had positive blood alcohol content (BAC) or urine drug screen (UDS) at the time of injury. No patients with a positive screen returned during the study as a trauma patient. CONCLUSION: Alcohol and drug screening for injured pediatric trauma patients is frequently omitted despite policy-required screening. Of those patients screened, 18% admitted to risky alcohol or drug-related behaviors or had positive BAL or UDS at presentation. Pediatric trauma screening for risky alcohol use identifies a significant number of children. Alcohol and drug screening in pediatric trauma appears over age 13 years to have a yield which justifies continued screening. Alcohol related trauma recidivism, however, does not seem common.