Adaptation of a standardized lifestyle intervention to maximize health outcomes in adolescent metabolic and bariatric surgery patients.

BACKGROUND: Metabolic and bariatric surgery (MBS) is safe and efficacious in treating adolescents with severe obesity. Behavioral/lifestyle programs can support successful preparation for surgery and post-MBS weight loss, but no standardized lifestyle intervention exists for adolescents. Here we describe the process of developing and adapting the Diabetes Prevention Program Group Lifestyle Balance (DPP/GLB) curriculum to support adolescents pre- and post-MBS. METHODS: We collected both qualitative and quantitative data from a diverse group of adolescents (N = 19, mean age 15.2 years, range 13-17, 76% female, 42% non-Hispanic Black, 41% Hispanic, 17% other). Additionally, we included data from 13 parents, all of whom were mothers. These participants were recruited from an adolescent MBS program at Children's Health System of Texas. In an online survey, we asked participants to rank their preferences and interests in DPP/GLB content topics. We complemented these results with in-depth interviews from a subset of 10 participants. This qualitative data triangulation informed the development of the TeenLYFT lifestyle intervention program, designed to support adolescents who were completing MBS and described here. This program was adapted from adolescent and parent DPP/GLB content preferences, incorporating the social cognitive model (SCM) and the socioecological model (SEM) constructs to better cater to the needs of adolescent MBS patients. RESULTS: Adolescents' top 3 ranked areas of content were: (1) steps to adopt better eating habits and healthier foods; (2) healthy ways to cope with stress; and (3) steps to stay motivated and manage self-defeating thoughts. Nearly all adolescent participants preferred online delivery of content (versus in-person). Mothers chose similar topics with the addition of information on eating healthy outside the home. Key themes from the adolescent qualitative interviews included familial support, body image and self-confidence, and comorbidities as key motivating factors in moving forward with MBS. CONCLUSIONS: The feedback provided by both adolescents and parents informed the development of TeenLYFT, an online support intervention for adolescent MBS candidates. The adapted program may reinforce healthy behaviors and by involving parents, help create a supportive environment, increasing the likelihood of sustained behavior change. Understanding adolescent/parent needs to support weight management may also help healthcare providers improve long-term health outcomes for this patient population.

Decision-Making in Pleural Drainage Following Lung Resection in Children: A Western Pediatric Surgery Research Consortium Survey.

INTRODUCTION: Studies of adults undergoing lung resection indicated that selective omission of pleural drains is safe and advantageous. Significant practice variation exists for pleural drainage practices for children undergoing lung resection. We surveyed pediatric surgeons in a 10-hospital research consortium to understand decision-making for placement of pleural drains following lung resection in children. METHODS: Faculty surgeons at the 10 member institutions of the Western Pediatric Surgery Research Consortium completed questionnaires using a REDCap survey platform. Descriptive statistics and bivariate analyses were used to characterize responses regarding indications and management of pleural drains following lung resection in pediatric patients. RESULTS: We received 96 responses from 109 surgeons (88 %). Most surgeons agreed that use of a pleural drain after lung resection contributes to post-operative pain, increases narcotic use, and prolongs hospitalization. Opinions varied around the immediate use of suction compared to water seal, and half routinely completed a water seal trial prior to drain removal. Surgeons who completed fellowship within the past 10 years left a pleural drain after wedge resection in 45 % of cases versus 78 % in those who completed fellowship more than 10 years ago (p = 0.001). The mean acceptable rate of unplanned post-operative pleural drain placement when pleural drainage was omitted at index operation was 6.3 % (±4.6 %). CONCLUSIONS: Most pediatric surgeons use pleural drainage following lung resection, with recent fellowship graduates more often omitting it. Future studies of pleural drain omission demonstrating low rates of unplanned postoperative pleural drain placement may motivate practice changes for children undergoing lung resection. LEVEL OF EVIDENCE: V.

Metabolic and Bariatric Surgery in Children: Current Practices and Outcomes.

PURPOSE OF REVIEW: This review will examine the most current evidence for Metabolic and Bariatric Surgery (MBS) in the pediatric population, specifically in terms of weight loss outcomes and improvement in comorbid conditions and complications. Additionally, we compare surgical and non-surgical interventions, review current guidelines, and propose a stepwise evidence-based approach to the management of obesity in children. RECENT FINDINGS: MBS is a safe option for appropriately selected pediatric patients which leads to significant and sustained weight loss. This weight loss is associated with improvement of related comorbid conditions. Laparoscopic sleeve gastrectomy (LSG) has emerged as the procedure of choice with a better safety profile. Despite the evidence, very few adolescents undergo MBS. New pharmacologic agents specifically the GLP-1/GIP agents have shown early promise especially in patients under body mass index 40, but the long-term effects are unknown. MBS is an effective tool in the management of pediatric obesity, and its use has been recommended by professional societies. Early referral to a multidisciplinary obesity team can help identify appropriate patients.

Pediatric Cervical Spine Injury Following Blunt Trauma in Children Younger Than 3 Years: The PEDSPINE II Study.

Importance: There is variability in practice and imaging usage to diagnose cervical spine injury (CSI) following blunt trauma in pediatric patients. Objective: To develop a prediction model to guide imaging usage and to identify trends in imaging and to evaluate the PEDSPINE model. Design, Setting, and Participants: This cohort study included pediatric patients (<3 years years) following blunt trauma between January 2007 and July 2017. Of 22 centers in PEDSPINE, 15 centers, comprising level 1 and 2 stand-alone pediatric hospitals, level 1 and 2 pediatric hospitals within an adult hospital, and level 1 adult hospitals, were included. Patients who died prior to obtaining cervical spine imaging were excluded. Descriptive analysis was performed to describe the population, use of imaging, and injury patterns. PEDSPINE model validation was performed. A new algorithm was derived using clinical criteria and formulation of a multiclass classification problem. Analysis took place from January to October 2022. Exposure: Blunt trauma. Main Outcomes and Measures: Primary outcome was CSI. The primary and secondary objectives were predetermined. Results: The current study, PEDSPINE II, included 9389 patients, of which 128 (1.36%) had CSI, twice the rate in PEDSPINE (0.66%). The mean (SD) age was 1.3 (0.9) years; and 70 patients (54.7%) were male. Overall, 7113 children (80%) underwent cervical spine imaging, compared with 7882 (63%) in PEDSPINE. Several candidate models were fitted for the multiclass classification problem. After comparative analysis, the multinomial regression model was chosen with one-vs-rest area under the curve (AUC) of 0.903 (95% CI, 0.836-0.943) and was able to discriminate between bony and ligamentous injury. PEDSPINE and PEDSPINE II models' ability to identify CSI were compared. In predicting the presence of any injury, PEDSPINE II obtained a one-vs-rest AUC of 0.885 (95% CI, 0.804-0.934), outperforming the PEDSPINE score (AUC, 0.845; 95% CI, 0.769-0.915). Conclusion and Relevance: This study found wide clinical variability in the evaluation of pediatric trauma patients with increased use of cervical spine imaging. This has implications of increased cost, increased radiation exposure, and a potential for overdiagnosis. This prediction tool could help to decrease the use of imaging, aid in clinical decision-making, and decrease hospital resource use and cost.

Associations of cephalad drainage in neonatal veno-venous ECMO - A mixed-effects, propensity score adjusted retrospective analysis of 20 years of ELSO data.

BACKGROUND: Neurologic complications can occur during neonatal Veno-Venous (VV) ECMO. The addition of a cephalad drainage cannula (i.e., VVDL+V) to dual lumen cannulation (i.e., VVDL) has been advocated to reduce such complications, but previous studies have presented mixed results. METHODS: Data from the ECMO Registry of the Extracorporeal Life Support Organization was used to extract all neonates (≤28 days old) who underwent VV ECMO for respiratory support between 2000 and 2019. Primary outcomes were mortality, conversion to Veno-Arterial (VA) ECMO, pump flows, and complications. A mixed-effects, propensity score adjusted analysis was performed. RESULTS: 4,275 neonates underwent VV ECMO, 581 (13.6%) via VVDL+V cannulation, and 3,694 (86.4%) via VVDL. On unadjusted analyses, VVDL+V patients had higher rates of mortality (25.5% vs 19.0%, p<0.001), conversion to VA ECMO (14.5% vs 4.1%, p<0.001), and higher pump flows at 4 h from ECMO initiation (112.7 vs 105.5 mL/Kg/min, p<0.001), but lower at 24 h (100.3 vs 104.0 mL/Kg/min, p = 0.004), and a higher proportion of them experienced hemorrhagic (29.3% vs 18.3%, p<0.001), cardiovascular (60.8% vs 45.8%, p<0.001), and mechanical (42.5% vs 32.6%, p<0.001) complications compared to VVDL patients. After adjusting for propensity scores and the multi-level nature of ELSO data, there were no differences in neurologic outcomes, pump flows, or mortality. Rather, VVDL+V cannulation was associated with higher rates of conversion to VA ECMO (adjusted odds ratio [AOR] 43.3, 95% CI 24.3 - 77.4, p<0.001), and increased mechanical (AOR 2.2, 95% CI 1.6 - 3.0, p<0.001) and hemorrhagic (AOR 2.0, 95% CI 1.4 - 3.0, p<0.001) complications. CONCLUSIONS: In this analysis, VVDL+V cannulation was not associated with any improvement in neurologic outcomes, pump flows, or mortality, but was rather associated with higher rates of conversion to Veno-Arterial ECMO, mechanical, and hemorrhagic complications.

Leuprolide-Induced Hyperosmolar Hyperglycemic State in an Elderly Patient: A Case Report and Literature Review.

We present a novel case of severe hyperosmolar hyperglycemic derangement in an elderly patient - without a known history of diabetes mellitus - after the first injection of leuprolide for the treatment of metastatic prostate adenocarcinoma. Whilst the available literature provided accumulative evidence of an association between insulin resistance and the use of gonadotropin-releasing hormone (GnRH) agonists, the initial presentation of leuprolide-induced impaired glycemic tolerance with a hyperosmolar hyperglycemic state (HHS) represents a clinical rarity that was seldom reported. A literature review was conducted to explore the underlying mechanisms of leuprolide-associated glucose intolerance. Screening for diabetes is recommended for patients receiving leuprolide therapy to identify at-risk patients and close glycemic monitoring is warranted in diabetic patients to minimize serious complications from poor glycemic control induced by leuprolide.

Impact of the COVID-19 Pandemic on Metabolic and Bariatric Surgery Utilization and Safety in the United States.

BACKGROUND: Metabolic and bariatric surgery (MBS) is a safe and effective treatment option for severe obesity. The utilization and health and safety outcomes of MBS in the United States (US) during the COVID-19 pandemic versus 2015-2019 among adolescent and adult populations and by ethnic group is largely unknown. METHODS: The 2015-2020 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) longitudinal (30-day) cohort data was used to compare adolescent and adult (N = 1,134,522) post-operative outcomes and to calculate MBS utilization pre-pandemic (2015-2019) versus pandemic (2020). Cochran-Armitage trend tests compared MBS utilization and safety outcomes over time from 2015 to 2020. Logistic regression analysis compared the odds of hospital readmission and MBS completion pre-pandemic versus pandemic by key characteristics. RESULTS: MBS utilization increased by 8.1% among youth (from 970 to 1140 procedures) and decreased by 10.2% among adults (from 205,232 to 167,384) from 2019 to 2020, respectively. MBS increased by 18.5% during the pandemic for youth who identified as other/multiracial (P trend < 0.001). Among US youth, the number of reoperations and reinterventions significantly decreased over the 6-year time frame (P trend < .001). Among US adults, 30-day post MBS mortality, reoperations, readmissions, and reinterventions all showed a significant decrease over time (P trend < .001) while septic shock and sepsis increased from pre-pandemic to the first year of the pandemic (P trend < 0.001). CONCLUSION: In comparison to 2019 (or to previous years), US MBS utilization increased for youth but decreased for adults during the first year of the COVID-19 pandemic. Safety outcomes were comparable to those of the pre-pandemic years.

Five Year Trends in the Utilization of Robotic Bariatric Surgery Procedures, United States 2015-2019.

PURPOSE: Robotic approaches have been steadily replacing laparoscopic approaches in metabolic and bariatric surgeries (MBS); however, their superiority has not been rigorously evaluated. The main goal of the study was to evaluate the 5-year utilization trends of robotic MBS and to compare to laparoscopic outcomes. METHODS: Retrospective analysis of 2015-2019 MBSAQIP data. Kruskal-Wallis test/Wilcoxon and Fisher's exact/chi-square were used to compare continuous and categorical variables, respectively. Generalized linear models were used to compare surgery outcomes. RESULTS: The use of robotic MBS increased from 6.2% in 2015 to 13.5% in 2019 (N= 775,258). Robotic MBS patients had significantly higher age, BMI, and likelihood of 12 diseases compared to laparoscopic patients. After adjustment, robotic MBS patients showed higher 30-day interventions and 30-day readmissions alongside longer surgery time (26-38 min). CONCLUSION: Robotic MBS shows higher intervention and readmission even after controlling for cofounding variables.

Employment search, initial employment experience, and career preferences of recent pediatric surgical fellowship graduates: An APSA survey, part of the right child/right surgeon initiative.

BACKGROUND: APSA's Right Child/Right Surgeon Initiative addresses issues concerning patient access to appropriate pediatric surgical care and workforce distribution. The APSA Workforce Committee sought to understand the experiences and motivations of recent graduates of Pediatric Surgery Training Programs entering the workforce. METHODS: Using APSA membership databases, we identified members who completed fellowship training from 2010 to 2019. An online survey was created using Survey Monkey, and invitations to participate were sent via email. RESULTS: 144 of 447 invited participants responded (32% response rate). 91% of respondents participated in dedicated research prior to fellowship, but only 64% perform research during their employment. 23% completed an additional clinical fellowship, but only 54% currently practice within the second field. When asked to identify the top three factors used to choose a position, the most common responses were "location or geography" (71%), "available mentorship" (53%), and "compensation and benefits" (37%). Describing their first position, 77% reported working in an academic institution, 78% reported working in a metropolitan/urban area, and 55% reported working in a free-standing children's hospital. 94% participate in General Surgery resident education, and 49% are faculty within a Pediatric Surgery fellowship. Overall, 92% of respondents were able to find the type of employment position that they had wanted. CONCLUSION: In our survey the overwhelming majority of young pediatric surgeons found the type of job they desired. Most report beginning their practice in more populated, urban areas within academic institutions. Geographic location and work environment played heavily into their employment decisions. These preferences could contribute to continued disparity in access to pediatric surgeons between urban and rural America and to dilution of experience for urban surgeons. Possible solutions include alternative incentive programs for employment in less populated areas or new training models for general surgeons in rural areas to train in fundamentals of Pediatric Surgery.

Disparity Between United States Adolescent Class II and III Obesity Trends and Bariatric Surgery Utilization, 2015-2018.

OBJECTIVES: Class II (120% > body mass index [BMI] < 140% of the 95th percentile for age and sex) and Class III (BMI >140% of the 95th percentile for age and sex) obesity are the fastest growing subcategories of obesity in the United States pediatric population. Metabolic and bariatric surgery (MBS) is a safe and effective treatment option for with class II/III obesity. The primary objectives of this analysis were to determine the (1) current US MBS utilization rates in those with class II/III obesity and (2) utilization rates and 30-day postoperative outcomes. BACKGROUND: The 2015 to 2018 National Health and Nutrition Examination Survey cross-sectional data (N = 19,225) generated US with class II/III obesity prevalence estimates. The 2015 to 2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) longitudinal (30 days) cohort data were used to compare adolescent and adult (N = 748,622) postoperative outcomes and to calculate utilization rates. METHODS: The 2015 to 2018 youth and adult MBS utilization rates were calculated using MBSAQIP data (numerator) and National Health and Nutrition Examination Survey data (denominator). Two-sample tests of proportions were performed to compare the MBS utilization rates by age, ethnicity, and sex and expressed per 1000. RESULTS: Mean age of the analytical MBSAQIP sample was 17.9 (1.15) years in youth (n = 3846) and 45.1 (11.5) in adults (N = 744,776), majority female (77.4%, 80.7%, respectively) and non-Hispanic White (68.5%, 59.4%, respectively). The overall 2015 to 2018 MBS utilization rate for youth was 1.81 per 1000 and 5.56 per 1000 for adults ( P < 0.001). Adult patients had slightly higher percentage (4.2%) of hospital readmissions compared to youth (3.4%, P = 0.01) but there were no other post-MBS complication differences. From 2015 to 2018 the US prevalence of youth with class II/III obesity increased in Hispanics and non-Hispanic Blacks (P trend < 0.001), but among youth who did complete MBS non-Hispanic Whites had higher rates of utilization (45.8%) compared to Hispanics (22.7%) and non-Hispanic blacks 14.2% (P = 0.006). CONCLUSIONS: MBS is an underutilized obesity treatment tool for both youth and adults, and among ethnic minority groups in particular.

Is metformin use associated with a reduced risk of oesophageal cancer? A systematic review and meta-analysis.

OBJECTIVES: Studies on the association between metformin use and the risk of oesophageal cancer (OC) have generated controversial findings. This updated meta-analysis was conducted to reassess the effects of metformin on OC. METHODS: A comprehensive search strategy was conducted to select relevant studies from origination to February 2021. Heterogeneity was evaluated through the Q test and I2 statistics. HRs and 95% CIs were pooled through either random-effect or fixed-effect models. Meta-regression, subgroup analyses, sensitivity analysis and publication bias diagnosis were also performed. RESULTS: Seven studies with 5 426 343 subjects were included. Metformin use was associated with reduced risk of OC (HR=0.69, 95% CI 0.54 to 0.87, p<0.001). Sensitivity analysis suggested that the results were relatively stable. CONCLUSION: Metformin is associated with a reduced risk of OC. More well-designed studies are still needed to further elaborate on these associations. PROSPERO REGISTRATION NUMBER: CRD42021237127.

Longitudinal Outcomes in Adolescents After Referral for Metabolic and Bariatric Surgery.

BACKGROUND: Metabolic and bariatric surgery (MBS) can be a well tolerated and effective treatment option for severe obesity in adolescents. We compared outcomes for adolescents that did and did not proceed to surgery. METHODS: A single-center longitudinal study (2015-2020). Patients were identified as LSG if they completed laparoscopic sleeve gastrectomy within 6 months of initial visit and NoLSG if they did not. Chi-square, Fisher exact, nonparametric Kruskal-Wallis tests, and Linear Mixed Models (LMM) were used to compare outcomes over 2 years. RESULTS: Three hundred fifty-two adolescents were referred with a mean age of 15.6 ±â€Š1.4, 69% girls, 38% Hispanic, and 78% had noncommercial insurance. The median baseline weight was 135 kg and body mass index (BMI) was 48 kg/m2; 42% had a BMI >50. Seventy-nine (22%) underwent LSG whereas 273 (78%) did not complete MBS primarily because of lack of interest. LSG patients had 21% total weight loss and 22% total BMI loss at 24 months whereas NoLSG patients had 4% total weight gain and 3% BMI gain (P < 0.01). Obesity-associated conditions improved in the LSG group (P < 0.01). Follow-up in both groups was poor (≤30% at 24 months). Patients with public insurance and those with BMI from 50 to 59.9 kg/m2 were high performing LSG patients. CONCLUSIONS: A minority (22%) of adolescents referred for MBS proceeded to surgery, despite its demonstrated efficacy and safety in adolescence. Those that did not undergo surgery continued to gain weight. Further research is needed to understand patient preferences or concerns related to MBS utilization during adolescence.

Mental health factors associated with progression to adolescent metabolic and bariatric surgery.

BACKGROUND: While bariatric surgery has demonstrated significant weight loss for adolescents with severe obesity, only a limited number of adolescents referred to surgery successfully complete the surgical program. Better identification of pre-surgical factors, especially mental health factors, associated with completing bariatric surgery may determine successful referrals to surgical programs versus alternative behavioral health interventions. OBJECTIVES: The primary objective of this article was to investigate the relationship between presurgical mental health factors and whether or not a patient received bariatric surgery within the first six months of entering the program. SETTING: Pediatric Children's Hospital, Bariatric Surgery Program within Pediatric Surgery Department. METHODS: A retrospective medical record review of all patients referred from 2016 to 2019 to an adolescent surgical weight loss program was conducted. Patients were determined as completers if they received a laparoscopic sleeve gastrectomy within 6 months of entering the program. Demographic and preoperative mental health factors among completers (n = 30) were compared with surgery noncompleters (n = 44) using enter method logistic regression. RESULTS: Regression analyses revealed that younger patients, White patients, patients with lower internalizing symptoms on a standardized measure, and patients with greater self-reported motivation for surgery at their initial surgery visit were more likely to obtain surgery within 6 months of starting the program. CONCLUSION: The findings underscore the importance of assessing patients' motivation early in the bariatric surgery referral process. This study highlights potential treatment implications in how best to mitigate patient barriers, such as internalizing symptoms and low motivation, to pursue bariatric surgery and remain committed to weight loss goals through techniques such as motivational interviewing.

Chronic Inflammatory Placental Lesions Correlate With Bronchopulmonary Dysplasia Severity in Extremely Preterm Infants.

OBJECTIVE: Correlation of BPD with placental pathology is important for clarification of the multifactorial pathogenesis of BPD; however, previous reports have yielded varying results. We report placental findings in no/mild BPD compared to moderate/severe BPD, and with and without pulmonary hypertension (PH). METHODS: Eligible infants were 230/7-276/7 weeks gestational age. BPD was defined by the need for oxygen at ≥28 days with severity based on need for respiratory support at ≥36 weeks. Acute and chronic inflammatory placental lesions and lesions of maternal and fetal vascular malperfusion were examined. RESULTS: Of 246 eligible infants, 146 (59%) developed moderate/severe BPD. Thirty-four (23%) infants developed PH, all but 1 being in the moderate/severe BPD group. Chronic deciduitis (32% vs 16%, P = .003), chronic chorioamnionitis (23% vs 12%, P = .014), and ≥ 2 chronic inflammatory lesions (13% vs 3%, P = .007) were more frequent in the moderate/severe BPD group. Development of PH was associated with placental villous lesions of maternal vascular malperfusion (30% vs 15%, P = .047). CONCLUSIONS: The association of chronic inflammatory placental lesions with BPD severity has not been previously reported. This supports the injury responsible for BPD as beginning before birth in some neonates, possibly related to cytokines associated with these chronic inflammatory lesions.

Sistrunk vs modified Sistrunk procedures: Does procedure type matter?

BACKGROUND: Thyroglossal Duct Cyst (TDC) is the most common congenital neck mass in children and is surgically managed with a Sistrunk procedure. Some surgeons perform a modified Sistrunk (mSis), involving the dissection of the fistula beyond the hyoid bone without coring out the foramen cecum at the base of the tongue. We aim to evaluate surgical outcomes of children undergoing Sistrunk (Sis) or modified Sistrunk (mSis) procedures for TDC at an academic pediatric institution. MATERIALS AND METHODS: We conducted a retrospective chart review of the Children's National Medical Center database from 2004 to 2014. Basic demographic information, preoperative characteristics, postoperative complications, and recurrence were extracted for children diagnosed with TDC. We estimated descriptive statistics using Kruskal-Wallis tests and Pearson's chi-square for continuous and categorical values. RESULTS: 157 patients that underwent TDC excision were identified. Sistrunk (Sis) was performed in 52 cases (33%) and modified Sistrunk (mSis) performed in 105 (67%) cases. 84 (54%) were female and the mean age at surgery was 5.4 years (SD=4.5). Overall recurrence was detected in 8 cases (5.1%) and did not differ significantly by procedure type [2 (4%) in Sis and 6 (6%) in mSis, p = 0.616]. Post-operative complications did not differ significantly between Sis and mSis procedure: swelling [6 (12%) and 18 (17%), p = 0.481]; seroma [5 (10%) and 10 (10%), p = 1.00]; surgical site infection [3 (6%) and 8 (8%), p = 0.752]; or post-excision incision and drainage [3 (6%) and 9 (9%), p = 0.752] (respectively). CONCLUSIONS: Our findings reveal no statistical difference in recurrence rates between Sis and mSis with no risk factors for recurrence identified. Furthermore, there was no difference in post-operative complications between the groups. Both surgical procedures were associated with few complications and low recurrence.

Influence of Epidural Ropivacaine with or without Dexmedetomidine on Postoperative Analgesia and Patient Satisfaction after Thoraco-Lumbar Spine Instrumentation: A Randomized, Comparative, and Double-Blind Study.

STUDY DESIGN: This was a prospective, randomized, and double-blind study. PURPOSE: Thoraco-lumbar spine surgery is associated with severe postoperative pain and can cause chronic pain. We aimed to compare the impact of epidural ropivacaine with and without dexmedetomidine on postoperative analgesia after thoracolumbar spine instrumentation wherein an epidural catheter was placed by the surgeon intraoperatively. OVERVIEW OF LITERATURE: Very few studies have reported the use of epidural dexmedetomidine in spine surgeries. When used via the epidural route, dexmedetomidine is safe and efficacious and is associated with reduced rescue analgesia consumption, increased duration of analgesia, reduced pain scores, but not with major hemodynamic adverse effects. METHODS: Total 60 American Society of Anesthesiologists I-III adult patients aged 18-65 years who were scheduled to undergo thoraco-lumbar spine instrumentation were randomly allocated into group RD (epidural ropivacaine+dexmedetomidine) or group R (epidural ropivacaine plus saline). We aimed to compare the total rescue analgesic consumption on postoperative day 0, 1, and 2. Moreover, we studied the time to first rescue analgesia with visual analogue scale score <4 and the overall patient satisfaction scores. RESULTS: There was no difference between the demographic characteristics of the two groups. The mean value of total rescue analgesia consumption was 162.5±68.4 mg in the RD group and 247.5±48.8 mg in the R group. The mean time to first rescue analgesia was 594.6±83.0 minutes in the RD group and 103.6±53.2 minutes in the R group. The mean patient satisfaction score was 4.2±0.7 in the RD group and 3.2±0.6 in the R group. No patient had any respiratory depression or prolonged motor blockade during the postoperative period. CONCLUSIONS: This study demonstrated the superior efficacy, in terms of postoperative analgesia and patient satisfaction scores, of epidural ropivacaine plus dexmedetomidine over that of ropivacaine alone in patients undergoing surgery for thoraco-lumbar spine.

Frequency of Blood Transfusion in Percutaneous Nephrolithotomy.

Introduction Percutaneous nephrolithotomy (PNL) has replaced open surgery for the treatment of kidney stones due to its less invasive nature. Bleeding still occurs due to renal vascular injuries, dependent upon the access route of the procedure. Several other factors are also related to the increased risk of bleeding. This study aims to find the association between blood transfusion and other factors such as age, gender, body mass index (BMI), size of the stone, operative time, preoperative hemoglobin (Hb) level, stone surface area, hypertension, and diabetes mellitus. Materials and methods This was a descriptive cross-sectional study conducted over a period of six months between November 2019 and April 2020 at a tertiary care hospital in Karachi, Pakistan. The sample size of 131 patients was calculated using open-source epidemiological software (Open-Epi). Inclusion criteria included patients from both genders and ages between 26 and 70 years. Patients ≤25 years, having a liver disease or bleeding disorders, or refusing to participate in the study, were excluded. Laboratory data included preoperative routine complete blood count, serum creatinine (normal 0.5-1.5 mg/dL), platelet count, bleeding and coagulation profile, and urine culture. All patients also underwent renal ultrasound scans. Treatment was postponed until a negative urine culture was obtained from patients with a positive urine culture.  Results The mean age of the patients was 42.4 ± 15.65 years. One third (29.8%) of the patients were females. The stone size was 850 ± 121.43 mm², the mean operative time of the procedure was 125.76 ± 53.4 minutes, and the mean number of cell packs transfused was 1.10 ± 0.31 units. Blood transfusion was done in 24 (18.3%) of the patients. Gender, diabetes mellitus, stone size, preoperative Hb level, and operative time were significantly related to blood transfusion.  Conclusions Increased bleeding risk while performing PNL has been associated with many factors such as operating time, the gender of the patients, and stone size. Therefore, these factors should be controlled for the procedure to decrease the risk of bleeding and the need for blood transfusion. Furthermore, the kidney vasculature should not be compromised while performing the procedure.

Different Types of Clinical Presentations and Stages of Retinoblastoma Among Children.

Introduction Retinoblastoma (Rb) is the most common intraocular malignant tumor of childhood. The different modes of Rb presentation comprise proptosis, anterior chamber inflammatory signs, spontaneous hyphema, secondary glaucoma, and strabismus. The primary aim of this study was to investigate the different clinical presentations and stages of Rb that may help in early detection and timely diagnosis to prevent the advancement of the disease and increase rates of survival in children.  Materials and methods This was a descriptive cross-sectional study conducted between December 2019 and May 2020 over a period of six months at a tertiary care hospital in Karachi, Pakistan. The sample size included 68 eyes of children with lesions of Rb at the time of presentation to the hospital. Brightness scans (B-scans), computed tomography (CT) scans, and magnetic resonance imaging (MRI) were performed. The International Intraocular Retinoblastoma Classification (IIRC) was used to stage each eye. In case of enucleation (if necessary) of the eye, the biopsy was performed to evaluate the histological features of cancer. All statistical analysis was performed using Statistical Package for Social Sciences version 17.0 (IBM Corp., Armonk, New York). Results The mean age of the children was 3.21 ± 1.75 years. Leukocoria was the most common clinical presentation observed in more than half (n = 35, 51.47%) of the sample population followed by proptosis reported in nearly two-fifths (n = 25, 36.76%), strabismus and phthisis bulbi observed in equal proportions (n = 3, 4.41%), and hypopyon documented in a minor proportion (n = 2, 2.94%) of patients. Regarding stages of the Rb disease, the most common stages were observed to be stage C and stage E.  Conclusions This study concludes that the early detection of Rb is possible through a better understanding of presenting features of the disease. It can prevent the progression of the disease to the advanced stages and decrease morbidity and mortality. The early detection of Rb can be made possible through the examination of red reflex on the regular check-ups of children as leukocoria is the most common clinical presentation.

Classification and reporting guidelines for the pathology diagnosis of placenta accreta spectrum (PAS) disorders: recommendations from an expert panel.

The terminology and diagnostic criteria presently used by pathologists to report invasive placentation is inconsistent and does not reflect current knowledge of the pathogenesis of the disease or the needs of the clinical care team. A consensus panel was convened to recommend terminology and reporting elements unified across the spectrum of PAS specimens (i.e., delivered placenta, total or partial hysterectomy with or without extrauterine tissues, curetting for retained products of conception). The proposed nomenclature under the umbrella diagnosis of placenta accreta spectrum (PAS) replaces the traditional categorical terminology (placenta accreta, increta, percreta) with a descriptive grading system that parallels the guidelines endorsed by the International Federation of Gynaecology and Obstetrics (FIGO). In addition, the nomenclature for hysterectomy specimens is separated from that for delivered placentas. The goal for each element in the system of nomenclature was to provide diagnostic criteria and guidelines for expected use in clinical practice.

Physician-Estimated Depth as a Screening Tool for Computed Tomography Evaluation of Pectus Excavatum.

BACKGROUND: Pectus excavatum (PE) is the most common congenital chest wall anomaly with a reported incidence of 1/300 to 1/400 live births and a male predominance. Preoperative evaluation of defect severity typically requires a calculation of the Haller index (HI) and/or correction index (CI) using computed tomography (CT) or x-rays. The purpose of this study was to determine whether physician-estimated depth (PED), a bedside screening tool, could be used to identify a subset of pediatric patients in whom CT was unnecessary. METHODS: After institutional review board approval (IRB #032018-091), we retrospectively reviewed all patients with a diagnosis of PE between 2009 and 2018 at our academic pediatric center. Demographic information including age, sex, and body mass index were abstracted. Imaging was reviewed to obtain HI and CI and to retrospectively calculate PED. The PED is calculated at the bedside by measuring the depth of the pectus at the site of greatest depression relative to a horizontal surface laid across the deformity. For this retrospective study, we calculated the CT-derived PED by measuring the depth from the horizontal on the respective CT images. Patients without imaging studies and patients with pectus carinatum, arcuatum, or mixed deformities were excluded from this study. RESULTS: A total of 94 patients met inclusion criteria. Of these, 82% were male, with a median age of 15 y. Patients were further subdivided by BMI, with 46% of patients having a BMI of <18.5 kg/m2 (i.e., underweight), whereas 54% of patients had a BMI of ≥18.5 kg/m2. Using a threshold PED of 2 cm, patients with a BMI of <18.5 kg/m2 had correct classification rates of 93% and 95% using PED relative to HI and CI, respectively. Patients with a BMI of ≥18.5 kg/m2 had correct classification rates of 80% and 88% using PED relative to HI and CI, respectively, at the same 2 cm threshold. CONCLUSIONS: PED is a viable screening tool for the preoperative evaluation of PE with a 2 cm threshold providing the combination of high sensitivity, specificity, and correct classification rates especially in underweight patients.