Vehicle Detection and Attribution from a Multi-Sensor Dataset Using a Rule-Based Approach Combined with Data Fusion.

Vehicle detection using data fusion techniques from overhead platforms (RGB/MSI imagery and LiDAR point clouds) with vector and shape data can be a powerful tool in a variety of fields, including, but not limited to, national security, disaster relief efforts, and traffic monitoring. Knowing the location and number of vehicles in a given area can provide insight into the surrounding activities and patterns of life, as well as support decision-making processes. While researchers have developed many approaches to tackling this problem, few have exploited the multi-data approach with a classical technique. In this paper, a primarily LiDAR-based method supported by RGB/MSI imagery and road network shapefiles has been developed to detect stationary vehicles. The addition of imagery and road networks, when available, offers an improved classification of points from LiDAR data and helps to reduce false positives. Furthermore, detected vehicles can be assigned various 3D, relational, and spectral attributes, as well as height profiles. This method was evaluated on the Houston, TX dataset provided by the IEEE 2018 GRSS Data Fusion Contest, which includes 1476 ground truth vehicles from LiDAR data. On this dataset, the algorithm achieved a 92% precision and 92% recall. It was also evaluated on the Vaihingen, Germany dataset provided by ISPRS, as well as data simulated using an image generation model called DIRSIG. Some known limitations of the algorithm include false positives caused by low vegetation and the inability to detect vehicles (1) in extremely close proximity with high precision and (2) from low-density point clouds.

Median Arcuate Ligament Syndrome with Orthostatic Intolerance: Intermediate-Term Outcomes following Surgical Intervention.

OBJECTIVES: To report the intermediate-term outcome following surgical intervention for median arcuate ligament syndrome (MALS) in adolescents and young adults with orthostatic intolerance (OI) to assess clinical improvement in the gastrointestinal and 5 other functional domains and if relief of arterial obstruction is associated with resolution of clinical symptoms. STUDY DESIGN: Thirty-one patients were given 2 dysautonomia-designed questionnaires to assess changes in symptoms following operative intervention in 6 functional domains and underwent postoperative repeat abdominal ultrasound examinations. RESULTS: Average follow-up after surgery was 22.4 ± 14.8 months. Self-assessed quality of health on a Likert scale (1-10 with 10 being normal) improved from 4.5 ± 2.1 preoperatively to 5.3 ± 2.4 postoperatively (P = not significant). Gastrointestinal symptoms of abdominal pain, nausea, and vomiting improved in 63% (P = .007), 53% (P = .040), and 62% (P = .014) of patients, respectively. Cardiovascular symptoms of dizziness, syncope, chest pain, and palpitations improved in 45% (P = not significant), 50% (P = not significant), 54% (P = .043), and 54% (P = .037) of patients, respectively. Transabdominal ultrasound peak supine expiratory velocity decreased from 348 ± 105 cm/s preoperatively to 251 ± 109 cm/s at 6 months or more after a ligament release procedure. Decrease of the postoperative celiac artery Doppler velocity was not associated with an improvement in gastrointestinal symptoms (P = .075). CONCLUSIONS: Adolescent and young adult patients with median arcuate ligament syndrome and OI have a good response to surgical intervention. About two-thirds of patients report significant improvement in symptoms of abdominal pain, nausea, and vomiting. Despite these encouraging data, many patients with MALS and OI continue to have an impaired quality of health.

Simulations of vehicular optical wireless communication systems and comparisons with DSRC systems.

Optical wireless communication (OWC) has been proposed as a complementary technique to radio frequency (RF) communications for vehicular applications. OWC systems can be categorized into two types based on the transmitters: the first one is the light-emitting diode (LED)-based OWC system, and the second is the laser diode (LD)-based OWC system. Simulations of both types of OWC systems are presented in this paper. To simulate the OWC systems precisely, outdoor experiments of OWC systems have been done and the measurements of background noise are applied in the simulations. In terms of the LED-based OWC system, the impulse responses are obtained by an improved ray tracing algorithm. To reduce the computational complexity, visibility graphs are applied in the improved ray tracing algorithm. Compared with the brute force algorithm, our improved algorithm is able to reduce the computational complexity from O(n3) to O(n2log⁡(n)), where n is the number of mobile terminals. In LD-based OWC systems, the performance and stability are highly dependent on the tracking system in vehicular applications. Therefore, this paper also analyzes the requirements of tracking accuracy in LD-based OWC systems. Finally, the simulated LED-based OWC system is compared with the dedicated short-range communication (DSRC) system under different traffic densities. Our experimental and simulation results have demonstrated that OWC can be a complementary technique for DSRC under conditions of high traffic density.

Variations in the management of adolescent adnexal torsion at a single institution and the creation of a unified care pathway.

PURPOSE: Adnexal torsion is a gynecologic emergency, requiring intervention for tissue preservation. At our institution, torsion is managed by pediatric surgeons or gynecologists. We evaluated differences between specialties to streamline evaluation for children with gynecological emergencies, develop a clinical pathway, and prevent care delays. METHODS: A retrospective review of adolescents undergoing intervention for adnexal torsion from 2004-2018 was performed. Differences in time to intervention, operation duration, the procedure performed, and length of stay (LOS) between the specialties were analyzed. RESULTS: Eighty-six patients underwent 94 operations for presumed adnexal torsion with 87 positive cases. Pediatric surgeons performed 60 operations and 34 cases were performed by gynecologists. Preservation of fertility was the goal in both cohorts and the rate of oophoropexy, cystectomy, and oophorectomy were similar between the cohorts (p = 0.14, p = 1.0, p = 0.39, respectively). There was no difference in intra-operative time (p = 0.69). LOS was shorter in the gynecology cohort (median 1 day [1-2] vs. 2 days [2-3], p > 0.001). CONCLUSIONS: Adnexal torsion is a time-sensitive diagnosis requiring prompt intervention for ovarian or fallopian tube preservation. A multidisciplinary institutional care pathway should be developed and implemented.

Evidence of GMPPA founder mutation in indigenous Guatemalan population associated with alacrima, achalasia, and mental retardation syndrome.

Congenital disorders of glycosylation (CDG) are a heterogeneous group of inborn errors of metabolism mostly causing multisystem disease. In 2013, biallelic mutations in the GMPPA gene were described in association with one such CDG known as alacrima, achalasia, and mental retardation syndrome (AAMR). To date, 18 patients have been reported, nearly all displaying the same pathognomonic triad of symptoms described in the name. This condition shares considerable phenotypic overlap with Triple-A syndrome caused by biallelic mutations in the AAAS gene; however, AAMR lacks the characteristic adrenocortical findings associated with Triple-A syndrome. We report three patients from two unrelated families with the same homozygous GMPPA mutation (c.265dup, p.L89fs). Notably, both families reported indigenous Maya-Mam heritage and originated from the town of Concepción Chiquirichapa in Quezaltenango, Guatemala. Our cases help to expand the AAMR phenotype by outlining dysmorphic features not well described in the prior cases. Additionally, we encourage all providers with patients presenting with this unique triad of symptoms to consider sequencing of the GMPPA gene. Special consideration should be given to families of Guatemalan Maya-Mam ancestry who may also have this identified founder mutation. Finally, this condition may indeed be underdiagnosed based on a review of the literature.

Assessing surgical care delivery at facilities caring for higher volumes of minority children utilizing the pediatric quality indicator for perforated appendicitis: a propensity-matched analysis.

INTRODUCTION: The pediatric quality indicator (PDI) measures released by the Agency for Healthcare Research and Quality (AHRQ) provide an impetus for benchmarking quality of care in children. The PDI-17, aimed at studying perforation in appendicitis, is one such measure that this study aims to utilize to assess surgical care delivery and outcomes in children managed at majority-minority hospitals. METHODS: The Kid Inpatient Database (2000-2012) was queried for pediatric patients (< 18 years) with a diagnosis of appendicitis, with and without perforation. Facilities were categorized into tertiles based on rates of perforation (PDI-17). Similarly, tertiles were generated based on volume of minority patients (Black and Hispanic) treated at each facility. Multivariable regression analysis adjusted for demographic parameters, hospital-level characteristics, propensity score quintiles, clinically relevant outcomes, and tertiles of minority patients treated. RESULTS: Of the 322,805 patients with appendicitis 28.7% had perforated appendicitis. Patients presenting to facilities caring for a higher volume of perforated appendicitis were younger with public insurance or no insurance and, however, these patients were less likely to belong to a minority group (p < 0.05). Additionally, these patients were less likely to belong to the highest income quartile (OR [95% CI] 0.45 [0.39-0.52]). Hospitals treating the highest volume of minority patients [majority-minority hospitals (MMHs)] had an 87% (OR [95% CI] 1.87 [1.77-1.98]) increased likelihood of also treating the highest rates of perforated appendicitis. CONCLUSION: Hospitals treating a high volume of complicated appendicitis are less likely to care for minority groups. Additionally, MMHs lacking experience and volume in caring for complicated appendicitis have an increased likelihood of patients with perforations which is indicative of poor healthcare access.

Potent LpxC Inhibitors with In Vitro Activity against Multidrug-Resistant Pseudomonas aeruginosa.

New drugs with novel mechanisms of resistance are desperately needed to address both community and nosocomial infections due to Gram-negative bacteria. One such potential target is LpxC, an essential enzyme that catalyzes the first committed step of lipid A biosynthesis. Achaogen conducted an extensive research campaign to discover novel LpxC inhibitors with activity against Pseudomonas aeruginosa We report here the in vitro antibacterial activity and pharmacodynamics of ACHN-975, the only molecule from these efforts and the first ever LpxC inhibitor to be evaluated in phase 1 clinical trials. In addition, we describe the profiles of three additional LpxC inhibitors that were identified as potential lead molecules. These efforts did not produce an additional development candidate with a sufficiently large therapeutic window and the program was subsequently terminated.

Primary Omental Torsion in a Pediatric Patient: Case Report and Review of the Literature.

Primary omental torsion is a rare cause of acute abdominal pain with a clinical presentation resembling acute appendicitis. Here, we report the case of a 7-year-old child presenting with right lower quadrant pain. Primary omental torsion was discovered upon laparoscopy, and the torsed omentum was excised without postoperative complications. Potential causes, contributing factors, diagnosis, and treatment are discussed.

Evaluating the impact of a minimally invasive pediatric surgeon on hospital practice: comparison of two children's hospitals.

PURPOSE: Widespread adoption of minimally invasive surgery (MIS) techniques in pediatric surgery has progressed slowly, and the shift in practice patterns has been variable among surgeons. We hypothesized that a pediatric surgeon committed to MIS could effectively change surgical practice by creating an emphasis on MIS. METHODS: Annual case volumes from 2000 to 2009 at two tertiary care pediatric hospitals, one with a dedicated minimally invasive pediatric surgeon, were evaluated for trends in MIS for ten different operations. Univariate analyses of the differences between hospitals in the use of the open versus laparoscopic approach were performed. The Breslow-Day test was used to examine differences in use of laparoscopic procedures across hospitals in early versus middle and middle versus late time periods. RESULTS: Between the two hospitals, for 9 of the 10 types of surgery, the number of laparoscopic and open procedures differed significantly (p values ranged from <0.0001 to 0.003). Over the 10-year period, the hospital with a dedicated MIS surgeon had a larger proportion of procedures done laparoscopically for all years. This difference reached statistical significance for appendectomy (p < 0.0001), congenital diaphragmatic hernia (p < 0.0002), chest wall reconstruction (p < 0.0001), cholecystectomy (p = <0.0001), gastrostomy (p < 0.0001), nissen fundoplication (p < 0.0001) oophorectomy (p < 0.0001), pyloromyotomy (p < 0.0001) and splenectomy (p = 0.0006). After grouping the years into early (2000-2003), middle (2004-2006) and late (2007-2009) categories, the hospital with a dedicated MIS surgeon had a significantly higher rate of increase in use of laparoscopic surgery between the early and middle years for four procedures: diaphragmatic hernia repair (p = 0.003), chest wall reconstruction (p = 0.0086), cholecystectomy (0.0083) and endorectal pull-through (p = 0.025). CONCLUSION: The presence of a dedicated minimally invasive pediatric surgeon led to a significant change in surgical practice with an overall trend of increasing MIS several years in advance of a hospital that did not have a dedicated MIS surgeon. This has implications for resident training in academic medical centers and potential patient care outcomes.

Stereoscopic augmented reality for laparoscopic surgery.

BACKGROUND: Conventional laparoscopes provide a flat representation of the three-dimensional (3D) operating field and are incapable of visualizing internal structures located beneath visible organ surfaces. Computed tomography (CT) and magnetic resonance (MR) images are difficult to fuse in real time with laparoscopic views due to the deformable nature of soft-tissue organs. Utilizing emerging camera technology, we have developed a real-time stereoscopic augmented-reality (AR) system for laparoscopic surgery by merging live laparoscopic ultrasound (LUS) with stereoscopic video. The system creates two new visual cues: (1) perception of true depth with improved understanding of 3D spatial relationships among anatomical structures, and (2) visualization of critical internal structures along with a more comprehensive visualization of the operating field. METHODS: The stereoscopic AR system has been designed for near-term clinical translation with seamless integration into the existing surgical workflow. It is composed of a stereoscopic vision system, a LUS system, and an optical tracker. Specialized software processes streams of imaging data from the tracked devices and registers those in real time. The resulting two ultrasound-augmented video streams (one for the left and one for the right eye) give a live stereoscopic AR view of the operating field. The team conducted a series of stereoscopic AR interrogations of the liver, gallbladder, biliary tree, and kidneys in two swine. RESULTS: The preclinical studies demonstrated the feasibility of the stereoscopic AR system during in vivo procedures. Major internal structures could be easily identified. The system exhibited unobservable latency with acceptable image-to-video registration accuracy. CONCLUSIONS: We presented the first in vivo use of a complete system with stereoscopic AR visualization capability. This new capability introduces new visual cues and enhances visualization of the surgical anatomy. The system shows promise to improve the precision and expand the capacity of minimally invasive laparoscopic surgeries.

Cemented liner exchange with bone grafting halts the progression of periacetabular osteolysis.

The aims of this were to examine the effect of acetabular liner exchange and intra-operative bone grafting surgery on peri-prosthetic osteolysis. Seven patients with well-fixed Harris-Galante-1 acetabular components received cemented exchange liners for worn liners associated with pre-operatively CT-quantified osteolysis. During surgery, accessible osteolytic lesions were debrided and bone-grafted. Except for one patient with recurrent dislocation and acetabular component revision, the other patients had CT scans at a median of 4 months and at approximately 4 years after surgery. None of the pre-operative lesions increased in volume during the post-operative reporting period and no new lesions were detected. These results show that cemented liner exchange surgery can halt the progression of osteolysis and that bone grafting has the potential to restore bone.

Endoscopic retrograde cholangiopancreatography is safe and effective for the diagnosis and treatment of pancreaticobiliary disease following abdominal organ transplant in children.

ERCP is a diagnostic and therapeutic imaging modality widely used in adult pancreaticobiliary disease, including the treatment of anastomotic strictures following liver and small bowel transplant. We have previously reported a large series of ERCP in children and demonstrated its safety and utility in pediatric disease. The aim of this study was to evaluate the safety of and indications for ERCP following abdominal organ transplant among pediatric patients by performing a subgroup analysis of our large cohort. Forty-eight ERCPs were performed on 25 children ages 62 days to 20 yr following isolated liver, isolated small bowel, or composite graft transplant. Mean time from transplantation at the time of ERCP was 18 months. The most common indication for ERCP was the evaluation of non-specific hepatobiliary complaints, including abdominal pain and elevated liver enzymes. ERCP was also commonly performed for the evaluation or treatment of known or suspected biliary tree strictures. Seventy-seven percent of cases included therapeutic intervention, including sphincterotomy in 40%, stent placement in 29%, and stone extraction in 19%. The overall complication rate among post-transplant patients was low (2.9%) and not significantly different than the complication rate reported in our previous study. A history of abdominal organ transplant was not associated with an increased risk of complication following ERCP (OR = 0.41, 95% CI = 0.05-3.33). In our experience, ERCP can be safely performed in children following liver, small bowel, and composite graft transplant with outcomes similar to those seen in a general pediatric population and may be especially useful for the diagnosis and treatment for biliary strictures following transplant. Further investigation of the relationship between the timing of ERCP relative to transplant and the safety of the procedure is needed.

Video. Diagnostic laparoscopy and preoperative planning in ischiopagus tripus conjoined twins: a surgical first, with detailed demonstration of the complex anatomical relationships.

BACKGROUND: Diagnosis and management of conjoined twins are constantly evolving. New imaging techniques provide important anatomic details and help in planning the separation procedure. Despite these technological advances, however, the complex arrangement of conjoined organs is somewhat difficult to interpret, leaving unresolved questions at time of surgery. The authors present a video demonstrating laparoscopy as an adjunct in the preoperative planning of separation of ischiopagus tripus conjoined twins as well as illustrating the complex anatomy in a combination of video, drawings, and radiologic imaging. To date, this is the first time that laparoscopy has been used in preoperative assessment of conjoined twins. METHODS: After elective cesarean delivery, ischiopagus tripus conjoined twins were thoroughly evaluated with conventional imaging, including plain radiographs and computed tomography scan with three-dimensional (3-D) reconstruction images. The anatomy of the gastrointestinal and genitourinary tracts was further defined with barium enema, retrograde pyelography, and cystoscopy. In addition to these tests, diagnostic laparoscopy was performed at time of tissue expander placement. An angled scope, introduced through a 5-mm umbilical port, was used to visualize the intraperitoneal organs as well as all accessible retroperitoneal structures. RESULTS: Laparoscopy provided useful information regarding the bowel distribution between the twins. In addition, it helped demonstrate the relationship of shared solid organs with other intra-abdominal structures and identify anatomic landmarks used in the subsequent separation of the twins. Finally, laparoscopy helped confirm the presence, number, and morphology of the internal female genitalia. CONCLUSIONS: Diagnostic laparoscopy is a useful tool in evaluation of ischiopagus tripus conjoined twins. It is an important adjunct to preoperative studies in preparing for an expeditious and safe separation procedure.

Per Oral Endoscopic Myotomy (POEM) for pediatric achalasia: Institutional experience and outcomes.

BACKGROUND: The surgical treatment of achalasia by both laparoscopic and endoscopic approaches has been recognized as the definitive management in children. Despite reported low volumes in many centers, there has been an increasing worldwide experience with endoscopic approaches to pediatric achalasia. The aim of this study is to report our institutional experience with per oral endoscopic myotomy (POEM) as first-line or revisional therapy for achalasia. METHODS: An IRB approved retrospective review of all patients who underwent operative procedures for achalasia, specifically with the POEM technique, from July 2015 to September 2021. Data including demographics, intra-operative details, pre and post operative Eckardt scores, complications, outcomes, and follow-up were obtained. RESULTS: During the study period, a total of 43 children underwent 46 operations for achalasia including POEM and laparoscopic Heller myotomy (LHM). Operations included 37 POEMS (33 primary POEMS; 3 POEMS after failed LHM; and 1 POEM after failed POEM). Additionally, 9 LHM operations including, 4 primary LHM; 3 attempted POEMS converted to LHM; 1 attempted POEM after failed LHM converted to redo LHM; and 1 LHM after failed POEM. In the POEM group (n = 37), based on the high resolution esophageal manometry findings Chicago Classification types at diagnosis were as follows: 9 patients were type I (24.3%); 25 patients were type II (67.6%); 2 patients were type III (5.9%) and 1 patient was unknown type (2.7%). Sixteen children (43.2%) had prior endoscopic treatment of achalasia prior to POEM [Pneumatic Balloon Dilatation (PBD), and/or Botox injection (BTI)],), while prior operative intervention occurred in 4 patients (10.8%), 3 LHM and 1 POEM. Age at operation was 2-18 years (mean ± SD age: 11.6 ± 4.5 years). Weight at operation 11.8-100.7 kg (mean ± SD kg; 39 ± 19.9 kg). Range of baseline Eckardt score was 4-10 (mean ± SD: 6.73 ± 1.5). Operative time was 64-359 min (mean ± SD minutes: 138.1 ± 62.2 min). Intraoperative complications occurred in 16 patients (43.2%) but did not require reoperation during index admission including: 4 mucosotomy (11.8%); 9 pneumothoraces (24.3%); 2 pneumomediastinum (5.4%); 10 pneumoperitoneum (27%); 0 sub-mucosal tunnel bleeding (0%); 0 open conversion/death (0%). Post operative complications included: 5 recurrent dysphagia (13.5%); 0 esophageal leak (0%); 3 GERD (8.1%); 1 failed POEM (2.7%). Median length of stay was 2 days (mean ± SD days: 2.4 ± 0.9 day). Follow-up ranged from 1 to 74 months (median 15 months), mean follow-up 22.6 months ± 20 months. Post POEM Eckardt score was 0.6 ± 0.9. Five patients required a single PBD post POEM (13.5%) and 1 patient required a repeat myotomy (LHM) after POEM (2.7%) for a 16.2% reintervention rate. Subsequent normalization of Eckardt scores (≤ 3) and symptomatic relief was achieved in all patients (100%). CONCLUSIONS: POEM as first-line therapy for pediatric achalasia, or as a secondary procedure after failed prior myotomy or POEM, in our experience is safe and effective. We have shown equivalent results to our own prior experience with LHM. Long-term follow-up will be performed to monitor for recurrent symptoms, adequate physical growth, and general development. LEVEL OF EVIDENCE: II.

Recidivism following childhood maltreatment necessitating inpatient care in the United States.

INTRODUCTION: Non-accidental trauma (NAT) is one of the common causes of injury in children in the United States (US). Abuse and maltreatment affect 2 per 100,000 children annually and may go unrecognized. The aim of this study to quantify the recidivistic nature of NAT in the US pediatric population. METHODS: The National Readmissions Database (2007-2015) was queried for pediatric (≤18y) trauma patients. Children presenting for non-accidental trauma were further identified. Data was obtained on demographic, clinical, and hospital-level characteristics. Body regions with an Abbreviated Injury Scale (AIS) greater than three were further identified. Multivariable logistic regression analysis (adjusting for age, gender, insurance status, year, Injury Severity Score [ISS], hospital region, and mechanism of injury) was utilized to determine factors influencing unintentional and intentional (assault) non-accidental traumatic injuries. RESULTS: NAT represents 1.6% (n = 4,634/286,508) of all pediatric trauma. The median age of presentation was <1y [IQR:0-3] with a male predominance (56.2%). Median ISS was 9 [IQR:2-16]. 87.5% of incidents represented assault (intentional). The most commonly affected body region was the head and neck (32.8%), followed by the extremities (11.4%) and soft tissue trauma or burns (6.3%). Penetrating trauma accounted for 18% of these injuries. 3.2% were readmitted to the hospital for a recurrent episode. 85.5% presented to the hospital for their initial evaluation. Mortality rates were 3.8% for those re-admitted to the hospital. The most common perpetrators were other specified persons known to the family, followed by fathers and mothers. CONCLUSION: Although uncommon, recidivism, after an initial episode of NAT, can have devastating consequences. The majority of the perpetrators of abuse are individuals known to the patient or family. Health policy aimed towards developing preventative strategies is needed to facilitate early recognition and tackle abuse in children. LEVEL OF EVIDENCE: III. TYPE OF EVIDENCE: Case Control Study.

Mini thoracic CT adequately determines Haller index and decreases radiation exposure in children with pectus excavatum.

INTRODUCTION: The preoperative assessment of Pectus Excavatum (PE) is resource intensive. CT chest for the purpose of calculating a Haller index (HI) remains a central component and is necessary for third-party reimbursment for surgical correction. With the goal of minimizing radiation exposure, a strategy was introduced to perform a mini-Thoracic CT (mini-CT) for the calculation of HI. OPERATIVE TECHNIQUE: The mini-CT was performed as follows: a radio-opaque marker (ROM) was placed at the clinical deepest point of the deformity. The CT was then columnated to scan 3 cm above and 3 cm below the ROM. HI was calculated according to previously described technique. Seven children with PE who underwent mini-CT were age and weight matched to 7 children with PE who underwent standard low dose CT chest during the same time period. Radiation doses were evaluated using dose length product (DLP) and effective dose (mSv) between the two groups. Significance of differences was determined using the students t-test. The DLP of mini-CT compared to chest-CT was 17.9 vs 48.9,mGycm respectively. (p< 0.001) The mSv of the mini-CT compared to chest-CT was 0.32 vs 0.88, sMV respectively. (p<0.001) Both DLP and mSv were reduced by 63% in children who received a mini-CT. All children obtained insurance authorization and underwent uncomplicated Nuss repair. CONCLUSION: For children with pectus excavatum deformities the mini-Thoracic CT is an effective method to calculate the HI. Compard to the conventional low dose chest CT, the mini-CT strategy significantly reduces radiation exposure to the child by 63% with no impact on third-party authorizations or Nuss repair.

The impact of regionality and hospital status on mortality associated with non-accidental trauma.

INTRODUCTION: Non-accidental trauma (NAT) affects 2 per 100,000 children annually in the US and may go unrecognized. The aim of this study to quantify the burden of NAT and to evaluate regional variations in mortality. METHODS: The Kids Inpatient Database (2000-2012) was queried for pediatric patients presenting with a diagnosis of NAT. Data was obtained on demographic, clinical and hospital-level characteristics. Primary outcome measure was mortality. Multivariable logistic regression models for age, sex, race/ethnicity, insurance status, income quartile, hospital volume, region (Northeast, South, West and Midwest), teaching status, and injury severity scores. RESULTS: NAT represented 1.92% (n = 15,999) of all trauma patients. Mortality rates were 3.98% for patients presenting with NAT. African American children had a higher likelihood of mortality compared to White children (OR[95%CI]:1.35[1.03-1.79]), however, this effect was not statistically significant for patients being treated at designated children's hospitals (OR[95%CI]:1.23(0.78-1.95) and urban facilities (OR[95%CI]:1.30[0.99-1.72]). Statistically significant regional variations in mortality, lost significance for patients treated at designated children's hospitals (p > 0.05). CONCLUSION: NAT has devastating consequences and is associated with a high mortality rate. Treatment at designated children's hospitals results in the loss of variation in mortality, resulting in diminished disparities and improved outcomes. These findings align with current trends towards the "regionalization of pediatric health care" and reflects the value of regional transfer centers that are.

An appraisal of endoscopic retrograde cholangiopancreatography (ERCP) for pancreaticobiliary disease in children: our institutional experience in 231 cases.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an important tool used by clinicians in the diagnosis and management of pancreaticobiliary disease. The safety and utility of ERCP for adults has been well documented. However, experience with ERCP for pediatric patients remains limited. This study aimed to examine the utility and safety of ERCP for diagnosis and therapy in pediatric surgical conditions. METHODS: An institutional review board-approved retrospective chart review of all children younger than 21 years who underwent ERCP at a single children's hospital between 1992 and 2008 was performed. Age, sex, medical history, presenting symptoms, laboratory values, and discharge diagnoses were recorded. The ERCP findings, interventions performed, complications, and associated surgical procedures also were recorded. RESULTS: A total of 231 ERCPs were performed for 167 children (98 girls and 69 boys) ages 62 days to 21 years. The mean patient age was 11.4 years, with 11% (n = 18) of the ERCPs performed for children younger than 2 years. Common indications for ERCP included chronic or recurrent pancreatitis (n = 106), acute pancreatitis (n = 42), and choledocholithiasis (n = 26). Additional indications included choledochal cyst (n = 2), congenital biliary obstruction (n = 2), and malignant biliary obstruction (n = 1). Therapeutic interventions were performed in 159 cases (69%) including sphincterotomy (n = 96), stone extraction (n = 55), and stent insertion (n = 52). Complications occurred for only 11 patients (4.76%), including 7 cases of post-ERCP pancreatitis. The use of ERCP for imaging resulted in surgical procedures in 58 cases. CONCLUSION: Endoscopic retrograde cholangiopancreatography was used most commonly for children with pancreatitis and gallstone disease. It was used frequently for infants with a low complication rate. The majority of patients required therapeutic intervention, suggesting an important role for ERCP in the management of pancreaticobiliary disease in infants and children.

Feasibility of laparoscopic Nissen fundoplication after pediatric lung or heart-lung transplantation: should this be the standard?

BACKGROUND: Five-year graft survival in the pediatric lung transplant (LTxp) population is less than 50%, with obliterative bronchiolitis (OB) the leading cause of death at 1, 3, and 5 years post-transplant. Bronchiolitis obliterans syndrome (BOS), defined using spirometry values, is the clinical surrogate for the histological diagnosis of obliterative bronchiolitis. Surgical correction of documented gastroesophageal reflux disease (GERD) has been proposed as a means to potentially delay the onset of BOS and prolong allograft survival in adults before or after lung transplantation but only one such study exists in children. We have examined the safety and possible benefits of laparoscopic antireflux surgery in pediatric patients following lung (LTxp) and heart-lung transplantation (HLTxp). METHODS: An Institutional Review Board (IRB)-approved retrospective chart review was performed to evaluate the outcomes and complications of laparoscopic antireflux surgery in pediatric lung and heart-lung transplant patients. Spirometry data were collected for BOS staging using BOS criteria for children. RESULTS: Twenty-five lung and heart-lung transplants were performed between January 2003 and July 2009. Eleven transplant recipients, including six double-lung and five heart-lung (HLTxp), with a median age of 11.7 years (range 5.1-18.4 years), underwent a total of 12 laparoscopic Nissen fundoplications at a median of 427 days after transplant (range 51-2310 days). GERD was determined based upon clinical impression, pH probe study, gastric emptying study, and/or esophagram in all patients. Three patients already had a gastrostomy tube in place and two had one placed at the time of fundoplication. There were no conversions to open surgery, 30-day readmissions, or 30-day mortalities. Complications included one exploratory laparoscopy for free air 6 days after laparoscopic Nissen fundoplication for a gastric perforation that had spontaneously sealed. Another patient required a revision laparoscopic Nissen 822 days following the initial fundoplication for a paraesophageal hernia and recurrent GERD. The average length of hospital stay was 4.4 ± 1.7 days. Nine of the 12 fundoplications were performed in patients with baseline spirometry values prior to fundoplication and who could also complete spirometry reliably. One of these nine operations was associated with improvement in BOS stage 6 months after fundoplication; seven were associated with no change in BOS stage; and one was associated with a decline in BOS stage. CONCLUSION: It is feasible to perform laparoscopic Nissen fundoplication in pediatric lung and heart-lung transplant recipients without mortality or significant morbidity for the treatment of GERD. The real effect on pulmonary function cannot be assessed due to our small sample size and lack of reproducible spirometry in our younger patients. Additional studies are needed to elucidate the relationship between antireflux surgery and the potential for improving pulmonary allograft function and survival in children which has been previously observed in adult patients.

Case series of metal allergy following Nuss procedure: Not only for stainless steel bars.

BACKGROUND: Pectus excavatum is often managed with the Nuss procedure. Metal allergies to pectus bars occur in 5% of patients, though pre-operative testing is not generally routine. OBJECTIVES: This study describes our experience with pre-operative metal allergy testing and post-operative allergic reactions to pectus bars. METHODS: A retrospective study of patients who underwent a Nuss procedure at our institution from 2010-2020 was performed. Patients with documented "metal" allergy, defined by the need for and positive response to steroid treatment and the absence of infection, were included. Data on patient characteristics and clinical course were analyzed. RESULTS: Five of 204 patients (2.5%) identified developed allergic metal reactions. Three of five patients developed allergic reactions to titanium bars, with two requiring early removal of the bar (< 2-3 years). Four patients required more than one course of steroids, and three required debridements for skin breakdown. All patients have maintained good surgical correction at one- and three-years post removal. CONCLUSIONS: Pectus bar metal allergies occur with both stainless steel and titanium bars. Properly selected patients for pre-operative FinnⓇ Chamber testing may reduce the overall incidence of stainless-steel allergies but may miss titanium bar allergies. Early recognition and treatment of bar allergies may salvage the bar and avoid premature removal.