Endoluminal Silicone-Covered Stenting in Children: Novel Applications and Lessons Learned.

BACKGROUND: Silicone-covered endoluminal stents have been applied to various hollow visceral disorders in adult patients with varying success. Efficacy of retrievable endoluminal stenting in children is less well-established. PURPOSE: The purpose of this study was to evaluate our experience with evolving applications of endoluminal silicone-covered stenting in children. RESEARCH DESIGN: Eight children 19 years and younger having silicone-covered stent placement for various indications at a single institution (2014-2021) were reviewed retrospectively. RESULTS: Eight patients received a total of 26 silicone-covered stents. Four stent placements (15.4%) were associated with a direct adverse event. To resolve the endoluminal disorder, four patients received multiple stents or further intervention. When evaluating novel applications, clinical benefit was noted for one patient with vaginal atresia, and another after ileal pouch anal anastomosis disruption. CONCLUSION: This experience highlights the broad and innovative applications for endoluminal silicone-covered natural orifice stenting in children. Acute processes respond well and rapidly to stenting, although chronic, established fistula may require additional manipulations or surgery.

A Standardized Diagnostic Pathway for Suspected Appendicitis in Children Reduces Unnecessary Imaging.

Ultrasound (US) for the diagnosis of acute appendicitis is often nondiagnostic, and additional imaging is required. A standardized approach may reduce unnecessary imaging. Methods: We retrospectively analyzed all patients who had imaging for appendicitis in our emergency department in 2017 and evaluated patient characteristics associated with nondiagnostic US. Using these results, we developed a pediatric appendicitis score (PAS)-based imaging pathway and compared imaging trends prepathway and postpathway implementation. Results: A total of 971 patients received imaging for suspected appendicitis prepathway in 2017. Female sex, obesity, and low/intermediate PAS were significantly associated with nondiagnostic US, but not magnetic resonance imaging (MRI) (P < 0.0001). Nearly one-third of patients received multiple imaging studies (US followed by MRI/computed tomography). As low/intermediate PAS was most strongly associated with a nondiagnostic US on multivariate analysis, we developed a PAS-based imaging stewardship pathway to eliminate imaging in low-PAS patients and reduce the number of patients with an intermediate PAS who received multiple imaging studies by obtaining an MRI as the first-line study. After implementation, only 22 low-PAS patients received imaging (compared with 238 preimplementation), and the proportion of intermediate-PAS patients receiving multiple imaging studies decreased from 31.4% to 13% (P < 0.0001). The cost of imaging per 100 patients increased from $24,255 to $31,082. Conclusion: A PAS-based imaging stewardship pathway reduces unnecessary imaging for suspected appendicitis.

Neointimal Hyperplasia after Carotid Transection and Anastomosis Surgery is Associated with Degradation of Decorin and Platelet Derived Growth Factor Signaling.

OBJECTIVE: Intimal hyperplasia (IH) is the expansion of the vascular intimal region after intervention, which can lead to stenosis and eventual failure of vascular grafts or interventional procedures such as angioplasty or stent placement. Our goals were to investigate the development of IH in a rabbit open surgical model and to evaluate the associated pathophysiological processes involving decorin and the platelet derived growth factor-BB / platelet derived growth factor receptor-ß / mitogen activated protein kinase (PDGF/PDGFR-ß/MAPK) pathway. METHODS: We conducted carotid transection and primary anastomosis on five New Zealand White rabbits to induce IH and examined the associated pathophysiological changes. Tissue was obtained for histological and protein analysis on post-operative day 21 using the contralateral vessel as a control. Intimal medial thickness (IMT) was calculated to measure IH and compared with the unoperated side. Western blot analysis was performed on tissue lysates to determine the expression of decorin core protein, PDGF-BB, PDGFR-ß, and phosphorylated-MAPK (ph-MAPK). Immunofluorescence microscopy was used to assess tissue distribution of matrix metalloproteinase-2 (MMP-2) and phosphorylated-PDGFR-ß (ph-PDGFR-ß). RESULTS: Bilateral carotid arteries were harvested on postoperative day 21. We compared the IMT in operated with unoperated specimens. IMT was significantly elevated in operated arteries vs. unoperated arteries in all 5 animals (148.6 µm +/- 9.09 vs. 103.40 µm +/- 7.08; 135.2 µm +/- 8.30 vs. 92.40 µm +/- 2.35; 203.1 µm +/- 30.23 vs.104.00 µm +/- 4.52; 236.2 µm +/- 27.22 vs. 141.50 µm +/- 9.95; 226.9 µm +/- 11.12 vs. 98.8 µm +/- 3.78). Western blot analysis revealed degradation of decorin protein in the operated tissue, including loss of a 50 kDa band and the appearance of a cleaved fragment at 10 kDa. Decorin and MMP-2 were observed, via immunofluorescence microscopy, in the neointima of the operated vessels. Western blot analysis also revealed increased PDGF-BB, PDGFR-ß, and ph-MAPK levels in operated tissue. Immunofluorescent staining for ph-PDGFR-ß primarily localized to the neointima, indicating increased signaling through PDGF in this region. CONCLUSION: Carotid transection and primary reanastomosis in rabbits induced IH that was associated with MMP-2 activation, degradation of decorin, and activation of the PDGF/PDGFR-ß /MAPK pathway. The findings in this study should lead to further mechanistic evaluation of these pathways to better understand the potential to modify the intimal hyperplastic response to surgery.

Institution-initiated text messaging can reduce unplanned emergency department visits after appendectomy.

BACKGROUND/PURPOSE: The purpose of this study was to reduce unplanned Emergency Department (ED) visits for minor complaints in children after appendectomy through proactive institution-driven communication and utilization of telehealth resources. METHODS: We developed a text messaging system to initiate communication with parents of postappendectomy patients and connect them with a telehealth visit or a phone call with a surgical provider as needed. Using descriptive statistics, chi square, and statistical process control analytics, we compared rates of postoperative ED visits for the 8 months pre- and post-implementation of the messaging system and summarized the feedback we received from patients. RESULTS: A total of 791 laparoscopic appendectomies were performed in two institutions (preintervention = 382, post-intervention = 409). The postoperative ED visit rate decreased from 5.8% preimplementation to 2.4% post-implementation (p = 0.02). Over one-fifth of families messaged (21.6%) had questions in the postoperative period. The majority expressed interest in a video visit (52.5%), while some preferred to speak with the surgeon's office (25%). Over 90% of respondents found the system helpful, and 4.9% opted out. CONCLUSION: Implementation of a hospital-initiated text messaging system has the potential to reduce ED visits in the immediate postoperative period after appendectomy. This system can be scaled to include different surgeries across multiple disciplines. LEVEL OF EVIDENCE: III. TYPE OF STUDY: Clinical Retrospective Pre/Post Intervention Study.

Reducing resource utilization for patients with uncomplicated appendicitis through use of same-day discharge and elimination of postoperative antibiotics.

BACKGROUND: There is controversy over certain aspects of post-appendectomy care for children with uncomplicated appendicitis. Some institutions have embraced the practice of same-day discharge after appendectomy, while others are hesitant due to concerns about increased readmissions or emergency department (ED) visits. Similarly, some surgeons have transitioned to treating gangrenous appendicitis with a single perioperative dose, while others are concerned about increased risk of infection in this population. METHODS: We developed a pathway for the management of patients undergoing appendectomy for uncomplicated acute appendicitis which included same-day discharge and elimination of postoperative antibiotics for patients with gangrenous appendicitis. We compared outcomes for children treated at our institution before and after implementation of the protocol. RESULTS: We identified 575 patients undergoing appendectomy for uncomplicated appendicitis (307 pre- and 268 post-protocol). We observed a significant decrease in postoperative length-of stay (10.6 to 2.6 h, p < 0.0001). There were no increases in postoperative complications, such as superficial (2.6% vs 1.1%, p = 0.19) or organ-space surgical-site infection (1.6% vs 0.4%, p = 0.14), percutaneous drain placement (1.3% vs 0%, p = 0.06), postoperative ED visits (5.5% vs 5.2%, p = 0.87) or readmission (3.3% vs 1.5%, p = 0.17). CONCLUSIONS: These findings suggest that incorporating same-day discharge for simple appendicitis and eliminating postoperative antibiotics for children with gangrenous appendicitis does not increase complication rates. Implementation of similar pathways across institutions has the potential to significantly reduce resource utilization for children undergoing appendectomy for uncomplicated appendicitis. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Laboratory Testing Methods for Novel Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2).

Following the first reports of coronavirus disease-19 (COVID-19) by China to the World Health Organization (WHO) on 31st December 2019, more than 4,302,774 novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) cases have been reported by authorities in 212 countries and territories by 12th May 2020. The outbreak and spread of COVID-19 worldwide, highlights the critical need for developing rapid and accurate diagnostic testing methods for emerging human coronavirus (CoV) infections. Testing is crucial to track the spread of disease during a pandemic, and to swiftly permit public health interventions including isolation, quarantine, and appropriate clinical management of afflicted individuals. The key components of viral diagnostic tests are (1) collection of the appropriate sample (blood, nasal swab, and throat swab), (2) availability of the genetic and proteomic sequences of the novel virus for analysis, and (3) rapid and accurate laboratory testing methods. The current gold standard for the molecular diagnosis of SARS-CoV-2 infection is the real-time reverse transcriptase-polymerase chain reaction (RT-PCR) for the qualitative and quantitative detection of viral nucleic acids. Other relevant laboratory methods include enzyme-linked immunoassays (EIA) for viral antibody and antigen detection, and serum viral neutralization (SVN) assays for antibody neutralization determination. The challenges faced in developing a diagnostic test for a novel pathogen are the ability to measure low viral loads for early detection, to provide low or no cross-reactivity with other viral strains and to deliver results rapidly. Several point-of-care molecular devices are currently being integrated for fast and accurate diagnosis of SARS-CoV-2 infections. This review discusses the current laboratory methods available to test for coronaviruses by focusing on the present COVID-19 outbreak.

Admission of Pediatric Concussion Injury Patients: Is It Necessary?

BACKGROUND: Currently there is no consensus on the management of patients with a concussion and negative computed tomography (CT) of the head. This study examined the necessity of admitting pediatric patients with concussive symptoms. The purpose of this study was to determine if pediatric patients evaluated in the emergency department (ED) for concussion with a negative head CT scan require routine hospital admission. MATERIALS AND METHODS: A retrospective chart review of pediatric trauma patients admitted to the hospital for a concussion from 2010 to 2017 was conducted after IRB approval (1709005621). Only patients with a negative head CT were included. Demographic information, ED evaluation, and hospital course were reviewed. RESULTS: A total of 90 patients (Mage = 10 y; 72.2% male) were included in the analysis. The average Glasgow coma scale was 14.6 (range 9-15). Loss of consciousness was reported by 36.7% (n = 33) of patients. Reported symptoms included nausea/emesis in 35.5% (n = 32) and altered mental status in 40% (n = 36). Following admission, 94.4% of patients were discharged within 24 h of admission. Of the four patients (4.4%) that stayed longer than 24 h, only two hospitalizations were related to the concussion (inability to tolerate diet). One patient had a fever unrelated to the concussion and one stayed because of social issues. Average length of stay for these patients was 2.75 d (range 2-4 d). There was no difference in Glasgow coma scale in comparison to patients who were discharged within 24 h. CONCLUSIONS: Although there are a large number of pediatric patients evaluated in the ED for concussion injuries, very few of these patients require any further care. Our study suggests that patients with concussion and a negative head CT who tolerate a diet can be safely discharged home.