Ovarian Salvage With Prompt Surgical Intervention for Adnexal Torsion: Does Timing Matter?

BACKGROUND: Adnexal torsion requires treatment to limit ischemic injury and tissue loss. Optimal time to surgical intervention has not been established. We compared outcomes of ovarian loss amongst pediatric patients. METHODS: We conducted a retrospective review of 88 patients with adnexal torsion from March 2014 through April 2021. Rates of ovarian loss were compared for patients who underwent surgery within and beyond 60 minutes from diagnosis. RESULTS: Most patients underwent surgery more than 60 minutes from the time of diagnosis (83%; median time 116 minutes). Comparing patients with and without ovarian loss, there was no statistically significant difference in time to surgery from time of diagnosis (P = .618). Patients with ovarian loss had a longer duration of symptoms (24 vs 96 hours; P = .017). CONCLUSIONS: While surgical repair of adnexal torsion may be urgent, this study suggests that duration of symptoms should be considered when assessing a patient's likelihood of ovarian loss.

Delayed diagnosis of spontaneous intestinal perforation among very low birth weight neonates: A single center experience.

OBJECTIVE: To assess incidence and effect of delayed diagnosis of spontaneous intestinal perforation (SIP). STUDY DESIGN: Retrospective case series review of 58 VLBW neonates with SIP at our institution. RESULT: SIP was diagnosed in 6.1%, 10%, and 15.1% of VLBW, ELBW, and ≤750 g neonates, respectively. Abdominal distension (58.6%) and abdominal discoloration (53.4%) were the most common presenting signs/symptoms. Smaller (≤750 g) neonates were more likely to present with hypotension and higher FiO2, and larger (751-1500 g) neonates with increased abdominal girth and abdominal distension. All but one neonate had radiographic pneumoperitoneum, and 25.9% had pneumoperitoneum on an X-ray prior to the X-ray at SIP diagnosis. An education module reduced delay in SIP diagnosis. CONCLUSION: SIP presentation varies by birth weight and gestational age. Since SIP diagnosis is often first suggested on X-ray, all X-rays of VLBW neonates in the first 2 weeks of life should be scrutinized for pneumoperitoneum.

Investigating Clinical and Cost Burdens of Law Enforcement-Related K9 Injuries: The Impact of "the Bite" on a Community Hospital.

The decision to introduce canines (K9s) to a law enforcement (LE) agency does not typically involve the evaluation of the fiscal or clinical impact on local hospitals. This study compared injury, cost, and care associated with K9s to a common nonlethal force method, the Thomas A Swift Electrical Rifle (TASER), to highlight the cost and resources required to treat both patient types. Patients treated for LE-related K9 and TASER injuries at a Level I community-based trauma center (2011-2016) were evaluated for level of care required (e.g., surgeon/specialist), clinical interventions, proxy medical costs, and length of stay (LOS). Nearly one-third of K9 patients required tertiary-level medical care. The cost of treating the K9-inflicted injuries (n = 75) was almost twice as costly as care for patients subdued with a TASER (n = 80); the K9 patients had significantly (one-tailed t tests) higher medical costs (P = 0.036), required more medical procedures (P = 0.014), and had longer LOS (P = 0.0046) than the TASER patients. Patients with K9 injuries had higher acuity and were significantly more expensive to treat with longer LOS than TASER injuries. LE agencies considering establishing and operating a K9 unit should initiate discussions with their local medical first responders and health-care facilities regarding the capabilities to treat severe K9 injuries to ensure adequate resource allocation.

Outcomes of laparoscopic nissen fundoplications in children younger than 2-years: single institution experience.

BACKGROUND: Variation exists in the diagnostic testing for gastroesophageal reflux (GER) in infants and in the application of surgical therapy. There has been an increase in antireflux surgery (ARS) since the development of laparoscopy but the outcomes in high-risk infants is unclear. This study examines the results of laparoscopic fundoplication in infants less than 2 years. METHODS: The results of infants less than 2 years undergoing laparoscopic Nissen fundoplication (Lap-F) from 2012 to 2015 were retrospectively reviewed and outcomes were followed until 2017. RESULTS: There were 106 patients, median gestational age 32.50 weeks ± 6.35 SD and non-corrected age at operation 23.0 weeks ± 19.0 SD, mean weight of 4.81 kg ± 2.10 SD. One of the most common reasons for surgical consultation was improvement in respiratory status after insertion of nasoduodenal feeding tube. Of the Lap-F, 100 were with gastrostomy tube (GT). There were no conversions to open or intraoperative complications. The complication rate was 4.71%, and the reoperation rate was 5.66%, one fundoplication revision and the others gastrostomy revisions. The median time for feeds and to reach goal were 1 (1-14) and 4 (2-279) days, respectively. The 30-day mortality was 0.9% and long-term it was 4.71%. The long-term mortality was related to the underlying medical problems. The median follow-up was 113 (3-286) weeks. One patient required revision of the fundoplication and none required esophageal dilatation during the follow-up period. CONCLUSION: Fundoplication is effective for relief of symptoms of GER in children younger than 2 years. The procedure has a low morbidity and mortality in this population.

Congenital H-type tracheoesophageal fistula: A multicenter review of outcomes in a rare disease.

OBJECTIVE: To perform a multicenter review of outcomes in patients with H-type tracheoesophageal fistula (TEF) in order to better understand the incidence and causes of post-operative complications. BACKGROUND: H-type TEF without esophageal atresia (EA) is a rare anomaly with a fundamentally different management algorithm than the more common types of EA/TEF. Outcomes after surgical treatment of H-type TEF are largely unknown, but many authoritative textbooks describe a high incidence of respiratory complications. METHODS: A multicenter retrospective review of all H-type TEF patients treated at 14 tertiary children's hospital from 2002-2012 was performed. Data were systematically collected concerning associated anomalies, operative techniques, hospital course, and short and long-term outcomes. Descriptive analyses were performed. RESULTS: We identified 102 patients (median 9.5 per center, range 1-16) with H-type TEF. The overall survival was 97%. Most patients were repaired via the cervical approach (96%). The in-hospital complication rate, excluding vocal cord issues, was 16%; this included an 8% post-operative leak rate. Twenty-two percent failed initial extubation after repair. A total of 22% of the entire group had vocal cord abnormalities (paralysis or paresis) on laryngoscopy that were likely because of recurrent laryngeal nerve injury. Nine percent required a tracheostomy. Only 3% had a recurrent fistula, all of which were treated with reoperation. CONCLUSIONS: There is a high rate of recurrent laryngeal nerve injury after H-type TEF repair. This underscores the need for meticulous surgical technique at the initial repair and suggests that early vocal cord evaluation should be performed for any post-operative respiratory difficulty. Routine evaluation of vocal cord function after H-type TEF repair should be considered. THE LEVEL OF EVIDENCE RATING: Level IV.

Bronchogenic cyst in the intradiaphragmatic location.

Bronchogenic cysts are congenital foregut malformations thought to develop due to abnormal budding of tracheal diverticulumand proximal bronchial structures during embryologic development. The cyst is lined by ciliated pseudostratified columnar epithelium and the wall contains cartilage and layers of smooth muscle. These lesions most commonly are seen in the mediastinum, lung, or pleural spaces. The intradiaphragmatic location of the bronchogenic cyst rarely has been reported in the literature. We report the clinical presentation and computed tomography and magnetic resonance imaging findings in a pediatric patient who presented with left-sided chest pain and was found to have a mass in the region of the diaphragm.

The protective role of intestinal alkaline phosphatase in necrotizing enterocolitis.

BACKGROUND: Enterocytes produce intestinal alkaline phosphatase (iAP), which detoxifies lipopolysaccharide (LPS), a mediator in necrotizing enterocolitis (NEC) pathogenesis. We hypothesize that aberrant expression or function of iAP contributes to the pathogenesis of NEC. MATERIALS AND METHODS: Newborn Sprague Dawley rat pups were divided into three main groups. Control pups were breast fed, while two groups were exposed to intermittent hypoxia, LPS, and formula feeding for 4 d to induce NEC. Bovine iAP, with and without the presence of LPS, was administered orally to one of the NEC groups. The intestine was harvested and used to detect alkaline phosphatase (AP) activity and protein expression. Terminal ileum sections were used to grade intestinal injury and stained for AP. Comparisons were made with adult rat duodenum. RESULTS: Compared with adult rats, control pups expressed significantly less AP protein but had 2-fold higher AP activity. NEC pup AP activity was significantly decreased compared to controls (P < or = 0.05), which paralleled both the AP protein expression and immunofluorescence assay results. Following iAP administration, immunofluorescence, protein expression, and activity of AP were significantly increased compared with NEC pups without iAP supplementation. All NEC pups had intestinal injury grades > or = 2 on a 4-point scale, while control and iAP-treated pups had grades < 0.25 (P < 0.001). CONCLUSIONS: Enteral administration of iAP to rat pups with experimental NEC increased AP activity levels to that of controls, and appears to protect the intestine. This opens up a new area of study in NEC pathophysiology as well as a potential novel treatment strategy to prevent the development of NEC.

Is it safe to discharge intussusception patients after successful hydrostatic reduction?

PURPOSE: The aim of this study was to evaluate whether discharge from the emergency department (ED) after successful hydrostatic reduction (HR) of intussusception is safe. METHODS: We conducted a single institution review of patient records with a diagnosis code of intussusception from 1995 to 2006. Data collected included age, clinical presentation, imaging, surgical interventions, pathology, recurrence, and disposition. Statistical analysis utilized chi(2) tests, where P < or = .05 was considered significant. RESULTS: A total of 309 patients with intussusception were identified. One hundred twenty-three patients (39.8%) required surgical intervention, 138 (44.6%) patients were managed nonoperatively as inpatients, and 48 (15.5%) were treated nonoperatively and discharged from the ED. There were 18 recurrences (5.8%). Recurrence rates did not significantly differ between patients who required operative reduction and those who were managed nonoperatively with HR and either observed as inpatients or discharged from the ED. Seven patients with recurrences required surgical intervention, and 1 of those children had a pathologic lead point, which was nonneoplastic. CONCLUSIONS: Recurrence rates do not differ between children observed as inpatients and those discharged home after successful HR. Missed neoplastic pathologic lead points were not found in the patients who required an operation after a recurrence. Our data suggests that it is safe to discharge patients selectively from the ED after successful HR.

Conservative management of giant omphalocele with topical povidone-iodine and its effect on thyroid function.

PURPOSE: The aim of the study was to evaluate topical povidone-iodine as a bridge to delayed fascial closure of giant omphaloceles with emphasis on its effect on thyroid function. METHODS: Newborns from a single institution with giant omphaloceles treated with topical povidone-iodine for a 10-year period were reviewed. Recorded data included sex, associated anomalies, length of stay, frequency of povidone-iodine application, thyroid function tests, frequency of laboratory draws, and thyroid supplementation administration. RESULTS: Six neonates with giant omphaloceles were treated with povidone-iodine. Thyroid function testing occurred weekly as inpatients and monthly as outpatients, with abnormal values normalized by the subsequent laboratory draw. One patient demonstrated persistent hypothyroidism and subsequently died secondary to cardiac complications, but this infant's newborn thyroid screening suggested congenital hypothyroidism. Five patients remained euthyroid and ultimately achieved fascial closure without the need for a prosthetic implant. None of these patients had abnormal outpatient thyroid tests nor did they require thyroid hormone supplementation. CONCLUSION: Topical povidone-iodine promotes escharification and epithelialization of the omphalocele sac. Because transient hypothyroidism may occur, thyroid function studies may guide inpatient therapy. After sac desiccation, systemic effects of iodine are minimal and thyroid supplementation is not necessary. Topical povidone-iodine is an effective initial strategy for giant omphaloceles and does not produce clinically significant hypothyroidism.

Mesenteric nitric oxide and superoxide production in experimental necrotizing enterocolitis.

BACKGROUND: A proposed mechanism of intestinal injury in necrotizing enterocolitis (NEC) involves vascular dysfunction through altered nitric oxide synthase (NOS) activity. We hypothesize that this dysfunction results in an imbalance in nitric oxide (*NO) and superoxide (O(2)(*-)) production by the intestinal vascular endothelium, which contributes to the intestinal injury seen in NEC. MATERIALS AND METHODS: Neonatal rat pups were divided into two groups. Control pups were breast fed and housed with their mother. Experimental NEC pups were housed separately and either exposed to formula feeding and 5% to 10% hypoxia alone (FF/H) or with the addition of lipopolysaccharide (FF/H/LPS). Mesenteries from each group were analyzed for *NO and O(2)(*-) production with and without NOS inhibition by N(G)-monomethyl-L-arginine (L-NMMA). Western blot analysis for eNOS, phosphorylated eNOS (phospho-eNOS), and inducible NOS (iNOS) was performed, and each terminal ileum was graded for intestinal injury by histology. RESULTS: Histology revealed mild intestinal injury (grade 1-2 on a 4-point scale) in the FF/H group and severe injury (grade 3-4) in the FF/H/LPS group. The FF/H cohort had significantly increased *NO and lower O(2)(*-) production, while the FF/H/LPS group shifted to significantly decreased *NO and increased O(2)(*-) production. L-NMMA inhibited >50% of O(2)(*-) production in all three groups but only inhibited *NO production in control and FF/H pups. Western blot analysis revealed increased levels of phospho-eNOS in FF/H pups and increased iNOS in FF/H/LPS pups. CONCLUSIONS: This study demonstrates in the progression of NEC, intestinal ischemia is associated with a shift from *NO to O(2)(*-) production, which is NOS-dependent. Potentially greater injury results from impaired vasodilatation and over-production of reactive oxygen species.

Diagnostic peritoneal lavage: a review of indications, technique, and interpretation.

Diagnostic peritoneal lavage (DPL) is a highly accurate test for evaluating intraperitoneal hemorrhage or a ruptured hollow viscus, but is performed less frequently today due to the increased use of focused abdominal sonography for trauma (FAST) and helical computed tomography (CT). All three of these exams have advantages and disadvantages and thus each still play unique roles in the evaluation of abdominal trauma. Since DPL is performed less frequently today, a review of its indications, technique, and interpretation is pertinent.