Let Kids Play: Using Virtual Reality as a Substitute for General Anesthesia for Minor Procedures in Pediatric Population.

BACKGROUND: In the pediatric population, virtual reality (VR) has been used as an adjunct to augment analgesia and reduce the need for opioids. In this study, we review our experience using VR in lieu of anesthesia or sedation to enable minor procedures in children. METHODS: A retrospective chart review study was performed on patients who presented to our institution from 2019 to 2022 for hormone implant placement, exchange, or removal with VR distraction. Demographic and procedure information was recorded. The primary outcome was successful procedure completion without requiring pharmacologic sedation or analgesia. RESULTS: A total of 111 patients underwent the following minor procedures with VR and without anesthesia or sedation. Fourteen patients had multiple encounters resulting in a total of 126 encounters. The median age was 11 [6] years. 43 patients were female, 23 were female to male, 6 were non-binary, 7 were male, and 32 were male to female. 58 % had private insurance. Most common diagnosis was precocious puberty (54 %) followed by gender dysphoria (46 %). Most common procedure was implant placement (72 %). 69 % of procedures were performed in the clinic and 31 % in the OR. All procedures were completed without requiring the administration of additional sedation or anesthesia. None of the patients required intravenous catheter placement for the procedure. No intra-procedural complications were recorded. CONCLUSION: VR is a feasible option that can spare children from sedation or general anesthesia for minor procedures. VR may enable minor procedures in children to be successfully performed in clinic setting.

Use of Neoadjuvant Vandetanib in Aggressive Pediatric Medullary Thyroid Carcinoma.

Novel use of vandetanib in a child with aggressive MTC with prolonged response to treatment.

Parathyroid Autofluorescence in Pediatric Thyroid Surgery: Experience With False Positive and False Negative Results.

Devices for near-infrared light stimulation of autofluorescence (NIRAF) allow for intraoperative identification of parathyroid glands with high sensitivity in adults. However, their performance in the pediatric population is unknown. In this case series with chart review at a tertiary academic children's hospital, we investigated pediatric patients undergoing thyroid surgery and concurrent use of a probe-based NIRAF device. Thirteen patients (ages 6-18 years) underwent thyroid and/or neck dissection procedures, and 2 patients had revision procedures for a total of 15 cases with the NIRAF device. Eight cases had NIRAF values that matched surgeon opinion of parathyroid tissue or histology when available. Six cases had false positive NIRAF readings (40.0%) and 1 case had false negative readings (6.7%). Compared with surgeon opinion or histology, the NIRAF device confirmed 26 of 34 parathyroid gland candidates (76.5%). These devices need further investigation in pediatric patients, whose tissues may have different autofluorescence characteristics.

Sociodemographic Disparities in the Diagnostic Management of Pediatric Thyroid Nodules.

Importance: Thyroid cancer is the most common pediatric endocrine malignant neoplasm. Disparities in the workup of thyroid nodules may be significantly associated with thyroid cancer outcomes. Objective: To determine the association of sociodemographic factors with the odds of receiving a biopsy, timeliness of the procedure, and risk of nodule malignancy. Design, Setting, and Participants: This was a retrospective cross-sectional study using insurance claims data from the Optum Clinformatics Data Mart database. The study cohort comprised pediatric patients diagnosed with single thyroid nodules between 2003 and 2020. Data analysis was performed from January 1, 2003, to June 30, 2020. Main Outcomes and Measures: Multivariable logistic regression models were used to identify demographic variables associated with biopsy and nodule malignant neoplasm. A multivariable linear regression model was used to assess the time between thyroid nodule diagnosis and biopsy. Results: Of 11 643 children (median [IQR] age at diagnosis or procedure, 15 [12-17] years; 8549 [73.2%] were female and 3126 [26.8%] were male) diagnosed with single thyroid nodules, 2117 (18.2%) received a biopsy. Among the patients who received a biopsy, 304 (14.4%) were found to have a malignant nodule. Greater parental education was associated with a shorter diagnosis-to-biopsy interval (mean difference, -7.24 days; 95% CI, -13.75 to -0.73). Older age at nodule diagnosis (odds ratio [OR], 1.11; 95% CI, 1.09-1.13) and female gender (OR, 1.25; 95% CI, 1.11-1.40) were associated with increased odds of receiving a biopsy, while Black/African American (OR, 0.80; 95% CI, 0.65-0.99) and Hispanic (OR, 0.84; 95% CI, 0.72-0.99) patients had lower odds of receiving a biopsy compared with White patients. Finally, female gender (OR, 1.08; 95% CI, 0.80-1.47) was not associated with lower odds of nodule malignant neoplasm. Conclusions and Relevance: Findings of this cross-sectional study highlight disparities in the diagnostic management of pediatric thyroid nodules. These results call for future work to ensure equitable access to thyroid care for all children.

Optimizing Professional Practice Evaluation to Enable a Nonpunitive Learning Health System Approach to Peer Review.

Healthcare organizations are focused on 2 different and sometimes conflicting tasks; (1) accelerate the improvement of clinical care delivery and (2) collect provider-specific data to determine the competency of providers. We describe creating a process to meet both of these aims while maintaining a culture that fosters improvement and teamwork. METHODS: We created a new process to sequester activities related to learning and improvement from those focused on individual provider performance. We describe this process, including data on the number and type of cases reviewed and survey results of the participant's perception of the new process. RESULTS: In the new model, professional practice evaluation committees evaluate events purely to identify system issues and human factors related to medical decision-making, resulting in actional improvements. There are separate and sequestered processes that evaluate concerns around an individual provider's clinical competence or behavior. During the first 5 years of this process, 207 of 217 activities (99.5%) related to system issues rather than issues concerning individual provider competence or behavior. Participants perceived the new process as focused on identifying system errors (4.3/5), nonpunitive (4.2/5), an improvement (4.0/5), and helped with engagement in our system and contributed to wellness (4.0/5). CONCLUSION: We believe this sequestered approach has enabled us to achieve both the oversight mandates to ensure provider competence while enabling a learning health systems approach to build the cultural aspects of trust and teamwork that are essential to driving continuous improvement in our system of care.

Laparoscopic Excision of Congenital Hepatic Cysts in the Pediatric Population: A Case Series and Literature Review.

PURPOSE: Congenital hepatic cysts are rare. Surgical excision is indicated for symptoms, complications, and to rule out malignancy. Laparoscopic management in the pediatric population has not been extensively documented. We present a series involving laparoscopic excision of pediatric congenital hepatic cysts and review the literature. METHODS: Data were collected over 15 years from two pediatric surgeons at three medical centers. Presence of a hepatic cyst excised laparoscopically was the only inclusion criterion. Data were collected on the cyst size, type, pathology, and location, as well as on length of hospital stay, complications, and 1 year recurrence rate. RESULTS: Four patients were identified: a 7-week-old male presenting with feeding intolerance due to a hepatic cyst; a 6-year-old male presenting with a hepatic cyst identified by ultrasound during evaluation for appendicitis; a male neonate diagnosed at birth with a left thoracic cyst that communicated through the diaphragm with a hepatic cystic lesion; and a 14-year-old male presenting with a 25 cm × 11 cm hepatic cyst. All lesions were excised laparoscopically. CONCLUSION: Our series is the largest documenting complete laparoscopic excision of congenital solitary hepatic cysts in the pediatric population. Laparoscopic excision is a safe and effective approach for the pediatric population.

Severe lactic acidosis and multiorgan failure due to thiamine deficiency during total parenteral nutrition.

A 16-year-old perioperative paediatric patient presented with refractory lactic acidosis and multiorgan failure due to thiamine-deficient total parenteral nutrition during a recent national multivitamin shortage. Urgent empiric administration of intravenous thiamine resulted in prompt recovery from this life-threatening condition. Despite readily available treatment, a high index of suspicion is required to prevent cardiovascular collapse and mortality.

Comparison of IMS Platforms for detecting and recovering Escherichia coli O157 and Shigella flexneri in foods.

Two automated platforms using immunomagnetic separation technology were compared for detecting and recovering Escherichia coli O157 in ground beef and sprouts and Shigella flexneri in green onions. The foods were inoculated with <20 CFU/25 g and tested at 5 and 24 h postincubation. Immunomagnetic beads were mixed with food enrichments, processed through the Pathatrix Auto or KingFisher Flex, and tested by real-time PCR (qPCR) and recovery on selective agars. At 5 h, the Pathatrix Auto detected E. coli O157 in 90% and 60% of the ground beef and sprouts samples and S. flexneri in all of the green onion samples. It also recovered E. coli O157 in all the samples but could not recover S. flexneri in any of the green onion samples. In comparison, the KingFisher Flex detected E. coli O157 in 80% and 30% of the ground beef and sprouts samples and S. flexneri in all of the green onion samples. It also recovered E. coli O157 in 90% of the ground beef samples but none of the sprouts samples and S. flexneri in 20% of the green onion samples. At 24 h, both platforms detected and recovered the target bacteria in all of the samples.

O serogroup specific real time PCR assays for the detection and identification of nine clinically relevant non-O157 STECs.

TaqMan™ real time PCR assays were designed for each of the non-O157 STEC O serogroups most commonly associated with human illness: O26, O45, O91, O103, O111, O113, O121, O128, and O145. The nine RT-PCR assays can be run as single assays when a known pathogen is of concern, or multiplexed in three reactions, to quickly screen for the most clinically relevant O serogroups. All assays included an internal amplification control constructed from the green fluorescent protein gene as an indicator of PCR inhibition. Of 103 strains tested, the inclusive tests accurately identified the O serogroup for 101 strains. The exclusive tests for each assay yielded no false positives for over 120 Escherichia coli strains and 23 non-E. coli bacteria tested. Furthermore, the RT-PCR assays were tested by inoculating four food matrices, milk, apple juice, lettuce, and ground beef, at ≤30 CFU/25 g or mL. Following a 24h selective enrichment, the RT-PCR assays detected STECs in all foods except for one ground beef sample inoculated with O111, and all apple juice samples inoculated with O113. The assays could also detect each O serogroup in human stool specimens inoculated with STECs at 1000 CFU/0.5 g of stool following 24 h enrichment.

Microbead-based immunoassay for simultaneous detection of Shiga toxins and isolation of Escherichia coli O157 in foods.

Shiga toxin-producing Escherichia coli (STEC) is a significant foodborne pathogen with great economic consequences. There has been an increased food safety concern with this organism since outbreaks of human illnesses caused by this pathogen were first reported in 1982. Therefore, developing a reliable, sensitive, and rapid assay capable of detecting E. coli O157 and the main toxins produced by STEC (i.e., Shiga toxins 1 [Stx(1)] and 2 [Stx(2)]) will directly benefit regulatory agencies by minimizing analysis time. Here, we use Luminex technology to detect multiple analytes in a single 50-ml sample. Using commercially available monoclonal antibodies coupled to carboxylated magnetic microbeads, we developed an immunoassay capable of simultaneously serotyping E. coli O157 and detecting Stx(1) and/or Stx(2). The specificity and sensitivity of this immunoassay was tested against a collection of 34 E. coli isolates belonging to various O serogroups phenotypically different for Stx. The results were compared with microplate sandwich enzyme-linked immunosorbent assay (ELISA), and no cross-reactivity was observed for any of the monoclonal antibodies used. An increased sensitivity up to 1,000 times was observed in the microbead-based immunoassay when compared with the microplate sandwich ELISA. The results indicate that Luminex technology has the potential to simultaneously detect multiple targets without loss of specificity and/or sensitivity. A blind experiment was conducted with 48 samples of ground beef, lettuce, and milk spiked with ≤2 CFU/g E. coli. All the samples were correctly identified, with no false positives or false negatives. This microbead-based immunoassay could be extended to simultaneously detect additional foodborne pathogens and their toxic markers.

Outcomes of sutureless gastroschisis closure.

INTRODUCTION: A new technique of gastroschisis closure in which the defect is covered with sterile dressings and allowed to granulate without suture repair was first described in 2004. Little is known about the outcomes of this technique. This study evaluated short-term outcomes from the largest series of sutureless gastroschisis closures. METHODS AND PATIENTS: A retrospective case control study of 26 patients undergoing sutureless closure between 2006 and 2008 was compared to a historical control group of 20 patients with suture closure of the abdominal fascia between 2004 and 2006. Four major outcomes were assessed: (1) time spent on ventilator, (2) time to initiating enteral feeds, (3) time to discharge from the neonatal intensive care unit, and (4) rate of complications. RESULTS: In multivariate analysis, sutureless closure of gastroschisis defects independently reduced the time to extubation as compared to traditional closure (5.0 vs 12.1 days, P = .025). There was no difference in time to full enteral feeds (16.8 vs 21.4 days, P = .15) or time to discharge (34.8 vs 49.7 days, P = .22) with sutureless closure. The need for silo reduction independently increased the time to extubation (odds ratio, 4.2; P = .002) and time to enteral feeds (odds ratio, 5.2; P < .001). Small umbilical hernias were seen in all patients. CONCLUSION: Sutureless closure of uncomplicated gastroschisis is a safe technique that reduces length of intubation and does not significantly alter the time required to reach full enteral feeds or hospital discharge.

Abnormal intra-QRS potentials associated with percutaneous transluminal coronary angiography-induced transient myocardial ischemia.

This article introduces a novel concept of abnormal intra-QRS potentials (AIQPs) associated with myocardial ischemia. AIQPs are microvolt-level potentials--subtle alterations in the QRS of the high-resolution electrocardiogram (ECG)--isolated from the unfiltered signal-averaged ECG (SAECG) by a method of mathematical modeling. The aims of the study were (1) to determine the characteristics of potentials in the SAECG related to ischemically altered activation during percutaneous transluminal coronary angiography (PTCA), (2) to determine their relationship with standard 12-lead ECG variables, and (3) to investigate whether AIQPs have a specific pathophysiologic basis in myocardial ischemia. Continuous high-resolution ECG data were acquired from 12 patients before, during, and after PTCA. SAECGs were computed every 60 seconds using an enhanced method of signal averaging. AIQP, ST-segment deviation, and changes in standard ECG QRS duration were measured in each 1-minute SAECG. AIQP amplitudes increased significantly during balloon inflation, compared with the preinflation state. AIQPs exhibited a greater prevalence (12 of 12 patients) than ST-segment deviation changes of more than 100 microV (7 of 12 patients), or measurable changes in standard QRS duration (4 of 12 patients). In patients with significant changes in 12-lead ECG variables during balloon inflation, AIQPs were strongly correlated with both ST-segment and QRS-duration changes. AIQP timing was correlated with the artery occluded, suggesting a specific, ischemia-influenced origin of the signal. AIQPs show promise as a time-localized, sensitive new ECG marker of ischemically altered ventricular activation.

Clinical and histologic evaluation of anorganic bovine bone collagen with or without a collagen barrier.

This study evaluated an anorganic bovine-derived xenograft (Bio-Oss Collagen) in the treatment of human periodontal defects. Four patients with intrabony defects on teeth that were treatment planned for extraction were enrolled in the study. Presurgical measurements of probing depth, attachment level, and recession were recorded. The surgical procedure consisted of flap reflection, debridement of the osseous defects and root surface, placement of a notch through calculus into the root surface, topical application of a tetracycline paste to the root surface, grafting with Bio-Oss Collagen, and flap closure. Three of the eight defects examined received a resorbable collagen barrier (Bio-Gide) in addition to the bone graft. Patients were seen every 2 weeks for plaque control and review of oral hygiene measures. Six months postsurgery, clinical parameters were rerecorded prior to en bloc resection of teeth and adjacent graft sites. The majority of sites showed a favorable clinical response with respect to probing depth reduction and clinical attachment gain. Histologic analysis demonstrated new bone, cementum, and periodontal ligament coronal to the reference notch in two of the eight specimens. Two sites demonstrated new attachment, and four showed a long junctional epithelium. Periodontal regeneration is possible following a bone-replacement graft of Bio-Oss Collagen.

Initial implant position determines the magnitude of crestal bone remodeling.

BACKGROUND: The ability to predict the amount of bone remodeling around implants is important for a stable and predictable esthetic result. The purpose of this study was to investigate the amount of radiographic bone remodeling that occurs over time using a one-piece implant system. METHODS: Twenty-seven patients receiving implants in the maxilla and 15 receiving implants in the mandible were included in the study. All implants were placed with a non-submerged surgical technique with varying locations of the rough-smooth border with respect to the alveolar crest. Clinical exams and radiographs were taken on the day of implant placement, at 6 months, and annually up to 5 years. Linear measurements from digitized radiographs were made from the implant shoulder to the first bone-to-implant contact at all time points. RESULTS: A significant amount of bone remodeling compared to baseline occurred for all implants at the 6-month follow-up visit (1.10 mm), with the remaining time points showing virtually no change (0.1 mm). A relationship was found between the amount of bone remodeling and the location of the rough-smooth border with respect to the alveolar crest. Those implants with the rough-smooth border surgically placed below the crest had, on average, a greater amount of remodeling at 6 months (average 1.72 mm) than implants with the rough-smooth border placed at or near the crest (average 0.68 mm). In both situations, this remodeling: 1) occurred early (within 6 months), 2) reached a similar level, and 3) remained virtually unchanged up through 60 months (0.05 mm). CONCLUSIONS: A physiologic dimension appears to exist between the bone and the implant-crown interface around one-piece implants that is established early and maintained over time. These results are significant because they demonstrate in patients that the magnitude of initial bone remodeling around these one-piece dental implants is dependent on the positioning of the rough-smooth border of the implant in an apico-coronal dimension. Furthermore, the dimension, from the crown-implant interface to the first bone-to-implant contact, is consistent with the formation of a biologic width similar to that found around the natural dentition.

The giant umbilical cord: an unusual presentation of a patent urachus.

Umbilical cord anomalies remain a frequent newborn nursery consultation for the pediatric surgeon. The authors report on a giant umbilical cord associated with a patent urachus. Although it is an uncommon anomaly, operative exploration must be carried out to repair the associated urachal remnant.

Routine MRI evaluation of low imperforate anus reveals unexpected high incidence of tethered spinal cord.

BACKGROUND/PURPOSE: Previous clinical practice has included evaluation for the presence of tethered cord in those children who have imperforate anus with a high lesion. To define the incidence in children with low lesions, the authors reviewed their experience with a protocol employing routine magnetic resonance imaging (MRI), regardless of the level of the lesion, to determine the presence of a tethered cord in all children with imperforate anus. METHODS: A retrospective review of children with imperforate anus was conducted over the last 13 years at our institution. Lesions were categorized as high versus low based on the supralevator or infralevator position of the fistula. RESULTS: Sixty-three patients completed evaluation for a tethered cord. Twenty-two (34.9%) of these 63 patients had a tethered cord: 11 of 41 (26.8%) patients with high lesions and 11 of 22 (50.0%) of those with low lesions. Of those children with a low lesion, 83% of the boys had a tethered cord, whereas 38% of the girls had a tethered cord. Forty-five percent of the patients with low lesions and a tethered cord did not have any other lumbosacral anomalies. All 22 children with a tethered cord underwent surgical release. CONCLUSIONS: The incidence of tethered cord in children with low lesions of imperforate anus is not lower than those with high lesions. The authors advocate early evaluation of all children with imperforate anus for a tethered cord.