Evaluating Natural History and Follow Up Strategies for Non-obstructive Urolithiasis in Pediatric Population.

Objective: While small non-obstructive stones in the adult population are usually observed with minimal follow-up, the same guidelines for management in the pediatric population have not been well-studied. We evaluate the clinical outcomes of small non-obstructing kidney stones in the pediatric population to better define the natural history of the disease. Methods: In this IRB-approved retrospective study, patients with a diagnosis of kidney stones from January 2011 to March 2017 were identified using ICD9 and ICD10 codes. Patients with ureteral stones, obstruction, or stones >5 mm in size were excluded. Patients with no follow-up after initial imaging were also excluded. Patients with a history of stones or prior stone interventions were included in our population. Frequency of follow-up ultrasounds while on observation were noted and any ER visits, stone passage episodes, infections, and surgical interventions were documented. Results: Over the 6-year study period, 106 patients with non-obstructing kidney stones were identified. The average age at diagnosis was 12.5 years and the average stone size was 3.6 mm. Average follow-up was 17 months. About half of the patients had spontaneous passage of stones (54/106) at an average time of 13 months after diagnosis. Stone location did not correlate with spontaneous passage rates. Only 6/106 (5.7%) patients required stone surgery with ureteroscopy and/or PCNL at an average time of 12 months after initial diagnosis. The indication for surgery in all 6 cases was pain. 17/106 (16%) patients developed febrile UTIs and a total of 43 ER visits for stone-related issues were noted, but no patients required urgent intervention for an infected obstructing stone. Median interval for follow-up was every 6 months with renal ultrasounds, which then was prolonged to annual follow up in most cases. Conclusions: The observation of pediatric patients with small non-obstructing stones is safe with no episodes of acute obstructive pyelonephritis occurring in these patients. The sole indication for intervention in our patient population was pain, which suggests that routine follow-up ultrasounds may not be necessary for the follow-up of pediatric non-obstructive renal stones ≤5 mm in size.

Multi-Institution Case Series of Pediatric Patients with Laparoscopic Repair of Morgagni Hernia.

INTRODUCTION: Morgagni Larray hernia (MLH) is a very rare disease, which accounts for less than 5% of all congenital diaphragmatic hernias. Laparoscopic repair has been widely used and accepted as a treatment option for patients with this disease. The purpose of our study is to analyze the outcomes of patients with MLH who underwent laparoscopic repair, and to evaluate their postoperative course for outcome, morbidity, and mortality. MATERIALS AND METHODS: A retrospective chart review was performed of patients who were diagnosed with MLH and treated laparoscopically by 10 board-certified pediatric surgeons. RESULTS: Fourteen patients were included in the study. One patient died 1 month postoperatively due to respiratory complications unrelated to the surgery. Thirteen patients were followed for a median of 1.75 years (interquartile 0.3-6.95). There was a single recurrence, which resulted in a partial resection of the hernia sac and repaired without a mesh. We had a success rate of 92.86%. CONCLUSION: MLH is a rare congenital diaphragmatic hernia that is usually diagnosed incidentally. Laparoscopic repair has high success rates and is a viable option for patients with this pathology.

Influence of clinician referral on Nebraska women's decision-to-abortion time.

OBJECTIVE: To assess the association of clinician referral with decision-to-abortion time. STUDY DESIGN: We conducted a cross-sectional survey of women seeking abortion at all three Nebraska abortion clinics. We defined referral as direct (information for an abortion clinic), inappropriate (information for a clinic that does not provide abortions) or no referral. Women reported when they recognized their pregnancy, decided to seek abortion and contacted a clinician. The primary outcome - decision-to-abortion time - was time from certain decision to abortion. We used multivariate linear regression analysis, controlling for potential confounders. RESULTS: Participants (n=356) were a mean of 26.8±5.3years old, primarily white (62%), unmarried (88%) and urban (87%), with a mean gestational duration of 8(2/7)weeks (S.D.±20days). Forty-six percent (164) had contacted a clinician and 30% (104) had discussed abortion with one before their abortion. Of those, 30% received a direct referral, 6% received an inappropriate referral and 64% received no referral. Decision-to-abortion time did not vary by referral type [mean difference compared with direct referral: inappropriate referral, 1.1days, 95% confidence interval (CI) -13.4 to 15.6, p=.88; no referral, -0.4days, 95% CI -7.0 to 6.3]. The most common reasons cited for delay in obtaining an abortion were an inability to get an earlier appointment (105/263, 40%) and time needed to raise money to pay for the abortion (73/263, 28%). CONCLUSION: While neither occurrence of referral nor type was associated with decision-to-abortion times, women in Nebraska continue to face barriers to timely abortion care. IMPLICATIONS: Additional research is needed to explore whether quality clinician referral improves abortion access and whether increased resources should be dedicated to improving referral patterns.