Orchiopexy: one procedure, two diagnoses - different male infertility outcomes.

Infertility, affecting one in six couples, is often related to the male partner's congenital and/or environmental conditions or complications postsurgery. This retrospective study examines the link between orchiopexy for undescended testicles (UDT) and testicular torsion (TT) in childhood and adult fertility as assessed through sperm analysis. The study involved the analysis of semen samples from 7743 patients collected at Soroka University Medical Center (Beer Sheva, Israel) between January 2009 and December 2017. Patients were classified into two groups based on sperm concentration: those with concentrations below 5 × 106 sperm per ml (AS group) and those above (MN group). Medical records and surgical histories were reviewed, categorizing orchiopexies by surgical approach. Among 140 individuals who had undergone pediatric surgery, 83 (59.3%) were placed in the MN group and 57 (40.7%) in the AS group. A higher likelihood of being in the MN group was observed in Jewish compared to Arab patients (75.9% vs 24.1%, P = 0.006). In cases of childhood UDT, 45 (78.9%) patients exhibited sperm concentrations below 5 × 106 sperm per ml (P < 0.001), and 66 (76.7%) had undergone unilateral and 18 (20.9%) bilateral orchiopexy. Bilateral orchiopexy was significantly associated with lower sperm concentration, total motility, and progressive motility than unilateral cases (P = 0.014, P = 0.001, and P = 0.031, respectively). Multivariate analysis identified UDT as a weak risk factor for low sperm concentration (odds ratio [OR]: 2.712, P = 0.078), with bilateral UDT further increasing this risk (OR: 6.314, P = 0.012). Jewish ethnicity and TT diagnosis were associated with a reduced risk of sperm concentrations below 5 × 106 sperm per ml. The findings indicate that initial diagnosis, surgical approach, and ethnicity markedly influence male fertility outcomes following pediatric orchiopexy.

Physician and nurses' perception of paediatric trauma care in Israeli emergency departments.

BACKGROUND: Treatment of paediatric trauma requires specialized infrastructure, medical equipment, medical staff and ancillary support personnel that have been specifically trained for such tasks. AIMS AND OBJECTIVES: To examine the perceptions and attitudes of physicians and nurses in general and paediatric emergency departments (PEDs) on training, confidence, and management of paediatric trauma in order to facilitate the establishment of an optimal model for admitting and treating paediatric trauma patients. DESIGN: Drawing on published literature and a previously conducted qualitative study that explored the provision of medical care to paediatric trauma patients, we conducted an attitude survey. METHODS: A 26-item paper-based questionnaire was distributed by nurse managers to all staff working within general EDs and PEDs of 22 medical centres across Israel. RESULTS: Of 843 physicians and nurses who completed the survey, 61.1% considered PEDs the most appropriate facility for treating both minor and severe paediatric trauma, 88.5% believed that minor paediatric trauma should be treated in designated paediatric trauma centres, and 53.6% deemed that paediatric emergency medicine specialists are the most suitable primary decision makers in paediatric trauma. PED teams expressed greater professional confidence for treating paediatric trauma and multiple casualty incident patients. Greater professional confidence was positively correlated with paediatric trauma training, greater exposure to paediatric trauma cases, and working in larger medical centres. CONCLUSIONS: The results of the current study suggest that PEDs are perceived to be more appropriate for dealing with paediatric trauma. Also, treatment of severe trauma may be more appropriate in centres that admit large numbers of paediatric trauma cases. RELEVANCE TO CLINICAL PRACTICE: Emergency medicine teams should undergo training for dealing with paediatric trauma. Such training would develop their skills, increase their confidence, and enhance their emotional abilities to cope with paediatric trauma.

A management model for admission and treatment of pediatric trauma cases.

BACKGROUND: Pediatric trauma, particularly major trauma cases, are often treated in less than optimal facilities by providers who lack training and experience in treating severely injured children. We aimed to develop a management model for admission and treatment of pediatric trauma using the Theory of Constraints (TOC). METHODS: We conducted interviews with 17 highly experienced policy makers, senior nursing managers and medical managers in pediatrics and trauma. The interviews were analyzed by qualitative methods. The TOC was utilized to identify undesirable effects (UDEs) and core challenges, and to design a focused current reality tree (CRT). Subsequently, a management model for optimal admission and treatment of pediatric trauma was constructed. RESULTS: The CRT was illustrated according to 4 identified UDEs focusing on lack of: (1) clear definitions of case manager in pediatric trauma; (2) uniform criteria regarding the appropriate site for admitting pediatric trauma, (3) standard guidelines and protocols for treatment of trauma cases and for training of trauma medical teams; and (4) standard guidelines for evacuating pediatric trauma patients. The management model for treatment and admission of pediatric trauma is based on 3 major elements: human resources, hospital policy concerning the appropriate emergency department (ED) for pediatric trauma patients and clear definitions regarding children and trauma levels. Each of the elements contains components that should be clearly defined in order for a medical center to be designated for admitting and treating pediatric trauma patients. CONCLUSIONS: Our analysis suggests that the optimal ED for pediatric trauma cases is one with available operating rooms, intensive care beds, an imaging unit, laboratories and equipment suitable for treating children as well as with staff trained to treat children with trauma. To achieve optimal outcomes, medical centers in Israel should be classified according to their trauma treatment capabilities and their ability to treat varied severities of pediatric trauma cases.

Bogota Bag Temporary Abdominal Closure Surgical Technique in Children: A 15-Year Single Center Experience.

BACKGROUND: Temporary abdominal closure (TAC) surgical technique relates to a procedure in which the post-surgical abdominal wall remains open in certain indications. The Bogota bag (BB) technique is a tension-free TAC method that covers the abdominal contents with a sterilized fluid bag. There are very few reports of pediatric patients treated with this technique. OBJECTIVES: To describe our institution's 15 years of experience using the BB technique on pediatric patients. METHODS: A retrospective cohort study describing our experience treating patients with BB was conducted. The medical files of 17 pediatric patients aged 0-18 years were reviewed. RESULTS: Between January 2000 and December 2014, 17 patients were treated with BB at our medical center (6 females, median age 12 years). Indications for BB were a need for a surgical site re-exploration, mechanical inability for primary abdominal closure, and high risk for ACS development. Median BB duration was 5 days and median bag replacement was 2 days. Median ICU length of stay (LOS) was 10 days and hospital LOS was 27 days. The ICU admission and BB procedure was tolerated well by 6 patients who were discharged home without complications. Of the remaining 11 patients, 6 patients died during the admission (35%) and the others presented with major complications not related to the BB but to the patient's primary disease. CONCLUSIONS: This report represents the largest series of children treated with BB. The technique is simple to perform, inexpensive, and has very few complications.

The impact of medical clowns exposure over postoperative pain and anxiety in children and caregivers: An Israeli experience.

While postoperative pain management was shown to reduce unwanted physiological and emotional outcomes, pediatric postoperative pain management remains suboptimal. Medical-clowns were shown to be beneficial in many medical contexts including reduction of stress, anxiety and pain. This study was set to assess the effectiveness of medical-clowns on pediatric postoperative pain reduction. Children age 4 or above, planned for elective hernia repair surgery were recruited. Children were randomly divided to a control or medicalclown escorted groups. Demographical and clinical data were collected using questionnaires and electronic sheets. Children escorted by clowns reported lower levels of pain upon admittance, discharge and 12- hours post-surgery. Statistically significant reduction of parental distress and significantly higher serum cortisol levels were observed in the clown-therapy group. Although small, our study supports the possibility that preoperative medical-clown therapy might be a cheap, safe and yet beneficial method for postoperative pain reduction.

Central venous catheter-associated bloodstream infections.

BACKGROUND: To investigate the epidemiologic and microbiological aspects of long-term central vein catheter (CVC)-associated bloodstream infections (CABSI) in children <18 years old treated at the hemato-oncology unit during 1998-2008. PATIENTS AND METHODS: The two long-term access devices used were Hickman and Port-A-Cath catheters. Information retrieved included demographic data, baseline pathologies, methods of insertion, anatomical insertion sites, duration of use, microbiological, and antibiotic susceptibility data and outcome. RESULTS: There were 178 CABSI episodes; average number of episodes/1,000 catheter days was 4.7. More CABSI episodes were recorded among patients with Hickman catheter than in patients with Port-A-Cath catheter (5.05 vs. 3.57/1,000 catheter days, P = 0.059). The CVC was removed due to BSI in 52/178 (29.2%) episodes. Overall, 243 pathogens were isolated (144 Gram-negative, 92 Gram-positive, and 7 Candida spp). More Enterobacteriaceae spp. were isolated in CABSI in patients with Hickman catheters than in patients with Port-A-Cath catheters (35/103, 34%, vs. 10/65, 15%, P = 0.008); more coagulase-negative staphylococci were isolated in patients with Port-A-Cath catheters than in patients with Hickman catheters (25/65, 38.5%, vs. 23/103, 22.3%, P = 0.02). No differences in pathogen distribution were found between CABSI recorded for jugular versus subclavian veins, open versus close inserted-CVC or for CVC requiring removal versus those treated conservatively. No fatalities directly related to CABSI were recorded. CONCLUSIONS: CABSI rates were higher in patients with Hickman catheters compared with those with Port-A-Cath catheters; Gram-negative organisms were the dominant etiologic agents of CABSI; CABSI in patients with Hickman catheters had different etiologies compared with patients with Port-A-Cath catheters.

Nasopharyngeal carriage of individual Streptococcus pneumoniae serotypes during pediatric pneumonia as a means to estimate serotype disease potential.

BACKGROUND: We aimed at estimating pneumococcal serotype-specific disease potential in pediatric community-acquired alveolar pneumonia (CAAP), by comparing nasopharyngeal pneumococcal carriage during disease to carriage in healthy children. METHODS: Pneumococcal nasopharyngeal cultures were obtained from children < 5 years old admitted to the emergency room or hospitalized with radiologically diagnosed CAAP and from healthy controls. Disease potential was estimated by calculating serotype-specific odds ratios (OR) of a given serotype to be carried during disease compared with healthy children (after adjustment for age, ethnicity, previous antibiotic therapy, and season). RESULTS: A total of 603 and 1504 isolates were obtained from CAAP and healthy children, respectively. A significant OR > 1.0 of a specific serotype being carried during disease (suggesting a higher disease potential) was observed with serotypes (by decreasing rank) 1, 5, 22F, 7F, 14, 9V, and 19A. A significant OR < 1.0 of being carried during disease (suggesting a lower disease potential) was observed with serotypes 6A, 6B, 23A, and 35B. Carriage of PCV7 serotypes (grouped) during CAAP was highest in age group 6 to 17 months. PCV10 and PCV13 provided significantly higher coverage for both 6 to 17 and 18 to 35 month age groups. CONCLUSIONS: It is suggested that serotypes 1, 5, 7F, 9V, 14, 19A, and 22F have a higher disease potential for childhood pneumonia than do serotypes 6A, 6B, 23A, and 35B.

Current management of pediatric acute otitis media.

Acute otitis media (AOM) is the most common childhood bacterial infection for which antibiotics are prescribed worldwide. The most common pathogens causing AOM in children are Streptococcus pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis and Group A streptococcus. Antibiotic resistance is increasing among the bacterial pathogens causing AOM, with percentages of penicillin- and macrolide-resistant S. pneumoniae strains estimated to be between 30 and 70%, and of beta-lactamase-producing H. influenzae ranging between 20 and 40%. The introduction of the seven-valent pneumococcal conjugated vaccine had a major role in decreasing the number of vaccine-related S. pneumoniae AOM episodes, recurrent AOM cases and cases requiring the insertion of ventilation tubes. In parallel, it caused a rapid shift in the microbiology of AOM, characterized by an increase in the number of non-vaccine S. pneumoniae serotypes and H. influenzae isolates. The management of AOM in childhood has evolved considerably during recent years as a result of the new insights provided by the publication of the American Academy of Pediatrics and American Academy of Family Physicians guidelines for the treatment of AOM. The new treatment guidelines establish a clear hierarchy among various antibacterials used in the treatment of AOM and also the use of an age-stratified approach to AOM by recommending an observation strategy ('watchful waiting') without the use of antibacterials for some groups of AOM patients. Adherence to such a policy in patients with uncertain/questionable AOM diagnosis and/or mild-to-moderate symptoms, in addition to its implementation in patients over 2 years of age, could substantially reduce the use of antibacterials for the treatment of AOM and play a major role in the strategy of decreasing antibacterial resistance.

Community-acquired complicated intra-abdominal infections in children hospitalized during 1995-2004 at a paediatric surgery department.

UNLABELLED: Information on the epidemiologic, clinical, microbiologic and therapeutic aspects of community-acquired complicated intra-abdominal infections in paediatrics is limited. The objectives of this study were to investigate the epidemiologic, clinical, microbiologic and therapeutic characteristics of community-acquired complicated intra-abdominal infections occurring in children aged 1 month-15 y. Medical charts and microbiology data of all children hospitalized with complicated intra-abdominal infections were retrospectively examined. Complicated intra-abdominal infections were defined as infections extending beyond the viscus of origin into the peritoneal space, with subsequent development of abscess or peritonitis. One hundred and twenty-three patients with complicated intra-abdominal infections (99/123, 80% >5 y of age) were included; 113 (92%) had complicated acute appendicitis. Twelve (10%) patients underwent computerized tomography-guided percutaneous drainage of periappendicular abscesses. The mean rate of complicated intra-abdominal infections among patients with complicated acute appendicitis was 10% without significant changes during the study years. Positive intra-abdominal cultures were recorded in 97/108 (90%) evaluable patients; 65/97 (67%) cases were characterized by mixed bacterial flora growth. One hundred and ninety pathogens (aerobes n=164, 86%; anaerobes n=26, 14%) were isolated. Escherichia coli was the most common pathogen (94 isolates, 57%). In vitro amoxicillin/clavulanate coverage of E. coli and Klebsiella spp was modest (81% and 86%, respectively). The ampicillin/gentamicin/metronidazole regimen was more appropriate in vitro than the amoxicillin/clavulanate regimen (3/80, 4% resistant pathogens compared with 8/43, 19%; p=0.02). Post-operative complications were recorded in 33/123 (27%) patients. Time until defervescence to < 37.5 degrees C was shorter in children with periappendicular abscess than in children with generalized peritonitis (6+/-4 vs 4+/-3 days; p=0.009). IN CONCLUSION: (1) most community-acquired complicated intra-abdominal infections occurred as a result of acute appendicitis; (2) the rate of complicated intra-abdominal infections among patients with acute appendicitis was low and without significant changes during the study period; (3) E. coli was the most frequently isolated pathogen; (4) amoxicillin/clavulanate provided only partial coverage for complicated intra-abdominal infection pathogens and should be used with caution in the empiric treatment of complicated intra-abdominal infections.

Intussusception in children in Southern Israel: disparity between 2 populations.

BACKGROUND: Intussusception has been associated with 1 rotavirus vaccine. Our objective was to determine intussusception rates in children in southern Israel during a 15-year period before the introduction of new rotavirus vaccines. METHODS: All children born at the Soroka Medical Center are hospitalized in that center, enabling population-based studies. Two populations reside in Southern Israel: the Jewish population (comparable to a Western population) and the Bedouin population (comparable to a developing population). Retrospectively, all children <5 years of age admitted with ICD-9 code for intussusception were recorded as well as their demographic and clinical data. RESULTS: During 1990-2004, 316 patients with intussusception [241 (76%) Jewish children and 75 (24%) Bedouin children] were recorded. None died. The mean annual rates for children <5 years (per 100,000) were 49.3 +/- 17.4 and 18.9 +/- 9.6 for Jewish and Bedouin children, respectively (P < 0.001), with a significant increase in intussusception rates during the study period in Bedouin (P = 0.022), but not in Jewish children (P = 0.38). Mean annual intussusception rates per 100,000 for children <12 months were 199.6 +/- 5.2 and 66.8 +/- 44.1 for Jews and Bedouin infants, respectively (P < 0.001). In Bedouin children, a significantly higher number of cases were observed from March to May, whereas no seasonality pattern was noted in Jewish children. Negative correlation between intussusception and gastroenteritis was found in Bedouin infants during the summer months, whereas no such correlation was found in Jewish infants. CONCLUSIONS: Pre-rotavirus vaccination intussusception rate is high especially among Jewish infants in Southern Israel. Intussusception rates increased significantly during the study period in Bedouin infants.

Domestic water supplies as a possible source of infection with Simkania.

OBJECTIVES: Simkania negevensis, a Chlamydia-like microorganism that has been associated with respiratory infections in children and adults, can multiply within free-living amoebae; moreover, it has been detected in domestic water supplies. The aim of this study was to determine whether there is similarity between Simkania organisms found in water and those detected in clinical samples. METHODS: PCR, membrane immunoassay for the detection of Simkania antigen, and isolation in cell culture were used for the detection of S. negevensis in nasopharyngeal wash samples (NPW) of 34 children with pneumonia and in domestic water samples from their homes. Sequencing of PCR amplicons was used for comparison of Simkania strains isolated from clinical samples and from water samples. RESULTS: In 26 cases (76%) both NPW and water were positive, and partial 16S rDNA sequences suggested that they may be the same organisms. CONCLUSION: Simkania found in domestic water supplies may be transmitted to children .

Pediatric wandering spleen successfully treated by laparoscopic splenopexy.

Wandering spleen is a rare clinical condition associated with a high incidence of splenic torsion and infarction. The preferred treatment is splenopexy to reposition the spleen in the left upper quadrant of the abdomen. We report the case of a 12-year-old girl who presented with intermittent abdominal pain. An abdominal sonography was diagnostic of wandering spleen. The patient was successfully treated by laparoscopic splenopexy. The spleen was repositioned in the left upper quadrant and fixed to the posterior abdominal wall by a mesh patch attached by staples. To reinforce the splenopexy we created an additional support by plicating the phrenocolic ligament and suturing it to the lateral abdominal wall, making a pouch for the inferior pole of the spleen. The postoperative course was rapid and uneventful. A normal spleen position was verified by radionuclide scans at 3 days and 6 months postoperatively. Laparoscopic splenopexy is an excellent option for organ-preserving treatment in wandering spleen.

Superficial skin infection caused by Streptococcus pneumoniae in children.

Pneumococcal superficial skin infections are rarely described. We present 3 cases of Streptococcus pneumoniae superficial skin infections in previously healthy children. In 2 cases, lesions occurred on facial skin; in the third case they occurred on the scrotal raphe. One isolate was fully penicillin-resistant.

Twelve years of minimally invasive surgery in children and adolescents: a single center experience.

BACKGROUND/PURPOSE: Minimally invasive surgery plays an important role in the daily practice of pediatric surgeons. However, there have been few reports of large series of patients. The aim of this paper is to report our experience over the past 12 years with a broad range of pediatric laparoscopic procedures. METHODS: We performed a retrospective analysis of 1084 minimally invasive procedures conducted in the department of pediatric surgery from June 1992 to March 2004. RESULTS: The mean age of the patients was 14 years (range, 1-19). Seven hundred forty-six operations (69%) were thoracoscopic sympathectomy for hyperhydrosis. Other common operations were high ligation of spermatic vessels (n=98), cholecystectomy (n=65), exploration of nonpalpable testes (n=53), appendectomy (n=55), female adnexal surgery (n=24), and splenectomy (n=13). Thirty miscellaneous procedures included Nissen fundoplication, liver biopsies, diagnostic laparoscopy, Morgani and Bochdalek hernia repair, Swenson procedures, V-P shunt placement, splenic and hepatic cyst removal, thorcoscopy for pleural empyema, treatment of gastric ulcer perforation, and nephrectomy. We reviewed the indications for surgery, the surgical technique, and the outcome for each procedure. All patients in this series were well at follow-up and there was no long-term morbidity. CONCLUSION: Although laparoscopic procedures have gained an integral place in pediatric surgery and are relatively safe, advanced laparoscopic procedures should be developed, practiced and evaluated in dedicated surgical units to ensure a broad base of experience on which to base future decisions and guidelines.

How much of a misnomer is "asymptomatic" intestinal malrotation?

BACKGROUND: Intestinal malrotation is usually observed in the neonatal period with signs of acute high intestinal obstruction due to midgut volvulus. However, malrotation presenting beyond the neonatal period and well into adult life is associated with a variety of atypical and frequently non-specific gastrointestinal symptoms that may often cause prolonged delay in diagnosis and appropriate treatment. OBJECTIVES: To emphasize the difficulty in predicting the risk of midgut volvulus based on age or symptoms, and to recommend surgery in all patients found to have intestinal malrotation even if they are considered asymptomatic. METHODS: We reviewed 41 patients with malrotation treated over a period of 24 years at the Soroka University Medical Center. RESULTS: In our series, 27 patients (66%) had acute midgut volvulus while 14 (34%) had malrotation found during investigation of various long-term gastrointestinal non-specific symptoms. Two patients died of total parenteral nutrition-related sepsis following extensive resection of small bowel. A total of 28 patients was available for long-term follow-up and are asymptomatic. CONCLUSIONS: We recommend elective laparotomy and Ladd procedure in all patients found to have intestinal malrotation. This will prevent the catastrophic results of midgut volvulus and a variety of gastrointestinal symptoms wrongly attributed to other conditions in the span of a lifetime.