RESUMEN
OBJECTIVE: The aim of this study was to estimate the prevalence of food insecurity among children with overweight/obesity presenting for weight management treatment and examine whether food insecurity predicts early change in body mass index (BMI), expressed as a percentage of the 95th percentile (%BMIp95). METHOD: Children (N = 69; ages 3-18 years) presenting to a hospital-based pediatric weight management intervention and 1 parent/guardian per child (N = 69) were included. At the first appointment, parents/guardians completed the US Household Food Security Survey Module: Six-item Short Form and a demographics questionnaire. Height and weight of the children were measured at the first and third appointments to calculate %BMIp95. RESULTS: Among participating families, 29.0% reported experiencing food insecurity. Controlling for the ratio of income to poverty, 11.4% of the variance in %BMIp95 change from the first to third appointments was accounted for by food insecurity, âµF (1, 66) = 8.46, p = 0.01. Children with greater food insecurity demonstrated a smaller magnitude of %BMIp95 decrease, representing a small-to-medium effect size within the context of the regression model (f2 = 0.13). CONCLUSION: A high proportion of families with children receiving weight management treatment reported experiencing food insecurity in comparison with US households with children. There may be unique characteristics of food insecurity, as opposed to household income alone, that explain the smaller magnitude of BMI decrease observed early in treatment. Future research should explore complex associations among food insecurity, income, BMI, and race over time.
Asunto(s)
Abastecimiento de Alimentos , Obesidad , Niño , Humanos , Índice de Masa Corporal , Sobrepeso/epidemiología , Sobrepeso/terapia , Inseguridad AlimentariaRESUMEN
BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have been successfully implemented in several surgical fields; however, the application of ERAS in the pediatric population is still limited. OBJECTIVES: The aim was to determine if implementation of an ERAS protocol can improve outcomes of laparoscopic sleeve gastrectomy (LSG) in adolescents. SETTING: University Hospital, United States. METHODS: A retrospective analysis of 112 adolescent patients who underwent LSG from February 2011 to July 2019 was conducted. An ERAS protocol was instituted in June 2016. Conventional care patients (n = 51) were compared with ERAS patients (n = 61). Comparisons were made using Χ2 tests or Fisher's exact for categoric data and Wilcoxon-rank sum tests for continuous data. Multiple linear regression was used to adjust length of stay for patient characteristics. RESULTS: The 2 cohorts were similar in age, sex, race, number of co-morbidities, and preoperative body mass index. The volume of intraoperative fluid, intraoperative and postoperative opioids were significantly reduced in the ERAS group (P < .0001). The number of ERAS elements received per patient increased from a median of 9 to 15 (P < .0001). ERAS group had more discharges on postoperative day 1 (48% versus 6 %, respectively). Length of stay was significantly lower in the ERAS group (2.34 versus 2.04 median d, respectively). Difference was still significant after adjusting for age, sex, race/ethnicity, payor status, American Society of Anesthesiologists score, preoperative body mass index, and the duration of surgery (P < .0001). There were no differences in postoperative complications and 30-day readmissions. CONCLUSIONS: An LSG ERAS protocol is associated with significant reduction in perioperative opioid use and length of stay with no increase in complications or readmission rates.
Asunto(s)
Recuperación Mejorada Después de la Cirugía , Laparoscopía , Adolescente , Niño , Gastrectomía , Humanos , Tiempo de Internación , Complicaciones Posoperatorias , Estudios RetrospectivosRESUMEN
Sleeve gastrectomy is an effective tool for inducing sustainable weight loss in adolescents with obesity. It is a seemingly straight-forward procedure, and yet deceptive in technical nuances. This review highlights the technical preparation (equipment, patient positioning, pre-operative management), and conduct (anatomy, instruments, methodology, pitfalls) of the operation, and concludes with essentials for anticipating and managing complications of the operation. Throughout the discussion, we emphasize practical techniques to maintain patient safety while achieving maximum weight loss benefits.
Asunto(s)
Cirugía Bariátrica/métodos , Gastrectomía/métodos , Obesidad Infantil/cirugía , Adolescente , Cirugía Bariátrica/instrumentación , Cirugía Bariátrica/normas , Gastrectomía/instrumentación , Gastrectomía/normas , HumanosAsunto(s)
Apendicectomía , Apendicitis , Betacoronavirus , COVID-19 , Niño , Infecciones por Coronavirus , Humanos , Pandemias , Neumonía Viral , SARS-CoV-2RESUMEN
Purpose: The purpose of this study was to determine if utilization of biologic mesh underlay during thoracoscopic congenital diaphragmatic hernia (CDH) primary repair (PR) results in reduced 5-year hernia recurrence rates. Methods: A retrospective review was completed for all primarily repaired CDH utilizing a thoracoscopic approach from January 1, 2003 to June 31, 2013. Patients were included in the study cohort if they had a thoracoscopic PR of their CDH without any mesh reinforcement or with biologic mesh underlay. Charts were then reviewed for no less than 5 years postoperatively for reports of clinical and/or radiographic hernia recurrence. The cumulative annual hernia recurrence as well as other demographic factors were analyzed. Results: Within the study period, 46 patients were identified that met study criteria. Three patients were lost to follow-up. Fifteen of the remaining patients (15/43: 34.9%) had a biologic underlay. Within the cohort, seven recurrences were noted within 5 years of the index procedure (7/43; 16.7%). Four recurrences occurred within the first postoperative year, and all occurred by the third postoperative year. One recurrence was in a patient with a biologic underlay at 4 months after repair. This was a clinically/radiographically silent 4 mm defect and noted at laparoscopy for another indication (1/15: 6.6%). The remainder occurred in primarily repaired patients without mesh reinforcement (6/28: 21.4%). Conclusions: Thoracoscopic PR of CDH can be successfully performed in select patients. The use of a biologic mesh underlay in this subset of patients appears to confer reduced hernia recurrence.
Asunto(s)
Hernias Diafragmáticas Congénitas/cirugía , Herniorrafia/métodos , Mallas Quirúrgicas , Toracoscopía/métodos , Productos Biológicos , Femenino , Estudios de Seguimiento , Herniorrafia/instrumentación , Humanos , Recién Nacido , Masculino , Recurrencia , Estudios Retrospectivos , Toracoscopía/instrumentación , Resultado del TratamientoRESUMEN
INTRODUCTION: Thoracoscopic repair of congenital diaphragmatic hernia (CDH) has been associated with faster recovery, earlier extubation, and decreased morbidity. Nevertheless, thoracoscopic repair is rarely attempted in the post-extracorporeal membrane oxygenation (ECMO) patient. Commonly cited reasons for not attempting thoracoscopy include concerns that the patients' respiratory status is too tenuous to tolerate insufflation pressures or that presumed defect size is so large that it precludes thoracoscopic repair. Our purpose is to review our experience with post-ECMO thoracoscopic CDH repair and evaluate the success of this approach. METHODS: We performed retrospective analysis of attempted thoracoscopic CDH repairs after ECMO decannulation at our institution from 2001 to 2015. Primary outcome was rate of conversion. Secondary outcomes were intraoperative end-tidal CO2, time to extubation, and rate of recurrence. RESULTS: We identified 21 post-ECMO patients in whom thoracoscopic CDH repair was attempted. Thoracoscopic repair was successfully completed in 28%. No patients had reported intolerance to insufflation at 3-7 mmHg. Average end-tidal CO2 at 15 operative minutes was 36.9 mmHg in the thoracoscopic group versus 50.7 mmHg in the open group and at 60 minutes was 34.25 mmHg versus 45.6 mmHg, respectively. One patient in the thoracoscopic group died and 1 experienced a large pneumothorax. In the converted group there was one clinically significant pneumothorax and three pleural effusions. Survivors after thoracoscopy were extubated an average of 5.6 ± 2.6 days after surgery versus 19.4 ± 10 days in the converted group (P < .05). Recurrence rates at last follow-up were equal between the two groups at 20%. CONCLUSIONS: Thoracoscopic CDH repair is both safe and feasible after ECMO with no increase in operative morbidity or mortality. Insufflation pressures of 3-7 mmHg are well tolerated without undue increase in end-tidal CO2. When compared to conversion cases, thoracoscopic repair is associated with significantly decreased time to extubation with no difference in recurrence.
Asunto(s)
Oxigenación por Membrana Extracorpórea/efectos adversos , Hernias Diafragmáticas Congénitas/cirugía , Herniorrafia/métodos , Toracoscopía/métodos , Extubación Traqueal/estadística & datos numéricos , Conversión a Cirugía Abierta/estadística & datos numéricos , Estudios de Factibilidad , Herniorrafia/efectos adversos , Humanos , Recién Nacido , Recurrencia , Estudios Retrospectivos , Toracoscopía/efectos adversos , Resultado del TratamientoRESUMEN
Importance: The pediatric perforated appendix rate is a quality metric measured by the Agency for Healthcare Research and Quality (AHRQ) that reflects access to care. The association of health care utilization prior to presentation with appendicitis is unknown. Objective: To determine whether increased health care utilization prior to presentation with appendicitis is associated with lower perforated appendicitis rates in children. Design, Setting, and Participants: Retrospective cohort study of privately insured children drawn from large employer and insurance company administrative data found in the Truven MarketScan national insurance claims database. Cases of appendicitis were identified among 38â¯348 children 18 years or younger from January 1, 2010, through December 31, 2013, with corresponding primary health care encounters from January 1, 2009, through December 31, 2012. In all, 19â¯109 eligible children were identified using International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes for appendicitis after excluding those patients who did not have continuous insurance coverage during the study period. Statistical analysis was performed from September 1, 2016, to October 15, 2017. Exposures: Health care utilization was determined by the number of outpatient clinic encounters for each patient in the 1 to 12 months before presentation with appendicitis. Main Outcomes and Measures: Perforated appendicitis was defined according to the AHRQ by using ICD-9 codes for perforation and hospital length of stay of 3 or more days. Logistic regression models were used for perforated appendicitis after adjustment for age, sex, income, gastrointestinal comorbidities, geographic region, and insurance type. Results: We identified 38â¯348 children 18 years or younger with ICD-9 diagnosis codes for appendicitis, and 19â¯109 children remained for analysis after applying exclusion criteria. Of these, 11â¯422 were boys (59.8%); the mean (SD) age was 12.4 (3.9) years. Of the 19â¯109 children identified who underwent appendectomy, 5509 (28.8%) presented with perforated appendicitis. Children with perforation had lower outpatient health care utilization in the year before presentation compared with those diagnosed with acute appendicitis (4554 of 5509 children [82.7%] vs 11â¯937 of 13â¯600 [87.8%]; P < .001). In the adjusted model, outpatient health care utilization before presentation was associated with lower odds of perforated appendicitis (odds ratio [OR], 0.63; 95% CI, 0.58-0.69; P < .001). This association increased with visit frequency in the year before presentation (OR, 0.86; 95% CI, 0.77-0.95 for 1-2 visits, P = .003; OR, 0.61; 95% CI, 0.55-0.67 for 3-6 visits, P < .001; and OR, 0.43; 95% CI, 0.38-0.48 for ≥7 visits [5-18 years], P < .001). Covariates associated with perforation included younger age, geographic region, family income, and higher out-of-pocket insurance plans. Conclusions and Relevance: Among insured children 18 years or younger, increased health care utilization was associated with lower rates of perforated appendicitis. Primary health care relationships may facilitate timely presentation or serve as a marker for health-related self-efficacy, thereby contributing to outcomes for acute surgical conditions.
Asunto(s)
Apendicitis/epidemiología , Seguro de Salud/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Enfermedad Aguda , Adolescente , Apendicectomía/estadística & datos numéricos , Apendicitis/economía , Apendicitis/cirugía , Niño , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Long-term dysphagia occurs in up to 50% of repaired esophageal atresia and tracheoesophageal fistula (EA/TEF) patients. The underlying factors are unclear and may include stricture, esophageal dysmotility, or associated anomalies. Our purpose was to determine whether structural airway abnormalities (SAA) are associated with dysphagia in EA/TEF. METHODS: We conducted a retrospective chart review of children who underwent EA/TEF repair in our hospital system from 2007 to 2016. Children with identified SAA (oropharyngeal abnormalities, laryngeal clefts, laryngomalacia, vocal cord paralysis, and tracheomalacia) were compared to those without airway abnormalities. Dysphagia outcomes were determined by the need for tube feeding and the modified pediatric Functional Oral Intake Scale (FOIS) at 1 year. RESULTS: SAA was diagnosed in 55/145 (37.9%) patients with EA/TEF. Oropharyngeal aspiration was more common in children with SAA (58.3% vs. 36.4%, p=0.028). Children with SAA were more likely to require tube feeding both at discharge (79.6% vs. 48.3%, p<0.001) and at 1 year (52.7% vs. 13.6%, p<0.001) and had lower mean FOIS (4.18 vs. 6.21, p<0.001). In the logistic regression model adjusting for gestational age, long gap EA, and esophageal stricture, the presence of SAA remained a significant risk factor for dysphagia (OR 4.17 (95% CI 1.58-11.03)). CONCLUSION: SAA are common in children with EA/TEF and are associated with dysphagia, even after accounting for gestational age, esophageal gap and stricture. This study highlights the need for a multidisciplinary approach, including early laryngoscopy and bronchoscopy, in the evaluation of the EA/TEF child with dysphagia. LEVEL OF EVIDENCE: Level II retrospective prognostic study.
Asunto(s)
Anomalías Múltiples , Trastornos de Deglución/etiología , Atresia Esofágica/complicaciones , Anomalías del Sistema Respiratorio/complicaciones , Fístula Traqueoesofágica/complicaciones , Anomalías Múltiples/cirugía , Niño , Preescolar , Trastornos de Deglución/diagnóstico , Atresia Esofágica/cirugía , Femenino , Humanos , Lactante , Recién Nacido , Modelos Logísticos , Masculino , Pronóstico , Anomalías del Sistema Respiratorio/cirugía , Estudios Retrospectivos , Factores de Riesgo , Fístula Traqueoesofágica/cirugíaRESUMEN
Congenital diaphragmatic hernia can be approached successfully using minimally invasive techniques. Although there are may be a suggestion of higher recurrence rates with thoracoscopic repair, this may be due to the learning curve. However, open repair is associated with additional morbidity, most notably an increased rate of small bowel obstruction. Appropriate patients who have congenital diaphragmatic hernia should be offered the benefits of minimally invasive repair.
Asunto(s)
Eventración Diafragmática/cirugía , Hernias Diafragmáticas Congénitas/cirugía , Herniorrafia/métodos , Toracoscopía/métodos , Humanos , Recién Nacido , Posicionamiento del Paciente , Cuidados PreoperatoriosRESUMEN
BACKGROUND: Surgeons balance competing interests of minimizing duration of stay with readmissions. Complications that occur early after discharge often result in readmissions. This study examines the relationship between duration of stay, timing of complications, and readmission risk. METHODS: Cases from the 2012-2014 National Surgical Quality Improvement Project-Pediatric were organized into 30 procedural groups. Procedures where duration of stay approximated the median day of complication were identified. A theoretical model was applied to minimize readmissions by extending duration of stay. RESULTS: From 30 procedure groups, 3 were identified where duration of stay approximated median day of compilations: complicated appendectomy, antireflux operation, and abdominal operation without bowel resection. The complicated appendectomy readmission rate drops from 12.2% to 8.2%, increasing duration of stay from 3 to 8 days at the cost of 16,428 additional hospital days among 4,740 patients (3.5 days/patient). Readmission optimization tapers after duration of stay of 8 days. Similar findings were observed for antireflux operation and abdominal operation without bowel resection with readmission optimization at duration of stay of 5 days (2.6 days/patient) and 7 days (5.3 days/patient), respectively. CONCLUSION: Our theoretical model aimed at balancing readmissions by extending duration of stay to capture early complications results in a substantial increase in hospital days illustrating the conflict between competing quality metrics and limited resources.
Asunto(s)
Tiempo de Internación , Readmisión del Paciente , Complicaciones Posoperatorias/epidemiología , Factores de Edad , Niño , Femenino , Humanos , Masculino , Modelos Teóricos , Mejoramiento de la Calidad , Estudios Retrospectivos , Factores de Tiempo , Estados UnidosRESUMEN
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.
Asunto(s)
Fístula Traqueoesofágica/cirugía , Preescolar , Esofagoplastia , Femenino , Humanos , Incidencia , Lactante , Recién Nacido , Laringoscopía , Masculino , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Enfermedades Raras , Recurrencia , Traumatismos del Nervio Laríngeo Recurrente/complicaciones , Reoperación , Estudios Retrospectivos , Fístula Traqueoesofágica/clasificación , TraqueostomíaRESUMEN
Little is known regarding the subsequent course of non-alcoholic fatty liver disease (NAFLD) diagnosed in childhood. The objectives of this single-center study were to gather data on long-term health outcomes and to assess the feasibility of contacting former pediatric patients. In a large pediatric medical center, electronic records were searched to initially identify 162 former patients who had a liver biopsy between 2000 and 2010. Of these, 44 subjects met the criteria for age at follow-up (≥18 year) and biopsy-proven NAFLD, and were recruited via postal and electronic mail. Participants were invited to complete a brief telephone survey on current health status. Supplemental data was also obtained from pediatric medical charts of all subjects. At NAFLD diagnosis, 18% of subjects had diabetes, 91% were obese, 61% had NASH, and 56% had fibrosis on biopsy. At follow-up, 10 subjects (23%) responded to the survey. Based on the survey and chart review, after a mean follow-up of 4.5 years, 5 additional subjects developed diabetes for a period prevalence of 30%, and most subjects (78%) remained obese at last follow-up. Additional prospective studies are needed to fully describe the longitudinal risks associated with pediatric NAFLD, and will require multi-dimensional strategies to successfully recruit former patients.
RESUMEN
INTRODUCTION: Prolonged operative time (OT) is considered a reflection of procedural complexity and may be associated with poor outcomes. Our purpose was to explore the association between prolonged OT and complications in children's surgery. METHODS: 182,857 cases from the 2012-2014 NSQIP-Pediatric were organized into 33 groups. OT for each group was analyzed by quartile, and regression models were used to determine the relationship between prolonged OT and complications. RESULTS: Variations in OT existed for both short and long procedures. Cases in the longest quartile had twice the odds of postoperative complications after adjusting for age, sex and BMI (OR 1.85; 95% CI 1.78-1.91). Procedure-specific prolonged OT was associated with postoperative complications for the majority (85%) of procedural groupings. Prolonged OT was associated with minor complications in gynecologic (OR 4.17; 95% CI 2.19-7.96), urologic (OR 2.88; 95% CI 2.40-3.44), and appendix procedures (OR 2.88; 95% CI 2.49-3.34). There were increased odds of major complications in foregut (OR 6.56; 95% CI 4.99-8.64), gynecologic (OR 3.07; 95% CI 1.84-5.13), and spine procedures (OR 2.99; 95% CI 2.57-3.28). CONCLUSIONS: Prolonged OT is associated with increased odds of postoperative complications across a spectrum of children's surgical procedures. Factors contributing to prolonged OT merit further investigation and may serve as a target for future quality improvement. LEVEL OF EVIDENCE: Level III.
Asunto(s)
Tempo Operativo , Complicaciones Posoperatorias/etiología , Procedimientos Quirúrgicos Operativos/efectos adversos , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Niño , Femenino , Humanos , Masculino , Complicaciones Posoperatorias/epidemiología , Mejoramiento de la Calidad , Factores de Riesgo , Infección de la Herida Quirúrgica/epidemiología , Factores de TiempoRESUMEN
BACKGROUND: Infants with congenital cardiac disease (CCD) often require gastrostomy tube placement (GT) and need antireflux procedures, such as fundoplications. Our purpose was to compare morbidity/mortality rates among infants with CCD undergoing GT, fundoplication, or both. METHODS: Using the NSQIP-Pediatric, we identified 4070 patients <1-year-old who underwent GT and/or fundoplication from 2012 to 2014. 2346 infants (58%) had CCD categorized as minor, major or severe. Regression models were used to estimate the association of CCD with morbidity/mortality. RESULTS: Among all patients undergoing fundoplication, there were increased odds of morbidity/mortality among CCD patients compared to non-CCD patients (OR 2.15; p < 0.001). Odds of complications decreased when procedures were performed laparoscopically or later in the first year of life. Using GT alone as a reference, fundoplication alone (OR 1.67; p < 0.001) and GT with fundoplication (OR 1.82; p < 0.001) had increased odds of morbidity/mortality among cardiac patients. Increased risk persisted after stratification by severity of CCD and after accounting for surgical approach. CONCLUSION: Fundoplication is associated with increased odds of morbidity/mortality in infants with CCD compared to GT alone. Risks are lower with laparoscopic approach and if surgery is delayed until later in the first year of life. Timing and surgical approach for patients with CCD requires further investigation.
Asunto(s)
Fundoplicación/estadística & datos numéricos , Reflujo Gastroesofágico/epidemiología , Reflujo Gastroesofágico/cirugía , Cardiopatías Congénitas/epidemiología , Cardiopatías Congénitas/cirugía , Complicaciones Posoperatorias/epidemiología , Comorbilidad , Femenino , Humanos , Lactante , Masculino , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
Objective Outcomes for gastroschisis (GS) remain highly variable and avoiding infectious complications (ICs) may represent a significant improvement opportunity. Our objective was to provide estimates of the impact of IC on length of stay (LOS) and costs. Study Design Using a national database, 1,378 patients with GS were identified. Patient and hospital characteristics were compared and LOS and costs evaluated for patients with and without IC. Results Two-thirds of all GS patients had IC, and IC were common for simple and complex GS (65, 73%, respectively). After controlling for patient and hospital factors, LOS in patients with IC was significantly longer than in patients without IC (4.5-day increase, p = 0.001). Specifically, sepsis was associated with increasing median LOS by 11 days (p ≤ 0.001), candida infection by 14 days (p < 0.001), and wound infection by 7 days (p = 0.007). Although overall costs did not differ between patients with and without IC, costs were elevated based on specific IC. Sepsis increased median costs by $22,380 (95% confidence interval [CI]: $14,372-30,388; p ≤ 0.001), wound infection by $32,351 (95% CI: $17,221-47,481; p ≤ 0.001), catheter-related infection by $57,180 (95% CI: $12,834-101,527; p = 0.011), and candida infections by $24,500 (95% CI: $8,832-40,167; p = 0.002). Conclusion IC among GS patients are common and contribute to increased LOS and costs. Quantifying clinical and financial ramifications of IC may help direct future quality improvement efforts.
Asunto(s)
Candidiasis/epidemiología , Gastrosquisis/cirugía , Costos de la Atención en Salud , Tiempo de Internación/estadística & datos numéricos , Sepsis/epidemiología , Infección de la Herida Quirúrgica/epidemiología , Candidiasis/economía , Bases de Datos Factuales , Femenino , Costos de Hospital , Humanos , Recién Nacido , Cuidado Intensivo Neonatal/economía , Tiempo de Internación/economía , Masculino , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Sepsis/economía , Infección de la Herida Quirúrgica/economíaRESUMEN
PURPOSE: Accidental puncture or laceration (APL) has been endorsed as a patient safety indicator and is being used to compare hospital performance and for reimbursement. We sought to determine the positive predictive value (PPV) of APL as a quality metric in a pediatric population. METHODS: We retrospectively reviewed all cases that met APL administrative criteria over 5years in a quaternary pediatric hospital system. Events were categorized as false positive (FP) or true positive (TP). TP cases were further categorized as "potentially consequential" or "inconsequential". The PPV of APL was calculated, and a z-test was used to provide 95% confidence intervals. RESULTS: Of the 238 cases identified, 204 were categorized as TP (86%; 95% CI: 80%-90%). Thirty-four of these events (17%) involved injuries that were considered "inconsequential". True events that required repair were identified as "potentially consequential" (n=170). Thus, the PPV of APL was 71% (95% CI: 65%-77%). Extenuating factors such as adhesive disease or abnormal anatomy were present in 39% of TP cases. Thirty-four cases (14%) were categorized as FP because no documented injury was found. CONCLUSIONS: A large proportion of APL events are either false or clinically irrelevant, thus questioning its usability as a patient safety indicator for children undergoing surgery. TYPE OF STUDY: Retrospective review. LEVEL OF EVIDENCE: IV.
Asunto(s)
Hospitales Pediátricos/normas , Laceraciones/etiología , Seguridad del Paciente/normas , Punciones , Indicadores de Calidad de la Atención de Salud , Accidentes , Niño , Femenino , Georgia , Humanos , Masculino , Estudios RetrospectivosRESUMEN
Childhood obesity remains a significant public health issue. Approximately 8% of adolescent girls and 7% of adolescent boys have severe (≥class 2) obesity. Adolescent severe obesity is associated with numerous comorbidities, and persists into adulthood. Bariatric surgery is the most effective treatment available, resulting in major weight loss and resolution of important comorbid conditions. Clinical practice guidelines for pediatric obesity treatment recommend consideration of surgery after failure of behavioral approaches. Careful screening and postoperative management of patients by a multidisciplinary team is required. Long-term studies are needed to assess the impact of adolescent bariatric surgery.
Asunto(s)
Cirugía Bariátrica , Obesidad Mórbida/cirugía , Obesidad Infantil/cirugía , Adolescente , Comorbilidad , Femenino , Humanos , Masculino , Resultado del Tratamiento , Pérdida de PesoRESUMEN
BACKGROUND: Postoperative length of stay (pLOS) is an easily tracked outcome that reflects health care efficiency and resource utilization. The purpose of this study was to determine the contribution of practice variation on pLOS for children with perforated appendicitis. METHODS: Children ages 2-18years with appendectomy for complicated appendicitis were selected from the National Surgical Quality Improvement Program-Pediatric. Extended pLOS (EpLOS) was defined as ≥7days (75th percentile). The contribution of comorbidities, operative traits, and postoperative complications to EpLOS was evaluated using regression models and matched subgroup analyses. RESULTS: Of 2585 children with complicated appendicitis in our study, 835 had EpLOS. Regression analysis found that EpLOS was associated with extended operative time (odds ratio (OR) 1.99; 95% confidence interval (CI) 1.63-2.44), dehiscence (OR 13.19; 95% CI 1.52-114.23), wound infection (OR 7.39; 95% CI 2.63-20.80), organ space infection (OR 92.51; 95% CI 34.03-251.50), and pneumonia (OR 4.55; 95% CI 1.06-19.44). Over three-fourths of the variation in pLOS could not be explained by preoperative, intraoperative, or postoperative factors. CONCLUSIONS: There is significant variation in pLOS for children undergoing appendectomy that is not accounted for by comorbidities, operative traits, or complications indicating an opportunity to improve outcomes through modifying practice patterns.