Acquired Urethrovaginal Fistula and Urethral Atresia in a Patient with a Sacrococcygeal Teratoma.

Acquired urethrovaginal fistulae and urethral atresia are rare findings in pediatric patients, but have been described in adult patients related to trauma or iatrogenic injury. Little exists in the published literature to guide management of such conditions in children, but lessons learned from congenital causes can help. Herein we discuss the preoperative evaluation and management of a child with an acquired urethrovaginal fistula and urethral atresia likely related to in utero compression from an intrapelvic sacrococcygeal teratoma and provide several images detailing the complex anatomy.

Long-term neurodevelopmental outcomes in children born with gastroschisis: the tiebreaker.

PURPOSE: We evaluated 2-year neurodevelopmental outcomes in children with gastroschisis. METHODS: We reviewed the records of children with gastroschisis treated between August 2001 and July 2008. Children discharged from the neonatal intensive care unit were referred to the state-sponsored Developmental Tracking Infant Progress Statewide (TIPS) program. We reviewed TIPS assessments performed before age 2 years. School districts evaluated children referred by TIPS and determined their eligibility for early intervention services. Poor outcomes were defined as scores of "failure" or "moderate/high risk" on the screening assessment or enrollment in early intervention services by 2 years. Children with gastroschisis were compared with case-matched nonsurgical, nonsyndromic children of similar gestational age and birth weight. RESULTS: One hundred five children were born with gastroschisis, and 46 were followed up with TIPS. There was no statistically significant difference in performance on screening assessments or in the rate of enrollment in early intervention services between the gastroschisis children and controls. CONCLUSIONS: Children born with gastroschisis have similar 2-year neurodevelopmental outcomes as nonsurgical, nonsyndromic neonatal intensive care unit children of similar gestational age and birth weight. Both groups of children have a higher rate of enrollment in early intervention than their healthy peers. These data suggest that neurodevelopmental outcomes in gastroschisis children are delayed secondary to prematurity rather than the presence of the surgical disease.

Using hospital outcomes to predict 30-day mortality among injured patients insured by Medicare.

HYPOTHESIS: Survival until a fixed time after injury is a more useful outcome variable than survival until hospital discharge. DESIGN: We sought to determine whether 30-day survival could be accurately predicted by hospital discharge status. SETTING: Academic research. PATIENTS: We analyzed Medicare fee-for-service records for patients 65 years or older admitted with a principal diagnosis of injury (International Classification of Diseases, Ninth Revision, Clinical Modification codes 800-959, excluding 905-909, 930-939, and 958). MAIN OUTCOME MEASURES: Patients were classified by maximum Abbreviated Injury Score (range, 1-5) and Charlson comorbidity score (0, 1, 2, or ≥ 3). We modeled the conditional probability of survival at 30 days given hospitalization survival (P[S30SH]) as a function of census region, age, sex, maximum Abbreviated Injury Score, Charlson comorbidity score, length of stay, and discharge home or not. RESULTS: A total of 436 104 patients met inclusion criteria, and a model was created using half the sample. For northeastern women aged 65 to 69 years with a maximum Abbreviated Injury Score of less than 3, Charlson comorbidity score of 0, and discharge home with length of stay less than 3 days, the model predicted P (S30SH) to be 0.998. The P (S30SH) was lower for other census regions, male sex, older age, more severe injury, and greater comorbidity. The equation had modest predictive ability when applied to individuals in the other half of the sample (area under the receiver operating characteristic curve, 0.75) and closely predicted P (S30SH) within numerous subpopulations. CONCLUSION: For injured patients insured by Medicare, P (S30SH) can be estimated using administrative data known at the time of hospital discharge.

Asymptomatic isolated celiac artery dissection after a fall.

Isolated injury to mesenteric vessels in blunt trauma is uncommon. Most patients with these injuries present with abdominal pain, shock, or laboratory evidence of bowel and/or liver ischemia. We report herein the case of a man with asymptomatic isolated celiac artery dissection after blunt trauma suspected by screening abdominal computed tomography and confirmed by catheter-based angiography. The patient was treated with 3 months of oral anticoagulation alone.

Regional variation in hospital mortality and 30-day mortality for injured Medicare patients.

BACKGROUND: We sought to evaluate how survival of older patients with injuries differs by geographic region within the United States. METHODS: We analyzed Medicare fee-for-service records for patients aged 65 years and older with principal injury diagnoses (ICD-9 800-959, excluding 905, 930-939, 958). Cases were classified by Maximum Abbreviated Injury Score (AISmax) and Charlson Comorbidity score (0, 1, 2, >or=3). Hospital mortality and 30-day mortality were modeled as functions of age, sex, AISmax, comorbidity, and geographic region (northeast, midwest, south, west). RESULTS: Hospital and 30-day mortality were both higher with male sex and increased age, AISmax, or Charlson score. Adjusted hospital mortality was highest in the northeast and south, but 30-day adjusted mortality was lowest in the same two regions. CONCLUSIONS: Regional differences in risk-adjusted hospital survival for older patients with injuries are different from regional differences in 30-day survival. Hospital mortality as an outcome for older injured patients should be interpreted cautiously.