Associations between gestational age at birth and infection-related hospital admission rates during childhood in England: Population-based record linkage study.

BACKGROUND: Children born preterm (<37 completed weeks' gestation) have a higher risk of infection-related morbidity than those born at term. However, few large, population-based studies have investigated the risk of infection in childhood across the full spectrum of gestational age. The objectives of this study were to explore the association between gestational age at birth and infection-related hospital admissions up to the age of 10 years, how infection-related hospital admission rates change throughout childhood, and whether being born small for gestational age (SGA) modifies this relationship. METHODS AND FINDINGS: Using a population-based, record-linkage cohort study design, birth registrations, birth notifications and hospital admissions were linked using a deterministic algorithm. The study population included all live, singleton births occurring in NHS hospitals in England from January 2005 to December 2006 (n = 1,018,136). The primary outcome was all infection-related inpatient hospital admissions from birth to 10 years of age, death or study end (March 2015). The secondary outcome was the type of infection-related hospital admission, grouped into broad categories. Generalised estimating equations were used to estimate adjusted rate ratios (aRRs) with 95% confidence intervals (CIs) for each gestational age category (<28, 28-29, 30-31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41 and 42 weeks) and the models were repeated by age at admission (<1, 1-2, 3-4, 5-6, and 7-10 years). An interaction term was included in the model to test whether SGA status modified the relationship between gestational age and infection-related hospital admissions. Gestational age was strongly associated with rates of infection-related hospital admissions throughout childhood. Whilst the relationship attenuated over time, at 7-10 years of age those born before 40 weeks gestation were still significantly higher in comparison to those born at 40 weeks. Children born <28 weeks had an aRR of 6.53 (5.91-7.22) during infancy, declining to 3.16 (2.50-3.99) at ages 7-10 years, in comparison to those born at 40 weeks; whilst in children born at 38 weeks, the aRRs were 1·24 (1.21-1.27) and 1·18 (1.13-1.23), during infancy and aged 7-10 years, respectively. SGA status modified the effect of gestational age (interaction P<0.0001), with the highest rate among the children born at <28 weeks and SGA. Finally, study findings indicated that the associations with gestational age varied by subgroup of infection. Whilst upper respiratory tract infections were the most common type of infection experienced by children in this cohort, lower respiratory tract infections (LRTIs) (<28 weeks, aRR = 10.61(9.55-11.79)) and invasive bacterial infections (<28 weeks, aRR = 6.02 (4.56-7.95)) were the most strongly associated with gestational age at birth. Of LRTIs experienced, bronchiolitis (<28 weeks, aRR = 11.86 (10.20-13.80)), and pneumonia (<28 weeks, aRR = 9.49 (7.95-11.32)) were the most common causes. CONCLUSIONS: Gestational age at birth was strongly associated with rates of infection-related hospital admissions during childhood and even children born a few weeks early remained at higher risk at 7-10 years of age. There was variation between clinical subgroups in the strength of relationships with gestational age. Effective infection prevention strategies should include focus on reducing the number and severity of LRTIs during early childhood.

Is the Preoperative Glycated Hemoglobin (HbA1c) Level Predictive of the Severity of Diabetic Hand Infection According to Surgical and Clinical Outcomes?

OBJECTIVE: We purposed to investigate whether preoperative HbA1c level is associated with the severity of surgical treatment in diabetic hand infection cases. MATERIALS AND METHODS: Between December 2015 and October 2018, 102 patients were surgically treated due to diabetic hand infection. Of the patients, 75 who met the criteria for diabetic hand infection were included in the study. The patients were divided into two groups: Group 1, < 8.5% HbA1c level (poorly controlled); and Group 2, 8.5% or higher HbA1c level (uncontrolled). Preoperative, intraoperative, and postoperative data were recorded. Drainage, VAC, ray/open amputation, and microsurgical reconstruction were performed according to the examination and clinical findings. p<0.05 was considered statistically significant. RESULTS: The study groups consisted of 41 patients (5 female/36 male; median age 59 years, range 32-68) in Group 1 and 34 patients (6 female/28 male; median age 62 years, range 28-67) in Group 2. The mean follow-up period was 21.14±10.42 months in Group 1 and 16.70±10.19 months in Group 2, which were not significantly different (p>0.05). The most common microbiological pathogen was polymicrobial in both study groups (39% in Group 1 and 41.2% in Group 2). Drainage was the most common surgical procedure in both groups and there was no significant difference between the groups in terms of the surgical techniques that were used (p>0.05). CONCLUSION: Although HbA1c level is an important biomarker for monitoring glycemia in diabetic patients, it is not associated with the severity of surgical treatment in diabetic hand infections.

No difference in 90-day complication rate following open versus arthroscopic Latarjet procedure.

The purpose of this study was to compare the 90-day complication rate between the open and arthroscopic Latarjet procedure. A retrospective review of patients who underwent an open or arthroscopic Latarjet procedure at NYU Langone Health between 2012 and 2019 was performed. The complications, readmissions, and reoperations within 90 days were assessed. Outcomes were compared between the two approaches, and a p value of < 0.05 was considered to be statistically significant. The study included 150 patients (open: 110; arthroscopic: 40), with no patients lost to follow-up within the first 90 days. Both cohorts were similar in terms of patient demographics. No intra-operative complications were observed in either group. Overall, there were 4 post-operative complications with the open approach and 2 with the arthroscopic approach (3.6% and 5.0%, respectively; n.s.) during the study period. Three patients required a readmission within the 90-day period; one patient in both groups required a revision Latarjet for graft fracture, and one patient in the open Latarjet required irrigation and debridement for deep infection (n.s.). With the open approach, there were 2 (2.3%) wound complications, 1 graft complication, and 1 (1.1%) nerve injury. With the arthroscopic approach, there was 1 (2.8%) wound complication and 1 (2.8%) hardware complication. The safety, and 90-day complication and readmission profile of arthroscopic Latarjet is similar to open Latarjet procedure. LEVEL OF EVIDENCE: Level III.

Microbiological evaluation of resection margins of the infected diabetic foot ulcer.

AIM: To evaluate the impact of surgical debridement on the microbiology of resection margins of an infected diabetic foot ulcer and to compare the use of marginal sampling as a guide for antimicrobial therapy. METHODS: Forty consecutive participants were studied. Tissue samples from infected diabetic foot ulcers were obtained at first contact by podiatrists. After surgical debridement to macroscopically healthy tissue, multiple samples were obtained from the margins of the residuum and also from excised non-viable tissue. Debridement was done by a single surgeon. Bacterial species were classified according to pathogenic potential a priori into Red Group-Definite pathogen causing infection, Yellow Group-Likely to be causing infection if present in more than one specimen and Green Group -Commensals, not causing infection. RESULTS: There was a relative reduction of 49% (p = 0.002) in bacteria in the most pathogenic (red) group, and 59% (p = 0.002) in the yellow group in podiatry samples compared with resection specimen. Positive cultures from margins of the residuum were observed in 75% of cases. There was a relative reduction of 67% (p = 0.0001) in bacteria in the red and 48% (p = 0.06) in the yellow group in marginal samples from the residuum compared with podiatry samples. CONCLUSIONS: After surgical debridement to healthy tissue, positive cultures from marginal tissue samples provided vital information on the presence of pathogenic bacteria. This allowed antibiotics to be individualised post-surgical debridement.

Defining the volume of consultations for musculoskeletal infection encountered by pediatric orthopaedic services in the United States.

OBJECTIVE: Adequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States. STUDY DESIGN: Eighteen institutions from the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported. RESULTS: 87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI. CONCLUSION: At large, academic pediatric tertiary care centers, pediatric orthopaedic services consult on an average of ~3,000 'rule-out' MSKI cases annually. These patients account for nearly 1 in 10 orthopaedic consultations, of which 1 in 3 are culture positive. Considering that 2 in 3 consultations were culture negative, estimating resources required for pediatric orthopaedic consult services to work up and treat children based on culture positive administrative discharge data underestimates clinical need. Finally, ascertainment bias must be considered when comparing differences in culture rates from different institution's pediatric orthopaedics services, given the variability in when orthopaedic physicians become involved in a MSKI workup.

Exposure to surgery is associated with better long-term outcomes in patients admitted to Swedish intensive care units.

BACKGROUND: Long-term outcomes of patients admitted to intensive care units (ICUs) after surgery are unknown. We investigated the long-term effects of surgical exposure prior to ICU admission. METHODS: Registry-based cohort study. The adjusted effect of surgical exposure for mortality was examined using Cox regression. Secondary analysis with conditional logistic regression in a case-control subpopulation matched for age, gender, and Simplified Acute Physiology Score III (SAPS3) was also conducted. RESULTS: 72 242 adult patients (56.9% males, median age 66 years [IQR 50-76]), admitted to Swedish ICUs in 3-year (2012-2014) were followed for a median of 2026 days (IQR 1745-2293). Cardiovascular diseases (17.5%), respiratory diseases (15.8%), trauma (11.2%), and infections (11.4%) were the leading causes for ICU admission. Mortality at longest follow-up was 49.4%. Age; SAPS3; admissions due to malignancies, respiratory, cardiovascular and renal diseases; and transfer to another ICU were associated with increased mortality. Surgical exposure prior to ICU admission (adjusted hazard ratio [aHR] 0.90; 95% CI 0.87-0.94; P < .001), admissions from the operation theatre (aHR 0.94; CI 0.90-0.99; P = .022) or post-anaesthesia care unit (aHR 0.92; CI 0.87-0.97; P = .003) were associated with decreased mortality. Conditional logistic regression confirmed the association between surgical exposure and decreased mortality (adjusted odds ratio 0.82; CI 0.75-0.91; P < .001). CONCLUSIONS: Long-term ICU mortality was associated with known risk factors such as age and SAPS3. Transfer to other ICUs also appeared to be a risk factor and requires further investigation. Prior surgical exposure was associated with better outcomes, a noteworthy observation given limited ICU admissions after surgery in Sweden.

Notable Racial and Ethnic Disparities Persist in Lower Extremity Amputations for Critical Limb Ischemia and Infection.

INTRODUCTION: The purpose of this study is to investigate the current disparities for major lower extremity amputation in patients with critical limb ischemia (CLI) and infection. METHODS: A retrospective analysis of the National Surgical Quality Improvement Program's database for the years 2011 to 2017 was conducted. Multivariate models were used to isolate the effect of race and ethnicity on the likelihood of a below-knee or above-knee amputation (BKA and AKA, respectively) for CLI secondary to type 2 diabetes mellitus, atherosclerosis, peripheral vascular disease, chronic osteomyelitis, and deep soft-tissue infections. RESULTS: For all diagnoses, blacks were 93.3%, and Hispanics were 61.9% more likely to undergo a BKA than white patients (P < 0.001). In addition, black patients had a 133.0% higher risk of an AKA than white patients (P < 0.001). Disparities were greatest with blacks undergoing surgery for CLI secondary to atherosclerosis (BKA odds ratio 2.093; AKA: odds ratio 2.625). Black patients also had an elevated risk of amputation secondary to diabetes, peripheral vascular disease, and deep soft-tissue infections (P < 0.001). DISCUSSION: This nationally representative, cohort-based study demonstrates that notable racial and ethnic disparities for lower extremity amputations persist, with a higher proportion of black and Hispanic patients undergoing amputation compared with limb salvage procedures for atraumatic CLI and infection. LEVEL OF EVIDENCE: Level III prognostic.

Burden of Surgical Infections in a Tertiary-Care Pediatric Surgery Service in Uganda.

Background: Delayed presentation of surgical disease often leads to infection in low- and middle-income countries (LMICs). In addition, many primary infections require surgical intervention. The burden of infection in children's surgery in LMICs is poorly defined and may tax the limited availability of surgical resources. Methods: A prospective surgical database was reviewed for all children presenting to a Ugandan tertiary referral hospital from January 2012 to August 2016. All patients presenting with infection were included and analyzed by operative intervention and survival. Results: Of the 3,494 children admitted over the time period, 712 (20.4%) presented with infection. A total of 455 patients (64%) with an infection underwent an operation, with an in-hospital mortality rate of 12.5%. Operations involving infections represented 20% of the volume of the children's surgery department. Common conditions were abscesses (n = 308; 43.4%), typhoid intestinal perforations (n = 85; 12.0%), appendicitis (n = 78; 11.0%) and perforated bowel caused by ileocolic intussusception (n = 37; 5.2%). Patients with esophageal atresia presenting with aspiration pneumonia had an in-hospital mortality rate of 78.6%, those with abdominal sepsis a 67% mortality rate, and neonatal infants with necrotizing enterocolitis a 50% mortality rate. Conclusion: There is a high volume of infection in children requiring surgery, contributing to a high mortality rate. Resource allocation for children's surgical care in LMIC should be directed toward timely diagnosis and surgical intervention of these conditions.

Management of Chronic Infected Intra-Articular Fractures of the Proximal Tibia with Ilizarov Ring Fixation.

Infected nonunion and malunion of tibial plateau are rare injuries with no standardized protocols for treatment. This study assessed the outcome of chronic infected intra-articular proximal tibial fractures with and without metaphyseal bone loss managed with the Ilizarov ring fixator. A series of six patients of intra-articular infected nonunion of the tibial plateau and two patients with malunited plateau with metaphyseal nonunion were treated in a tertiary care hospital. Three of these eight patients had a metaphyseal bone loss or bone gap after debridement and underwent internal transport with distal corticotomy to obtain the bone length. The remaining five patients underwent static ring fixation after correction of the articular deformity. Clinical evaluation was done by Knee Society Score, Rasmussen radiological and Association for the Study and Application of Methods of Ilizarov scores. All patients but one achieved union with the ring fixator. The average follow-up was 33 months (range, 12-120 months). Average time to achieve union was 11.5 months (range, 3-30). The scores were good in four patients and poor in the rest four, out of which three had undergone internal transport. Proximal tibia intra-articular infected nonunion and malunion with or without metaphyseal bone loss can be treated successfully with the Ilizarov fixator. Malunion of the tibial plateau has to be addressed in cases with varus alignment of the limb or articular step-off of ≥ 5mm between the two tibial surfaces. Patients with associated metaphyseal bone loss tend to have complications and take a longer duration to heal. Single-stage treatment avoids intra-articular malunion and loss of limb alignment.

Absorbable Polyglactin vs. Non-Cross-linked Porcine Biological Mesh for the Surgical Treatment of Infected Incisional Hernia.

BACKGROUND: The use of absorbable meshes during contaminated or infected incisional hernia (IH) repair is associated with high morbidity and recurrence rates. Biological meshes might be more appropriate but have been described in highly heterogeneous series. This study aimed at comparing the efficacy of absorbable vs. biological meshes for the treatment of contaminated or infected IH in a homogeneous series with a standardized technique. METHODS: Data of all patients operated on between 2008 and 2015 for contaminated or infected IH, using an absorbable (A) Vicryl® or a biological (B) Strattice® mesh, were reviewed. Patient characteristics, infectious complication rates, and recurrence-free outcome (RFO) were compared between the two groups. A propensity score methodology was applied to a Cox regression model to deal with unbalanced characteristics between groups. RESULTS: Patient demographics in A (n = 57) and in B (n = 24) were similar except that B patients had larger parietal defects (p < 0.001) and higher Center for Disease Control (CDC) wound class (p = 0.034). Patients in A had statistically significantly more postoperative early (61.4% vs. 33.3%, p = 0.03) and late (31.2% vs. 8.3%, p = 0.046) infectious complications. Six-, 12-, and 36-month RFO rates were 77%, 47%, and 24%, and 96%, 87%, and 82% in A and B, respectively, p < 0.001. Raw multivariable Cox regression analysis found that B (HR = 0.1, 95% CI [0.03-0.34], p < 0.001) was independently associated with prolonged RFO (HR = 0.091, 95% CI [0.045-0.180], p < 0.001). CONCLUSION: Biological meshes seem to be superior to absorbable meshes in patients with contaminated or infected incisional hernia. These results need to be confirmed by prospective randomized trials.

Surgical outcomes of diabetic hand infections in Lagos, Nigeria.

Background: Hand infections in diabetics can be a major cause of functional impairment. In patients with Tropical Diabetic hand syndrome prompt surgical intervention may salvage the hand, but return to premorbid function remain a challenge. Objectives: A retrospective study of consecutive diabetic patients with hand infections was done in 2 tertiary institutions in Lagos, Nigeria to identify the epidemiology, modes of presentation, types of surgical intervention and outcomes of treatment. Results: Twenty one patients were studied over a 5 year period. ten males, eleven females. All were type 2 Diabetes. 52.4%(11) were diagnosed less than a year prior to presentation. 61.9%(13) had digit/hand gangrene on presentation. All operated patients (20) had wound debridements. 52.5% (11) digit/hand amputations and this was the commonest surgical procedures done. Other surgeries done include skin grafts and `flap reconstructions. There was a 19% mortality rate. Less than a fifth were able return to their premorbid occupation after 3 months. But all had reduced range of motion in the interphalangeal joints in the adjacent digits. Conclusions: There is a high morbidity rate for hand infections in the diabetic, even though majority of the hands were salvaged, most patients were unable to return to their premorbid occupation at 3 months.

Factores asociados a las complicaciones de la cirugía electiva de las hernias inguinales / Factors associated with the complications of elective surgery of inguinal hernias

Introducción: La hernia inguinal es una de las enfermedades que más comúnmente requiere tratamiento operatorio y representa entre el 10- 15 por ciento de todas las intervenciones programadas. El porcentaje de complicaciones posoperatorias es de 5- 10 por ciento y aunque no son totalmente evitables, deben conocerse sus posibles causas para lograr reducir su incidencia. Objetivo: Identificar los factores asociados a las complicaciones de la cirugía electiva de las hernias inguinales. Métodos: Se realizó un estudio observacional y descriptivo, de una serie de 246 pacientes operados de hernias inguinales mediante cirugía electiva en el servicio de Cirugía General del Hospital Provincial Docente "Saturnino Lora" de Santiago de Cuba durante el bienio 2016-2017. Resultados: Se constataron 18 complicaciones (7,3 por ciento). Predominó el grupo etario de 51 a 70 años (47,8 por ciento) y el sexo masculino sobre las féminas con razón de 15,4:1. El estado físico preoperatorio fue clasificado ASA 1 en 183 pacientes (74,4 por ciento) y ASA 2 en 62 (25,2 por ciento). El 72,2 por ciento de los complicados tenían al menos una enfermedad asociada. El tipo 2 según clasificación de Nyhus prevaleció con 73 (29,7 por ciento) y 8 (44,4 por ciento) de los complicados. Conclusiones: Los factores referentes a la edad mayor de 50 años, sexo masculino, antecedentes de hipertensión arterial y diabetes mellitus, y hernias tipo II según la clasificación de Nyhus se asocian a la presentación de complicaciones agudas (edema del cordón espermático e infección del sitio operatorio) y crónicas (recidiva y granuloma) de la cirugía electiva de las hernias inguinales(AU)

Introduction: Inguinal hernia is a common surgical treatment illness and represents 10-15 percent of the programmed surgery. The postoperative complications records are 5-10 percent, although they are not avoidable, it is mandatory to know the possible causes to decrease the incidence rate. Objective: To identify the associated factors on the complications of elective inguinal hernia surgery. Methods: An observational and descriptive study of a series of 246 patients operated on elective inguinal hernia surgery in the General Surgery Service of "Saturnino Lora" Hospital of Santiago de Cuba during the years 2016-2017. Results: There were 18 complications (7,3 percent) of the sample. The age group of 51 to 70 years (47,8 percent) predominated and the male sex over females with a ratio of 15,4:1. Preoperative physical state was classified ASA 1 in 183 patients (74,4 percent) and ASA 2 in 62 (25,2 percent). 72,2 percent of the complicated patients had at least one associated disease. Type 2 according to Nyhus classification prevailed with 73 (29,7 percent) patients of the sample, and eight (44,4 percent) of complicated patients. Conclusions: Associated factors on acute and chronic complications of elective inguinal hernia surgery related to age, sex, associated illness, preoperative physical state and type of hernia according to Nyhus classification do not differ from that reported by the national and foreign literature(AU)

Surgical configurations of the pectoralis major flap for reconstruction of sternoclavicular defects: a systematic review and new classification of described techniques.

OBJECTIVES: The pectoralis major flap has been considered the workhorse flap for chest and sternoclavicular defect reconstruction. There have been many configurations of the pectoralis major flap reported in the literature for use in reconstruction sternoclavicular defects either involving bone, soft tissue elements, or both. This study reviews the different configurations of the pectoralis major flap for sternoclavicular defect reconstruction and provides the first ever classification for these techniques. We also provide an algorithm for the selection of these flap variants for sternoclavicular defect reconstruction. METHODS: EMBASE, Cochrane library, Ovid medicine and PubMed databases were searched from its inception to August of 2019. We included all studies describing surgical management of sternoclavicular defects. The studies were reviewed, and the different configurations of the pectoralis major flap used for sternoclavicular defect reconstruction were cataloged. We then proposed a new classification system for these procedures. RESULTS: The study included 6 articles published in the English language that provided a descriptive procedure for the use of pectoralis major flap in the reconstruction of sternoclavicular defects. The procedures were classified into three broad categories. In Type 1, the whole pectoris muscle is used. In Type 2, the pectoralis muscle is split and either advanced medially (type 2a) or rotated (type 2b) to fill the defect. In type 3, the clavicular portion of the pectoralis is islandized on a pedicle, either the thoracoacromial artery (type 3a) or the deltoid branch of the thoracoacromial artery (type 3b). CONCLUSION: There are multiple configurations of the pectoralis flap reported in the English language literature for the reconstruction of sternoclavicular defects. Our classification system, the Opoku Classification will help surgeons select the appropriate configuration of the pectoralis major flap for sternoclavicular joint defect reconstruction based on size of defect, the status of the vascular anatomy, and acceptability of upper extremity disability. It will also help facilitate communication when describing the different configurations of the pectoralis major flap for reconstruction of sternoclavicular joint defects.

Risk factors for postoperative intracranial infections in patients with pituitary adenoma after endoscopic endonasal transsphenoidal surgery: pneumocephalus deserves further study.

OBJECTIVE: The authors sought to identify the relevance between pneumocephalus and postoperative intracranial infections, as well as bacteriological characteristics and risk factors for intracranial infections, in patients with pituitary adenomas after endoscopic endonasal transsphenoidal surgery. METHODS: In total, data from 251 consecutive patients with pituitary adenomas who underwent pure endoscopic endonasal transsphenoidal surgeries from 2014 to 2018 were reviewed for preoperative comorbidities, intraoperative techniques, and postoperative care. RESULTS: This retrospective study found 18 cases of postoperative pneumocephalus (7.17%), 9 CNS infections (3.59%), and 12 CSF leaks (4.78%). Of the patients with pneumocephalus, 5 (27.8%) had CNS infections. In patients with CNS infections, the culture results were positive in 7 cases and negative in 2 cases. The statistical analysis suggested that pneumocephalus (maximum bubble diameter of ≥ 1 cm), diaphragmatic defects (intraoperative CSF leak, Kelly grade ≥ 1), and a postoperative CSF leak are risk factors for postoperative CNS infections. CONCLUSIONS: In pituitary adenoma patients who underwent pure endoscopic endonasal transsphenoidal surgeries, intraoperative saddle reconstruction has a crucial role for patients with postoperative intracranial infections. Additionally, postoperative pneumocephalus plays an important role in predicting intracranial infections that must not be neglected. Therefore, neurosurgeons should pay close attention to the discovery of postoperative intracranial pneumocephalus because this factor is as important as a postoperative CSF leak. Pneumocephalus (maximum bubble diameter of ≥ 1 cm), diaphragmatic defects (an intraoperative CSF leak, Kelly grade ≥ 1), and a postoperative CSF leak were risk factors predictive of postoperative intracranial infections. In addition, it is essential that operative procedures be carefully performed to avoid diaphragmatic defects, to reduce exposure to the external environment, and to decrease patients' suffering.

Epidemiology and mortality of pediatric surgical conditions: insights from a tertiary center in Uganda.

INTRODUCTION/PURPOSE: The burden of pediatric surgical disease is largely unknown in low- and middle-income countries such as Uganda where access to care is limited. METHODS: Implementation of a locally led database in January 2012 at a Ugandan tertiary referral hospital, and review of 3465 prospectively collected pediatric surgical admissions from January 2012 to August 2016. RESULTS: 2090 children (60.3%) underwent surgery during admission. 59% were male and 41% female. 28.6% of admissions were in neonates and 50.4% were in children less than 1 year old. Congenital anomalies including Hirschsprung's, anorectal malformations, intestinal atresias, omphalocele, and gastroschisis were the most common diagnoses (38.6%) followed by infections (15.0%) and tumors (8.6%). Mortality rates were substantially higher than those of high-income countries; for example, gastroschisis and intussusception had mortality rates of 90.1% and 19.7%, respectively. Post-operative mortality was highest in the congenital anomalies group (15.0%). CONCLUSION: There is a high burden of infant congenital anomalies with higher mortality rates compared to high-income countries. The unit performs primarily specialized procedures appropriate for a tertiary center. We hope that these data will facilitate evaluation of ongoing quality improvement and capacity-building initiatives.

Operative management of clavicular malunion in midshaft clavicular fractures: a report of 59 cases.

BACKGROUND: Nonoperative management has long been the preferred treatment for clavicular fractures; however, good outcomes, particularly with a shortened and malunited clavicle, are not universal. We report on radiographic and patient-based outcomes of a patient cohort with symptomatic clavicular malunions managed with corrective osteotomy, plate fixation, and local bone graft. We hypothesized that local bone graft would be sufficient for achieving union and length of malunion time would not affect the outcome. METHOD: Over a 10-year period, 59 cases underwent operative management of symptomatic clavicular malunion. The surgical technique included osteotomy of the malunion, restoration of length, fixation with a plate, and local bone graft. The average length of time between fracture and surgery was 193.42 weeks (range, 8 weeks to 30 years). All patients were followed up postoperatively until radiographic union was achieved. Disabilities of the Arm, Shoulder and Hand scores were obtained and patients completed questionnaires to assess patient-based outcomes postoperatively. RESULTS: All 59 cases achieved union with an average time of 9.25 weeks (range, 6-38 weeks) and only required local bone graft. All patients improved postoperatively with a mean Disabilities of the Arm, Shoulder and Hand score of 1.81 (range, 0-20.68) at 12 months. In 2 patients, infection developed, requiring revision of fixation, and union was subsequently achieved. Two patients had fractures adjacent to their hardware after union was achieved. CONCLUSIONS: Corrective osteotomy with restoration of length and alignment, soft-tissue preservation, local bone graft, and plate fixation is a reliable treatment option for midshaft clavicular malunion. Union can be achieved, with good clinical outcomes independent of malunion time.

An endoscopic or minimally invasive surgical approach for infected necrotizing pancreatitis: a systematic review and meta-analysis

Background and aim: the incidence of acute pancreatitis is rising across the world, thus further increasing the burden on healthcare services. Approximately 10% of patients with acute pancreatitis will develop infected necrotizing pancreatitis (INP), which is the leading cause of high mortality in the late phase. There is currently no consensus with regard to the use of endoscopic or minimally invasive surgery as the first-line therapy of choice for INP. However, more clinical research with regard to the superiority of an endoscopic approach has been recently published. Therefore, we conducted a systematic review and meta-analysis to determine which of the two treatments leads to a better prognosis. Methods: four databases (Medline, SINOMED, EMBASE and Cochrane Library) were searched for eligible studies from 1980 to 2018, comparing endoscopic and minimally invasive surgery for INP. Results: two randomized controlled trials (RCTs) and seven clinical cohort studies were included. After the analysis of data amenable to polling, significant advantages were found in favor of the endoscopic approach in terms of pancreatic fistulas (OR = 0.10, 95% CI 0.04-0.30, p < 0.001) and the length of hospital stay (weighted mean difference [WMD] = -24.72, 95% CI = -33.87 to -15.57, p < 0.001). No marked differences were found in terms of mortality, multiple organ failure, intra-abdominal bleeding, enterocutaneous fistula, recurrence of pseudocysts, and length of stay (LOS) in the Intensive Care Unit (ICU), endocrine insufficiency and exocrine insufficiency. Conclusion: compared with minimally invasive surgery, an endoscopic approach evidently improved short-term outcomes for infected necrotizing pancreatitis, including pancreatic fistula and the length of hospital stay. Furthermore, relevant multicenter RCTs are eager to validate these findings

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Tunneled Pleural Catheters for Patients With Chronic Pleural Infection and Nonexpandable Lung.

Chronic pleural infection is characterized by thickened pleura and nonexpandable lung often requiring definitive surgical intervention, such as decortication and/or pleural obliteration procedures. Such procedures are associated with significant morbidity and require proper patient selection for a successful outcome. We report a cohort of 11 patients with pleural space infection and a nonexpandable lung treated with tunneled pleural catheters (TPCs). Following placement, hospital discharge and TPC removal occurred after a median of 5 and 36 days, respectively. Three patients presented with residual loculated effusion that resolved with instillation of intrapleural fibrinolytic therapy. One patient eventually required open window thoracostomy for ongoing pleural infection due to poor medical compliance with TPC care and drainage instructions. TPCs represent an alternative option for drainage of an infected pleural space in nonsurgical candidates with a nonexpandable lung. Their use, as a compliment to traditional treatment, may facilitate prompt hospital discharge and ambulatory management in patients with limited life expectancy.