RETRACTED: Factors Affecting Readmission After Pediatric Thyroid Resection: A National Surgical Quality Improvement Program-Pediatric Evaluation.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the authors because of an error involving the dataset which doubled the reported sample size, thereby invalidating the analysis. The authors reported this error immediately upon discovering the problem. The authors regret the error.

Comparison of Pediatric and Adult Solid Pseudopapillary Neoplasms of the Pancreas.

BACKGROUND: Solid pseudopapillary neoplasms (SPPNs) comprise the majority of pediatric pancreatic neoplasms. We queried the National Cancer Database to compare pediatric and adult patients with SSPNs to examine differences in demographics, tumor characteristics, treatment, and overall survival. We aimed to determine if survival differences existed between adult and pediatric patients with SPPN. METHODS: The National Cancer Database (2004-2014) was reviewed, and patients were stratified by age at diagnosis: pediatric (≤21 y) and adult (≥22 y). Demographics, comorbidities, tumor characteristics, diagnostic periods, treatments, and survival rates were compared using pooled variance t-tests and chi-square, followed by multivariate Cox proportional hazard model (α = 0.05). Log-rank test was used to compare survival. RESULTS: A total of 468 patients were analyzed and categorized according to age group. Four hundred and fourteen patients were included in the survival analysis. The pediatric patients were primarily female, Caucasian, had no comorbidities, and presented with stage I disease. Race/ethnicity, gender, socioeconomic status, comorbidities, and disease stage at presentation were similar between the groups. There was no difference in time to initiation of therapy or to surgical intervention. No significant difference was found in type of surgical resection, chemotherapy, or radiotherapy utilization. Despite the similarities between groups, comparison of overall survival demonstrated improved survival of pediatric SPPN compared with adult SPPN in every pathologic stage. CONCLUSIONS: These results suggest that pediatric and adult SPPNs are similar with regards to demographics, tumor characteristics, and treatment modalities. However, survival was better in children with SPPNs, which may be due to differences in tumor biology and may serve for risk stratification of prognosis.

Pancreatic islet cell tumors in adolescents and young adults.

BACKGROUND: Pancreatic islet cell tumors are rare in adolescents, and most studies published to date focus on older patients. We utilized a national database to describe the histology and clinical pattern of pancreatic islet cell tumors in adolescent and young adult (AYA) patients, and to compare AYAs to older adults. We hypothesized that AYAs with pancreatic islet cell tumors would have better overall survival. METHODS: The National Cancer Data Base (NCDB, 1998-2012) was queried for AYA patients (15-39 years) with a pancreatic islet cell tumor diagnosis. Demographics, tumor characteristics, treatment modalities, and outcomes were abstracted and compared to adults (≥40 years). RESULTS: 383 patients (56.4% female, 65% non-Hispanic Whites) were identified, with a median age of 27 (IQR 16-34) years. Islet cell carcinoma was the most common histology. Of patients with known stage of disease, 49% presented with early stage (I or II). Seventy percent of patients underwent surgical resection, including local excision 44%, Whipple procedure 37.5%, or total pancreatectomy 19%. Chemotherapy was utilized in 27% and radiotherapy in 7%. All-cause mortality was 36%. AYA patients underwent more extensive resections (p = 0.001) and had lower mortality rates (p < 0.001), with no differences in tumor stage or use of adjuvant therapies, when compared to adults. CONCLUSIONS: AYA patients with pancreatic islet cell tumors had comparable utilization of adjuvant therapies but underwent more extensive resections and demonstrated a higher overall survival rate than adult counterparts. Further investigation into approaches to earlier diagnosis and tailoring of multimodality therapy of these neoplasms in the AYA population is needed. LEVELS OF EVIDENCE: Prognostic Study, Level II - retrospective study.

Improving imaging strategies in pediatric appendicitis: a quality improvement initiative.

BACKGROUND: Data from the American College of Surgeons National Surgical Quality Improvement Program identified our hospital as an outlier for preoperative computed tomography (CT) use in the diagnosis of acute appendicitis in children. We performed a quality improvement project to reduce this utilization in favor of ultrasound-based diagnoses (ultrasonography [US]) through creation and implementation of an evidence-based appendicitis algorithm. METHODS: Over a 2-y period (1 y preceding and 1 y following institution of the algorithm), the clinical information of all pediatric patients operated on for suspicion of acute appendicitis following imaging studies in our institution was collated. Basic characteristics were compared before and after protocol implementation using the chi-square test for categorical variables and the nonparametric, independent sample test of medians for numerical variables. Imaging modalities used and clinical outcomes were compared using chi-square analysis. RESULTS: A total of 227 patients (117 preprotocol and 110 postprotocol implementation) were evaluated in our emergency department and operated on for suspicion of acute appendicitis. There were no differences in age, sex, race, or body mass index between the two periods. There were also no differences in length of stay (P = 0.27), acute and perforated appendicitis rates (P = 0.59), negative appendectomy rates (P = 0.40), or postoperative complications (P = 0.19). There was a significant reduction in the utilization of CT, from 65.8% to 22.0%, with a concurrent increase in the utilization of US (P < 0.001). CONCLUSIONS: With the implementation of a standardized, multidisciplinary algorithm, CT utilization was decreased and concurrently US utilization was increased without sacrificing diagnostic accuracy or patient outcomes.

Disparities in fertility-sparing surgery in adolescent and young women with stage I ovarian dysgerminoma.

BACKGROUND: In many cancers, racial and socioeconomic disparities exist regarding the extent of surgery. For ovarian dysgerminoma, fertility-sparing (FS) surgery is recommended whenever possible. The aim of this study was to investigate rates of FS versus non-fertility-sparing (NFS) procedures for stage I ovarian dysgerminoma in adolescents and young adults (AYAs) by ethnicity/race and socioeconomic status. MATERIALS AND METHODS: The National Cancer Data Base was queried for patients with ovarian dysgerminoma from 1998 to 2012. After selecting patients aged 15-39 y with stage I disease, a multivariate regression analysis was performed, and rates of FS and NFS procedures were compared, first according to ethnicity/race, and then by socioeconomic surrogate variables. RESULTS: Among the 687 AYAs with stage I ovarian dysgerminoma, there was no significant difference in rates of FS and NFS procedures based on ethnicity/race alone (P = 0.17), but there was a significant difference in procedure type for all three socioeconomic surrogates. The uninsured had higher NFS rates (30%) than those with government (21%) or private (19%) insurance (P = 0.036). Those in the poorest ZIP codes had almost twice the rate of NFS procedures (31%) compared with those in the most affluent ZIP codes (17%). For those in the least-educated regions, 24% underwent NFS procedures compared to 14% in the most-educated areas (P = 0.027). CONCLUSIONS: AYAs with stage I ovarian dysgerminoma in lower socioeconomic groups were more likely to undergo NFS procedures than those in higher socioeconomic groups, but there was no difference in rates of FS versus NFS procedures by ethnicity/race. Approaches aimed at reducing socioeconomic disparities require further examination.

Socioeconomic disparities affect survival in malignant ovarian germ cell tumors in AYA population.

BACKGROUND: Malignant ovarian germ cell tumors (MOGCTs) are a rare form of ovarian malignancy. Socioeconomic status (SES) has been shown to affect survival in several gynecologic cancers. We examined whether SES impacted survival in adolescent and young adults (AYAs) with MOGCT. MATERIALS AND METHODS: The National Cancer Data Base was used to identify AYAs (aged 15-39 years) with MOGCT from 1998 to 2012. Three SES surrogate variables identified were as follows: insurance type, income quartile, and education quartile. Pooled variance t-tests and chi-square tests were used to compare tumor characteristics, the time from diagnosis to staging/treatment, and clinical outcome variables for each SES surrogate variable, while controlling for age and race/ethnicity in a multivariate model. Kaplan-Meier survival estimates were calculated using the log-rank test. RESULTS: A total of 3125 AYAs with MOGCT were identified. Subjects with lower SES measures had higher overall stage and T-stage MOGCTs at presentation. There was no significant difference in the time to staging/treatment, extent of surgery, or use of chemotherapy by SES. Subjects from a lower education background, from a lower income quartile, and without insurance had decreased survival (P ≤ 0.02 for all). Controlling for overall stage and T-stage, the difference in survival was no longer significant. CONCLUSIONS: AYAs with MOGCT from lower SES backgrounds presented with more advanced stage disease. Further studies that focus on the underlying reasons for this difference are needed to address these disparities.

Testicular tumors in prepubescent patients.

BACKGROUND/PURPOSE: Pediatric testicular tumors are rare, constituting only 1% of all pediatric solid tumors. Single-institution studies addressing pediatric testicular tumors published to date have been limited in the number of patients. METHODS: We utilized the National Cancer Data Base (1998-2012) to review all prepubescent patients (≤12 years old) with testicular neoplasms. Demographics, tumor characteristics, treatment modalities, and outcomes were abstracted. RESULTS: A total of 479 patients were identified, with a median age of 3 years (IQR 0-4) at diagnosis. 67% of cases were diagnosed by 3 years of age. Yolk sac tumors were the most common histology (202 patients, 42.2%). Most tumors were diagnosed at a low stage. Resection was performed in 465 boys, with 75% having undergone radical orchiectomies. Chemotherapy was utilized in 28% of cases and radiotherapy in 7%. With mean follow-up of 5.6 years, mortality rate was 3%. No difference in mortality was noted based on histology or extent of surgical resection. CONCLUSIONS: This series of prepubertal testicular tumors is the largest yet reported and highlights the patient demographics, tumor characteristics, treatment modalities and outcomes for these tumors. TYPE OF STUDY: Prognosis study LEVEL OF EVIDENCE: II.

Effects of socioeconomic status on children with well-differentiated thyroid cancer.

BACKGROUND: Well-differentiated thyroid cancer is the most common endocrine malignancy in children. Adult literature has demonstrated socioeconomic disparities in patients undergoing thyroidectomy, but the effects of socioeconomic status on the management of pediatric well-differentiated thyroid cancer remains poorly understood. METHODS: Patients ≤21 years of age with well-differentiated thyroid cancer remains were reviewed from the National Cancer Data Base. Three socioeconomic surrogate variables were identified: insurance type, median income, and educational quartile. Tumor characteristics, diagnostic intervals, and clinical outcomes were compared within each socioeconomic surrogate variable. RESULTS: A total of 9,585 children with well-differentiated thyroid cancer remains were reviewed. In multivariate analysis, lower income, lower educational quartile, and insurance status were associated with higher stage at diagnosis. Furthermore, lower income quartile was associated with a longer time from diagnosis to treatment (P < .002). Similarly, uninsured children had a longer time from diagnosis to treatment (28 days) compared with those with government (19 days) or private (18 days) insurance (P < .001). Despite being diagnosed at a higher stage and having a longer time interval between diagnosis and treatment, there was no significant difference in either overall survival or rates of unplanned readmissions based on any of the socioeconomic surrogate variables. CONCLUSION: Children from lower income families and those lacking insurance experienced a longer period from diagnosis to treatment of their well-differentiated thyroid cancer remains. These patients also presented with higher stage disease. These data suggest a delay in care for children from low-income families. Although these findings did not translate into worse outcomes for well-differentiated thyroid cancer remains, future efforts should focus on reducing these differences.

Viscoelastic monitoring in pediatric trauma: a survey of pediatric trauma society members.

BACKGROUND: Viscoelastic monitoring (VEM), including thromboelastography (TEG) and rotational thromboelastometry (ROTEM) in the setting of goal-directed hemostatic resuscitation has been shown to improve outcomes in adult trauma. The American College of Surgeons (ACS) Committee on Trauma recommends that "thromboelastography should be available at level I and level II trauma centers". The purpose of this study is to determine the current availability and utilization of VEM in pediatric trauma. METHODS: After IRB and Pediatric Trauma Society (PTS) approval, a survey was administered to the current members of the PTS via Survey Monkey. The survey collected demographic information, hospital and trauma program type, volume of trauma admissions, and use and/or availability of VEM for pediatric trauma patients. RESULTS: We received 107 responses representing 77 unique hospitals. Survey respondents were: 61% physicians, 29% nurses, 6% trauma program managers, and 4% nurse practitioners/physician assistants. Over half of providers worked in a free standing children's hospital. Seventy-seven percent of respondents were from hospitals that had >200 trauma admissions/year, 42% were providers at ACS level 1 pediatric trauma centers, and 62% practiced at state level 1 designated centers. VEM was available to 63% of providers, but only 31% employed VEM in pediatric trauma patients. For those who had no VEM available, over 73% would utilize this technology if it was available. Seventy-one percent of providers continue to rely on conventional coagulation assays to monitor coagulopathy in pediatric trauma patients after admission. CONCLUSIONS: While a growing body of evidence demonstrates the benefit of viscoelastic hemostatic assays in management of adult traumatic injuries, VEM during active resuscitation is infrequently used by pediatric trauma providers, even when the technology is readily available. This represents a timely and unique opportunity for quality improvement in pediatric trauma.

Utilization of the NSQIP-Pediatric Database in Development and Validation of a New Predictive Model of Pediatric Postoperative Wound Complications.

BACKGROUND: Surgical wound classification, introduced in 1964, stratifies the risk of surgical site infection (SSI) based on a clinical estimate of the inoculum of bacteria encountered during the procedure. Recent literature has questioned the accuracy of predicting SSI risk based on wound classification. We hypothesized that a more specific model founded on specific patient and perioperative factors would more accurately predict the risk of SSI. STUDY DESIGN: Using all observations from the 2012 to 2014 pediatric National Surgical Quality Improvement Program-Pediatric (NSQIP-P) Participant Use File, patients were randomized into model creation and model validation datasets. Potential perioperative predictive factors were assessed with univariate analysis for each of 4 outcomes: wound dehiscence, superficial wound infection, deep wound infection, and organ space infection. A multiple logistic regression model with a step-wise backwards elimination was performed. A receiver operating characteristic curve with c-statistic was generated to assess the model discrimination for each outcome. RESULTS: A total of 183,233 patients were included. All perioperative NSQIP factors were evaluated for clinical pertinence. Of the original 43 perioperative predictive factors selected, 6 to 9 predictors for each outcome were significantly associated with postoperative SSI. The predictive accuracy level of our model compared favorably with the traditional wound classification in each outcome of interest. CONCLUSIONS: The proposed model from NSQIP-P demonstrated a significantly improved predictive ability for postoperative SSIs than the current wound classification system. This model will allow providers to more effectively counsel families and patients of these risks, and more accurately reflect true risks for individual surgical patients to hospitals and payers.

Survey on Robot-Assisted Surgical Techniques Utilization in US Pediatric Surgery Fellowships.

INTRODUCTION: Robotic technology has transformed both practice and education in many adult surgical specialties; no standardized training guidelines in pediatric surgery currently exist. The purpose of our study was to assess the prevalence of robotic procedures and extent of robotic surgery education in US pediatric surgery fellowships. MATERIALS AND METHODS: A deidentified survey measured utilization of the robot, perception on the utility of the robot, and its incorporation in training among the program directors of Accreditation Council for Graduate Medical Education (ACGME) pediatric surgery fellowships in the United States. RESULTS: Forty-one of the 47 fellowship programs (87%) responded to the survey. While 67% of respondents indicated the presence of a robot in their facility, only 26% reported its utilizing in their surgical practice. Among programs not utilizing the robot, most common reasons provided were lack of clear supportive evidence, increased intraoperative time, and incompatibility of instrument size to pediatric patients. While 58% of program directors believe that there is a future role for robotic surgery in children, only 18% indicated that robotic training should play a part in pediatric surgery education. Consequently, while over 66% of survey respondents received training in robot-assisted surgical technique, only 29% of fellows receive robot-assisted training during their fellowship. CONCLUSIONS: A majority of fellowships have access to a robot, but few utilize the technology in their current practice or as part of training. Further investigation is required into both the technology's potential benefits in the pediatric population and its role in pediatric surgery training.

Outcome assessment of renal replacement therapy in neonates.

BACKGROUND: Recent advances in renal replacement therapy (RRT) have brought about a proliferation of dialysis in neonates (<30 d). This study aimed to assess morbidity and mortality after RRT initiation in this population. METHODS: Retrospective chart review of all patients between 2006 and 2014 requiring RRT initiated in the first 30 d of life was performed. RESULTS: A total of 49 patients were identified, of which 39 were boys and 10 were girls. Thirty-two patients (65%) had end-stage renal disease, 11 (22%) had errors of metabolism, and six (12%) required RRT for other pathologies. Median age and weight at RRT onset were 6 (4-14) d and 3.1 (2.7-4.0) kg, respectively. A total of 201 surgeries were performed. Excluding catheter revisions, 83 new hemodialysis (HD) and 28 new peritoneal dialysis lines were placed, with maximum of six HD and four peritoneal catheters placed in single patient. Catheter-associated morbidities occurred in 100% of patients. Most common complications for HD included circuit clotting (87%), bleeding (68%), and bacteremia (50%). Peritoneal dialysis complications included peritonitis (83%), malpositioned catheters (72%), and leaks (55%). Overall mortality was 65.3%, with 56% of all deaths occurring within first month of life and 94% occurring within first year. Among long-term survivors (median follow-up of 5.3 y), 44% were severely and 22% moderately developmentally delayed. CONCLUSIONS: Although RRT is becoming more technically feasible for neonates with renal and metabolic diseases, it remains associated with significant morbidity and mortality. Pediatric surgeons must be aware of the challenges, taking them into account when considering the care of these critically ill children.