Postoperative opioid analgesic use after Nuss versus Ravitch pectus excavatum repair.

BACKGROUND/PURPOSE: Anticipated postoperative pain may affect procedure choice in patients with pectus excavatum. This study aims to compare postoperative pain in patients undergoing Nuss and Ravitch procedures. METHODS: A 5year retrospective review was performed. Data on age, gender, Haller index, procedure, pain scores, pain medications, and length of hospital stay were collected. Total inpatient opioid administration was converted to morphine equivalent daily dose per kilogram (MEDD/kg) and compared between procedures. RESULTS: One hundred eighty-one patients underwent 125 (69%) Nuss and 56 (31%) Ravitch procedures. Ravitch patients were older (15.7 yo vs 14.6 yo, p=0.004) and had a higher Haller index (5.21 vs 4.10, p=<0.001). Nuss patients had higher average daily pain scores, received 25% more opioids (MEDD/kg 0.66 vs. 0.49, p=<0.001), and received twice as much IV diazepam/kg. In the multivariate analysis, higher MEDD/kg correlated with both the Nuss procedure and older age in the Nuss group. Opioid administration did not correlate with Haller index or Nuss bar fixation technique. Increased NSAID administration did not correlate with lower use of opioids. CONCLUSION: The Nuss procedure is associated with greater postoperative pain compared to the Ravitch procedure. Opioid use is higher in older patients undergoing the Nuss procedure, but is not associated with severity of deformity.

Management of neonatal ovarian cysts and its effect on ovarian preservation.

BACKGROUND/PURPOSE: Management of asymptomatic neonatal ovarian cysts varies. Some surgeons advocate initial observation, while others recommend immediate operation depending on cyst size and complexity. This study aims to compare outcomes of initial observation versus primary surgery, focusing on incidence of postnatal torsion and ovarian preservation. METHODS: A retrospective study (1997-2012) of neonates with an ovarian mass was performed. Data on cyst size, ultrasound characteristics, clinical course, complications, and pathology were extracted. RESULTS: Thirty-seven neonates with asymptomatic ovarian cysts were identified (N=25 observed, N=12 primary surgery). Overall, 12/25 (48%) observed had successful cyst regression, including 3/8 (38%) cysts ≥50mm and 6/15 (40%) complex. 13/25 patients (52%) underwent surgery for failure of cyst regression (11/13) or concern for interval torsion (2/13). Postnatal torsion occurred in 1/25 observation patients (4%), or 1/8 (13%) with cysts≥50mm. Overall rate of ovarian preservation between groups was not statistically different [6/8 (75%) observed versus 8/9 (89%) primary surgery; P=0.577]. Pathology found viable ovarian tissue in all oophorectomy specimens (N=3). CONCLUSIONS: Postnatal torsion is rare. A period of observation spares half of neonates from an operation, without decreasing ovarian salvage. Initial management should consist of observation, regardless of size or complex characteristics. If operative intervention is necessary, ovary preserving techniques should be utilized.

Referring physicians' decision making for pediatric anti-reflux procedures.

BACKGROUND: Rates of anti-reflux procedures (ARP) vary greatly among pediatric hospitals. How pediatric subspecialists make referral decisions for ARPs has not been described. The aim of this study was to characterize pediatric subspecialists' decision making for referring children for ARPs. METHODS: Pediatric subspecialists at a single children's hospital were interviewed about their decision making when referring for ARPs. Qualitative analysis was performed on clinicians' perceptions of the risks and benefits of the treatment options. Clinical algorithms were derived from each interview and were compared using the Clinical Algorithm Nosology. Clinical Algorithm Structural Analysis (CASA) scores were calculated to assess algorithm complexity. Clinical Algorithm Patient Abstraction (CAPA) scores on a scale from 0 (different) to 10 (identical) were generated based on algorithm agreement. RESULTS: The interviews yielded 15 algorithms. There was substantial variation in the providers' perceived risks and benefits of the treatment options. CASA scores ranged from 8 to 28 and CAPA scores ranged from 0 to 5.7 (median, 0), indicating great variation in both complexity and patient management. Management variation included testing (33% of algorithms incorporated pH probe test, 67% upper gastrointestinal, and 47% small bowel follow-through), procedure contraindications (33% considered history of gagging a contraindication to ARP), and use of gastrojejunostomy tubes (20% using gastrojejunostomy tube before ARP). CONCLUSION: No standards exist for the decision to refer children with gastroesophageal reflux disease for ARP. There is great variation among pediatric subspecialists in their decision making. Differences in providers' perception of the risks and benefits of these procedures contribute to this variation.

Predictors of ovarian malignancy in children: overcoming clinical barriers of ovarian preservation.

BACKGROUND/PURPOSE: Ovarian preservation is desirable in girls with benign ovarian masses. We aimed to 1) identify clinical predictors of malignant ovarian masses, 2) investigate how often ovarian tissue is present to preserve in benign masses, and 3) identify factors associated with successful ovarian preservation. METHODS: Retrospective analysis (1997-2012) of girls age 1-18years with an ovarian mass managed operatively. Data on presenting symptoms, imaging, biochemical markers, treatment, outcome, and pathology were extracted. RESULTS: We identified 150 patients. Large mass size, solid components, and elevated tumor markers (AFP, ßHCG, and/or LDH) were significantly predictive of malignancy. All masses <10cm, predominantly cystic, and with negative tumor markers were benign. Masses with all three of these characteristics would decrease a 20% malignancy pretest probability to a posttest probability of 0.25%. Benign masses managed by oophorectomy contained normal ovarian tissue in 76% of the specimens. For benign masses, successful ovarian preservation was significantly associated with size <10cm, predominantly cystic, laparoscopy, and absence of torsion or calcifications. CONCLUSION: Ovarian masses that are <10cm, primarily cystic, and have negative tumor markers are most likely benign. Viable ovarian tissue is frequently present in benign masses, so significant efforts should be made for ovarian preservation.

Movement-evoked hyperalgesia induced by lipopolysaccharides is not suppressed by glucocorticoids.

Systemic exposure to lipopolysaccharides (LPS) produces a variety of effects, including movement-evoked hyperalgesia that can be measured using the grip force assay in mice. Because both lethality and enhanced sensitivity to cutaneous pain following exposure to endotoxins have each been attributed to inflammatory mediators, we explored the possibility that LPS-induced movement-evoked hyperalgesia is also sensitive to manipulations of glucocorticoids that regulate these other LPS responses. We found that the hyperalgesic effect of LPS (5mg/kg s.c.) in mice that were adrenalectomized did not differ from that in control mice that were sham operated, even though mortality after LPS was potentiated by adrenalectomy. The development of tolerance to the movement-evoked hyperalgesic effect of LPS also did not differ between adrenalectomized and sham-operated control mice. In addition, mifepristone (25mg/kg s.c.), a glucocorticoid antagonist, did not attenuate the hyperalgesic effect of LPS (2mg/kg s.c.), yet this dose of mifepristone was sufficient to enhance the incidence of lethality induced by LPS. Enhancement of glucocorticoid activity by two injections of dexamethasone (1mg/kg s.c.) had no effect on the degree of hyperalgesia in mice injected with LPS (5mg/kg s.c.), yet this dose of dexamethasone was sufficient to attenuate the incidence of mortality induced by LPS in adrenalectomized mice. Finally, morphine (10mg/kg i.p.) reversed the decrease in grip force caused by LPS (5mg/kg i.p.), supporting the interpretation that decreases in grip force produced by LPS reflect muscle hyperalgesia that is not sensitive to glucocorticoids.