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Semin Pediatr Surg ; 30(5): 151099, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34635281

RESUMO

New communication technologies and generational differences in communication techniques create ethical challenges for pediatric surgeons. Using two hypothetical cases we explore the ethics of modern communication in pediatric surgery. The first case explores the ethics of text messaging with patients and families and of social media posts, both of which have useful ethical analogues in older communication technologies. The second case explores ways that generational experiential differences in learning can foster misunderstandings between team members at different levels of training and potentially impact important medical care decisions. The ethical rules that govern the delivery of patient care also apply to what we say and how we say it. Effective, ethical and compassionate communication will often be the aspect of therapy most appreciated by the patient and family.


Assuntos
Comunicação , Empatia , Idoso , Criança , Humanos
7.
J Pediatr Surg ; 56(12): 2148-2156, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34030879

RESUMO

PURPOSE: The impact of thoracoscopic surgery on outcomes in children with congenital lung malformations (CLM) remains controversial. The purpose of this study was to determine the effect of operative approach on perioperative outcomes in infants undergoing lobectomy for an asymptomatic CLM. METHODS: After IRB approval, a retrospective cohort study was conducted on 506 children with a CLM resected at one of eleven children's hospitals over a seven-year period. Infants undergoing elective lobectomy were identified, and covariates were balanced based on operative approach using propensity scores with full matching. Outcomes were analyzed based on intention to treat with weighted conditional regression. RESULTS: One hundred seventy-five infants met inclusion criteria. There were 67 (38.3%) open, 89 (50.9%) thoracoscopic, and 19 (10.9%) thoracoscopic-converted-to-open lobectomies. Thoracoscopic lobectomy was associated with significantly longer operative times (26 min, 95% CI 6-47 min, p = 0.012) but used less epidural anesthesia (OR 0.02, 95% CI 0.004-0.11, p<0.001) when compared to open lobectomy. There were no significant differences in intraoperative blood loss, postoperative complications, chest tube duration, or length of stay. CONCLUSIONS: Thoracoscopy has become the most common operative approach for elective lobectomy in infants with asymptomatic CLMs. The non-inferiority of thoracoscopic lobectomy in postoperative outcomes supports its continued use as an alternative to open lobectomy. LEVEL OF EVIDENCE: Treatment study, Level III.


Assuntos
Neoplasias Pulmonares , Pneumonectomia , Criança , Humanos , Lactente , Tempo de Internação , Pulmão/cirurgia , Neoplasias Pulmonares/cirurgia , Pontuação de Propensão , Estudos Retrospectivos , Toracoscopia , Resultado do Tratamento
8.
J Perinatol ; 41(7): 1755-1759, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34035447

RESUMO

OBJECTIVE: To provide generalizable estimates for expected outcomes of simple gastroschisis (SG) and complex gastroschisis (CG) patients from a large multi-institutional cohort for use during counseling. STUDY DESIGN: A retrospective study of 394 neonates with gastroschisis at 11 children's hospitals from January 2013 to March 2017 was performed. Analysis by Fisher's exact tests and Wilcoxon rank sum tests were performed. Outcomes of complex and simple gastroschisis are reported. RESULT: There were 315 (80%) SG and 79 (20%) CG. CG had increased time from birth to closure (6 vs 4.4 days), closure to goal feeds (69 vs 23 days), ventilator use (90% vs 73%), SSIs (31% vs 11%), NEC (14% vs 6%), PN use (71 vs 24 days), LOS (104.5 vs 33 days), and mortality (11% vs 0%). CONCLUSION: This study provides generalizable estimates for expected outcomes of patients with both SG and CG that can be utilized during counseling. CG has significantly worse in-hospital outcomes.


Assuntos
Gastrosquise , Gastrosquise/epidemiologia , Hospitais Pediátricos , Humanos , Recém-Nascido , Tempo de Internação , Motivação , Estudos Retrospectivos , Estatísticas não Paramétricas , Resultado do Tratamento
9.
J Surg Res ; 264: 309-315, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33845414

RESUMO

BACKGROUND: The objective of our study was to describe the workup, management, and outcomes of pediatric patients with breast masses undergoing operative intervention. MATERIALS AND METHODS: A retrospective cohort study was conducted of girls 10-21 y of age who underwent surgery for a breast mass across 11 children's hospitals from 2011 to 2016. Demographic and clinical characteristics were summarized. RESULTS: Four hundred and fifty-three female patients with a median age of 16 y (IQR: 3) underwent surgery for a breast mass during the study period. The most common preoperative imaging was breast ultrasound (95%); 28% reported the Breast Imaging Reporting and Data System (BI-RADS) classification. Preoperative core biopsy was performed in 12%. All patients underwent lumpectomy, most commonly due to mass size (45%) or growth (29%). The median maximum dimension of a mass on preoperative ultrasound was 2.8 cm (IQR: 1.9). Most operations were performed by pediatric surgeons (65%) and breast surgeons (25%). The most frequent pathology was fibroadenoma (75%); 3% were phyllodes. BI-RADS scoring ≥4 on breast ultrasound had a sensitivity of 0% and a negative predictive value of 93% for identifying phyllodes tumors. CONCLUSIONS: Most pediatric breast masses are self-identified and benign. BI-RADS classification based on ultrasound was not consistently assigned and had little clinical utility for identifying phyllodes.


Assuntos
Neoplasias da Mama/terapia , Fibroadenoma/terapia , Mastectomia Segmentar/estatística & dados numéricos , Tumor Filoide/terapia , Conduta Expectante/estatística & dados numéricos , Adolescente , Biópsia com Agulha de Grande Calibre , Mama/diagnóstico por imagem , Mama/patologia , Mama/cirurgia , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/patologia , Criança , Tomada de Decisão Clínica/métodos , Diagnóstico Diferencial , Autoavaliação Diagnóstica , Estudos de Viabilidade , Feminino , Fibroadenoma/diagnóstico , Fibroadenoma/patologia , Humanos , Mastectomia Segmentar/normas , Tumor Filoide/diagnóstico , Tumor Filoide/patologia , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Ultrassonografia Mamária , Conduta Expectante/normas , Adulto Jovem
10.
J Surg Res ; 263: 110-115, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33647800

RESUMO

BACKGROUND: Management of ovarian torsion has evolved toward ovarian preservation regardless of ovarian appearance during surgery. However, patients with torsion and an ovarian neoplasm undergo a disproportionately high rate of oophorectomy. Our objectives were to identify factors associated with ovarian torsion among females with an ovarian mass and to determine if torsion is associated with malignancy. METHODS: A retrospective review of females aged 2-21 y who underwent an operation for an ovarian cyst or neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariate logistic regression was used to assess factors associated with torsion. Imaging data were assessed for sensitivity, specificity, and predictive value in identifying ovarian torsion. RESULTS: Of 814 girls with an ovarian neoplasm, 180 (22%) had torsion. In risk-adjusted analyses, patients with a younger age, mass size >5 cm, abdominal pain, and vomiting had an increased likelihood of torsion (P < 0.01 for all). Patients with a mass >5 cm had two times the odds of torsion (odds ratio: 2.1; confidence interval: 1.2, 3.6). Imaging was not reliable at identifying torsion (sensitivity 34%, positive predictive value 49%) or excluding torsion (specificity 72%, negative predictive value 87%). The rates of malignancy were lower in those with an ovarian mass and torsion than those without torsion (10% versus 17%, P = 0.01). Among the 180 girls with torsion and a mass, 48% underwent oophorectomy of which 14% (n = 12) had a malignancy. CONCLUSIONS: In females with an ovarian neoplasm, torsion is not associated with an increased risk of malignancy and ovarian preservation should be considered.


Assuntos
Cistadenoma/epidemiologia , Cistos Ovarianos/epidemiologia , Neoplasias Ovarianas/epidemiologia , Torção Ovariana/epidemiologia , Teratoma/epidemiologia , Adolescente , Criança , Pré-Escolar , Cistadenoma/complicações , Cistadenoma/diagnóstico , Cistadenoma/cirurgia , Diagnóstico Diferencial , Feminino , Humanos , Tratamentos com Preservação do Órgão/estatística & dados numéricos , Cistos Ovarianos/complicações , Cistos Ovarianos/diagnóstico , Cistos Ovarianos/cirurgia , Neoplasias Ovarianas/complicações , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/cirurgia , Torção Ovariana/etiologia , Torção Ovariana/patologia , Torção Ovariana/cirurgia , Ovariectomia/estatística & dados numéricos , Ovário/diagnóstico por imagem , Ovário/patologia , Ovário/cirurgia , Estudos Retrospectivos , Fatores de Risco , Teratoma/complicações , Teratoma/diagnóstico , Teratoma/cirurgia , Tomografia Computadorizada por Raios X , Ultrassonografia , Adulto Jovem
11.
Pediatrics ; 147(4)2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33762310

RESUMO

BACKGROUND: Pediatric lung lesions are a group of mostly benign pulmonary anomalies with a broad spectrum of clinical disease and histopathology. Our objective was to evaluate the characteristics of children undergoing resection of a primary lung lesion and to identify preoperative risk factors for malignancy. METHODS: A retrospective cohort study was conducted by using an operative database of 521 primary lung lesions managed at 11 children's hospitals in the United States. Multivariable logistic regression was used to examine the relationship between preoperative characteristics and risk of malignancy, including pleuropulmonary blastoma (PPB). RESULTS: None of the 344 prenatally diagnosed lesions had malignant pathology (P < .0001). Among 177 children without a history of prenatal detection, 15 (8.7%) were classified as having a malignant tumor (type 1 PPB, n = 11; other PPB, n = 3; adenocarcinoma, n = 1) at a median age of 20.7 months (interquartile range, 7.9-58.1). Malignancy was associated with the DICER1 mutation in 8 (57%) PPB cases. No malignant lesion had a systemic feeding vessel (P = .0427). The sensitivity of preoperative chest computed tomography (CT) for detecting malignant pathology was 33.3% (95% confidence interval [CI]: 15.2-58.3). Multivariable logistic regression revealed that increased suspicion of malignancy by CT and bilateral disease were significant predictors of malignant pathology (odds ratios of 42.15 [95% CI, 7.43-340.3; P < .0001] and 42.03 [95% CI, 3.51-995.6; P = .0041], respectively). CONCLUSIONS: In pediatric lung masses initially diagnosed after birth, the risk of PPB approached 10%. These results strongly caution against routine nonoperative management in this patient population. DICER1 testing may be helpful given the poor sensitivity of CT for identifying malignant pathology.


Assuntos
Neoplasias Pulmonares/patologia , Blastoma Pulmonar/patologia , Pré-Escolar , Estudos de Coortes , RNA Helicases DEAD-box/genética , Feminino , Humanos , Lactente , Recém-Nascido , Tempo de Internação , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/genética , Neoplasias Pulmonares/cirurgia , Mutação , Metástase Neoplásica/genética , Gravidez , Diagnóstico Pré-Natal , Blastoma Pulmonar/diagnóstico por imagem , Blastoma Pulmonar/genética , Blastoma Pulmonar/cirurgia , Síndrome do Desconforto Respiratório do Recém-Nascido/etiologia , Estudos Retrospectivos , Ribonuclease III/genética , Tomografia Computadorizada por Raios X
12.
Prehosp Emerg Care ; 25(4): 588-592, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32776812

RESUMO

The American College of Surgeons Committee on Trauma (ACS-COT), the American College of Emergency Physicians (ACEP), the National Association of State EMS Officials (NASEMSO), the National Association of EMS Physicians (NAEMSP) and the National Association of EMTs (NAEMT) have previously offered varied guidance on the use of ketamine in trauma patients. The following consensus statement represents the collective positions of the ACS-COT, ACEP, NASEMSO, NAEMSP and NAEMT. This updated uniform guidance is intended for use by emergency medical services (EMS) personnel, EMS medical directors, emergency physicians, trauma surgeons, nurses and pharmacists in their treatment of the trauma patient in both the prehospital and hospital setting.


Assuntos
Serviços Médicos de Emergência , Ketamina , Consenso , Serviço Hospitalar de Emergência , Hospitais , Humanos
13.
J Pediatr Surg ; 56(1): 47-54, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33131776

RESUMO

BACKGROUND/PURPOSE: This study evaluated compliance with a multi-institutional quality improvement management protocol for Type-C esophageal atresia with distal tracheoesophageal fistula (EA/TEF). METHODS: Compliance and outcomes before and after implementation of a perioperative protocol bundle for infants undergoing Type-C EA/TEF repair were compared across 11 children's hospitals from 1/2016-1/2019. Bundle components included elimination of prosthetic material between tracheal and esophageal suture lines during repair, not leaving a transanastomotic tube at the conclusion of repair (NO-TUBE), obtaining an esophagram by postoperative-day-5, and discontinuing prophylactic antibiotics 24 h postoperatively. RESULTS: One-hundred seventy patients were included, 40% pre-protocol and 60% post-protocol. Bundle compliance increased 2.5-fold pre- to post-protocol from 17.6% to 44.1% (p < 0.001). After stratifying by institutional compliance with all bundle components, 43.5% of patients were treated at low-compliance centers (<20%), 43% at medium-compliance centers (20-80%), and 13.5% at high-compliance centers (>80%). Rates of esophageal leak, anastomotic stricture, and time to full feeds did not differ between pre- and post-protocol cohorts, though there was an inverse correlation between NO-TUBE compliance and stricture rate over time (ρ = -0.75, p = 0.029). CONCLUSIONS: Compliance with our multi-institutional management protocol increased 2.5-fold over the study period without compromising safety or time to feeds and does not support the use of transanastomotic tubes. LEVEL OF EVIDENCE: Level II. TYPE OF STUDY: Treatment Study.


Assuntos
Atresia Esofágica , Fístula Traqueoesofágica , Criança , Atresia Esofágica/complicações , Atresia Esofágica/cirurgia , Humanos , Lactente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Fístula Traqueoesofágica/complicações , Fístula Traqueoesofágica/cirurgia , Resultado do Tratamento
14.
Eur J Pediatr Surg ; 2020 Dec 27.
Artigo em Inglês | MEDLINE | ID: mdl-33368085

RESUMO

INTRODUCTION: Gastroschisis feeding practices vary. Standardized neonatal feeding protocols have been demonstrated to improve nutritional outcomes. We report outcomes of infants with gastroschisis that were fed with and without a protocol. MATERIALS AND METHODS: A retrospective study of neonates with uncomplicated gastroschisis at 11 children's hospitals from 2013 to 2016 was performed.Outcomes of infants fed via institutional-specific protocols were compared with those fed without a protocol. Subgroup analyses of protocol use with immediate versus delayed closure and with sutured versus sutureless closure were conducted. RESULTS: Among 315 neonates, protocol-based feeding was utilized in 204 (65%) while no feeding protocol was used in 111 (35%). There were less surgical site infections (SSI) in those fed with a protocol (7 vs. 16%, p = 0.019). There were no differences in TPN duration, time to initial oral intake, time to goal feeds, ventilator use, peripherally inserted central catheter line deep venous thromboses, or length of stay. Of those fed via protocol, less SSIs occurred in those who underwent sutured closure (9 vs. 19%, p = 0.026). Further analyses based on closure timing or closure method did not demonstrate any significant differences. CONCLUSION: Across this multi-institutional cohort of infants with uncomplicated gastroschisis, there were more SSIs in those fed without an institutional-based feeding protocol but no differences in other outcomes.

15.
Ann Surg ; 2020 Nov 17.
Artigo em Inglês | MEDLINE | ID: mdl-33214447

RESUMO

OBJECTIVE: To assess current clinical outcomes in children with prenatally diagnosed congenital lung malformations (CLMs) and to identify prenatal characteristics associated with adverse outcomes. SUMMARY BACKGROUND DATA: Despite a wide spectrum of clinical disease, the identification of fetal CLM subgroups at increased risk for hydrops and respiratory compromise at delivery have not been well defined. METHODS: A retrospective cohort study was conducted using an operative database of prenatally diagnosed CLMs managed at eleven children's hospitals from 2009-2016. Statistical analyses were performed using non-parametric bivariate or multivariable logistic regression. RESULTS: Three hundred forty-four children were analyzed. Fifteen (5.5%) fetuses were managed with maternal steroids in the setting of hydrops, and prenatal surgical intervention was uncommon (1.7%). Seventy-five (21.8%) had respiratory symptoms at birth, and 34 (10.0%) required neonatal lung resection. Congenital pulmonary airway malformation volume ratio (CVR) measurements were recorded in 169 (49.1%) cases and were significantly associated with perinatal outcome, including hydrops, respiratory distress at birth, need for supplemental oxygen, neonatal ventilator use, and neonatal resection (p < 0.001). An initial CVR ≤ 1.4 was significantly correlated with a reduced risk for hydrops [area under the curve (AUC), 0.93; 95% confidence interval (CI), 0.87-1.00]. A maximum CVR < 0.9 (AUC, 0.72; 95% CI, 0.67-0.85) was associated with a low risk for respiratory symptoms at birth. CONCLUSION: In this large, multi-institutional study, an initial CVR ≤ 1.4 identifies fetuses at very low risk for hydrops, and a maximum CVR < 0.9 is associated with asymptomatic disease at birth. These findings represent an opportunity for standardization and quality improvement for prenatal counseling and delivery planning.

16.
JAMA ; 324(6): 581-593, 2020 08 11.
Artigo em Inglês | MEDLINE | ID: mdl-32730561

RESUMO

Importance: Nonoperative management with antibiotics alone has the potential to treat uncomplicated pediatric appendicitis with fewer disability days than surgery. Objective: To determine the success rate of nonoperative management and compare differences in treatment-related disability, satisfaction, health-related quality of life, and complications between nonoperative management and surgery in children with uncomplicated appendicitis. Design, Setting, and Participants: Multi-institutional nonrandomized controlled intervention study of 1068 children aged 7 through 17 years with uncomplicated appendicitis treated at 10 tertiary children's hospitals across 7 US states between May 2015 and October 2018 with 1-year follow-up through October 2019. Of the 1209 eligible patients approached, 1068 enrolled in the study. Interventions: Patient and family selection of nonoperative management with antibiotics alone (nonoperative group, n = 370) or urgent (≤12 hours of admission) laparoscopic appendectomy (surgery group, n = 698). Main Outcomes and Measures: The 2 primary outcomes assessed at 1 year were disability days, defined as the total number of days the child was not able to participate in all of his/her normal activities secondary to appendicitis-related care (expected difference, 5 days), and success rate of nonoperative management, defined as the proportion of patients initially managed nonoperatively who did not undergo appendectomy by 1 year (lowest acceptable success rate, ≥70%). Inverse probability of treatment weighting (IPTW) was used to adjust for differences between treatment groups for all outcome assessments. Results: Among 1068 patients who were enrolled (median age, 12.4 years; 38% girls), 370 (35%) chose nonoperative management and 698 (65%) chose surgery. A total of 806 (75%) had complete follow-up: 284 (77%) in the nonoperative group; 522 (75%) in the surgery group. Patients in the nonoperative group were more often younger (median age, 12.3 years vs 12.5 years), Black (9.6% vs 4.9%) or other race (14.6% vs 8.7%), had caregivers with a bachelor's degree (29.8% vs 23.5%), and underwent diagnostic ultrasound (79.7% vs 74.5%). After IPTW, the success rate of nonoperative management at 1 year was 67.1% (96% CI, 61.5%-72.31%; P = .86). Nonoperative management was associated with significantly fewer patient disability days at 1 year than did surgery (adjusted mean, 6.6 vs 10.9 days; mean difference, -4.3 days (99% CI, -6.17 to -2.43; P < .001). Of 16 other prespecified secondary end points, 10 showed no significant difference. Conclusion and Relevance: Among children with uncomplicated appendicitis, an initial nonoperative management strategy with antibiotics alone had a success rate of 67.1% and, compared with urgent surgery, was associated with statistically significantly fewer disability days at 1 year. However, there was substantial loss to follow-up, the comparison with the prespecified threshold for an acceptable success rate of nonoperative management was not statistically significant, and the hypothesized difference in disability days was not met. Trial Registration: ClinicalTrials.gov Identifier: NCT02271932.


Assuntos
Antibacterianos/uso terapêutico , Apendicectomia , Apendicite/tratamento farmacológico , Apendicite/cirurgia , Doença Aguda , Adolescente , Apendicectomia/métodos , Apendicite/diagnóstico por imagem , Apêndice/diagnóstico por imagem , Criança , Feminino , Seguimentos , Humanos , Laparoscopia , Masculino , Pontuação de Propensão , Qualidade de Vida , Viés de Seleção , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Ultrassonografia
17.
J Pediatr Surg ; 55(12): 2746-2751, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32595036

RESUMO

BACKGROUND: The social vulnerability index (SVI) is used to assess resilience to external influences that may affect human health. Social vulnerability has been noted to be a barrier to healthcare access for pediatric patients. We hypothesized that Pennsylvania (PA) pediatric trauma patients high on the social vulnerability index would have significantly lower rates of rehab admission following admission to a hospital for traumatic injury. METHODS: The SVI was determined for each PA zip code area utilizing the census tract based 2014 SVI provided by the CDC along with a weighted crosswalk between census tracts and zip code areas using the Housing and Urban Development zip code crosswalk files. The rate of the uninsured population was extracted from the CDC SVI files in addition to other US Census variables based upon estimates from the 2014 American Community Survey (ACS). We also included the individual primary payer status of each subject. Pediatric (age <15 years) trauma admissions with in-hospital mortality excluded, were extracted from the PA Healthcare Cost Containment Council (PHC4) for all hospital admissions for the period of 2003-2015 (n = 63,545). Complete case analysis was conducted based upon the final model providing a sample of 52,794. Cases were coded as rehab patients based upon discharge status (n = 603; 1.1%). A multi-level logistic model was used to determine if subjects had a higher odds of being discharged to rehab based on SVI, undertriage rates of their zip code area of residence and their own primary payer status; this was adjusted for age, multi-system injury and a head, chest or abdomen injury with abbreviate injury scale (AIS) severity > = 3. RESULTS: SVI and undertriage rates of the zip code areas of residence were not significantly associated with admission to rehab. The individual primary payer status of the subject was significantly associated with admission to rehab (OR 95%CI vs. self/uninsured; Medicaid 3.65 1.84-7.24; Commercial = 3.09 1.56-6.11; other/unknown = 2.85 1.02-7.93). Admission to rehab was also significantly associated with age, injury severity (ISS), head or chest injury with AIS scores > = 3, year of admission and hospital type. CONCLUSION: Individual patient level factors (primary payer of patient) may be associated with the odds of rehab admission rather than neighborhood factors. LEVEL OF EVIDENCE: Epidemiologic: Level III.


Assuntos
Traumatismo Múltiplo , Centros de Traumatologia , Adolescente , Criança , Humanos , Escala de Gravidade do Ferimento , Pessoas sem Cobertura de Seguro de Saúde , Pennsylvania/epidemiologia , Características de Residência , Estados Unidos
18.
J Pediatr Surg ; 55(11): 2284-2288, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32151403

RESUMO

PURPOSE: To report outcomes of sutured and sutureless closure for gastroschisis across a large multi-institutional cohort. METHODS: A retrospective study of infants with uncomplicated gastroschisis at 11 children's from 2014 to 2016 was performed. Outcomes of sutured and sutureless abdominal wall closure were compared. RESULTS: Among 315 neonates with uncomplicated gastroschisis, sutured closure was performed in 248 (79%); 212 undergoing sutured closure after silo and 36 undergoing primary sutured closure. Sutureless closure was performed in 67 (21%); 37 primary sutureless closure, 30 sutureless closure after silo placement. There was no significant difference in gestational age, gender, birth weight, total days on TPN, and time from closure to initial oral intake or goal feeds. Sutureless closure patients had less general anesthetics, ventilator use/time, time from birth to final closure, antibiotic use after closure, and surgical site/deep space infections. Subgroup analysis demonstrated primary sutureless closure had less ventilator use and anesthetics than primary sutured closure. Sutureless closure after silo led to less ventilator use/time, anesthetics, and antibiotics compared to those with sutured closure after silo. CONCLUSION: Sutureless abdominal wall closure of neonates with gastroschisis was associated with less general anesthetics, antibiotic use, surgical site/deep space infections, and decreased ventilator time. These findings support further prospective study by our group. LEVEL OF EVIDENCE: Level III.


Assuntos
Parede Abdominal , Gastrosquise , Procedimentos Cirúrgicos sem Sutura , Suturas , Técnicas de Fechamento de Ferimentos/instrumentação , Parede Abdominal/cirurgia , Gastrosquise/cirurgia , Humanos , Recém-Nascido , Estudos Prospectivos , Estudos Retrospectivos , Resultado do Tratamento
19.
Pediatrics ; 145(3)2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32071259

RESUMO

Many cancers presenting in children and adolescents are curable with surgery, chemotherapy, and/or radiotherapy. Potential adverse consequences of treatment include sterility, infertility, or subfertility as a result of gonad removal, damage to germ cells as a result of adjuvant therapy, or damage to the pituitary and hypothalamus or uterus as a result of irradiation. In recent years, treatment of solid tumors and hematologic malignancies has been modified in an attempt to reduce damage to the gonadal axis. Simultaneously, advances in assisted reproductive technology have led to new possibilities for the prevention and treatment of infertility. This clinical report reviews the medical aspects and ethical considerations that arise when considering fertility preservation in pediatric and adolescent patients with cancer.


Assuntos
Sobreviventes de Câncer , Preservação da Fertilidade , Infertilidade/etiologia , Neoplasias/terapia , Adolescente , Antineoplásicos/efeitos adversos , Criança , Aconselhamento , Criopreservação , Preservação da Fertilidade/ética , Humanos , Cobertura do Seguro , Seguro Saúde , Masculino , Oócitos/citologia , Radioterapia/efeitos adversos , Espermatozoides
20.
J Pediatr Surg ; 55(1): 122-125, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31677824

RESUMO

PURPOSE: The purpose of this study was to determine the diagnostic accuracy of tumor markers for malignancy in girls with ovarian neoplasms. METHODS: A retrospective review of girls 2-21 years who presented for surgical management of an ovarian neoplasm across 10 children's hospitals between 2010 and 2016 was performed. Patients who had at least one concerning feature on imaging and had tumor marker testing were included in the study. Sensitivity, specificity, and negative and positive predictive values (PPV) of tumor markers were calculated. RESULTS: Our cohort included 401 patients; 22.4% had a malignancy. Testing for tumor markers was inconsistent. AFP had high specificity (98%) and low sensitivity (42%) with a PPV of 86%. The sensitivity, specificity, and PPV of beta-hCG was 44%, 76%, and 32%, respectively. LDH had high sensitivity (95%) and Inhibin A and Inhibin B had high specificity (97% and 92%, respectively). CONCLUSIONS: Tumor marker testing is helpful in preoperative risk stratification of ovarian neoplasms for malignancy. Given the variety of potential tumor types, no single marker provides enough reliability, and therefore a panel of tumor marker testing is recommended if there is concern for malignancy. Prospective studies may help further elucidate the predictive value of tumor markers in a pediatric ovarian neoplasm population. TYPE OF STUDY: Retrospective Cohort Review. LEVEL OF EVIDENCE: Level III.


Assuntos
Biomarcadores Tumorais/sangue , Gonadotropina Coriônica Humana Subunidade beta/sangue , L-Lactato Desidrogenase/sangue , Neoplasias Ovarianas/sangue , Neoplasias Ovarianas/diagnóstico , alfa-Fetoproteínas/metabolismo , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Inibinas/sangue , Neoplasias Ovarianas/cirurgia , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Adulto Jovem
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