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OBJECTIVE: To compare early outcomes and 24-hour survival after LVR with the novel polyethylene glycol-20k-based crystalloid (PEG-20k), WB, or hextend in a preclinical model of lethal HS. BACKGROUND: Posttraumatic HS is a major cause of preventable death. current resuscitation strategies focus on restoring oxygen-carrying capacity (OCC) and coagulation with blood products. Our lab shows that PEG-20k is an effective non-sanguineous, LVR solution in acute models of HS through mechanisms targeting cell swelling-induced microcirculatory failure. METHODS: Male pigs underwent splenectomy followed by controlled hemorrhage until lactate reached 7.5-8.5âmmol/L. They were randomized to receive LVR with PEG-20k, WB, or Hextend. Surviving animals were recovered 4âhours post-LVR. Outcomes included 24-hour survival rates, mean arterial pressure, lactate, hemoglobin, and estimated intravascular volume changes. RESULTS: Twenty-four-hour survival rates were 100%, 16.7%, and 0% in the PEG-20k, WB, and Hextend groups, respectively (P= 0.001). PEG-20k significantly restored mean arterial press, intravascular volume, and capillary perfusion to baseline, compared to other groups. This caused complete lactate clearance despite decreased OCC. Neurological function was normal after next-day recovery in PEG-20k resuscitated pigs. CONCLUSION: Superior early and 24-hour outcomes were observed with PEG-20k LVR compared to WB and Hextend in a preclinical porcine model of lethal HS, despite decreased OCC from substantial volume-expansion. These findings demonstrate the importance of enhancing microcirculatory perfusion in early resuscitation strategies.
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Choque Hemorrágico , Animais , Modelos Animais de Doenças , Humanos , Lactatos/farmacologia , Masculino , Microcirculação , Polietilenoglicóis/farmacologia , Polietilenoglicóis/uso terapêutico , Ressuscitação , Choque Hemorrágico/terapia , SuínosRESUMO
INTRODUCTION: Institutions have reported decreases in operative volume due to COVID-19. Junior residents have fewer opportunities for operative experience and COVID-19 further jeopardizes their operative exposure. This study quantifies the impact of the COVID-19 pandemic on resident operative exposure using resident case logs focusing on junior residents and categorizes the response of surgical residency programs to the COVID-19 pandemic. MATERIALS AND METHODS: A retrospective multicenter cohort study was conducted; 276,481 case logs were collected from 407 general surgery residents of 18 participating institutions, spanning 2016-2020. Characteristics of each institution and program changes in response to COVID-19 were collected via surveys. RESULTS: Senior residents performed 117 more cases than junior residents each year (P < 0.001). Prior to the pandemic, senior resident case volume increased each year (38 per year, 95% confidence interval 2.9-74.9) while junior resident case volume remained stagnant (95% confidence interval 13.7-22.0). Early in the COVID-19 pandemic, junior residents reported on average 11% fewer cases when compared to the three prior academic years (P = 0.001). The largest decreases in cases were those with higher resident autonomy (Surgeon Jr, P = 0.03). The greatest impact of COVID-19 on junior resident case volume was in community-based medical centers (246 prepandemic versus 216 during pandemic, P = 0.009) and institutions which reached Stage 3 Program Pandemic Status (P = 0.01). CONCLUSIONS: Residents reported a significant decrease in operative volume during the 2019 academic year, disproportionately impacting junior residents. The long-term consequences of COVID-19 on junior surgical trainee competence and ability to reach cases requirements are yet unknown but are unlikely to be negligible.
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COVID-19 , Cirurgia Geral , Internato e Residência , COVID-19/epidemiologia , Competência Clínica , Estudos de Coortes , Educação de Pós-Graduação em Medicina , Cirurgia Geral/educação , Humanos , PandemiasRESUMO
BACKGROUND: Neonates born in low- and middle-income countries (LMICs) with esophageal atresia (EA) and tracheoesophageal fistula (TEF) often do not have access to adequate surgical care. We have partnered with the non-profit organization World Pediatric Project (WPP) to facilitate care for such patients. METHODS: Our protocol included placement of a gastrostomy tube by local surgeons before definitive repair at the Children's Hospital of Richmond at VCU (CHoR). The outcomes of WPP-sponsored patients with EA and TEF in this program (n = 9) were compared to patients born in the U.S. with the same condition at CHoR (n = 9). RESULTS: The baseline characteristics of the groups aside from the age at admission to CHoR and at day of surgery were comparable (0.5 ± 1.3 days vs. 15.3 ± 11.1 days, p < 0.0001; 1.1 ± 3.9 days vs. 37.3 ± 8.3 days, p < 0.0001, respectively). All patients received definitive repair without mortality; the average length of stay after surgery was lower in the WPP group. There were 4 surgical complications in the U.S. group and 1 in WPP group. All patients were weaned off of TPN and all WPP patients are now on a regular PO diet. Every WPP patient has been seen in follow-up in the U.S. and in their home country. CONCLUSION: We provided successful multidisciplinary care for neonates with EA and TEF from LMICs with outcomes similar to the neonates with the same abnormality in the U.S. The partnership with WPP has been invaluable as it has provided essential support to identify and manage these patients. LEVEL OF EVIDENCE: IV.
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Atresia Esofágica , Fístula Traqueoesofágica , Recém-Nascido , Humanos , Criança , Fístula Traqueoesofágica/complicações , Países em Desenvolvimento , Complicações Pós-Operatórias/etiologia , Gastrostomia/efeitos adversos , Estudos RetrospectivosRESUMO
GATA transcription factors play critical roles in cellular differentiation and development. However, their roles in mature tissues are less understood. In C. elegans larvae, the transcription factor ELT-2 regulates terminal differentiation of the intestine. It is also expressed in the adult intestine, where it was suggested to maintain intestinal structure and function, and where it was additionally shown to contribute to infection resistance. To study the function of elt-2 in adults we characterized elt-2-dependent gene expression following its knock-down specifically in adults. Microarray analysis identified two ELT-2-regulated gene subsets: one, enriched for hydrolytic enzymes, pointed at regulation of constitutive digestive functions as a dominant role of adult elt-2; the second was enriched for immune genes that are induced in response to Pseudomonas aeruginosa infection. Focusing on the latter, we used genetic analyses coupled to survival assays and quantitative RT-PCR to interrogate the mechanism(s) through which elt-2 contributes to immunity. We show that elt-2 controls p38-dependent gene induction, cooperating with two p38-activated transcription factors, ATF-7 and SKN-1. This demonstrates a mechanism through which the constitutively nuclear elt-2 can impact induced responses, and play a dominant role in C. elegans immunity.
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Proteínas de Caenorhabditis elegans/metabolismo , Caenorhabditis elegans/imunologia , Fatores de Transcrição GATA/metabolismo , Regulação da Expressão Gênica , Imunidade Inata/genética , Mucosa Intestinal/metabolismo , Proteínas Quinases p38 Ativadas por Mitógeno/metabolismo , Fatores Ativadores da Transcrição/genética , Fatores Ativadores da Transcrição/metabolismo , Animais , Caenorhabditis elegans/genética , Proteínas de Caenorhabditis elegans/genética , Proteínas de Ligação a DNA/genética , Proteínas de Ligação a DNA/metabolismo , Fatores de Transcrição GATA/genética , Técnicas de Silenciamento de Genes , Larva/genética , Larva/metabolismo , Regiões Promotoras Genéticas , Pseudomonas aeruginosa , Fatores de Transcrição/genética , Fatores de Transcrição/metabolismo , Proteínas Quinases p38 Ativadas por Mitógeno/genéticaRESUMO
BACKGROUND: No reflow in capillaries (no reflow) is the lack of tissue perfusion that occurs once central hemodynamics are restored. This prevents oxygen transfer and debt repayment to vital tissues after shock resuscitation. Since metabolic swelling of cells and tissues can cause no reflow, it is a target for study in shock. We hypothesize no reflow secondary to metabolic cell swelling causes the problem not addressed by current strategies that increase central hemodynamics alone. METHODS: Anesthetized swine were bled until plasma lactate reached 7.5 mM to 9 mM. Intravenous low volume resuscitation solutions were administered (6.8 mL/kg over 5 minutes) consisting of; (1) lactated Ringer (LR), (2) autologous whole blood, (3) high-dose vitamin C (200 mg/kg), or (4) 10% PEG-20k, a polymer-based cell impermeant that corrects metabolic cell swelling. Outcomes were macrohemodynamics (MAP), plasma lactate, capillary flow in the gut and tongue mucosa using orthogonal polarization spectral imaging (OPSI), and survival to 4 hours. RESULTS: All PEG-20k resuscitated swine survived 240 minutes with MAP above 60 mm Hg compared with 50% and 0% of the whole blood and LR groups, respectively. The vitamin C group died at just over 2 hours with MAPs below 40 and high lactate. The LR swine only survived 30 minutes and died with low MAP and high lactate. Capillary flow positively correlated ( p < 0.05) with survival and MAP. Sublingual OPSI correlated with intestinal OPSI and OPSI was validated with a histological technique. DISCUSSION: Targeting micro-hemodynamics in resuscitation may be more important than macrohemodynamics. Fixing both is optimal. Sublingual OPSI is clinically achievable to assess micro-hemodynamic status. Targeting tissue cell swelling that occurs during ATP depletion in shock using optimized osmotically active cell impermeants in crystalloid low volume resuscitation solutions improves perfusion in shocked tissues, which leverages a primary mechanism of injury.
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Choque Hemorrágico , Animais , Suínos , Choque Hemorrágico/tratamento farmacológico , Microcirculação , Soluções Cristaloides/uso terapêutico , Hemodinâmica , Lactato de Ringer , Edema , Perfusão , Lactatos , Ácido Ascórbico/uso terapêutico , Ressuscitação/métodos , Soluções Isotônicas/farmacologia , Soluções Isotônicas/uso terapêuticoRESUMO
BACKGROUND: Retained surgical sharps (RSS) is a "never event" that is preventable but may still occur despite of correct count and negative X-ray. This study assesses the feasibility of a novel device ("Melzi Sharps Finder®" or MSF) in effective detection of RSS. METHODS: The first study consisted of determination of the presence of RSS or identification of RSS in an ex-vivo model (a container with hay in a laparoscopic trainer box). The second study consisted of determining presence of RSS in an in-vivo model (laparoscopy in live adult Yorkshire pigs) with 3 groups: C-arm, C-arm with MSF and MSF. The third study used similar apparatus though with laparotomy and included 2 groups: manual search and MSF. RESULTS: In the first study, the MSF group had a higher rate of identification of a needle and decreased time to locate a needle versus control (98.1% vs. 22.0%, p < 0.001; 1.64 min ± 1.12vs. 3.34 min ± 1.28, p < 0.001). It also had increased accuracy of determining the presence of a needle and decreased time to reach this decision (100% vs. 58.8%, p < 0.001; 1.69 min ± 1.43 vs. 4.89 min ± 0.63, p < 0.001). In-the second study, the accuracy of determining the presence of a needle and time to reach this decision were comparable in each group (88.9% vs. 100% vs. 84.5%, p < 0.49; 2.2 min ± 2.2 vs. 2.7 min ± 2.1vs. 2.8 min ± 1.7, p = 0.68). In the third study, MSF group had higher accuracy in determining the presence of a needle and decreased time to reach this decision than the control (97.0% vs. 46.7%, p < 0.001; 2.0 min ± 1.5 vs. 3.9 min ± 1.4; p < 0.001). Multivariable analysis showed that MSF use was independently associated with an accurate determination of the presence of a needle (OR 12.1, p < 0.001). CONCLUSIONS: The use of MSF in this study's RSS models facilitated the determination of presence and localization of RSS as shown by the increased rate of identification of a needle, decreased time to identification and higher accuracy in determining the presence of a needle. This device may be used in conjunction with radiography as it gives live visual and auditory feedback for users during the search for RSS.
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Importance: There is variability in practice and imaging usage to diagnose cervical spine injury (CSI) following blunt trauma in pediatric patients. Objective: To develop a prediction model to guide imaging usage and to identify trends in imaging and to evaluate the PEDSPINE model. Design, Setting, and Participants: This cohort study included pediatric patients (<3 years years) following blunt trauma between January 2007 and July 2017. Of 22 centers in PEDSPINE, 15 centers, comprising level 1 and 2 stand-alone pediatric hospitals, level 1 and 2 pediatric hospitals within an adult hospital, and level 1 adult hospitals, were included. Patients who died prior to obtaining cervical spine imaging were excluded. Descriptive analysis was performed to describe the population, use of imaging, and injury patterns. PEDSPINE model validation was performed. A new algorithm was derived using clinical criteria and formulation of a multiclass classification problem. Analysis took place from January to October 2022. Exposure: Blunt trauma. Main Outcomes and Measures: Primary outcome was CSI. The primary and secondary objectives were predetermined. Results: The current study, PEDSPINE II, included 9389 patients, of which 128 (1.36%) had CSI, twice the rate in PEDSPINE (0.66%). The mean (SD) age was 1.3 (0.9) years; and 70 patients (54.7%) were male. Overall, 7113 children (80%) underwent cervical spine imaging, compared with 7882 (63%) in PEDSPINE. Several candidate models were fitted for the multiclass classification problem. After comparative analysis, the multinomial regression model was chosen with one-vs-rest area under the curve (AUC) of 0.903 (95% CI, 0.836-0.943) and was able to discriminate between bony and ligamentous injury. PEDSPINE and PEDSPINE II models' ability to identify CSI were compared. In predicting the presence of any injury, PEDSPINE II obtained a one-vs-rest AUC of 0.885 (95% CI, 0.804-0.934), outperforming the PEDSPINE score (AUC, 0.845; 95% CI, 0.769-0.915). Conclusion and Relevance: This study found wide clinical variability in the evaluation of pediatric trauma patients with increased use of cervical spine imaging. This has implications of increased cost, increased radiation exposure, and a potential for overdiagnosis. This prediction tool could help to decrease the use of imaging, aid in clinical decision-making, and decrease hospital resource use and cost.
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Traumatismos da Coluna Vertebral , Ferimentos não Penetrantes , Adulto , Criança , Humanos , Masculino , Lactente , Feminino , Estudos de Coortes , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Traumatismos da Coluna Vertebral/etiologia , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/complicações , Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/lesões , Tomografia Computadorizada por Raios X , Estudos Retrospectivos , Centros de TraumatologiaRESUMO
BACKGROUND: Traditionally, vasopressors and crystalloids have been used to stabilize brain dead donors; however, the use of crystalloid is fraught with complications. This study aimed to investigate the effectiveness of a newly developed impermeant solution, polyethylene glycol-20k IV solution (PEG-20k) for resuscitation and support of brain dead organ donors. METHODS: Brain death was induced in adult beagle dogs and a set volume of PEG-20k or crystalloid solution was given thereafter. The animals were then resuscitated over 16 h with vasopressors and crystalloid as necessary to maintain mean arterial pressure of 80-100 mmHg. The kidneys were procured and cold-stored for 24 h, after which they were analyzed using the isolated perfused kidney model. RESULTS: The study group required significantly less crystalloid volume and vasopressors while having less urine output and requiring less potassium supplementation than the control group. Though the two groups' mean arterial pressure and lactate levels were comparable, the study group's kidneys showed less preservation injury after short-term reperfusion indexed by decreased lactate dehydrogenase release and higher creatinine clearance than the control group. CONCLUSIONS: The use of polyethylene glycol-20k IV solution for resuscitating brain dead donors decreases cell swelling and improves intravascular volume, thereby improving end organ oxygen delivery before procurement and so preventing ischemia-reperfusion injury after transplantation.
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Morte Encefálica , Polietilenoglicóis , Animais , Soluções Cristaloides , Modelos Animais de Doenças , Cães , Humanos , Polietilenoglicóis/farmacologia , Doadores de TecidosRESUMO
PURPOSE: The burden of surgical disease in children from low and middle-income countries (LMICs) is becoming more recognized as significant and undertreated. We recently reviewed our health system's experience with providing quaternary-level surgical care to children from LMICs through a partnership with World Pediatric Project (WPP), a not-for-profit organization. METHODS: A retrospective review was performed of all WPP-sponsored patients who received surgical care at our children's hospital from LMICs in the Caribbean and Central America from July 2000 to August 2018. RESULTS: Two hundred and fifty-five patients (average age: 5.9 ± 5.3 years; range: <1-18 years) from 14 countries received a total of 371 moderately to significantly complex operations from 10 pediatric surgical subspecialties, with cardiac, neurosurgery, craniofacial and general/thoracic surgical subspecialties being the most common. The average length of hospital stay was 10.7 ± 18.9 days. All patients had the opportunity to follow-up with local providers and/or visiting WPP-sponsored surgical teams. 227 patients (93.8%) were seen by WPP providers or released to an in-country physician partnering with WPP. There were 21 (8.2%) total, minor and major, postoperative complications. Five deaths (2.0%) occurred at our institution and 7 from disease progression, after returning to their home country. CONCLUSIONS: Providing complex surgical care to LMIC children in the US may help address a significant global burden. This care can be provided by multiple subspecialists with excellent outcomes, good follow-up, and low complication and mortality rates. Having a supportive health care system, volunteer surgeons, and an organization that manages logistics and provides financial support is essential. TYPE OF STUDY: Clinical research, retrospective review LEVEL OF EVIDENCE: Level IV.
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Países em Desenvolvimento , Cirurgiões , Adolescente , Criança , Pré-Escolar , Humanos , Lactente , Procedimentos Neurocirúrgicos , Pobreza , Estudos RetrospectivosRESUMO
BACKGROUND: Optimal inguinal hernia repair timing remains controversial. It remains unclear how COVID-19 related elective surgery cancellations impacted timing of inguinal hernia repair and whether any delays led to complications. This study aims to determine whether elective surgery cancellations are safe in pediatric inguinal hernia. METHODS: This multicenter retrospective cohort study at 14 children's hospitals included patients ≤18 years who underwent inguinal hernia repair between September 13, 2019, through September 13, 2020. Patients were categorized by whether their inguinal hernia repair occurred before or after their hospital's COVID-19 elective surgery cancellation date. Incarceration and emergency department encounters were compared between pre and postcancellation. RESULTS: Of 1,404 patients, 604 (43.0%) underwent inguinal hernia repair during the postcancellation period, 92 (6.6%) experienced incarceration, and 213 (15.2%) had an emergency department encounter. The postcancellation period was not associated with incarceration (odds ratio 1.54; 95% confidence interval 0.88-2.71; P = .13) or emergency department encounters (odds ratio 1.53; 95% confidence interval 0.94-2.48; P = .09) despite longer median times to inguinal hernia repair (precancellation 29 days [interquartile range 13-55 days] versus postcancellation 31 days [interquartile range 14-73 days], P = .01). Infants were more likely to have the emergency department be their index presentation in the postcancellation period (odds ratio 1.69; 95% confidence interval 1.24-2.31; P < .01). CONCLUSION: Overall, COVID-19 elective surgery cancellations do not appear to increase the likelihood of incarceration or emergency department encounters despite delays in inguinal hernia repair, suggesting that cancellations are safe in children with inguinal hernia. Assessment of elective surgery cancellation safety has important implications for health policy.
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COVID-19 , Hérnia Inguinal , COVID-19/epidemiologia , Criança , Estudos de Coortes , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Hérnia Inguinal/complicações , Hérnia Inguinal/cirurgia , Herniorrafia/efeitos adversos , Humanos , Lactente , Estudos RetrospectivosRESUMO
Donation after circulatory death (DCD) has expanded the donor pool for liver transplantation. However, ischemic cholangiopathy (IC) after DCD liver transplantation causes inferior outcomes. The molecular mechanisms of IC are currently unknown but may depend on ischemia-induced genetic reprograming of the biliary epithelium to mesenchymal-like cells. The main objective of this study was to determine if cholangiocytes undergo epithelial to mesenchymal transition (EMT) after exposure to DCD conditions and if this causally contributes to the phenotype of IC. Human cholangiocyte cultures were exposed to periods of warm and cold ischemia to mimic DCD liver donation. EMT was tested by assays of cell migration, cell morphology, and differential gene expression. Transplantation of syngeneic rat livers recovered under DCD conditions were evaluated for EMT changes by immunohistochemistry. Human cholangiocytes exposed to DCD conditions displayed migratory behavior and gene expression patterns consistent with EMT. E-cadherin and CK-7 expressions fell while N-cadherin, vimentin, TGFß, and SNAIL rose, starting 24 hours and peaking 1-3 weeks after exposure. Cholangiocyte morphology changed from cuboidal (epithelial) before to spindle shaped (mesenchymal) a week after ischemia. These changes were blocked by pretreating cells with the Transforming Growth Factor beta (TGFß) receptor antagonist Galunisertib (1 µM). Finally, rats with liver isografts cold stored for 20 hours in UW solution and exposed to warm ischemia (30 minutes) at recovery had elevated plasma bilirubin 1 week after transplantation and the liver tissue showed immunohistochemical evidence of early cholangiocyte EMT. Our findings show EMT occurs after exposure of human cholangiocytes to DCD conditions, which may be initiated by upstream signaling from autocrine derived TGFß to cause mesenchymal specific morphological and migratory changes.
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Transição Epitelial-Mesenquimal , Isquemia/patologia , Transplante de Fígado/efeitos adversos , Animais , Humanos , Masculino , RatosRESUMO
BACKGROUND: A retained surgical item (RSI) is defined as a never-event and can have drastic consequences on patient, provider, and hospital. However, despite increased efforts, RSI events remain the number one sentinel event each year. Hard foreign bodies (e.g. surgical sharps) have experienced a relative increase in total RSI events over the past decade. Despite this, there is a lack of literature directed towards this category of RSI event. Here we provide a systematic review that focuses on hard RSIs and their unique challenges, impact, and strategies for prevention and management. METHODS: Multiple systematic reviews on hard RSI events were performed and reported using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. Database searches were limited to the last 10 years and included surgical "sharps," a term encompassing needles, blades, instruments, wires, and fragments. Separate systematic review was performed for each subset of "sharps". Reviewers applied reciprocal synthesis and refutational synthesis to summarize the evidence and create a qualitative overview. RESULTS: Increased vigilance and improved counting are not enough to eliminate hard RSI events. The accurate reporting of all RSI events and near miss events is a critical step in determining ways to prevent RSI events. The implementation of new technologies, such as barcode or RFID labelling, has been shown to improve patient safety, patient outcomes, and to reduce costs associated with retained soft items, while magnetic retrieval devices, sharp detectors and computer-assisted detection systems appear to be promising tools for increasing the success of metallic RSI recovery. CONCLUSION: The entire healthcare system is negatively impacted by a RSI event. A proactive multimodal approach that focuses on improving team communication and institutional support system, standardizing reports and implementing new technologies is the most effective way to improve the management and prevention of RSI events.
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Obesity is among the most common and costly chronic disorders worldwide. Estimates suggest that in the United States obesity affects one-third of adults, accounts for up to one-third of total mortality, is concentrated among lower income groups, and increasingly affects children as well as adults. A lack of effective options for long-term weight reduction magnifies the enormity of this problem; individuals who successfully complete behavioral and dietary weight-loss programs eventually regain most of the lost weight. We included evidence from basic science, clinical, and epidemiological literature to assess current knowledge regarding mechanisms underlying excess body-fat accumulation, the biological defense of excess fat mass, and the tendency for lost weight to be regained. A major area of emphasis is the science of energy homeostasis, the biological process that maintains weight stability by actively matching energy intake to energy expenditure over time. Growing evidence suggests that obesity is a disorder of the energy homeostasis system, rather than simply arising from the passive accumulation of excess weight. We need to elucidate the mechanisms underlying this "upward setting" or "resetting" of the defended level of body-fat mass, whether inherited or acquired. The ongoing study of how genetic, developmental, and environmental forces affect the energy homeostasis system will help us better understand these mechanisms and are therefore a major focus of this statement. The scientific goal is to elucidate obesity pathogenesis so as to better inform treatment, public policy, advocacy, and awareness of obesity in ways that ultimately diminish its public health and economic consequences.
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Cirurgia Bariátrica/métodos , Endoscopia Gastrointestinal/métodos , Laparoscopia/métodos , Obesidade Infantil/terapia , Adolescente , Cirurgia Bariátrica/instrumentação , Criança , Endoscopia Gastrointestinal/instrumentação , Humanos , Laparoscopia/instrumentação , Obesidade Infantil/cirurgiaRESUMO
PURPOSE: The purpose of this study was to assess the utilization of a handheld telemedicine (TM) device in the postoperative care of pediatric surgical patients. METHODS: We performed postoperative TM evaluations using an advanced medical tablet immediately prior to seeing the patients in clinic as well as at two different time points from their home. The caregivers and physicians were surveyed about their overall satisfaction. RESULTS: Twenty-four postoperative patients who underwent a variety of general surgical operations were included. There were no changes to the TM plan of care following "in person" evaluations (nâ¯=â¯12) and no complications, missed diagnoses, emergency department visits, or additional clinic visits in those who only had TM postoperative evaluations (nâ¯=â¯12). Caregiver satisfaction ratings were 3.92⯱â¯0.28 out of 4 (4â¯=â¯very satisfied). Ninety-two percent of caregivers responded that they would be comfortable with a TM-only postoperative evaluation in the future. The physician was able to formulate an accurate assessment and plan using the device. The average travel distance saved was 44.7⯱â¯45.5â¯miles (rangeâ¯=â¯10-150â¯miles). CONCLUSIONS: These preliminary data suggest safe and effective care with high caregiver and physician satisfaction can be provided by utilizing TM in the postoperative care of pediatric surgical patients. LEVEL OF EVIDENCE: IV.
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Computadores de Mão , Cuidados Pós-Operatórios/instrumentação , Telemedicina/instrumentação , Adolescente , Atitude do Pessoal de Saúde , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Masculino , Satisfação do Paciente , Pediatria , Projetos Piloto , Cuidados Pós-Operatórios/métodos , Especialidades Cirúrgicas , Telemedicina/métodosRESUMO
BACKGROUND: Metabolic and bariatric surgery in adolescents with severe obesity has been demonstrated to be safe and have long-term treatment efficacy. However, less than 0.1% of adolescents meeting criteria undergo surgery. METHODS: A prospective pilot study of adolescents who underwent laparoscopic gastric plication (LGP) was conducted to evaluate safety and effects on anthropometrics and weight-related medical and psychological comorbidities. RESULTS: Four adolescents enrolled and underwent LGP; two withdrew 90â¯days postoperatively and two were followed through 36â¯months. Preprocedure body mass index was 41.7-53.7â¯kg/m2 with decreases in % change of BMI of 17.5% and 39.7% at 36â¯months after surgery. Patients reported early satiety, good hunger control, and limited nausea at all time points. There were no major complications. Mild gastroesophageal reflux and abdominal pain occurred; both resolved without surgical intervention. Minor improvements in psychological comorbidities were also reported. CONCLUSIONS: LGP can be safely performed in adolescents with severe obesity and achieves modest weight loss. Although limited by its small sample size, this study provides preliminary support for LGP as an appropriate surgical option for adolescents. A larger, multidisciplinary study is planned. TYPE OF STUDY: Prospective case series review. LEVEL OF EVIDENCE: Level IV evidence: case series without comparison.