Protocolized management of pediatric complicated appendicitis leads to improved outcomes.

PURPOSE: We aimed to evaluate a complicated appendicitis clinical practice guideline at our institution. METHODS: Records were compared before and after protocol implementation. We standardized an ED consult pathway, antibiotic use and need for early appendectomy (EA) versus interval appendectomy (IA). We evaluated demographics, clinical characteristics, and outcomes. Subgroup analysis was performed to compare patients with small abscess treated with IA pre-protocol versus similar patients treated by EA post-protocol. RESULTS: In total 246 patients were reviewed (Pre-protocol = 152, Post-protocol = 94). Pre-protocol early appendectomy rate was 51% versus 82% on post-protocol patients. There were no differences in demographics. Post-protocol the use of preoperative imaging significantly decreased (Pre 92% vs. 56%, p = 0.0001), as well as the use of discharge antibiotics (Pre 93% vs. Post 27%, p = 0.0001) with no change in abscess rate. Overall, post-protocol patients had fewer total CT scans performed (Pre 40% vs. Post 28%, p = 0.03) and decreased total length of stay (Pre 7.7 vs. Post 6.5 days, p = 0.049). On subgroup analysis, post-protocol EA with no or small abscess had lower median number of admissions, decreased total LOS (Pre IA 9 days vs. Post EA 5 days, p = 0.00001) and fewer complications (Pre IA 42% vs. EA 22%, p = 0.022). CONCLUSION: The establishment of a standardized pediatric complicated appendicitis protocol may lead to improved outcomes and resource utilization. Patients presenting with no or small abscess may be the least likely to benefit from interval appendectomy. LEVEL OF EVIDENCE: Level III.

Sun Protection Outreach Teaching by Students (SPOTS)-Evaluating the Efficacy of Skin Cancer Prevention Education for Adolescents.

BACKGROUND: The Sun Protection Outreach Teaching by Students (SPOTS) program addresses an unmet need by training medical students to teach adolescents about skin cancer prevention and early detection. OBJECTIVE: To measure (1) changes in adolescents' knowledge, attitudes, and behaviors regarding sun protection and (2) the impact on medical students' confidence in skin cancer preventive counseling. METHODS: Pre-SPOTS and 1-month post-SPOTS program surveys were completed by adolescent participants and medical student instructors. RESULTS: Amongst adolescent students, analysis of 1,142 pre-program surveys and 618 post-program surveys revealed statistically significant improvements in knowledge, attitudes, and behaviors. Among the favorable results, 26%, 41%, and 20% improvements over baseline were observed in SPF knowledge, preference for natural untanned skin, and intent to wear sunscreen, respectively (p < .001). One-third of adolescents reported having tried to increase sunscreen use. Amongst medical students, analysis of 78 pre-teaching and 74 post-teaching surveys revealed an increase in feeling "very confident" in counseling patients, from 23% pre-teaching to 82% post-teaching (p < .001). CONCLUSION: SPOTS demonstrated a dual benefit to adolescents and medical students. The program is available for dermatologists to implement in their communities.

Mechanical Strain of the Trilobed Transposition Flap in Artificial Skin Models: Pivotal Restraint Decreases With Decreasing Rotational Angles.

BACKGROUND: In transposition flaps, thicker tissue and higher degrees of rotation are associated with increased pivotal restraint; however, limited experimental data exist quantifying the degree to which these affect flap biomechanics. The use of artificial skin models in conjunction with digital image correlation technology allows for investigation into biomechanical properties of skin flaps. OBJECTIVE: To quantify the effects of tissue thickness and rotational angles on pivotal restraint within transposition flaps using artificial skin models. METHODS: Ninety degree bilobed and trilobed flaps were used to close defects in artificial skin models of increasing thicknesses. Digital image correlation was used to quantify strain. Quantitative and qualitative differences in strain were assessed in increasing flap thicknesses and between flap designs. RESULTS: Increasing flap thickness was associated with decreasing strain. In the bilobed flap, increasing thickness was associated with displacement of the flap pivot point away from the distal flap edge. Comparatively, lower angles of rotation in the trilobed flap were not associated with migration of the flap pivot point. CONCLUSION: Increased pivotal restraint observed in higher degrees of rotation is due to migration of the flap pivot point. This model supports the common practice of decreasing flap angles to compensate for pivotal restraint.

Aesthetic Outcomes of Nasal Burow's Grafts With Interdomal Sutures After Mohs Micrographic Surgery.

BACKGROUND: Post-Mohs reconstruction of distal nasal defects is challenging. Many repair options exist, each with advantages and disadvantages. Utilization of a Burow's graft in combination with manipulation of the underlying nasal cartilages with interdomal sutures is an underreported yet effective repair option. OBJECTIVE: To present the authors' experience with Burow's grafts facilitated by interdomal sutures for repair of nasal defects after Mohs micrographic surgery (MMS). MATERIALS AND METHODS: Patients who underwent repair with Burow's grafts and interdomal sutures from 2013 to 2017 at a single university were identified. Demographics, follow-up, and complications were recorded. Two independent, board-certified dermatologists evaluated photographs for cosmesis and alar symmetry. RESULTS: Thirty-one patients were identified. A total of 5/31 patients (16.1%) experienced minor complications without permanent sequelae. A total of 4/31 (12.9%) patients underwent cosmetic revision. No incidences of pincushioning, nasal valve dysfunction, or graft necrosis occurred. Aesthetic ratings were good to excellent with mean visual analog score of 80.8. Alar symmetry was excellent. CONCLUSION: A Burow's full-thickness skin graft facilitated by an interdomal suture to maintain nasal tip orientation and projection is an elegant repair technique for distal nasal oncologic defects with good to excellent aesthetic outcomes. It should be considered in the armamentarium for repair of distal nasal defects after MMS.

Laparoscopic-assisted divided colostomy for anorectal malformation case series: a description of technique, clinical outcomes and a review of the literature.

OBJECTIVE: To present a case series of pediatric patients who underwent a laparoscopic-assisted divided colostomy for anorectal malformations, describe our technique, and provide a review of the literature on laparoscopic-assisted colostomy in pediatric patients. METHODS: We performed a retrospective review of six patients born with anorectal malformations, who received a laparoscopic-assisted colostomy from 2012 to 2016 at Cardinal Glennon Children's Medical Center. RESULTS: The average operating time was 74.5 min. Laparoscopic colostomy types included divided (n = 5) and end colostomy with Hartmann's (n = 1). Location of the colostomy was selected just distal to the descending colon (n = 5) or at the sigmoid flexure (n = 1). Feeds and stoma production was achieved within 24 h from surgery in most patients. There were no major complications except one patient having a mucosal fistula prolapse that was easily reduced. CONCLUSIONS: Laparoscopic-assisted colostomy in the management of anorectal malformations is a safe and effective technique. It offers similar advantages of the open technique, with the added benefits of avoiding wound-related complications and improved cosmetic results.