Management of Gastroschisis: Timing of Delivery, Antibiotic Usage, and Closure Considerations (A Systematic Review From the American Pediatric Surgical Association Outcomes & Evidence Based Practice Committee).

BACKGROUND: No consensus exists for the initial management of infants with gastroschisis. METHODS: The American Pediatric Surgical Association (APSA) Outcomes and Evidenced-based Practice Committee (OEBPC) developed three a priori questions about gastroschisis for a qualitative systematic review. We reviewed English-language publications between January 1, 1970, and December 31, 2019. This project describes the findings of a systematic review of the three questions regarding: 1) optimal delivery timing, 2) antibiotic use, and 3) closure considerations. RESULTS: 1339 articles were screened for eligibility; 92 manuscripts were selected and reviewed. The included studies had a Level of Evidence that ranged from 2 to 4 and recommendation Grades B-D. Twenty-eight addressed optimal timing of delivery, 5 pertained to antibiotic use, and 59 discussed closure considerations (Figure 1). Delivery after 37 weeks post-conceptual age is considered optimal. Prophylactic antibiotics covering skin flora are adequate to reduce infection risk until definitive closure. Studies support primary fascial repair, without staged silo reduction, when abdominal domain and hemodynamics permit. A sutureless repair is safe, effective, and does not delay feeding or extend length of stay. Sedation and intubation are not routinely required for a sutureless closure. CONCLUSIONS: Despite the large number of studies addressing the above-mentioned facets of gastroschisis management, the data quality is poor. A wide variation in gastroschisis management was documented, indicating a need for high quality RCTs to provide an evidence-based approach when caring for these infants. TYPE OF STUDY: Qualitative systematic review of Level 1-4 studies.

Individualized guidelines: the potential for increasing quality and reducing costs.

BACKGROUND: Current guidelines focus on a particular risk factor and specify criteria for categorizing persons into a small number of treatment groups. OBJECTIVE: To compare current guidelines with individualized guidelines (that use readily available characteristics from each person to calculate the risk reduction expected from treatment and to identify persons for treatment in ranked order of decreasing expected benefit), in the context of blood pressure management. DESIGN: Analysis of person-specific, longitudinal data. SETTING: The ARIC (Atherosclerosis Risk in Communities) Study. PARTICIPANTS: Persons aged 45 to 64 years without preexisting cardiovascular disease who currently do not receive antihypertensive treatment. INTERVENTION: Treatment according to the criteria of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 guidelines); individualized guidelines, or treatment in decreasing order of expected benefit; and random care, or treatment of persons selected at random. MEASUREMENTS: Number of myocardial infarctions (MIs) and strokes and medical costs. RESULTS: Compared with treating people according to random care, individualized guidelines could prevent the same number of MIs and strokes as JNC 7 guidelines at savings that are 67% greater than using JNC 7 guidelines, or it could prevent 43% more MIs and strokes for the same cost as treatment according to JNC 7 guidelines. The superiority of individualized guidelines was not sensitive to a wide range of assumptions about costs, treatment effectiveness, level of risk for cardiovascular disease in the population, or effects on workflow. The degree of superiority was sensitive to the accuracy of the method used to rank patients and to its span (the proportion of the population for whom all of the outcomes of interest can be calculated). LIMITATIONS: Specific results apply to the effects of blood pressure management on MI and stroke in the ARIC Study population. The methods for calculating individual benefits require quantitative evidence about the relationships among risk factors, long-term outcomes, and treatment effects. CONCLUSION: Use of individualized guidelines can help to increase the quality and reduce the cost of care.

Victim, perpetrator, family, and incident characteristics of infant and child homicide in the United States Air Force.

OBJECTIVE: The present study describes factors related to fatal abuse in three age groups in the United States Air Force (USAF). METHOD: Records from 32 substantiated cases of fatal child abuse in the USAF were independently reviewed for 60 predefined factors. RESULTS: Males were over-represented in young child victims (between 1 year and 4 years of age) and child victims (between 4 years and 15 years of age) but not in infant victims (between 24 hours and 1 year of age). African-American infant victims and perpetrators were over-represented. Younger victims were more likely to have been previously physically abused by the perpetrator. Perpetrators were predominantly male and the biological fathers of the victims. Infant and young child perpetrators reported childhood abuse histories, while child perpetrators reported the highest frequency of mental health contact. Victims' families reported significant life stressors. Families of young child victims were more likely divorced, separated, or single. Incidents with infants and young children tended to occur without witnesses; incidents with child victims tended to have the victim's sibling(s) and/or mother present. Fatal incidents were more frequent on the weekend, in the home, and initiated by some family disturbance. CONCLUSIONS: Differences among groups in factors related to infant and child homicide across age groups may assist in the development of more tailored abuse prevention efforts and may also guide future investigations.