Surgical Resection of Bilateral Polycystic Ovaries Causing Ureteral Obstruction.

Ovarian cysts in adolescents are typically managed conservatively given the low rate of malignancy and the cysts typically regress over time. We present a case of a 14 year-old female with large bilateral adnexal cysts causing ureteral obstruction which was successfully treated with surgical resection and ensuring maximum preservation of ovarian tissue.

Pyloric Duplication Cyst in Newborn Male.

An enteric duplication cyst (EDC) is a rare congenital anomaly. Although EDCs can occur at any point throughout the gastrointestinal tract, they are most commonly reported in the ileum and only around 5-7% are of gastroduodenal origin. We report a case of a pyloric duplication cyst in a 3 hour old male with prenatal ultrasound showing a cystic mass. The patient had an abdominal ultrasound after birth that showed a mass with probable trilaminar wall. The diagnosis of pyloric duplication cyst was made in surgery and confirmed with histopathologic examination following resection. The patient is doing well with appropriate weight gain at follow-up appointments.

The PEET procedure: Punch Excision of Epithelialized Tracts for gastrocutaneous fistula closure.

BACKGROUND: Persistent Gastrocutaneous Fistula (GCF) is common problem encountered in the pediatric population. Several management options for intervening on pediatric persistent GCF have been described and range from open surgical management to medical management. Here we describe a novel adaptation on a previously described technique that utilizes a punch biopsy to excise the GCF we have coined as Punch Excision of Epithelialized Tracts (PEET). METHODS: The steps to this procedure include passing a punch biopsy tool over a Foley catheter. The catheter is inserted into the GCF tract, the balloon is inflated, the catheter is retracted against the abdominal wall, and the punch biopsy instrument is pushed through the skin and subcutaneous tissue circumferentially excising the tract. RESULTS: Four patients at our institution have undergone GCF excision using the PEET approach. Mean duration of the GCF in our four patients was 9 months. Mean follow-up after GCF excision using the PEET approach was 7.8 months. No patients in the cohort had any post-operative complications including surgical site wound infection, emergency department visits, or re-hospitalizations related to their surgical care. CONCLUSION: Based on our preliminary findings in this small patient cohort, we believe the PEET approach for managing persistent pediatric GCF has short-term efficacy and has the potential upside of utilizing fewer hospital resources to perform the procedure in a time-efficient manner.

Small bowel obstruction from hollow foreign body ingestion: A case report and brief review of literature.

While ingestion of a foreign body by children is common, diagnosis is often challenging, especially when the consumption by a young child is unwitnessed and presenting symptoms mimic other medical conditions. If the foreign body does not pass spontaneously, radiological imaging studies are typically performed, but visualization and identification of the ingested foreign object can be inconclusive, especially when an unidentified mass is radio translucent. Under this circumstance, physicians often have to go on a "fishing expedition", using exploratory endoscopy and/or surgery to identify and extract the object that became lodged. In this report we discuss a case of a 3 year-old boy who presented with abdominal pain and signs of bowel obstruction. Imaging revealed an ingested "radiolucent" foreign body, masqueraded as soft-tissue mass and enteric duplication cyst, delaying the diagnosis. Systematic shape and density reanalysis of CT and US imaging suggested a hollow object lodged at the terminal ileum. The patient underwent exploratory laparotomy with extraction of a hollow toy "fish". There is a dearth of literature regarding hollow ingested objects. This case report highlights the importance of systematic density and shape imaging analyses in order to identify and locate hollow ingested objects.

Incidence, Prevalence, and Outcomes of Pediatric Trauma in Rural Appalachia (West Virginia) From 2017 to 2019.

Background Appalachian rural pediatric trauma has its unique incidence, presentation, and distribution due to the mechanisms of injury, geographic location, access to care, and social issues.  Purpose To review, analyze, and understand pediatric trauma in West Virginia during the period 2017-2019. Materials and methods After institutional review board approval, the statewide trauma database was queried and analyzed in a retrospective cohort study for all pediatric trauma ages zero to 18 from 2017-2019 in the Appalachian regions one through four in West Virginia. The following were analyzed: gender, injury mechanism, Glasgow Coma Scale Score (GCS) at admission, injury severity score (ISS), toxicology screen results, hospital length of stay, duration of ventilatory support, number of procedures performed during admission, presence of non-accidental trauma, cardiac arrest, patient discharge disposition, and mortality. Results One-thousand eighty-two (1182) patients between the ages of zero to 18 were admitted to the trauma center. An average of 37% was female and 63% male. In the 11-18 age group, 24% were female and 76% were male. Most injuries were due to blunt force (89%), followed by penetrating injuries (7.2%) and burns (1.4%). The majority had minor or moderate injuries with 95% receiving a Glasgow Coma Scale (GCS) >13 and 72% listed as minor on the injury severity score (ISS). Children in ages 0-2 years had the highest proportion of poor (0-8) GCS scores, high ISS (>14) scores, most hospital admission days, most days on a ventilator, highest mortality, most pre-hospital cardiac arrests, child abuse, burns, and placement with child protective services. An average of 31% of children tested, and 17% in the age group of 0-2 had a positive toxicology screen. There were 3670 procedures done in total and the most common procedure performed was an ultrasound of the abdomen. Procedures were performed in 90% of the patients. Conclusions and relevance Based on our study, the zero to two-year-old pediatric trauma patients are most vulnerable to poor outcomes and may need targeted preventative interventions. Toxicology screens may need to be more widely implemented in pediatric trauma in the Appalachian region. Rural trauma in Appalachia has endemic issues related to substance abuse, poverty, and a lower degree of social support as compared to urban areas. Although the distribution of injury may follow a national distribution, mechanism, management, and outcomes can vary.

The "SHIFT" technique: Suprahepatic IntraFalciform tubing for placement of ventriculoperitoneal shunts.

Ventriculoperitoneal (VP) shunts in pediatric patients are an important aspect of management for patients with hydrocephalus and are fraught with complications. Surgical revision rates for VP shunts in the pediatric population are currently high, which necessitates innovation in operative techniques for placing VP shunts in attempt to decrease complication risks. Here we describe a novel approach for placement of VP shunts that we hypothesize can reduce potential morbidity among pediatric patients. By utilizing the falciform ligament of the liver and the suprahepatic recess to suspend and maintain the shunt, outcomes may portend fewer iatrogenic intra-abdominal injuries, enhanced ease of shunt removal, provide a large surface area for absorption of drained cerebrospinal fluid, and result in fewer adhesions secondary to device placement. We are referring to the operative technique as the "SupraHepatic IntraFalciform Tubing" (SHIFT) technique. In summary, the SHIFT shunt is fashioned by creating a window through the falciform ligament, inserting the shunt, and placing tubing in the suprahepatic recess.

Decision Tree Pattern Recognition Model for Radio Frequency Interference Suppression in NQR Experiments.

Radio frequency interference places a major limitation on the in-situ use of unshielded nuclear quadrupole or nuclear magnetic resonance methods in industrial environments for quality control and assurance applications. In this work, we take the detection of contraband in an airport security-type application that is subject to burst mode radio frequency interference as a test case. We show that a machine learning decision tree model is ideally suited to the automated identification of interference bursts, and can be used in support of automated interference suppression algorithms. The usefulness of the data processed additionally by the new algorithm compared to traditional processing is shown in a receiver operating characteristic (ROC) analysis of a validation trial designed to mimic a security contraband detection application. The results show a highly significant increase in the area under the ROC curve from 0.580 to 0.906 for the proper identification of recovered data distorted by interfering bursts.

Laparoscopic gastroesophageal dissociation in neurologically impaired children with gastroesophageal reflux disease.

PURPOSE: Neurologically impaired children with severe gastroesophageal reflux disease (GERD) are a challenging group of patients. We theorized that a laparoscopic gastroesophageal dissociation (LGED) may decrease reflux-related readmissions and healthcare visits, and improve quality of life (QOL) for them and their caregivers. METHODS: A retrospective review was performed on our pediatric patients that underwent an LGED along with a caregiver survey from 2013 to 2017. RESULTS: Twenty-two neurologically impaired patients (14months-17years) with severe GERD underwent an LGED. Patients weighed 7.9-57kg (avg=23.8kg), length of stay ranged from 5 to 20days (avg=12days), estimated blood loss ranged from <5cm3 to 450cm3 (avg=66cm3, median=25cm3), and duration of operation ranged from 299 to 641min (avg=462min). One death occurred on postoperative day 19 from gram negative sepsis (30-day perioperative mortality of 4.5%). There were a modest number of minor and major complications (follow-up avg.=13.7months, range=2-40months). There was a decrease in healthcare visits for respiratory illnesses (rated 5/5 from all 13/19 survey respondents) as well as improvements in perceived QOL of the patient (avg=4.3/5) and caregiver (avg=4.6/5). CONCLUSIONS: Our cohort of patients had a reduction in readmissions and healthcare visits, and improved QOL after undergoing an LGED based on the perceptions of their caregivers. In neurologically impaired patients with severe GERD, an LGED may be a viable alternative to traditional treatments. TYPE OF STUDY: Retrospective case series review. LEVEL OF EVIDENCE: Level IV evidence: case series without comparison.

Low-Volume Resuscitation for Hemorrhagic Shock: Understanding the Mechanism of PEG-20k.

Hemorrhagic shock leads to cell and tissue swelling and no reflow from compressed capillaries. Cell impermeants, including polyethylene glycol-20,000 (PEG-20k), reverse ischemia-induced cell swelling, extend low-volume resuscitation (LVR) time after shock, and increase tolerance to the low-volume state. The purpose of this study was to explore the mechanisms of action of PEG-20k containing LVR solutions. We hypothesized that PEG-20k acts as both an oncotic agent and an impermeant in the microcirculation, which moves water out of the space and into the capillaries to affect peripheral capillary filling and enhanced perfusion during the low-volume state. Rats were hemorrhaged until arterial lactate reached 9-10 mM/liter. Then, saline-based LVR solutions containing various impermeant materials were administered (10% blood volume). The LVR times for these solutions were determined by measuring the amount of time required for plasma lactate to climb back to 9 to 10 mM after LVR administration (low-volume tolerance). Capillary blood flow was measured by colored microspheres, and blood volume was measured by fluorescein isothiocyanate-labeled albumin dilution. Gluconate (impermeant), albumin (colloid), and PEG-20k (hybrid) increased LVR time over saline by 4-, 3-, and 8-fold, respectively. The combination of impermeant + albumin produced a biologic effect that was similar to PEG-20k alone. Capillary blood flow and plasma volume were decreased after shock with saline LVR but increased with PEG-20k, relative to saline. These data are consistent with the hypothesis that PEG-20k may act by establishing multiple osmotic gradients in the microcirculation to drive cell-to-capillary water transfer during hypovolemic shock.

Donor gluconate rescues livers from uncontrolled donation after cardiac death.

BACKGROUND: Ischemia from organ preservation or donation causes cells and tissues to swell owing to loss of energy-dependent mechanisms of control of cell volume. These volume changes cause substantial preservation injury, because preventing these changes by adding cell impermeants to preservation solutions decreases preservation injury. The objective of this study was to assess if this effect could be realized early in uncontrolled donation after cardiac death (DCD) livers by systemically loading donors with gluconate immediately after death to prevent accelerated swelling injury during the warm ischemia period before liver retrieval. METHODS: Uncontrolled DCD rat livers were cold-stored in University of Wisconsin solution for 24 hours and reperfused on an isolated perfused liver (IPL) device for 2 hours or transplanted into a rat as an allograft for 7 days. Donors were pretreated with a solution of the impermeant gluconate or a saline control immediately after cardiac death. Livers were retrieved after 30 minutes. RESULTS: In vivo, gluconate infusion in donors immediately before or after cardiac death prevented DCD-induced increases in total tissue water, decreased vascular resistance, increased oxygen consumption and synthesis of adenosine triphosphate, increased bile production, decreased lactate dehydrogenase release, and decreased histology injury scores after reperfusion on the IPL relative to saline-treated DCD controls. In the transplant model, donor gluconate pretreatment significantly decreased both alanine aminotransferase the first day after transplantation and total bilirubin the seventh day after transplantation. CONCLUSION: Cell and tissue swelling plays a key role in preservation injury of uncontrolled DCD livers, which can be mitigated by early administration of gluconate solutions to the donor immediately after death.

Cell Impermeant-based Low-volume Resuscitation in Hemorrhagic Shock: A Biological Basis for Injury Involving Cell Swelling.

OBJECTIVE: To determine the role of cell swelling in severe hemorrhagic shock and resuscitation injury. BACKGROUND: Circulatory shock induces the loss of energy-dependent volume control mechanisms. As water enters ischemic cells, they swell, die, and compress nearby vascular structures, which further aggravates ischemia by reducing local microcirculatory flow and oxygenation. Loading the interstitial space with cell impermeant molecules prevents water movement into the cell by passive biophysical osmotic effects, which prevents swelling injury and no-reflow. METHODS: Adult rats were hemorrhaged to a pressure of 30 to 35  mm Hg, held there until the plasma lactate reached 10  mM, and given a low-volume resuscitation (LVR) (10%-20% blood volume) with saline or various cell impermeants (sorbitol, raffinose, trehalose, gluconate, and polyethylene glycol-20k (PEG-20k). When lactate again reached 10  mM after LVR, full resuscitation was started with crystalloid and red cells. One hour after full resuscitation, the rats were euthanized. Capillary blood flow was measured by the colored microsphere technique. RESULTS: Impermeants prevented ischemia-induced cell swelling in liver tissue and dramatically improved LVR outcomes in shocked rats. Small cell impermeants and PEG-20k in LVR solutions increased tolerance to the low flow state by two and fivefold, respectively, normalized arterial pressure during LVR, and lowered plasma lactate after full resuscitation, relative to saline. This was accompanied by higher capillary blood flow with cell impermeants. CONCLUSIONS: Ischemia-induced lethal cell swelling during hemorrhagic shock is a key mediator of resuscitation injury, which can be prevented by cell impermeants in low-volume resuscitation solutions.

Implementation of pediatric cervical spine clearance guidelines at a combined trauma center: Twelve-month impact.

BACKGROUND: Pediatric cervical spine clearance guidelines should reduce computed tomography (CT) usage in combined pediatric and adult trauma centers biased by adult CT clearance. METHODS: Cervical spine clearance under age 15 years was compared 12 months before (128 patients) and after (105 patients) guideline implementation, emphasizing National Emergency X-Radiography Utilization Study (NEXUS) criteria when appropriate. RESULTS: CT scans in patients clearable by NEXUS criteria decreased 23% (p = 0.01) and decreased by 16% in cases where radiography other than CT was indicated by guidelines (p = 0.01). CONCLUSION: Guideline implementation can have an immediate effect in decreasing pediatric cervical spine CT usage and should improve across time. LEVEL OF EVIDENCE: Care management study, level IV.

Nonoperative management of pediatric aortic injury with seat belt syndrome.

"Seat belt syndrome" was first described by Garret and Braunstein in 1962. The syndrome involves skin and abdominal wall ecchymosis (seat belt sign) intra-abdominal solid organ and visceral injuries, as well as Chance fractures (compression and/or wedging deformity of the anterior portion of the vertebral body with disruption or fracture of the posterior elements, generally at L1-L3). We present a case of a 12-year-old male involved in a high-speed motor vehicle collision wearing only a lap belt resulting in seat belt syndrome, with disruption of the abdominal wall, mesenteric avulsion with multiple intestinal perforations, abdominal aortic dissection, and an L2 Chance fracture with cord transection. Intraoperative decision making is outlined with this scenario of complex injuries, and the literature of seat belt syndrome associated with blunt aortic injuries and its management is reviewed.

New low-volume resuscitation solutions containing PEG-20k.

BACKGROUND: Hypovolemic shock reduces oxygen delivery and compromises energy-dependent cell volume control. Consequent cell swelling compromises microcirculatory flow, which reduces oxygen exchange further. The importance of this mechanism is highlighted by the effectiveness of cell impermeants in low-volume resuscitation (LVR) solutions in acute studies. The objectives of this study were to assess impermeants in survival models and to compare them with commonly used crystalloid solutions. METHODS: Adult rats were hemorrhaged to a pressure of 30 mm Hg to 35 mm Hg, held there until the plasma lactate reached 10 mM, and given an LVR solution (5-10% blood volume) with saline alone (control) and saline with various concentrations of polyethylene glycol-20k (PEG-20k), Hextend, or albumin. When lactate again reached 10 mM following LVR, full resuscitation was started with crystalloid and red blood cells. Rats were either euthanized (acute) or allowed to recover (survival). The LVR time, which is the time from the start of the LVR solution until the start of full resuscitation, was measured as was survival and diagnostic laboratory values. In some studies, the capillary oncotic reflection coefficient was determined for PEG-20k to determine its relative impermeant and oncotic effects. RESULTS: PEG-20k (10%) significantly increased LVR times relative to saline (eightfold), Hextend, and albumin. Lower amounts of PEG-20k (5%) were also effective but less so than 10% doses. PEG-20k maintained normal arterial pressure during the low-volume state. Survival of a 180-minute LVR time challenge was 0% in saline controls and 100% in rats given PEG-20k as the LVR solution. Surviving rats had normal laboratory values 24 hours later. PEG-20k had an oncotic reflection coefficient of 0.65, which indicates that the molecule is a hybrid cell impermeant with significant oncotic properties. CONCLUSION: PEG-20k-based LVR solutions are highly effective for inducing tolerance to the low-volume state and for improving survival.

Histrelin for central precocious puberty-a single surgeon experience.

BACKGROUND: The most common cause of precocious puberty is idiopathic central precocious puberty (CPP), which is usually treated with monthly injections. An alternative treatment of precious puberty is a subcutaneous implant that contains histrelin acetate, which is continuously released for more than 1 y and then removed or replaced with a new implant. METHODS: The aim of this study was to conduct a retrospective review of one surgeon's experience with the histrelin implant and to examine patient satisfaction. After obtaining institutional review board approval, the charts of all children who had undergone at least one implant were reviewed. RESULTS: Fifty-eight children, average age 8.4 y old (range 7-14), underwent at least one histrelin implant insertion for treatment of CPP. Parents of 44 patients were able to be reached by telephone for this study and rated the histrelin implant treatment highly. All implants were placed, replaced, or removed without significant difficulty, and there were no complications. CONCLUSIONS: This study suggests that the use of a histrelin subcutaneous implant for control of CPP is a safe and effective method for the treatment of this condition.

Utility of admission serum lactate in pediatric trauma.

BACKGROUND/PURPOSE: Serum lactate measurement has a predictive value in adult trauma. To date, there has been no prospective analysis of the predictive value of admission serum lactate in pediatric trauma. METHODS: Admission serum lactate was prospectively measured over a two year period on all children under age 15 years who met trauma alert criteria at an urban Level 1 trauma center. Elevated serum lactate (>2.0 mmol/L) was correlated with Injury Severity Scores (ISS), injury types, and hospital outcomes. RESULTS: A total of 277 injured children with admission lactate measurements were evaluated. Patients with elevated lactate had higher mean ISS than those with normal lactate (12.8 vs. 5.1, p<0.01), and increased need for intubation, major procedures and ICU admission. Elevated lactate was associated with low specificity (54.4%), moderate sensitivity (86.7%) and high negative predictive value (94.5%) for detecting injury (ISS>15). Lactate measurements over 4.7 mmol/L were highly specific (95.8%) for injury. CONCLUSIONS: Elevated admission venous lactate level is associated with injury and outcomes, but lacks adequate sensitivity and specificity. Lactate over 4.7 mmol/L is strongly suggestive of severe injury, while lactate below 2.0 mmol/L is reassuring for not having injury. Lactates between 2.0 and 4.7 mmol/L remain indeterminate in predictive potential for injury or outcomes.

Use of del Nido Cardioplegia in Adult Cardiac Surgery.

UNLABELLED: Background: del Nido cardioplegia was developed to protect pediatric hearts, and similar to pediatric hearts, older adult hearts tolerate ischemia-reperfusion poorly. This study investigates the feasibility of del Nido cardioplegia as an alternative to conventional Buckberg cardioplegia in adult cardiac surgery. METHODS: A total of 142 adult patients undergoing cardiopulmonary bypass with del Nido cardioplegia and conventional Buckberg cardioplegia were retrospectively reviewed. RESULTS: Fewer doses of cardioplegia and fewer defibrillations were noted with del Nido cardioplegia, and there were no significant differences in incidence of postoperative events. CONCLUSION: del Nido cardioplegia may be a feasible alternative to conventional Buckberg cardioplegia.

Arnold Salzberg, HB, MD: The Pied Piper of MCV.

Salzbergian\solz-bərge-ən\ adjective of, relating to, or following the teachings of Arnold Salzberg. Noun one who embodies all that Arnold Salzberg taught about humanity. Noun one who has obtained his or her HB degree. Webster's dictionary would probably define "Salzbergian" as one who trained under Arnold Salzberg and exhibits the same great character traits, mentoring ability, and surgical skills. These might be the words that are used, but many times words cannot do justice to describing something so special. Arnold Salzberg was many things to many different people, "father figure," "wonderful advisor and resource," "ultimate mentor," "humanitarian," but when he was asked how he wanted to be remembered, he simply smiled and replied, "Icon…that would be nice." Never at a loss for words or humor and forever with an open door to his office, home, and heart, Dr. Salzberg embodied what so many medical students, residents, and attendings have been striving for, the ideal combination of physician and human being.