Evaluating the impact of infliximab use on surgical outcomes in pediatric Crohn's disease.

BACKGROUND: The impact of infliximab (IFX) on surgical outcomes is poorly defined in pediatric Crohn's disease (CD). We evaluated our institution's experience with IFX on postoperative complications and surgical recurrence. METHODS: A retrospective review of children who underwent intestinal resection with primary anastomosis for CD from 1/2002 to 10/2014 was performed. Data collected included IFX use and surgical outcomes. Preoperative IFX use was within 3months of surgery. RESULTS: Seventy-three patients were included with median age 15years (range: 9-18). The most frequent indications for operation were obstruction (n=26) and fistulae (n=19). Nine patients (13%) had a surgical recurrence at a median of 2.3years (IQR 0.7-3.5). Twenty-two patients received preoperative IFX at median of 26days (IQR 14-46). There were 7 postoperative complications: 2 bowel obstructions, and 5 superficial wound infections. Outcomes of patients stratified by IFX were not different. When stratified by indication, refractory disease was associated with higher preoperative IFX use (IFX use 55% vs. no IFX use 28%, p=0.027). No specific indication was associated with increased reoperation rates. CONCLUSION: Pediatric CD patients treated with preoperative IFX undergo intestinal resection with primary anastomosis with acceptable morbidity. The heterogeneous approach to medical management underscores the need for guidelines to direct treatment.

Spontaneous pneumomediastinum in the pediatric patient.

BACKGROUND: Spontaneous pneumomediastinum (SPM) data in children are limited. We investigated the management of SPM at our institution. METHODS: We reviewed children with pneumomediastinum treated from January 2011 to October 2014. Primary (no precipitating factors) and secondary (underlying respiratory disease) SPM patients were included. Admission data and clinical outcomes were recorded. RESULTS: A total of 129 patients were included. Average age was 11.6 ± 4.6 years; 90 males (70%). Frequent presenting symptoms were chest pain (n = 76) and dyspnea (n = 51). Of the total, 89 patients (69%) were admitted. No patient required additional interventions. Of those, 85 patients (65.9%) had follow-up. Patients with secondary SPM (n = 58) were more likely than primary (n = 71) to be admitted (84% vs 56%, P = .001), receive oxygen (69% vs 35%, P = .04), and have longer stays (2 days [interquartile range, 1 to 3] vs 1 day [interquartile range, 0 to 1], P < .001). Readmission rates were equivalent. CONCLUSIONS: Differentiating types of SPM is important as clinical course differs. Secondary SPM patients are more frequently admitted than primary SPM patients.

Management of traumatic duodenal hematomas in children.

BACKGROUND: Duodenal hematomas from blunt abdominal trauma are uncommon in children and treatment strategies vary. We reviewed our experience with this injury at a large-volume children's hospital. MATERIALS AND METHODS: A retrospective case series was assembled from January 2003-July 2014. Data collected included demographics, clinical and radiographic characteristics, and hospital course. Patients with grade I injuries based on the American Association for the Surgery of Trauma Duodenum Injury Scale were compared with those with grade II injuries. RESULTS: Nineteen patients met inclusion criteria at a median age of 8.91 y (range, 1.7-17.2 y). Mechanisms of injury included direct abdominal blow or handle bar injury (n = 9), nonaccidental trauma (n = 5), falls (n = 3), and motor vehicle accident (n = 2). Ten patients had grade I hematomas and nine had grade II. Hematomas were most frequently seen in the second portion of the duodenum (n = 9). Five patients underwent a laparotomy for concerns for hollow viscus injury. No patients required operative drainage of the hematoma; however, one patient underwent percutaneous drainage. Twelve patients received parenteral nutrition (PN) for a median duration of 9 d (range, 5-14 d). Median duration of PN for grade I was 6.5 d (range, 5-8 d) versus 12 d for grade II (range, 9-14 d; P = 0.016). Complications included one readmission for concern of bowel obstruction requiring bowel rest. CONCLUSIONS: This study suggests that duodenal hematomas can be successfully managed nonoperatively. Grade II hematomas are associated with longer duration of PN therapy and consequently longer hospital stays. These data can assist in care management planning and parental counseling for patients with traumatic duodenal hematomas.

Medical errors: excess hospital costs and lengths of stay.

To focus on effective patient safety strategies in an environment of intense competition for resources, a method of quantifying the effect of potential sources of medical errors was developed. This study assessed excess length of stay (LOS) and hospitalization costs associated with patients who experienced errors. The distribution of the errors occurring within the mean LOS experienced by others with the same diagnosis and severity was also examined. Patients with errors had longer stays and greater costs when compared to controls.

Longitudinal changes in growth parameters are correlated with changes in pulmonary function in children with cystic fibrosis.

OBJECTIVE: Nutritional status is associated with pulmonary health and survival in children with cystic fibrosis (CF). This study evaluated the weight gain pattern of children with CF in relation to the longitudinal trends of their pulmonary function. Our hypothesis was that children who experience continuous weight gain at a given rate will have better average forced expiratory volume in 1 second (FEV(1)) and change in FEV(1) than children who have weight gain patterns that deviate from this rate, even when total weight gain seems adequate. METHODS: Prospectively collected data were examined in 319 children, aged 6 to 8, who were routinely followed at the Minnesota Cystic Fibrosis Center. One to 67 measurements of weight (kg), height (cm), and FEV(1) (mL) were taken per child during this 2-year period. The data were analyzed by repeated measure regression analysis and by growth pattern analysis. RESULTS: At baseline, a 1-kg higher initial weight was associated with a 55-mL higher average FEV(1). During the follow-up period, a 1-kg gain in weight was associated with an increase in FEV(1) by 32 mL. Children who had a steady weight gain tended to experience greater increases in FEV(1) than children who experienced periodic losses in weight. CONCLUSIONS: We established that children who weigh more and who gain weight at an appropriate and uninterrupted rate have a better FEV(1) trajectory. Aggressive nutritional support to maintain growth in these children may therefore improve FEV(1), which can be taken as a surrogate for better lung health, and may ultimately lead to better survival.