Extracorporeal membrane oxygenation for multisystem inflammatory syndrome in children.

Early reports suggested that pediatric COVID-19 cases were less severe in children. Most children requiring intensive care admission in these reports had underlying medical conditions. Shortly after the surge of adult COVID-19 cases in Detroit, Michigan, previously healthy children began to present with shock with multiorgan dysfunction, elevated inflammatory markers, and physical exam findings with features of Kawasaki disease. This disease process was later called multisystem inflammatory syndrome in children (MIS-C.) In this case series, we describe three previously healthy children who presented with severe manifestations of MIS-C, including cardiogenic shock and profound systemic inflammation. These children developed severely depressed myocardial function with end-organ injury and were cannulated to veno-arterial extracorporeal membrane oxygenation (VA-ECMO) due to cardiogenic shock with arrhythmia. All three children improved with VA-ECMO support and anti-inflammatory treatment. All had complete recovery of myocardial function at discharge and 6-month follow-up with no significant morbidity.

Urothelial Rests, Incidental Finding in a Patient with Acute Appendicitis: A Case Report and Literature Review.

Background: Urothelial rests, also known as Walthard rests, are benign nests of epithelial cells that most often are found in the female gynecologic tract. Only four of these urothelial rests have been described in the appendix. Case report: A 10-year-old female underwent an appendectomy for appendicitis. Histologically, there was acute appendicitis, and an incidental urothelial rest was identified, confirmed by immunostains positive for p63, CK7, and negative for synaptophysin. CD34 highlighted a rim of endothelial cells. Conclusion: Urothelial rests, which often appear in the female gynecologic tract, can occur in other sites such as the appendix. These benign lesions require differentiation from neuroendocrine lesions. The rim of endothelial cells in our report supports a vascular migrational origin.

Minimally-invasive liver resection in pediatric patients: initial experience and outcomes.

BACKGROUND: Minimally Invasive Liver Resection (MILR) is an evolving procedure in the adult population for benign and malignant lesions, offering less morbidity while maintaining acceptable outcomes. However, there lacks a published MILR experience in the pediatric population besides case reports. This report describes a pediatric MILR experience in terms of pathology, clinical specifics, and patient outcomes. METHODS: This is a retrospective review of 36 pediatric patients undergoing MILR for benign and malignant conditions. MILR was performed by pure laparoscopy, hand-assisted laparoscopy, and a hybrid laparoscopic assisted method. Data points reviewed include patient demographics, pathology, operative technique, complications, and recurrence. RESULTS: Patients with benign (15) and malignant (21) conditions underwent segmentectomy, sectionectomy, or hemihepatectomy by MILR. Thirty-one were completed with pure laparoscopy and 20 underwent hemihepatectomy. Operative time and blood loss correlated with magnitude of resection with five patients requiring a blood transfusion. Complications were minor and included a seroma, port infection, port dehiscence, line infection, and hypertrophic scar. At median follow-up of 12 months (range 6-36 months), there were no mortalities, re-operations, or recurrences. DISCUSSION: MILR can be performed in pediatric patients for benign and malignant conditions with good technical and oncologic outcomes and low morbidity.

Nonpowder firearms cause significant pediatric injuries.

BACKGROUND: We hypothesize that nonpowder firearms cause significant injuries in children, often requiring intervention. We have noted a difference in demographics of children presenting with injuries from nonpowder firearms compared with patients injured by powder firearms. We reviewed our institution's experience with patients with nonpowder firearm injuries to evaluate these aspects. METHODS: A retrospective chart review was completed for all patients with a firearm injury from 2003 through February 2013 to a pediatric urban Level I trauma center. Patients were excluded if they were 18 years of age or older or readmitted. Demographics, injury circumstances, interventions, and outcomes were reviewed for 303 patients. The χ test and analysis of variance were completed with a statistical significance of p < 0.05. RESULTS: There were 57 nonpowder firearm injuries and 246 injuries from other firearms. Injuries occurred from BB, pellet, and paintball guns. Treatment included computed tomography scan in 39 patients, three bedside procedures, one angiography, and operative intervention in 25 patients. The most common injury locations were the eye (n = 37), head (n = 7), and neck (n = 6). Children injured by nonpowder firearms were less likely to be female (p = 0.04), more likely to be white (p < 0.01), and less likely to be injured in a violence-related event (p < 0.01). CONCLUSION: Nonpowder firearms can cause severe pediatric injuries requiring operative intervention and significant radiographic exposure from computed tomography scans. Prevention and education are important in decreasing this risk in the pediatric population and should be targeted to a different population than powder firearm prevention. LEVEL OF EVIDENCE: Epidemiologic study, level V.

Timing of optimal surgical intervention for neonates with necrotizing enterocolitis.

Up to half of all patients with necrotizing enterocolitis require acute surgical treatment. Determining when to operate on these patients can be challenging. Utilizing a combination of clinical and metabolic indicators, we sought to identify the optimal timing of surgical intervention. A retrospective chart review was conducted on patients with necrotizing enterocolitis from 2001 to 2010. Previously validated clinical (abdominal erythema, palpable abdominal mass, hypotension), radiographic (pneumoperitoneum, portal venous gas, fixed bowel loop, severe pneumatosis intestinalis), and laboratory (acidosis, bacteremia, hyponatremia, bandemia, neutropenia, thrombocytopenia) indicators were assessed for the ability to predict the need for acute surgical intervention as a simple indicator score, based on the sum of the indicators listed above. A total of 197 patients were included. One hundred and twenty-four procedures (28 peritoneal drains, 96 laparotomy) were performed on 122 patients (62%). Median indicator score was 4 (range: 0-8). Logistic regression identified abdominal erythema (odds ratio [OR] = 3.3, P = 0.001), acidosis (OR = 2.6, P = 0.004), and hypotension (OR = 1.9, P = 0.05) as independently associated with surgical intervention. A significant increase in surgical intervention was noted for patients with indicator score of 3 or more. In conclusion, if three or more indicators exist, operative intervention is very likely required. In the absence of pneumoperitoneum, abdominal erythema, acidosis, and hypotension are especially important.

Financial implication of proposed legislation on hospital reimbursement for the injured drunk driver.

The state of Michigan currently has no-fault automobile insurance with personal injury protection, providing anyone injured in motor vehicle collisions with unlimited medical and rehabilitation benefits and lost wage recovery. A new bill proposal, Michigan House Bill 5588, will eliminate hospital reimbursement for those who are found to be intoxicated at the time of a motor vehicle collision. These medical costs will be passed on to patients, which may result in a large reimbursement deficit for hospitals caring for these patients. This retrospective review examines the costs of caring for all intoxicated drivers who were admitted to a Level 1 trauma center after a motor vehicle collision over a 2-year period. Intoxicated drivers were younger (P = 0.0002), had a lower Glasgow Coma Scale (P = 0.0013), and were more likely to meet Level 1 trauma criteria (P = 0.0002). The sum of total charges for injured drunk drivers totaled $5.2 million. When taking into account fixed and variable costs of care, lost hospital net income would be $3 million (21.9%) over a 3-year span whether House Bill 5588 passes. In conclusion, the passage of House Bill 5588 will lead to a large financial burden for hospitals that treat intoxicated drivers.

Trends in pediatric firearm-related injuries over the past 10 years at an urban pediatric hospital.

PURPOSE: Firearm injuries are the second most common cause of trauma deaths in American children. We reviewed gunshot wounds treated at an urban children's hospital to determine the most likely time for injuries to occur over 10 years. METHODS: A retrospective chart review was completed for patients with a firearm injury from January 2003 to December 2012. Patients were excluded if over 17 years or readmitted. Demographics, injury circumstances, interventions, and outcomes were reviewed for 289 patients. Chi square and ANOVA analyses were completed. Alpha was chosen as p<0.05. RESULTS: Mean age was 12 years, 74% were male and 80% African American. Unintentional injuries occurred in 26% and violence related in 72%. The most common months of injury were August and June, the least common November and October. Unintentional injuries were more likely to occur during the day and violence related injuries were more likely at night (p=0.01). The incidence was lowest 2008-2010 and highest in 2006 and 2011. Mortality was 3.5%. CONCLUSIONS: We noted an increasing incidence of pediatric firearm related injuries in the last two years of the study with over half requiring operative intervention. Most injuries were violence related and occurred in a large city during summer months.

Raman spectroscopy in the diagnosis of ulcerative colitis.

INTRODUCTION: At present, the diagnosis of ulcerative colitis (UC) requires the histologic demonstration of characteristic mucosal inflammatory changes. A rapid and noninvasive diagnosis would be of value, especially if it could be adapted to a simple rectal probe. Raman spectroscopy creates a molecular fingerprint of substances by detecting laser light scattered from asymmetric, vibrating, and chemical bonds. We hypothesize that Raman spectroscopy can distinguish UC from non-UC colon tissue rapidly and accurately. MATERIALS AND METHODS: Colon tissue specimens were obtained from patients operated at the Children's Hospital of Michigan, United States, including UC colon and non-UC colon. The samples were examined with a Renishaw inVia Raman microscope (Gloucestershire, United Kingdom) with a 785 nm laser. Principal component analysis and discriminant function analysis were used to classify groups. Final classification was evaluated against histologic diagnoses using leave-one-out cross-validation at a spectral level. RESULTS: We compared Raman spectroscopy examination of colon specimens from four patients with UC and four patients without UC. A total of 801 spectra were recorded from colon specimens. We evaluated 100 spectra each from the mucosal and serosal surfaces of patients with UC and 260 spectra from the mucosal surface and 341 spectra from the serosal surface of the patients who did not have UC. For samples from the mucosal surface, the Raman analysis had a sensitivity of 82% and a specificity of 89%. For samples from the serosal surface, Raman spectroscopy had a sensitivity of 87% and a specificity of 93%. When considering each tissue sample and deciding the diagnosis based on the majority of spectra from that sample, there were no errors in the diagnosis. CONCLUSIONS: Raman spectroscopy can distinguish UC from normal colon tissue rapidly and accurately. This technology offers the possibility of real-time diagnosis as well as the ability to study changes in UC-afflicted colon tissue that do not appear histologically.

Timing of ostomy reversal in neonates with necrotizing enterocolitis.

INTRODUCTION: Most neonates with necrotizing enterocolitis (NEC) requiring laparotomy have bowel resection and intestinal diversion. At present, there is no consensus regarding the best time for enterostomy reversal. Our aim is to determine if there is any difference in outcomes of infants whose enterostomy was reversed early versus late. MATERIALS AND METHODS: We retrospectively reviewed medical records of patients with NEC admitted to the neonatal intensive care unit at a large urban children's hospital from 2002 to 2010. The patients underwent operative intervention with creation and subsequent reversal of stomas. Patient characteristics, operative characteristics, and postoperative care were recorded. RESULTS: A total of 206 neonates were diagnosed with NEC and 44 met the inclusion criteria. Seven had ostomies reversed within 8 weeks, 20 underwent reversal 8 to 12 weeks after initial operation, and 17 underwent ostomy reversal greater than 12 weeks from creation. Early reversal did not affect the incidence of total parenteral nutrition-associated cholestasis (p = 0.16), length of parenteral nutrition (p = 0.12), or ability to reach full enteral nutrition (p = 0.30). Ventilator days were not different (p = 0.08). We found no difference in contamination at laparotomy (p = 0.61) or adhesions at reversal (p = 0.73). Mortality rate (p = 0.15) and complications following reversal (p = 0.25) were not different. CONCLUSION: There is no advantage to early or late enterostomy reversal in the endpoints studied.

Enteral nutrition and total parenteral nutrition components in the course of total parenteral nutrition-associated cholestasis in neonatal necrotizing enterocolitis.

BACKGROUND: Newborns with necrotizing enterocolitis (NEC) are at high risk for the development of total parenteral nutritional-associated cholestasis (TPNAC). Patients with NEC were evaluated to determine risk factors for development of TPNAC and predictors of resolution. We hypothesized that there are additional factors relating to the timing of enteral nutrition or TPN components that effect development and persistence of TPNAC in patients with NEC that may be altered to decrease the chance of progression to liver failure. METHODS: This was a retrospective chart review of NEC patients from 2001 to 2010. TPNAC was defined as direct bilirubin ≥2 mg/dL, the level used for cholestasis in neonatal studies relating to TPNAC. RESULTS: Of 178 patients with NEC, 96 developed TPNAC, and in 27 TPNAC had resolved by discharge. Days of TPN did not affect TPNAC resolution by discharge (P = 1.0). TPNAC was less likely to occur in patients with body weights >1,500 g, enteral nutrition within the first week of life, no infection, fewer TPN days, and lesser hospital stay (P < .01). There were many factors affecting resolution of cholestasis. Enteral nutrition within 6 days of birth decreased development of TPNAC (P < .01), and resumption of enteral nutrition within 3 weeks after NEC diagnosis increased the resolution of cholestasis (P < .01). No component of TPN was important for the development or resolution of cholestasis. CONCLUSION: Of the factors that effect development and resolution of TPNAC in NEC, the ones that we can alter include early enteral feeds and surveillance for infection.

Angiosarcoma involving native abdominal aortic aneurysm sac after endograft repair.

Primary angiosarcoma of the aorta is a rare malignancy that is characterized by rapid proliferation and propensity for metastasis. It has been reported only 35 times in the surgical literature. This case report presents a 66-year-old man diagnosed with angiosarcoma of his native aorta 7 years after endograft repair of an abdominal aortic aneurysm. We then reviewed the world surgical literature for occurrence, tumorigenic studies, prognosis, and management of aortic angiosarcoma. Because native aortic tissue is retained after endovascular repair of an abdominal aortic aneurysm, the treating physician should have an awareness of this pathology and entertain the diagnosis as appropriate.