Variation in the use of laparoscopy with inguinal hernia repairs in a sample of pediatric patients at children's hospitals.

INTRODUCTION/BACKGROUND: Metachronous contralateral inguinal hernias (MCH) occur in approximately 10% of pediatric patients following unilateral inguinal hernia repairs (UIHR). Laparoscopic evaluation of the contralateral internal ring is a method of identifying high-risk individuals for prophylactic contralateral exploration and repair. OBJECTIVE: The objective of this study was to assess variation in utilization of diagnostic laparoscopy, and report costs associated with the evaluation of a contralateral patent processus vaginalis during hernia repair in pediatric hospitals. STUDY DESIGN: The Pediatric Health Information System database was searched to identify outpatient surgical encounters for pediatric patients with a diagnosis of inguinal hernia during a 1-year period (2014). Records were identified that contained diagnostic codes for unilateral or bilateral inguinal hernia in combination with a procedure code for open hernia repair with or without diagnostic laparoscopy. RESULTS: After exclusions there were 3952 hernia repairs performed at 30 hospitals; median age was 4 years (IQR 1-7), 78.8% were male, and 64.9% Caucasian. Three-quarters (76.7%) had UIHR, 8.6% had unilateral repairs with laparoscopy (UIHRL), 12.2% had bilateral inguinal hernia repairs (BIHR), and 2.4% had bilateral repairs with laparoscopy (BIHRL). Where laparoscopy was used, 78% resulted in a unilateral repair and 22% in a bilateral procedure. The percent of patients undergoing laparoscopy varied from 0 to 57% among hospitals, and 0-100% among surgeons. Pediatric surgeons were more than three times more likely to perform a diagnostic laparoscopy compared with pediatric urologists. Median adjusted costs were $2298 (IQR 1659-2955) for UIHR, $2713 (IQR 1873-3409) for UIHRL, $2752 (IQR 2230-3411) for BIHR, and $2783 (IQR 2233-3453) for BIHRL. Median costs varied over two-fold among hospitals ($1310-4434), and over four-fold among surgeons ($948-5040). DISCUSSION: Data suggested that <10% of patients with clinically unilateral inguinal hernias developed MCH. A negative diagnostic laparoscopy ensured that 0.9-1.31% developed MCH. However, up to 30% of patients underwent contralateral exploration/repair when diagnostic laparoscopy was used. The current study found increased costs associated with the use of laparoscopy, with considerable variation in costs among surgeons and hospitals. These data elucidate competing financial and clinical consequences associated with the use of diagnostic laparoscopy with clinically unilateral hernias. CONCLUSIONS: Variation existed in the use of laparoscopy during inguinal hernia repairs and associated costs within the current sample from children's hospitals in the United States. The additional costs of laparoscopic evaluation must be considered against the clinical utility and therapeutic consequences of identifying individuals with a higher risk of metachronous contralateral inguinal hernia.

Alarm safety and oxygen saturation targets in the Vermont Oxford Network iNICQ 2015 collaborative.

OBJECTIVES: To assess progress of neonatal intensive care units (NICUs) participating in the Vermont Oxford Network iNICQ 2015: Alarm Safety Collaborative in achieving Joint Commission 2014 alarm safety goals with respect to oximeters, and to compare patient-level oxygen saturation (SpO2) and oximeter alarm data to local policies. STUDY DESIGN: Prospective multicenter audits in February and August 2015 assessed implementation of policies addressing Joint Commission 2014 Alarm Safety goals, and ascertained SpO2 targets, oximeter alarm settings and compliance with policy-specified SpO2 targets and alarms. RESULTS: Eighty-six NICUs completed both audits. Of 13 policies addressing mandated goals, median (interquartile range) 8 (5, 9) policies were implemented at audit 1 and 9 (6, 11) at audit 2 (P=0.004). At audit 1, 28 NICUs had implemented ⩾9 policies versus 47 at audit 2. For 794 infants <31 weeks gestation, <36 weeks postmenstrual age, and on supplemental oxygen, median SpO2 target lower limit was 88% (interquartile range 87%, 90%; range 75% to 94%), upper limit 95% (interquartile range 94%, 96%; range 85% to 100%). High oximeter alarm was set according to local policy for 63% of infants, for whom SpO2 >97% was less frequent than when high alarm was not set to policy (10.1% vs 21.5%, P=0.006). CONCLUSIONS: Participating NICUs showed significant progress between audits in their implementation of Joint Commission Alarm Safety goals for oximeter monitoring. Oximeter high alarm not set per local policy is associated with increased hyperoxemia in preterm infants. Recommendations to standardize oxygen saturation targets for infants at risk for oxygenation-related outcomes have not been widely adopted.

A well-baby peer counseling program is not associated with human milk receipt in the NICU.

OBJECTIVE: Evaluate the impact of a non-neonatal intensive care unit (NICU)-specific peer counseling (PC) program on the cessation of human milk receipt at and post-NICU discharge. STUDY DESIGN: A multivariable logistic regression model used data from 400 mother-infant dyads from a level IV NICU to compare cessation of human milk receipt at NICU discharge by PC program status. Kaplan-Meier distributions and a multivariable Cox proportional hazards model assessed the relationship between participants/non-participants and cessation of human milk post-NICU discharge. RESULTS: No statistically significant differences between groups in cessation of human milk either by or post-discharge were observed. Identified variables associated with the outcome(s) of interest included maternal and infant age, length of stay, presence of a breastfeeding duration goal and frequency of NICU lactation consultant contact. CONCLUSION: Exposure to a non NICU-specific PC program was not associated with human milk receipt either by or post-NICU discharge.

Trends in treatment and in-hospital mortality for neonates with congenital diaphragmatic hernia.

OBJECTIVE: We performed a retrospective cohort study in order to examine recent trends in use of post-partum treatments and in-hospital mortality for congenital diaphragmatic hernia (CDH). STUDY DESIGN: Included were infants with CDH, born in 2003 to 2012 and hospitalized at ⩽7 days of age at one of 33 United States tertiary referral children's hospitals with extracorporeal membrane oxygenation (ECMO) programs. In-hospital mortality as well as use of ECMO, surfactant and a variety of vasodilators were examined for trends during the study period. RESULT: Inclusion criteria were met by 3123 infants with CDH. Among 2423 term or near-term infants, odds of death decreased annually for those with isolated or complex CDH. For 700 premature or low-birth weight infants with CDH, in-hospital mortality did not change. Among treatments for CDH, increasing with time in the study cohort were use of milrinone and sildenafil individually, and use of multiple vasodilators during the hospitalization. CONCLUSION: Survival improved in large subgroups of term or near-term infants with CDH in this 10-year multicenter cohort, temporally associated with increasing use of multiple vasodilators. Use of vasodilators for infants with CDH is increasing despite a lack of evidence supporting efficacy or safety. Prospective research is needed to clarify specific causal effects contributing to improving survival in these infants.

Transcribed oxygen saturation vs oximeter recordings in very low birth weight infants.

OBJECTIVE: The objective of this study was to compare hand-transcribed oxygen saturation (SpO2) with electronic oximeter data in very low birth weight infants (VLBWI, <1500 g). STUDY DESIGN: Oximeter data were downloaded from birth through 36 weeks postmenstrual age (PMA) for VLBWI before and after interventions to improve neonatal intensive care unit oxygen management. Transcribed SpO2 values were obtained by chart review. Proportions of transcribed and oximetry data in target (85 to 93%), hypoxemic (80 to 84%), and hyperoxemic (≥98%) ranges before and after intervention were compared. RESULT: There were 30,441 oximetry hours before intervention and 54,538 oximetry hours after intervention. Transcribed SpO2 values correlated strongly with oximeter overall. However, during hours on supplemental oxygen, transcribed values significantly overdocumented target range and underdocumented values 80 to 84 and ≥98%. This finding varied by respiratory support and PMA, and increased after intervention. CONCLUSION: Transcribed SpO2 values overdocumented target range and underdocumented hyperoxemic and hypoxemic ranges compared with electronic oximeter data. These results support incorporating electronic oximeter data into medical records.

Diuretics for very low birth weight infants in the first 28 days: a survey of the U.S. neonatologists.

OBJECTIVE: The objective of this study was to describe factors influencing diuretic use by neonatologists caring for very low birth weight neonates. STUDY DESIGN: We surveyed 400 U.S. neonatologists. Respondents made therapeutic decisions in clinical scenarios involving very low birth weight infants at 7, 14 and 28 days of age. RESULT: Response rate was 39%. Diuretic therapy was chosen in 31% of scenario decisions, with pro re nata dosing selected early and regular dosing more common at later ages. Diuretic use was strongly associated with method of respiratory support, and was chosen less often by those also choosing fluid restriction and those concerned about patent ductus arteriosus risk. After adjusting for these factors, excessive weight gain, expected improvement in work of breathing and expected decrease in ventilator days were also associated with diuretic use. CONCLUSION: The extent of and expectations for diuretic therapy by neonatologists caring for very low birth weight neonates may exceed evidence for efficacy.

Cumulative illness severity and progression from moderate to severe retinopathy of prematurity.

OBJECTIVE: To test cumulative neonatal illness severity (IS) and IS fluctuation as predictors of progression from moderate to severe retinopathy of prematurity (ROP). METHODS: Data from research databases and medical record review were collected for infants from four neonatal intensive care unit (NICUs) admitted between 1995 and 2001 and diagnosed with prethreshold ROP. Cumulative neonatal IS measured using daily Scores for Neonatal Acute Physiology (SNAP) for the first 28 days of life, and IS fluctuation as assessed by summing changes between daily SNAP scores, were tested as predictors of progression to threshold ROP using logistic regression. RESULTS: Infants progressing to threshold (n=79), compared to those not progressing to threshold (n=130), had significantly (P<0.05) lower gestational ages (25.2+/-1.1 versus 25.8+/-1.4 weeks), higher cumulative neonatal SNAP (255+/-77 versus 224+/-63 weeks) and had more severe hospitalizations as indicated by diagnoses and medical management. In regression analysis, gestational age, chronological age and presence of plus disease at first diagnosis of prethreshold were associated with development of threshold. After adjusting for these factors, cumulative neonatal SNAP was significantly associated with progression to threshold. However, addition of cumulative SNAP to the model only increased receiver-operating characteristic curve area from 0.77 to 0.78 (NS). Other factors, including SNAP fluctuation, were not associated with progression to threshold after adjustment using this model. CONCLUSIONS: Cumulative neonatal IS, as measured by cumulative SNAP, is an independent risk factor for progression from moderate to severe ROP. However, cumulative IS does not enhance assessment of risk for ROP progression after adjusting for simpler clinical factors.

Neonatal progeroid syndrome: more than one disease?

We report on an infant with the neonatal progeroid syndrome whose clinical course and autopsy findings indicate that this may be a heterogeneous phenotype. The infant had intrauterine growth retardation, absence of subcutaneous fat, and a wizened, aged face, all apparently characteristic of the condition, but also had congenital heart defects and urinary reflux not reported in previous cases. An elevated maternal serum alpha fetoprotein was noted at 16 weeks of gestation and late-onset growth retardation appeared after 31 weeks. Autopsy findings showed normal cerebral myelination, in contrast to findings of sudanophilic leukodystrophy in the one patient with the syndrome previously examined at autopsy. These findings suggest that the neonatal progeroid syndrome may be a phenotype and have more than one cause.