Pediatric surgical site infection in the developing world: a Kenyan experience.

BACKGROUND: The purpose of the current study was to determine the incidence of pediatric surgical site infections(SSIs) at an academic children's hospital in rural sub-Saharan Africa and to identify potentially modifiable risk factors. METHODS: Prospectively collected data from 1,008 surgical admissions to Bethany Kids Kijabe Hospital (Kijabe, Kenya) were analyzed retrospectively. Follow-up data were available in 940 subjects. RESULTS: SSIs occurred in 6.8% of included subjects(N = 64). Superficial (69%) and deep (29%) infections of the back (38%) and head (25%) were most common. When comparing children who developed SSI to those who did not, we found that wound contamination classification and duration of operation were the only variables with significant differences between groups. CONCLUSIONS: Our rate of SSI among pediatric patients insub-Saharan Africa is the lowest reported in the literature to date. More work is needed to identify modifiable risk factors for pediatric SSI in low- and middle-income countries.

Contemporary pediatric splenectomy: continuing controversies.

PURPOSE: We undertook the current study to update the literature on pediatric splenectomy in the age of minimally invasive proficiency among pediatric surgeons. The study is designed to address specific concerns among surgeons about the suitability of the laparoscopic approach in specific situations and among hematologists about the relative benefits and risks of splenectomy in children. METHODS: Retrospective analysis of clinicopathologic data for 118 children who underwent open (OS) or laparoscopic (LS) splenectomy at an urban tertiary children's hospital from January 2000 to July 2008. RESULTS: One hundred and three cases (87%) were started as LS. Operative times were equivalent for LS and OS (P = 0.8). In the LS group, there were four conversions (3.9%) from LS to OS and five early post-operative complications (4.9%). Median length of stay was 2 days for LS and 4 days for both OS and LS converted to OS (P < 0.0001). The ten largest spleens removed by LS had greater mass (P = 0.02) and tended to have greater volume (P = 0.1) than those removed by OS. Children with hereditary spherocytosis, ITP, and hemoglobinopathy had favorable clinical outcomes, regardless of operative approach. There were no cases of overwhelming post-splenectomy sepsis in this series. CONCLUSIONS: Laparoscopic splenectomy is the preferred approach for splenectomy in children with hematological diseases, with or without splenomegaly. Compared to open splenectomy, laparoscopic splenectomy has equivalent operative time and improved length of stay. Both approaches have excellent therapeutic outcomes for appropriate indications.

Pediatric thyroidectomy: a collaborative surgical approach.

INTRODUCTION: We have developed a collaborative approach to pediatric thyroid surgery, with operations performed at a children's hospital by a pediatric surgeon and an endocrine surgeon. We hypothesize that this strategy minimizes specialist-specific limitations and optimizes care of children with surgical thyroid disease. METHODS: Data from all partial and total thyroidectomies performed by the pediatric-endocrine surgery team at a tertiary children's hospital between 1995 and 2009 were collected and analyzed retrospectively. Statistical analyses were performed with IBM SPSS software (SPSS, Chicago, IL). RESULTS: Thirty-five children met the inclusion criteria (69% female; median age, 13 years; median follow-up, 1119 days). The indications for operation were thyroid nodule (71%), genetic abnormality with predisposition to thyroid malignancy (17%), multinodular goiter (5.7%), Grave disease (2.9%), and Hashimoto thyroiditis (2.9%). Sixteen children (46%) underwent thyroid lobectomy, and 19 children (54%) underwent total thyroidectomy. Median length of stay was 1 day (1 day after lobectomy vs 2 days after total thyroidectomy, P < .0001). There were 4 cases of transient hypocalcemia after total thyroidectomy, but there were no nerve injuries or other in-hospital complications in either group (overall complication rate, 11%). CONCLUSIONS: For pediatric thyroidectomy and thyroid lobectomy, collaboration of high-volume endocrine and pediatric surgeons as well as pediatric endocrinologists at a dedicated pediatric medical center provides optimal surgical outcomes.

Neonatal resuscitation skills among pediatricians and family physicians: is residency training preparing for postresidency practice?

BACKGROUND: Pediatricians and family physicians are responsible for providing newborn resuscitation, yet Accreditation Council for Graduate Medical Education requirements for training in this area during residency differ markedly for the two specialties. Our objectives were to determine (1) the extent to which neonatal resuscitation training differs for pediatric and family medicine residents; (2) the extent to which general pediatricians and family physicians engage in newborn resuscitation in their practice; and (3) whether use of resuscitation skills differs between urban/suburban and rural providers. METHODS: We surveyed a national cohort of pediatricians and family physicians who obtained board certification between 2001 and 2005. Data were analyzed based on type of physician and setting of current practice. RESULTS: Survey response rate was 22% (382 of 1736). Compared with family medicine physicians, pediatricians received more neonatal resuscitation training during residency. Most members of both groups had attended no deliveries in the year prior to the survey (75% [111 of 148] versus 74% [114 of 154]). In their current practice, the groups were equally likely to have provided a newborn bag and mask ventilation, chest compressions, and resuscitation medications. Pediatricians were more likely than family physicians to have attempted to either intubate a newborn (20% [28 of 148] versus 10% [16 of 153]; P  =  .0495) or insert umbilical catheters (15% [22 of 148] versus 5% [8 of 153]; P  =  .005). Regardless of specialty, rural physicians were much more likely to report that they attended deliveries (61% [41 of 67] versus 15% [36 of 234]; P < .001). Among rural pediatricians attending deliveries, 44% (7 of 16) reported feeling inadequately prepared for at least one delivery in the past year. CONCLUSIONS: Few primary care pediatricians and family physicians provide newborn resuscitation after residency. For those who do attend deliveries, current training 5 provide insufficient preparation. Flexible, individualized residency curricula could target intensive resuscitation training to individuals who plan to practice in rural areas and/or attend deliveries after graduation.

The inflammatory response to injury in children.

PURPOSE OF REVIEW: Severely injured children have a decreased incidence and different pattern of multiple organ failure when compared with adults. This article reviews recent advances in understanding the mechanisms leading to this discrepancy. RECENT FINDINGS: Post injury, inflammation-related outcomes are age-related, as demonstrated by epidemiological and laboratory investigations that confirm a relative protection from acute lung injury and multiple organ failure in children. The importance of the innate immune system in initiating and regulating the inflammatory response to injury is also increasingly well understood, but relatively little research has focused on the implications of a maturing innate immune system for the inflammatory response to injury in children. The development of age-appropriate immunomodulatory interventions for the prevention and treatment of postinjury inflammatory dysregulation depends on continued investigation of mechanisms responsible for the unique pediatric inflammatory response to trauma. SUMMARY: The inflammatory response to injury in children is functionally and mechanistically unique, as suggested by age-related differences in the incidence and pattern of systemic inflammation and multiple organ failure after major trauma. We review the current clinical and basic science literature related to postinjury inflammation in childhood, focusing on the developmental biology of innate immunity and the implications of a maturing immune system for trauma-related interventions and outcomes.

Operative vs nonoperative management of blunt pancreatic trauma in children.

PURPOSE: The aim of this study was to evaluate the outcome of nonoperative vs operative management of blunt pancreatic trauma in children. METHODS: Retrospective review of pancreatic injuries from 1995 to 2006 at an urban level I regional pediatric trauma center. RESULTS: Forty-three children with pancreatic injury were included in the analysis. Injuries included grade I (n = 18), grade II (n = 6), grade III (n = 17), and grade IV (n = 2). For grade II to IV injuries, patients managed operatively (n = 14) and nonoperatively (n = 11) had similar lengths of stay and rates of readmission, despite increased pancreatic complications (PCs) in the nonoperative cohort (21% vs 73%; P = .02). There was a trend toward increased non-PCs in patients managed with resection (P = .07). Twelve patients underwent successful diagnostic endoscopic retrograde cholangiopancreatography in which duct injury was identified. In this group, nonoperative management was pursued in 6 patients but was associated with increased rates of PC (86% nonoperative vs 29% operative; P = .02). CONCLUSIONS: Operative management of children with grades II to IV pancreatic injury results in significantly decreased rates of PCs but fails to decrease length of stay in the hospital, possibly as a result of non-PCs. Endoscopic retrograde cholangiopancreatography may serve as a useful diagnostic modality for guiding operative vs nonoperative management decisions.

Predicting response to splenectomy in children with immune thrombocytopenic purpura.

PURPOSE: Predicting the response to splenectomy in children with immune thrombocytopenic purpura (ITP) continues to be a clinical challenge. The purpose of this study is to identify preoperative predictors of outcome for splenectomy in children with ITP. METHODS: The charts of 19 children who underwent splenectomy for ITP were retrospectively reviewed. Platelet responses to treatment are categorized as complete response (CR, > or =150,000/microL), partial response (PR, > or =50,000 but <150,000/microL), or nonresponse (NR, <50,000/microL). RESULTS: After splenectomy, 13 patients (68%) had CR, 3 (16%) had PR, and 3 (16%) had NR. No correlation existed between CR to splenectomy and any of the following: age, platelet count at diagnosis, last platelet count before splenectomy, platelet count on postoperative day 1, or responses to preoperative intravenous immunoglobulin, WinRho, or Rituximab. However, all 7 patients who had NR to a full course of steroids subsequently had CR to splenectomy. Nonresponse to steroid therapy was directly correlated with CR to splenectomy (P = .01, Fisher's Exact test). Furthermore, postsplenectomy platelet counts were inversely related to peak platelet response to steroids (correlation coefficient = -0.68, P = .01). CONCLUSIONS: Preoperative responsiveness to steroid therapy, as measured by peak platelet count, predicts NR to splenectomy for ITP in children, whereas NR to steroid therapy is highly correlated with CR to splenectomy. These findings challenge the widely held notion that steroid responsiveness portends a favorable outcome after splenectomy.

Serum sickness following rabbit antithymocyte-globulin induction in a liver transplant recipient: case report and literature review.

Thymoglobulin (Genzyme, Cambridge, MA) is an antithymocyte globulin preparation used for induction immunosuppression therapy in solid organ transplantation. It is being utilized with increasing frequency in orthotopic liver transplantation (OLT) in an effort to minimize or delay the use of calcineurin inhibitors due to their inherent nephrotoxicity. Experience with thymoglobulin in OLT remains limited. We report a case of serum sickness in a patient who received thymoglobulin following OLT. The patient experienced intermittent fevers, polyarthralgia, and acute renal failure 9 days after completion of thymoglobulin administration. The patient's symptoms resolved rapidly and completely with a course of intravenous steroids. We review a set of diagnostic criteria for serum sickness and emphasize the importance of early recognition of the process. Early treatment of serum sickness with steroids or plasmapheresis is highly effective and can reduce unnecessary morbidity from this unusual sequela of induction immunosuppression with antithymocyte globulin.

Publication rates of abstracts presented at annual musculoskeletal tumor society meetings.

Beware of the unpublished abstract! What is the publication rate of abstracts presented at Musculoskeletal Tumor Society meetings, and how does this compare with other orthopaedic and medical meetings? Three hundred thirty-six podium presentations from six annual meetings were identified and their publication was searched at a minimum of 3 years after the event. An effort was made to determine what percent of these abstracts eventually were published in a peer-reviewed journal. It was determined that 137 abstracts were published for a publication rate of 41%. The average time between presentation at the meeting and publication was 21.8 plus or minus 13.5 months. The published articles appeared in 48 peer-reviewed journals. The rate of publication and time until publication was similar to other orthopaedic meetings and to other medical disciplines. Changes to the cohort, title, or authors occurred in approximately (1/3) of the published articles compared with the abstracts. These results suggest that for various reasons the majority of presented material at Musculoskeletal Tumor Society meetings may not survive peer review and may not be scientifically valid.