Background Well-differentiated thyroid cancer is the most common endocrine malignancy in children. Adult literature has demonstrated socioeconomic disparities in patients undergoing thyroidectomy, ...but the effects of socioeconomic status on the management of pediatric well-differentiated thyroid cancer remains poorly understood. Methods Patients ≤21 years of age with well-differentiated thyroid cancer remains were reviewed from the National Cancer Data Base. Three socioeconomic surrogate variables were identified: insurance type, median income, and educational quartile. Tumor characteristics, diagnostic intervals, and clinical outcomes were compared within each socioeconomic surrogate variable. Results A total of 9,585 children with well-differentiated thyroid cancer remains were reviewed. In multivariate analysis, lower income, lower educational quartile, and insurance status were associated with higher stage at diagnosis. Furthermore, lower income quartile was associated with a longer time from diagnosis to treatment ( P < .002). Similarly, uninsured children had a longer time from diagnosis to treatment (28 days) compared with those with government (19 days) or private (18 days) insurance ( P < .001). Despite being diagnosed at a higher stage and having a longer time interval between diagnosis and treatment, there was no significant difference in either overall survival or rates of unplanned readmissions based on any of the socioeconomic surrogate variables. Conclusion Children from lower income families and those lacking insurance experienced a longer period from diagnosis to treatment of their well-differentiated thyroid cancer remains. These patients also presented with higher stage disease. These data suggest a delay in care for children from low-income families. Although these findings did not translate into worse outcomes for well-differentiated thyroid cancer remains, future efforts should focus on reducing these differences.
Abstract Background Viscoelastic monitoring (VEM), including TEG® (thromboelastography) and ROTEM® (rotational thromboelastometry) in the setting of goal directed hemostatic resuscitation has been ...shown to improve outcomes in adult trauma. The American College of Surgeons (ACS) Committee on Trauma recommends that “thromboelastography should be available at Level I and Level II trauma centers”. The purpose of this study is to determine the current availability and utilization of VEM in pediatric trauma. Methods After IRB and Pediatric Trauma Society (PTS) approval, a survey was administered to the current members of the PTS via Survey Monkey®. The survey collected demographic information, hospital and trauma program type, volume of trauma admissions, and use and/or availability of VEM for pediatric trauma patients. Results We received 107 responses representing 77 unique hospitals. Survey respondents were: 61% physicians, 29% nurses, 6% trauma program managers, and 4% NPs/PAs. Over half of providers worked in a free standing children’s hospital. Seventy-seven percent of respondents were from hospitals that had > 200 trauma admissions/year, 42% were providers at ACS Level 1 pediatric trauma centers, and 62% practiced at State Level 1 designated centers. VEM was available to 63% of providers, but only 31% employed VEM in pediatric trauma patients. For those who had no VEM available, over 73% would utilize this technology if it was available. Seventy-one percent of providers continue to rely on conventional coagulation assays (CCA) to monitor coagulopathy in pediatric trauma patients after admission. Conclusions While a growing body of evidence demonstrates the benefit of viscoelastic hemostatic assays in management of adult traumatic injuries, VEM during active resuscitation is infrequently used by pediatric trauma providers, even when the technology is readily available. This represents a timely and unique opportunity for quality improvement in pediatric trauma.
Background Surgical wound classification, introduced in 1964, stratifies the risk of surgical site infection (SSI) based on a clinical estimate of the inoculum of bacteria encountered during the ...procedure. Recent literature has questioned the accuracy of predicting SSI risk based on wound classification. We hypothesized that a more specific model founded on specific patient and perioperative factors would more accurately predict the risk of SSI. Study Design Using all observations from the 2012 to 2014 pediatric National Quality Surgical Improvement-Pediatric (NSQIP-P) Participant Use File, patients were randomized into model creation and model verification datasets. Potential perioperative predictive factors were assessed with univariate analysis for each of 4 outcomes: wound dehiscence, superficial wound infection, deep wound infection, and organ space infection. A multiple logistic regression model with a step-wise backwards elimination was performed. A receiver operating characteristic curve with c-statistic was generated to assess the model discrimination for each outcome. Results A total of 183,233 patients were included. All perioperative NSQIP factors were evaluated for clinical pertinence. Of the original 43 perioperative predictive factors selected, 6 to 9 predictors for each outcome were significantly associated with postoperative SSI. The predictive accuracy level of our model compared favorably with the traditional wound classification in each outcome of interest. Conclusions The proposed model from NSQIP-P demonstrated a significantly improved predictive ability for postoperative SSIs than the current wound classification system. This model will allow providers to more effectively counsel families and patients of these risks, and more accurately reflect true risks for individual surgical patients to hospitals and payers.
Abstract Background Recent advances in renal replacement therapy (RRT) have brought about a proliferation of dialysis in neonates (<30 days). This study aimed to assess morbidity and mortality ...following RRT initiation in this population. Methods Retrospective chart review of all patients between 2006 and 2014 requiring RRT initiated in the first 30 days of life was performed. Results Forty-nine patients were identified, 39 boys and 10 girls. Thirty-two patients (65%) had end stage renal disease, 11 (22%) had errors of metabolism and 6 (12%) required RRT for other pathologies. Median age and weight at RRT onset were 6 (4-14) days and 3.1 (2.7-4.0) kg, respectively. Total of 201 surgeries were performed. Excluding catheter revisions, 83 new hemodialysis and 28 new peritoneal-dialysis lines were placed, with maximum of 6 hemodialysis and 4 peritoneal catheters placed in single patient. Catheter-associated morbidities occurred in 100% of patients. Most common complications for hemodialysis included circuit clotting (87%), bleeding (68%) and bacteremia (50%). Peritoneal dialysis complications included peritonitis (83%), malpositioned catheters (72%), and leaks (55%). Overall mortality was 65.3%, with 56% of all deaths occurring within first month of life and 94% occurring within first year. Among long-term survivors (median follow-up of 5.3 years), 44% were severely and 22% moderately developmentally delayed. Conclusions While RRT is becoming more technically feasible for neonates with renal and metabolic diseases, it remains associated with significant morbidity and mortality. Pediatric surgeons must be aware of the challenges, taking them into account when considering the care of these critically ill children.
Abstract Background Gastric fundoplication is the most common noncardiac operation in children with congenital cardiac disease. While prior studies validated safety of laparoscopy in this population, ...we hypothesize that children with cardiac risk factors (CRFs) are likelier to undergo open fundoplication (OF) but experience greater morbidity than after laparoscopic fundoplication (LF). Materials and methods Utilizing 2013 National Surgical Quality Improvement Program-Pediatrics Public-Use-File, pediatric patients undergoing LF and OF were stratified to none, minor, major, or severe CRFs. Multivariate logistic regression determined preoperative variables and postoperative outcomes associated with LF or OF. Results A total of 1501 fundoplication patients were identified with 92% undergoing LF. OF patients were likelier to have minor (odds ratio OR: 2.36, P < 0.001), major (OR: 2.41, P = 0.003), and severe CRFs (OR: 4.36, P < 0.001). Children ≤ 1 y (OR: 3.38, P = 0.048) and those with tracheostomy were likelier to have OF (OR: 2.3, P = 0.006). Overall, the OF group had higher postoperative morbidity (OR: 2.41, P < 0.001). Specifically, children with minor or major CRFs experienced more complications following OF compared to LF. Conclusions OF is more common in patients ≤1 y old; patients with minor, major, or severe CRFs; and those with tracheostomy. LF should be considered in children with minor and major CRFs, as OF in those patients results in greater pulmonary, infectious, and hematological sequelae.
PDF
