Abstract Background For a number of pediatric and adult conditions, morbidity and mortality are increased when patients present to the hospital on a weekend compared to weekdays. The objective of ...this study was to compare pediatric surgical outcomes following weekend versus weekday procedures. Methods Using the Nationwide Inpatient Sample and the Kids’ Inpatient Database, we identified 439,457 pediatric (< 18 years old) admissions from 1988 to 2010 that required a selected index surgical procedure (abscess drainage, appendectomy, inguinal hernia repair, open fracture reduction with internal fixation, or placement/revision of ventricular shunt) on the same day of admission. Outcome metrics were compared using logistic regression models that adjusted for patient and hospital characteristics as well as procedure performed. Results Patient characteristics of those admitted on the weekend (n = 112,064) and weekday (n = 327,393) were similar, though patients admitted on the weekend were more likely to be coded as emergent (61% versus 53%). After multivariate adjustment and regression, patients undergoing a weekend procedure were more likely to die (OR 1.63, 95% CI 1.21–2.20), receive a blood transfusion despite similar rates of intraoperative hemorrhage (OR 1.15, 95% CI 1.01–1.26), and suffer from procedural complications (OR 1.40, 95% CI 1.14–1.74). Conclusion Pediatric patients undergoing common urgent surgical procedures during a weekend admission have a higher adjusted risk of death, blood transfusion, and procedural complications. While the exact etiology of these findings is not clear, the timing of surgical procedures should be considered in the context of systems-based deficiencies that may be detrimental to pediatric surgical care.
Extensive literature has proved that the Nuss procedure leads to permanent remodeling of the chest wall in pediatric patients with pectus excavatum (PE). However, limited long-term follow-up data are ...available for adults. Herein, we report a single-institution experience in the management of adult PE with the Nuss procedure, evaluating long-term outcomes and overall patient satisfaction after bar removal.
Adult patients who underwent PE repair with a modified Nuss procedure between January 1998 and June 2011 were retrospectively identified. Outcomes of interest were postoperative pain, recurrence, and patient satisfaction. A modified single-step Nuss questionnaire was administered to evaluate patient satisfaction and quality-of-life improvement after PE repair.
Ninety-eight patients with a median age of 30.9 years (range, 21.8 to 55.1 years) at the time of repair were identified. One bar was placed in most patients (89.7%). Four patients (4.1%) required reoperation for bar displacement. Results after bar removal were overall satisfactory in 94.4% of patients; 2 patients required reoperation for recurrence. Thirty-nine patients participated in the survey. Satisfaction with chest appearance was reported by 89.7% of responders. Seven patients reported dissatisfaction with the overall results; the most common complaints were severe postoperative chest pain and dissatisfaction with surgical scars.
Favorable long-term results can be achieved with the Nuss procedure in adults. However, postoperative pain may require a more aggressive analgesic regimen, and it may be the overriding factor in the patient's perception of the quality of the postoperative course.
Pectus excavatum (PE) can be associated with congenital and acquired cardiac disorders that also require surgical repair. The timing and specific surgical technique for repair of PE remains ...controversial. The present study reports the experience of combined repair of PE and open heart surgery at Johns Hopkins Hospital.
A retrospective case review was conducted of all patients who presented for repair of PE deformity while undergoing concurrent open heart surgery from 1998 through 2011.
A total of 9 patients met inclusion criteria. All patients had a connective tissue disorder. Repair of PE was performed by modified Nuss technique after completion of the cardiac procedure, performed through a median sternotomy. Open heart procedures were either aortic root replacement or mitral valvuloplasty. Eight patients had bar removal after an average period of 30.3 months. No PE recurrence, bar displacement, or upper sternal depression was reported in 7 patients. Postoperatively, 1 patient exhibited pectus carinatum after a separate spinal fusion surgery for scoliosis. One patient died of unrelated cardiac complications before bar removal.
Simultaneous repair of PE and open heart surgery is safe and effective. We recommend that the decision to perform a single-stage versus a multistage procedure should be reserved until after the cardiac procedure has been completed. In such cases, the Nuss technique allows for correction of the pectus deformity with good long-term cosmetic and functional results.
Abstract Background Optimal management of recurrent pectus excavatum (PE) has not been established. Here, we review our institutional experience in managing recurrent PE to evaluate long-term ...outcomes and propose an anatomic classification of recurrences, and a decision-making algorithm. Methods Clinical records of patients undergoing repair of recurrent PE (1996–2011) were reviewed. Univariate and multivariate logistic regression analyses were employed to examine patient characteristics as potential predictors for re-recurrence. Results Eighty-five patients with recurrent PE were identified during the study period. The initial operation was a Ravitch procedure in 85% of cases. Revision procedures were most frequently Nuss repairs ( N = 73, 86%), with remaining cases managed via open approach. Overall cosmetic and functional results were satisfactory in 67 patients (91.8%) managed with Nuss and in 7 (58%) patients managed with other techniques. Seven (8%) patients required additional surgical revision. Multivariate analysis identified no statistically significant patient or procedural factors predictive of re-recurrence. Conclusion This study demonstrates that the Nuss procedure can be an effective intervention for recurrent pectus excavatum, regardless of the initial repair technique. However, open repair remains valuable when managing severe cases with abnormalities of the sternocostal junction and cartilage regrowth under the sternum.
Purpose
The structural connectome is a comprehensive structural description of the network of elements and connections forming the brain. In recent years, this framework has progressively been used ...to investigate the pediatric brain.
Methods
We discuss the different steps and emphasize key technical aspects required for the successful reconstruction, analysis, and visualization of the pediatric structural connectome using current state-of-the-art neuroimaging and post-processing techniques.
Results
The two key components of structural connectome are a node (a cortical region obtained with high-resolution anatomical imaging) and an edge (structural association between cortical regions, defined with tractography). After delineation of nodes and edges, an association matrix can be generated by compiling all pairwise associations between nodes and applying a threshold to produce a binary adjacency matrix. Several measures can be used to characterize the topological architecture of the brain’s networks. Finally, we provide an overview of various visualization methods of the structural connectome in children.
Conclusion
The human connectome is the culmination of more than a century of conceptual and methodological innovation. Biological substrates of brain development such as cortical gyration and myelination challenge the acquisition, reconstruction, and analysis of structural connectome in children and require specific considerations compared to adults.
Abstract Background The safety and efficacy of minimally invasive pectus excavatum repair have been demonstrated over the last twenty years. However, technical details and perioperative management ...strategies continue to be debated. The aim of the present study is to review a large single-institution experience with the modified Nuss procedure. Methods A retrospective review was performed of patients who underwent primary pectus excavatum repair at a single tertiary hospital via a modified Nuss procedure that included: no thoracoscopy, retrosternal dissection achieved via a left-to-right thoracic approach, four-point stabilization of the bar, and no routine epidural analgesia. Data collected included demographics, preoperative symptoms, operative characteristics, hospital charges and postoperative outcomes. Results A total of 336 pediatric patients were identified. No cardiac perforations occurred and the rate of pericarditis was 0.6%. Contemporary rates of bar displacement have fallen to 1.2%. Routine use of chlorhexidine scrub reduced superficial site infections to 0.7%. Two patients (0.6%) with severe recurrence required reoperation. Bars were removed after an average period of 31.7(SD 13.2) months, with satisfactory cosmetic and functional results in 94.9% of cases. Conclusions We report here a single-institution large volume experience, including modifications to the Nuss procedure that make the technique simpler and safer, improve results, and minimize hospital charges.
Abstract Background Advances in surgical technique for pectus excavatum repair continue to change practice patterns. The present study examines trends in operative age in a nationwide administrative ...database. Methods A cross-sectional descriptive analysis was performed using the Nationwide Inpatient Sample (NIS) and Kids’ Inpatient Database (KID) data from 1998 to 2009. Pediatric discharges involving surgical repair of pectus excavatum were selected. Patients were sub-grouped by age at operation and calendar year of repair for further comparison. Results A total of 5830 elective admissions were identified that met inclusion criteria. Mean age at operation was 13.5 years, and this increased from 11.8 years to 14.4 years over the period studied and was accompanied by narrowing of the interquartile range. Examined over groups of four calendar years, patient age at the time of repair was significantly higher in more recent years in both unadjusted and multivariate analyses ( P < .001). Conclusions The age at operation in this sample has steadily increased, with an accompanying decrease in variability. This is consistent with previous findings and with overall trends in patient selection reported in the literature. This selection pattern may reflect evolving consensus regarding optimal management of pectus excavatum and provide clinical guidance regarding appropriate referral and intervention.
The complexity and high cost of neonatal and pediatric intensive care has generated increasing interest in developing measures to quantify the severity of patient illness. While these indices may ...help improve health care quality and benchmark mortality across hospitals, comprehensive understanding of the purpose and the factors that influenced the performance of risk stratification indices is important so that they can be compared fairly and used most appropriately. In this review, we examined 19 indices of risk stratification used to predict mortality in critically ill children and critically analyzed their design, limitations, and purposes. Some pediatric and neonatal models appear well-suited for institutional benchmarking purposes, with relatively brief data acquisition times, limited potential for treatment-related bias, and reliance on diagnostic variables that permit adjustment for case mix. Other models are more suitable for use in clinical trials, as they rely on physiologic variables collected over an extended period, to better capture the interaction between organ systems function and specific therapeutic interventions in acutely ill patients. Irrespective of their clinical or research applications, risk stratification indices must be periodically recalibrated to adjust for changes in clinical practice in order to remain valid outcome predictors in pediatric intensive care units. Longitudinal auditing, education, training, and guidelines development are also critical to ensure fidelity and reproducibility in data reporting.
Conclusion
: Risk stratification indices are valid tools to describe intensive care unit population and explain differences in mortality.
Noonan syndrome is a genetic condition that can present with complex thoracic defects, the management of which often presents a surgical challenge. We present the surgical approach applied to a ...severe combined excavatum/carinatum deformity that had resulted in a Z-type configuration of the chest in a 9-year-old girl with Noonan syndrome.
Operative management of acquired Jeune's syndrome Sacco Casamassima, Maria Grazia; Goldstein, Seth D; Salazar, Jose H ...
Journal of pediatric surgery,
2014, January 2014, 2014-Jan, 2014-1-00, 20140101, Letnik:
49, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Abstract Background Acquired Jeune's syndrome is a severe iatrogenic deformity of the thoracic wall following a premature and aggressive open pectus excavatum repair. We report herein our technique ...and experience with this rare condition. Methods From 1996 to 2011, nineteen patients with acquired Jeune's syndrome were retrospectively identified in a tertiary referral center. The technique used to expand and reconstruct the thoracic wall consisted of 1) release of the sternum from fibrous scar tissue, 2) multiple osteotomies along the lateral aspect of the ribs with anterior advancement of costal-cartilages to protect the heart, 3) stabilization of the thorax by placing a curved bar for retrosternal support and, 4) restoration of the sterno-costal junction by wiring the lower cartilages to the edge of the sternum. Results Major complications observed in this series were: bar displacement (seven cases), postoperative death from cardiac arrest following bronchoscopy (one case), late cardiac tamponade from migration of wire suture fragment (one case), and need for multiple reoperations (one case). Long-term cosmetic results and improvement in daily quality of life were reported as positive in the majority of cases. Conclusions Anterior chest wall reconstruction successfully treated our series of patients with acquired Jeune's syndrome. This multifaceted technique is an effective procedure that allows expansion of the thoracic cavity and improvement of aerobic activity.
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