Background
Minimally invasive surgery (MIS) has been widely adopted for common operations in pediatric surgery; however, its role in childhood tumors is limited by concerns about oncologic outcomes. ...We compared open and MIS approaches for pediatric neuroblastoma and Wilms tumor (WT) using a national database.
Methods
The National Cancer Data Base from 2010 to 2012 was queried for cases of neuroblastoma and WT in children ≤21 years old. Children were classified as receiving open or MIS surgery for definitive resection, with clinical outcomes compared using a propensity matching methodology (two open:one MIS).
Results
For children with neuroblastoma, 17% (98 of 579) underwent MIS, while only 5% of children with WT (35 of 695) had an MIS approach for tumor resection. After propensity matching, there was no difference between open and MIS surgery for either tumor for 30‐day mortality, readmissions, surgical margin status, and 1‐ and 3‐year survival. However, in both tumors, open surgery more often evaluated lymph nodes and had larger lymph node harvest.
Conclusion
Our retrospective review suggests that the use of MIS appears to be a safe method of oncologic resection for select children with neuroblastoma and WT. Further research should clarify which children are the optimal candidates for this approach.
Early access to diagnosis and care is essential to improve rates of survival from childhood cancer, particularly in low-income and middle-income countries (LMICs). Composite indices are increasingly ...used to compare country performance in many health fields. We aimed to develop a composite vulnerability index of risk of mortality associated with delays in care for childhood cancer in LMICs, and to compare the vulnerability index scores across countries.
The composite vulnerability index was built in ten steps. A previous systematic review of determinants of delays in cancer care for children guided data selection. We collected exposure variables (determinants of delays in care) and outcome variables (childhood cancer-related mortality) from several large datasets. Data were analysed with regression models to identify determinants of delays in care that contribute to childhood cancer mortality. Significant indicators were aggregated into domains according to the socio-ecological model. We used geospatial tools to summarise and compare the composite vulnerability index scores across countries.
We found that life expectancy, maternal education, fertility rate, availability of pathology services, bone marrow transplantation capacity, availability of treatment services (chemotherapy, radiotherapy, or surgery), number of pharmacists per 10 000 population, country income level, and out-of-pocket health expenditure were significantly associated with cancer mortality for children in LMICs. The highest levels of vulnerability were found in sub-Saharan Africa.
Our composite vulnerability index can potentially serve as a valuable policy decision tool to help monitor country performance and guide interventions to reduce delays in care for children with cancer in LMICs.
None.
For the Chinese, Portuguese, Arabic, Spanish and Swahili translations of the abstract see Supplementary Materials section.
Background
Choledochal cysts are rare congenital anomalies of the biliary tree that may lead to obstruction, chronic inflammation, infection, and malignancy. There is wide variation in the timing of ...resection, operative approach, and reconstructive techniques. Outcomes have rarely been compared on a national level.
Methods
We queried the Pediatric National Surgical Quality Improvement Program (NSQIP) to identify patients who underwent choledochal cyst excision from 2015 to 2020. Patients were stratified by hepaticoduodenostomy (HD) versus Roux‐en‐Y hepaticojejunostomy (RNYHJ), use of minimally invasive surgery (MIS), and age at surgery. We collected several outcomes, including length of stay (LOS), reoperation, complications, blood transfusions, and readmission rate. We compared outcomes between cohorts using nonparametric tests and multivariate regression.
Results
Altogether, 407 patients met the study criteria, 150 (36.8%) underwent RNYHJ reconstruction, 100 (24.6%) underwent MIS only, and 111 (27.3%) were less than one year old. Patients who underwent open surgery were younger (median age 2.31 vs. 4.25 years, p = 0.002) and more likely underwent RNYHJ reconstruction (42.7% vs. 19%, p = 0.001). On adjusted analysis, the outcomes of LOS, reoperation, transfusion, and complications were similar between the type of reconstruction, operative approach, and age. Patients undergoing RNYHJ had lower rates of readmission than patients undergoing HD (4.0% vs. 10.5%, OR 0.34, CI 0.12, 0.79, p = 0.02).
Conclusions
In children with choledochal cysts, most short‐term outcomes were similar between reconstructive techniques, operative approach, and age at resection, although HD reconstruction was associated with a higher readmission rate in this study. Clinical decision‐making should be driven by long‐term and biliary‐specific outcomes.
Does This Child Have Appendicitis? Bundy, David G; Byerley, Julie S; Liles, E. Allen ...
JAMA,
07/2007, Letnik:
298, Številka:
4
Journal Article
Recenzirano
Odprti dostop
CONTEXT Evaluation of abdominal pain in children can be difficult. Rapid, accurate diagnosis of appendicitis in children reduces the morbidity of this common cause of pediatric abdominal pain. ...Clinical evaluation may help identify (1) which children with abdominal pain and a likely diagnosis of appendicitis should undergo immediate surgical consultation for potential appendectomy and (2) which children with equivocal presentations of appendicitis should undergo further diagnostic evaluation. OBJECTIVE To systematically assess the precision and accuracy of symptoms, signs, and basic laboratory test results for evaluating children with possible appendicitis. DATA SOURCES We searched English-language articles in MEDLINE (January 1966–March 2007) and the Cochrane Database, as well as physical examination textbooks and bibliographies of retrieved articles, yielding 2521 potentially relevant articles. STUDY SELECTION Studies were included if they (1) provided primary data on children aged 18 years or younger in whom the diagnosis of appendicitis was considered; (2) presented medical history data, physical examination findings, or basic laboratory data; and (3) confirmed or excluded appendicitis by surgical pathologic findings, clinical observation, or follow-up. Of 256 full-text articles examined, 42 met inclusion criteria. DATA EXTRACTION Twenty-five of 42 studies were assigned a quality level of 3 or better. Data from these studies were independently extracted by 2 reviewers. RESULTS In children with abdominal pain, fever was the single most useful sign associated with appendicitis; a fever increases the likelihood of appendicitis (likelihood ratio LR, 3.4; 95% confidence interval CI, 2.4-4.8) and conversely, its absence decreases the chance of appendicitis (LR, 0.32; 95% CI, 0.16-0.64). In select groups of children, in whom the diagnosis of appendicitis is suspected and evaluation undertaken, rebound tenderness triples the odds of appendicitis (summary LR, 3.0; 95% CI, 2.3-3.9), while its absence reduces the likelihood (summary LR, 0.28; 95% CI, 0.14-0.55). Midabdominal pain migrating to the right lower quadrant (LR range, 1.9-3.1) increases the risk of appendicitis more than right lower quadrant pain itself (summary LR, 1.2; 95% CI, 1.0-1.5). A white blood cell count of less than 10 000/μL decreases the likelihood of appendicitis (summary LR, 0.22; 95% CI, 0.17-0.30), as does an absolute neutrophil count of 6750/μL or lower (LR, 0.06; 95% CI, 0.03-0.16). Symptoms and signs are most useful in combination, particularly for identifying children who do not require further evaluation or intervention. CONCLUSIONS Although the clinical examination does not establish a diagnosis of appendicitis with certainty, it is useful in determining which children with abdominal pain warrant immediate surgical evaluation for consideration of appendectomy and which children may warrant further diagnostic evaluation. More child-specific, age-stratified data are needed to improve the utility of the clinical examination for diagnosing appendicitis in children.
Abstract Background Splenic angioembolization (SAE) is increasingly used in the management of splenic injuries in adults, although its value in pediatric trauma is unclear. We sought to assess ...outcomes related to splenectomy vs SAE. Methods The National Trauma Data Bank was queried for patients 0 to 15 years of age from 2007 to 2011. Subgroup analysis of splenectomy vs SAE was performed for high-grade injuries using propensity analysis and inverse probability weighting. Results Of 11,694 children presenting with splenic trauma, over 90% were treated nonoperatively. Adjusted analysis of high-grade injuries included 265 children who underwent splenectomy and 199 who underwent SAE. The Injury Severity Score, number of transfusions, and complications rates were not significantly different between the 2 groups. Overall adjusted mortality for children with high-grade injuries was 13.4% following splenectomy and 10.0% following SAE ( P = .31) Conclusion Patients undergoing SAE for high-grade splenic trauma have comparable morbidity and mortality with splenectomy.
Lack of surgical care has been highlighted as a critical global health problem, and short-term medical missions (STMMs) have become a de facto measure to address this shortfall. Participation in ...STMMs is an increasingly popular activity for foreign medical professionals to undertake in low- and middle-income countries (LMICs) where their clinical skills may be in short supply. While there is emerging literature on the STMM phenomenon, patient experiences of surgical missions are underrepresented. This research addresses this gap through thirty-seven in-depth interviews with patients or caregivers who received care from a short-term surgical mission within the three years prior to the four-week data collection period in July and August 2013. Interviews were conducted in Antigua, Guatemala and nearby communities, and participants came from 9 different departments of the country. These first-hand accounts of health-seeking through a surgical mission provide important insights into the benefits and challenges of STMMs that patients encounter, including waiting time, ancillary costs, and access to care. Patient agency in care-seeking is considered within the pluralistic, privatized health care context in Guatemala in which foreign participants deliver STMM care.
•Unique focus on patients' perspectives of short-term surgical missions.•Contributes to understanding short-term surgical missions within the Guatemalan context.•Identifies benefits and challenges associated with short-term surgical mission care for patients.•Considers patient agency in becoming recipients of aid through use of STMMs.
Abstract
BACKGROUND
Significant care continuum delays between acute traumatic brain injury (TBI) and definitive surgery are associated with poor outcomes. Use of the “3 delays” model to evaluate TBI ...outcomes in low- and middle-income countries has not been performed.
OBJECTIVE
To describe the care continuum, using the 3 delays framework, and its association with TBI patient outcomes in Kampala, Uganda.
METHODS
Prospective data were collected for 563 TBI patients presenting to a tertiary hospital in Kampala from 1 June to 30 November 2016. Four time intervals were constructed along 5 time points: injury, hospital arrival, neurosurgical evaluation, computed tomography (CT) results, and definitive surgery. Time interval differences among mild, moderate, and severe TBI and their association with mortality were analyzed.
RESULTS
Significant care continuum differences were observed for interval 3 (neurosurgical evaluation to CT result) and 4 (CT result to surgery) between severe TBI patients (7 h for interval 3 and 24 h for interval 4) and mild TBI patients (19 h for interval 3 and 96 h for interval 4). These postarrival delays were associated with mortality for mild (P = .05) and moderate TBI (P = .03) patients. Significant hospital arrival delays for moderate TBI patients were associated with mortality (P = .04).
CONCLUSION
Delays for mild and moderate TBI patients were associated with mortality, suggesting that quality improvement interventions could target current triage practices. Future research should aim to understand the contributors to delays along the care continuum, opportunities for more effective resource allocation, and the need to improve prehospital logistical referral systems.
The identification of cells capable of neuronal differentiation has great potential for cellular therapies. We examined whether murine and human adipose-derived adult stem (ADAS) cells can be induced ...to undergo neuronal differentiation. We isolated ADAS cells from the adipose tissue of adult BalbC mice or from human liposuction tissue and induced neuronal differentiation with valproic acid, butylated hydroxyanisole, insulin, and hydrocortisone. As early as 1–3
h after neuronal induction, the phenotype of ADAS cells changed towards neuronal morphology. Following neuronal induction, muADAS cells displayed immunocytochemical staining for GFAP, nestin and NeuN and huADAS cells displayed staining for intermediate filament M, nestin, and NeuN. Following neuronal induction of murine and human ADAS cells, Western blot analysis confirmed GFAP, nestin, and NeuN protein expression. Pretreatment with EGF and basic FGF augmented the neuronal differentiation of huADAS cells. The neuronal differentiation of stromal cells from adipose tissue has broad biological and clinical implications.
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