Staged imaging pathway for the evaluation of pediatric appendicitis

Purpose

Despite significant radiation exposure involved with computed tomography (CT) in evaluation of pediatric appendicitis, its use is still widespread. The goal of this study was to assess the effect of a staged imaging pathway for appendicitis to significantly decrease CT use while maintaining diagnostic accuracy.

Methods

Chart review was performed for patients evaluated for appendicitis over a 12-month period prior to and after pathway implementation.

Results

There was a significant decrease in CT use as initial imaging after implementation of the pathway; 87.1–13.4 % for evaluations positive for appendicitis (decrease 84.6 %, p < 0.0001) and 82.6–9.2 % for evaluations negative for appendicitis (decrease 88.9 %, p < 0.0001). Use of CT during any point in the evaluation decreased from 91.7 to 25.1 % (decrease 72.6 %, p < 0.0001). The negative appendectomy rate was similar; 5.4 % prior, 4.9 % post (p = 0.955). The missed appendicitis rate did not statistically change; 1.1 % prior, 3.7 % post (p = 0.523). The perforation rate was not statistically altered; 6.5 % prior; 9.8 % post (p = 0.421). 350 less patients underwent CT during the year following the pathway.

Conclusions

The staged imaging pathway resulted in a marked decrease in children exposed to CT without compromising diagnostic accuracy.

     

Urinary biomarkers in pediatric appendicitis

Purpose

The diagnosis of pediatric appendicitis is still a challenge, resulting in perforation and negative appendectomies. The aim of this study was to evaluate novel biomarkers in urine and to use the most promising biomarkers in conjunction with the Pediatric Appendicitis Score (PAS), to see whether this could improve the accuracy of diagnosing appendicitis.

Methods

A prospective study of children with suspected appendicitis was conducted with assessment of PAS, routine blood tests, and measurements of four novel urinary biomarkers: leucine-rich α-2-glycoprotein (LRG), calprotectin, interleukin 6 (IL-6), and substance P. The biomarkers were blindly determined with commercial ELISAs. Urine creatinine was used to adjust for dehydration. The diagnosis of appendicitis was based on histopathological analysis.

Results

Forty-four children with suspected appendicitis were included, of which twenty-two (50 %) had confirmed appendicitis. LRG in urine was elevated in children with appendicitis compared to children without (p < 0.001), and was higher in children with gangrenous and perforated appendicitis compared to those with phlegmonous appendicitis (p = 0.003). No statistical significances between groups were found for calprotectin, IL-6 or substance P. LRG had a receiver operating characteristic area under the curve of 0.86 (95 % CI 0.79–0.99), and a better diagnostic performance than all routine blood tests. LRG in conjunction with PAS showed 95 % sensitivity, 90 % specificity, 91 % positive predictive value, and 95 % negative predictive value.

Conclusion

LRG, adjusted for dehydration, is a promising novel urinary biomarker for appendicitis in children. LRG in combination with PAS has a high diagnostic performance.

     

Creating diagnostic criteria for perforated appendicitis using cross-sectional imaging

Introduction

Preoperative determination of perforated versus acute appendicitis can be difficult. We compared CT and MRI performance in diagnosing perforated appendicitis, and created diagnostic criteria.

Methods

We retrospectively reviewed all pediatric patients who underwent appendectomy within one day of CT or MRI between 1/1/2013 and 1/16/2016. True diagnosis was determined by pathology report. Findings on CT/MRI were grouped into “hard” findings (abscess, pneumoperitoneum, extruded fecalith, appendiceal wall with visible hole) and “soft” findings (extensive/diffuse inflammation/free fluid, phlegmon). Correlation of white blood cell count (WBC), temperature, peritoneal signs, and symptom duration >72 h with perforation was assessed using logistic regression. Significant correlates were incorporated in clinical criteria.

Results

135 patients underwent appendectomy after CT/MRI. Fifty patients underwent MRI and 85 CT. Using hard and/or soft findings, MRI was 86.7% sensitive and 74.3% specific, compared to 68.4% (p = 0.19) and 92.4% (p = 0.025) for CT. WBC > 15, temperature >38.0 °C, and peritoneal signs predicted perforation. Diagnostic accuracy of MRI was highest using imaging findings alone. Accuracy of CT was improved by mandating at least one of the previous three clinical correlates, resulting in 68.4% sensitivity and 93.9% specificity.

Conclusions

MRI trended toward more sensitive and CT was more specific for complicated appendicitis. CT specificity is improved by our algorithm.

     

Clinical features and risk factors of bile duct perforation associated with pediatric congenital biliary dilatation

Purpose

This study aimed to investigate the clinical features and risk factors of bile duct perforation in pediatric congenital biliary dilatation (CBD) patients.

Methods

CBD patients, whose initial symptom was abdominal pain, were enrolled in this study and were divided into perforated and non-perforated groups. The clinical features of the perforated group were investigated. Moreover, the age at operation, sex, and morphologic features of the extrahepatic bile duct were compared between the groups.

Results

Fifteen cases of bile duct perforation (10.4%) were identified among the 144 CBD patients who had abdominal pain. Majority of bile duct perforation occurred in patients aged?<?4 years. The median duration from onset of abdominal pain to bile duct perforation was 6 (4–14) days. Age at onset [<?4 years old; P?=?0.02, OR 13.9, (1.663, 115.3)], shape of extrahepatic bile duct [non-cystic type; P?=?0.009, OR 8.36, (1.683, 41.5)], and dilatation of the common channel [P?=?0.02, OR 13.6, (1.651, 111.5)] were risk factors of bile duct perforation.

Conclusions

Emergent bile duct drainage might be planned to prevent bile duct perforation if CBD patients have the abovementioned risk factors and experience persistent abdominal pain lasting for a few days from onset.

     

Perforations associated with peripherally inserted central catheters in a neonatal population

Background

Peripherally inserted central catheters (PICCs) are increasingly used in neonates but perforations can result in devastating complications such as pericardial and pleural effusions. Identifying risk factors may guide surveillance and reduce morbidity and mortality.

Objective

To determine the risk factors for PICC perforation in neonates.

Materials and methods

Retrospective case:control (1:2) study of neonates admitted between 2004-2014. Charts and imaging were reviewed for clinical and therapeutic risk factors.

Results

Among 3,454 PICCs, 15 cases of perforation (incidence 0.4%, 5 pericardial effusions, 10 pleural effusions) were matched to 30 controls, based on gestation and insertion date. Timing of perforations post-insertion was median 4 days for pericardial effusions and 21.5 days for pleural effusions. A risk factor for pericardial effusion was lower weight at PICC insertion compared with controls. There were no statistically significant differences between cases and controls in catheter material, insertion site, PICC size and lumen number. Among upper limb PICCs, pericardial effusions were associated with tip positions more proximal to the heart at insertion (P=0.005) and at perforation (P=0.008), compared with controls. Pleural effusions were associated with tip positions more distal from the heart at perforation (P=0.008). Within 48 h before perforation, high/medium risk infusions included total parenteral nutrition (100% cases vs. 56.7% controls, P=0.002) and vancomycin (60% cases vs. 23.3% controls, P=0.02).

Conclusion

PICC-associated pericardial effusions and pleural effusions are rare but inherent risks and can occur at any time after insertion. Risk factors and etiologies are multifactorial, but PICC tip position may be a modifiable risk factor. To mitigate this risk, we have developed and disseminated guidelines for target PICC positions and routinely do radiographs to monitor PICCs for migration and malposition in our NICU. The increased knowledge of risk profiles from this study has helped focus surveillance efforts and facilitate early recognition and treatment.

     

Impact of simulation-based training on perceived provider confidence in acute multidisciplinary pediatric trauma resuscitation

Purpose

Simulation-based training has the potential to improve team-based care. We hypothesized that implementation of an in situ multidisciplinary simulation-based training program would improve provider confidence in team-based management of severely injured pediatric trauma patients.

Methods

An in situ multidisciplinary pediatric trauma simulation-based training program with structured debriefing was implemented at a free-standing children’s hospital. Trauma providers were anonymously surveyed 1 month before (pre-), 1 month after (post-), and 2 years after implementation.

Results

Survey response rate was 49% (n?=?93/190) pre-simulation, 22% (n?=?42/190) post-simulation, and 79% (n?=?150/190) at 2-year follow-up. These providers reported more anxiety (p?=?0.01) and less confidence (p?=?0.02) 1-month post-simulation. At 2-year follow-up, trained providers reported less anxiety (p?=?0.02) and greater confidence (p?=?0.01), compared to untrained providers.

Conclusions

Implementation of an in situ multidisciplinary pediatric trauma simulation-based training program may initially lead to increased anxiety, but long-term exposure may lead to greater confidence.

Level of evidence

II, Prospective cohort.

     

Empyema Due to Thoracic Migrating Appendicolith

Background

Retained appendicolith following appendicectomy, and can cause recurrent abscess in the abdomen and retroperitoneum.

Case characteristics

11-yr-old boy who presented with subpulmonic abscess and pneumonia following appendicectomy for perforated appendicitis.

Observations

Thoracotomy revealed a thick walled subpulmonic abscess surrounding an appendicolith along with a rent in the posterolateral aspect of the diaphragm.

Message

In children presenting with pus collections and a history of recent appendicectomy, the possibility of a migrating appendicolith should be considered.

     

Radiation dose associated with CT-guided drain placement for pediatric patients

Background

To date, there are limited radiation dose data on CT-guided procedures in pediatric patients.

Objective

Our goal was to quantify the radiation dose associated with pediatric CT-guided drain placement and follow-up drain evaluations in order to estimate effective dose.

Materials and methods

We searched the electronic medical record and picture archiving and communication system (PACS) to identify all pediatric (<18 years old) CT-guided drain placements performed between January 2008 and December 2013 at our institution. We compiled patient data and radiation dose information from CT-guided drain placements as well as pre-procedural diagnostic CTs and post-procedural follow-up fluoroscopic abscess catheter injections (sinograms). Then we converted dose–length product, fluoroscopy time and number of acquisitions to effective doses using Monte Carlo simulations and age-appropriate conversion factors based on annual quality-control testing.

Results

Fifty-two drainages were identified with mean patient age of 11.0 years (5 weeks to 17 years). Most children had diagnoses of appendicitis (n=23) or inflammatory bowel disease (n=11). Forty-seven patients had diagnostic CTs, with a mean effective dose of 7.3 mSv (range 1.1–25.5 mSv). Drains remained in place for an average of 16.9 days (range 0–75 days), with an average of 0.9 (0–5) sinograms per patient in follow-up. The mean effective dose for all drainages and follow-up exams was 5.3 mSv (0.7–17.1) and 62% (32/52) of the children had effective doses less than 5 mSv.

Conclusion

The majority of pediatric patients who have undergone CT-guided drain placements at our institution have received total radiation doses on par with diagnostic ranges. This information could be useful when describing the dose of radiation to parents and providers when CT-guided drain placement is necessary.

     

Cytogenetic Profiles of 472 Indian Children with Acute Myeloid Leukemia

Objective

To analyze the cytogenetic abnormalities of a large cohort of consecutive pediatric Acute Myeloid Leukemia (AML) patients, treated on a uniform protocol.

Design

Review of case records.

Setting

Pediatric Cancer Center of tertiary care hospital between June 2003 and June 2016.

Participants

617 consecutive de novo pediatric AML patients were screened and 472 patients were found eligible. Eligibility criteria included non M3 patients, successful cytogenetic profile and availability of complete records

Main outcome measure

Cytogenetic profile.

Results

Gum-hypertropy, chloromas and rate of complete remission were significantly different between European Leukemia Network classification (ELN) cytogenetic risk groups (P<0.01). t (8;21) (141, 29.8%), loss of Y chromosome (61,12.9%) and trisomy 8 (39, 8.3%) were the most common abnormalities. Among the chromosomal gains, trisomy 8 and trisomy 21 (both P<0.01) were significantly different among the three ELN risk groups. Among the chromosome losses, monosomy 5, 7 (both P<0.01) and 9 (P=0.03), loss of X and loss of Y (both P<0.01) were statistically different amongst three cytogenetic risk groups. Event-free survival (P<0.01) and overall survival (P<0.01) were found to be significantly different among the three risk groups.

Conclusions

The higher frequency of t (8; 21) and its association with chloroma in Indian pediatric patients is different from other studies around the world.

     

Impact of hospital volume on outcomes of percutaneous ASD/PFO closure in pediatric patients

Background

We investigated the effect of hospital volume on percutaneous closure of atrial septal defect/patent foramen ovale (ASD) among pediatric patients.

Methods

We identified patients undergoing percutaneous closure of ASD with device using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure code 35.52 from the National Inpatient Sample, years 2002–2011. Patients with age ≤ 18 years and primary diagnosis code 745.5 for ASD were included. Hospital volume was calculated using unique identification numbers and divided into tertiles for analysis. Multivariate regression analysis was performed to determine independent predictors of procedure-related complications which were coded using specific codes released by Healthcare Cost and Utilization Project.

Results

6162 percutaneous ASD closure procedures were analyzed. There was no mortality associated with percutaneous ASD closure. Cardiac complications (9.5%) were most common. On multivariate analysis, age increment of 3 years decreased the odds of developing complications (OR 0.83, 95% CI 0.79–0.87, P < 0.001). Odds of developing complications in the 2nd (OR 0.74, 95% CI 0.62–0.89, P = 0.007) and 3rd tertiles (OR 0.34, 95% CI 0.27–0.42, P < 0.001) were lower as compared to the 1st tertile of hospital volume.

Conclusion

Increasing annual hospital volume is an independent predictor of lower complication rates in percutaneous ASD closure cases with no associated mortality in pediatric patients.

     

TLR4 preconditioning is associated with low success of OK-432 treatment for lymphatic malformations in children

Purpose

We have recently shown that the relative TLR4 expression on monocytes of low responding pediatric patients after OK-432 treatment is significantly reduced after stimulation with lipopolysaccharide (LPS) compared with high responding children. The aim of this study was to perform further analysis to explain this observation.

Methods

Monocytes from children with high (HR, n = 5) and low response (LR, n = 6) after previous OK-432 treatment were stimulated with LPS for 20 h and analyzed with fluorescence-activated cell sorting (mean fluorescence intensity, MFI; level of significance P ≤ 0.05).

Results

Mean MFI after LPS stimulation was comparable in both groups (HR 1142 ± 652 units, LR 839 ± 427 units, P = 0.85). Significant changes after LPS stimulation are explained by higher pre-stimulation values in the LR group compared with the HR group (950 ± 718 vs. 477 ± 341, P = 0.25) with considerable differences of the mean expression changes after LPS stimulation (HR 665 ± 683 vs. LR ?111 ± 605, P = 0.08).

Conclusion

The previously shown reduced TLR4 upregulation on monocytes after LPS stimulation in the LR group compared with the HR group can be primarily explained by TLR preconditioning. This observation implies the use of absolute values with definite thresholds.

     

Effect of timing of cannulation on outcome for pediatric extracorporeal life support

Purpose

Literature reports worse outcomes for operations performed during off-hours. As this has not been studied in pediatric extracorporeal life support (ECLS), we compared complications based on the timing of cannulation..

Methods

This is a retrospective review of 176 pediatric ECLS patients between 2004 and 2015. Patients cannulated during daytime hours (7:00 A.M. to 7:00 P.M., M-F) were compared to off-hours (nighttime or weekend) using t-test and Chi-square.

Results

The most common indications for ECLS were congenital diaphragmatic hernia (33 %) and persistent pulmonary hypertension (23 %). When comparing regular hours (40 %) to off-hours cannulation (60 %), there were no significant differences in central nervous system complications, hemorrhage (extra-cranial), cannula repositioning, conversion from venovenous to venoarterial, mortality on ECLS, or survival-to-discharge. The overall complication rate was slightly lower in the off-hours group (45.7 % versus 61.9 %, P = 0.034).

Conclusion

Outcomes were not significantly worse for patients undergoing ELCS cannulation during off-hours compared to normal weekday working hours.

     

Feeding Problems and Nutrient Intake in Children with and without Autism: A Comparative Study

Objective

To compare parent reported feeding difficulties and nutritional adequacy of children with Autism Spectrum Disorders (ASD) to an age and socio-economically matched group of typically developing children.

Methods

The scores on Children’s Eating Behavior Inventory (CEBI), three-day food records, anthropometric measures and adequacy of micro- and macro- nutrients were compared for 63 children diagnosed with ASD and 50 typically developing children enrolled from the department of pediatrics of a tertiary care teaching hospital from North India.

Results

The majority (79%) of the parents of ASD children reported some concern regarding their feeding behavior as compared to 64% of the parents of typically developing children. As compared to controls, ASD children had significantly higher CEBI scores (97.28 vs. 89.48, t = 3.15, P = 0.002) and more feeding problems (6.42 vs. 2.70, t = 3.74, P = 0.001). Relative to controls, ASD children consumed fewer number of food items (P = 0.022), particularly fruits (P = 0.004), vegetables (P = 0.011), and proteins (P = 0.015); had significantly lower daily intake of potassium (P = 0.001), copper (P = 0.007), and folate (P = 0.001). Although children with autism did not differ significantly from controls on intake of calories, height, weight, or body mass index, significantly greater proportion of ASD children failed to meet the estimated average requirement of thiamine (P = 0.039), vitamin C (P = 0.013), and copper (P = 0.005).

Conclusions

The findings underscore the need for comprehensive assessment and empirically-supported interventions for eating problems and dietary deficiencies found in ASD children.

     

Image-guided placement of percutaneous de novo low-profile gastrojejunostomy tubes in the pediatric population: a study of feasibility and efficacy

Background

De novo low-profile gastrojejunostomy tubes in pediatric patients offer less external catheter bulk and decreased propensity for dislodgement as children become more mobile. While small cohort studies have evaluated de novo placement of coaxial, adjustable-length, percutaneous gastrojejunostomy (GJ) tubes in children, placement of de novo low-profile GJ tubes in pediatric patients has not been analyzed.

Objective

This study evaluates technical feasibility, safety and clinical efficacy of percutaneous, retrograde placement of de novo low-profile GJ tubes in infants and children.

Materials and methods

Following institutional review board approval, all de novo low-profile GJ tube placements in patients were retrospectively reviewed between May 2014 and May 2017. Technical parameters of fluoroscopy time, tube size, T-fasteners and complications were recorded. Clinical data, including age, indication, weight gain and complications, were analyzed.

Results

Thirty-four de novo low-profile GJ tubes were placed in 34 patients (median age: 9.4 months, range: 2 months-11.8 years; median pre-procedural weight: 7.5 kg, range: 2.9-31.6 kg). Twenty-one 14-Fr and 13 16-Fr GJ tubes were placed with technical success rate of 100%. Average weight gain 3 months’ post procedure was 1.1 kg (range: 0.3-4.8 kg) and average weight percentile for age increase was 9.6% (range: -48.9% to 53.5%). One major complication occurred following balloon inflation within the tract causing pain requiring urgent replacement of the GJ tube. Minor complications occurred in 11 patients (32%): accidental dislodgement (n=9), skin irritation (n=4), tube dysfunction (n=2), leakage (n=2) and tube migration into the esophagus (n=1).

Conclusion

Percutaneous, antegrade, image-guided placement of de novo low-profile GJ tubes is technically feasible, safe and clinically efficacious in appropriately selected pediatric patients.

     

Can common serum biomarkers predict complicated appendicitis in children?

Purpose

As appendicitis in children can be managed differently according to the severity of the disease, we investigated whether commonly used serum biomarkers on admission could distinguish between simple and complicated appendicitis.

Methods

Admission white blood cell (WBC), neutrophil (NEU), and C-reactive protein (CRP) levels were analysed by ROC curve, and Kruskal–Wallis and contingency tests. Patients were divided according to age and histology [normal appendix (NA), simple appendicitis (SA), complicated appendicitis (CA)].

Results

Of 1197 children (NA = 186, SA = 685, CA = 326), 7% were <5 years, 55% 5–12, 38% 13–17. CA patients had higher CRP and WBC levels than NA and SA (p < 0.0001). NEU levels were lower in NA compared to SA or CA (p < 0.0001), but were similar between SA and CA (p = 0.6). CA patients had higher CRP and WBC levels than SA patients in 5–12- (p < 0.0001) and 13–17-year groups (p = 0.0075, p = 0.005), but not in <5-year group (p = 0.72, p = 0.81). We found CRP >40 mg/L in 58% CA and 37% SA (p < 0.0001), and WBC >15 × 10⁹/L in 58% CA and 43% SA (p < 0.0001).

Conclusions

Admission CRP and WBC levels may help the clinician predict complicated appendicitis in children older than 5 years of age. Early distinction of appendicitis severity using these tests may guide caregivers in the preoperative decision-making process.

     

Airway foreign bodies in pediatric patients: anatomic location of foreign body affects complications and outcomes

Background

Airway foreign bodies (FB) are a common medical emergency within the pediatric population. While deaths are not uncommon, the in-hospital mortality rates and correlation with anatomic location of the airway foreign body have not been previously reported.

Methods

The KID database was reviewed for 2003, 2006, 2009, and 2012 for pediatric patients with a discharge diagnosis of airway foreign body using ICD-9 codes (933.1, 934.x).

Results

11,793 patients, ages 0–17, were found to have an airway FB. Of patients admitted for airway FB 21.2 % required mechanical ventilation during their hospitalization, and the overall mortality rate was 2.5 %. Location of the airway FB was dependent on age (p < 0.01). Use of mechanical ventilation was dependent on the location of the airway FB (p < 0.01) and being transferred from another hospital (OR 2.59, p < 0.01). Univariate analysis demonstrated differences in in-hospital mortality based on location (p < 0.01), use of a ventilator during hospitalization (OR 24.4, p < 0.01), and transfer from another hospital (OR 2.11, p < 0.01).

Conclusions

The in-hospital mortality rate for airway foreign bodies is 2.5 %. The anatomic location of airway FB in pediatric patients varies by age, and affects the need for mechanical ventilation and in-hospital mortality.

     

Home intravenous versus oral antibiotics following appendectomy for perforated appendicitis in children: a randomized controlled trial

Purpose

To compare the effect of home intravenous (IV) versus oral antibiotic therapy on complication rates and resource utilization following appendectomy for perforated appendicitis.

Methods

This was a randomized controlled trial of patients aged 4–17 with surgically treated perforated appendicitis from January 2011 to November 2013. Perforation was defined intraoperatively and divided into three grades: I—contained perforation, II—localized contamination to right gutter/pelvis, and III—diffuse contamination. Patients were randomized to complete a ten-day course of home antibiotic therapy with either IV ertapenem or oral amoxicillin–clavulanate. Thirty-day postoperative complication rates including abscess, readmission, wound infection, and charges were compared.

Results

Eighty-two patients were enrolled. Forty four (54%) were randomized to the IV group and 38 (46%) to the oral group. IV patients were older (12.3?±?3.6 versus 10.1?±?3.6, p?<?0.05) with higher BMI (20.9?±?5.8 versus 17.9?±?3.5, p?<?0.05). There were no differences in gender, comorbidities, or perforation grade (I—20.4% vs. 26.3%, II—36.4% vs. 34.2%, III—43.2% vs. 39.5%, all p?>?0.05). Comparing IV to oral, there was no difference in length of stay (4.4?±?1.5 versus 4.4?±?2.0 days, p?>?0.05), postoperative abscess rate (11.6% vs. 8.1%, p?>?0.05), or readmission rate (14.0% vs. 16.2%, p?>?0.05). Hospital and outpatient charges were higher in the IV group (p?<?0.0001).

Conclusion

Oral antibiotics had equivalent outcomes and incurred fewer charges than IV antibiotics following appendectomy for perforated appendicitis.

     

Association of Fluid Overload with Mortality in Critically-ill Mechanically Ventilated Children

Objectives

To study the association of fluid overload with mortality and morbidity in critically-ill mechanically ventilated children.

Design

Prospective observational study.

Setting

Pediatric Intensive Care Unit (PICU) of a tertiary care hospital, New Delhi, India.

Participants

118 children (age 1 mo - 15 y) requiring mechanical ventilation.

Outcome measures

Primary: Association of fluid overload with mortality. Secondary: Association of fluid overload with oxygenation, organ dysfunction, duration of mechanical ventilation and PICU stay.

Results

Cumulative fluid overload of ≥15% was observed in 74 (62.7%) children. About 50% of these children reached cumulative fluid overload of ≥15% within the first 5 days of PICU stay. The mortality was 40.5% in those with ≥15% cumulative fluid compared to 34% in the rest [OR (95% CI): 1.02 (0.97, 1.07)]. On multivariate analysis, after adjusting for confounders, cumulative fluid overload ≥15% was associated with higher maximum PELOD (pediatric logistic organ dysfunction) score (Median: 21 vs. 12; P = 0.03), longer median duration of mechanical ventilation (10 vs. 4 d; P <0.0001) and PICU stay (13.5 vs. 6 d; P <0.0001). There was no significant association of fluid overload with oxygenation index (P=0.32).

Conclusion

There is no association of fluid overload with mortality. However, it is associated with poor organ function, longer duration of mechanical ventilation and PICU stay in critically-ill, mechanically ventilated children.

     

Pediatric papillary thyroid carcinoma: outcomes and survival predictors in 2504 surgical patients

Objective

To evaluate outcomes and predictors of survival of pediatric thyroid carcinoma, specifically papillary thyroid carcinoma.

Methods

SEER was searched for surgical pediatric cases (≤20 years old) of papillary thyroid carcinoma diagnosed between 1973 and 2011. Demographics, clinical characteristics, and survival outcomes were analyzed using standard statistical methods. All papillary types, including follicular variant, were included.

Results

A total of 2504 cases were identified. Overall incidence was 0.483/100,000 persons per year with a significant annual percent change (APC) in occurrence of 2.07 % from baseline (P < 0.05). Mean age at diagnosis was 16 years and highest incidence was found in white, female patients ages 15–19. Patients with tumor sizes <1 cm more likely received lobectomies/isthmusectomies versus subtotal/total thyroidectomies [OR = 3.03 (2.12, 4.32); P < 0.001]. Patients with tumors ≥1 cm and lymph node-positive statuses [OR = 99.0 (12.5, 783); P < 0.001] more likely underwent subtotal/total thyroidectomy compared to lobectomy/isthmusectomy. Tumors ≥1 cm were more likely lymph node-positive [OR = 39.4 (16.6, 93.7); p < 0.001]. Mortality did not differ between procedures. Mean survival was 38.6 years and higher in those with regional disease. Disease-specific 30-year survival ranged from 99 to 100 %, regardless of tumor size or procedure. Lymph node sampling did not affect survival.

Conclusions

The incidence of pediatric papillary thyroid cancer is increasing. Females have a higher incidence, but similar survival to males. Tumors ≥1 cm were likely to be lymph node-positive. Although tumors ≥1 cm were more likely to be resected by subtotal/total thyroidectomy, survival was high and did not differ based on procedure.

     

Pediatric Asthma and Food Allergy

Objective

To quantitatively summarize the evidence from observational studies on the relation between pediatric asthma and food allergy.

Methods

A literature search was conducted in Medline and EMBASE (August 2016). Two independent reviewers appraised the studies and extracted the estimates of interest. Methodological quality of the included studies was assessed using National Heart Lung and Blood Institute (NHLBI) Quality Assessment Tools. Data were pooled using random-effects meta-analysis.

Results

A total of 32 relevant studies were identified but only 8 studies met the inclusion criteria. Using random-effect model, food allergy showed strong association with asthma in children (OR = 2.87 [95% CI: 2.05–4.00]; P < 0.0001).

Conclusions

This study suggested that food allergy is associated with an increased risk of asthma in children.