Defining Practice Readiness in Pediatric Surgery Fellowship: A Qualitative Analysis

INTRODUCTION

While competency-based training is at the forefront of educational innovation in General Surgery, Pediatric Surgery training programs should not wait for downstream changes. There is currently no consensus on what it means for a pediatric surgery fellow to be "practice-ready". In this study, we aimed to provide a framework for better defining competency and practice readiness in a way that can support the Milestones system and allow for improved assessment of pediatric surgery fellows.

METHODS

For this exploratory qualitative study, we developed an interview guide with nine questions focused on how faculty recognize competency and advance autonomy among pediatric surgery fellows. Demographic information was collected using an anonymous online survey platform. We iteratively reviewed data from each interview to ensure adequate information power was achieved to answer the research question. We used inductive reasoning and thematic analysis to determine appropriate codes. Additionally, the Dreyfus model was used as a framework to guide interpretation and contextualize the responses. Through this method, we generated common themes.

RESULTS

A total of 19 pediatric surgeons were interviewed. We identified four major themes from 127 codes that practicing pediatric surgeons associate with practice-readiness of a fellow: skill-based competency, the recognition and benefits of struggle, developing expertise and facilitating autonomy, and difficulties in variability of evaluation. While variability in evaluation is not typically included in the concept of practice readiness, assessment and evaluation were described by study participants as essential aspects of how practicing pediatric surgeons perceive practice readiness and competency in pediatric surgery fellows. Competency was further divided into interpersonal versus technical skills. Sub-themes within struggle included personal and professional struggle, benefits of struggle and how to identify and assist those who are struggling. Autonomy was commonly stated as variable based on the attending.

CONCLUSION

Our analysis yielded several themes associated with practice readiness of pediatric surgery fellows. We aim to further refine our list of themes using the Dreyfus Model as our interpretive framework and establish consensus amongst the community of pediatric surgeons in order to define competency and key elements that make a fellow practice-ready. Further work will then focus on establishing assessment metrics and educational interventions directed at achieving such key elements.

How Many Operative Performance Ratings Does a Pediatric Surgery Fellow Need to Be Deemed Practice Ready?

PURPOSE

Identifying the number of cases required for a fellow to achieve competence has been challenging. Workplace-based assessment (WBA) systems make collecting performance data practical and create the opportunity to translate WBA ratings into probabilistic statements about a fellow's likelihood of performing to a given standard on a subsequent assessment opportunity.

METHODS

We compared data from two pediatric surgery training programs that used the performance rating scale from the Society for Improving Medical Professional Learning (SIMPL). We used a Bayesian generalized linear mixed effects model to examine the relationship past and future performance for three procedures: Laparoscopic Inguinal Hernia Repair, Laparoscopic Gastrostomy Tube Placement, and Pyloromyotomy.

RESULTS

For site one, 26 faculty assessed 9 fellows on 16 procedures yielding 1094 ratings, of which 778 (71%) earned practice-ready ratings. For site two, 25 faculty rated 3 fellows on 4 unique procedures yielding 234 ratings of which 151 (65%) were deemed practice-ready. We identified similar model-based future performance expectations, with prior practice-ready ratings having a similar average effect across both sites (Site one, B = 0.25; Site two, B = 0.25). Similar prior practice-ready ratings were needed for Laparoscopic G-Tube Placement (Site one = 13; Site two = 14), while greater differences were observed for Laparoscopic Inguinal Hernia Repair (Site one = 10; Site two = 15) and Pyloromyotomy (Site one = 10; Site two = 15).

CONCLUSION

Our approach to modeling operative performance data is effective at determining future practice readiness of pediatric surgery fellows across multiple faculty and fellow groups. This method could be used to establish minimum case number requirements.

TYPE OF STUDY

Original manuscript, Study of Diagnostic Test.

LEVEL OF EVIDENCE

II.

Procalcitonin and Pediatric Traumatic Brain Injury: Differentiating Neuro-Storming From Infection

INTRODUCTION

Recurrent febrile episodes represent a diagnostic challenge in the pediatric traumatic brain injury (TBI) population as they may indicate presence of infection versus sterile neuro-storming. Procalcitonin (PCT) is a promising biomarker used in pediatric sepsis; however, data are limited regarding use in TBI. We hypothesized PCT helps discern neuro-storming from sepsis in children with TBI.

MATERIALS AND METHODS

A single-institution retrospective review (2014-2021) identified pediatric patients (aged 0-18 y) with moderate-to-severe TBI and intensive care unit admission > 2 d. Patients with multiple febrile events who underwent infectious evaluation including cultures and PCT drawn within 48 h of fever were included. Demographics, vital signs, infectious biomarkers including PCT, and culture data were captured. Univariate and multivariate analyses were performed to determine variables associated with culture positive status.

RESULTS

One hundred and fifty six patients were admitted to the intensive care unit with moderate-to-severe TBI during the study period. Eighty five patients (54%) experienced recurrent febrile episodes. Twenty four (28%) met inclusion criteria, undergoing 32 total infectious workups. Twenty one workups were culture-positive (66%) in a total of 18 patients. Median PCT levels were not statistically different between culture-positive and culture-negative workups (P = 0.94). In multivariate modeling, neither PCT [odds ratio 0.89 (confidence interval: 0.75-1.05)] nor temperature [odds ratio 7.34 (confidence interval: 0.95-57.16)] correlated with positive bacterial cultures.

CONCLUSIONS

In this small pilot analysis, recurrent febrile episodes were common and PCT did not correlate with sepsis or neuro-storming in pediatric TBI patients. Prospective protocols are needed to better understand the utility of PCT and identify predictors of bacterial infection to improve early diagnosis of sepsis in this population.

Is the changing landscape of fellowship recruitment during COVID-19 here to stay?

BACKGROUND

The 2020 Pediatric Surgery (PS) fellowship selection process was heavily impacted by the COVID-19 pandemic. A review of lessons learned can help determine best practices for the future. The purpose of the study was to analyze the virtual interview experience and assess opportunities to improve the post-pandemic fellowship recruitment process.

STUDY DESIGN

Using a 28-question survey of Program Directors (PDs) of PS fellowships as well as a 44-question survey of applicants to PS fellowships in the US and Canada, we gathered information on the recruitment process during the COVID-19 pandemic (2020). Dichotomous, multiple choice and open-ended questions about the changes in process, platforms used, format, comparison to on-site interviews and overall satisfaction were used for objective and subjective feedback.

RESULTS

A 95% participation rate was recorded for the PD survey. 24 out of 55 programs (44%) changed their on-site interviews to virtual format due to the pandemic. Most PDs described their overall impression of virtual interviews as satisfactory (66%, 16/24) and did not have an impact on the applicant's success in the match (35/54; 65%). About 50% of PDs preferred to have on-site interviews with virtual screening in the future. While the participation rate from applicants was much less (26 of 70), responses confirmed our survey results. Majority preferred on-site interviews (17/26), 6 of which preferred virtual screening followed by on-site interviews.

CONCLUSION

Components of virtual screening and interviews were found to have benefits financially and from both time and stress perspectives, and thus might survive past the pandemic. LEVELS OF EVIDENCE LEVEL IV: .

Success in pediatric surgery: An updated survey of Program Directors 2020

BACKGROUND

One of the most competitive surgical sub-specialty fellowships remains Pediatric Surgery (PS), which requires candidates to develop a strong and research-oriented curriculum vitae. Although some objective factors of matriculation are known, factors for the interview selection and ranking per the program directors (PDs) have not been reviewed in over a decade.

METHODS

A web-based survey of US and Canadian PS program directors (PDs) (n = 58) was used to evaluate a comprehensive list of factors in the selection criteria for PS fellowships. A mix of dichotomous, ranking, five-point Likert scale, and open-ended questions evaluated applicant characteristics, ABSITE scores, research productivity, interview day, and rank order criteria.

RESULTS

Fifty-five programs responded to the survey for a 95% participation rate. PDs desired an average of two years in dedicated research and weighted first authorship and total number of publications heavily. Only 38% of programs used an ABSITE score cutoff for offering interviews; however, the majority agreed that an overall upward trend was important. Quality letters of recommendation, especially from known colleagues, carried weight when deciding to offer interviews. Interview performance, being a team player, observed interpersonal interactions, perceived operative skills and patient care, and leadership were some of the notable factors when finalizing rank lists.

CONCLUSIONS

A multitude of factors define a successful matriculant, including quality of letters of recommendation, quality and quantity of publications, supportive phone calls, observed interactions, interview performance, perceptions of being team player with leadership skills as well as perceptions of good operative skills and patient care.

LEVEL OF EVIDENCE

Type II.

TYPE OF STUDY

Prognostic (retrospective).

White paper: Onco-fertility in pediatric patients with Wilms tumor

The survival of childhood Wilms tumor is currently around 90%, with many survivors reaching reproductive age. Chemotherapy and radiotherapy are established risk factors for gonadal damage and are used in both COG and SIOP Wilms tumor treatment protocols. The risk of infertility in Wilms tumor patients is low but increases with intensification of treatment including the use of alkylating agents, whole abdominal radiation or radiotherapy to the pelvis. Both COG and SIOP protocols aim to limit the use of gonadotoxic treatment, but unfortunately this cannot be avoided in all patients. Infertility is considered one of the most important late effects of childhood cancer treatment by patients and their families. Thus, timely discussion of gonadal damage risk and fertility preservation options is important. Additionally, irrespective of the choice for preservation, consultation with a fertility preservation (FP) team is associated with decreased patient and family regret and better quality of life. Current guidelines recommend early discussion of the impact of therapy on potential fertility. Since most patients with Wilms tumors are prepubertal, potential FP methods for this group are still considered experimental. There are no proven methods for FP for prepubertal males (testicular biopsy for cryopreservation is experimental), and there is just a single option for prepubertal females (ovarian tissue cryopreservation), posing both technical and ethical challenges. Identification of genetic markers of susceptibility to gonadotoxic therapy may help to stratify patient risk of gonadal damage and identify patients most likely to benefit from FP methods.

Imaged-guided and muscle sparing laparoscopic anorectoplasty using real-time magnetic resonance imaging

A challenge when repairing imperforate anus is positioning the neo-rectum into the center of the sphincter muscle complex (SMC) with limited muscle injury and scarring. Unfortunately, the path through the components of the SMC are often non-linear. We have used MRI to delineate the complex and guide the needle through the center using standard MRI-guidance (Raschbaum GR et al. J Pediatr Surg 45:220-223, 2010; Thomas TT et al. J Pediatr Surg 35:927-930, 2000). However, asynchronous scanning requires multiple, time-consuming scans to advance the needle in stepwise fashion. Asynchronous scanning also prevents visualizing the needle as it is advanced. We recently integrated software into the MRI operative suite that allows placement of the needle with real-time MRI. We report the feasibility and utility of real-time MRI-assisted laparoscopic assisted anorectoplasty (RT MRI-LAARP). Needle guidance was performed with Siemens Espree 1.5 T MRI with T1 Flash RT Sequence. After needle placement, laparoscopic mobilization, fistula takedown and pull-through was performed using the needle to guide dilation to create a tract to pull-through the neo-rectum. Charts of patients who underwent RT MRI-LAARP were reviewed. Demographics, anatomy, number of needle passes, OR duration and complications are reported. There were five children that underwent RT MRI-LAARP; one was a redo secondary to a retracted rectovestibular fistula. Operative time ranged from 187-505 min. Average hospital stay was 4.0 ± 1.0 days. There were no intraoperative complications although one patient had temporary urinary retention post-op. Muscle sparring laparoscopic anorectoplasty using real-time MRI is feasible and facilitates needle placement through the SMC.

A prospective study of pediatric and adolescent renal cell carcinoma: A report from the Children's Oncology Group AREN0321 study

BACKGROUND

To the authors' knowledge, AREN0321 is the first prospective clinical study of pediatric and adolescent renal cell carcinoma (RCC). Goals of the study included establishing epidemiological, treatment, and outcome data and confirming that patients with completely resected pediatric RCC, including lymph node-positive disease (N1), have a favorable prognosis without adjuvant therapy.

METHODS

From 2006 to 2012, patients aged <30 years with centrally reviewed pathology of RCC were enrolled prospectively.

RESULTS

A total of 68 patients were enrolled (39 of whom were male; median age of 13 years [range, 0.17-22.1 years]). Stage was classified according to the American Joint Committee on Cancer TNM stage seventh edition as stage I in 26 patients, stage II in 7 patients, stage III in 26 patients, and stage IV in 8 patients, and was not available in 1 patient. Sixty patients underwent resection of all known sites of disease, including 2 patients with stage IV disease. Surgery included radical nephrectomy (53 patients [81.5%]), partial nephrectomy (12 patients [18.5%]), and unknown (3 patients [4.4%]). Histology was TFE-associated RCC (translocation-type RCC; tRCC) in 40 patients, RCC not otherwise specified and/or other in 13 patients, papillary RCC in 9 patients, and renal medullary carcinoma (RMC) in 6 patients. Lymph node status was N0 in 21 patients, N1 in 21 patients (tRCC in 15 patients, RMC in 3 patients, papillary RCC in 2 patients, and not otherwise specified and/or other in 1 patient), and Nx in 26 patients. The 4-year event-free survival and overall survival rates were 80.2% (95% CI, 69.6%-90.9%) and 84.8% (95% CI, 75.2%-94.5%), respectively, overall and 87.5% (95% CI, 68.3%-100%) and 87.1% (95% CI, 67.6%-100%), respectively, for the 16 patients with N1M0 disease. Among patients presenting with metastases, 2 of 8 patients (2 of 5 patients with RMC) were alive (1 with disease) at the time of last follow-up, including 1 patient who was lost to follow-up (succinate dehydrogenase deficiency). The predominant RCC subtypes associated with mortality were tRCC and RMC.

CONCLUSIONS

Favorable short-term outcomes can be achieved without adjuvant therapy in children and adolescents with completely resected RCC, independent of lymph node status. A prospective study of patients with tRCC and RMC with M1 or recurrent disease is needed to optimize treatment.

Precision oncology: A primer for pediatric surgeons from the APSA cancer committee

Although most children with cancer can be cured of their disease, a subset of patients with adverse tumor types or biological features, and those with relapsed or refractory disease have significantly worse prognosis. Furthermore, current cytotoxic therapy is associated with significant late effects. Precision oncology, using molecular therapeutics targeted against unique genetic features of the patient's tumor, offers the potential to transform the multimodal therapy for these patients. Potentiated by advances in sequencing technology and molecular therapeutic development, and accelerated by large-scale multi-institutional basket trials, the field of pediatric precision oncology has entered the mainstream. These novel therapeutics have important implications for surgical decision making, as well as pre- and postoperative care. This review summarizes the current state of precision medicine in pediatric oncology including the active North American and European precision oncology clinical trials. LEVEL OF EVIDENCE: Treatment study Level V.

Fast spontaneous recovery from acute necrotizing eosinophilic myopericarditis without need for immunosuppressive therapy: a case report of a 27-year-old male

Background

Eosinophilic myocarditis (EM) is rare but accounts for 12-22% of histologically proven acute myocarditis cases. Acute necrotizing EM is considered an aggressive, life-threatening disease which is usually treated by high-dose corticosteroid therapy.

Case summary

We report the case of a 27-year-old man with acute severe pericarditic chest pain, moderately reduced left ventricular (LV) ejection fraction, and a small pericardial effusion. Troponin I level was highly elevated in the absence of coronary artery disease, leading to the diagnosis of acute myopericarditis. In the absence of blood eosinophilia and despite a negative cardiac magnetic resonance study, LV endomyocardial biopsy revealed an acute necrotizing EM. With conventional antiphlogistic and heart failure therapy, the patient became symptom-free and inflammatory and cardiac necrosis markers as well as LV ejection fraction normalized within days. Thus, in the absence of a systemic hypereosinophilic disorder, there was no need for steroid therapy. Long-term follow-up over 12 months showed sustained normalization of cardiac structure and function.

Discussion

Acute necrotizing eosinophilic myopericarditis is not always a dreadful cardiac disease. There are idiopathic cases which may quickly resolve without immunosuppression. There seems to be a publication bias towards critical cases.

Percutaneous closure of an iatrogenic aorto-right atrial fistula of the sinus of Valsalva through total arm approach: a case report

Background 

Creation of an iatrogenic aorto-right atrial fistula is a rare but clinically relevant complication of cardiac surgery. Transfemoral percutaneous closure is an attractive alternative to surgical repair, but there are no reports about transcatheter repair using a complete arm access.

Case summary 

We present the case of a 44-year-old woman with heart failure (NewYork Heart Association Class III) due to a longstanding iatrogenic fistula from the non-coronary aortic cusp to the right atrium (RA) with aorta to RA shunting and severe tricuspid regurgitation (TR) caused by mitral valve replacement 15 years ago. The patient was successfully treated by percutaneous closure with an Amplatzer Vascular Plug II using complete brachial access. Following the procedure right heart chambers and TR decreased and symptoms resolved.

Discussion 

To the best of our knowledge this is the first report of percutaneous repair of an aorto-right atrial fistula using total arm accesses (radial artery and basilic vein). In appropriately selected patients, this approach is an attractive alternative to femoral access.

What are the long-term consequences of youth exposure to firearm injury, and how do we prevent them? A scoping review

The long-term consequences of exposure to firearm injury-including suicide, assault, and mass shootings-on children's mental and physical health is unknown. Using PRISMA-ScR guidelines, we conducted a scoping review of four databases (PubMed, Scopus, PsychINFO, and CJ abstract) between January 1, 1985 and April 2, 2018 for articles describing long-term outcomes of child or adolescent firearm injury exposure (n = 3582). Among included studies (n = 31), most used retrospective cohorts or cross-sectional studies to describe the correlation between firearm injury and post-traumatic stress. A disproportionate number of studies examined the effect of mass shootings, although few of these studies were conducted in the United States and none described the impact of social media. Despite methodologic limitations, youth firearm injury exposure is clearly linked to high rates of post-traumatic stress symptoms and high rates of future injury. Evidence is lacking on best practices for prevention of mental health and behavioral sequelae among youth exposed to firearm injury. Future research should use rigorous methods to identify prevalence, correlates, and intervention strategies for these at-risk youth.

Can fecal continence be predicted in patients born with anorectal malformations?

PURPOSE

The purpose of this study was to identify factors associated with attaining fecal continence in children with anorectal malformations (ARM).

METHODS

We performed a multi-institutional cohort study of children born with ARM in 2007-2011 who had spinal and sacral imaging. Questions from the Baylor Social Continence Scale were used to assess fecal continence at the age of ≥4 years. Factors present at birth that predicted continence were identified using multivariable logistic regression.

RESULTS

Among 144 ARM patients with a median age of 7 years (IQR 6-8), 58 (40%) were continent. The rate of fecal continence varied by ARM subtype (p = 0.002) with the highest rate of continence in patients with perineal fistula (60%). Spinal anomalies and the lateral sacral ratio were not associated with continence. On multivariable analysis, patients with less severe ARM subtypes (perineal fistula, recto-bulbar fistula, recto-vestibular fistula, no fistula, rectal stenosis) were more likely to be continent (OR = 7.4, p = 0.001).

CONCLUSION

Type of ARM was the only factor that predicted fecal continence in children with ARM. The high degree of incontinence, even in the least severe subtypes, highlights that predicting fecal continence is difficult at birth and supports the need for long-term follow-up and bowel management programs for children with ARM.

TYPE OF STUDY

Prospective Cohort Study.

LEVEL OF EVIDENCE

II.

Update on neuroblastoma

Neuroblastoma is an embryonic cancer arising from neural crest stem cells. This cancer is the most common malignancy in infants and the most common extracranial solid tumor in children. The clinical course may be highly variable with the possibility of spontaneous regression in the youngest patients and increased risk of aggressive disease in older children. Clinical heterogeneity is a consequence of the diverse biologic characteristics that determine patient risk and survival. This review will focus on current progress in neuroblastoma staging, risk stratification, and treatment strategies based on advancing knowledge in tumor biology and genetic characterization. TYPE OF STUDY: Review article. LEVEL OF EVIDENCE: Level II.

Screening practices and associated anomalies in infants with anorectal malformations: Results from the Midwest Pediatric Surgery Consortium

BACKGROUND

This study evaluates screening practices and the incidence of associated anomalies in infants with anorectal malformations (ARM).

METHODS

We performed a multi-institutional retrospective cohort study of children born between 2007 and 2011 who underwent surgery for ARM at 10 children's hospitals. ARM type was classified based on the location of the distal rectum, and all screening studies were reviewed.

RESULTS

Among 506 patients, the most common ARM subtypes were perineal fistula (40.7%), no fistula (11.5%), and vestibular fistula (10.1%). At least 1 screening test was performed in 96.6% of patients, and 11.3% of patients underwent all. The proportion of patients with ≥1 abnormal finding on any screening test varied by type of ARM (p<0.001). Screening rates varied from 15.2% for limb anomalies to 89.7% for renal anomalies. The most commonly identified anomalies by screening category were: spinal: tethered cord (20.6%); vertebral: sacral dysplasia/hemisacrum (17.8%); cardiac: patent foramen ovale (58.0%); renal: hydronephrosis (22.7%); limb: absent radius (7.9%).

CONCLUSION

Screening practices and the incidence of associated anomalies varied by type of ARM. The rate of identifying at least one associated anomaly was high across all ARM subtypes. Screening for associated anomalies should be considered standard of care for all ARM patients.

TYPE OF STUDY

Multi-institutional retrospective cohort study.

LEVEL OF EVIDENCE

III.

Substance Use as a Risk Factor for Sleep Problems Among Adolescents Presenting to the Emergency Department

OBJECTIVES

To determine correlates of sleep problems among adolescents. Specifically, to assess the relative strength of associations between sleep problems and dating victimization, reasons for emergency department (ED) visit, depression, unhealthy alcohol use, and other drug use (marijuana, nonmedical use of prescription opioids, stimulants, and tranquilizers).

METHODS

A total of 1852 adolescents aged 14 to 20 years presenting for care to the University of Michigan Emergency Department, Ann Arbor, Michigan, during 2011-2012, self-administered a computerized health survey. Sleep problems were identified if any of the 4 items on the Sleep Problems Questionnaire were rated by a patient as greater than 3 on a 0 to 5 scale. Adolescents who were too sick to be screened in the ED were eligible to participate in the study during their inpatient stay. Exclusion criteria for baseline included insufficient cognitive orientation precluding informed consent, not having parent/guardian present if younger than 18 years, medical severity precluding participation, active suicidal/homicidal ideation, non-English-speaking, deaf/visually impaired, or already participated in this study on a prior visit.

RESULTS

23.5% of adolescents reported clinically significant sleep problems. Female gender, depression, dating victimization, tobacco use, nonmedical use of prescription medication, and an ED visit for medical reasons were each associated with sleep problems among adolescents, even while controlling for age, other types of drug use, receiving public assistance, and dropping out of school.

CONCLUSIONS

These exploratory findings indicate that ED-based screening and brief intervention approaches addressing substance use and/or dating victimization may need to account for previously undiagnosed sleep problems.

Nonmedical prescription stimulant use among youth in the emergency department: prevalence, severity and correlates

This study examined the prevalence, severity and correlates of nonmedical prescription stimulant use (NPSU) among youth in the emergency department (ED). Participants 14-20 years old presenting to the ED completed a survey. A multinomial logistic regression was used to compare those without NPSU, with mild NPSU and with moderate/severe NPSU on demographics, risk factors and ED utilization. There were 4389 participants; 8.3% reported past-year NPSU and 44% of those with past 3-month NPSU reported at least monthly use. After controlling for demographics, participants with mild NPSU or moderate/severe NPSU had higher odds of all substance use risk factors compared to those with no NPSU. Also, those with moderate/severe NPSU were more likely to report dating violence and nonmedical use of opioids or sedatives and less likely to use marijuana compared to those with mild NPSU. Healthcare setting screening and intervention efforts should consider NPSU concomitant with other substance use and explore the association of dating violence with NPSU.

Accuracy of the abdominal examination for identifying children with blunt intra-abdominal injuries

OBJECTIVE

To determine the accuracy of complaints of abdominal pain and findings of abdominal tenderness for identifying children with intra-abdominal injury (IAI) stratified by Glasgow Coma Scale (GCS) score.

STUDY DESIGN

This was a prospective, multicenter observational study of children with blunt torso trauma and a GCS score ≥13. We calculated the sensitivity of abdominal findings for IAI with 95% CI stratified by GCS score. We examined the association of isolated abdominal pain or tenderness with IAI and that undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion, or ≥2 nights of intravenous fluid therapy).

RESULTS

Among the 12 044 patients evaluated, 11 277 (94%) had a GCS score of ≥13 and were included in this analysis. Sensitivity of abdominal pain for IAI was 79% (95% CI, 76%-83%) for patients with a GCS score of 15, 51% (95% CI, 37%-65%) for patients with a GCS score of 14, and 32% (95% CI, 14%-55%) for patients with a GCS score of 13. Sensitivity of abdominal tenderness for IAI also decreased with decreasing GCS score: 79% (95% CI, 75%-82%) for a GCS score of 15, 57% (95% CI, 42%-70%) for a GCS score of 14, and 37% (95% CI, 19%-58%) for a GCS score of 13. Among patients with isolated abdominal pain and/or tenderness, the rate of IAI was 8% (95% CI, 6%-9%) and the rate of IAI undergoing acute intervention was 1% (95% CI, 1%-2%).

CONCLUSION

The sensitivity of abdominal findings for IAI decreases as GCS score decreases. Although abdominal computed tomography is not mandatory, the risk of IAI is sufficiently high that diagnostic evaluation is warranted in children with isolated abdominal pain or tenderness.

Association between the seat belt sign and intra-abdominal injuries in children with blunt torso trauma in motor vehicle collisions

OBJECTIVES

The objective was to determine the association between the abdominal seat belt sign and intra-abdominal injuries (IAIs) in children presenting to emergency departments with blunt torso trauma after motor vehicle collisions (MVCs).

METHODS

This was a planned subgroup analysis of prospective data from a multicenter cohort study of children with blunt torso trauma after MVCs. Patient history and physical examination findings were documented before abdominal computed tomography (CT) or laparotomy. Seat belt sign was defined as a continuous area of erythema, ecchymosis, or abrasion across the abdomen secondary to a seat belt restraint. The relative risk (RR) of IAI with 95% confidence intervals (CIs) was calculated for children with seat belt signs compared to those without. The risk of IAI in those patients with seat belt sign who were without abdominal pain or tenderness, and with Glasgow Coma Scale (GCS) scores of 14 or 15, was also calculated.

RESULTS

A total of 3,740 children with seat belt sign documentation after blunt torso trauma in MVCs were enrolled; 585 (16%) had seat belt signs. Among the 1,864 children undergoing definitive abdominal testing (CT, laparotomy/laparoscopy, or autopsy), IAIs were more common in patients with seat belt signs than those without (19% vs. 12%; RR = 1.6, 95% CI = 1.3 to 2.1). This difference was primarily due to a greater risk of gastrointestinal injuries (hollow viscous or associated mesentery) in those with seat belt signs (11% vs. 1%; RR = 9.4, 95% CI = 5.4 to 16.4). IAI was diagnosed in 11 of 194 patients (5.7%; 95% CI = 2.9% to 9.9%) with seat belt signs who did not have initial complaints of abdominal pain or tenderness and had GCS scores of 14 or 15.

CONCLUSIONS

Patients with seat belt signs after MVCs are at greater risk of IAI than those without seat belt signs, predominately due to gastrointestinal injuries. Although IAIs are less common in alert patients with seat belt signs who do not have initial complaints of abdominal pain or tenderness, the risk of IAI is sufficient that additional evaluation such as observation, laboratory studies, and potentially abdominal CT scanning is generally necessary.

Dose-intensive response-based chemotherapy and radiation therapy for children and adolescents with newly diagnosed intermediate-risk hodgkin lymphoma: a report from the Children's Oncology Group Study AHOD0031

PURPOSE

The Children's Oncology Group study AHOD0031, a randomized phase III study, was designed to evaluate the role of early chemotherapy response in tailoring subsequent therapy in pediatric intermediate-risk Hodgkin lymphoma. To avoid treatment-associated risks that compromise long-term health and to maintain high cure rates, dose-intensive chemotherapy with limited cumulative doses was used.

PATIENTS AND METHODS

Patients received two cycles of doxorubicin, bleomycin, vincristine, etoposide, cyclophosphamide, and prednisone (ABVE-PC) followed by response evaluation. Rapid early responders (RERs) received two additional ABVE-PC cycles, followed by complete response (CR) evaluation. RERs with CR were randomly assigned to involved-field radiotherapy (IFRT) or no additional therapy; RERs with less than CR were nonrandomly assigned to IFRT. Slow early responders (SERs) were randomly assigned to receive two additional ABVE-PC cycles with or without two cycles of dexamethasone, etoposide, cisplatin, and cytarabine (DECA). All SERs were assigned to receive IFRT.

RESULTS

Among 1,712 eligible patients, 4-year event-free survival (EFS) was 85.0%: 86.9% for RERs and 77.4% for SERs (P < .001). Four-year overall survival was 97.8%: 98.5% for RERs and 95.3% for SERs (P < .001). Four-year EFS was 87.9% versus 84.3% (P = .11) for RERs with CR who were randomly assigned to IFRT versus no IFRT, and 86.7% versus 87.3% (P = .87) for RERs with positron emission tomography (PET) -negative results at response assessment. Four-year EFS was 79.3% versus 75.2% (P = .11) for SERs who were randomly assigned to DECA versus no DECA, and 70.7% versus 54.6% (P = .05) for SERs with PET-positive results at response assessment.

CONCLUSION

This trial demonstrated that early response assessment supported therapeutic titration (omitting radiotherapy in RERs with CR; augmenting chemotherapy in SERs with PET-positive disease). Strategies directed toward improved response assessment and risk stratification may enhance tailoring of treatment to patient characteristics and response.

Nonmedical prescription opioid and sedative use among adolescents in the emergency department

OBJECTIVES

Nonmedical prescription opiate use (NPOU) and nonmedical prescription sedative use (NPSU) are serious public health concerns. The objectives of this study were to determine the prevalence and emergency department (ED) visit characteristics and other correlates associated with past-year NPOU and NPSU among adolescents and young adults using the ED.

METHODS

Participants aged 14 to 20 presenting to the ED at the University of Michigan Medical Center between September 2010 and September 2011 were systematically recruited. A computerized self-report screening survey with validated items measuring past-year NPOU, NPSU, substance use, and violence was delivered to participants, and a retrospective chart review was performed.

RESULTS

Of the 2135 participants (86.0% response rate), 222 (10.4%) reported either NPOU or NPSU. Among the 185 (8.7%) participants that reported NPOU, 14.6% had a current home prescription for an opioid and among the 115 (5.4%) with NPSU, 12.3% had a current home prescription for a sedative. After controlling for demographics (age, gender, race, public assistance), correlates of NPOU or NPSU included other substance use, and drinking and driving or riding with a drinking driver. Additional correlates of NPOU included receiving an intravenous opioid in the ED and for NPSU, dating violence, presenting to the ED for a noninjury complaint, and previous ED visit in the past year.

CONCLUSIONS

Nearly 1 in 10 young people who use the ED for care report NPOU or NPSU, and only 12.3% and 14.6% report having current home prescriptions for sedatives and opioids. The ED represents a key location for screening and intervention efforts.

The quantification of liver anatomical changes and assessment of occupant liver injury patterns

Liver injuries can be significant in vehicle crashes. In this study, the liver anatomy was quantified in both adult and pediatric populations as a function of gender and age. Five anatomical liver measurements were determined using CT scans of 260 normal livers. These measurements include the area and volume, and the length, width, and girth of the liver (IRB HUM00041441). To characterize geometrical shape, an inscribed sphere and circumscribed ellipsoid were fitted on the measurements. In the pediatric population the liver area and volume continuously increased with age. When normalized by patient weight, volume measurements show a decrease in volume with age, suggesting that the liver occupies a smaller proportion of the body with age. In the adult population, liver measurements varied with gender. The superior and inferior locations of the liver were also recorded with respect to the spine. The lower portion was at the L3 in small children and at L2 as children approached puberty. It stayed in that area through the 60+ group, offering more ribcage protection. Liver injury patterns were also assessed in crash occupants. Seventy-two occupants with moderate to severe (AIS 2+) liver injuries were investigated. A new methodology was presented and consisted of quantifying blood volumes. The results were compared to overall liver volume and injury scales. No clear distinction on the injury pattern was observed by age group. Liver injuries were more commonly associated with AIS 2+ thoracic injuries in adults than in children. Most injuries occurred in the right lobe.

Image based feasibility of renal sparing surgery for very low risk unilateral Wilms tumors: a report from the Children's Oncology Group

PURPOSE

Nephrectomy with lymph node sampling is the recommended treatment for children with unilateral Wilms tumor under the Children's Oncology Group protocols. Using radiological assessment, we determined the feasibility of performing partial nephrectomy in a select group of patients with very low risk unilateral Wilms tumor.

MATERIALS AND METHODS

We reviewed imaging studies of 60 patients with a mean age of less than 2 years with very low risk unilateral Wilms tumor (mean weight less than 550 gm) to assess the feasibility of partial nephrectomy. We evaluated percentage of salvageable parenchyma, tumor location and anatomical features preventing a nephron sparing approach.

RESULTS

A linear relationship exists between tumor weight and computerized tomography estimated tumor volume. Mean tumor weight in the study population was 315 gm. Partial nephrectomy was deemed feasible in only 5 of 60 patients (8%).

CONCLUSIONS

When considering a select population with very low risk unilateral Wilms tumor (lower volume tumor), only a small percentage of nonpretreated patients are candidates for nephron sparing surgery.

Treatment of pediatric lymphocyte predominant Hodgkin lymphoma (LPHL): A report from the Children's Oncology Group

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Background: LPHL, an uncommon subtype of HL, typically presents with low stage disease and responds to regimens used for classical HL. Recurrence is uncommon, but second malignant neoplasms (SMN) or development of non-Hodgkin lymphoma (NHL) can occur. Therefore, reducing radiation exposure may be of benefit. We report the results of a prospective trial in which a selected subset of patients had surgery alone and the remainder were treated with limited chemotherapy +/- involved-field radiation therapy (IFRT). Methods: Patients ages 0-21 years with newly diagnosed, low risk LPHL were eligible for AHOD03P1. Low risk was defined as clinical Stage IA or IIA without bulk disease (mediastinal mass > 1/3 of the thoracic diameter or nodal aggregate > 6 cm). Patients with Stage IA LPHL with an unresected node or more than a single involved node or Stage IIA were treated with 3 cycles of AV-PC (doxorubicin/vincristine/prednisone/cyclophosphamide). Patients with Stage IA LPHL in a single node that was completely resected were initially observed without further therapy; those who recurred after surgery with low risk LPHL received AV-PC x 3. Patients with < complete response (CR) to AV-PC x 3 received 2100 cGY IFRT. Results: 180 eligible patients with low risk LPHL were enrolled and completed study therapy. 52 patients underwent initial surgery alone; their 3 year EFS = 81.5%. 137 patients received AV-PC x 3; 128 were treated at diagnosis and 9 upon relapsing after surgery alone. 11 patients receiving AV-PC had < CR and received IFRT. 12 first events occurred among these 137 patients (11 relapses and 1 SMN, a NHL). One relapse occurred in a patient who received IFRT. The median follow-up among the 125 remaining patients is 39 (range 3 -76) months. Current 4-year EFS estimate is 88.1% (95% CI: 79.5%-93.3%) for these 137 patients. 4 year EFS for the entire cohort of 180 patients = 86.2%; their overall survival (OS) is 100%. Conclusions: Pediatric LPHL patients have an excellent EFS with chemotherapy that is less intensive than standard regimens; >90% of patients can avoid RT. NHL as a first event may be related to the underlying LPHL and not an effect of treatment. The salvage rate for the few relapses is high, and OS to date is excellent. Clinical trial information: NCT00107198.

Treatment of pediatric stage IA lymphocyte-predominant Hodgkin lymphoma with surgical resection alone: A report from the Children's Oncology Group

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Background: Lymphocyte-predominant Hodgkin lymphoma (LPHL) is an uncommon histologic subtype comprising up to 10% of cases in pediatric series. Patients with LPHL typically present with low stage disease and are responsive to regimens used for classical HL. Recurrence is uncommon; secondary malignant neoplasms or evolution to non-Hodgkin lymphoma are more common events. Small retrospective studies have suggested that some patients with stage I LPHL can be cured with surgery alone. We report the results of a large prospective study using a treatment algorithm in which a selected subset of patients received surgery alone. Methods: Patients ages 0-21 years with newly-diagnosed, low risk LPHL were eligible for AHOD03P1. Low risk was defined as clinical Stage IA and IIA in the absence of bulk disease (a mediastinal mass > 1/3 of the thoracic diameter or a nodal aggregate > 6 cm). Central pathology review was performed to confirm LPHL histology. Baseline evaluations included CT and FDG-PET. Patients with Stage IA disease in a single node that was completely resected were observed without further therapy. Total resection (TR) was confirmed by rapid central review of CT and FDG-PET. In some cases the extent of resection was equivocal; repeat imaging 6-7 weeks after initial evaluation was used to allocate such patients to either observation or chemotherapy. Patients who recurred were assigned to treatment with 3 cycles of AV-PC (doxorubicin/vincristine/prednisone/cyclophosphamide). Results: Between January 2006 and November 2010, 52 patients with Stage IA, single node LPHL were enrolled with a confirmed TR. Nine patients have experienced a relapse; 8 were Stage I and 1 was Stage II at relapse. The median time to relapse was 10 (range 1-17) months. The median follow up among the 43 remaining patients is 26 (range 4-60) months. The current 2 year EFS estimate among these patients is 80.3% (95% CI: 65.3% -89.3%). Overall survival for the 52 patients is 100%. Conclusions: With this strategy of surgical resection followed by observation in a highly select cohort of pediatric LPHL, up to 80% of patients may be spared chemotherapy. Follow up is limited but overall survival to date is excellent.

Isolated infrarenal caval disruption secondary to minimal blunt trauma

Injuries to the inferior vena cava (IVC) are highly lethal and are usually associated with gunshot wounds. Blunt injury to the IVC is a rare entity that is usually located in the retrohepatic space. We present the case of an infrarenal caval disruption in a 9-year-old as a result of minimal blunt trauma. A computed tomography scan showed that the patient had a large retroperitoneal hematoma associated with IVC disruption and proximal thrombus just below the renal veins. There was no evidence of either arterial or other intra-abdominal injuries. The patient had a fall in hematocrit and abdominal tenderness prompting operative exploration. Before laparotomy, bilateral balloon occlusion devices were placed in both femoral veins. The patient was noted to have a total disruption of his IVC just above the origin of his iliac veins. The anterior two-third of the IVC was avulsed, thus leaving the posterior portion against the retroperitoneum. Given the patient's hemodynamic instability and amount of venous damage, the IVC was oversewn and a damage control operation was undertaken. The following day, the patient was brought back to the operating room for a second-look laparotomy and abdominal closure. A pathologic examination revealed a high-grade spindle cell sarcoma. Blunt injury to the IVC is a rare entity and its location outside of the retrohepatic space should alert the surgeon to a potential underlying malignant etiology.