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Introduction: Data support use of video-assisted thoracoscopic surgery (VATS) for safe and effective resection of paraspinal masses in children. Our aim was to describe outcomes following this operation using a novel technique and to compare its use with that of other established techniques. Subjects and Methods: We performed a retrospective chart review of all children (<18 years old) undergoing thoracoscopic resection of paraspinal masses in 2000-2011. Demographics, operative details, and clinical outcomes were summarized and compared between those undergoing resection using a Harmonic® (Ethicon Endo-Surgery, Blue Ash, OH) blade scalpel (HBS) and those who did not. Results: Sixteen cases were identified (median age, 57.5 months; range, 2-204 months). Six cases (37%) underwent VATS with use of the HBS, and 10 (63%) did not. Demographic and clinical factors were well matched. Median tumor diameter was larger in the HBS group (49.2 cm3 versus 18.7 cm3; P=.07). Operative time was similar between groups (121 versus 138 minutes; P=.25), as was the estimated blood loss (10 mL versus 30 mL; P=.91) and chest tube duration (2.1 versus 1.8 days; P=.78). Three cases of Horner's syndrome developed in the standard resection group, and one complication occurred in the HBS group. Conclusions: The Harmonic blade scalpel can be used as a simple alternative to standard dissection techniques for thoracoscopic resection of paraspinal masses in children. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to highlight the unique case of an intrathoracic mesothelial cyst in a 5-year-old child that was treated with a thoracoscopic resection. Background: Mesothelial cysts are benign cysts lined by a single layer of mesothelial cells. These rare lesions can be found on, or adjacent to, serous membranes but are only occasionally located within the thorax. In children, less than 10 intrathoracic cases have been described thus far, most of which are diaphragmatic in origin. Case: An asymptomatic 5-year-old female presented with a left-sided mediastinal mass incidentally discovered on a chest radiograph during a work-up for scoliosis. Magnetic resonance imaging demonstrated a hypodense, nonenhancing lesion measuring 3 2.5 8 cm in the left paravertebral region. Video-assisted thoracoscopy was employed for diagnosis and excision. The thin-walled cyst was dissected free from the pleura and completely excised thoracoscopically. Histopathology showed a benign, unilocular cyst lined with a cuboidal mesothelium that stained strongly positive for cytokeratin. Conclusion: Mediastinal mesothelial cysts have very rarely been reported in the pediatric population. In the case presented, the benign cyst was easily excised by using a minimally invasive thoracoscopic approach. Given the appropriate indications, we feel that thoracoscopic resection is well suited for such cases. [ABSTRACT FROM AUTHOR]

Negative pressure therapy (NPT) has been accepted as a valuable adjunct for wound closure in adults; however, reports on its effectiveness in young children and infants, including neonates, are limited. A retrospective chart review was conducted on children treated with NPT at a single institution between January 2003 and December 2005. Wound volumetric measurements were calculated at the start and end of therapy. Sixty-eight patients with 82 wounds were identified. The mean age was 8.5 years (range 7 days–18 years). Twenty patients (29%) were 2 years of age or younger, including eight neonates. Wound types included: pressure ulcers ( n=13), extremity wounds ( n=18), dehisced surgical wounds ( n=19), open sternal wounds ( n=10), wounds with fistulas ( n=3), and complex abdominal wall defects ( n=6). Low suction pressures (<100 mmHg) were generally used in children younger than 4 years of age. Following NPT, 93% of wounds decreased in volume. The average wound volume decrease was 80% ( p<0.01, n=56). NPT can be effectively used to manage a variety of wounds in children and neonates. No major complications were identified in our retrospective review. Prospective studies are required to better refine the use of this technology in children. [ABSTRACT FROM AUTHOR]

Background: Pediatric trauma patients sustaining blunt abdominal trauma (BAT) with intra-abdominal injury (IAI) are frequently admitted to the intensive care unit (ICU). This study was performed to identify predictors for ICU admission following BAT.Methods: Prospective study of children (< 16 years) who presented to 14 Level-One Pediatric Trauma Centers following BAT over a 1-year period. Patients were categorized as ICU or non-ICU patients. Data collected included vitals, physical exam findings, laboratory results, imaging, and traumatic injuries. A multivariable hierarchical logistic regression model was used to identify predictors of ICU admission. Predictive ability of the model was assessed via tenfold cross-validated area under the receiver operating characteristic curves (cvAUC).Results: Included were 2,182 children with 21% (n = 463) admitted to the ICU. On univariate analysis, ICU patients were associated with abnormal age-adjusted shock index, increased injury severity scores (ISS), lower Glasgow coma scores (GCS), traumatic brain injury (TBI), and severe solid organ injury (SOI). With multivariable logistic regression, factors associated with ICU admission were severe trauma (ISS > 15), anemia (hematocrit < 30), severe TBI (GCS < 8), cervical spine injury, skull fracture, and severe solid organ injury. The cvAUC for the multivariable model was 0.91 (95% CI 0.88-0.92).Conclusion: Severe solid organ injury and traumatic brain injury, in association with multisystem trauma, appear to drive ICU admission in pediatric patients with BAT. These results may inform the design of a trauma bay prediction rule to assist in optimizing ICU resource utilization after BAT.Study Design: Prognosis study.Level Of Evidence:1: [ABSTRACT FROM AUTHOR]

Growing teratoma syndrome is defined as conversion of a metastatic immature tumor to a mature tumor after adjuvant chemotherapy and remains an area of investigation because of its unclear pathogenesis. Because of its risk of malignant transformation, the primary treatment strategy for pediatric patients is surgical resection. In this report we present a case of a pediatric patient with recurrent growing teratoma syndrome who was treated with chemotherapy, debulking procedures, and cryoablation for the growing nodules throughout her abdominal cavity. The patient has had a good clinical outcome without recurrent malignant tumor. These masses do not always regress with chemotherapy and complete surgical excision or ablation should be attempted when possible. [ABSTRACT FROM AUTHOR]

Objectives: The aims of this study were to assess parent acceptance of firearms education delivered by clinical providers, determine whether parents engage in firearms safety dialog with their children, and evaluate reasons for ownership and storage behaviors.Methods: The parents of children ages 0 to 18 years completed surveys while in a pediatric inpatient setting in Texas. Demographics, acceptability, current behaviors, and storage practices were queried. Responses between firearms owners and nonowners were analyzed using the Fisher exact and χ2 tests.Results: Of the 115 parents who completed surveys, 41% reported owning firearms. Most parents were likely or highly likely to follow their pediatrician's gun safety advice (67%), were accepting of safety videos in waiting rooms (59%), and accepted firearms locks distributed by clinical providers (69%). Nonowners were less likely than owners to have spoken to their children about gun safety (P = 0.004). Parents owned firearms for self-protection and recreation (50%), self-protection only (38%), or recreation only (12%). Owners stored them unloaded (75%), used safety devices (95%), and stored them in the closet of the master bedroom (54%).Conclusions: Talking about firearms safety in a healthcare setting was not a contentious issue in the majority of our sample. Parents were accepting of provider-led firearms guidance regardless of ownership status. This provides an opportunity for providers to focus on effective messaging and time-efficient delivery of firearms safety education. [ABSTRACT FROM AUTHOR]

Wilms tumor accounts for more than 90% of all malignant kidney neoplasms in children. Survival after diagnosis and treatment is excellent in most high-income countries. Low- and middle-income countries (LMICs) continue to struggle with Wilms tumor detection and treatment. The purpose of this study was to compare the global incidence and outcomes of Wilms tumor. Wilms tumor incidence data from the World Health Organization (WHO), International Incidence of Childhood Cancer, Volume III, was analyzed according to world region and country socioeconomic status using descriptive statistics and independent-sample Kruskal–Wallis Test. A literature review was also performed to assess outcomes and identify common themes. Wilms tumor was most common in children aged 0-4 y (median incidence 15.1 [IQR 11.8-18.7] ASR/million). High-income countries reported significantly higher median incidence than middle-income countries (8.6 [7.4–9.3] versus 6.1 [4.9–8.7] ASR/million; P < 0.01), although low-income countries reported the highest median incidence overall (9.8 [6.2–16.4] ASR/million). Low-income countries had the fewest countries with registries (n = 6). Overall survival ranged from 70% to 97% in high-income countries, 61%–94% in upper-middle-income countries, 0%–85% in lower-middle-income countries, and 25%–53% in low-income countries. Delay in diagnosis, lack of available treatment, and inadequate follow up contributed to the large variations in outcomes. Reported Wilms tumor incidence is highest in low-income countries, and these are also the countries that have the lowest survival. Lack of significance may reflect incomplete and absent data reporting from lower income countries. Accurate and comprehensive registries are the first steps to appropriate resource allocation in order to improve outcomes for this highly curable childhood malignancy. [ABSTRACT FROM AUTHOR]

Purpose: Although trauma is the leading cause of death for the pediatric population, few studies have addressed the preventable/potentially preventable death rate (PPPDR) attributable to trauma.Methods: This is a retrospective study of trauma-related death records occurring in Harris County, Texas in 2014. Descriptive and Chi-squared tests were conducted for two groups, pediatric and adult trauma deaths in relation to demographic characteristics, mechanism of injury, death location and survival time.Results: There were 105 pediatric (age < 18 years) and 1738 adult patients. The PPPDR for the pediatric group was 21.0%, whereas the PPPDR for the adult group was 37.2% (p = 0.001). Analysis showed fewer preventable/potentially preventable (P/PP) deaths resulting from any blunt trauma mechanism in the pediatric population than in the adult population (19.6% vs. 48.4%, p < 0.001). Amongst the pediatric population, P/PP traumatic brain injury (TBI) were more common in the youngest age range (age 0-5) vs. the older (6-12 years) pediatric and adolescent (13-17 years) patients.Conclusion: Our results identify areas of opportunities for improving pediatric trauma care. Although the overall P/PP death rate is lower in the pediatric population than the adult, opportunities for improving initial acute care, particularly TBI, exist. [ABSTRACT FROM AUTHOR]

Purpose: To describe the practice pattern for routine laboratory and imaging assessment of children following blunt abdominal trauma (BAT).Methods: Children (age < 16 years) presenting to 14 pediatric trauma centers following BAT over a 1-year period were prospectively identified. Injury, demographic, routine laboratory and imaging utilization data were collected. Descriptive, comparative, and correlation analysis was performed.Results: 2188 children with a median age of 8 (4,12) years were included and the median injury severity score was 5 (1,10). There were significant differences in activation status, injury severity, and mechanism across centers; however, there was no correlation of level of activation, injury severity, or severe mechanism with test utilization. Routine laboratory and imaging utilization for hematocrit, hepatic enzymes, pancreatic enzymes, base deficit urine microscopy, chest and pelvis X-ray, and abdominal computed tomography (CT) varied significantly among centers. Only obtaining a hematocrit had a moderate correlation with CT use. There was no correlation between centers that were high or low frequency laboratory utilizers with CT use.Conclusions: Wide variability exists in the routine initial laboratory and imaging assessment in children following BAT. This represents an opportunity for quality improvement in pediatric trauma.Level Of Evidence: Level II. [ABSTRACT FROM AUTHOR]

Abstract Background Massive transfusion protocols with balanced blood product ratios have been associated with improved outcomes in adult trauma. The impact on pediatric trauma is unclear. Material and methods A retrospective review of the Pediatric Trauma Quality Improvement Program data set was performed using data from January 2015 to December 2016. Trauma patient's ≤ 18 y of age, who received red blood cells (RBCs) and were massively transfused were included. Children with burns, dead on arrival, and nonsurvivable injuries were excluded. Outcome data and mortality were assessed based on low (<1:2), medium (≥1:2, <1:1), and high (≥1:1) plasma and platelet to RBC ratios. Results There were 465 children included in the study (median age, 8 [2-16] y; median injury severity score, 34 [29-34]; mortality rate, 38%). Those transfused a medium plasma:RBC ratio received the greatest blood product volume in 24 h (90 [56-164] mL/kg; P < 0.01). Those in the low plasma:RBC group underwent fewer hemorrhage control procedures [56 (34%); P < 0.01], but ratio was not significant when controlling for age and other variables. Survival was improved for those who received a high plasma:RBC ratio (P = 0.02). Platelet transfusions were skewed toward lower ratios (95%) with no difference in clinical outcomes between the groups. Conclusions A high ratio of plasma:RBC may result in decreased mortality in severely injured children receiving a massive transfusion. Prospective, multicenter studies are needed to determine optimal resuscitation strategies for these critically ill children. [ABSTRACT FROM AUTHOR]

Background Duodenal hematomas from blunt abdominal trauma are uncommon in children and treatment strategies vary. We reviewed our experience with this injury at a large-volume children's hospital. Materials and methods A retrospective case series was assembled from January 2003–July 2014. Data collected included demographics, clinical and radiographic characteristics, and hospital course. Patients with grade I injuries based on the American Association for the Surgery of Trauma Duodenum Injury Scale were compared with those with grade II injuries. Results Nineteen patients met inclusion criteria at a median age of 8.91 y (range, 1.7–17.2 y). Mechanisms of injury included direct abdominal blow or handle bar injury ( n = 9), nonaccidental trauma ( n = 5), falls ( n = 3), and motor vehicle accident ( n = 2). Ten patients had grade I hematomas and nine had grade II. Hematomas were most frequently seen in the second portion of the duodenum ( n = 9). Five patients underwent a laparotomy for concerns for hollow viscus injury. No patients required operative drainage of the hematoma; however, one patient underwent percutaneous drainage. Twelve patients received parenteral nutrition (PN) for a median duration of 9 d (range, 5–14 d). Median duration of PN for grade I was 6.5 d (range, 5–8 d) versus 12 d for grade II (range, 9–14 d; P = 0.016). Complications included one readmission for concern of bowel obstruction requiring bowel rest. Conclusions This study suggests that duodenal hematomas can be successfully managed nonoperatively. Grade II hematomas are associated with longer duration of PN therapy and consequently longer hospital stays. These data can assist in care management planning and parental counseling for patients with traumatic duodenal hematomas. [ABSTRACT FROM AUTHOR]

Introduction: Giant cystic meconium peritonitis is relatively rare. Patients often present with nonspecific physical findings such as distension and emesis. Plain abdominal films remain invaluable for identifying the characteristic calcifications seen with a meconium pseudocyst, and large eggshell calcifications are pathognomonic for the giant cystic subtype.Case Presentation: We present classic plain X-ray findings and an intraoperative image of a premature low birth weight two-day-old Hispanic male baby treated for giant cystic meconium peritonitis with a staged procedure involving peritoneal drainage, ostomy creation and closure.Conclusion: Pediatric surgeons have a range of potential therapeutic approaches for giant cystic meconium peritonitis. A delay of definitive surgical management in the setting of massive abdominal soiling is a safe and acceptable strategy if adequate temporizing drainage is performed in the early perinatal period. [ABSTRACT FROM AUTHOR]

Background: Intercellular adhesion molecule-1 (ICAM-1) permits leukocyte-endothelial adhesion and transmigration during inflammation. Membrane-bound ICAM-1 knockout mice have been used to understand this molecule’s role in wound-healing, but expressed spliced isoforms of ICAM-1 that may have impacted results. We aimed to characterize wound-healing in an ICAM-1 null model devoid of all ICAM-1 isoforms. Methods: Full-thickness 8-mm wounds were created on C57/BL6 wild-type (n = 24) and ICAM-1 null (n = 24) mice. Wound area was calculated using daily photographs. Histologic samples were harvested on postoperative Days 1, 3, 7, and 14. Wound margins were evaluated for mRNA expression of 13 inflammatory cytokines. A separate group of wild-type and ICAM-1 null mice (n = 24) received full-thickness incisions with tensiometry measured at Day 14. Separately, complete blood counts were measured in unwounded wild-type (n = 4) and ICAM-1 null mice (n = 4). Results: Wound-closure was significantly delayed in ICAM-1 null mice through Day 7 by gross and histologic measurement. mRNA expression of VEGF-A was increased in ICAM-1 null mice on Day 3, although no increase in VEGF-A was observed in the wound bed by immunohistochemistry. ICAM-1 null wounds demonstrated higher stiffness by tensiometry on Day 14 compared to the wild-type (1880 ± 926 kPa versus 478 ± 117 kPa; P < 0.01), and had higher counts of white blood cells (10,009 versus 5720 cells/μL, P < 0.05), neutrophils (2130 versus 630 cells/μL, P < 0.01), and lymphocytes (7130 versus 4,740 cells/μL, P < 0.05). Conclusions: ICAM-1 null mice demonstrate delayed wound-healing and decreased wound elasticity compared to wild-type controls. This lag, however, was less than observed in earlier membrane-bound ICAM-1 knockouts, suggesting that other ICAM-1 isoforms may promote delayed wound-healing. [Copyright &y& Elsevier]