Derivation and Validation of a Machine Learning Algorithm for Predicting Venous Thromboembolism in Injured Children

BackgroundVenous thromboembolism (VTE) causes significant morbidity in pediatric trauma patients. We applied machine learning algorithms to the Trauma Quality Improvement Program (TQIP) database to develop and validate a risk prediction model for VTE in injured children.MethodsPatients ≤18 years were identified from TQIP (2017–2019, n = 383,814). Those administered VTE prophylaxis ≤24 h and missing the outcome (VTE) were removed (n = 347,576). Feature selection identified 15 predictors: intubation, need for supplemental oxygen, spinal injury, pelvic fractures, multiple long bone fractures, major surgery (neurosurgery, thoracic, orthopedic, vascular), age, transfusion requirement, intracranial pressure monitor or external ventricular drain placement, and low Glasgow Coma Scale score. Data was split into training (n = 251,409) and testing (n = 118,175) subsets. Machine learning algorithms were trained, tested, and compared.ResultsLow-risk prediction: For the testing subset, all models outperformed the baseline rate of VTE (0.15%) with a predicted rate of 0.01–0.02% (p < 2.2e⁻¹⁶). 88.4–89.4% of patients were classified as low risk by the models.High-risk predictionAll models outperformed baseline with a predicted rate of VTE ranging from 1.13 to 1.32% (p < 2.2e⁻¹⁶). The performance of the 3 models was not significantly different.ConclusionWe developed a predictive model that differentiates injured children for development of VTE with high discrimination and can guide prophylaxis use.Level of EvidencePrognostic, Level II.Type of StudyRetrospective, Cross-sectional.     

Body image perception,compliance with a prosthesis and cognitive performance in transfemoral amputees

ObjectiveThe aim of the study was to assess mutual associations of body image perception, compliance with the prosthesis and cognitive performance in transfemoral amputees.MethodsFourty transfemoral amputee (30 male and 10 female), who had a traumatic and unilateral amputation were included in this study. The mean age of the patients at the time of study was 37 ± 9.9 and the mean age at amputation was 12.6 ± 9.4 years. Patients's body image perception and compliance with the prosthesis paramaters were evaluated with Amputee Body Image Scale (ABIS) and Trinity Amputation and Prosthesis Experience Scales (TAPES). MoCA (The Montreal Cognitive Assessment) has been used to determine the cognitive ability of the participant. All tests has been administered by dual task method during ambulation. Patients who had neurologic or cognitive deficit were excluded from the study.ResultsThere was a statistically significant relationship between an individual's body image perception and cognitive performance. Body image perception was significantly and negatively correlated with the MoCA score (r = −0.514, p < 0.001). There was a statistically significant positive correlation between psychosocial adjustment, prosthesis satisfaction and MoCA scores (r = 0.550, p < 0.001).ConclusionsBody image satisfaction, psychosocial adjustment, lack of activity restriction, and satisfaction with prosthesis are positively associated with cognitive performance of transfemoral amputees. Before beginning the amputee rehabilitation programs, we recommend to include not only physical functions, but also consider body image and cognitive functions as assessment parameters.Level of evidenceLevel IV, Diagnostic Study.     

Long-Term Esthetic Outcome of Different Treatment Modalities for Nontuberculous Mycobacterial Cervicofacial Lymphadenitis

BackgroundNontuberculous mycobacterial (NTM) cervicofacial lymphadenitis is a rare infection which almost exclusively occurs in children, most commonly children 0–5 years old. It can leave scars in highly visible areas. The present study aimed to evaluate the long-term esthetic outcome of different treatment modalities for NTM cervicofacial lymphadenitis.MethodsThis retrospective cohort study included 92 participants with a history of bacteriologically proven NTM cervicofacial lymphadenitis. All patients were diagnosed at least 10 years prior and were aged >12 years upon enrollment. Based on standardized photographs, the scars were assessed by subjects with the Patient Scar Assessment Scale, and by five independent observers with the revised and weighted Observer Scar Assessment Scale.ResultsThe mean age at initial presentation was 3,9 years and the mean follow-up time was 15.24 years. Initial treatments included surgical treatment (n = 53), antibiotic treatment (n = 29) and watchful waiting (n = 10). Subsequent surgery was performed in two patients, due to a recurrence after initial surgical treatment, and in 10 patients initially treated with antibiotic treatment or watchful waiting. Esthetic outcomes were statistically significantly better with initial surgery, compared to initial non-surgical treatment, based on patient scores of scar thickness, and based on observer scores of scar thickness, surface appearance, general appearance and the revised and weighted sum score of all assessment items.ConclusionsThe long-term esthetic outcome of surgical treatment was superior to non-surgical treatment. These findings could facilitate the process of shared decision making.Level of EvidenceLevel III     

Prenatal Sonography in Suspected Proximal Gastrointestinal Obstructions: Diagnostic Accuracy and Neonatal Outcomes

BackgroundThe purpose of this study was to assess diagnostic accuracy and neonatal outcomes in fetuses with a suspected proximal gastrointestinal obstruction (GIO).MethodsAfter IRB approval, a retrospective chart review was conducted on prenatally suspected and/or postnatally confirmed cases of proximal GIO at a tertiary care facility (2012–2022). Maternal-fetal records were queried for presence of a double bubble ± polyhydramnios, and neonatal outcomes were assessed to calculate the diagnostic accuracy of fetal sonography.ResultsAmong 56 confirmed cases, the median birthweight and gestational age at birth were 2550 g [interquartile range (IQR) 2028–3012] and 37 weeks (IQR 34–38), respectively. There was one (2%) false-positive and three (6%) false-negatives by ultrasound. Double bubble had a sensitivity, specificity, positive predictive value, and negative predictive value for proximal GIO of 85%, 98%, 98%, and 83%, respectively. Pathologies included 49 (88%) with duodenal obstruction/annular pancreas, three (5%) with malrotation, and three (5%) with jejunal atresia. The median postoperative length of stay was 27 days (IQR 19–42). Cardiac anomalies were associated with significantly higher complications (45% vs 17%, p = 0.030).ConclusionsIn this contemporary series, fetal sonography has high diagnostic accuracy for detecting proximal gastrointestinal obstruction. These data are informative for pediatric surgeons in prenatal counseling and preoperative discussions with families.Level of EvidenceDiagnostic Study, Level III.     

Impact of age within younger populations on outcomes following cervical surgery in the ambulatory setting

ObjectiveTo determine the effect of age within the younger population seen at ambulatory surgical centers on patient-reported outcome measures (PROMs) after cervical spine surgery.MethodsPatients of age <65 years undergoing single-level anterior cervical discectomy and fusion (ACDF) or cervical disc replacement (CDR) were included. Patients were divided by mean age of initial population (46 years). PROMs included Patient-reported Outcome Measurement Information System Physical Function (PROMIS-PF), 12-Item Short-Form Physical Component Survey (SF-12 PCS), Visual Analog Scale (VAS) neck, VAS arm, Neck Disability Index (NDI) collected preoperatively and at postoperative time points up to 2 years.Results138 patients were included, with 66 patients <46 years. Both cohorts demonstrated improvement from preoperative baseline with regard to all studied PROMs at multiple time points postoperatively (p ≤ 0.042, all). Between groups, the older cohort demonstrated greater mean PROMIS-PF scores preoperatively and at 6 weeks (p ≤ 0.011, both), while VAS arm scores were lower in the older group at 1 year (p = 0.002), and NDI scores were lower in the older group at 6 weeks and 1 year (p < 0.027, both). Minimal Clinically Important Difference (MCID) achievement rates were greater in the younger group in PROMIS PF at 2 years (p = 0.002), and in the older group in VAS arm score at 1 year (p = 0.007).ConclusionBoth cohorts showed significant improvement at multiple postoperative time points for all PROMs. Between groups, the older group reported more favorable physical function, VAS arm, and NDI scores at several time points. However, MCID achievement rates only significantly differed in two PROMs at singular time points. Difference in age in patients <65 years likely does not significantly affect long-term outcomes after cervical spine surgery.     

Effects of a Preoperative Carbohydrate Load on Postoperative Recovery in Children: A Randomised,Double-Blind,Placebo-Controlled Trial

BackgroundNausea and vomiting are common causes for prolonged postoperative length of hospital stay (LOS) in children. A preoperative carbohydrate load may reduce postoperative nausea and vomiting by improving the perioperative metabolic state. The aim of this study was to determine if a preoperative carbohydrate-containing drink would lead to an improvement in the perioperative metabolic state and consequently reduce the incidence of postoperative nausea, vomiting and LOS in children undergoing day-case surgical procedures.MethodRandomised, double-blind, placebo-controlled trial involving children aged 4 to 16-years undergoing day-case surgical procedures. Patients were randomised to receive a carbohydrate-containing drink or a placebo. During the induction of anaesthesia, a venous blood gas, and blood glucose and ketone levels were measured. Postoperatively, the incidence of nausea, vomiting, and LOS were documented.Results120 patients were randomised with 119/120 (99.2%) undergoing analysis. Blood glucose level was higher in the carbohydrate group; 5.4 mmol/L [3.3–9.4] versus 4.9 mmol/L [3.6–6.5] (p = 0.01). Blood ketone level was lower in the carbohydrate group; 0.2 mmol/L versus 0.3 mmol/L (p = 0.003). The incidence of nausea and vomiting was not different (p > 0.9 and p = 0.8, respectively). LOS in the carbohydrate group was 26 min shorter than the placebo group (p = 0.02).ConclusionAlthough a preoperative carbohydrate load may provide a more stable metabolic state at the induction of anaesthesia, we did not find a reduction in postoperative nausea and vomiting. A preoperative carbohydrate load has also minimal effects on the postoperative LOS.Type of studyRandomised clinical trial.Level of evidenceI.     

Long-Term Male Sexual Function and Fecal Incontinence Outcomes for Adult Patients with Hirschsprung Disease or Anorectal Malformation

BackgroundThis study sought to characterize sexual function and fecal incontinence related quality of life (QOL) outcomes for adult males with anorectal malformation (ARM) or Hirschsprung's Disease (HD).MethodsWe conducted a cross-sectional survey study of male patients ≥18 years with ARM or HD. Patients were identified from our institutional database, contacted and consented by telephone, and sent a REDCap survey via email. The International Index of Erectile Function (IIEF-5) and Male Sexual Health Questionnaire (MSHQ) evaluated erectile dysfunction (ED) and ejaculatory dysfunction (EjD), respectively. The Cleveland Clinic Incontinence Score (CCIS) and the Fecal Incontinence Quality of Life Scale (FIQLS) assessed fecal incontinence-related outcomes. A linear regression analysis of IIEF-5 scores compared to CCIS scores was used to evaluate for an association between ED and incontinence.ResultsOf 63 patients contacted, 48 completed the survey. The median age for respondents was 22.5 years (IQR 20–25). There were 19 patients with HD and 29 patients with ARM. On the IIEF-5 survey, 35.3% report some level of ED. On the MSHQ-EjD survey, the median score was 14 out of 15 (IQR 10.75–15), indicating few EjD concerns. The median CCIS was 5 (IQR 2.25–7.75) and the median FIQL scores ranged from 2.7 to 3.5 depending on the domain assessed, demonstrating some QOL challenges secondary to fecal incontinence. On linear regression analysis, IIEF-5 and CCIS scores were weakly associated (B = −0.55, p = 0.045).ConclusionsMale adult patients with ARM or HD may have ongoing concerns with sexual function and fecal incontinence.Level of EvidenceLevel 4.Type of StudyCross-Sectional Survey Study.     

The impact of long-term corticosteroid use on acute postoperative complications following lumbar decompression surgery

BackgroundCorticosteroids have a negative impact on the human immune system’s ability to function at an optimal level. Studies have shown that patients on long-term corticosteroids have higher infection rates. However, the rates of infection and other complications following lumbar decompression surgery remains under-investigated. The aim of our study was to determine the impact of preoperative long-term corticosteroid usage on acute, 30-day postoperative complications in a subset of patients undergoing lumbar spine decompression surgery, without fusion or instrumentation. We hypothesize that patients on long-term corticosteroids will have higher rates of infection and other postoperative complications after undergoing lumbar decompression surgery of the spine.MethodsA retrospective cohort study was conducted using data collected from the National Surgical Quality Improvement Program database data from 2005 to 2016. Lumbar decompression surgeries, including discectomies, laminectomies, and others were identified using CPT codes. Chi-square analysis was used to evaluate differences among the corticosteroid and non-corticosteroid groups for demographics, preoperative comorbidities, and postoperative complications. Logistic regression analysis was done to determine if long-term corticosteroid use predicts incidence of postoperative infections following adjustment.Results26,734 subjects met inclusion criteria. A total of 1044 patients (3.9%) were on long-term corticosteroids prior to surgical intervention, and 25,690 patients (96.1%) were not on long-term corticosteroids. Patients on long-term corticosteroids were more likely to be older (p < 0.001), female (p < 0.001), nonsmokers (p < 0.001), and have a higher American Society of Anesthesiologist class (p < 0.001). Multivariate analysis demonstrated that long-term corticosteroid usage was associated with increased overall complications (odds ratio [OR]: 1.543; p < 0.001), and an independent risk factor for the development of minor complications (OR: 1.808; p < 0.001), urinary tract infection (OR: 2.033; p = 0.002), extended length of stay (OR: 1.244; p = 0.039), thromboembolic complications (OR: 1.919; p = 0.023), and sepsis complications (OR: 2.032; p = 0.024).ConclusionLong-term corticosteroid usage is associated with a significant increased risk of acute postoperative complication development, including urinary tract infection, sepsis and septic shock, thromboembolic complications, and extended length of hospital stay, but not with superficial or deep infection in patients undergoing lumbar decompression procedures. Spine surgeons should remain vigilant regarding postoperative complications in patients on long-term corticosteroids, especially as it relates to UTI and propensity to decompensate into sepsis or septic shock. Thromboembolic risk attenuation is also imperative in this patient group during the postoperative period and the surgeon should weigh the risks and benefits of more intensive anticoagulation measures.     

Influence of bacteriobilia on postoperative complications in patients with periampullary tumors

BackgroundPeriampullary tumours (PAT) may cause obstruction of distal choledochus. The bile stasis is a risk factor for microbial colonisation of bile (bacteriobilia), cholangitis, hepatic insufficiency and coagulopathy. PAT obstruction can be managed surgically or non-operatively - by inserting a biliary drain or stent (BDS). Although BDS allows for adequate bile drainage, liver function restitution and coagulopathy, increased bacteriobilia has been reported and this is associated with an increased incidence of postoperative complications.MethodsA monocentric, prospective, comparative study including 100 patients operated with PAT. The effects of bacteriobilia and the presence of a drain in the biliary tract on the development of postoperative complications were evaluated.ResultsPositive microbial findings in bile were found in 67% of patients. It was 98% in the biliary drain group vs. 36% in non-drained patients (p = 0.0001). In 68% 2 or more different bacterial strains were simultaneously present (p = 0.0001). Patients with a positive microbial finding in bile had more frequent incidence of infectious complications 40.2% (27) vs. 9.1% (3); p = 0.0011. The most frequent infectious complication was wound infection 29.8% (20) vs. 3.03% (1); p = 0.0014. Similarly, a higher incidence of postoperative infectious complications occurred in patients with BDS - 36% (18) vs. 24% (12); p = 0.2752.ConclusionThe presence of a drain or stent in the biliary tract significantly increases the microbial colonisation of bile. It is associated with a significant increase in infectious complications, especially infections in the wound.     

Screening for VACTERL Anomalies in Children with Anorectal Malformations: Outcomes of a Standardized Approach

PurposeThe majority of patients with an anorectal malformation (ARM) have associated congenital anomalies. It is well established that all patients diagnosed with an ARM should undergo systematic screening, including renal, spinal, and cardiac imaging. This study aimed to evaluate the findings and completeness of screening, following local implementation of standardized protocols.MethodsA retrospective cohort study was performed assessing all patients with an ARM managed at our tertiary pediatric surgical center, following a standardized protocol implementation for VACTERL screening (January 2016–December 2021). Cohort demographics, medical characteristics, and screening investigations were analyzed. Findings were compared with our previously published data (2000–2015), conducted prior to protocol implementation.ResultsOne hundred twenty-seven (64 male, 50.4%) children were eligible for inclusion. Complete screening was performed in 107/127 (84.3%) children. Of these, one or more associated anomalies were diagnosed in 85/107 (79.4%), whilst the VACTERL association was demonstrated in 57/107 (53.3%). The proportion of children that underwent complete screening increased significantly in comparison with those assessed prior to protocol implementation (RR 0.43 [CI 0.27–0.66]; p < 0.001). Children with less complex ARM types were significantly less likely to receive complete screening (p = 0.028). Neither presence of an associated anomaly, nor prevalence of the VACTERL association, differed significantly by ARM type complexity.ConclusionScreening for associated VACTERL anomalies in children with ARM was significantly improved following standardized protocol implementation. The prevalence of associated anomalies in our cohort supports the value of routine VACTERL screening in all children with ARM, regardless of malformation type.Level of EvidenceII.     

The Timing of Congenital Diaphragmatic Hernia Repair on Extracorporeal Membrane Oxygenation Impacts Surgical Bleeding Risk

BackgroundThe optimal timing of surgical repair for infants with congenital diaphragmatic hernia (CDH) treated with extracorporeal membrane oxygenation (ECMO) support remains controversial. The risk of surgical bleeding is considered by many centers as a primary factor in determining the preferred timing of CDH repair for infants requiring ECMO support. This study compares surgical bleeding following CDH repair on ECMO in early versus delayed fashion.MethodsA retrospective review of 146 infants who underwent CDH repair while on ECMO support from 1995 to 2021. Early repair occurred during the first 48 h after ECMO cannulation (ER) and delayed repair after 48 h (DR). Surgical bleeding was defined by the requirement of reoperative intervention for hemostasis or decompression.Results102 infants had ER and 44 infants DR. Surgical bleeding was more frequent in the DR group (36% vs 5%, p < 0.001) with an odds ratio of 11.7 (95% CI: 3.48–39.3, p < 0.001). Blood urea nitrogen level on the day of repair was significantly elevated among those who bled (median 63 mg/dL, IQR 20–85) vs. those who did not (median 9 mg/dL, IQR 7–13) (p < 0.0001). Duration of ECMO support was shorter in the ER group (median 13 vs 18 days, p = 0.005). Survival was not statistically different between the two groups (ER 60% vs. DR 57%, p = 0.737).ConclusionWe demonstrate a significantly lower incidence of bleeding and shorter duration of ECMO with early CDH repair. Azotemia was a strong risk factor for surgical bleeding associated with delayed CDH repair on ECMO.Level of evidenceLevel III cohort study.     

Are racial differences in hospital mortality after coronary artery bypass graft surgery real? A risk-adjusted meta-analysis

BackgroundDespite several reports, there are still conflicting data on the influence of ethnicity on mortality rates associated with coronary artery bypass grafting (CABG). We aimed to get further insights into the effect of race on mortality following CABG by performing a risk adjusted meta-analysis.MethodsRelevant studies were searched on PubMed, Embase, BioMed Central, and the Cochrane Central register. Pairwise meta-analysis was used to estimate the relative risk of hospital death of black, Hispanic, and Asian patients using white patients as reference. Risk adjusted meta-analytic estimates were obtained using generic inverse variance methods with random effect model.ResultsA total of 28 studies were selected for analysis. A total of 21 studies reported on hospital mortality in black (n = 222,892) versus white (n = 3,884,043) patients, 7 studies reported on Hispanic (n = 91,256) versus white (n = 1,458,524) and 9 studies reported on Asian (n = 27,820) versus white (n = 1,081,642). When compared with white patients, adjusted risk of hospital death was significantly greater for black patients (adjusted odds ratio [OR], 1.25; 95% confidence interval [CI], 1.13-1.39; P < .001), and not statistically different for Asian (OR, 1.33; 95% CI, 0.99-1.77; P = .05) and Hispanic patients (adjusted OR, 1.08; 95% CI, 0.94-1.23; P = .26). Meta-regression showed a significant trend toward lower mortality rates in most recent series in both black (P = .02) and white (P = .0007) and Asian (P = .01) but not for Hispanic (P = .41). However, as mortality rates were lower across the different races, the relative disadvantage between the study groups persisted, which may explain the lack of interaction between study period and race effect on mortality for black (adjusted P = .09), Asian (adjusted P = .63), and Hispanic (adjusted P = .97) patients.ConclusionsThe present meta-analysis showed that despite progress is being made in lowering in-hospital mortality rates among the major racial/ethnic groups, ethnical disparities in hospital mortality after CABG remain.     

Comparison of symptomatic unstable ankle with and without os subfibulare

BackgroundThis study aimed to compare the patients background, clinical scores, condition of the lateral ligament, mechanical instabilities, and chondral lesions in ankles with symptomatic os subfibulare compared to those in ankles with chronic lateral instability without os subfibulare.MethodsOf the 212 ankles with a chronic lateral instability that were surgically treated, 72 ankles had an os subfibulare. All ankles were examined by arthroscopy during surgery. Age, sex, preoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle–Hindfoot Scale scores, remnant condition of the lateral ligaments, and chondral lesions were compared between ankles with symptomatic os subfibulare and ankles with chronic lateral instability without os subfibulare.ResultsThere were no statistically significant differences between the groups in terms of the sex ratio (males: females, 35:37 vs. 53:87, n.s.) and the AOFAS Ankle–Hindfoot Scale scores (median; 75 vs. 77, n.s.). There were statistically significant differences in patient age (median: 20 vs. 24.5 years, p < 0.01), talar tilt angle (median: 9.0° vs 12.0°, p < 0.01), anterior drawer distance (6.2 vs. 7.0 mm, p < 0.01), chondral lesions (G0:G1:G2:G3, 35:21:66:5 vs. 40:44:27:29, p < 0.01), condition of the anterior talofibular ligament (intact: repairable remnant: poor remnant, 0:70:2 vs. 1:112:27, p < 0.01), and condition of the calcaneofibular ligament (intact: repairable remnant: poor remnant, 44:26:2 vs. 77:35:28, p < 0.01) between the groups.ConclusionThis study suggests that the condition of the lateral ligaments including mechanical instability and cartilage of the ankle were less severe in the ankles with symptomatic os subfibulare than in those with chronic lateral instability without os subfibulare. The patients’ age was lower in the ankles with symptomatic os subfibulare than in those with chronic lateral instability without os subfibulare. The clinical scores and gender ratio were not statistically different between the group.     

A systematic review and meta-analysis of BRCA1/2 mutation for predicting the effect of platinum-based chemotherapy in triple-negative breast cancer

IntroductionPlatinum-based chemotherapy (PBC) remains the mainstay of treatments for triple-negative breast cancer (TNBC). TNBC is a heterogeneous group, the issue of whether BRCA1/2 mutation carriers have a particular sensitivity to platinum agents is inconclusive. We conducted a meta-analysis to explore the relationship between BRCA1/2 mutation and PBC susceptibility in individuals with TNBC, aiming to gain more information on the size of the benefit of PBC in BRCA1/2 mutation carriers.Materials and methodsAll studies applying PBC with a subgroup of BRCA1/2 status were included. All endpoints, including pCR and RCB in the neoadjuvant phase, DFS in the adjuvant phase, ORR, PFS, and OS in the advanced phase, were assessed using HRs and 95% Cl.ResultsFrom the 22 studies included, there were 2158 patients with TNBC, with 392 (18%) bearing the BRCA1/2 gene mutation. Based on 13 studies applying neoadjuvant PBC, we discovered that BRCA1/2 mutation was substantially associated with a 17.6% increased pCR rate (HR 1.32, 95% CI 1.17–1.49, p < 0.00001; I² = 51%). Same result was observed in RCB0/I index (HR 1.38, 95% CI 1.08–1.76, P = 0.009; I² = 0%). The meta-analysis of 6 trials addressing advanced therapy revealed that ORR rates were significantly higher in patients with BRCA1/2 mutation (HR 1.91, 95% CI 1.48–2.47, p < 0.00001; I² = 32%), as well as PFS(HR 1.13, 95% CI 0.81–1.57, P = 0.47; I² = 0%) and OS (HR 1.89, 95% CI 1.22–2.92, P = 0.004; I² = 0%).ConclusionAccording to our meta-analysis of 22 trials in TNBC, BRCA1/2 mutation carriers were significantly more sensitive to PBC regimens, especially in neoadjuvant and advanced therapy.     

Decreased Incidence of Hirschsprung-Associated Enterocolitis During COVID-19 Across United States Children's Hospitals

BackgroundThe Coronavirus Disease 2019 pandemic provided a natural experiment to study the effect of social distancing on the risk of developing Hirschsprung's Associated Enterocolitis (HAEC).MethodsUsing the Pediatric Health Information System (PHIS), a retrospective cohort study of children (<18 years) with Hirschsprung's Disease (HSCR) across 47 United States children's hospitals was performed. The primary outcome was HAEC admissions per 10,000 patient-days. The exposure (COVID-19) was defined as April 2020–December 2021. The unexposed (historical control) period was April 2018–December 2019. Secondary outcomes included sepsis, bowel perforation, intensive care unit (ICU) admission, mortality, and length of stay.ResultsOverall, we included 5707 patients with HSCR during the study period. There were 984 and 834 HAEC admissions during the pre-pandemic and pandemic periods, respectively (2.6 vs. 1.9 HAEC admissions per 10,000 patient-days, incident rate ratio [95% confidence interval]: 0.74 [0.67, 0.81], p < 0.001). Compared to pre-pandemic, those with HAEC during the pandemic were younger (median [IQR]: 566 [162, 1430] days pandemic vs. 746 [259, 1609] days pre-pandemic, p < 0.001) and more likely to live in the lowest quartile of median household income zip codes (24% pandemic vs. 19% pre-pandemic, p = 0.02). There were no significant differences in rates of sepsis (6.1% pandemic vs. 6.1% pre-pandemic, p > 0.9), bowel perforation (1.3% pandemic vs. 1.2% pre-pandemic, p = 0.8), ICU admissions (9.6% pandemic vs. 12% pre-pandemic, p = 0.2), mortality (0.5% pandemic vs. 0.6% pre-pandemic, p = 0.8), or length of stay (median [interquartile range]: 4 [(Pastor et al., 2009; Gosain and Brinkman, 2015) 2,112,11 days pandemic vs. 5 [(Pastor et al., 2009; Tang et al., 2020) 2,102,10 days pre-pandemic, p = 0.4).ConclusionsThe COVID-19 pandemic was associated with significantly decreased incidence of HAEC admissions across US children's hospitals. Possible etiologies such as social distancing should be explored.Level of evidenceII.     

Remote Ischaemic Pre-Conditioning Reduces Intestinal Ischaemia Reperfusion Injury in a Newborn Rat

ObjectiveRemote ischaemic conditioning (RIC) has been shown to reduce ischaemia-reperfusion injury(IRI) in multiple organ systems. IRI is seen in multiple bowel pathologies in the newborn, including NEC. We investigated the potential of RIC as a novel therapy for various intestinal pathologies in the newborn.MethodsWe used an established intestinal IRI model in rat pups which results in similar intestinal injury to necrotising enterocolitis (NEC). Animals were randomly allocated to IRI only(n = 14), IRI + RIC(n = 13) or sham laparotomy(n = 10). The macroscopic extent of intestinal injury is reported as a percentage of total small bowel. Injury severity was measured using Chiu-Park scoring. Neutrophil infiltration/activation was assayed by myeloperoxidase activity. Immunohistochemistry was used to assess the expression of hypoxia-inducible factor alpha (HIF-1α). Data are median (interquartile range).ResultsAnimals that underwent RIC showed a decreased extent of macroscopic injury from 100%(85–100%) in the IRI only group to 58%(15–84%, p = 0.003) in the IRI + RIC group. Microscopic injury score was significantly lower in animals that underwent RIC compared to IRI alone (3.5[1.25–5] vs 5.5[4–6], p = 0.014). Intestinal myeloperoxidase activity in animals exposed to IRI was 3.4 mU/mg of tissue (2.5–3.7) and 2.1 mU/mg(1.5–2.8) in the IRI + RIC group(p = 0.047). HIF-1α expression showed a non-significant trend towards reduced expression in the IRI + RIC group.ConclusionsRIC reduces the extent and severity of bowel injury in this animal model, supporting the hypothesis that RIC has therapeutic potential for intestinal diseases in the newborn.     

Infantile hypertrophic pyloric stenosis in Bosnia and Herzegovina: A retrospective cohort study from the largest tertiary care facility

BackgroundInfantile hypertrophic pyloric stenosis (IHPS) is the most common condition requiring surgery in infancy, but the etiology of IHPS is still unclear. The study aimed to analyze the epidemiological and clinical features of the infants with IHPS in our setting and determine the yearly trends in IHPS incidence in the Sarajevo Canton between 2007 and 2016.MethodsWe retrospectively analyzed epidemiologic, clinical, and operative data of all infants undergoing pyloromyotomy for IHPS over ten years in the largest tertiary care facility in Bosnia and Herzegovina.ResultsFifty-three IHPS patients were diagnosed, yielding an overall incidence of 1.17 per 1000 live births (1.25 and 1.09 cases in 2007–2011 and 2012–2016, respectively). IHPS was more prevalent among male infants (ratio 6.6:1, p < 0.001). The mean age at onset of symptoms was 39.6 days (range, 17–107 days). The estimated median time from symptoms onset to hospitalization was 11 days (range, 1–17 days). The mean age at diagnosis was significantly longer in premature infants compared with term infants (p = 0.003). Both first-born rank and bottle-feeding were significantly associated with IHPS (p = 0.001 and p = 0.04, respectively). No seasonal variation associated with IHPS was detected (p = 0.25). No evidence was found of differences in the incidence of IHPS related to maternal age (p = 0.24) and smoking (p = 0.59).ConclusionOur data indicate a declining trend and provide insights into the clinical characteristics of IHPS in Bosnia and Herzegovina. Most of the obtained results are in line with the published data and could improve the quality of local pediatric services.     

Moment of truth-adding carboplatin to neoadjuvant/adjuvant chemotherapy in triple negative breast cancer improves overall survival: An individual participant data and trial-level Meta-analysis

ImportanceCarboplatin increases the pathological complete remission (pCR) rate in triple negative breast cancer (TNBC) when added to neoadjuvant chemotherapy, however, evidence on its effect on survival outcomes is controversial.MethodsThe study was prospectively registered at PROSPERO (CRD42021228386).We systematically searched PubMed, Embase, Cochrane Central Register of Clinical Trials, and conference proceedings from January 1, 2004 to January 30, 2022 for relevant randomized clinical trials (RCTs) of (neo)adjuvant chemotherapy in TNBC patients, with carboplatin in the intervention arm and standard anthracycline taxane (AT) in the control arm. PRISMA guidelines were used for this review. Data were pooled using fixed and random effects models as appropriate on extracted hazard ratios (HR). Individual patient data (IPD)for disease free survival (DFS) and overall survival (OS) were extracted from published survival curves of included RCTs; DFS and OS curves for each trial and the combined population were reconstructed, and HR estimated. The primary outcome was DFS; OS, pCR, and toxicity were secondary outcomes.ResultsEight trials with 2425 patients were included. Carboplatin improved DFS (HR 0.60; 95% CI 0.47 to 0.78; I² 45%, p < 0.001) compared with AT at trial level and IPD level (HR 0.66; 95%CI, 0.55 to 0.80, p < 0.001) analysis. The OS also improved with carboplatin at both trial level (HR 0.69, 95%CI 0.50 to 0.95, I² 41%, p = 0.02) and IPD level (HR 0.68; 95%CI, 0.54 to 0.87, p = 0.002) analysis. The pCR as expected, was better in the carboplatin arm (OR 2.11; 95% CI = 1.44–3.08; I² 67%, p = 0.009). Anaemia and thrombocytopaenia were higher in the carboplatin arm.Conclusionand relevance: Carboplatin added to (neo)adjuvant chemotherapy in TNBC improves survival, as shown in both trial level and IPD analysis.