Impact of Race and Insurance on Door-to-Appendectomy Time among Pediatric Patients

Racial and ethnic disparities in the rate of appendiceal rupture have been widely reported among the pediatric population. The main reasons for this remain largely unknown given that previous explanations pointing to signs of poor health care access have recently been shown to account for only a small percentage of the difference in perforation rates between white and minority children. Because the risk of perforation increases with time, racial disparities in time delay from emergency department presentation to OR appendectomy may help account for the higher appendiceal perforation rates observed among minority children. This is the first study dedicated to analyzing racial differences in door-to-appendectomy time. Insurance status and language barriers were also considered as variables of interest. Retrospective, observational study using admission and treatment data of 607 consecutive children less than or equal to 18 years of age with surgical confirmation of appendicitis. Patients were admitted from February 2, 2013 (start of electronic medical record use) to April 27, 2017. A significant association was found between race and perforation rate (p0.05 for all). Door-to-appendectomy times were also not significantly longer for Medicaid/uninsured patients (613 minutes) compared to private insurance patients (597 minutes) (p=0.60), nor for patients with language barriers (545 minutes) compared to patients without (612 minutes) (p=0.23). While there was a higher appendiceal perforation rate among minority children, it was not due to differences in door-to-appendectomy time. Insurance status and language barriers also did not lead to differential treatment among pediatric patients

Prognostic Factors and Survival in Pediatric and Adolescent Liposarcoma

Purpose. Liposarcoma is extremely rare in the pediatric population. To identify prognostic factors and determine treatment outcomes, we reviewed our institutional experience with pediatric liposarcoma. Methods. We retrospectively reviewed all pediatric patients (age < 22 years) with confirmed liposarcoma treated at Memorial Sloan-Kettering Cancer Center. Histologic subtype, tumor location, margin status, recurrence, and adjuvant therapy were analyzed and correlated with overall survival. Results. Thirtyfour patients (56% male) with a median age of 18.1 years were identified. Twenty-two (65%) had peripheral tumors and 12 (35%) had centrally located tumors. Histologically, 29 (85%) tumors were low grade, and 5 (15%) were high grade pleomorphic. Eleven (32%) had recurrent disease, 9 patients with central tumors and 2 patients with peripheral lesions. Eight deaths occurred, all in patients with central disease. Five-year overall survival was 78%, with a median follow-up time of 5.4 years (range, 0.3-30.3 years). Tumor grade (P = .003), histologic subtype (P = .01), and primary location (P < .001) all correlated with survival, as did stage (P < .001) and margin status (P = .001). Conclusions. Central location of the primary tumor, high tumor grade, and positive surgical margins are strongly correlated with poor survival in pediatric patients with liposarcoma

Shifting patterns of genomic variation in the somatic evolution of papillary thyroid carcinoma

Shows Single Nucleotide Substitutions in the MAPK Pathway. (XLSX 43 kb

NTRK fusion oncogenes in pediatric papillary thyroid carcinoma in northeast United States

BACKGROUND An increase in thyroid cancers, predominantly papillary thyroid carcinoma (PTC), has been recently reported in children. METHODS The histopathology of 28 consecutive PTCs from the northeast United States was reviewed. None of the patients (ages 6-18 years; 20 females, 8 males) had significant exposure to radiation. Nucleic acid from tumors was tested for genetic abnormalities (n = 27). Negative results were reevaluated by targeted next-generation sequencing. RESULTS Seven of 27 PTCs (26%) had neurotrophic tyrosine kinase receptor (NTRK) fusion oncogenes (NTRK type 3/ets variant 6 [NTRK3/ETV6], n =5; NTRK3/unknown, n = 1; and NTRK type 1/translocated promoter region, nuclear basket protein [NTRK1/TPR], n = 1), including 5 tumors that measured >2 cm and 3 that diffusely involved the entire thyroid or lobe. All 7 tumors had lymphatic invasion, and 5 had vascular invasion. Six of 27 PTCs (22%) had ret proto-oncogene (RET) fusions (RET/PTC1, n = 5; RET/PTC3, n = 1); 2 tumors measured >2 cm and diffusely involved the thyroid, and 5 had lymphatic invasion, with vascular invasion in 2. Thirteen PTCs had the B-Raf proto-oncogene, serine/threonine kinase (BRAF) valine-to-glutamic acid mutation at position 600 (BRAFV600E) (13 of 27 tumors; 48%), 11 measured <2 cm, and 6 had lymphatic invasion (46%), with vascular invasion in 3. Fusion oncogene tumors, compared with BRAFV600E PTCs, were associated with large size (mean, 2.2 cm vs 1.5 cm, respectively; P =.05), solid and diffuse variants (11 of 13 vs 0 of 13 tumors, respectively; P <.001), and lymphovascular invasion (12 of 13 vs 6 of 13 tumors, respectively; P =.02); BRAFV600E PTCs were predominantly the classic variant (12 of 13 vs 1 of 13 tumors). Two tumors metastasized to the lung, and both had fusion oncogenes (NTRK1/TPR, n = 1; RET/PTC1, n = 1). CONCLUSIONS Fusion oncogene PTC presents with more extensive disease and aggressive pathology than BRAFV600E PTC in the pediatric population. The high prevalence of the NTRK1/NTRK3 fusion oncogene PTCs in the United States is unusual and needs further investigation. Cancer 2016;122:1097-1107

Counseling for opioids prescribed at discharge of hospitalized adolescent trauma patients

Abstract Background Expert consensus recommends prescription opioid safety counseling be provided when prescribing an opioid. This may be especially important for youth with preexistent alcohol and other drug (AOD) use who are at higher risk of developing opioid use disorder. This study examined the frequency that adolescent trauma patients prescribed opioids at hospital discharge received counseling and if this differed by adolescents’ AOD use. Method This study was embedded within a larger prospective stepped-wedge type III hybrid implementation study of AOD screening across a national cohort of pediatric trauma centers. Data were collected during 2018–2021 from admitted adolescent trauma patients (12–17 yo) at seven centers. Patient data were extracted from the electronic health record (EHR) on any prescribed discharged opioids, documentation of counseling delivered on prescribed opioid, who delivered counseling, and patients’ AOD screening results. Additionally, adolescents received an online survey within 30 days of hospital discharge that included asking about hospital discussions on safe use of prescription pain medication. Results Of the 247 adolescent trauma patients enrolled, 158 completed the 30-day survey. AOD screening results were documented in the EHR for 139 patients (88%), with 69 (44.1%) screening AOD-positive. Opioids at discharge were prescribed to 86 (54.4%) adolescent patients, with no significant difference between those screened AOD-positive and AOD-negative (42.4% vs. 46.3%, p = 0.89). Counseling was documented in the EHR for 30 (34.9%) of those prescribed an opioid and was not significantly different by sex, age, race, ethnicity or between adolescent patients with documentation of AOD use (29.3%) versus those who did not (33.3%, p = 0.71). According to the adolescent survey, among those prescribed an opioid, 61.2% reported someone had talked with them about safe use of newly prescribed pain medications with again no difference between AOD-positive and AOD-negative screening results (p = 0.34). Conclusions Although adolescent trauma patients recalled discussions on safe use of prescribed pain medication more often than was documented in the EHR, these discussions were not universal and did not differ if adolescents had screened positive or negative for AOD use as documented in the EHR. Trial Registry: clinicaltrials.gov NCT03297060