Sudden Death in Pediatric Populations

Sudden death (SD) in children is rarer than in adults. In the pediatric population, SD accounts for less than one tenth of deaths from all causes. SD in infants is a separate entity commonly termed "sudden infant death syndrome (SIDS)". Previous studies on SD in pediatric patients primarily focused on infants and showed that the incidence of SIDS was much lower in Asian countries than in Western ones. However, these differences diminished after educational campaigns such as the back to sleep act in the late 1980s to early 1990s. The incidence of SIDS from Western reports has decreased from 2.69 to around 0.5-0.24 per 1,000 live births. Beyond infancy, the annual incidence of SD ranges from 1.3 to 7.5 per 100,000. In 2009, two population-based studies, one from Taiwan and the other from the US, explored the epidemiological profile of SD in children. The child health care indexes of these two countries are similar, but the annual incidence of pediatric SD was 7.5 and 2.7 per 100,000 in the USA and Taiwan, respectively. The implications of ethic-related differences requires further confirmation. Around 40% of pediatric SD could be from cardiac causes, either diagnosed or undiagnosed. Risk stratification for cardiac SD and patient selection for implantable cardioverter-defibrillator (ICD) therapy are recommended. However, the adoption of ICD as primary prevention for SD in children is still a challenging issue. Early detection of undiagnosed cardiac risk may be facilitated by cardiac screening either in newborns or the school-age population to better manage the risk of SD. However, the efficacy of such screening remains still controversial

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P &lt; 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Prophylactic postoperative ketorolac improves outcomes in diabetic patients assigned for cataract surgery

Moataz F Elsawy, Nermine Badawi, Hany A KhairyOphthalmology Department, Menoufia University Hospital, Menoufia, EgyptObjective: To evaluate the prophylactic role of topical non-steroidal anti-inflammatory drugs in reducing the incidence of central macular edema (CME) in diabetic eyes post-cataract surgery.Patients and methods: This study included 86 eyes (70 patients) with high risk characteristics for the development of CME after cataract surgery. All patients underwent phacoemulsification and intraocular lens implantation. Patients were divided into two equal groups (n = 43 [eyes]): a control group given topical dexamethasone 0.1%, four times/day for 12 weeks postoperatively and a study group given topical ketorolac tromethamine 0.4% twice daily in addition to topical dexamethasone 0.1% four times daily for 12 weeks. Patients were examined at 3, 6, and 12 weeks postoperatively for evaluation of CME development. The main study outcome was the change in the retinal fovea thickness measured with ocular coherence topography.Results: Ten eyes developed CME (11.6%); eight eyes in the control group and only two eyes in the study group. Mean retinal fovea thickness was significantly higher in the control group compared to the study group. Moreover, eyes of the control group developed CME significantly earlier than those of the study group.Conclusion: Prophylactic postoperative ketorolac 0.4% may have a role in reducing the frequency and severity of CME in diabetic eyes post-cataract surgery.Keywords: diabetes mellitus, cataract surgery, central macular edema, ketorolac, dexamethason

Epithelium-on corneal cross-linking treatment of progressive keratoconus: a prospective, consecutive study

Hany A Khairy, Hatem M Marey, Amin Faisal Ellakwa Ophthalmology Department, Menoufia University Hospitals, Menofia, Egypt Purpose: To evaluate the outcome of collagen cross-linking (CXL) without corneal epithelial debridement in patients treated for progressive keratoconus for whom the standard epithelium-off treatment cannot be applied, as their central corneal thickness (CCT) is less than 400 &micro;m. Patients and methods: This was a prospective, uncontrolled, interventional study involving 32 eyes of 30 patients with progressive keratoconus and CCT of less than 400 &micro;m. All patients received CXL treatment with application of riboflavin and exposure to ultraviolet light A for 30 minutes without corneal epithelial debridement. Patients were followed up to 12 months postoperatively. The main outcomes were changes in maximum-K reading, manifest refractive spherical equivalent, CCT, and best-corrected visual acuity (logarithm of minimum angle of resolution). Patients were also asked to report any pain or discomfort during the procedure. Results: At the end of the 12-month follow-up, CCT showed no significant change: from 392&plusmn;5.17 &micro;m preoperatively to 390&plusmn;4.45 &micro;m (P=0.102). Maximum-K reading decreased significantly, from 49.19&plusmn;2.30 D preoperatively to 46.96&plusmn;6.03 D postoperatively (P&lt;0.05). The mean manifest spherical equivalent showed no significant change: from 4.04&plusmn;1.51 D preoperatively to 4.17&plusmn;1.63 D postoperatively (P=0.110). Mean best-corrected visual acuity showed no significant change: from 0.29&plusmn;0.12 preoperatively to 0.31&plusmn;0.11 postoperatively (P=0.110). Conclusion: Epithelium-on CXL exhibits potential as a method for treating patients with progressive keratoconus and CCT of less than 400 &micro;m, in which the standard epithelium-off CXL cannot be applied. Over 12 months of follow-up, the epithelium-on CXL was safe and effective, with results comparable to that achieved with the epithelium-off technique in thicker corneas, and reduced rates of operative and postoperative discomfort. Keywords: keratoconus, cross-linking, refractive surgery, epitheliu

Prediction of pediatric PCNL outcomes using contemporary scoring systems

Purpose: To evaluate the applicability of contemporary percutaneous nephrolithotomy (PCNL) scoring systems in pediatric patients and to compare their predictive power for postoperative outcomes. Materials and methods: The records of 125 pediatric patients who were diagnosed with renal calculi and managed with PCNL between March 2011 and April 2016 were retrospectively analyzed. The predictive scoring systems; The Guy’s Stone Score (GSS), S.T.O.N.E. nephrolithometry and, Clinical Research Office of the Endourological Society (CROES) were calculated for all patients included in the study. Patient demographics, stone free rate (SFR), and complications were all reported and analyzed. Results: In patients with residual stones (group I) vs those who were (group II) stone free the median (IQR) of GSS was 2 (2-3) and 2 (1-2), CROES nomogram score was 215 (210-235) and 257 (240-264), and S.T.O.N.E. nephrolithometry score was 8 (7-9) and 5 (5-6), respectively (each <p0.0001). S.T.O.N.E. nephrolithometry score revealed the highest accuracy in predicting SFR. GSS was significantly correlated with complications but the CROES nomogram and S.T.O.N.E nephrolithometry were not significantly correlated with complications. Conclusion: The scoring systems could be used in predicting PCNL success in pediatric setting. However, further studies are required to make modifications in the scoring systems in pediatrics. The main variables in the scoring systems as stone burden, tract length and case volume were measured using records from adult patients. Besides these variables, the relatively small pelvicalyceal system and the higher incidence of anatomic malformations in pediatrics could potentially affect PCNL outcomes

Prediction of pediatric PCNL outcomes using contemporary scoring systems

Purpose: To evaluate the applicability of contemporary percutaneous nephrolithotomy (PCNL) scoring systems in pediatric patients and to compare their predictive power for postoperative outcomes. Materials and methods: The records of 125 pediatric patients who were diagnosed with renal calculi and managed with PCNL between March 2011 and April 2016 were retrospectively analyzed. The predictive scoring systems; The Guy’s Stone Score (GSS), S.T.O.N.E. nephrolithometry and, Clinical Research Office of the Endourological Society (CROES) were calculated for all patients included in the study. Patient demographics, stone free rate (SFR), and complications were all reported and analyzed. Results: In patients with residual stones (group I) vs those who were (group II) stone free the median (IQR) of GSS was 2 (2-3) and 2 (1-2), CROES nomogram score was 215 (210-235) and 257 (240-264), and S.T.O.N.E. nephrolithometry score was 8 (7-9) and 5 (5-6), respectively (each <p0.0001). S.T.O.N.E. nephrolithometry score revealed the highest accuracy in predicting SFR. GSS was significantly correlated with complications but the CROES nomogram and S.T.O.N.E nephrolithometry were not significantly correlated with complications. Conclusion: The scoring systems could be used in predicting PCNL success in pediatric setting. However, further studies are required to make modifications in the scoring systems in pediatrics. The main variables in the scoring systems as stone burden, tract length and case volume were measured using records from adult patients. Besides these variables, the relatively small pelvicalyceal system and the higher incidence of anatomic malformations in pediatrics could potentially affect PCNL outcomes