15 research outputs found
Management of Pediatric Appendicitis During the COVID-19 Pandemic: A Nationwide Multicenter Cohort Study
BACKGROUND: The COVID-19 pandemic has impacted timely access to care for children, including patients with appendicitis. This study aimed to evaluate the effect of the COVID-19 pandemic on management of appendicitis and patient outcomes.
METHODS: A multicenter retrospective study was performed including 19 children\u27s hospitals from April 2019-October 2020 of children (age≤18 years) diagnosed with appendicitis. Groups were defined by each hospital\u27s city/state stay-at-home orders (SAHO), designating patients as Pre-COVID (Pre-SAHO) or COVID (Post-SAHO). Demographic, treatment, and outcome data were obtained, and univariate and multivariable analysis was performed.
RESULTS: Of 6,014 patients, 2,413 (40.1%) presented during the COVID-19 pandemic. More patients were managed non-operatively during the COVID-19 pandemic compared to before the pandemic (147 (6.1%) vs 144 (4.0%), p \u3c 0.001). Despite this change, there was no difference in the proportion of complicated appendicitis between groups (1,247 (34.6%) vs 849 (35.2%), p = 0.12). COVID era non-operative patients received fewer additional procedures, including interventional radiology (IR) drain placements, compared to pre-COVID non-operative patients (29 (19.7%) vs 69 (47.9%), p \u3c 0.001). On adjusted analysis, factors associated with increased odds of receiving non-operative management included: increasing duration of symptoms (OR=1.01, 95% CI: 1.01-1.012), African American race (OR=2.4, 95% CI: 1.3-4.6), and testing positive for COVID-19 (OR=10.8, 95% CI: 5.4-21.6).
CONCLUSION: Non-operative management of appendicitis increased during the COVID-19 pandemic. Additionally, fewer COVID era cases required IR procedures. These changes in the management of pediatric appendicitis during the COVID pandemic demonstrates the potential for future utilization of non-operative management
Isolated Pediatric Pancreatic Transection Secondary to Ocean-Related Trauma
Context Isolated pancreatic transection is a rare but well-recognized complication following blunt trauma of the abdomen. Diagnosis at presentation may be difficult and delayed due to subtle initial symptoms and evolving nature of the injury. Case report We describe an isolated complete pancreatic transection in a 14-year-old female secondary to a previously unreported and highly unusual mechanism (being tossed by a wave). Diagnosis was obtained by computed tomography scan 24 hours following initial trauma. She was managed operatively with an open distal pancreatectomy with splenic preservation and no subsequent complications. Conclusions The force sustained from the blunt abdominal trauma of being tossed by a wave can be significant. The management of pancreatic injuries in children, particularly in the context of ductal transection, is controversial. Timely recognition and management is critical to optimal outcomes. Early operative intervention may help to avoid complications such as abscess or pseudocyst formation.Image:Â CT scan of the abdomen demonstrating complete transection of the pancreas
Omphalocele with intestinal prolapse through a patent omphalomesenteric duct: A case report
Introduction: The combination of a patent omphalomesenteric duct in the setting of an omphalocele is rare and has an unusual physical appearance on presentation. Case presentation: We share the case of a neonate who presented with omphalocele and a concurrent patent omphalomesenteric duct with intestinal prolapse. We report the early diagnosis and operative management of this presentation with intestinal resection and anastomosis, and primary closure of the omphalocele. The patient had no other abnormalities and after uncomplicated recovery, was able to discharge uneventfully tolerating oral feeds. Conclusion: Because the initial appearance of a patent omphalomesenteric duct in an omphalocele is unusual with visible bowel mucosa and an intact omphalocele membrane, this variation of an abdominal wall defect is at risk of being misdiagnosed as a ruptured omphalocele, gastroschisis, or another complex abdominal wall defect. Expeditious surgical management is indicated
A Rare Soft Tissue Tumor Masquerading as a Parathyroid Adenoma in a Patient with Birt-Hogg-Dubé Syndrome and Multiple Cervical Endocrinopathies
Birt-Hogg-Dubé (BHD) syndrome is an autosomal dominant disorder that presents with renal tumors, pulmonary cysts with spontaneous pneumothoraces, and skin hamartomas. We present a case of a 67-year-old female with multiple endocrinopathies and a history of BHD syndrome. In 2011, a thyroidectomy with a four-gland parathyroidectomy was performed for toxic multinodular goiter (TMNG) and parathyroid hyperplasia. On frozen section, a tumor was identified next to a hypercellular parathyroid. After being worked up, this tumor was determined to be an adult rhabdomyoma. This represents the first time that both TMNG and parathyroid hyperplasia have been present in a BHD patient. Additionally, this is the first adult rhabdomyoma reported in a patient with BHD syndrome. Adult rhabdomyomas have no reported associations; however, potential colocation of the mutation in BHD syndrome and translocation in adult rhabdomyomas on chromosome 17p suggests a possible connection. Further work is needed to better understand this connection
Successful operative rib fixation of traumatic flail chest in a patient with osteogenesis imperfecta
Perceptions of mistreatment among trainees vary at different stages of clinical training
Abstract
Background
Mistreatment of trainees remains a frequently reported phenomenon in medical education. One barrier to creating an educational culture of respect and professionalism may be a lack of alignment in the perceptions of mistreatment among different learners. Through the use of clinical vignettes, our aim was to assess the perceptions of trainees toward themes of potential mistreatment at different stages of training.
Methods
Based on observations from external experts embedded in the clinical learning environment, six thematic areas of potential mistreatment were identified: verbal abuse, specialty-choice discrimination, non-educational tasks, withholding/denying learning opportunities, neglect and gender/racial insensitivity. Corresponding clinical vignettes were created and distributed to 1) medical students, 2) incoming interns, 3) residents/fellows. Perceptions of the appropriateness of the interactions depicted in the vignettes were measured on a 5-point Likert scale. Scores were categorized into neutral or appropriate (\u22643) or inappropriate (i.e. mistreatment) (>3) and compared using chi-squared tests.
Results
Four hundred twenty seven trainees participated (182 students, 120 interns, 125 residents/fellows). Proportions of students perceiving mistreatment differed significantly from those of interns and residents/fellows in domains of verbal abuse, specialty discrimination and gender/racial insensitivity ( p \u2009<\u20090.05). In scenarios comparing interns to residents/fellows, no significant differences were noted in perceptions of mistreatment in the domains of non-educational tasks, withholding learning and neglect.
Conclusions
Perceptions of mistreatment differ at different developmental stages of medical training. After exposure to the clinical learning environment, perceptions of incoming interns did not differ from those of residents/fellows, implicating clinical rotations as a key period in indoctrinating students into the prevailing culture. More longitudinal studies are needed to confirm or better examine this phenomenon
Additional file 1: of Perceptions of mistreatment among trainees vary at different stages of clinical training
Case studies that were distributed to study participants. (DOCX 22 kb
Surgical Management of Ulcerative Colitis in Children and Adolescents: A Systematic Review from the APSA Outcomes and Evidence-Based Practice Committee.
INTRODUCTION: The incidence of ulcerative colitis (UC) is increasing. Roughly 20% of all patients with UC are diagnosed in childhood, and children typically present with more severe disease. Approximately 40% will undergo total colectomy within ten years of diagnosis. The objective of this study is to assess the available evidence regarding the surgical management of pediatric UC as determined by the consensus agreement of the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee (APSA OEBP).
METHODS: Through an iterative process, the membership of the APSA OEBP developed five a priori questions focused on surgical decision-making for children with UC. Questions focused on surgical timing, reconstruction, use of minimally invasive techniques, need for diversion, and risks to fertility and sexual function. A systematic review was conducted, and articles were selected for review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of Bias was assessed using Methodological Index for Non-Randomized Studies (MINORS) criteria. The Oxford Levels of Evidence and Grades of Recommendation were utilized.
RESULTS: A total of 69 studies were included for analysis. Most manuscripts contain level 3 or 4 evidence from single-center retrospective reports, leading to a grade D recommendation. MINORS assessment revealed a high risk of bias in most studies. J-pouch reconstruction may result in fewer daily stools than straight ileoanal anastomosis. There are no differences in complications based on the type of reconstruction. The timing of surgery should be individualized to patients and does not affect complications. Immunosuppressants do not appear to increase surgical site infection rates. Laparoscopic approaches result in longer operative times but shorter lengths of stay and fewer small bowel obstructions. Overall, complications are not different using an open or minimally invasive approach.
CONCLUSIONS: There is currently low-level evidence related to certain aspects of surgical management for UC, including timing, reconstruction type, use of minimally invasive techniques, need for diversion, and risks to fertility and sexual function. Multicenter, prospective studies are recommended to better answer these questions and ensure the best evidence-based care for our patients.
LEVEL OF EVIDENCE: Level of evidence III.
STUDY TYPE: Systematic review