Which is more cost‐effective under the MELD system: primary liver transplantation, or salvage transplantation after hepatic resection or after loco‐regional therapy for hepatocellular carcinoma within Milan criteria?

AbstractObjectiveThe optimal strategy for treating hepatocellular carcinoma (HCC), a disease with increasing incidence, in patients with Child–Pugh class A cirrhosis has long been debated. This study evaluated the cost‐effectiveness of hepatic resection (HR) or locoregional therapy (LRT) followed by salvage orthotopic liver transplantation (SOLT) vs. that of primary orthotopic liver transplantation (POLT) for HCC within the Milan Criteria.MethodsA Markov‐based decision analytic model simulated outcomes, expressed in costs and quality‐adjusted life years (QALYs), for the three treatment strategies. Baseline parameters were determined from a literature review. Sensitivity analyses tested model strength and parameter variability.ResultsBoth HR and LRT followed by SOLT were associated with earlier recurrence, decreased survival, increased costs and decreased quality of life (QoL), whereas POLT resulted in decreased recurrence, increased survival, decreased costs and increased QoL. Specifically, HR/SOLT yielded 3.1QALYs (at US$96000/QALY) and LRT/SOLT yielded 3.9QALYs (at US$74000/QALY), whereas POLT yielded 5.5QALYs (at US$52000/QALY). Sensitivity analyses supported these findings at clinically meaningful probabilities.ConclusionsUnder the Model for End‐stage Liver Disease (MELD) system, in patients with HCC within the Milan Criteria, POLT increases survival and QoL at decreased costs compared with HR or LRT followed by SOLT. Therefore, POLT is the most cost‐effective strategy for the treatment of HCC

Which is more cost‐effective under the MELD system: primary liver transplantation, or salvage transplantation after hepatic resection or after loco‐regional therapy for hepatocellular carcinoma within Milan criteria?

AbstractObjectiveThe optimal strategy for treating hepatocellular carcinoma (HCC), a disease with increasing incidence, in patients with Child–Pugh class A cirrhosis has long been debated. This study evaluated the cost‐effectiveness of hepatic resection (HR) or locoregional therapy (LRT) followed by salvage orthotopic liver transplantation (SOLT) vs. that of primary orthotopic liver transplantation (POLT) for HCC within the Milan Criteria.MethodsA Markov‐based decision analytic model simulated outcomes, expressed in costs and quality‐adjusted life years (QALYs), for the three treatment strategies. Baseline parameters were determined from a literature review. Sensitivity analyses tested model strength and parameter variability.ResultsBoth HR and LRT followed by SOLT were associated with earlier recurrence, decreased survival, increased costs and decreased quality of life (QoL), whereas POLT resulted in decreased recurrence, increased survival, decreased costs and increased QoL. Specifically, HR/SOLT yielded 3.1QALYs (at US$96000/QALY) and LRT/SOLT yielded 3.9QALYs (at US$74000/QALY), whereas POLT yielded 5.5QALYs (at US$52000/QALY). Sensitivity analyses supported these findings at clinically meaningful probabilities.ConclusionsUnder the Model for End‐stage Liver Disease (MELD) system, in patients with HCC within the Milan Criteria, POLT increases survival and QoL at decreased costs compared with HR or LRT followed by SOLT. Therefore, POLT is the most cost‐effective strategy for the treatment of HCC

Radiographic and Clinical Factors in Pediatric Patients With Surgical Small-bowel Intussusception

Background When evaluating a pediatric patient with abdominal pain, identification of a small bowel–to–small bowel intussusception (SBI) on radiologic imaging can create a diagnostic dilemma. The clinical significance and need for surgical exploration of SBI is highly variable, as most of them are considered clinically insignificant. We hypothesize that combination of clinical and radiologic factors in an exclusively SBI population will yield factors that guide the clinician in making operative decisions. Methods A comprehensive database from a pediatric tertiary hospital was reviewed from January 1, 2011, to December 31, 2016, for any radiographic study mentioning intussusception. Results were reviewed for patients having only SBI (i.e., not ileocolic intussusception), and this comprised the study cohort. The electronic medical records for these patients were reviewed for clinical presentation variables, need for operative intervention, and identification of the intussusception during surgery. Patients with SBI due to enteral feeding tubes were excluded from the study. Results Within the study period, 139 patients were identified with an SBI on radiologic imaging. Univariate analysis yielded numerous clinical and radiologic factors highly predictive of the need for surgical intervention. However, upon multivariate analysis, only a history of prior abdominal surgery (odds ratio [OR]: 7.2; CI: 1.1-46.3), the presence of focal abdominal pain (OR: 22.1; CI: 4.2-116.3), and the intussusception length (cm; OR: 10.6; CI: 10.3-10.8) were correlated with the need for surgical intervention. Conclusions SBI is a disease process with a highly variable clinical significance. The presence of focal abdominal pain, a history of prior abdominal surgery, and the intussusception length are the greatest predictors of the need for operative intervention

Pediatric Complicated Appendicitis During the COVID-19 Pandemic: A National Perspective

This article is made available for unrestricted research re-use and secondary analysis in any form or be any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemicIntroduction: The COVID-19 pandemic has changed the public’s perception of safety in accessing healthcare across common surgical emergencies, including acute appendicitis in children. Here, we aim to determine whether the COVID-19 pandemic is associated with poorer appendicitis outcomes and predict that there are higher complicated appendicitis (CA) rates during this time. Methods: A retrospective cohort study was conducted in patients younger than 19 years with a new diagnosis of acute appendicitis. Rates of CA were compared in the pre- (3/1/2019-5/31/2019) and post-COVID (3/1/2020-5/31/2020) timeframes using the Pediatric Health Information System national database. The primary end point of interest was CA rates. Secondary end point of interest was hospital length of stay. A p value < 0.05 was significant. Results: Nationally, 6,212 patients had acute appendicitis pre-COVID compared with 5,372 post-COVID. The CA rate post-COVID was 33%, which was significantly higher than 30% CA rate pre-COVID, and the rate of uncomplicated appendicitis post-COVID was lower (p < 0.001). An overall increase in hospital length of stay nationally was observed for all patients treated post-COVID (p < 0.001), as well as in those with CA (p < 0.001). Conclusion: The COVID-19 pandemic is directly associated with higher disease burden in pediatric acute appendicitis. The healthcare system must understand its role in alleviating public fear in seeking healthcare for patients and their families to encourage timely medical care

Cretaceous/Tertiary boundary cephalopods.

122 p. : ill. (some col.), maps (some col.); 26 cm.Includes bibliographical references (p. 111-122).Geological investigations in the upper Manasquan River Basin, central Monmouth County, New Jersey, reveal a Cretaceous/Tertiary (= Cretaceous/Paleogene) succession consisting of approximately 2 m of the Tinton Formation overlain by 2 m of the Hornerstown Formation. The top of the Tinton Formation consists of a very fossiliferous unit, approximately 20 cm thick, which we refer to as the Pinna Layer. It is laterally extensive and consists mostly of glauconitic minerals and some angular quartz grains. The Pinna Layer is truncated at the top and is overlain by the Hornerstown Formation, which consists of nearly equal amounts of glauconitic minerals and siderite. The base of the Hornerstown Formation is marked by a concentration of siderite nodules containing reworked fossils. This layer also contains a few fossils of organisms that were living in the environment during the time of reworking. At some downdip sites, there is an additional layer (the Burrowed Unit), which is sandwiched between the top of the Pinna Layer and the concentrated bed of nodules. This unit is very thin and is characterized by large burrows piping down material from above. The Pinna Layer is abundantly fossiliferous and represents a diverse, nearshore marine community. It contains approximately 110 species of bivalves, gastropods, cephalopods, echinoids, sponges, annelids, bryozoans, crustaceans, and dinoflagellates. The cephalopods include Eutrephoceras dekayi (Morton, 1834), Pachydiscus (Neodesmoceras) mokotibensis Collignon, 1952, Sphenodiscus lobatus (Tuomey, 1856), Eubaculites carinatus (Morton, 1834), Eubaculites latecarinatus (Brunnschweiler, 1966), Discoscaphites iris (Conrad, 1858), Discoscaphites sphaeroidalis Kennedy and Cobban, 2000, Discoscaphites minardi Landman et al., 2004b, Discoscaphites gulosus (Morton, 1834), and Discoscaphites jerseyensis, n.sp. The dinoflagellates include Palynodinium grallator Gocht, 1970, Thalassiphora pelagica (Eisenack, 1954) Eisenack & Gocht, 1960, Deflandrea galeata (Lejeune-Carpentier, 1942) Lentin & Williams, 1973, and Disphaerogena carposphaeropsis Wetzel, 1933. These ammonites and dinoflagellates are indicative of the uppermost Maastrichtian, corresponding to the upper part of calcareous nannofossil Subzone CC26b. The mode of occurrence of the fossils in the Pinna Layer suggests an autochthonous accumulation with little or no postmortem transport. Many of the benthic organisms are preserved in life position. For example, specimens of Pinna laqueata Conrad, 1858, are oriented in a vertical position, similar to that of modern members of this genus. The echinoids also occur in aggregations of hundreds of individuals, suggesting gregarious feeding behavior. In addition, there are monospecific clusters of baculites and scaphites. These clusters are biological in origin and could not have been produced by hydraulic means. Scaphite jaws are also present, representing the first reports of these structures in the Upper Cretaceous of the Atlantic Coastal Plain. They occur both as isolated specimens and inside the body chamber, and indicate little or no postmortem transport. The Pinna Layer represents a geologically short interval of time. The fact that most of the animals are mature suggests that the community persisted for at least 5-10 years. If multiple generations of animals are present, perhaps reflecting multiple episodes of colonization and burial, then this unit probably represents more time, amounting to several tens of years. The fact that the Pinna Layer is truncated at the top implies a still longer period of time, amounting to hundreds of years. These age estimates are consistent with observed rates of sedimentation in nearshore environments. Iridium analyses of 37 samples of sediment from three sites in the Manasquan River Basin reveal an elevated concentration of iridium of 520 pg/g, on average, at the base of the Pinna Layer. The iridium profile is aymmetric with an abrupt drop off above the base of this unit and a gradual decline below the base. The elevated concentration of iridium is not as high as that recorded from some other Cretaceous/Tertiary boundary sections. However, it is sufficiently above background level to suggest that it is related to the global Ir anomaly documented at many other localities, and attributed to a bolide impact. The position of the iridium anomaly at the base of the Pinna Layer is inconsistent with the biostratigraphic data, because this anomaly occurs below the unit containing fossils indicative of the uppermost Maastrichtian. We present two alternative hypotheses: (1) If the enriched concentration of iridium is in place, it marks the Cretaceous/Tertiary boundary by reference to the global stratotype section and point at El Kef, Tunisia. The position of the iridium anomaly further implies that the Pinna community was living at the moment of impact and may even have flourished in its immediate wake. Subsequently, the community may have been buried by pulses of mud-rich sediment, possibly associated with enhanced riverine discharge following the impact. The Burrowed Unit may represent a subsequent pulse of riverine discharge that scoured the top of the Pinna Layer. (2) The iridium anomaly was originally located at the top of the Pinna Layer and was displaced downward due to bioturbation and/or chemical diffusion. This hypothesis implies that the Pinna Layer was deposited prior to the deposition of the iridium. The Pinna community may have died before or at the moment of impact. Erosion of the top of the Pinna Layer and deposition of the Burrowed Unit may have been associated with events immediately following the impact. In both hypotheses, the sea floor experienced an extended period of erosion and reworking in the early Danian, which may have lasted for several hundred thousand years, producing a concentrated lag of siderite nodules containing reworked fossils in the basal part of the Hornerstown Formation. This lag deposit is equivalent to the Main Fossiliferous Layer at the base of the Hornerstown Formation elsewhere in New Jersey. This period of erosion and reworking was probably associated with a transgression in the early Danian. The post-impact community was greatly reduced in diversity, with most of the species representing Cretaceous survivors

The Incidence of Venous Thromboembolism in Children Following Colorectal Resection for Inflammatory Bowel Disease: A Multi-Center Study

Background/Purpose Children with inflammatory bowel disease (IBD) have increased risk for venous thromboembolism (VTE). We sought to determine incidence and risk factors for postoperative VTE in a multicenter cohort of pediatric patients undergoing colorectal resection for IBD. Methods Retrospective review of children ≤18 years who underwent colorectal resection for IBD from 2010 to 2016 was performed at four children's hospitals. Primary outcome was VTE that occurred between surgery and last follow-up. Factors associated with VTE were determined using univariable and multivariable analyses. Results Two hundred seventy-six patients were included with median age 15 years [13,17]. Forty-two children (15%) received perioperative VTE chemoprophylaxis, and 88 (32%) received mechanical prophylaxis. DVT occurred in 12 patients (4.3%) at a median of 14 days postoperatively [8,147]. Most were portomesenteric (n = 9, 75%) with the remaining catheter-associated DVTs in extremities (n = 3, 25%). There was no association with chemoprophylaxis (p > 0.99). On Cox regression, emergent procedure [HR 18.8, 95%CI: 3.18–111], perioperative plasma transfusion [HR 25.1, 95%CI: 2.4–259], and postoperative infectious complication [HR 10.5, 95%CI: 2.63–41.8] remained predictive of DVT. Conclusion Less than 5% of pediatric IBD patients developed postoperative VTE. Chemoprophylaxis was not protective but rarely used. Patients with risk factors identified in this study should be monitored or given prophylaxis for VTE

Infants with esophageal atresia and right aortic arch: Characteristics and outcomes from the Midwest Pediatric Surgery Consortium

Purpose Right sided aortic arch (RAA) is a rare anatomic finding in infants with esophageal atresia with or without tracheoesophageal fistula (EA/TEF). In the presence of RAA, significant controversy exists regarding optimal side for thoracotomy in repair of the EA/TEF. The purpose of this study was to characterize the incidence, demographics, surgical approach, and outcomes of patients with RAA and EA/TEF. Methods A multi-institutional, IRB approved, retrospective cohort study of infants with EA/TEF treated at 11 children's hospitals in the United States over a 5-year period (2009 to 2014) was performed. All patients had a minimum of one-year follow-up. Results In a cohort of 396 infants with esophageal atresia, 20 (5%) had RAA, with 18 having EA with a distal TEF and 2 with pure EA. Compared to infants with left sided arch (LAA), RAA infants had a lower median birth weight, (1.96 kg (IQR 1.54–2.65) vs. 2.57 kg (2.00–3.03), p = 0.01), earlier gestational age (34.5 weeks (IQR 32–37) vs. 37 weeks (35–39), p = 0.01), and a higher incidence of congenital heart disease (90% vs. 32%, p  0.29). Conclusion RAA in infants with EA/TEF is rare with an incidence of 5%. Compared to infants with EA/TEF and LAA, infants with EA/TEF and RAA are more severely ill with lower birth weight and higher rates of prematurity and complex congenital heart disease. In neonates with RAA, surgical repair of the EA/TEF is technically feasible via thoracotomy from either chest. A higher incidence of anastomotic strictures may occur with a right-sided approach

Search for the Epoch of Reionisation with HERA: Upper Limits on the Closure Phase Delay Power Spectrum

Radio interferometers aiming to measure the power spectrum of the redshifted 21 cm line during the Epoch of Reionisation (EoR) need to achieve an unprecedented dynamic range to separate the weak signal from overwhelming foreground emissions. Calibration inaccuracies can compromise the sensitivity of these measurements to the effect that a detection of the EoR is precluded. An alternative to standard analysis techniques makes use of the closure phase, which allows one to bypass antenna-based direction-independent calibration. Similarly to standard approaches, we use a delay spectrum technique to search for the EoR signal. Using 94 nights of data observed with Phase I of the Hydrogen Epoch of Reionization Array (HERA), we place approximate constraints on the 21 cm power spectrum at $z=7.7$. We find at 95% confidence that the 21 cm EoR brightness temperature is $\le$(372)$^2$ "pseudo" mK$^2$ at 1.14 "pseudo" $h$ Mpc$^{-1}$, where the "pseudo" emphasises that these limits are to be interpreted as approximations to the actual distance scales and brightness temperatures. Using a fiducial EoR model, we demonstrate the feasibility of detecting the EoR with the full array. Compared to standard methods, the closure phase processing is relatively simple, thereby providing an important independent check on results derived using visibility intensities, or related.Comment: 16 pages, 14 figures, accepted for publication by MNRA

Understanding the Value of Tumor Markers in Pediatric Ovarian Neoplasms

Purpose The purpose of this study was to determine the diagnostic accuracy of tumor markers for malignancy in girls with ovarian neoplasms. Methods A retrospective review of girls 2–21 years who presented for surgical management of an ovarian neoplasm across 10 children's hospitals between 2010 and 2016 was performed. Patients who had at least one concerning feature on imaging and had tumor marker testing were included in the study. Sensitivity, specificity, and negative and positive predictive values (PPV) of tumor markers were calculated. Results Our cohort included 401 patients; 22.4% had a malignancy. Testing for tumor markers was inconsistent. AFP had high specificity (98%) and low sensitivity (42%) with a PPV of 86%. The sensitivity, specificity, and PPV of beta-hCG was 44%, 76%, and 32%, respectively. LDH had high sensitivity (95%) and Inhibin A and Inhibin B had high specificity (97% and 92%, respectively). Conclusions Tumor marker testing is helpful in preoperative risk stratification of ovarian neoplasms for malignancy. Given the variety of potential tumor types, no single marker provides enough reliability, and therefore a panel of tumor marker testing is recommended if there is concern for malignancy. Prospective studies may help further elucidate the predictive value of tumor markers in a pediatric ovarian neoplasm population