2014 Quick Shot Presentations
SCIENTIFIC SESSION III: QUICKSHOTS
PULMONARY RESECTION IN CHILDREN AND ADOLESCENTS WITH
OSTEOSARCOMA – IS IT STILL HELPFUL WHEN METASTATIC DISEASE IS NOT
LIMITED TO THE LUNGS?
Slade A.D., Warneke C.L., Hughes D.P., Lally P.A., Lally K.P., Hayes-Jordan A.A.,
Austin M.T., UT Houston Medical School
Background
To evaluate the impact of concurrent extra-pulmonary metastatic disease on overall
(OS) and event-free survival (EFS) for pediatric osteosarcoma patients undergoing
pulmonary metastatectomy.
Methods
We retrospectively reviewed all patients < 21 years old who received pulmonary
metastatectomy for osteosarcoma at our institution between January 1, 2001 and
December 31, 2011 (n=76). We compared OS and EFS between patients with
metastases limited to the lungs (Group A, n=58) to those with extra-pulmonary
metastases (Group B, n=18) at the time of first pulmonary metastatectomy. KaplanMeier survival curves were compared using log-rank test. Cox proportional hazards
regression analysis was used to determine independent predictors of survival.
Statistical significance is defined as P<0.05.
Results
The median age at diagnosis was 14.4 years (range 4-20 years). The estimated median
OS and EFS from first pulmonary metastatectomy were 2.0 years (95%CI 1.5,2.8 years)
and 5.5 months (95%CI 3.0,8.1 months), respectively. Fifty-five patients (72%) died due
to progression of metastatic disease. Median OS was significantly greater for Group A
(2.6 years, 95%CI 1.9,3.8) compared to Group B patients (0.9 years, 95% CI 0.6,1.4)
(log rank p<0.0001). Median EFS was significantly greater for Group A (7.9 months,
95%CI 5.0,10.7) compared to Group B patients (1.6 months, 95%CI 0.8,2.7) (log rank
p<0.0001). There were no long-term survivors in Group B. Independent predictors of
death included extra-pulmonary metastatic disease at the time of first thoracotomy (HR
3.1, 95%CI 1.7,5.7), bilateral pulmonary metastases (HR 3.0, 95%CI 1.7,5.3), and > 4
nodules resected at first thoracotomy (HR 2.8, 95%CI 1.7,4.9) (all p<0.001).
Conclusion
Osteosarcoma patients with concurrent extra-pulmonary metastatic disease at the time
of pulmonary metastatectomy have significantly worse survival compared to those with
disease limited to the lungs. Pulmonary metastatectomy should only be considered in a
select group of osteosarcoma patients.
A PEDIATRIC APPENDICITIS PATHWAY: THE IMPORTANCE OF ONGOING
QUALITY IMPROVEMENT SURVEILLANCE
Putnam L, Levy S, Johnson E, Williams K, Taylor K, Lally K, Tsao K, UT Houston
Medical School
Background
Same-day discharge (SDD) after laparoscopic appendectomy in adults for simple
(acute, non-gangrenous, non-perforated) appendicitis is safe and cost effective, but
similar observations have not been widely reported in children. In January of 2011, our
institution implemented a protocol for simple appendicitis. Nine months later, an initial
audit demonstrated significantly decreased lengths of stay (LOS) and overall cost
without increased complications. We hypothesized that a second audit would confirm
shorter LOS, increased SDD, and decreased cost.
Methods
A before-and-after study was performed on all pediatric patients (<18 years old) who
underwent appendectomy for simple appendicitis from July 2009 to December 2010
(pre-protocol) and from January 2011 to May 2013 (post-protocol). Audit #1 took place
in August 2011. LOS was determined to be from time of first recorded vital signs to time
of discharge. SDD was established as LOS less than 24 hours. Cost was calculated as
the per patient direct hospital costs minus operating room costs, accounting for only
protocol-related costs. Additional outcomes were readmissions and surgical site
infections (SSI).
Results
1,382 appendectomies were performed; 794 (57%) for simple appendicitis.
Demographics such as gender, age, and BMI between groups were similar. Preprotocol median (range) LOS was 35 (20-50) hours vs. audit #1: 24 (12-36) hours and
audit #2: 22 (9-35) hours (p<0.0001). SDD increased from 13% to 51% to 58%,
respectively. Pre-protocol cost was $3,090 versus $2,719 (12% cost savings) at audit
#1 and $2,915 (6% cost savings) at audit #2 for $118,544 cumulative cost savings.
Significant differences were found in SSI rate at audit #1 (1.6% vs 4.7%, p=0.036) and
readmission rate at audit #2 (1.2% vs. 4.5%, p=0.012).
Conclusion
Our simple pediatric appendicitis protocol decreased LOS and cost, and increased
SDD. Continued surveillance identified increases in post-protocol SSIs and
readmissions, allowing for timely investigation and response.
STRESS-INDUCED ACTIVATION OF TGFβ SIGNALING DURING ACUTE
ASCENDING AORTIC STRESS
Justin C. Choi, Darrell Wu, Yanqiu Zheng, Lin Zhang, Joseph S. Coselli, Ying H. Shen,
Scott A. LeMaire, BCM
Background
Thoracic aortic aneurysms and dissection (TAAD) exhibit activation of transforming
growth factor-beta (TGFβ) signaling. However, the mechanisms leading to TGFβ’s
activation in TAAD remain to be identified. Having recently found that activation of the
NLRP3 inflammasome cascade promotes TAAD, we hypothesized that this cascade
amplifies TGFβ signaling in the ascending aortic wall in response to acute stress.
Methods
Eight-week-old C56BL/6 (WT; n=10) and Nlrp3-/- (n=10) mice were challenged with
2000 ng/kg/min of angiotensin II (Ang II) for 1 week to induce ascending aortic stress.
Activation of TGFβ, elastic fiber fragmentation, and fibrotic changes in the aortic wall
were evaluated. The effect of the NLRP3 inflammasome cascade on TGFβ signaling
was also investigated in cultured human thoracic aortic smooth muscle cells (SMCs).
Results
Compared to Ang II-challenged WT mice, Nlrp3-/- mice had markedly reduced TGFβ
and furin levels in the ascending aorta, along with preserved elastic fiber architecture.
Ang II challenge in WT mice decreased SM-22α expression in the medial layer SMCs,
suggesting dedifferentiation of these cells. Additionally, fibroblasts were increased in the
adventitial layer, and many of these fibroblasts also expressed SM-22α, suggesting
potential transformation of SMCs into fibroblasts. Interestingly, this shift in cell type was
diminished in Ang II-challenged Nlrp3-/- mice. In our cell culture model, knocking down
the NLRP3 inflammasome cascade reduced PA-induced Smad4 expression, suggesting
involvement of the NLRP3 inflammasome in PA-induced activation of TGFβ signaling.
Conclusion
Acute stress leads to elevated TGFβ signaling levels, fibroblast proliferation, and
transformation of SMCs into fibroblasts in the ascending aorta. The NLRP3
inflammasome may play a role in stress-induced activation of TGFβ signaling.
CAN FETAL LUNG VOLUME RATIOS SERVE AS PREDICTORS OF NEONATAL
PULMONARY OUTCOMES: A COMPARISON OF CONGENITAL LUNG
MALFORMATION AND CONGENITAL DIAPHRAGMATIC HERNIA
Adesola C. Akinkuotu MD, Fariha Sheikh MD, Irving J. Zamora MD, Darrell L. Cass MD,
Timothy C. Lee MD, Christopher I. Cassady MD, Amy R. Mehollin-Ray MD, Jennifer L.
Williams, MD, Rodrigo Ruano MD PhD, Stephen E. Welty MD, Oluyinka O. Olutoye MD
PhD, Texas Children Clinical Center
Background
Congenital lung malformations (CLM) and congenital diaphragmatic hernias (CDH) may
be associated with pulmonary hypoplasia; yet pulmonary hypertension (PHTN) is more
typically associated with CDH. We hypothesize that given equivalent degrees of
pulmonary hypoplasia, neonates with CDH experience worse morbidity than those with
CLM.
Methods
A chart review of all fetuses diagnosed with CDH and CLM at a comprehensive fetal
center from January 2000- June 2013 was performed. Lung volumes were measured by
fetal MRI-based calculations of the observed-to-expected total lung volumes (O/ETFLV). For fetuses with CLM, O/E-TFLV was based on the volume of normal lung
tissue. A sub-analysis of patients with equal lung volumes was then performed.
Results
Of the 281 patients, 179 had CDH and 102 had CLM. Fetuses with CDH had overall
smaller mean O/E-TFLV than those with CLM (34.2±15.2% vs. 88.9±31.2%; p<0.001).
In addition, those with CDH had a higher incidence of PHTN on echocardiogram (55.7%
vs. 4.1%; p<0.001), 6-month mortality (30.3% vs. 3.5%, p<0.001), supplemental oxygen
requirement at 30 days of life (51.4% vs. 7.2%; p<0.001) and length of hospital stay
(44.5 vs. 4 days, p<0.001).
Of the patients matched by O/E-TFLV, there were 19 CDH and 25 CLM, as several
patients had the same lung volumes. Those with CDH had a significantly higher
incidence of PHTN than those with CLM (40 vs. 5.3%;p=0.013).. Those with CDH had a
longer hospital stay (29.5 vs. 6 days; p=0.046) and were three times more likely to
require supplemental oxygen at 30 days of life than those with CLM (36% vs. 11.1%,
p=0.086)
Conclusion
When matched by equivalent lung volumes, patients with CDH experience worse
morbidity compared to those with CLM. Our findings suggest that fetal lung volume
parameters commonly used to predict outcomes for fetuses with CDH should not be
extrapolated for fetuses with CLM.
TACKLING FOOTBALL-RELATED ABDOMINAL INJURIES IN CHILDREN
Fariha Sheikh MD (Presentor), Matthew Coker BS, Mirko Kljajic RN, Bindi NaikMathuria MD (Principal author), Baylor College of Medicine
Background
Current literature regarding football injuries primarily focuses on extremity and brain
injuries. The purpose of this study was to evaluate the incidence of abdominal trauma
related to football in the pediatric population to increase public awareness of the
characteristics and severity of these injuries.
Methods
Our trauma registry was interrogated to identify patients (age <17 years) who were
admitted following a sports-related injury between January 2009 and October 2013. A
retrospective chart review was performed to assess injury type and mechanism, time to
presentation and hospital course.
Results
Of 217 patients admitted for sports injuries, 184 (85%) were football-related and there
were 28 abdominal injuries (13%). Of these, 26 were football-related and 2 were
soccer-related. The average age of children who had football-related abdominal injuries
was 13 years (range 9-16 years). Type of injuries were as follows: 10 splenic
lacerations (8 were grades III-IV), 7 renal injuries, 2 liver hematomas, 2 duodenal
hematomas, 2 soft tissue injuries, 1 traumatic pancreatitis, 1 ureteral contusion, 1
testicular injury , 1 lumbar fracture and 1 hemorrhage from an incidentally discovered
Burkitt’s lymphoma. The most common presenting symptom was increasing or
persistent abdominal pain as noted in 81% of patients, followed by dizziness in 23%,
and hematuria, flank pain, and nausea/vomiting in 19%. Delayed presentation occurred
in 9 patients (35%) in whom an average of 3 days lapsed before presentation to the
emergency department (range 1-7 days). All except 2 patients were successfully
treated by non-operative management. Average length of hospital stay was 5 days
(range 1-26 days). No mortalities were encountered.
Conclusion
Football is the predominant sports-related mechanism of injury at a tertiary care
children’s hospital, and can result in serious abdominal injury. Coaches and parents
should maintain a high suspicion following a significant impact and seek early medical
care for prompt diagnosis and treatment.
IMPLEMENTATION OF AN ELECTRONIC MEDICAL RECORD (EMR) IMPROVES
QUALITY OF DOCUMENTATION IN A SUBSPECIALTY PRIVATE PRACTICE.
M. Cusick, S. McKnight, D. L. Howell, Jr., H. R. Bailey, M. Snyder, University of Texas
Affiliated Hospitals
Background
The use of electronic medical records (EMR) in the ambulatory setting has increased
drastically over the last five years. However, little has been reported on any changes in
the quality of the documentation. The purpose of this study was to investigate the
effects of EMR implementation on new patient documentation in a large subspecialty
private practice.
Methods
Method
Ten randomly selected new patient visit charts from before and after the implementation
of the EMR were chosen from each surgeon within the practice. Each chart was
reviewed for the necessary elements of Evaluation and Management (E/M) codes: chief
complaint (CC), history of present illness (HPI), past medical history (PMH), family
history (FH), social history (SH), review of systems (ROS), and physical exam (PE). The
components of documentation were compared - pre-EMR versus post-EMR. Paired ttests were used for comparisons.
Results
180 charts were reviewed. The majority of patients were seen with a chief complaint of
either rectal bleeding (36%) or anal pain (35%). Although there were no differences in
the documentation of chief complaint (100% pre-EMR vs. 100% post-EMR, p=NS) and
4 elements of HPI (98.9% pre-EMR vs. 100% post-EMR, p=NS) , there were significant
differences in the documentation of PMH (72.2% pre-EMR vs. 100% post-EMR,
p<0.01), FH (56.7% pre-EMR vs. 98.9% post-EMR, p<0.001), SH (57.8% pre-EMR vs.
98.9% post-EMR, p<0.001), and 10 point ROS (3.3% pre-EMR vs. 93.3% post-EMR,
p<0.001). Additionally, more comprehensive physical exams were documented postEMR (6.7% pre-EMR vs. 71% post-EMR, p<0.001).
Conclusion
Implementation of an EMR has resulted in more detailed documentation of new clinic
visits with a significant increase in the documentation of PMH, FH, SH, and ROS.
Additionally, a more comprehensive examination was documented with the use of an
EMR. Implementation of an EMR in a large subspecialty private practice has resulted in
more thorough and higher quality documentation.