Placement In Pediatric Patients Research Articles

Long-term vascular access for infants with moderate to severe osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is a genetic disorder that causes skeletal fragility. For the most fragile infants and young children with OI, intravenous (IV) bisphosphonate administration is essential, but IV access attempts often cause fractures. Port-a-caths help prevent these events, but some surgeons are hesitant to insert these devices in these infants due to lack of data on their safety. Retrospective study of pediatric patients with OI who underwent port-a-cath placement from 1999 to 2018; incidence of complications such as infection and thrombosis and need for reoperation or replacement are described. Port-a-caths were placed in 17 patients with OI (median age, 8 mos [5-23 mos]; median weight, 5.8kg [3.96-9.08kg]) and remained in place for a median of 53.5 mos (10-127 mos). One port-a-cath was replaced because of thrombosis. Two port-a-caths were removed because of malfunction, one for skin erosion, and one for infection. In these five cases, replacement was not needed because patients could safely tolerate IV access. Two patients have their port-a-cath in place and the remaining ten patients had theirs removed electively as it was no longer needed. Port-a-cath placement in pediatric patients with OI is safe and efficacious for durable central access, enabling reliable IV bisphosphonate delivery and reducing iatrogenic trauma.

Middle ear disease requiring myringotomy in the first two years after tracheotomy in the pediatric population

ObjectivesRisk factors for middle ear disease necessitating myringotomy with tympanostomy tube placement after a tracheostomy have not been thoroughly explored. This study investigates the incidence and risk factors for ear tube placement in pediatric patients with a tracheostomy. MethodsPediatric patients under age 18 who underwent tracheotomy between 2002 and 2010 at two institutions were identified. Patients were excluded if they had undergone myringotomy prior to, or at the same time as, the tracheotomy, or did not have at least two years of follow-up clinic visits. The presence of other comorbidities was recorded. Descriptive statistics and logistic regression models were used to assess the impact of clinical characteristics on outcomes. ResultsA total of 214 patients met inclusion criteria. Median patient age at time of tracheotomy was 6 months (IQR 2–17), median patient age at time of myringotomy with tubes was 12 months (IQR8-17), and median time between tracheotomy and myringotomy with tube placement was 8 months (IQR 5–11). Sixty-seven (31%) patients required myringotomy with tympanostomy tube placement within the first two years after tracheotomy. Fifty-eight (87%) patients who underwent myringotomy with tympanostomy tubes were younger than 2 years at the time of the procedure. Logistical regression found younger age at time of tracheotomy to be a risk factor (OR: 0.71, 95% CI: 0.5–0.9, p < 0.006). The combination of tracheostomy with gastric tube increased the risk of requiring myringotomy with tubes 2.79 fold (p < 0.009). Craniofacial abnormalities (p < 0.001), known genetic syndrome (p = 0.009), cleft palate (p < 0.001), age at time of tracheotomy (p < 0.001) and gastric tubes (p = 0.002) were all independently found to increase risk of myringotomy with tubes. Patients’ gestational age (p = 0.411), ventilator dependence (p = 0.33), and airway structural abnormalities (p = 0.632) did not increase this risk. ConclusionThis study reports a high incidence of myringotomy with tubes in children with tracheostomy relative to the general pediatric population. Many comorbid conditions that often accompany the need for tracheotomy place these patients at a higher risk for ear disease requiring surgical intervention. Risk factors for operative middle ear disease in this population included age at time of tracheostomy, craniofacial abnormalities, and presence of a G-tube.

Outcomes of a Pediatric Ultrasound-Guided Short Peripheral Catheter Training Program and Hands-On Poultry Simulation Course.

Ultrasound guidance is an effective technique for obtaining short peripheral catheter (SPC) access but requires training and practice for proficiency. The aim of this quality improvement initiative was to develop and assess a formal training program to increase the confidence and competency of intravenous (IV) therapy nurses in the placement of ultrasound-guided SPCs. IV therapy nurses completed a didactic and hands-on training course where they practiced ultrasound-guided SPC placement techniques on a poultry phantom during simulation, followed by performing ultrasound-guided SPC insertion on patients proctored by an interventional radiology physician. Data collection included preintervention and postintervention confidence self-assessment, frequency tracker, Difficult Intravenous Access (DIVA) scale scores, and total number of ultrasound-guided SPCs placed by the nurses. Ultrasound-guided SPC placement increased significantly after the training program. The IV therapy nurses placed 29 ultrasound-guided SPCs in 2017, 391 ultrasound-guided SPCs in 2018, and 711 ultrasound-guided SPCs in 2019. Mean DIVA scores rose from 4.54 in May 2018 to 5.17 in July 2018, indicating success in placing SPCs in more difficult patients. Implementation of an ultrasound-guided SPC placement program using poultry phantom simulation is a recommended nursing resource for increasing competency in ultrasound-guided SPC placement in pediatric patients.

Association of Thrombocytopenia With Bleeding Risk During Central Venous Catheter Placement in Pediatric Patients With Cancer

This cohort study evaluates bleeding complications in pediatric patients with cancer who have a platelet count of 50 ×103/μL or above vs below 50 ×103/μL during central venous catheter (CVC) placement.

Comprehensive Error Analysis for Robotic-assisted Placement of Pedicle Screws in Pediatric Spinal Deformity: The Initial Learning Curve.

Surgical navigation improves pedicle screw insertion accuracy and reliability. Robotic-assisted spinal surgery and screw placement has not been fully assessed in pediatric patients with spine deformity undergoing posterior spinal fusion. The purpose of this study was to describe the learning curve for robotically assisted pedicle screw placement in pediatric patients. A retrospective review on a consecutive series of the first 19 pediatric patients who underwent posterior spinal fusion by a single surgeon using robotic navigation was performed. Demographics, curve parameters, pedicle diameter, vertebral rotation, and additional outcome measures were recorded. Screw position was assessed with calibrated intraoperative 3-dimensional fluoroscopic images. All complications of planned and placed robotically placed screws were recorded. A total of 194 left-sided screws were planned as robot-assisted. One hundred sixty-eight of the robotically planned screws (86.6%) were placed with robot assistance; 29 robotically planned screws (15.0%) were abandoned or converted to freehand. The mean time per robotically placed screw was 3.6±2.4 minutes. Fifteen breaches (8.9%) and 1 anterior perforation occurred with 2 critical (>2 to 4 mm) breaches, 1 was associated with a durotomy, and both occurred in the first case. There were no intraoperative/postoperative neuromonitoring changes and no sequela from the durotomy. Six breaches occurred in the first case. The odds ratio of obtaining a breach in screws with a matched trajectory was 0.275 (95% confidence interval: 0.089-0.848). Screw time and accuracy improved and the number of breaches decreased after 10 cases. This series had 2 critical breaches (between 2 and 4 mm) on the first case. Overall, excluding the 2 critical breaches, 98.8% of robotically executed screws were placed without a critical breach, which is comparable to previous pediatric deformity studies. Caution should be exercised during the initial training period to avoid complications as experience and training lead to an improved understanding of surgical planning, skive, and soft-tissue pressure on the end-effector all of which can impact accuracy of robotically assisted pedicle screw placement. Case Series, IV.

Exceptionally early tympanostomy tube placement in pediatric patients with cleft lip and palate

ObjectiveAt our institution, cleft lip repair is performed at or before 8 weeks of age, and tympanostomy tubes (TT) have been inserted concurrently in some of these patients. Our objective was to determine the feasibility and present the preliminary results of TT placement at this early age. MethodsA retrospective review was conducted of 22 patients born with cleft lip and/or palate who had TT placement in the first 8 weeks of life. Data collected included complications and audiologic function post TT placement. ResultsSubjects had a mean age of 3.9 weeks at the time of TT placement and cleft lip repair. Thirteen patients (59%) reported otorrhea during the follow-up period. Eighteen of 21 (86%) patients who underwent auditory evaluation had normal audiological function following TT placement. One patient had sensorineural hearing loss and 2 patients had mild conductive hearing loss due to bilateral extruded TT and OME at 15.9 and 39.2 months after surgery. ConclusionExceptionally early TT is feasible. Placing TT at or before 8 weeks of age did not result in any major complications but demonstrated a high incidence of otorrhea. A randomized, prospective study with a larger sample size is necessary to determine the benefits of TT placement at this age.

A minimally invasive approach for atrial and ventricular sew-on epicardial lead placement.

Permanent pacemaker (PPM) placement in pediatric patients is rare. Indications for permanent pacing in children include congenital and postsurgical atrioventricular block, symptomatic sick sinus syndrome, and select neuromuscular disorders.1,2 PPMs are traditionally placed using transvenous systems in adults and larger children. However, young children are often not suitable candidates due to their size or history of congenital cardiac surgery.

Outcomes Following Heterotopic Placement of Right Ventricle to Pulmonary Artery Conduits

We sought to evaluate the outcomes following right ventricle to pulmonary artery (RV-PA) conduit placement in pediatric patients, excluding those with a RV-PA conduit for the Ross procedure which is associated with improved conduit durability, partly related to its orthotopic position. Outcomes for 119 patients who underwent RV-PA conduit placement at a single institution from January 2004 to December 2016 were reviewed. Primary outcome measures were reintervention-free survival (RFS) and overall survival. Survival analyses were performed using the Kaplan-Meier method, and risk factors associated with reintervention were evaluated. The median age at the time of conduit placement was 6 months (interquartile range, IQR: 1-14), and the median length of follow-up was 63 months (range: 0-156). During follow-up, 39 patients required conduit-related reintervention, while 6 patients died perioperatively with an overall survival of 90% at 10 years. Among the remaining 113 patients, the RFS at one, five, and ten years was 91% (84%-95%), 72% (60%-80%), and 33% (16%-50%), respectively. The median time to conduit replacement in the series was 43.5 months (IQR: 19.3-76.2). The use of a pulmonary homograft was associated with improved RFS (P = .03), and this was particularly pronounced in comparison with aortic homografts in neonates. Infection was the indication for replacement in only one patient. The majority of the conduits placed during the neonatal period required conduit replacement before the age of five years. Endocarditis was not a common indication for replacement. In neonates and infants, we prefer pulmonary homografts for most indications.

3D CT airway evaluation-guided intraluminal placement of endobronchial blocker in pediatric patients: a randomized controlled study.

BackgroundThe aim of the present study was to propose a new approach for 3D computed tomography (CT) airway evaluation-guided endobronchial blocker placement in pediatric patients, and to determine its efficiency in clinical application.MethodsA total of 127 pediatric patients aged 0.5–3 years who were scheduled for elective thoracic surgery using one-lung ventilation (OLV) were randomized into the bronchoscopy (BRO) group and the CT group. The degree of lung collapse, postoperative airway mucosal injury, pulmonary infection within 72 h after surgery, and hoarseness after tracheal extubation; duration of postoperative mechanical ventilation, intensive care unit (ICU) stay and hospitalization; success rate of first blocker positioning; and required time and repositioning for successful blocker placement were compared between the 2 groups.ResultsThe degree of lung collapse, postoperative airway mucosal injury, pulmonary infection within 72 h after surgery, and hoarseness after tracheal extubation; duration of postoperative mechanical ventilation, ICU stay and hospitalization; success rate of first blocker positioning; and required time and repositioning for successful blocker placement were similar between the 2 groups (all P>0.05).ConclusionsFor pediatric patients undergoing surgery with OLV, preoperative 3D CT airway evaluation could be used to guide endobronchial blocker placement, with a blocking efficiency similar to that of BRO-guided blocker placement.

Validation of sonographic assistance for placement of a nasogastric tube in pediatric patients.

Enteral access via nasogastric tube (NGT) placement can be essential in the provision of care in pediatric patients. Methods exist to confirm correct placement with success rates between 80% and 85%. Radiographic confirmation remains the "gold-standard," however; it exposes patients to ionizing radiation and fails to provide "real-time" information. In this study, we determined the feasibility of using sonography to assist in the placement of NGT insertions in pediatric patients that have difficulty cooperating. Thirty patients requiring NGT placement were stratified into three age groups. Upon NGT insertion, transverse and longitudinal ultrasound images were acquired to visualize tube progression through the esophagus. Subsequently, a focused ultrasonographic exam of the gastric antrum and body were performed. If amenable, an air bolus (1 mL/kg) was injected in the stomach if the NGT was not directly visualized. Following intubation, standard guidelines for NGT position confirmation were performed. The NGT was visualized in all esophageal views and 52% of gastric views. Subgroup analysis showed that successful visualization of tube placement in the stomach ranged from 40% (7-18 years) to 70% (3-6 years). Eighty percentage of air boluses injected were visualized. The use of ultrasonography may assist NGT placement in pediatric patients and reduce the incidence of suboptimal placement during insertion. We demonstrated successful NGT visualization through the esophagus regardless of age. NGT visualization in the stomach was challenging; however, injection of an air bolus may improve visualization. Further studies are required to improve the success rate of obtaining gastric views of the NGT.

Point-of-Care Ultrasound for Confirmation of Nasogastric and Orogastric Tube Placement in Pediatric Patients.

The aim of the study was to investigate the role of point-of-care ultrasound (POCUS) as an alternative imaging modality to confirm proper placement for nasogastric tubes (NGTs) and orogastric tubes (OGTs) in pediatric patients. This was a prospective descriptive study performed at a tertiary care free-standing children's hospital. Patients 21 years and younger requiring radiographic confirmation of NGT or OGT placement were eligible for enrollment. Bedside ultrasonography examination of the epigastric area was performed by a blinded pediatric emergency medicine physician. An abdominal radiograph was obtained to confirm NGT or OGT placement in all patients. A total of 26 patients with a mean age of 2.6 years (standard deviation, 3.9 years) were enrolled. All 26 patients had x-ray confirmation of NGT and OGTs correctly placed in the stomach. Confirmation of NGT or OGT placement by ultrasound was obtained in 23 patients. For these 23 patients, POCUS agreed with radiographic findings. For 3 patients, the NGT and OGT was unable to be identified by ultrasound. The sensitivity of ultrasound for detecting a properly placed tube was 88% (95% confidence interval, 70.0%-97.6%). This pilot study described ultrasound confirmation of NGT or OGT placement. If confirmed in larger studies, POCUS can be used as an objective tool for the confirmation of NGT or OGT placement in pediatric patients and limit the need for routine x-ray confirmation.

Evolution of pediatric ventricular assist devices and their neurologic and renal complications-A 24-year single-center experience.

Utilization of ventricular assist devices (VADs) in adult populations with severe heart failure as a bridge to transplant has become the standard of care over the past two decades. Analogously, the use of VADs in pediatric populations has become more commonplace as pediatric heart transplantation has become more prevalent. We still have much to learn, however, about the complications after VAD placement in pediatric patients, their impact on transplantation and, in particular, how outcomes have changed over time. The objectives of this study were to (a) review the experience of a single pediatric VAD center, (b) identify risk factors that could lead to poor outcomes in patients on the transplant waitlist after VAD implantation and (c) demonstrate changes in outcomes over time. A retrospective cohort analysis was performed comparing death as a primary outcome and stroke and acute kidney injury (AKI) as secondary outcomes, across the study period divided into three timed eras. We analyzed 88 patients supported by a VAD over a 24-year timeframe. The duration, age at implant and indication for VAD support did not change significantly across the eras. We found that the incidence of stroke decreased over the study period and, while the rates of AKI did not change over the study period, those who developed AKI, while supported on VAD, had an increased risk of death.

Implantable venous access devices in children with severe hemophilia: a tertiary pediatric institutional experience.

Clotting factor replacement forms the pillar of treatment for children with hemophilia. Most children can be treated using peripheral venipuncture, but very young children and children with poor venous access might require a central venous catheter. Short-term and long-term complications of implantable venous access device placement (also known as port placement) can result in important morbidity and mortality in children with hemophilia. The purpose of this study is to describe our experience with port placement in children and adolescents with severe hemophilia (<1% of the Factors VIII or IX). We performed a retrospective review over a 10-year period to identify port placement in pediatric patients with severe hemophilia. We reviewed demographic and procedural information, access frequency, mechanical complications, and central-line-associated bloodstream infections (CLABSI). Eighteen males were included, with median age at insertion of 3.9years (0.7-22.7years). Fifteen of the 18 patients had hemophilia Type A and 3/18 had Type B. Thirteen had high neutralizing inhibitor titers. Technical success in port placement was achieved in 26/27 (96.3%) patients, with 1 port failure caused by venous occlusion from prior catheter placement. Port catheter size ranged from 5 French (Fr) to 7.5 Fr. All were single-lumen and placed via right (76.9%) or left (23.1%) internal jugular vein; 59.3% were placed during general anesthesia, and all had factor replacement prophylaxis. A peripherally inserted central catheter (PICC) was placed concurrently in 69.2% of the cases; per hospital policy, the port was only accessed 15days post-placement to reduce the risk of site hematoma. Two patients were lost to follow-up. The total catheter days was 15,893. Ports were removed in 14/24 cases, most commonly because of CLABSI (7/24; 29.2%) and transition to peripheral infusion (3/24; 12.5%). Bleeding was the most common complication in the first 30days after placement. There were nine CLABSI events (0.57 per 1,000 catheter days), all in patients with high neutralizing inhibitor titers. A higher frequency of port access (more or equal to daily vs. less than daily) correlated with higher infection rates (P=0.02). Median time from port insertion to first infection was 348days (range 167-1,055days). There were four fibrin-sheath-related catheter occlusions (0.25 per 1,000 catheter days): three catheters were salvaged with intra-catheter tissue plasminogen activator (tPA) instillation resulting in a salvage of an additional 1,214 catheter days, and one catheter was removed after tPA failure (0.06 per 1,000 catheter days). Port maintenance in boys with severe hemophilia is challenging given the need for long-term frequent device access that is associated with catheter-related infections. The rate of bleeding or infection did not differ in patients whether the device was accessed immediately or 15days post placement. With appropriate pre- and post-procedural factor replacement, immediate and early term severe complications are not common.

Pressure gradients, laboratory changes, and outcomes with transjugular intrahepatic portosystemic shunts in pediatric portal hypertension.

Indications for TIPS are well described in adults and involve complications of PHTN. Complications from PHTN are associated with PSG of>12mmHg in adults. It is unclear if these parameters apply to children with PHTN. To assess whether adult criteria for TIPS placement can be utilized in children, describe laboratory changes over time, and report outcomes. We performed a retrospective review of 34 pediatric patients who underwent TIPS, examining indications, radiology, PSG reductions, laboratory changes, and outcomes. Most patients had PHTN due to parenchymal liver disease including congenital hepatic fibrosis (n=5), biliary atresia (n=5), cystic fibrosis-related liver disease (n=3) and cavernous transformation of the portal vein (n=6). Indications for TIPS included variceal bleeding, recurrent ascites, and maintenance of portal vein flow following thrombolysis. Variceal bleeding was observed in six children with PSG<12mmHg. Minor complications occurred in eight subjects. Continued bleeding occurred in one patient. Six patients were successfully bridged to transplantation, and three patients died secondary to end-stage disease. Standard laboratory tests stabilized after TIPS placement and hematocrit increased. TIPS placement in pediatric patients was performed for complications of PHTN. Unlike adult series, a substantial proportion of our cases treated extrahepatic PHTN from cavernous transformation of the portal vein. Children presented with sequelae of PHTN with PSG below 12mmHg, below the adult standard. We found TIPS in pediatrics to be safe and effective with laboratory stabilization and improvement in hematocrit.

Gastrostomy tubes appear to be safe following pediatric orthotopic heart transplant.

Gastrostomy tube (GT) placement is a common pediatric surgical procedure typically indicated for oral aversion. This may develop in patients with congenital heart disease (CHD) who require an orthotopic heart transplant (OHT). The safety profile of GT placement in OHT patients who are immunosuppressed is unknown. Given the potential increased risk of wound site complications on a patient receiving immunosuppression, we sought to determine the safety profile of GT placement in pediatric patients with OHT. We performed a retrospective case series of all pediatric OHT recipients who subsequently underwent GT placement from January 1, 2009, to August 1, 2018, at the University of Virginia Children's Hospital. Major GT complications of wound breakdown, wound infection, peristomal GT leakage, ileus, or persistent emesis, and minor GT complication including the presence of granulation tissue are reported. Six patients who had a pediatric OHT subsequently underwent GT placement over the study period. There were no major 30-day or 90-day GT complications. One patient had excessive granulation tissue at their GT site. There were no accounts of acute kidney injury, urinary tract infection, sepsis, or pneumonia. Gastrostomy tube (GT) placement appears to be safe in pediatric OHT patients who are on immunosuppressive medications and unable to feed orally. This is the first study documenting the safety profile of GTs in pediatric OHT patients and may aid clinicians to make decisions regarding this intervention.

Technical success and outcomes in pediatric patients undergoing transjugular intrahepatic portosystemic shunt placement: a 20-year experience

Transjugular intrahepatic portosystemic shunt (TIPS) placement has been extensively studied in adults. The experience with TIPS placement in pediatric patients, however, is limited. The purpose of this study was to report technical success and clinical outcomes in pediatric patients undergoing TIPS placement. Twenty-one children - 12 (57%) boys and 9 (43%) girls, mean age 12.1years (range, 2-17years) - underwent TIPS placement from January 1997 to January 2017. Etiologies of hepatic dysfunction included biliary atresia (n=5; 24%), cryptogenic cirrhosis (n=4; 19%), portal or hepatic vein thrombosis (n=4, 14%), autosomal-recessive polycystic kidney disease (n=3; 14%), primary sclerosing cholangitis (n=2; 10%) and others (n=3, 14%). Indications for TIPS placement included variceal hemorrhage (n=20; 95%) and refractory ascites (n=1; 5%). Technical success, manometry findings, stent type, hemodynamic success, complications, liver enzymes, and clinical outcomes were recorded. TIPS placement was technically successful in 20 of 21 (95%) children, with no immediate complications. Mean pre- and post-TIPS portosystemic gradient was 18.5±10.7mmHg and 7.1±3.9mmHg, respectively. Twenty-two total stents were successfully placed in 20 children. Stents used included: Viatorr (n=9; 41%), Wallstent (n=7; 32%), Express (n=5; 23%), and iCAST (n=1; 5%). All children had resolution of variceal bleeding or ascites. TIPS revision was required in 9 (45%) children, with a mean of 2.2 revisions. Hepatic encephalopathy developed in 10 children (48%), at a mean of 223.7 days following TIPS placement. During the study, 6 (29%) children underwent liver transplantation. TIPS placement in pediatric patients has high technical success with excellent resolution of variceal hemorrhage and ascites. TIPS revision was required in nearly half of the cohort, with hepatic encephalopathy common after shunt placement.

Changes in renal function after left ventricular assist device placement in pediatric patients: A Pedimacs analysis.

Renal dysfunction (RD) is prevalent among pediatric patients with advanced heart failure. Data are limited regarding changes in renal function after left ventricular assist device (LVAD) placement in this population. Pediatric LVAD recipients enrolled in the Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) between September 19, 2012 and June 30, 2016 were included. Longitudinal changes in renal function were analyzed for the entire cohort as well as subgroups stratified by patient and device characteristics. Logistic regression was used to attempt to identify factors associated with lack of improvement in renal function after LVAD placement. Post-LVAD outcomes were assessed using the Kaplan‒Meier method. Data from 247 patients from 39 centers were analyzed. Baseline RD (estimated glomerular filtration rate [eGFR] <90 ml/min/1.73 m2) was present in 150 (61%) patients. Overall, eGFR improved post-LVAD, peaking at 1 month post-implant. There was an inverse relationship between baseline eGFR and the degree of improvement at 1 month. Degree of improvement in eGFR at 1 month was not impacted by device type, age, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile, or diagnosis. Failure to normalize renal function at 1 week was correlated with persistent RD at 1 month. Post-implant outcomes did not differ among patients stratified by pre-implant renal function. Renal function improves post-LVAD placement in pediatric patients regardless of age, diagnosis, illness severity, or device type, with improvement most pronounced in patients with baseline RD. Identifying patients with irreversible renal dysfunction before LVAD placement remains difficult. Pre-LVAD renal function does not appear to impact survival to transplant.

Transcutaneous Osseointegrated Implants for Pediatric Patients With Aural Atresia

Patients with aural atresia typically have maximal conductive hearing loss, which can have negative academic and social consequences. Transcutaneous osseointegrated implants (TOIs) can potentially restore hearing on the affected side. To review the demographic, audiological, and surgical outcomes of TOI placement in pediatric patients with aural atresia and to describe a modification in incision technique in anticipation of later auricular reconstruction. This retrospective case series reviewed 41 cases of TOI placement in pediatric patients between January 1, 2014, and September 30, 2016, at Lurie Children's Microtia and Aural Atresia Clinic. Patients, all younger than 18 years and with atresia or microtia, received at least 6 months of follow-up and underwent testing before and after surgery. Patient age, indication for procedure, ear sidedness, case length, incision type, complications, and other postoperative events. Audiological outcomes before and after implantation were measured using pure-tone averages and the Hearing In Noise Test for Children, presented in variable signal to noise ratios. In total, 46 TOIs were performed in 38 pediatric patients, but only 41 implantations in 34 patients were included in this study. Of the 34 patients, 13 (38%) were males and 21 (62%) were females, with a mean age of 8.9 (range, 5-17) years at the time of TOI placement. Microtia on the implanted side was present in 39 cases (95%). A modified posterior-superior scalp incision technique was used in 30 (73%) of 41 ears, all in cases of microtia. One perioperative surgical complication occurred: a seroma requiring drainage. Two patients developed minor skin irritation and erythema at the magnet site related to the overnight use of the processor, which resolved when removed while sleeping. The mean (SD; range) score for the Speech In Noise test at 5 dB signal to noise ratio improved from 75.3% (14.4%; range, 50%-92%) correct in unaided/preoperative condition to 93.6% (6.95%; range, 80%-100%) correct in the aided/postoperative condition. The mean improvement in score was 18.3% (95% CI, 10.8%-25.9%), with an effect size of 1.62 (95% CI, 0.95-2.29). The mean pure-tone averages (SD; range) similarly improved from 63.7 (13.2; range, 25-11) dB to 9.6 (4.9; range, 5-15) dB. Transcutaneous osseointegrated implantation has a low complication rate among pediatric patients with atresia or microtia and can provide excellent audiological results. It should be included as a treatment option for this population of patients who meet audiological criteria.

Long-term outcomes for pediatric patients having transscleral fixation of the capsular bag with intraocular lens for ectopia lentis

To report the long-term outcomes of transscleral fixation of capsular tension rings (CTR) with intraocular lens (IOL) placement in pediatric patients with ectopia lentis. John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. Retrospective case series. Pediatric patients requiring lens extraction with transscleral capsular bag fixation with a CTR and IOL for ectopia lentis between January 2006 and January 2016 were analyzed. Thirty-seven patients (67 eyes) who had transscleral fixation of the capsular bag using a CTR fixated with 9-0 or 10-0 polypropylene (Prolene), 8-0 polytetrafluoroethylene (Gore-Tex), or 9-0 nylon were identified. The mean age at time of surgery was 7.25years (2 to 18years) and the mean follow-up was 35.3months (0.25 to 120months). The proportion of eyes showing improvement in corrected distance visual acuity (CDVA) postoperatively was 78.5%, which demonstrated significance with a 95% confidence interval. In the immediate postoperative period, 1 eye developed a hyphema and 1 eye required IOL repositioning. Long-term complications included posterior capsule opacification in 35 eyes (52%) and uveitis-glaucoma-hyphema syndrome in 1 eye (1.5%). Three eyes (4.4 %) required IOL repositioning for spontaneous delayed IOL dislocation, 2 sutured with 8-0 polytetrafluoroethylene at postoperative month 8 and postoperative year 3 and 1 sutured with 9-0 polypropylene at postoperative year7. Transscleral fixation of the capsular bag using a CTR improved CDVA and provided IOL stability in pediatric patients with ectopia lentis.

An optimized technique of endoscopic third ventriculocisternostomy (ETV) for children with occlusive hydrocephalus.

In this article, we present an optimized minimally invasive technique of ETV for children with occlusive hydrocephalus. The study comprises of 64 consecutive pediatric cases (34 boys and 30 girls aged from 1month to 5years) of occlusive hydrocephalus from various etiologies, which were treated with a modified technique of ETV. Mean clinical follow-up period after ETV was 24.2 ± 3.8months. Application of the new technique made it possible to significantly reduce the length of the soft tissue incision for access, and the use of upgraded instruments allowed to perform a twist drill hole in the skull to less than half a usual size. Access to the brain and lateral ventricle was performed by blunt trephination of the dura without the need for significant corticectomy or coagulation, and yielded minimal damage to the brain, which is very important in patients of young age. Continued endoscopic control during the approach down to the lateral ventricle increases safety and decreases risk of injury, and can be performed in cases of pathologies affecting the anatomical relationships of the lateral and third ventricle. Mortality in our cohort was 0%, and there were no postoperative neurological, endocrinological, or infectious complications. Patency rates of the first ETV performed was 78%, with the remaining patients requiring additional surgical procedures for complicated settings. This new technique of minimally invasive ETV placement in pediatric patients is an effective and safe method to treat occlusive hydrocephalus and can be recommended for extensive clinical use.