Risk Stratification Of Pediatric Patients Research Articles

Evaluation of the efficacy of EU-TIRADS and ACR-TIRADS in risk stratification of pediatric patients with thyroid nodules.

Pediatric thyroid nodules have a lower prevalence but a higher rate of malignancy (ROM) than those in adults. Ultrasound features suspected of malignancy lead to fine needle aspiration biopsy (FNAB) and subsequent cytological determination, upon which management is decided. Based on the characteristics of ultrasound, to standardize clinician decisions and avoid unnecessary FNAB, the European Thyroid Association and the American Radiology College have established guidelines for Thyroid Imaging, Reporting and Data System (EU-TIRADS and ACR-TIRADS) for ROM stratification of thyroid nodules. The aim of this study is to evaluate the diagnostic performance of ACR-TIRADS and EU-TIRADS in pediatric age. Subjects younger than 18 years of age with thyroid nodules greater than 0.5 cm observed in the 2000-2020 period were included. Data from 200 subjects were collected. The overall ROM was 13%, rising to 26% if nodules with a diameter >1 cm were considered. Patients with a malignant nodule were more likely to have a higher EU-TIRADS score (p=0.03). Missed cancer diagnoses were 26.9%. Using the EU-TIRADS system, 40% of FNABs could have been avoided, while this scoring system would have resulted in FNAB being performed in 12% of cases where the assessment of ultrasound features would not recommend FNAB. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 73.1%, 57.1%, 73.1%, and 50%, respectively. Even considering the ACR-TIRADS, a higher score correlated with a higher ROM (p<0.001). This system missed 6 diagnoses of cancer (23.1%). Using the ACR-TIRADS system, 45.3% of FNABs could have been avoided, while FNAB should have been performed in 12% of cases where it was not recommended by ultrasound characteristics. Sensitivity, specificity, PPV and NPV were 76.9%, 50%, 76.9%, and 42.9%, respectively. The present study confirms the correspondence of the EU-TIRADS and ACR-TIRADS categories with respect to malignancy but indicates not entirely satisfactory performance compared to FNAB alone. However, the use of the two TIRADS systems should be encouraged in multicentre studies to increase their performance and establish paediatric-specific points in the scoring criteria.

Adverse Respiratory Events After Pediatric Endoscopic Airway Surgeries.

Perioperative risk stratification of pediatric patients undergoing airway intervention remains crucial in identifying those at a higher risk of requiring postoperative intensive care unit (ICU) care. Here we determined the likelihood of and possible risk factors for developing perioperative adverse respiratory events (PAREs) requiring ICU care after various pediatric endoscopic airway surgeries (EASs). We conducted a retrospective chart review of pediatric patients who were aged <18 years and underwent EAS between 2015 and 2021. Early postoperative adverse events within 24 h of surgery were recorded and analyzed. Overall, 99 patients who underwent EAS were included. The age at the time of the intervention ranged from 8 months to 18years. Fifty-eight patients, median age was 4.83 years, underwent papilloma debulking with no high likelihood of PARE in this patient subgroup (OR = 0.48; 0.16-1.44). Twenty-five patients, median age was 9.72years, underwent balloon dilation of laryngotracheal stenosis with no increase in the likelihood of PARE in this patient population (OR = 2.02; 0.65-6.28). Early postoperative respiratory events occurred in 16 patients (16.2%). Most of these events (75%) manifested within 4 h after surgery. In a univariate analysis, intervention at the level of the subglottis or 2 or more laryngeal subsites increased the risk of PARE (OR = 6.57; 1.11-12.52 and OR = 3.73; 1.93-22.34, respectively). In a multivariate analysis, only intervention in the subglottic area maintained its effect (OR = 6.84; 1.82-25.65). Respiratory adverse events following pediatric EAS are not uncommon, and the majority are encountered shortly after surgery. Intervention in the subglottic area was an independent predictor of PARE.

Risk Stratification of Pediatric Patients with Differentiated Thyroid Cancer: Is Total Thyroidectomy Necessary for Patients at Any Risk?

Background: In the recent American Thyroid Association (ATA) guidelines for adult differentiated thyroid carcinoma (DTC) patients, risk stratification is clearly defined and lobectomy is acceptable for low-risk DTC. However, risk stratification for children with DTC in the ATA pediatric guidelines is rather unclear, and total thyroidectomy is recommended for all patients with any risk. The aim of this study was to attempt risk stratification based on our experience and to consider the appropriate extent of thyroidectomy, especially for low-risk DTC in the pediatric population. Patients and Methods: The subjects were 153 patients with DTC ≤18 years old, including 58 patients ≤15 years old and 136 female patients, who underwent initial curative surgery in our hospital between 1979 and 2014. Underlying pathology was papillary thyroid carcinoma in 130 patients and follicular thyroid carcinoma in 23. Risk factors related to disease-free survival (DFS) were analyzed and risk stratification was performed. Results: No patient died of the disease and 34 patients (22.2%) developed recurrences. At initial surgery, 30 patients (19.6%) had lymph node metastases diagnosed before initial surgery (cN1) and 9 (5.9%) had gross extrathyroidal extension (ETE). Significant factors related to DFS on multivariate analysis were cN1, ETE, and number of metastatic lymph nodes (NMLNs) ≥10, including microscopic MLNs. According to these factors, subjects were divided into three categories: low risk (no risk factors, n = 89); intermediate risk (1 risk factor, n = 37); and high risk (≥2 risk factors, n = 27). Ten-year DFS rates in the low-, intermediate-, and high-risk groups were 96%, 83%, and 48%, respectively. Only 12% of low-risk patients underwent total thyroidectomy. Because NMLNs become obvious only after surgery, another analysis after excluding "NMLNs" as a factor showed that cN and ETE were significant factors related to poor DFS. According to these two factors, risk stratification was attempted in the same manner. Ten-year DFS rates in the low- (no risk factor, n = 117), intermediate- (one risk factor, n = 29), and high-risk (two risk factors, n = 7) groups were 92%, 59%, and 43%, respectively. Only 12% of low-risk patients underwent total thyroidectomy. Conclusions: For low-risk pediatric patients, lobectomy may be sufficient as the initial surgical procedure.

Predictive factors for adverse outcomes in pediatric patients undergoing low-risk skin and soft tissue surgery: A database analysis of 6730 patients.

There is a paucity of data regarding risk stratification of pediatric patients presenting for low-risk skin and soft tissue surgery. We sought to determine the incidence and independent predictors of postoperative complications and unplanned 30-day readmission in a cohort of children undergoing low-risk skin and soft tissue surgery. The study included pediatric patients who underwent minor procedures of the skin and soft tissue at continuously enrolled American College of Surgeons National Surgical Quality Improvement Program Pediatric hospitals over a two-year period. The primary outcome was a 30-day postoperative complication composite. The secondary outcome was unplanned 30-day readmission. The final analysis included 6,730 patients. There were a total of 170 postoperative complications among 152 patients (2.23%) with the majority of complications being either wound-related or postoperative mechanical ventilation. The independent predictors for an increased risk of postoperative complication were American Society of Anesthesiologists classification ≥3 and nutritional deficiency. There were 41 unplanned readmissions (0.61%). The presence of a postoperative wound complication or a postoperative pulmonary complication during the index hospital stay was an independent risk factor for unplanned 30-day readmission. Pediatric patients with American Society of Anesthesiologists classification ≥3 and nutritional deficiency undergoing low-risk surgery are at risk for the development of postoperative complications. Patients who develop wound and postoperative pulmonary complications are at higher risk for unplanned 30-day readmission. Identification of these higher risk patients may allow the anesthesiologist to implement targeted therapies to minimize the likelihood of occurrence of these complications.

Risk factors associated with short-term complications and mortality after pediatric spinal arthrodesis.

OBJECTIVE Spinal arthrodesis is routinely performed in the pediatric population. However, there is limited information on the short-term outcomes of pediatric patients who have undergone spine fusion. Thus, the authors conducted a retrospective review of the Pediatric National Surgical Quality Improvement Program (NSQIP) database to determine the short-term mortality, complication, reoperation, and readmission rates of pediatric patients who underwent spinal arthrodesis for all indications. METHODS The Pediatric NSQIP database was queried for all patients who underwent spinal arthrodesis between 2012 and 2014. Patient demographics, comorbidities, body mass index, American Society of Anesthesiologists classification, and operative time were abstracted. Short-term mortality, reoperation, and readmission rates and complications were also noted. Univariate and multivariate analyses were performed to delineate patient risk factors that influence short-term mortality, complications, reoperation, and readmission rates. RESULTS A total of 4420 pediatric patients who underwent spinal fusion were identified. Common indications for surgical intervention included acquired/idiopathic scoliosis or kyphoscoliosis (71.2%) and genetic/syndromic scoliosis (10.7%). The mean patient age was 13.7 ± 2.9 years, and 70% of patients were female. The overall 30-day mortality was 0.14%. Multivariate analysis showed that female sex and pulmonary comorbidities significantly increased the odds of reoperation, with odds ratios of 1.43 and 1.78, respectively. CONCLUSIONS In the NSQIP database for pediatric patients undergoing spinal arthrodesis for all causes, there was a 3.6% unplanned reoperation rate, a 3.96% unplanned readmission rate, and a 9.0% complication rate. This analysis provides data for risk stratification of pediatric patients undergoing spinal arthrodesis, allowing for optimized care.

Homeobox Gene Involvement in Normal Hematopoiesis and in the Pathogenesis of Childhood Leukemias.

Homeobox (HOX) genes are a superfamily of highly conserved genes with essential functions in many aspects of mammalian development. Their expression is tightly regulated throughout the duration of definitive hematopoiesis, so the pathogenetic mechanism that leads to leukemia suggests that malignant transformation is directly intertwined with the deregulation of HOX gene expression. Even though HOX gene involvement has been reviewed extensively in adult leukemias, childhood leukemias have received much less attention and mainly in the context of leukemias harboring MLL (mixed-lineage leukemia) gene translocations. In recent years, scientific evidence has highlighted HOX gene involvement in the development of other subtypes of childhood leukemias and added HOX gene family members that were previously unrelated to the pathogenesis of childhood leukemia. This has significant implications when considering both the risk stratification of pediatric patients and potential targets for successful therapy. Through the identification of HOX target genes, their resulting interactions, and the cognate signaling pathways, we hope to gain a better understanding of the molecular mechanism(s) underlying the ectopic activation of these genes in childhood leukemias and subsequently to reveal new molecular targets for successful therapy in cases of poor prognosis or resistant disease.

Initial and Dynamic Risk Stratification of Pediatric Patients With Differentiated Thyroid Cancer.

The objective of this study was to evaluate the usefulness of American Thyroid Association (ATA) risk classification and dynamic risk stratification (DRS) based on the response to initial therapy in pediatric patients with differentiated thyroid cancer (DTC). This historical cohort study included 77 pediatric patients with DTC who underwent thyroid surgery. Clinical outcomes during median 5.3 years of follow up were assessed according to 3 ATA risk groups and 4 DRS groups. In ATA risk classification, 22%, 48%, and 30% of patients were in the low-, intermediate-, and high-risk groups, respectively. There was no significant difference in disease-free survival (DFS) between the indeterminate and the low-risk group. The risk of recurrent/persistent disease was significantly higher only in the high risk group [hazard ratio (HR), 18.4; P = 0.005]. In DRS, 49%, 13%, 6%, and 31% of patients were classified in the excellent, indeterminate, biochemical incomplete, and structural incomplete response groups, respectively. The risk of recurrent/persistent disease was significantly higher in the indeterminate group (HR, 10.2; P = 0.045) and in the structural incomplete group (HR, 98.7; P = 0.005) compared with the excellent response group. DRS based on the response to initial therapy could be useful in addition to initial ATA pediatric risk classification to predict recurrent/persistent disease in pediatric patients with DTC.

Long-Term Follow up of Pediatric Patients with Hodgkin Lymphoma Treated with High Dose Therapy and Autologous Stem Cell Transplantation

Introduction: Despite improved outcomes for children with Hodgkin lymphoma (HL), relapsed and refractory disease remain a challenge for a subset of patients. High dose therapy followed by autologous stem cell transplantation (ASCT) is the standard of care for relapsed disease, largely based on data from studies in adults. As new therapies emerge for HL, risk stratification of pediatric patients with relapsed disease will be essential to determine which patients are likely to benefit from ASCT and which patients should be selected for alternative therapy. In this study we report the long-term outcome of 34 pediatric patients with HL who underwent ASCT at a single institution.Methods: We conducted a retrospective analysis of 34 consecutive pediatric patients with HL who underwent ASCT at Memorial Sloan Kettering Cancer Center from 1989-2013. Data collected included age, histology, treatment prior to ASCT, disease status at the time of transplant, conditioning regimen, and outcome after ASCT. Given recent data supporting a Childhood Hodgkin International Prognostic Score (CHIPS) for risk stratification in first-line therapy(Schwartz et al, ASH Abstract #3649, 2011), this score was calculated at the time of relapse to evaluate its prognostic relevance in the relapse setting. One point was awarded for each of the following: stage IV disease, bulky mediastinal adenopathy, albumin <3.5, and fever. Kaplan-Meier survival analysis was used to estimate the probability of overall survival (OS) and disease-free survival (DFS).Patient Characteristics: Pathologic classification included nodular sclerosis (n=30), mixed cellularity (n=1), lymphocyte predominant (n=2), or subtype unspecified (n=1). The median age was 17.9 yrs (range 9.7-21) and 47% of patients were male. Thirty-three patients had relapsed disease; one patient had primary refractory disease. The median time from diagnosis to first relapse was 13 months (range 5-60). Twenty-five patients (73.5%) had chemotherapy responsive disease at the time of transplant (CR or PR). Others had stable disease (n=6), mixed response (n=2) or progressive disease (n=1). Thirty-one of 34 patients received radiation therapy either during initial treatment or as part of a salvage regimen. Four patients received brentuximab vedotin at the time of relapse. ASCT preparative regimen consisted of cyclophosphamide-etoposide + total lymphoid irradiation (n=14) or + carmustine (n=16), while 4 patients received the BEAM regimen. All but two patients treated after 1997 received chemotherapy-only preparative regimens.Results: The median follow up for the cohort was 70.5 months (range 2.5-144). The 12-year OS and DFS were 65.1% and 63.6% respectively. The cause of death included HL (n=7), sepsis (n=1) and end stage renal disease (n=1). Patient age, stage at diagnosis, and time from diagnosis to relapse were not associated with differences in DFS. Patients who received an ASCT after 1997 had a better outcome than those who received an ASCT before 1997 (DFS 44.9% vs. 81.8%, p=0.012). Patients with chemotherapy sensitive disease at the time of transplant had a superior DFS (74.5% vs. 33.3%, p=0.005). Although not statistically significant, there was a trend toward improved outcome among patients with early stage disease at relapse (stage I/II) compared to advanced stage (III/IV) (DFS 81.3% vs. 54.2%, p=0.098). Among 21 patients with data available to calculate CHIPS at time of relapse, there was a superior OS among those with a lower CHIPS with OS of 100%, 70%, 50%, and 0% for patients with a CHIPS of 0, 1, 2, and 3 respectively (p=0.021). There were no patients with a CHIPS of 4. There was a trend toward improved DFS among patients with a low CHIPS, however this was not statistically significant (DFS of 100%, 70%, 66.7%, and 0% in patients with a CHIPS of 0, 1, 2, and 3 respectively, p=0.176).Conclusions: ASCT offers the prospect of durable, disease free survival for a significant proportion of pediatric patients with relapsed HL. The outcome among patients who received an ASCT in recent years (1997-2013) was high (DFS 81.8%). Chemotherapy sensitive disease at the time of transplant was associated with superior DFS. To our knowledge this is the first report evaluating the potential utility of CHIPS in the relapse setting. Despite the small sample size (n=21) CHIPS was predictive of OS, suggesting that this measure should be studied further as a potential prognostic marker in relapsed HL. DisclosuresTrippett:Seattle Genetics, Inc.: Research Funding; OSI Pharmaceuticals: Research Funding. Kernan:Gentium S.p.A.: Research Funding. Prockop:Atara Biotherapeutics: Other: I have no financial disclosures, but Atara Biotherapeutics has exercised a licensing agreement with Memorial Sloan Kettering Cancer Center and MSKCC and some investigators at MSKCC have a financial interest in Atara.. Scaradavou:National Cord Blood Program- New York Blood Center: Employment. Moskowitz:Celgene: Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Honoraria, Research Funding; Merck: Membership on an entity's Board of Directors or advisory committees, Research Funding; Genentech: Membership on an entity's Board of Directors or advisory committees; Pharmacyclics: Research Funding.

A Recurrent Immunophenotype at Diagnosis Independently Identifies High Risk Pediatric AML: A Report from the Children's Oncology Group Trial AAML0531

Background: Risk stratification of pediatric patients with acute myeloid leukemia (AML) combines cytogenetics and molecular markers at diagnosis with detection of measurable residual disease (MRD) by multidimensional flow cytometry (MDF) after initial induction chemotherapy (EOI1). However, using MDF to distinguish between favorable and poor risk groups by diagnostic immunophenotype has not been sufficiently reproducible for clinical implementation.Objective: We sought to characterize a recurrent, unique diagnostic immunophenotype identified among patients treated on Children's Oncology Group trial AAML0531 and determine the clinical characteristics, frequency, and outcome of patients with this immunophenotype in a large cohort.Patients and Methods: Of the 1022 newly diagnosed pediatric patients with de novo AML who enrolled in protocol AAML0531 (exclusive of patients with promyelocytic leukemia and Down syndrome), 812 who submitted a specimen for MDF at diagnosis and gave consent to MRD testing were eligible for the study.Results: A recurrent diagnostic phenotype was identified by a combination of high intensity CD56 expression, a lack of HLA-DR, dim to negative CD38 expression and dim to negative CD45 expression (designated as RAM phenotype). At diagnosis 19 patients (2.3%) expressed this phenotype and MRD was subsequently detected by MDF in 16/19 patients at EOI1 at a level of 0.02%-41% (median 0.3). Eleven patients with this phenotype submitted bone marrow specimens for MDF analysis at all 3 additional monitoring time points during therapy and in 8 patients MDF analysis revealed disease persistence throughout treatment. The experimental cohort (RAM cohort, N=19) and 2 control cohorts, one consisting of all other patients with CD56 positive AML (CD56+ control, N=166) and the other of patients with CD56 negative AML (CD56- control, N=627), were analyzed for clinical outcomes.Patients in the RAM cohort were significantly younger with a median age at diagnosis of 1.26 years [range 0.75-16.89] than those in the CD56+ control (median 7.57 years [range 0.01-29.8], p=0.002) and the CD56- control (median 10.64 [range 0.02-23.94], p<0.001). All patients in the RAM cohort were classified as standard risk per study protocol compared to 55% (p<0.001) for the CD56+ control and 46% (p<0.001) for the CD56- control. Patients in the RAM cohort were FLT3-ITD- and wild type for CEBPA, NPM1, and WT1. Of them, 7 had normal cytogenetics, 1 had trisomy 8, and 11 had other cytogenetic abnormalities not associated with prognostic subgroups, including the 11q23/MLL rearrangement. According to morphology, patients in the RAM cohort were more often classified as having megakaryoblastic AML (38%) compared to the CD56+ control (2.0%, p<0.001) and the CD56- control (4.0%, p<0.001).MDF analysis detected MRD in 84% of RAM cohort compared to 29% (p<0.001) for the CD56+ control and 33% (p<0.001) for the CD56- control cohorts. MRD detected at EOI1 was compared to morphologic complete remission (CR). Morphologic CR at EOI1 was achieved in 11 (58%) patients in the RAM cohort (58%) versus 71% of patients in the CD56+ (p=0.250) and 74% of patients in the CD56- (p=0.116) control cohorts. Patients in the RAM cohort had a 3-year event free survival (EFS) of 16% versus 52% for those in the CD56+ (p=0.003) and 51% for those in the CD56- (p<0.001) control cohorts. The 3-year overall survival (OS) for patients in the RAM cohort was 26% versus 66% for those in the CD56+ (p<0.001) and 70% for those in the CD56- (p<0.001) control cohorts. Multivariable Cox regression analysis revealed that the diagnostic RAM immunophenotype was an independent predictor of adverse outcome (hazard ratios [and 95% confidence intervals]: OS= 3.4 (1.84 - 6.18), relapse risk from CR=4.97 (2.67 - 9.24), DFS from CR=4.27 (2.04 - 8.95)).Conclusions: A definitive diagnostic phenotype is identified that is highly predictive of poor outcome in pediatric AML. The survival of patients with the RAM phenotype is similar to or worse than those with high-risk molecular features. It occurs in 10% of infants (<1 year old) with AML who lack known risk factors, do not respond to standard therapy, and have extremely poor outcomes. This phenotype can be identified rapidly at diagnosis, allowing clinicians to predict failure before initiating therapy, and thereby allowing administration of more effective alternative therapies and minimizing exposure to non-efficacious treatment. DisclosuresBrodersen:Hematologics Inc.: Employment. Menssen:Hematologics Inc.: Employment. Pardo:Hematologics Inc.: Employment. Voigt:Hematologics Inc.: Employment. Loken:Hematologics Inc.: Equity Ownership.

Utility of Exercise Testing and Adenosine Response for Risk Assessment in Children with Wolff-Parkinson-White Syndrome.

We aimed to determine the correlation between noninvasive testing (exercise stress testing [EST] and adenosine responsiveness of accessory pathway [AP] ) and invasive electrophysiology study (EPS) for assessment antegrade conduction of the AP in Wolff-Parkinson-White syndrome. This prospective, observational study enrolled 40 children (58% male children, median age of 13 years, and median weight of 47.5 kg) with Wolff-Parkinson-White syndrome. Conduction through the AP to a cycle length of ≤250 ms was considered rapid or high-risk; otherwise, patients were nonrapid or low-risk. The sudden disappearance of the delta-wave was seen in 10 cases (25%) during EST. Accessory pathway was found to be high-risk in 13 cases (13/40, 32.5%) while the accessory path was identified as low-risk in 27 cases; however, six patients (15%) had blocked AP conduction with adenosine during EPS. Low-risk classification by EST alone to identify patients with nonrapid conduction in baseline EPS had a specificity of 93% and a positive predictive value of 90% (accuracy 54%). Blocked AP conduction with adenosine as a marker of nonrapid baseline AP conduction had a specificity of 93% and a positive predictive value of 84%. Finally, AP was adenosine nonresponsive in the majority of patients (28/30, 93%) with persistent delta-waves, 40% of those who had a sudden disappearance of delta-waves had an adenosine-responsive AP (P value: .028). Abrupt loss of preexcitation during EST and blocked AP conduction with adenosine had high specificity and positive predictive value for nonrapid and low-risk antegrade conduction during baseline invasive EPS. Successful risk stratification of pediatric patients with Wolff-Parkinson-White is possible through the use of EST and the adenosine responsiveness of AP.

Cost-Effectiveness of Various Risk Stratification Methods for Asymptomatic Ventricular Pre-Excitation

Accessory pathways with "high-risk" properties confer a small but potential risk of sudden cardiac death. Pediatric guidelines advocate for either risk stratification or ablation in patients with ventricular pre-excitation but do not advocate specific methodology. We sought to compare the cost of differing risk-stratification methodologies in pediatric patients with ventricular pre-excitation in this single institutional, retrospective cohort study of asymptomatic pediatric patients who underwent risk stratification for ventricular pre-excitation. Institutional methodology consisted of stratification using graded exercise testing (GXT) followed by esophageal testing in patients without loss of pre-excitation and ultimately ablation in high-risk patients or patients who became clinically symptomatic during follow-up. A decision analysis model was used to compare this methodology with hypothetical methodologies using different components of the stratification technique and an "ablate all" method. One hundred and two pediatric patients with asymptomatic ventricular pre-excitation underwent staged risk stratification; 73% of patients were deemed low risk and avoided ablation and the remaining 27% ultimately were successfully ablated. The use of esophageal testing was associated with a 23% (p ≤0.0001) reduction in cost compared with GXT stratification alone and a 48% (p ≤0.0001) reduction compared with the "ablate all" model. GXT as a lone stratification method was also associated with a 15% cost reduction (p ≤0.0001) compared with the "ablate all" method. In conclusion, risk stratification of pediatric patients with asymptomatic ventricular pre-excitation is associated with reduced cost. These outcomes of cost-effectiveness need to be combined with the risks and benefits associated with ablation and risk stratification.

Primary payer status is significantly associated with postoperative mortality, morbidity, and hospital resource utilization in pediatric surgical patients within the United States

PurposeCurrent healthcare reform efforts have highlighted the potential impact of insurance status on patient outcomes. The influence of primary payer status (PPS) within the pediatric surgical patient population remains unknown. The purpose of this study was to examine risk-adjusted associations between PPS and postoperative mortality, morbidity, and resource utilization in pediatric surgical patients within the United States. MethodsA weighted total of 153,333 pediatric surgical patients were evaluated using the national Kids' Inpatient Database (2003 and 2006): appendectomy, intussusception, decortication, pyloromyotomy, congenital diaphragmatic hernia repair, and colonic resection for Hirschsprung's disease. Patients were stratified according to PPS: Medicare (n=180), Medicaid (n=51,862), uninsured (n=12,539), and private insurance (n=88,753). Multivariable hierarchical regression modeling was utilized to evaluate risk-adjusted associations between PPS and outcomes. ResultsOverall median patient age was 12years, operations were primarily non-elective (92.4%), and appendectomies accounted for the highest proportion of cases (81.3%). After adjustment for patient, hospital, and operation-related factors, PPS was independently associated with in-hospital death (p<0.0001) and postoperative complications (p<0.02), with increased risk for Medicaid and uninsured populations. Moreover, Medicaid PPS was also associated with greater adjusted lengths of stay and total hospital charges (p<0.0001). Importantly, these results were dependent on operation type. ConclusionsPrimary payer status is associated with risk-adjusted postoperative mortality, morbidity, and resource utilization among pediatric surgical patients. Uninsured patients are at increased risk for postoperative mortality while Medicaid patients accrue greater morbidity, hospital lengths of stay, and total charges. These results highlight a complex interaction between socioeconomic and patient-related factors, and primary payer status should be considered in the preoperative risk stratification of pediatric patients.

Noninvasive Risk Stratification Techniques in Pediatric Patients with Ventricular Preexcitation

Individuals with ventricular preexcitation (VP) are known to have an increased risk of sudden death. This risk has been associated with conduction properties of the accessory pathway. Patients with VP underwent risk stratification through the use of exercise and transesophageal testing. All patients were initially screened with exercise testing and those with preexcitation throughout exercise went on to have transesophageal testing. Patients who demonstrated high-risk pathway characteristics by transesophageal testing or developed clinical indications for an electrophysiology (EP) study underwent ablation. This stepwise risk stratification technique was evaluated for the ability to avoid the need for intracardiac EP study. Patients stratified as low risk were contacted for follow-up. One hundred and twenty-nine exercise studies were performed in 127 patients. Thirty-five of 129 exercise studies demonstrated accessory pathway block during exercise. Twenty-seven of 35 underwent no additional testing. Sixty-six patients underwent transesophageal testing. Forty-nine of 66 patients demonstrated low-risk pathway characteristics and 40 of 49 underwent no further testing. In total, 68 of 129 (53%) patients avoided the need for intracardiac EP study and ablation. A noncardiac indication for the initial diagnostic electrocardiogram was associated with lower likelihood of intracardiac EP study. None of the patients stratified as low risk had additional invasive procedures or life-threatening arrhythmias upon follow-up. Successful risk stratification of pediatric patients with VP is possible through the use of exercise and transesophageal testing. In this patient population, half of the patients were able to avoid an intracardiac EP study.