Single Pediatric Institution Research Articles

Central nervous system complications during treatment in childhood acute leukemia.

Central nervous system (CNS) complications can be seen in patients with leukemia, depending on the disease itself and the chemotherapeutic agents used. This study focused on CNS complications during treatment in children with acute leukemia in a single pediatric institution. CNS complications were evaluated retrospectively in 115 patients with ALL and AML. Patients with CNS leukemia infiltration at the time of diagnosis or during a neurological event, late-onset encephalopathy, peripheral neuropathy, or a previous history of neurological abnormalities were excluded from the study. A total of 115 children's clinical records with acute leukemia over a four-year period were reviewed. Acute CNS complications developed in 23.1% of acute myeloid leukemia (AML) patients and in 13.5% of acute lymphoblastic leukemia (ALL) patients. CNS complications developed most frequently during the induction phase of the treatment (66.7%). Seizures were the most common symptom (9 patients, 50%), followed by hemiparesis (4 patients, 22.2%) and headache (4 patients, 22.2%). Six patients (33.3%) had chemotherapy-induced toxic leukoencephalopathy, two (11.1%) had Wernicke's encephalopathy, and one patient (5.6%) each had sinus vein thrombosis, posterior reversible encephalopathy syndrome, and CNS infection. Sequelae occurred in three patients (16.7%), and only one patient (5.6%) died due to a CNS complication. Awide variety of symptoms can be observed in childhood leukemia, depending on the disease itself, the chemotherapeutic agents used and a lot of other conditions such as nutritional problems. Our research shows that several CNS complications might manifest with similar symptoms; differentiated diagnosis between the underlying etiological reasons can be made by neuroimaging.

Machine learning identifies clusters of the normal adolescent spine based on sagittal balance.

This study applied a machine learning semi-supervised clustering approach to radiographs of adolescent sagittal spines from a single pediatric institution to identify patterns of sagittal alignment in the normal adolescent spine. We sought to explore the inherent variability found in adolescent sagittal alignment using machine learning to remove bias and determine whether clusters of sagittal alignment exist. Multiple semi-supervised machine learning clustering algorithms were applied to 111 normal adolescent sagittal spines. Sagittal parameters for resultant clusters were determined. Machine learning analysis found that the spines did cluster into distinct groups with an optimal number of clusters ranging from 3 to 5. We performed an analysis on both 3 and 5-cluster groups. The 3-cluster groups analysis found good consistency between methods with 96 of 111, while the analysis of 5-cluster groups found consistency with 105 of 111 spines. When assessing for differences in sagittal parameters between the groups for both analyses, there were differences in T4-12 TK, L1-S1 LL, SS, SVA, PI-LL mismatch, and TPA. However, the only parameter that was statistically different for all groups was SVA. Based on machine learning, the adolescent sagittal spine alignments do cluster into distinct groups. While there were distinguishing features with TK and LL, the most important parameter distinguishing these groups was SVA. Further studies may help to understand these findings in relation to spinal deformities.

“Racism Happens Every Day, All the Time”: Black Families’ Outpatient Experiences of Racism Across a Large Pediatric System

ObjectiveTo qualitatively understand and characterize the experience of racism in outpatient pediatric healthcare settings from the perspectives of Black families. MethodsWe conducted focus groups with parents or guardians of Black children, recruited from academic primary care offices at a single pediatric institution. Focus groups were facilitated virtually by Black team members using an open-ended, semi-structured focus group guide. We analyzed focus group transcripts using iterative, thematic, inductive open coding performed independently by trained coders, with final codes reached by group consensus. ResultsWe conducted 6 focus groups of 3 to 5 participants each and 1 individual interview, with 24 total parents. We identified the following themes: 1) “I just felt like we was a number”: Black families perceived experiences that felt impersonal and lacked empathy; 2) “Why is the doctor treating me like I don’t matter?”: Black families perceived experiences with poor care and worse treatment; 3) Black families experience racism across socioecological levels when interacting with pediatric health systems; 4) Positive perceived experiences can guide improvement; and 5) Improvement will require antiracist efforts across the levels of racism. ConclusionsIn this qualitative study, we found that Black families have had many poor pediatric experiences, perceive racism as affecting child health broadly across socioecological levels, and recommend a multidimensional antiracist approach to improvement. Our findings underscore the importance of elevating Black family voices in developing policies that prioritize antiracism and work to eliminate the harmful impacts of racism on child health.

Diagnosing and Grading of Sinusoidal Obstructive Syndrome after Hematopoietic Stem Cell Transplant of Children, Adolescent and Young Adults treated in a Pediatric Institution with Pediatric Protocols

Sinusoidal obstructive syndrome (SOS), or veno-occlusive disease, of the liver has been recognized as a complex, life-threatening complication in the posthematopoietic stem cell transplant (HSCT) setting. The diagnostic criteria for SOS have evolved over the last several decades with a greater understanding of the underlying pathophysiology, with 2 recent diagnostic criteria introduced in 2018 (European Society of Bone Marrow Transplant [EBMT] criteria) and 2020 (Cairo criteria). We sought out to evaluate the performance characteristics in diagnosing and grading SOS in pediatric patients of the 4 different diagnostic criteria (Baltimore, Modified Seattle, EBMT, and Cairo) and severity grading systems (defined by the EBMT and Cairo criteria). Retrospective chart review of children, adolescent, and young adults who underwent conditioned autologous and allogeneic HSCT between 2017 and 2021 at a single pediatric institution. A total of 250 consecutive patients underwent at least 1 HSCT at UCSF Benioff Children's Hospital San Francisco for a total of 307 HSCT. The day 100 cumulative incidence of SOS was 12.1%, 21.1%, 28.4%, and 28.4% per the Baltimore, Modified Seattle, EBMT, and Cairo criteria, respectively (P < .001). We found that patients diagnosed with grade ≥4 SOS per the Cairo criteria were more likely to be admitted to the Pediatric Intensive Care Unit (92% versus 58%, P = .035) and intubated (85% versus 32%, P = .002) than those diagnosed with grade ≥4 per EBMT criteria. Age <3 years-old (HR 1.76, 95% [1.04 to 2.98], P = .036), an abnormal body mass index (HR 1.69, 95% [1.06 to 2.68], P = .027), and high-risk patients per our institutional guidelines (HR 1.68, 95% [1.02 to 2.76], P = .041) were significantly associated with SOS per the Cairo criteria. We demonstrate that age <3 years, abnormal body mass index, and other high-risk criteria associate strongly with subsequent SOS development. Patients with moderate to severe SOS based on Cairo severity grading system may correlate better with clinical course based on ICU admissions and intubations when compared to the EBMT severity grading system.

Time considerations and outcomes in pediatric tracheostomy decannulation

ObjectiveThe study objective is to identify factors that impact the time to decannulation in pediatric patients ages 0 through 18 years who are tracheostomy-dependent. MethodsThis retrospective chart review from January 1, 2005 through December 31, 2020 identified pediatric tracheostomy patients at a single pediatric institution. Data extracted included demographic, socioeconomic factors, and clinical characteristics. Multivariate regression and survival analysis were used to identify factors associated with successful decannulation and decreased time with tracheostomy. ResultsOf the 479 tracheostomy-dependent patients identified, 162 (33.8%) were decannulated. Time to decannulation ranged from 0.5 months to 189.2 months with median of 24 months (IQR 12.91–45.71). In the multivariate analysis, patients with bronchopulmonary dysplasia (p = 0.021) and those with Passy-Muir® Valve at discharge (p = 0.015) were significantly associated with decannulation. In contrast, neurologic comorbidities (p = 0.06), presence of gastrostomy tube (p < 0.001), or discharged on a home ventilator (p < 0.001) were associated with indefinite tracheostomy. When adjusting for age, sex, race, ethnicity, and insurance status, for every one month delay in establishment of outpatient otolaryngology care, time to decannulation was delayed by 0.5 months (p = 0.010). For each additional outpatient otolaryngology follow-up visit, time to decannulation increased by 3.36 months (p < 0.001). ConclusionsDecannulation in pediatric tracheostomy patients is multifactorial. While timely establishment of outpatient care did correlate with quicker decannulation, factors related to medical complexity may have a greater impact on time to decannulation. Our results can help guide institutional decannulation protocols, as well as provide guidance when counseling families regarding tracheostomy expectations.

Management and subsequent outcomes of patellar sleeve injuries: A retrospective case series of 90 pediatric and adolescent patients.

This study aims to report the epidemiology of patellar sleeve injuries, describe diagnostic findings and treatment, and assess functional outcomes following different treatments. A medical database was queried from 1990 to 2016 to identify patients ≤18 years presenting to a single pediatric institution with a patellar sleeve injury. Patients with significant comorbidities or previously operatively treated for ipsilateral knee injuries were excluded. Standard demographic data, mechanism of injury, skeletal maturity, injury-related radiographic parameters, along with treatment paradigms, post-treatment clinical and radiographic findings, and patient-reported outcomes were collected. A total of 90 patients, mean age of 10.7 years (range: 7-17) was included, of which 69 (77%) were male. Seventy-three percent of all injuries occurred while playing sports (particularly football/basketball/soccer), with "direct blow" or "landing" being the most prevalent mechanisms of injury. Twenty-six (29%) underwent operative treatment, with transosseous suture fixation being the most popular surgical technique (73%). Of the 64 (71%) non-operatively treated patients, 18 (39%) were placed in a hinged knee brace locked in extension with the remainder split between casting and standard knee immobilizer. Compared to the non-operative cohort, a higher percentage of the operative group had a pre-treatment extensor lag (p < 0.001) and greater fragment displacement (p < 0.001) with patella alta (p < 0.001) on imaging. There was no difference in outcome scores (Pedi-IKDC/Lysholm) or patella alta on radiographs between groups. Post-treatment surveys indicated no difference in residual pain or ability to return to sport. This large case series provides valuable epidemiologic, clinical, and radiographic data describing patellar sleeve fractures, along with outcomes following non-operative and operative treatments. IV.

A Retrospective Review of Patient-reported Outcomes after Postaxial Polydactyly Ligation and Surgical Excision

Background: Interventions for type B postaxial polydactyly include suture ligation and surgical excision, yet there is a paucity of literature comparing the outcomes of these procedures. This study sought to compare patient-reported long-term outcomes of postaxial digit excision. Methods: A six-question survey was distributed from January 2021 to March 2022 to patients who underwent treatment for type B postaxial polydactyly at a single pediatric institution from 2010 to 2016. Patients were queried about the incidence of pain sensitivity, keloid healing, and/or persistent presence of bump (“nubbin”) at the treatment site. Results: A total of 158 responses accounting for 258 digits were attained for a 53% response rate. The majority of digits (67.4%, n = 174) were surgically excised. Median age at procedure was 49 days: 13.0 days for ligation, 63.0 days for surgical excision. Median age at survey was 8 [IQR 5.4–10.2] years. Short-term (&lt;30 days after procedure) complications rate was 1.6%. The rate of a raised or sensitive scar was 39.5% (ligation 51.5% versus surgery 35.4%, P &lt; 0.05). The likelihood of postoperative sensitivity (P = 0.80) was similar among groups. However, the odds of a residual bump or raised scar at the surgical site was significantly higher in the ligation group (P = 0.001). These findings remained significant in the adjusted analysis. Conclusion: This study suggests that suture ligation can be used in select cases without increasing the prevalence of long-term pain or sensitivity, albeit with greater risk of a bump or raised scar at the excision site compared with surgical excision.

Socioeconomic, Racial, and Insurance Disparities in Clinical Outcomes After Surgery Among Patients With Idiopathic Scoliosis.

Socioeconomic status (SES), race, and insurance type correlate with initial curve severity for patients with idiopathic scoliosis, but less is known regarding how these variables impact surgical outcomes. The objectives of this study were to determine the influence of SES, race, and insurance on preoperative appointment attendance, likelihood of obtaining a preoperative second opinion, brace prescription, missed 6 or 12-month postsurgical appointments, incidence of emergency department visits 0 to 90 days after surgery, and major complications within a year of surgery. A review of 421 patients diagnosed with idiopathic scoliosis who underwent surgery at a single high-volume pediatric spinal deformity institution between May 2015 and October 2021 was conducted. Area Deprivation Index, a quantitative measure of SES, was collected. Scores were stratified by quartile; higher scores indicated a lower SES. χ 2 tests for correlation were performed to determine whether clinical outcomes were dependent upon Area Deprivation Index, race, or insurance type; P ≤0.05 was significant. The sample was 313 Caucasian (74%), 69 (16%) black, and 39 (9.3%) other patients. More patients had private versus public insurance (80% vs 20%) and were of higher SES. The likelihood of missing preoperative appointments was higher for black patients ( P = 0.037). Those with lower SES missed more postoperative appointments and received less bracing and second opinions ( P = 0.038, P = 0.017, P = 0.008, respectively). Being black and publicly insured correlated with fewer brace prescriptions ( P < 0.001, P = 0.050) and decreased rates of obtaining second opinions ( P = 0.004, P = 0.001). Patients with idiopathic scoliosis surgery who were Caucasian, privately insured, and of higher SES were more likely to seek preoperative second opinions, be prescribed a brace, and attend postoperative appointments. Recognition of the inherent health care disparities prevalent within each pediatric spine surgery referral region is imperative to better inform local and national institutional level programs to educate and assist patients and families most at risk for disparate access to scoliosis care. Level III; retrospective case-control study.

Recurrent Toe Walking in Pediatric Orthopedic Patients: Idiopathic vs Concomitant Sensory Processing Disorders

Category: Other Introduction/Purpose: The purpose of this study is to compare rates of recurrent toe-walking following operative intervention between idiopathic toe walkers and toe walkers with associated sensory processing/autism spectrum disorders. Methods: An IRB-approved retrospective review of patients at a single pediatric institution who underwent surgical treatment for toe-walking over a 12-year period was conducted. Children with peripheral or central neurologic disorders, muscle disorders, congenital foot/extremity deformities, prior ankle/foot surgery, and those not managed with an isolated triceps surae procedure were excluded. The remaining patients were divided into those with idiopathic toe-walking (ITW Group) and those with toe- walking associated with sensory processing/autism spectrum disorders (SPD Group). Recurrence of toe walking and need for additional surgery for recurrence were compared between cohorts. Recurrence rates and subsequent operations were assessed for each group. Multivariate regression and Fischer exact test were used to evaluate differences in group characteristics. Results: 106 patients met inclusion criteria. 29 patients (27%) had an associated sensory processing disorder, the remaining 77 patients comprised the ITW group. There were no differences between groups in length of follow-up (p=0.08) or type of initial surgery performed (p=0.48). The SPD group contained a significantly greater percentage of males (75% vs 56%, p=0.01) and were younger at the age of index surgery (8.5 vs 10 years, p=0.03). At an average follow-up time of 1.2 years, 11 patients (10%) developed clinical recurrence, of whom, 4 underwent a subsequent intervention. The SPD group had significantly higher rates of recurrence than idiopathic toe walkers (24% vs 5%, p=0.009). Multivariate regression analysis demonstrated that an underlying sensory processing disorder was an independent predictor of recurrence (p=0.018, OR=7.5). Conclusion: Clinical recurrence following the surgical treatment of toe-walking is over seven times greater in children with autism spectrum and/or other sensory processing disorders than idiopathic counterparts.

Outcomes of paediatric septic arthritis patients: rates of re-admission, re-operation, and unplanned emergency room visits after discharge.

This study is aimed at determining the rates and predictors of re-operation and re-admission in children with septic arthritis treated at an institution without routine clinical practice guidelines. This is a retrospective cohort study of patients less than 18 years old who underwent surgery for septic arthritis between January 1, 2009, and January 1, 2019, at a single tertiary-care paediatric institution. Uni- and multivariate analysis was performed to identify any risk factors associated with re-operation or unplanned visits to the emergency department after hospital admission compared to patients who had an uncomplicated post-operative course. One hundred and forty-four patients were included. The mean age was five years (range 1 month-17 years), and the most commonly affected joint was the hip. The re-admission rate was 1% (n = 2), and the re-operation rate was 8% (n = 12). Twenty percent of patients (n = 29) had unplanned presentations to the emergency department (ED) after discharge. Discharge CRP level was not significantly higher in patients with unplanned presentations to the ED or re-operation. Positive joint fluid culture and infection of any other joint than the hip increased the likelihood of re-operation. Patients who had septic arthritis of the hip were more likely to have an unplanned ED presentation. Rates of re-admission and re-operation were similar to literature despite lack of a standardized treatment pathway or discharge protocol. Outcomes of pediatric septic arthritis did not correlate with discharge CRP level. There was a high rate of unplanned ED visits after discharge.

Elective musculoskeletal surgery is associated with postoperative weight changes in pediatric and adolescent patients.

Patients of elective orthopedic surgeries often reduce activity levels during postoperative recovery. It is unclear whether these extended periods of modified activities lead to weight changes. The purpose of this study was to evaluate changes in body mass index percentile in pediatric patients over 2.5 years following primary musculoskeletal surgeries. Institutional records for utilized current procedural terminology codes were used to identify patients aged 21 years or younger who underwent elective surgery at a single pediatric orthopedic institution between October 2016 and December 2018. Non-primary surgeries and patients without preoperative body mass index measurements were excluded. Demographic characteristics, height, weight, and body mass index within 30 months of surgery were collected. Body mass index relative to age was calculated. Analysis of body mass index changes at follow-up intervals of 3-7, 9-18, and 24-30 months after surgery was performed for the overall sample, within surgical categories, and within preoperative weight classifications. A total of 1566 patients (53.1% female, average age 12.4 years) were included. Over one-third of patients were overweight or obese at presentation. The average change in body mass index percentile relative to baseline was increased at all follow-up intervals. Values reached significance at 9-18 months (p = .002) and 24-30 months (p = .001). While underweight and normal-weight patients had increased body mass index at all three timepoints, overweight or obese patients decreased. Patients undergoing elective orthopedic procedures may experience significant changes in body mass index percentile postoperatively. At extremes of weight, patients experience improvement toward the mean, but most patients may undergo body mass index increases beyond what would be expected during normal growth. Retrospective level III.

Spinal Fusion in Patients With Classic Amyoplasia and General Arthrogryposis.

Arthrogryposis multiplex congenita is a group of conditions characterized by joint contractures affecting 2 or more joints. This study describes results of spinal fusion in patients with classic amyoplasia and general arthrogryposis. IRB approved retrospective review of patients with a diagnosis of classic amyoplasia and general arthrogryposis who had a primary definitive posterior spinal fusion between 1990 and 2017 at a single pediatric institution. Patients with distal and syndromic arthrogryposis were excluded as well as patients treated with growth-sparing spinal instrumentation. The Modified Clavien-Dindo-sink (MCDS) classification system was used to describe postoperative complications. Over the 28-year period, 342 patients were diagnosed with amyoplasia and general arthrogryposis. Among the 342 patients, 60 (18%) had scoliosis, and 22 (6% of the cohort and 37% of those with scoliosis) were treated surgically. Six patients had growth-sparing techniques, initial fusion elsewhere, or ˂1 year of follow-up, leaving 15 patients. Of the 15, 9 (60%) had a posterior spinal fusion (PSF) and 6 (40%) had a combined anterior spinal fusion (ASF)/PSF. The ASF/PSF group was significantly younger at surgery, had a greater American Society of Anesthesiologists status, longer surgery duration, and lower implant density. The average preoperative major coronal deformity in ASF/PSF patients (108 degrees) was greater than patients treated with PSF alone (88 deg). There were 11 complications in 7 patients, with the most common being deep infection requiring reoperation (5/11, 45%). There was 1 instance (1/11, 9%) of each: prolonged intensive care unit admission (>72 h), superficial wound dehiscence, symptomatic implants requiring removal/revision, coronal plane progression requiring extension of fusion, recurrent pneumothorax requiring return to OR, and pseudoarthrosis leading to implant failure (without revision). Complications occurred in 1/9 (11%) PSF-only patients and 6/6 (100%) ASF/PSF patients with all 6 ASF/PSF patients requiring at least 1 reoperation. The average coronal correction was 48% in the PSF-only group and 28% in the ASF/PSF group. Complication rates after spinal fusion for scoliosis in arthrogryposis multiplex congenita patients are high, especially in patients undergoing ASF/PSF, deep infection is common, and major coronal plane curve correction is modest. II Retrospective Study.

341 Post-Operative Outcomes and Rare Complications in Pediatric Stereotactic Electroencephalography: A Retrospective Review from a High Volume Pediatric Epilepsy Center

INTRODUCTION: Stereotactic electro-encephalography (sEEG) allows for spatial and temporal localization of epileptic foci for definitive treatment guidance. High volume center studies are more likely to detect rare, although potentially significant complications. METHODS: A retrospective review of 58 sEEG cases performed by a single surgeon at a single pediatric academic institution was performed. Patients &lt;18 years old were included. Patients without 5 years of follow-up were excluded. RESULTS: 25 (49%) of the patients undergoing SEEG were non-lesional on pre-operative imaging. 50 patients (98%) received surgical treatment of their epilepsy following sEEG. 19 underwent open surgical resection of EZ, 16 laser interstitial thermal ablation, 13 responsive neurostimulation, and 1 was treated with DBS. We achieved Engle 1, 2, 3, and 4 level outcomes in 22 (55%), 8 (20%), 5(13%), 5 (13%) of patients respectively. Engle outcome scores were comparable for lesional and non-lesional EZ in patients who underwent resection (Engle 1 outcome in 10/12 and 1/2 respectively) and ablation (6/9 and 6/7, respectively). IPH occurred in 3 cases (5.2%), with only one requiring surgical evacuation. 2 of the 3 hemorrhages caused transient neurologic deficits and the third caused a longstanding hemiparesis. Two (3.4%) cases developed asymptomatic pseudo-aneurysms identified on routine delayed vascular imaging. One was treated successfully with endovascular coiling, however the second was too distal and required surgical clipping. There were no complications from either pseudo-aneurysm treatment. CONCLUSIONS: sEEG offers favorable morbidity, source localization, and seizure control in surgical lesions. We recommend surveillance imaging with CTA or MRA 3-6 months post operatively to rule out pseudoaneurysm formation given.

Robot-assisted Laparoscopic Pyeloplasty: Experience of a Single Pediatric Institution, Including Long-term and Safety Outcomes

To evaluate the efficacy and safety of robot-assisted laparoscopic pyeloplasty (RALP) and describe the short and long-term outcomes of pediatric RALP. We retrospectively reviewed all patients ..±21 years old who underwent primary RALP from 7/2007 through 12/2019. Patients were excluded from postoperative analysis if follow-up data after stent removal was not available. The primary outcome was surgical success, defined as radiographic improvement of hydronephrosis without need for reoperation. Secondary outcomes were time to reoperation and 90-day complication rate. A total of 356 patients underwent primary repair of ureteropelvic junction obstruction during the study period; 29.ßpatients were limited to intraoperative data due to lack of follow-up imaging. Radiographic improvement at latest follow-up was seen in 308/327 (94.2%). Ten of 327 patients (3.1%) underwent reoperation: 7 were identified within 1 year of RALP and 3 were identified over 1 year after RALP. The median time to reoperation was 13.0 months (IQR 9.3-21.7). We defined long-term as>3 years after pyeloplasty. Over one-third (122/327, 37.3%) of the cohort had>3 years of follow-up, none of whom developed evidence of recurrent obstruction requiring reoperation beyond 3 years. Complications occurred within 90 days of surgery in 20/327 (6.1%). This largest single-institution series confirms short- and long-term surgical effectiveness and safety of RALP. Our data also indicate that most patients who needed reoperation were identified within 1 year, and reoperation more than 3 years after RALP is rare.

Robotics Coupled With Navigation for Pediatric Spine Surgery: Initial Intraoperative Experience With 162 Cases.

This study assesses intraoperative efficacy, accuracy, and complications of pedicle screw placement using robotic-assisted navigation (RAN) in pediatric spine surgery. A retrospective review of patients who underwent spine deformity surgery using RAN at a single pediatric institution from 2019 to 2021 was conducted. Patient demographics, perioperative metrics, screw execution and accuracy, technical difficulties, and other outcomes were summarized. In cases with postoperative computed tomography scans, screws were classified using the Gertzbein and Robbins classification scale. Fisher exact tests were used to assess the relationship between procedural changes and lateral screw malposition. One hundred sixty-two cases with an average patient age of 15.1 years (range, 4 to 31y) were reviewed. The most common diagnosis was adolescent idiopathic scoliosis (n=80) with an average major curve of 65 degrees. Of 1467 screws attempted, 1461 were executed successfully (99.6%). All failures were in Type D pedicles and were lateral deviations recognized with routine intraoperative fluoroscopy. In cases with postoperative computed tomography imaging, 100% of screws (n=197) were placed with complete containment (Grade A). Remaining screws were graded as accurate by mirroring fluoroscopy and planned computer software positions. In 4% of cases, loss of registration was detected by a safety check before drilling at the planned level. There were no neurological deficits or returns to the operating room. Two changes occurred as part of the learning curve associated with this technique. (1) Adoption of a high-speed navigated drill: Change 1 (last 74 cases). (2) Drilling all pilot holes robotically first, then placing screws within the robotically established tracts to avoid motion and subsequent registration disruption: Change 2 (last 39 cases). Change 1 was less likely to result in screw malposition as no screws skived lateral with the technique ( P =0.03). Change 2 trended toward statistical significance for avoidance of screw malposition and loss of registration, as no loss of registration occurred after adopting this technique. This study highlights the safety and screw accuracy associated with the use of RAN in pediatric patients. Level III.

Paediatric admissions with SARS-CoV-2 during the Delta and Omicron waves: an Australian single-centre retrospective study

BackgroundThe clinical course of Australian children admitted to hospital with COVID-19 infection is not well understood, particularly over the Omicron period.MethodsThis study describes paediatric admissions to a single tertiary paediatric...

Management of severe scoliosis in patients with Turner's syndrome: A case series

Aims and objectivesThe prevalence and treatment of severe scoliosis and other spinal anomalies in patients with Turner's syndrome (TS) is not well reported. This is the largest case series to date regarding the treatment course and outcomes of severely scoliotic TS patients. MethodsA retrospective chart review was performed to identify all patients with TS seen at a single center academic pediatric institution from 2007 to 2021. Of these, the presence of concomitant severe scoliosis or other spinal anomalies was determined, defined by a major coronal curve measuring 45° or greater. Demographic, clinical, surgical, and radiologic data was collected at both pre- and post-intervention time points. ResultsA retrospective chart review identified 306 patients with TS. Of those, six were identified to have severe scoliosis or other severe spinal anomalies requiring fusion. All four posterior spinal fusion (PSF) patients demonstrated improvement of their spinal curvature. One patient who electively pursued only bracing demonstrated minimal improvement and surgery was subsequently recommended, but not pursued. One patient expired from a pre-existing heart condition prior to intervention. All postoperative complications resolved with no further complications. The only brace-related complication was an allergic rash related to the brace material. ConclusionAll four patients who underwent PSF demonstrated significant improvement of their spinal curvature with few post-surgical complications. None of the patients in the bracing cohort demonstrated stabilization of their spinal curvature. Therefore, these data corroborate with prior studies, suggesting that operative management consisting of spinal fusion with instrumentation provides optimal clinical outcomes, compared to bracing only.

Reducing Opioid Prescriptions after Common Outpatient Pediatric Urologic Surgeries: A Quality Improvement Assessment.

We formally challenged providers at our institution to reduce opioid doses per prescription and administration to patients overall. We performed a retrospective chart review at our single pediatric institution to establish baseline opioid prescribing values from July 2017 to March 2018. We aimed to reduce this value by 50% in 6 months and sustain this decrease throughout the project duration. We performed 1,518 orchiopexies, 1,505 circumcisions, and 531 IHRs. The percent change in the average number of opioid doses prescribed per patient from baseline values assessed to 2021 was statistically significant for orchiopexies (P < 0.0001), IHRs (P < 0.0001), and circumcisions (P < 0.0001). In addition, the change in the percentage of patients prescribed opioids from baseline was statistically significant for all 3 procedures (P < 0.001). This project demonstrated that through an organized quality improvement initiative, the average number of opioid medications prescribed and the total percentage of patients prescribed opioids following common outpatient pediatric urologic procedures can be decreased by at least 50% and sustained through project duration.

1095. Retrospective Review of SARS-CoV-2 Infection in Immunocompromised Children at a Single Pediatric Institution

Abstract Background Immunocompromised individuals are considered higher risk for severe COVID-19 disease. Much of this data was collected from adults with limited pediatric reporting, although a recent study showed no worse outcome in immunocompromised children. In this study, we characterize our experience of immunocompromised children who were hospitalized with acute SARS-CoV-2 infection and aimed to identify a sub-group of patients who had worse outcomes. Methods We reviewed charts of all immunocompromised children hospitalized with SARS-CoV-2 RT-PCR positive results at our hospital from March 2020-April 2022. Disease severity was characterized according to the NIH COVID-19 guidelines. Clinical characteristics and outcomes were assessed. Individuals were grouped into solid organ transplant recipients, solid tumors, liquid tumors, and stem cell transplant recipients. Proportions were calculated per group in addition to the exact binomial confidence intervals (95%). Results We identified 39 pediatric aged patients ranging from 7 months to 20 years of age with a median age of 10. 35.9% (14/39) of individuals were solid organ transplant recipients, 25.6% (10/39) had solid tumors, 33% (13/39) had liquid tumors, and 5% (2/39) were stem cell transplant recipients. 17.9% were asymptomatic, 66.7% had mild disease, and 15.4% had severe/critical COVID-19 disease. The median time of positive SARS CoV-2 RT-PCR was 32 days. Six children had prolonged SARS-CoV-2 RT-PCR positive testing between 29-97 days with a mean of 49 days. Viral strand specific RNA testing for replicating virus was also persistently positive. Six experienced severe/critical disease resulting in death of three. Most of the patients were treated with predominantly T cell depleting agents (∼74%). However, four patients who had prolonged active critical infection were treated with B cell depleting agents or had known B cell dysfunction. Conclusion The majority of the immunocompromised children in our cohort had mild COVID-19 disease. A subset of individuals experienced ongoing prolonged RT-PCR positivity and testing indicating persistent viral replication, with three demonstrating an inability to control the virus and resulting in death. Worse outcomes may be related to their immune dysfunction and use of B cell depleting agents. Disclosures All Authors: No reported disclosures.

Complication Rates in Patients With Classic and Radiographic Variants of Seymour Fractures.

At a tertiary-care, level 1 pediatric trauma center, we have observed fractures of the distal phalanx involving the physis, with associated nail bed injuries, that are distinct from the classic description of the Seymour fracture. We investigated the time to definitive management and the associated morbidity of these Seymour fracture variants compared with classically described Seymour fractures. We hypothesize that these Seymour variants are similarly problematic in terms of complications and delays to the definitive treatment and thus warrant increased awareness. A retrospective chart review was performed of all patients with distal phalanx fractures involving the physis and associated nail bed injuries that were treated with operative intervention at a single pediatric specialty institution over a 9-year period. Radiographs and clinical photographs were reviewed to determine if the patient presented with a classic Seymour fracture or variant. Primary outcomes included time from injury to definitive treatment and complication rate. Of the 66 Seymour fractures identified in the chart review, 36 (55%) were identified as classic Seymour fractures and 30 (45%) were identified as variants. The mean time to operative intervention in the classic and variant groups was 7.3 versus 12.7 days (P=0.216). The complication rates in the classic and variant groups were 11.1% versus 23.3% (P=0.185), with infections accounting for nearly all complications identified. Overall infection rates for the classic and variant cohorts were 8.3% and 20.0% (P=0.169), respectively, with the majority presenting preoperatively (5.6% vs. 13.3%, P=0.274). We found that patients with classic Seymour fractures or radiographic variants had statistically similar incidence rates, complication rates, and delays in treatment, with a trend towards higher complication rates and delayed time to treatment in patients with variant-type injuries. We propose a minor expansion of the definition of Seymour fractures to include common variants to increase awareness of these problematic injuries, minimize delays in treatment, and decrease complications. Level III; Retrospective Comparative Study.