Bairdain Sigrid, Dodson Brenda, Zurakowski David, Rhein Lawrence, Snyder Brian D, Putman Melissa, Jennings Russell W
Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
Department of Pharmacy, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
Bone Rep. 2015 Jun 14;3:1-4. doi: 10.1016/j.bonr.2015.06.002. eCollection 2015 Dec.
To identify factors associated with an increased risk of fractures in Long-Gap Esophageal Atresia (LGEA) patients. Following implementation of a risk-stratified program, we hypothesized a reduction in fracture incidence within this potentially high-risk population.
A retrospective review of LGEA-patients admitted between 2005 and 2014 was conducted. Symptomatic fractures with radiographic confirmation were defined as events. Univariate and multivariable analysis evaluated factors including admission weight-for-age z-score, primary versus secondary Foker process (FP), weight at Foker Stage I, days and episodes of paralysis, number of parenteral nutrition (PN) days, cumulative dose of loop diuretics adjusted for body weight and days exposed, and exposure to non-loop diuretics. A fracture-prevention protocol was initiated in 2012; incidence was evaluated pre and post-intervention.
Fifty-nine patients met inclusion criteria. Twenty-three (39%) patients in the entire cohort incurred at least one fracture during their hospitalization utilizing the Foker process. Given this high percentage, a targeted fracture-prevention protocol was initiated in 2012. Fracture incidence decreased from 48% prior to the protocol to 21% following the protocol ( = 0.046). Several variables that were associated with an increased risk of fractures on univariate analysis included prior esophageal anastomosis attempt ( = 0.008), number of separate episodes of paralysis ( = 0.002), exposure to non-loop diuretics ( = 0.006), cumulative loop diuretic dose ( < 0.001), as well as cumulative loop diuretic over days exposed ( < 0.001). Intensive care unit (ICU) stay ( = 0.002) and total length of hospitalization ( < 0.001) were also significantly longer among patients with a fracture. Number of separate episodes of paralysis was the only independent risk factor for the development of a fracture; patients having more than 3 episodes of paralysis had an estimated risk of fracture 15 times higher than those patients paralyzed only once or twice (O.R. 15.87, 95% C.I.: 1.47-171.23, = 0.008).
Episodes of paralysis appeared to be the most significant risk factor for fractures in patients with LGEA who underwent the Foker procedure. The incidence of symptomatic fractures decreased significantly following implementation of a standardized protocol in this series of LGEA patients with continued prospective evaluation.
确定与长段食管闭锁（LGEA）患者骨折风险增加相关的因素。在实施风险分层计划后，我们假设该潜在高风险人群的骨折发生率会降低。
对2005年至2014年期间收治的LGEA患者进行回顾性研究。将经影像学证实的有症状骨折定义为事件。单因素和多因素分析评估的因素包括入院时年龄别体重Z评分、初次与二次Foker手术（FP）、Foker I期体重、麻痹天数和发作次数、肠外营养（PN）天数、根据体重和暴露天数调整的襻利尿剂累积剂量以及非襻利尿剂暴露情况。2012年启动了骨折预防方案；对干预前后的发生率进行了评估。
59例患者符合纳入标准。在整个队列中，23例（39%）患者在接受Foker手术住院期间至少发生了一次骨折。鉴于这一高比例，2012年启动了针对性的骨折预防方案。骨折发生率从方案实施前的48%降至方案实施后的21%（P = 0.046）。单因素分析中与骨折风险增加相关的几个变量包括先前的食管吻合术尝试（P = 0.008）、单独的麻痹发作次数（P = 0.002）、非襻利尿剂暴露（P = 0.006）、襻利尿剂累积剂量（P < 0.001）以及襻利尿剂暴露天数的累积量（P < 0.001）。骨折患者的重症监护病房（ICU）住院时间（P = 0.002）和总住院时间（P < 0.001）也显著更长。单独的麻痹发作次数是骨折发生的唯一独立危险因素；麻痹发作超过3次的患者骨折风险估计比仅麻痹1次或2次的患者高15倍（比值比15.87，95%置信区间：1.47 - 171.23，P = 0.008）。
对于接受Foker手术的LGEA患者，麻痹发作似乎是骨折的最重要危险因素。在这一系列LGEA患者中实施标准化方案并持续进行前瞻性评估后，有症状骨折的发生率显著降低。
