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Introduction: Dog bites are a unique and unusual injury in children, associated with atypical bacterial species, high infection rates, and controversial surgical treatment. Expert recommendations currently guide management and no surgical evidence-based guidelines exist. We conducted a systematic review to answer three management questions: (1) What are the best practices for wound management? (2) In what circumstances should prophylactic antibiotics be administered? (3) In what circumstances should rabies prophylaxis be given?, Methods: A structured review was performed using a keyword search querying "pediatric" "dog bite" "management". Results were reported according to the PRISMA methodology. The quality of nonrandomized studies was evaluated according to Methodological Index for Non-Randomized Studies (MINORS). Qualitative analysis was performed., Results: A total of 803 studies were identified and 53 studies were included in the final analysis. Current literature suggests that primary closure of bites which are well irrigated and sharply debrided within 8 h of injury, is not associated with increased infection. While dog bites are associated with an overall high rate of infection (6-25 %), routine antibiotic prophylaxis in low-risk wounds does not lower that risk. Postexposure prophylaxis for rabies is indicated for all dog bites where the rabies status of the dog cannot be determined, or the animal cannot be quarantined for 10 days., Conclusion: High-quality evidence regarding the surgical management of pediatric dog bites is limited. Trial data have demonstrated improved outcomes in wound healing and infection rates with a focus on copious irrigation and diligent wound debridement, although independent validation is needed., Level of Evidence: Level II - systematic review., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Ultrashort bowel syndrome is a rare, but morbid surgical problem without effective treatment. Recent clinical analysis has demonstrated the critical influence of ileal length on ultimate enteral autonomy. Surgical techniques to increase ileal length in nondilated bowel do not exist. We describe a novel technique to lengthen ileum in children with ultrashort bowel syndrome., Methods: Beginning in May 2021 prospective candidate children were identified. Candidacy for ileal tube lengthening included diagnosis of ultrashort bowel syndrome, intact ileocecal valve with remnant ileum, and proximal intestinal stoma or draining gastrostomy. Informed consent was obtained. Following laparoscopic lysis of adhesions, a balloon catheter was inserted through a left flank stab incision and into the lumen of the remnant ileum around a purse string suture. Cecopexy was performed in the right-lower quadrant. Clips were used to mark the cecum and the proximal extent of ileum. The catheter length was fixed externally at the completion of the procedure. Serial x-rays were used to measure distraction effect while increasing tension was applied to the catheter over the subsequent weeks. Ileal tube lengthening was performed until the end of the catheter was reached or the tube was dislodged. A contrast study was performed at the completion of lengthening. Intestinal length at time of restoration of continuity and clinical outcomes were recorded., Results: Four infants were enrolled from May 2021-July 2023. Diagnoses leading to ultrashort bowel syndrome were mesenteric teratoma, necrotizing enterocolitis, and multiple intestinal atresia. At the time of restoration of intestinal continuity, a median of 1.75 cm (45 %) additional ileal length was achieved at a median of 25.5 days. There were no serious complications following ileal tube lengthening and no additional operative interventions were required., Conclusions: Ileal lengthening through internal distraction is a feasible surgical intervention to salvage ileum for infants with ultrashort bowel syndrome. Ileal tube lengthening may result in distraction enterogenesis, providing a novel intervention to increase intestinal length., Level of Evidence: IV (Case series without comparison group).

Background: External Oblique Intercostal (EOI) fascial plane blockade is a relatively new regional anesthetic technique used for a variety of upper abdominal surgical procedures. Proponents of this block praise its simple sonoanatomy, extensive local anesthetic (LA) spread, and ease of catheter placement, while avoiding encroachment into the surgical field or dressing sites; nevertheless, it is underutilized in pediatric surgery. Kasai portoenterostomy is a common pediatric surgical procedure for biliary atresia typically done via an open abdominal approach with an extended subcostal incision. Postoperative analgesic management with epidural anesthetic techniques are considered but may be limited by periprocedural coagulopathy concerns., Case Presentation: We present a case of a neonate who underwent successful analgesic management of Kasai portoenterostomy with bilateral EOI block catheters. Opioid consumption and other postoperative outcomes were comparative to previously reported literature of epidural analgesia in this patient population., Conclusions: The purpose of this report is to describe the outcomes and technical approach in a neonate who received EOI blocks as an alternative to epidural anesthetic management. Further studies are needed to compare the efficacy and complication rate of EOI blockade to epidural analgesia for Kasai portoenterostomy surgery., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: A paucity of data exists with regard to the incidence, management, and outcomes of venous thromboembolism (VTE) in injured children. We sought to determine the impact of institutional chemoprophylaxis guidelines on VTE rates in a pediatric trauma population., Methods: A retrospective review of injured children (≤15 years) admitted between 2009 and 2018 at 10 pediatric trauma centers was performed. Data were gathered from institutional trauma registries and dedicated chart review. The institutions were surveyed as to whether they had chemoprophylaxis guidelines in place for high-risk pediatric trauma patients, and outcomes were compared based on the presence of guidelines using χ 2 analysis ( p < 0.05)., Results: There were 45,202 patients evaluated during the study period. Three institutions (28,359 patients, 63%) had established chemoprophylaxis policies during the study period ("Guidelines"); the other seven centers (16,843 patients, 37%) had no such guidelines ("Standard"). There were significantly lower rates of VTE in the Guidelines group, but these patients also had significantly fewer risk factors. Among critically injured children with similar clinical presentations, there was no difference in VTE rate. Specifically within the Guidelines group, 30 children developed VTE. The majority (17/30) were actually not indicated for chemoprophylaxis based on institutional guidelines. Still, despite protocols only one VTE patient in the guidelines group who was indicated for intervention ended up receiving chemoprophylaxis prior to diagnosis. No consistent ultrasound screening protocol was in place at any institution during the study., Conclusion: The presence of an institutional policy to guide chemoprophylaxis for injured children is associated with a decreased overall frequency of VTE, but this disappears when controlling for patient factors. However, the overall efficacy is impacted by a combination of deficits in guideline compliance and structure. Further prospective data are needed to help determine the ideal role for chemoprophylaxis and protocols in pediatric trauma., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: United States landfill waste generated in the operating room (OR) is estimated to be three billion tons per year. The goal of this study was to analyze the environmental and fiscal impact of right-sizing surgical supplies at a medium-sized children's hospital using lean methodology to reduce physical waste generated in the operating room., Methods: A multidisciplinary task force was created to reduce waste in the OR of an academic children's hospital. A single-center case study, proof-of-concept, and scalability analysis of operative waste reduction was performed. Surgical packs were identified as a target. Pack utilization was monitored during an initial pilot analysis for 12 d then followed by a focused 3-week period, capturing all unused items by participating surgical services. Items discarded in more than 85% of cases were excluded in subsequent preformed packs., Results: Pilot review identified 46 items in 113 procedures for removal from surgical packs. Subsequent 3-week analysis focusing on two surgical services, and 359 procedures identified a potential $1,111.88 savings with elimination of minimally used items. Over 1 y, removal of all minimally used items from seven surgical services diverted two tons of plastic landfill waste, saved $27,503 in surgical pack acquisition-costs, and prevented the theoretical loss of $13,824 in wasted supplies. Additional purchasing analysis has resulted in another $70,000 of savings through supply chain streamlining. Application of this process nationally could prevent >6000 tons of waste in the United States per year., Conclusions: Application of a simple iterative process to reduce waste in the OR can result in substantial waste diversion and cost savings. Broad adoption of such a process to reduce OR waste could greatly reduce the environmental impact of surgical care., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Per-oral endoscopic myotomy (POEM) has is an alternative treatment to laparoscopic Heller myotomy for children with achalasia. The EndoFLIP functional luminal imaging system is used to measure esophagogastric junction (EGJ) distensibility pre- and post-POEM. Previous adult studies have established a correlation between obstructive symptoms and Distensibility Index (DI). Here we analyze the utility of EndoFLIP in diagnosis and management of achalasia in the largest study on pediatric POEM patients and hypothesize that DI may aid diagnosis and treatment of pediatric achalasia., Methods: Demographics, preoperative basal and residual pressures measured on manometry, and EndoFLIP measurements pre- and post-POEM were recorded for children that underwent POEM. Pearson correlation coefficient and T-scores were used to assess for correlation between manometry measurements and pre-POEM DI. Linear regression was conducted to analyze the relationship between pre-POEM DI, Eckardt scores, and manometry pressures., Results: Of 33 patients that underwent POEM and EndoFLIP since 2014 (21 male, 12 female), the median pre-POEM Eckardt score decreased from 7 to 1 post-POEM. The median basal pressure was 50 ± 25 mmHg, pre-POEM DI was 0.9 (0.8-1.6) mm 2 /mmHg and the post-POEM DI was 3.8 (3.2-4.4) mm 2 /mmHg. There was no correlation between DI and basal pressure or residual pressure, though there was a strong negative correlation between Eckardt scores and DI., Conclusion: The EndoFLIP system is a valuable tool in adult patients in diagnosing achalasia and defining the endpoint of the POEM procedure. We find that there is a role for EndoFLIP in the pediatric population in diagnosis and management of the disease., Type of Study & Level of Evidence: Study of diagnostic test; Level IV., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: This prospective observational cohort study evaluates risk-stratified venous thromboembolism (VTE) screening in injured children. While the reported incidence of VTE is 6% to 10% among critically injured children, there is no standard for screening. Venous thromboembolism may have long-term sequelae in children, including postthrombotic syndrome., Methods: Patients admitted to a level 1 pediatric trauma center were risk stratified for VTE using a validated prediction algorithm. Children at high risk (risk scores ≥523; i.e., ≥1% risk) received screening duplex ultrasonography. Children at moderate risk (risk scores 410-522; i.e., 0.3-0.99% risk) were screened as a comparison/control., Results: Three-hundred fifty-five children were consecutively risk stratified from October 2019 to May 2021. Forty-seven children received screening duplex ultrasounds: 21 from a high-risk cohort and 26 from a moderate-risk cohort. Four children were diagnosed with VTE in the high-risk cohort compared with seven in the moderate-risk cohort ( p = 0.53). Total incidence of VTE among screened children was 23.4% (11 of 47). Asymptomatic VTE accounted for 81.8% of all events (9 of 11). Fifty-four percent (6 of 11) of VTE were central venous catheter associated. Venous thromboembolism in surviving children resolved by 3 to 6 months with no symptoms of postthrombotic syndrome after 1 year. No cases of VTE were identified in unscreened children, yielding an institutional VTE incidence of 3.1% (11 of 355)., Discussion: Risk-stratified screening demonstrates a significant incidence of asymptomatic VTE in injured children. These results may guide reevaluation of prediction algorithms developed from symptomatic VTE risk and longitudinal study of the sequelae of asymptomatic VTE., Level of Evidence: Prognostic and Epidemiological; Level III., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Lean methodology is frequently utilized in high income settings to maximize capacity and operational efficiency during process improvement (PI) initiatives. To date there has been little published on the application of these techniques in low- and-middle-income countries (LMIC) despite the potential benefits in resource limited settings. We describe a pilot project developed in 2018 to promote sustainable operating theater efficiency at two hospitals in Abuja, Nigeria. This study details the first known attempt to use Lean techniques to improve surgical care systems in LMIC., Methods: Perioperative committees were established at two Nigerian institutions to evaluate current processes, identify problems, and compile a list of priorities. A physician champion and a PI specialist in conjunction with local physician-partners held a workshop to teach practical applications of PI methodology as part of an ongoing collaboration. Pre and post-workshop surveys were administered, and theme coding was used to categorize free responses. Results were compared with a chi-square test., Results: In total, 42 individuals attended the PI workshop. After the workshop, 37 respondents reported the workshop as valuable both personally and for the perioperative committee (P < 0.001), and all reported that PI methodology could benefit the institution overall., Conclusions: By identifying stakeholders, holding a workshop to teach tools of PI, and establishing a committee for ongoing improvement, it is possible to implement quality improvement techniques at LMIC hospitals, which may be of future benefit. Sustainability in this project will be facilitated by tele mentoring, and future efforts include expansion beyond the perioperative setting., (Copyright © 2021. Published by Elsevier Inc.)

Background: Venous thromboembolism (VTE) in injured children is rare, but its consequences are significant. Several risk stratification algorithms for VTE in pediatric trauma exist with little consensus, and all are hindered in development by relying on registry data with known inaccuracies. We performed a multicenter review to evaluate trauma registry fidelity and confirm the effectiveness of one established algorithm across diverse centers., Methods: Local trauma registries at 10 institutions were queried for all patients younger than 18 years admitted between 2009 and 2018. Additional chart review was performed on all "VTE" cases and random non-VTE controls to assess registry errors. Corrected data were then applied to our prediction algorithm using 10 real-time variables (Glasgow Coma Scale, age, sex, intensive care unit admission, transfusion, central line placement, lower extremity/pelvic fracture, major surgery) to calculate VTE risk scores. Contingency table classifiers and the area under a receiver operator characteristic curve were calculated., Results: Registries identified 52,524 pediatric trauma patients with 99 episodes of VTE; however, chart review found that 13 cases were misclassified for a corrected total of 86 cases (0.16%). After correction, the algorithm still displayed strong performance in discriminating VTE-fated encounters (sensitivity, 69%; area under the receiver operating characteristic curve, 0.96). Furthermore, despite wide institutional variability in VTE rates (0.04-1.7%), the algorithm maintained a specificity of >91% and a negative predictive value of >99.7% across centers. Chart review also revealed that 54% (n = 45) of VTEs were directly associated with a central line, usually femoral (n = 34, p < 0.001 compared with upper extremity), and that prophylaxis rates were underreported in the registries by about 50%; still, only 19% of the VTE cases had been on prophylaxis before diagnosis., Conclusion: The VTE prediction algorithm performed well when applied retrospectively across 10 diverse pediatric centers using corrected registry data. These findings can advance initiatives for VTE screening/prophylaxis guidance following pediatric trauma and warrant prospective study., Level of Evidence: Clinical decision rule evaluated in a single population, level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Following the shooting at Sandy Hook Elementary School, the Hartford Consensus produced the Stop the Bleed program to train bystanders in hemorrhage control. In our region, the police bureau delivers critical incident training to public schools, offering instruction in responding to violent or dangerous situations. Until now, widespread training in hemorrhage control has been lacking. Our group developed, implemented and evaluated a novel program integrating hemorrhage control into critical incident training for school staff in order to blunt the impact of mass casualty events on children., Methods: The staff of 25 elementary and middle schools attended a 90-minute course incorporating Stop the Bleed into the critical incident training curriculum, delivered on-site by police officers, nurses and doctors over a three-day period. The joint program was named Protect Our Kids. At the conclusion of the course, hemorrhage control kits and educational materials were provided and a four-question survey to assess the quality of training using a ten-point Likert scale was completed by participants and trainers., Results: One thousand eighteen educators underwent training. A majority were teachers (78.2%), followed by para-educators (5.8%), counselors (4.4%) and principals (2%). Widely covered by local and state media, the Protect Our Kids program was rated as excellent and effective by a majority of trainees and all trainers rated the program as excellent., Conclusions: Through collaboration between trauma centers, police and school systems, a large-scale training program for hemorrhage control and critical incident response can be effectively delivered to schools., (© 2021. The Author(s).)

Background: Prolonged emergency department length of stay in trauma patients is associated with increased hospital length of stay and inhospital mortality. This problem is compounded in pediatric patients, as injured children have less physiologic reserve and may exhibit only subtle warning signs before decompensation., Objective: To determine the impact of deploying pediatric rapid response nurses to full trauma activations for patients transferred to the pediatric intensive care unit on emergency department length of stay., Methods: This is a before-and-after analysis of a quality improvement initiative deploying pediatric rapid response nurses to full trauma activations. Trauma registry data collected from January 2016 to August 2020 were statistically analyzed. Demographic and outcome variables were assessed by unpaired t test and χ2 analysis., Results: A total of 94 patients met inclusion criteria as full activations admitted to the intensive care unit during the study period. The preimplementation group (n = 60) was 88% (n = 53) male, with a median age of 6.9 years and a median Injury Severity Score of 21. The postimplementation group (n = 34) was 62% (n = 21) male, with a median age of 5.6 years and a median Injury Severity Score of 17. The emergency department length of stay decreased from median (interquartile range) 48.5 (36.0-84.75) min (preimplementation) to 36.5 (27.5-55.5) min (postimplementation; p = .019)., Conclusion: Deployment of pediatric rapid response nurses to full trauma activations facilitates the assessment and transfer of pediatric trauma to the intensive care unit and decreases emergency department length of stay., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Society of Trauma Nurses.)

Background: The purpose of this study was to provide an evaluation of a performance improvement initiative that operationalized universal concussion screening for all pediatric trauma admissions at a Level I pediatric trauma center. Mild traumatic brain injury may be difficult to identify in injured children. We implemented a screening tool to identify the risk for concussion after traumatic injury and to improve access to cognitive evaluation and intervention in children. Prior to implementation of our screening tool, children admitted without obvious head injury or those younger than 12 years were not being screened for concussion risk., Methods: We employed a nurse-driven screening tool, derived from the Centers for Disease Control and Prevention Acute Concussion Evaluation, on all pediatric trauma patients ages 0-17 years. The screening tool identifies symptoms of physical, cognitive, sleep, or emotional deficits and prompts a cognitive evaluation with concussion education. The tool was administered by nursing and tracked in the electronic medical record., Results: Key stakeholders were interviewed to identify workflow barriers and education gaps following implementation. Enhancements to the electronic medical record and refocused nursing education improved compliance from 41% in the first 12 months to 91% at 24 months post-implementation (p < .001). The increasing number of evaluations additionally resulted in overall more cognitive evaluations as an initial step in identifying and treating previously unrecognized traumatic brain injury., Conclusions: A pediatric concussion screening tool is simple to administer, applies to all developmental ages, and improves diagnostic capture of traumatic brain injury in pediatric trauma when administered by nurses with support through the electronic medical record., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Society of Trauma Nurses.)

Purpose: Current literature regarding outcomes of gastroschisis closure methods do not highlight differences in patients who successfully undergo primary closure with those who fail and require silo placement. We hypothesize that failure of primary closure has significant effects on clinical outcomes such as length of stay and time to enteral feeding., Methods: We conducted a retrospective review between 2009 and 2018 of gastroschisis patients at a tertiary pediatric referral hospital. We compared patients successfully undergoing primary closure to patients who failed an initial primary closure attempt. Bivariate and multivariate linear regression models were used to assess the association of closure method on clinical outcomes., Results: Sixty-eight neonates were included for analysis, with 44 patients who underwent primary closure and 24 who failed primary closure. On multivariate regression analysis, primary closure patients had shorter estimated time to starting and to full enteral feeds and decreased LOS as compared to those who failed primary closure. Two patients (4.44%) had complications related to primary closure., Conclusion: Patients able to undergo primary closure for gastroschisis were more likely to have a shorter length of stay, shorter time to enteral feeds, and use much fewer medical resources. Initial primary closure is a safe method for most patients.

Background: Employing an institutional initiative to minimize variance in pediatric surgical care, we implemented a set of perioperative bundled interventions for all colorectal procedures to reduce surgical site infections (SSIs)., Methods: Implementation of a standard colon bundle at two children's hospitals began in December 2014. Subjects who underwent a colorectal procedure during the study period were analyzed. Demographics, outcomes, and complications were compared with Wilcoxon Rank-Sum, Chi-square and Fisher exact tests, as appropriate. Multivariable logistic regression was performed to assess the influence of time period (independent of protocol implementation) on the rate of subsequent infection., Results: One hundred and forty-five patients were identified (preprotocol=68, postprotocol= 77). Gender, diagnosis, procedure performed and wound classification were similar between groups. Superficial SSIs (21% vs. 8%, p=0.031) and readmission (16% vs. 4%, p=0.021) were significantly decreased following implementation of a colon bundle. Median hospital days, cost, reoperation, intraabdominal abscess, and anastomotic leak were unchanged before and after protocol implementation (all p > 0.05). Multivariable logistic regression found time period to be independent of SSIs (OR: 0.810, 95% CI: 0.576-1.140)., Conclusion: Implementation of a standard pediatric perioperative colon bundle can reduce superficial SSIs. Larger prospective studies are needed to evaluate the impact of colon bundles in reducing complications, hospital stay and cost., Level of Evidence: III - Retrospective cohort study., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Significant variability exists in the triage of injured children with most systems using mechanism of injury and/or physiologic criteria. It is not well established if existing triage criteria predict the need for intervention or impact morbidity and mortality. This study evaluated existing evidence for pediatric trauma triage. Questions defined a priori were as follows: (1) Do prehospital trauma triage criteria reduce mortality? (2) Do prehospital trauma scoring systems predict outcomes? (3) Do trauma center activation criteria predict outcomes? (4) Do trauma center activation criteria predict need for procedural or operative interventions? (5) Do trauma bay pediatric trauma scoring systems predict outcomes? (6) What secondary triage criteria for transfer of children exist?, Methods: A structured, systematic review was conducted, and multiple databases were queried using search terms related to pediatric trauma triage. The literature search was limited to January 1990 to August 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was applied with the methodological index for nonrandomized studies tool used to assess the quality of included studies. Qualitative analysis was performed., Results: A total of 1,752 articles were screened, and 38 were included in the qualitative analysis. Twelve articles addressed questions 1 and 2, 21 articles addressed question 3 to 5, and five articles addressed question 6. Existing literature suggest that prehospital triage criteria or scoring systems do not predict or reduce mortality, although selected physiologic parameters may. In contrast, hospital trauma activation criteria can predict the need for procedures or surgical intervention and identify patients with higher mortality; again, physiologic signs are more predictive than mechanism of injury. Currently, no standardized secondary triage/transfer protocols exist., Conclusion: Evidence supporting the utility of prehospital triage criteria for injured children is insufficient, while physiology-based trauma system activation criteria do appropriately stratify injured children. The absence of strong evidence supports the need for further prehospital and secondary transfer triage-related research., Level of Evidence: Systematic review study, level II.

Background: The infectious risk of central venous line (CVL) placement in children with neutropenia (absolute neutrophil count [ANC] <500/mm 3 ) is not well defined. This study aims to investigate the early (≤30 days) and late (>30 days) infectious complications of CVLs placed in pediatric patients with and without neutropenia., Methods: A retrospective review was conducted of all CVLs placed by pediatric surgeons at two institutions from 2010 to 2017. Multivariable logistic regression was performed to identify risk factors for line infection. Propensity score-matched cohorts of patients with and without neutropenia were compared in a 1:1 ratio. Wilcoxon rank-sum, Chi-square, Fisher's exact, and log-rank tests were also performed., Results: Review identified 1,102 CVLs placed in 937 patients. Fifty-four patients were neutropenic at the time of placement. Multivariable analysis demonstrated tunneled catheters and subclavian access as associated with line infection. The propensity score-matched cohort included 94 patients, 47 from each group. Demographic and preoperative data were similar between the groups (p > 0.05). Patients with neutropenia were no more likely to develop early (4.3% vs. 2.1%, p = 1.000) or late (19.1% vs. 17.0%, p = 1.000) infectious complications than patients without neutropenia, with similar median time to infection (141 vs. 222 days, p = 0.370)., Conclusion: A policy of selective CVL placement in neutropenic patients with standardized postoperative line maintenance is safe. Future directions include defining criteria by which neutropenic patients could be prospectively selected for safe CVL placement., Level of Evidence: II - Retrospective cohort study., Competing Interests: Conflict of interest The following authors have no financial disclosures: AJC, KVM, ED, SK, MWB, DN, MCH, NAH., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background/purpose: The purpose of this study was to characterize current practices to prevent venous thromboembolism (VTE) in children and measure adherence to recent joint consensus guidelines from the Pediatric Trauma Society and Eastern Association for the Surgery of Trauma (PTS/EAST)., Methods: An 18-question survey was sent to the membership of PTS and the Trauma Center Association of American. Responses were compared with Chi-square test., Results: One hundred twenty-nine members completed the survey. Most respondents were from academic (84.5%), Level 1 pediatric (62.0%) trauma centers. Criteria for VTE prophylaxis varied between hospitals with freestanding pediatric trauma centers significantly more likely to stratify children by risk factors than adult trauma centers (p = 0.020). While awareness of PTS/EAST guidelines (58.7% overall) was not statistically different between hospital types (44% freestanding adult, 52% freestanding pediatric, 71% combined adult pediatric, p = 0.131), self-reported adherence to these guidelines was uniformly low at 37.2% for all respondents. Lastly, in three clinical scenarios, respondents chose VTE screening and prophylaxis plans in accordance with a prospective application of PTS/EAST guidelines 55.0% correctly., Conclusion: Currently no consensus regarding the prevention of VTE in pediatric trauma exists. Prospective application of PTS/EAST guidelines has been limited, likely due to poor quality of evidence and a reliance on post-injury metrics. Results of this survey suggest that further investigation is needed to more clearly define the risk of VTE in children, evaluate, and prospectively validate alternative scoring systems for VTE prevention in injured children., Level of Evidence: N/A-Survey.

Background/purpose: Rare life-threatening complications after central venous line (CVL) placement in children may encourage the routine use of postoperative imaging, despite multiple studies demonstrating the limited utility of this practice. The aim of this study was to investigate the nature of this discordance., Methods: A 10-question survey was sent to 1,239 members of the American Pediatric Surgical Association (APSA) addressing contemporary practices regarding CVL placement and postoperative imaging., Results: Five hundred eighteen (42%) surveys were completed. The majority of respondents routinely obtain a chest radiograph (CXR) after image-guided CVL placement (52%). Years in practice, operative volume, and practice type were not statistically associated with postoperative CXR usage (all p > 0.05). 'Routine' users were more likely to cite "standard of care" (p < 0.001), position verification (p < 0.001), and complication identification (p < 0.001) as indications for use than those who use CXR selectively., Conclusion: Routine use of postoperative CXR after image-guided CVL placement remains common among pediatric surgeons. Significant variation exists in the indication for this study, with considerable disagreement between 'selective' and 'routine' users. Consideration should be given for an APSA standardized guideline utilizing a clinically-driven approach to CVL placement and postoperative imaging to align with evidence-based practice., Level of Evidence: N/A - descriptive analysis of survey results., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: We sought to validate a risk model to predict venous thromboembolism (VTE) in pediatric trauma through an analysis of a contemporary cohort in the National Trauma Data Bank (NTDB)., Study Design: Prospective internal validation was performed in 10 randomly stratified samples of children (age 0-17 years) from the NTDB 2013-2016. Model discrimination was determined by calculation of the c-statistic (AUC), and calibration was evaluated through analysis of observed to expected (O:E) ratio. Recalibration was performed with application of a mixed-effects logistic regression. Model parameters were reestimated based on recalibration., Results: Retrospective review identified 481,485 pediatric trauma patients with 729 (0.2%) episodes of VTE. Discriminatory ability of the model in all random cohorts was significant with AUC > 0.93 (p < 0.001). Inadequate calibration was noted in 4 of 10 cohorts and the entire dataset (p < 0.001) with an O:E ratio of 1.79. Model recalibration resulted in similar discrimination (AUC = 0.95) with improved calibration (O:E ratio = 1.33, p < 0.0001)., Conclusion: Pediatric trauma prediction models can provide useful data for VTE risk stratification in injured children, but these models must be validated and calibrated prior to use. Recalibration of the model in question resulted in improved accuracy in a contemporary NTDB dataset. These data provide an appropriately calibrated and validated model for clinical use., Level of Evidence: II - Prospective internal validation of a multivariable prediction model., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: We describe an institutional program (INR- Interval NSQIP Review), to augment NSQIP utility through structured, multidisciplinary review of surgical outcomes in order to create near 'real-time' adverse event (AE) monitoring and improve surgeon awareness., Methods: INR is a monthly meeting of quality analysts, surgeons and nursing leadership initiated to validate AE with NSQIP criteria, review data in real-time, and perform in-depth case analyses. Occurrence classification concerns were referred for national NSQIP review. Monthly reports were distributed to surgeons with AE rates and case-specific details., Results: Since implementation, 377/3,026 AE underwent in-depth review. Of those, 7 occurrences were referred for clarification by central NSQIP review. Overall 37 (1.2%) were not consistent with NSQIP-defined AE after INR. Time from occurrence to surgeon review decreased by 223 days (296 vs. 73 days, p = 0.006)., Discussion: Structured monthly institutional review of AE prior to submission can create greater transparency and confidence of NSQIP data, reduce time from occurrence to surgeon recognition, and improve stakeholder understanding of AE definitions. This approach can be tailored to institutional needs and should be evaluated for downstream improvement in patient outcomes., Competing Interests: Declaration of competing interest The following authors have no financial disclosures: AC, BH, SP, SK, EH, ST, JF, KA., (Copyright © 2020. Published by Elsevier Inc.)

Background: Image-guided percutaneous core needle biopsy (PCNB) is increasingly utilized to diagnose solid tumors. The objective of this study is to determine whether PCNB is adequate for modern biologic characterization of neuroblastoma., Procedure: A multi-institutional retrospective study was performed by the Pediatric Surgical Oncology Research Collaborative on children with neuroblastoma at 12 institutions over a 3-year period. Data collected included demographics, clinical details, biopsy technique, complications, and adequacy of biopsies for cytogenetic markers utilized by the Children's Oncology Group for risk stratification., Results: A total of 243 children were identified with a diagnosis of neuroblastoma: 79 (32.5%) tumor excision at diagnosis, 94 (38.7%) open incisional biopsy (IB), and 70 (28.8%) PCNB. Compared to IB, there was no significant difference in ability to accurately obtain a primary diagnosis by PCNB (95.7% vs 98.9%, P = .314) or determine MYCN copy number (92.4% vs 97.8%, P = .111). The yield for loss of heterozygosity and tumor ploidy was lower with PCNB versus IB (56.1% vs 90.9%, P < .05; and 58.0% vs. 88.5%, P < .05). Complications did not differ between groups (2.9 % vs 3.3%, P = 1.000), though the PCNB group had fewer blood transfusions and lower opioid usage. Efficacy of PCNB was improved for loss of heterozygosity when a pediatric pathologist evaluated the fresh specimen for adequacy., Conclusions: PCNB is a less invasive alternative to open biopsy for primary diagnosis and MYCN oncogene status in patients with neuroblastoma. Our data suggest that PCNB could be optimized for complete genetic analysis by standardized protocols and real-time pathology assessment of specimen quality., (© 2020 Wiley Periodicals, Inc.)

Background: The aim of this study was to investigate the utility of postoperative chest radiograph (CXR) after image-guided central venous line (CVL) placement in children., Methods: A retrospective review was conducted of all tunneled CVLs placed at two pediatric institutions from 2010 to 2017. A subgroup analysis comparing a clinically driven approach to postoperative imaging against routine imaging was performed., Results: During the study period, 1080 lines were placed in 915 patients. There were 892 postoperative CXRs (82.6%). An abnormality was seen on 40 radiographs (4.5%, n = 891), with 16 false-positive (1.3%) and 5 false-negative (0.6%) CXRs. The sensitivity and specificity of CXR to identify complications requiring intervention were 50.0% (95% confidence interval [95% CI], 10.0-90.0) and 95.8% (95% CI, 94.5-97.1), respectively. Positive predictive value of CXR was 7.5% (95% CI, 0-15.7) with a negative predictive value of 99.6% (95% CI, 99.2-100). A clinically driven approach to postoperative imaging was associated with 41% decrease in CXR (P < 0.001) without increased incidence of missed complications. Only three complications requiring intervention (0.3%) were suspected on postoperative CXR alone, and all of those were symptomatic before intervention., Conclusions: Routine postoperative CXR offers minimal value in identifying technical complications requiring intervention after image-guided CVL placement in asymptomatic children. We recommend abandoning this practice in favor of a clinical symptom-driven approach to postoperative imaging., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Venous thromboembolism (VTE) in injured children is rare, but sequelae can be morbid and life-threatening. Recent trauma society guidelines suggesting that all children over 15 years old should receive thromboprophylaxis may result in overtreatment. We sought to evaluate the efficacy of a previously published VTE prediction algorithm and compare it to current recommendations., Methods: Two institutional trauma registries were queried for all pediatric (age < 18 years) patients admitted from 2007 to 2018. Clinical data were applied to the algorithm and the area under the receiver operating characteristic (AUROC) curve was calculated to test algorithm efficacy., Results: A retrospective review identified 8271 patients with 30 episodes of VTE (0.36%). The VTE prediction algorithm classified 51 (0.6%) as high risk (> 5% risk), 322 (3.9%) as moderate risk (1-5% risk) and 7898 (95.5%) as low risk (< 1% risk). AUROC was 0.93 (95% CI 0.89-0.97). In our population, prophylaxis of the 'moderate-' and 'high-risk' cohorts would outperform the sensitivity (60% vs. 53%) and specificity (96% vs. 77%) of current guidelines while anticoagulating substantially fewer patients (373 vs. 1935, p < 0.001)., Conclusion: A VTE prediction algorithm using clinical variables can identify injured children at risk for venous thromboembolic disease with more discrimination than current guidelines. Prospective studies are needed to investigate the validity of this model., Level of Evidence: III-Clinical decision rule evaluated in a single population.

Background: Gastrojejunostomy (GJ) tubes are frequently used to provide nutrition in patients who do not tolerate gastric feeding. Despite their widespread use, there is little literature on the lifespan of GJ tubes, reasons for failure, and recommendations for optimal techniques and timing of replacement. We aimed to evaluate the natural history of GJ tubes in pediatric patients., Materials and Methods: We reviewed all pediatric patients who underwent GJ tube placement or exchange at our institution from January 2012 to July 2018. Demographic data, time, and indication for replacement or removal of GJ tubes were collected. End points were permanent removal of GJ tube or mortality., Results: Seventy-nine patients underwent 205 GJ tube procedures with a median of 2 GJ tubes per patient. Median GJ tube lifespan was 98 d (interquartile range = 54-166). The two most common indications for tube exchange were structural or mechanical problems (43.1%) and GJ tube dislodgement (34.6%). Although most GJ tube exchanges (66%) were performed under general anesthesia or with moderate sedation, 34% of exchanges were done without sedation. During the study period, 12 patients (15.2%) died from their primary disease, nine patients (11.4%) required subsequent fundoplication, one (1.3%) underwent a jejunostomy, and 23 (29.1%) progressed to gastric feeds without fundoplication at a median time of 208 d., Conclusions: GJ tubes offer a safe and effective feeding option in patients intolerant of gastric feeding. GJ tubes fail most commonly from intrinsic structural or mechanical issues, and many patients ultimately tolerate gastric feeds without need for further intervention. Exchange of tubes without anesthesia is a viable option., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Trauma-induced coagulopathy seen on rotational thromboelastometry (ROTEM) is associated with poor outcomes in adults; however, this relationship is poorly understood in the pediatric population. We sought to define thresholds for product-specific transfusion and evaluate the prognostic efficacy of ROTEM in injured children., Methods: Demographics, ROTEM, and clinical outcomes from severely injured children (age, < 18 years) admitted to a Level I trauma center between 2014 and 2018 were retrospectively analyzed. Receiver operating characteristic curves were plotted and Youden indexes were calculated against the endpoint of packed red blood cell transfusion to identify thresholds for intervention. The ROTEM parameters were compared against the clinical outcomes of mortality or disability at discharge., Results: Ninety subjects were reviewed. Increased tissue factor-triggered extrinsic pathway (EXTEM) clotting time (CT) >84.5 sec (p = 0.049), decreased EXTEM amplitude at 10 minutes (A10) <43.5 mm (p = 0.025), and decreased EXTEM maximal clot firmness (MCF) <64.5 mm (p = 0.026) were associated with need for blood product transfusion. Additionally, EXTEM CT longer than 68.5 seconds was associated with mortality or disability at discharge., Conclusion: Coagulation dysregulation on thromboelastometry is associated with disability and mortality in children. Based on our findings, we propose ROTEM thresholds: plasma transfusion for EXTEM CT longer than 84.5 seconds, fibrinogen replacement for EXTEM A10 less than 43.5 mm, and platelet transfusion for EXTEM MCF less than 64.5 mm., Level of Evidence: Prognostic, Level III; Therapeutic, Level IV.

Background: As medical therapy improves, splenectomy has been relegated to third- or fourth-line therapy for immune thrombocytopenic purpura (ITP) in many hematologic practices. However, these medications have well-known associated morbidity and changes in treatment algorithms may affect the timing and degree of response to splenectomy as well as complications in heavily treated ITP patients., Materials and Methods: This is a retrospective study of consecutive patients who underwent ITP splenectomy from January 1994 to June 2017. Nonresponders after splenectomy and those with recurrent disease were compared to complete responders., Results: The cohort included 84 patients. Median number of medications received before splenectomy was 3 (1-6). 14.3% of patients had a medication-related complication, including heart failure, adrenal insufficiency, diabetes mellitus, infection, and osteoporosis. After splenectomy, 83.5% had a complete response, 7.5% partial response, and 9% no response. Complete response was associated with response to steroids before surgery (P < 0.01). Among responders, 19% had recurrent disease, which was associated with lower platelet count at diagnosis (P < 0.01). Forty-four patients (52.0%) had nonelective splenectomies for persistent bleeding or dangerously low platelets despite maximal medical therapy. Ten patients had Clavien-Dindo grade II or higher surgical complications (11.9%). Seven of these complications were related to recurrent or refractory ITP., Conclusions: Many ITP patients have complications related to medication use, and 52.0% required nonelective splenectomy despite maximal medical therapy. Earlier splenectomy may avoid medication-related complications and may reduce the complications from splenectomy. Splenectomy remains an effective and safe treatment for ITP., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The rapid growth of global pediatric surgery beyond direct care delivery into research, education, and advocacy necessitates re-evaluation of the traditional ethical paradigms which have governed our partnerships in low- and middle-income countries (LMIC). Within this paper, we consider current and emerging ethical challenges and discuss principles to consider in order to promote autonomous systems for pediatric surgical care in LMIC.

Background: Expediting evaluation and intervention for severely injured patients has remained a mainstay of advanced trauma care. One technique, direct to operating room (DOR) resuscitation, for selective adult patients has demonstrated decreased mortality. We sought to investigate the application of this protocol in children., Methods: All DOR pediatric patients from 2009 to 2016 at a pediatric Level I trauma center were identified. Direct to OR criteria included penetrating injury, chest injuries, amputations, significant blood loss, cardiopulmonary resuscitation, and surgeon discretion. Demographics, injury patterns, interventions, and outcomes were analyzed. Observed mortality was compared with expected mortality, calculated using Trauma Injury Severity Score methodology, with two-tailed t tests, and a p value less than 0.5 was considered significant., Results: Of 2,956 total pediatric trauma activations, 82 (2.8%) patients (age range, 1 month to 17 years) received DOR resuscitation during the study period. The most common indications for DOR were penetrating injuries (62%) and chest injuries (32%). Forty-four percent had Injury Severity Score (ISS) greater than 15, 33% had Glasgow Coma Scale (GCS) score of 8 or less, and 9% were hypotensive. The most commonly injured body regions were external (66%), head (34%), chest (30%), and abdomen (27%). Sixty-seven (82%) patients required emergent procedural intervention, most commonly wound exploration/repair (35%), central venous access (22%), tube thoracostomy (19%), and laparotomy (18%). Predictors of intervention were ISS greater than 15 (odds ratio, 14; p = 0.013) and GCS < 9 (odds ratio = 8.5, p = 0.044). The survival rate to discharge for DOR patients was 84% compared with an expected survival of 79% (Trauma Injury Severity Score) (p = 0.4). The greatest improvement relative to expected mortality was seen in the subgroup with penetrating trauma (84.5% vs 74.4%; p = 0.002)., Conclusion: A selective policy of resuscitating the most severely injured children in the OR can decrease mortality. Patients suffering penetrating trauma with the highest ISS, and diminished GCS scores have the greatest benefit. Trauma centers with appropriate resources should evaluate implementing similar policies., Level of Evidence: Diagnostic tests or criteria, level II.

Background: Recent mass casualty events in the United States have highlighted the need for public preparedness to prevent death from uncontrolled hemorrhage. The Pediatric Trauma Society (PTS) reviewed the literature regarding pediatric tourniquet usage with the aim to provide recommendations about the utility of this adjunct for hemorrhage control in children., Methods: Search terms "pediatric" and "tourniquet" were used to query the US National Library of Medicine National Institutes of Health for pertinent literature. Exclusion criteria include not involving children, not involving the use of an extremity tourniquet, primary outcomes not related to hemorrhage control, tourniquet use to prevent snake envenomation, single case reports, and only foreign language formats available. Bibliographies of remaining studies reviewed to identify additional pertinent research. Four physician members of the PTS Guidelines Committee reviewed identified studies., Results: One hundred thirty-four studies were identified. One hundred twenty-three studies were excluded. Seven additional studies were identified through bibliography review. Eighteen pertinent studies were reviewed. Seven articles evaluated physiologic response to tourniquet use in operating room settings. Six articles were generated from combat experience in conflicts in Afghanistan and Iraq. Four articles discussed technical details of tourniquet usage. One article evaluated the use of tourniquets during the Boston Marathon bombing in 2015., Conclusion: Despite limited data of limited quality regarding their use, the PTS supports the usage of tourniquets in the prehospital setting and during the resuscitation of children suffering from exsanguinating hemorrhage from severe extremity trauma. Expedited, definitive care must be sought, and tourniquet pressure and time should be limited to the least amount possible. The Society supports the ACS "Stop the Bleed" campaign and encourages further investigation of tourniquet use in children., Level of Evidence: Guidelines/algorithm study, level IIIa.

Background: An expedited recovery protocol for management of pediatric blunt solid organ injury (spleen, liver, and kidney) was instituted across two Level 1 Trauma Centers, managed by nine pediatric surgeons within three hospital systems., Methods: Data were collected for 18months on consecutive patients after protocol implementation. Patient demographics (including grade of injury), surgeon compliance, National Surgical Quality Improvement Program (NSQIP) complications, direct hospital cost, length of stay, time in the ICU, phlebotomy, and re-admission were compared to an 18-month control period immediately preceding study initiation., Results: A total of 106 patients were treated (control=55, protocol=51). Demographics were similar among groups, and compliance was 78%. Hospital stay (4.6 vs. 3.5days, p=0.04), ICU stay (1.9 vs. 1.0days, p=0.02), and total phlebotomy (7.7 vs. 5.3 draws, p=0.007) were significantly less in the protocol group. A decrease in direct hospital costs was also observed ($11,965 vs. $8795, p=0.09). Complication rates (1.8% vs. 3.9%, p=0.86, no deaths) were similar., Conclusions: An expedited, hemodynamic-driven, pediatric solid organ injury protocol is achievable across hospital systems and surgeons. Through implementation we maintained quality while impacting length of stay, ICU utilization, phlebotomy, and cost. Future protocols should work to further limit resource utilization., Type of Study: Retrospective cohort study., Level of Evidence: Level II., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Pituitary function plays an integral role in the physiologic response to traumatic injury. A significant proportion of trauma patients develop partial pituitary insufficiency. While isolated deficiencies of individual pituitary hormones are common, there are few reports in the literature of traumatic pan-pituitary failure with deficiency of all major pituitary hormones. We present a case of a patient involved in a motorcycle accident who sustained a sella turcica fracture, epidural hemorrhage, subdural hemorrhage, optic nerve palsy, and bilateral abducens nerve palsies. Three days after the accident, the patient became hypotensive and progressed to cardiopulmonary arrest. He was resuscitated and had spontaneous return of circulation. Despite adequate fluid resuscitation and vasopressor support, he remained profoundly hypotensive. Following administration of hydrocortisone, his blood pressures dramatically improved. He was found to have laboratory abnormalities, suggesting deficiencies of corticotropins, somatotropins, thyrotropins, gonadotropins, prolactin, and antidiuretic hormone. This is the first reported case of a patient with traumatic total panhypopituitarism complicated by acute adrenal crises during initial postinjury hospitalization. A review of the literature with comparison with other studies of trauma patients with deficiencies in five or more axes is presented. A high level of suspicion for central adrenal insufficiency and prompt administration of corticosteroids in the setting of symptomatic pituitary trauma can result in favorable outcomes. Screening for and treating posttraumatic hypopituitarism can result in improved rehabilitation and increased quality of life for trauma patients.

Objectives/hypothesis: To determine structural biomechanical changes in tracheal scaffolds resulting from cellular reduction and storage at -80(o) C., Study Design: Laboratory-based study., Methods: Forty-four rabbit tracheal segments were separated into four treatment groups: untreated (group A, control), cellular-reduced (group B), storage at -80(o) C followed by cellular reduction (group C), and cellular-reduced followed by storage at -80(o) C (group D). Tracheal segments were subjected to uniaxial tension (n = 21) or compression (n = 23) using a universal testing machine to determine sutured tensile yield load and radial compressive strengths at 50% lumen occlusion. Mean differences among groups for tension and compression were compared by analysis of variance with post-hoc Tukey-Kramer test., Results: The untreated trachea (group A) demonstrated mean yield strength of 5.93 (± 1.65) N and compressive strength of 2.10 (± 0.51) N. Following treatment/storage, the tensile yield strength was not impaired (group B = 6.79 [± 1.58] N, C = 6.21 [± 1.40] N, D = 6.26 [± 1.18]; P > 0.10 each). Following cellular reduction, there was a significant reduction in compressive strength (group B = 0.44 N [± 0.13], P < 0.0001), but no further reduction due to storage (group C = 0.39 N [± 0.10]; P = 0.97 compared to group B)., Conclusion: The data suggest cellular reduction leads to loss of compressive strength. Freezing at -80°C (either before, or subsequent to cellular reduction) may be a viable storage method for tracheal grafts., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Surgical advancements rely heavily on validated animal models. The New Zealand White (NZW) rabbit is a widely used model for airway research, including regenerative medicine applications. Currently, the biomechanical properties of the normal rabbit trachea are not known. Our objective was to define these properties to assist in the standardization and understanding of future airway research using this model., Study Design: Laboratory-based study., Methods: Fresh tracheas from four adult NZW rabbits were dissected into 20 segments. To examine the biomechanical properties, segments were subjected to uniaxial tension (n = 9) and compression (n = 11) testing. Yield and maximum load (tension) and force at 50% displacement (compression) were recorded, and differences between segments were examined using analysis of covariance., Results: Normative data for native rabbit trachea show mean maximum load = 6.44 newtons (N), yield load = 5.93 N, and compressive strength = 2.10 N. In addition to establishing the baseline measurements, statistically significant differences in tensile measures based on location along the trachea and diameter were identified. Proximal segments had significantly higher maximum load (P = .0029) and yield load (P = .0062) than distal segments. Association between diameter and both maximum load (P = .0139) and yield load (P = .0082) was observed., Conclusions: The adult NZW rabbit trachea is intrinsically less able to withstand tensile and compressive forces, compared to other airway models such as sheep or cadaveric human. Establishment of normative values will enable future research into changes in tracheal biomechanical properties during regenerative medicine manipulation and processing., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: The primary objective was to design a reporter assay to measure molecular release kinetics from a new porous-wall hollow glass microsphere biomaterial with great potential in regenerative medicine and drug delivery. Second, future avenues for research will be discussed specifically in regard to potential clinical uses in laryngology., Study Design: Basic science data report., Methods: We developed an assay using fluorescent nanocrystals or quantum dots (Qdot 605) as a reporter. A Nuance FX multispectral imaging system was used to detect fluorescence in aqueous phase. Spectral output of known concentrations of aqueous Qdot 605 was measured by the Nuance system to create a standard curve., Results: These data were plotted and fit to a curve. Qdot 605 emission demonstrates excellent correlation with concentration in a log-log relationship [R(2) = 0.99649, median error = 9.9%], indicating that the Qdot 605 assay is reliable and should be explored regarding its ability to evaluate the drug-eluting properties of this material., Conclusions: We have derived a method to measure Qdot concentration using fluorescent microscopy, which will facilitate future research on this exciting new biomaterial. This material has great potential for use in head and neck surgery. Specific avenues within laryngology to be investigated include laryngeal and tracheal reconstruction, vocal fold healing, and nerve regeneration. Furthermore, we believe this is the first documented use of the Nuance system to determine aqueous molecular concentrations., Level of Evidence: NA., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: A hospital's clinical information system may require a specific environment in which to flourish. This environment is not yet well defined. We examined whether specific hospital characteristics are associated with highly automated and usable clinical information systems., Methods: This was a cross-sectional survey of 125 urban hospitals in Texas, United States using the Clinical Information Technology Assessment Tool (CITAT), which measures a hospital's level of automation based on physician interactions with the information system. Physician responses were used to calculate a series of CITAT scores: automation and usability scores, four automation sub-domain scores, and an overall clinical information technology (CIT) score. A multivariable regression analysis was used to examine the relation between hospital characteristics and CITAT scores., Results: We received a sufficient number of physician responses at 69 hospitals (55% response rate). Teaching hospitals, hospitals with higher IT operating expenses (>$1 million annually), IT capital expenses (>$75,000 annually) and hospitals with larger IT staff (> or = 10 full-time staff) had higher automation scores than hospitals that did not meet these criteria (p < 0.05 in all cases). These findings held after adjustment for bed size, total margin, and ownership (p < 0.05 in all cases). There were few significant associations between the hospital characteristics tested in this study and usability scores., Conclusion: Academic affiliation and larger IT operating, capital, and staff budgets are associated with more highly automated clinical information systems.