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Background Pilonidal disease adversely affects the quality of life (QoL) of adolescents with this condition. We report the impact of minimally invasive care on the QoL of a series of adolescent patients in a dedicated Pilonidal Care Clinic. Methods Beginning in February 2019, all patients completed QoL surveys prior to each visit reporting current symptoms and their QoL impact. Data were collected prospectively with objective disease severity and treatment details. Patients with at least 2 clinic visits were included. Demographics, procedures performed, and median QoL scores by severity were analyzed. Results 74 patients were included. Mean age was 17.3 years (SD 2.4), mean BMI was 27.5 (SD 6.2), median follow-up duration was 4 months (2–12). At intake patients reported a median total QoL impact of 12 for those with mild disease, 11 for those with moderate disease, and 12 with severe disease. Median total QoL impact resolved by the second visit for patients with mild disease, the third for moderate disease, and decreased 88% by the fourth visit for patients with severe disease. Conclusion Pilonidal disease has a profound impact on most patients’ quality of life. Minimally invasive care promptly resolves negative impacts on quality of life in adolescents.

Background Trauma is the leading cause of death among children and adolescents in Brazil. Measurement of quality of care is important, as well as interventions that will help optimize treatment. We aimed to evaluate adherence to standardized trauma care following the introduction of a checklist in one of the busiest Latin American trauma centers. Material and methods A prospective, non-randomized interventional trial was conducted. Assessment of children younger than age 15 was performed before and after the introduction of a checklist for trauma primary survey assessment. Over the study period, each trauma primary survey was observed and adherence to each step of a standardized primary assessment protocol was recorded. Clinical outcomes including mortality, admission to pediatric intensive-care units, use of blood products, mechanical ventilation, and number of CT scans in the first 24 h were also assessed. Results A total of 80 patients were observed (39 pre-intervention and 41 post-intervention). No statistically significant differences were observed between the pre- and post-intervention groups in regard to adherence to checklist by specialty (57.7% versus 50.5%, p = 0.115) and outcomes. No mortality was observed. Conclusion In our trauma center, the quality of the adherence to standardized trauma assessment protocols is poor among both surgical and non-surgical providers. The quality of this assessment did not improve after the introduction of a checklist. Further work aimed at organizing the approach to pediatric trauma including triage and trauma education specifically for pediatric providers is needed.

Background Mechanical pleurodesis can prevent recurrence of spontaneous pneumothorax but is associated with significant postoperative pain. Adequate pain control is not only beneficial for patient comfort but also critical for mobilization and pulmonary recovery. Thoracic epidural catheters and paravertebral blocks have been used to alleviate pain after thoracoscopic surgery. However, no studies have evaluated the safety and efficacy of paravertebral block vs epidural analgesia vs no block in children undergoing pleurodesis. Methods In this retrospective case series review, data were extracted from a single institution's integrated patient outcome database on children who underwent thoracoscopic pleurodesis from 2013 to 2018. Demographics, operative indication, procedure performed, and perioperative pain management were assessed by chart review. Patients whose operation was converted to thoracotomy, who had an underlying diagnosis of chronic pain, or who underwent pleurodesis for other indications were excluded. The primary outcomes were postoperative pain scores and opioid consumption. Secondary outcomes included psot anesthesia care unit length of stay, hospital length of stay, functional outcomes during recovery, and any adverse events. Results 66 patients met inclusion criteria: 23 received thoracic epidurals, 34 received paravertebral blocks, and 9 received no epidural/paravertebral block. Patient characteristics did not significantly differ among groups. Although mean pain scores were statistically significantly lower in the epidural group on post-op day 1, all three groups' pain scores were in the 1 to 3 out of 10 range during the entire postoperative period. Thus, this statistical significance had little clinical significance as all groups had good pain control. The epidural group had significantly lower opioid consumption on post-op days 0 - 2 compared to paravertebral block. No adverse events related to epidural or paravertebral block were noted. Discussion We present the an analysis of epidural vs paravertebral block (with comparison to no regional analgesia) following pleurodesis in children. Pain is well managed, regardless of the method; however, additional systemic opioid consumption was decreased in the epidural analgesia cohort. Prospective trials and comparisons with other analgesic techniques for pediatric thoracic surgeries are needed. Conclusions Thoracic epidural analgesia offers a reduction in opioid use in the first two post-op days after pleurodesis but did not produce a clinically significant reduction in pain scores in comparison with paravertebral block or no block.

High-grade pediatric renal trauma may be associated with a urine leak and appropriate management remains unclear. Data on patients with a traumatic renal injury were retrieved from the trauma registry and data warehouse of a pediatric level 1 trauma center over a 15-year period. Demographics, diagnoses, imaging, interventions performed, and follow-up information on patients with a urine leak were analyzed. 187 renal injuries were identified and 32 (17%) were high grade. There were 21 (11%) diagnoses of urine leak, comprising the study population. Leaks were identified 0–10 day post-injury. All patients underwent initial computerized tomography (CT); however, 10 (48%) lacked excretory-phase imaging, leading to repeat CT. Ten patients (48%) did not undergo an intervention for their leak, and 11 (52%) underwent at least one, most commonly stent placement (10). Comparing non-intervention and intervention groups: Injury Severity Score (ISS) and initial Shock Index – Pediatric Adjusted (SIPA) were similar, but there was variation in antibiotic prophylaxis (60% vs 100%), average number of imaging studies performed (6.4 vs 8.1) and average length of hospital stay in days (7.7 vs 8.6). Traumatic urine leaks are unusual, and half require no intervention. Management is variable and the development of care guidelines could decrease variation. Given their infrequency a multi-institutional study is required to generate sufficient patient volume.

Purpose The purpose of this study was to evaluate the resource utilization and outcome of a minimally invasive pilonidal protocol (MIPP) versus surgical excision (SE) in adolescents with pilonidal disease. Methods Improved hygiene, laser epilation (LE), and sinusectomy were implemented as a minimally invasive pilonidal protocol (MIPP) in March 2016. Following IRB approval, 34 consecutive MIPP patients with moderate and severe disease were compared with a random sample of 17 SE patients treated prior to MIPP implementation. Number of visits, laser epilation (LE) treatments, care duration, operations, operating room (OR) time, charges, and condition at last visit were analyzed. Charges were standardized for 2018. Results No differences were found in age or body mass index between groups. SE patients underwent an average 1.6 excisions/patient (cumulative 2598 OR minutes) and no LE. MIPP patients underwent an average 1.4 sinusectomies and 3.5 LEs/patient. Six sinusectomies (0.17/patient) were performed in OR (cumulative 258 OR minutes). No differences in number of visits or care duration were found between groups. At last follow-up, 82% of MIPP and 18% of SE patients were healed or asymptomatic (p Conclusion A minimally invasive pilonidal protocol reduces charges and improves outcome compared with surgical excision in adolescents. Level of evidence III. Type of study Retrospective comparative study.

Expansion of access to surgical care can improve health outcomes, although the impact that scale-up of the surgical workforce will have on child mortality is poorly defined. In this study, we estimate the number of child deaths potentially avertable by increasing the surgical workforce globally to meet targets proposed by the Lancet Commission on Global Surgery. To estimate the number of deaths potentially avertable through increases in the surgical workforce, we used log-linear regression to model the association between surgeon, anesthetist and obstetrician workforce (SAO) density and surgically amenable under-5 mortality rate (U5MR), infant mortality rate (IMR), and neonatal mortality rate (NMR) for 192 countries adjusting for potential confounders of childhood mortality, including the non-surgical workforce (physicians, nurses/midwives, community health workers), gross national income per capita, poverty rate, female literacy rate, health expenditure per capita, percentage of urban population, number of surgical operations, and hospital bed density. Surgically amenable mortality was determined using mortality estimates from the UN Inter-agency Group for Child Mortality Estimation adjusted by the proportion of deaths in each country due to communicable causes unlikely to be amenable to surgical care. Estimates of mortality reduction due to upscaling surgical care to support the Lancet Commission on Global Surgery (LCoGS) minimum target of 20–40 SAO/100,000 were calculated accounting for potential increases in surgical volume associated with surgical workforce expansion. Increasing SAO workforce density was independently associated with lower surgically amenable U5MR as well as NMR (p

Background: The impact of public health policy to reduce the spread of COVID-19 on access to surgical care is poorly defined. We aim to quantify the surgical backlog during the COVID-19 pandemic in the Brazilian public health system and determine the relationship between state-level policy response and the degree of state-level delays in public surgical care. Methods: Monthly estimates of surgical procedures performed per state from January 2016 to December 2020 were obtained from Brazil's Unified Health System Informatics Department. Forecasting models using historical surgical volume data before March 2020 (first reported COVID-19 case) were constructed to predict expected monthly operations from March through December 2020. Total, emergency, and elective surgical monthly backlogs were calculated by comparing reported volume to forecasted volume. Linear mixed effects models were used to model the relationship between public surgical delivery and two measures of health policy response: the COVID-19 Stringency Index (SI) and the Containment & Health Index (CHI) by state. Findings: Between March and December 2020, the total surgical backlog included 1,119,433 (95% Confidence Interval 762,663–1,523,995) total operations, 161,321 (95%CI 37,468–395,478) emergent operations, and 928,758 (95%CI 675,202–1,208,769) elective operations. Increased SI and CHI scores were associated with reductions in emergent surgical delays but increases in elective surgical backlogs. The maximum government stringency (score = 100) reduced emergency delays to nearly zero but tripled the elective surgical backlog. Interpretation: Strong health policy efforts to contain COVID-19 ensure minimal reductions in delivery of emergent surgery, but dramatically increase elective backlogs. Additional coordinated government efforts will be necessary to specifically address the increased elective backlogs that accompany stringent responses.

BackgroundMany organizations have issued recommendations to limit elective surgery during the coronavirus disease 2019 (COVID-19) pandemic. We surveyed providers of children’s surgical care working in low-income and middle-income countries (LMICs) to understand their perspectives on surgical management in the wake of the COVID-19 pandemic and how they were subsequently modifying their surgical care practices.MethodsA survey of children’s surgery providers in LMICs was performed. Respondents reported how their perioperative practice had changed in response to COVID-19. They were also presented with 26 specific procedures and asked which of these procedures they were allowed to perform and which they felt they should be allowed to perform. Changes in surgical practice reported by respondents were analyzed thematically.ResultsA total of 132 responses were obtained from 120 unique institutions across 30 LMICs. 117/120 institutions (97.5%) had issued formal guidance on delaying or limiting elective children’s surgical procedures. Facilities in LICs were less likely to have issued guidance on elective surgery compared with middle-income facilities (82% in LICs vs 99% in lower middle-income countries and 100% in upper middle-income countries, p=0.036). Although 122 (97%) providers believed cases should be limited during a global pandemic, there was no procedure where more than 61% of providers agreed cases should be delayed or canceled.ConclusionsThere is little consensus on which procedures should be limited or delayed among LMIC providers. Expansion of testing capacity and local, context-specific guidelines may be a better strategy than international consensus, given the disparities in availability of preoperative testing and the lack of consensus towards which procedures should be delayed.

While interval appendectomy following nonoperative management of perforated appendicitis is delayed until several weeks after presentation, the optimal time from presentation to interval appendectomy is unknown.The data warehouse of a large children's hospital was queried for interval appendectomies from 2006 to 2019. Data extracted included demographics, initial and operative hospitalization details, and pathology findings. Student's t-test and logistic regression were used where appropriate.500 patients were identified with a mean age of 10 years, 53% male. Mean time to operation was 12.7 weeks. Operation prior to 12 weeks was associated with increased odds of acute inflammation on pathology (OR = 2, p 0.01). Acute inflammation was associated with increased mean operative time (101 vs 84 min, p 0.01). Presence of an appendicolith, initial hospitalization length, drain placement, readmission prior to operation, age and gender were all non-predictive of acute inflammation. Only 11% of appendices had an occluded lumen and 17% an appendicolith. Carcinoid tumors were identified in 6 patients (1.2%).Acute inflammation is found many weeks after perforation and is associated with increased operative time. Acute inflammation is more likely to be present in operations performed prior to 12 weeks.

IntroductionTrauma is the leading cause of death and disability among Brazilian children and adolescents. Trauma protocols such as those developed by the Advanced Trauma Life Support course are widely taught, but few studies have assessed the degree to which the use of protocolized trauma assessment improves outcomes. This study aims to quantify the adherence of trauma assessment protocols among different types of frontline trauma providers.MethodsA prospective observational study of pediatric trauma care in one of the busiest Latin American trauma centers was conducted during 6 months. Trauma primary survey assessments were observed and adherence to each step of a standardized primary assessment protocol was recorded. Adherence to the assessment protocol was compared among different types of providers, the time of presentation and severity of injury. The relationship between protocol adherence and clinical outcomes including mortality, length of hospital stay, admission to pediatric intensive care unit, use of blood components, mechanical ventilation and number of imaging exams performed in the first 24 hours were also assessed.ResultsEmergency department evaluations of 64 patients out of 274 pediatric admissions were observed over a period of 6 months. 50% of the primary assessments were performed by general surgeons, 34.4% by residents in general surgery and 15.6% by pediatricians. There was an average adherence rate of 34.1% to the trauma protocol. Adherence among each specific step included airway: 17.2%; breathing: 59.4%; circulation: 95.3%; disability: 28.8%; exposure: 18.8%. No differences between specialties were observed. Patients with a more thorough primary assessment underwent fewer CT scans (receiver operating characteristic curve area: 0.661; p=0.027).ConclusionsOur study demonstrates that trauma assessment protocol adherence among trauma providers is low. Thorough initial assessment reduced the use of CT scans suggesting that standardized pediatric trauma assessments may be a way to reduce unnecessary radiological imaging among children.Level of evidenceIV.Study typePediatric and global trauma.

OBJECTIVE The authors sought to evaluate the contemporary management of pediatric open skull fractures and assess the impact of variations in antibiotic and operative management on the incidence of infectious complications. METHODS The records of children who presented from 2009 to 2017 to 6 pediatric trauma centers with an open calvarial skull fracture were reviewed. Data collected included mechanism and anatomical site of injury; presence and depth of fracture depression; antibiotic choice, route, and duration; operative management; and infectious complications. RESULTS Of the fractures among the 138 patients included in the study, 48.6% were frontal and 80.4% were depressed; 58.7% of patients underwent fragment elevation. The average duration of intravenous antibiotics was 4.6 (range 0–21) days. Only 53 patients (38.4%) received a single intravenous antibiotic for fewer than 4 days. and 56 (40.6%) received oral antibiotics for an average of 7.3 (range 1–20) days. Wounds were managed exclusively in the emergency department in 28.3% of patients. Two children had infectious complications, including a late-presenting hardware infection and a superficial wound infection. There were no cases of meningitis or intracranial abscess. Neither antibiotic spectrum or duration nor bedside irrigation was associated with the development of infection. CONCLUSIONS The incidence of infectious complications in this population of children with open skull fractures was low and was not associated with the antibiotic strategy or site of wound care. Most minimally contaminated open skull fractures are probably best managed with a short duration of a single antibiotic, and emergency department closure is appropriate unless there is significant contamination or fragment elevation is necessary.

(1) To investigate the clinical presentation, diagnosis, and treatment of slipping rib syndrome in athletes; (2) to investigate the hooking maneuver for diagnosis of slipping rib syndrome.Retrospective chart review of 362 athletes with rib pain.Pediatric-based sports medicine clinic between January 1, 1999, and March 1, 2014.Costochondritis, Tietze, fractures, rib tip syndrome, and unclear diagnoses were excluded. Athletes were included who had a palpable rib subluxation, mechanical rib symptom, positive hooking maneuver, or resolution of pain after the resection of a slipping rib segment.Slipping rib syndrome is associated with athletic performance.Fifty-four athletes were diagnosed with slipping rib syndrome, of which 38 (70%) were females. Mean age at presentation was 19.1 years (range 4-40 years). Mean number of previous specialist consultations per athlete was 2.3 and mean time from symptom onset to diagnosis was 15.4 months. The hooking maneuver was attempted 21 times (38.9%). Unilateral symptoms presented in 49 athletes (90.7%). The most symptomatic rib was the 10th, affecting 24 athletes (44.4%), eighth and ninth were affected in 17 athletes (31.5%) each. Most, 39 (72.2%), reported insidious onset of symptoms. Running, rowing, lacrosse, and field hockey were frequently associated activities. Twelve athletes had psychiatric diagnoses (22.2%), 10 (19.2%) were hypermobile. Sixty-six total imaging studies were performed. The most successful treatment options included: osteopathic manipulative treatment (71.4%), surgical resection (70%), and diclofenac gel (60%).Most athletes with slipping rib syndrome were active females with insidious onset of unilateral pain, a high prevalence of hypermobility and prolonged pain. The hooking maneuver was underused.

Background Thoracic aortic injury is a potentially life-threatening injury associated with rapid deceleration mechanisms. Diagnosis is made by chest computed tomography (CT), which is associated with a risk of radiation-induced malignancy. We sought to determine the incidence of aortic injuries in the pediatric population to weigh against the risk of CT imaging. Methods The Pediatric Health Information Systems was queried for children ≤18 years with discharge diagnosis code of thoracic aortic injury (901.0) between December 2004 and 2014. Data abstracted included patient age, gender, diagnosis and procedure codes, and discharge disposition, where available. We also queried for imaging codes to determine what type of chest imaging the child received. Results Between December 2004 and 2014, 311,850 children were admitted to Pediatric Health Information Systems hospitals with traumatic injury. Of these patients, 46 (0.015%) were coded with a thoracic aortic injury and an accompanying E-code. Twenty-seven patients (58.7%) were male, and the median age was 13 years. The most common mechanism of injury was motor vehicle collision (63%, n = 29). Eighteen hospitals (41.9%) had no patients with a thoracic aortic injury in the 10-year period. In children with a thoracic aortic injury, the mortality rate was 11% (n = 5) and 22 (47.8%) underwent a chest CT during their hospitalization. Forty percent (124,909) of all trauma patients underwent chest CT, with a positive rate for aortic injury of 1.8/10,000. The reported estimated cancer risk from a chest CT scan is 25/10,000 for girls and 7.5/10, 000 in boys, greater than the positive CT rate. Conclusion Thoracic aortic injuries are rare in children in the United States. The risk of cancer associated with screening chest CT is greater than the likelihood of identifying an aortic injury. Therefore, screening chest CT scans are unwarranted in injured children. Level of evidence Therapeutic/Care Management, level IV.

BACKGROUND The purpose of this study was to determine the relationship between timing and volume of crystalloid before blood products and mortality, hypothesizing that earlier transfusion and decreased crystalloid before transfusion would be associated with improved outcomes. METHODS A multi-institutional prospective observational study of pediatric trauma patients younger than 18 years, transported from the scene of injury with elevated age-adjusted shock index on arrival, was performed from April 2018 to September 2019. Volume and timing of prehospital, emergency department, and initial admission resuscitation were assessed including calculation of 20 ± 10 mL/kg crystalloid boluses overall and before transfusion. Multivariable Cox proportional hazards and logistic regression models identified factors associated with mortality and extended intensive care, ventilator, and hospital days. RESULTS In 712 children at 24 trauma centers, mean age was 7.6 years, median (interquartile range) Injury Severity Score was 9 (2-20), and in-hospital mortality was 5.3% (n = 38). There were 311 patients(43.7%) who received at least one crystalloid bolus and 149 (20.9%) who received blood including 65 (9.6%) with massive transfusion activation. Half (53.3%) of patients who received greater than one crystalloid bolus required transfusion. Patients who received blood first (n = 41) had shorter median time to transfusion (19.8 vs. 78.0 minutes, p = 0.005) and less total fluid volume (50.4 vs. 86.6 mL/kg, p = 0.033) than those who received crystalloid first despite similar Injury Severity Score (median, 22 vs. 27, p = 0.40). On multivariable analysis, there was no association with mortality (p = 0.51); however, each crystalloid bolus after the first was incrementally associated with increased odds of extended ventilator, intensive care unit, and hospital days (all p < 0.05). Longer time to transfusion was associated with extended ventilator duration (odds ratio, 1.11; p = 0.04). CONCLUSION Resuscitation with greater than one crystalloid bolus was associated with increased need for transfusion and worse outcomes including extended duration of mechanical ventilation and hospitalization in this prospective study. These data support a crystalloid-sparing, early transfusion approach for resuscitation of injured children. LEVEL OF EVIDENCE Therapeutic, level IV.

Objective Unintentional window falls represent a preventable source of injury and death in children. Despite major campaigns in some larger cities, there continue to be unintentional falls from windows throughout the United States. We aimed to identify risk factors and trends in unintentional window falls in the pediatric population in a national and regional sample. Methods A retrospective analysis of annual emergency department (ED) visits from the National Electronic Injury Surveillance System using product codes specific to windows, as well as patient encounters for unintentional window falls from January 2007 to August 2017 using site-specific trauma registries from 10 tertiary care children's hospitals in New England. National and state-specific census population estimates were used to compute rates per 100,000 population. Results There were 38,840 ED visits and 496 regional patients who unintentionally fell from a window across the study period between 0 and 17 years old. The majority of falls occurred in children under the age of 6 and were related to falls from a second story or below. A decreased trend in national ED visits was seen, but no change in rates over time for regional trauma center encounters. A high number of falls was found to occur in smaller cities surrounding metropolitan areas and from single family residences. Conclusions Falls from windows represent a low proportion of overall types of unintentional sources of injury in children but are a high risk for severe disability. These results provide updated epidemiologic data for targeted intervention programs, as well as raise awareness for continued education and advocacy.

BackgroundPancreatic pseudocysts may develop after high-grade pancreatic injuries in children. Many resolve without intervention, and the management of symptomatic pseudocysts that persist remains controversial, with various open, percutaneous and laparoscopic approaches to intervention described. Successful endoscopic cyst gastrostomy has been reported in children with pancreatic pseudocysts of mixed etiology.MethodsThe trauma registry and electronic medical record of a level 1 pediatric trauma center were queried for children with a symptomatic pseudocyst following pancreatic trauma over a 12-year period, from 2008 to 2019.ResultsWe describe a case series of five consecutive children with persistent symptomatic pancreatic pseudocysts following blunt abdominal trauma all successfully treated with endoscopic cyst gastrostomy.DiscussionEndoscopic cyst gastrostomy appears to be safe and effective in the management of symptomatic pancreatic pseudocysts in children following pancreatic trauma.Level of evidence5 – retrospective case series.

Introduction Blunt abdominal trauma is a common problem in children. Computed tomography (CT) is the gold standard for imaging in pediatric blunt abdominal trauma, however up to 50% of CTs are normal and CT carries a risk of radiation-induced cancer. Contrast enhanced ultrasound (CEUS) may allow accurate detection of abdominal organ injuries while eliminating exposure to ionizing radiation. Methods Children aged 7–18 years with a CT-diagnosed abdominal solid organ injury underwent grayscale/power Doppler ultrasound (conventional US) and CEUS within 48 h of injury. Two blinded radiologists underwent a brief training in CEUS and then interpreted the CEUS images without patient interaction. Conventional US and CEUS images were compared to CT for the presence of injury and, if present, the injury grade. Patients were monitored for contrast-related adverse reactions. Results Twenty one injured organs were identified by CT in eighteen children. Conventional US identified the injuries with a sensitivity of 45.2%, which increased to 85.7% using CEUS. The specificity of conventional US was 96.4% and increased to 98.6% using CEUS. The positive predictive value increased from 79.2% to 94.7% and the negative predictive value from 85.3% to 95.8%. Two patients had injuries that were missed by both radiologists on CEUS. In a 100 kg, 17 year old female, a grade III liver injury was not seen by either radiologist on CEUS. Her accompanying grade I kidney injury was not seen by one of the radiologist on CEUS. The second patient, a 16 year old female, had a grade III splenic injury that was missed by both radiologists on CEUS. She also had an adjacent grade II kidney injury that was seen by both. Injuries, when noted, were graded within 1 grade of CT 33/35 times with CEUS. There were no adverse reactions to the contrast. Conclusion CEUS is a promising imaging modality that can detect most abdominal solid organ injuries in children while eliminating exposure to ionizing radiation. A multicenter trial is warranted before widespread use can be recommended. Level of evidence Level II; Diagnostic Prospective Study.

Pediatric intra-abdominal injuries (IAI) from blunt abdominal trauma (BAT) rarely require emergent intervention. For those children undergoing procedural intervention, our aim was to understand the timing and indications for operation and angiographic embolization.We prospectively enrolled children younger than 16 years after BAT at 14 Level I Pediatric Trauma Centers over a 1-year period. Patients with IAI who received an intervention (IAI-I) were compared with those who did not receive an intervention using descriptive statistics and univariate analysis; p less than 0.05 was considered significant.Two hundred sixty-one (11.9%) of 2,188 patients had IAI. Forty-five (17.2%) IAI patients received an acute procedural intervention (38 operations, seven angiographic embolization). The mean age for patients requiring intervention was 7.1 ± 4.1 years and not different from the population. Most patients (88.9%) with IAI-I were normotensive. IAI-I patients were significantly more likely to have a mechanism of motor vehicle collision (66.7% vs. 38.9%), more likely to present as a Level I activation (44.4% vs. 26.9%), more likely to have a Glascow Coma Scale less than 14 (31.1% vs. 15.5%), and more likely to have an abnormal abdominal physical examination (93.3% vs. 65.7%) than patients that did not require acute intervention. All patients underwent computed tomography scan before intervention. Operations consisted of laparotomy (n = 21), laparoscopy converted to open (n = 11), and laparoscopy alone (n = 6). The most common surgical indications were hollow viscus injury (HVI) (11 small bowel, 10 colon, 6 small bowel/colon, 2 duodenum). All interventions for solid organ injury, including seven angioembolic procedures, occurred within 8 hours of arrival; many had hypotension and received a transfusion. Procedural interventions were more common for HVI than for solid organ injury (59.2% vs. 7.6%). Postoperative mortality from IAI was 2.6%.Acute procedural interventions for children with IAI from BAT are rare, predominantly for HVI, are performed early in the hospital course and have excellent clinical outcomes.Prognostic/epidemiologic study, level III; therapeutic study, level IV.

The utility of focused assessment with sonography for trauma (FAST) in children is poorly defined with considerable practice variation. Our purpose was to investigate the role of FAST for intra-abdominal injury (IAI) and IAI requiring acute intervention (IAI-I) in children after blunt abdominal trauma (BAT).We prospectively enrolled children younger than 16 years after BAT at 14 Level I pediatric trauma centers over a 1-year period. Patients who underwent FAST were compared with those that did not, using descriptive statistics and univariate analysis; p value less than 0.05 was considered significant. FAST test characteristics were performed using computed tomography (CT) and/or intraoperative findings as the gold standard.Two thousand one hundred eighty-eight children (age, 7.8 ± 4.6 years) were included. Eight hundred twenty-nine (37.9%) received a FAST, 340 of whom underwent an abdominal CT. Ninety-seven (29%) of these 340 patients had an IAI and 27 (7.9%) received an acute intervention. CT scan utilization after FAST was 41% versus 46% among those who did not receive FAST. The frequency of FAST among centers ranged from 0.84% to 94.1%. There was low correlation between FAST and CT utilization (r = -0.050, p0.001). Centers that performed FAST at a higher frequency did not have improved accuracy. The test performance of FAST for IAI was sensitivity, 27.8%; specificity, 91.4%; positive predictive value, 56.2%; negative predictive value, 76.0%; and accuracy, 73.2%. There were 81 injuries among the 70 false-negative FAST. The test performance of FAST for IAI-I was sensitivity, 44.4%; specificity, 88.5%; positive predictive value, 25.0%; negative predictive value, 94.9%; and accuracy, 85.0%. Fifteen children with a negative FAST received acute interventions. Among the 27 patients with true positive FAST examinations, 12 received intervention. All had an abnormal abdominal physical examination. No patient underwent intervention before CT scan.As currently used, FAST has a low sensitivity for IAI, misses IAI-I and rarely impacts management in pediatric BAT.Prognostic and epidemiologic study, level II; diagnostic tests or criteria study, level II; therapeutic/care management study, level III.

Computed tomography scans of the abdomen/pelvis (CTAP) in the adult population may reveal findings unrelated to the injury, such as a mass; the occurrence of incidental findings in pediatric patients remains unknown. This study aims to determine the percentage of pediatric trauma patients with incidental findings. Data regarding consecutive 250 patients who underwent CTAP during their evaluation were retrieved from our level 1 pediatric trauma center trauma registry. Interpretations were reviewed for mention of incidental findings. Records for patients with incidental findings were examined to determine what further evaluation occurred. Nine patients were excluded due to incomplete records. Of the remaining 241 patients, 114 incidental findings were identified among 86 (35.7%) patients. There were 47 clinically significant incidental findings, occurring in 41 (17%) patients. Seven patients (8.1%) had further workup of their findings; Three (3.5%) went on to have an operation (two patients with ureteropelvic junction obstruction and one with high-riding testicle). No potential tumors were found in this population. Incidental findings were mentioned in 25.5% of discharge summaries. Pediatric trauma CTAP reveals incidental findings at a lower rate than in their adult counterparts. Documentation of findings should be improved for optimal care of the injured child.

Background Opiates are the traditional treatment for postoperative pain. Recognition that increased availability of opiates in the community is associated with increased addiction has led to efforts to decrease postoperative opiate distribution. However, there are concerns that without opiates, pain relief might be inadequate. Study Design We analyzed opiate prescriptions to children who had undergone appendectomy during 3 time periods: before intervention (July 2012 through February 2013), after opiate prescriptions were standardized and reduced (December 2016 through December 2017), and after opiate prescriptions were eliminated (January 2018 through December 2018). We determined how many opiate prescriptions had been written and how many had been filled in each time period. Patients were contacted by phone to identify their medication use and quality of pain management. Results Pre-intervention, 75 children underwent appendectomy, and all received opiate prescriptions, with a mean of 15 doses of oxycodone prescribed per patient. After reduction, 208 children underwent appendectomy and 30% received opiate prescriptions, for a mean of 1.5 doses of oxycodone per patient. After elimination, 270 patients underwent appendectomy and 3 patients (1.1%) received opiate prescriptions, for a mean of 0.05 doses of oxycodone per patient. Patients contacted by phone expressed no pain relief issues and no patients needed opiates later. Conclusions Using a stepwise process, we have eliminated the use of opiates for postdischarge pain in children undergoing laparoscopic appendectomy. This intervention has resulted in the elimination of 4,035 doses of oxycodone from the community during the study period, while ensuring that postoperative pain control has been adequate.

Introduction Anterior cutaneous nerve entrapment syndrome (ACNES) is an underrecognized etiology of chronic abdominal pain that causes great morbidity to those affected. We sought to determine the outcome of neurectomy for ACNES in children. Methods Demographic and clinical data on children who underwent neurectomy for ACNES by a single surgeon from 10/2011 to 01/2017 were reviewed. Results Twenty-six patients underwent neurectomy for ACNES. Five were male and average age was 15years (10–21). Median (IQR) preoperative pain duration was 15 (8–29) months and 19 reported their pain was 10/10 (6–10). Thirteen patients were taking antidepressants, 12 Gabapentin, and 4 narcotics. Most had been hospitalized at least once secondary to the pain. All 26 had undergone diagnostic studies including: nuclear medicine scan, fluoroscopy, computed tomography, magnetic resonance imaging, sonography, endoscopy and surgery. Once the diagnosis was suspected, all underwent at least one ultrasound-directed nerve block, which provided relief lasting from 6h to 14days. Patients then underwent outpatient surgery with division of the involved nerve(s). There were no perioperative complications. Most patients reported incisional discomfort for 3–14days afterward, and immediate resolution of the nerve pain without cutaneous numbness. Postoperatively, 15 patients (58%) were pain free long-term; pain recurred to a lesser severity in 8 (31%) and recurred to the same extent in 3 (11%), with average time to recurrence of 6.7months. Of those whose pain recurred to a lesser extent, all achieved long term relief, 4 improved with time, 1 through repeat neurectomy, 2 through medical treatment for underlying psychiatric disorders and 1 through treatment for newly diagnosed inflammatory bowel disease. Of those children with pain recurring to the same extent, all underwent repeat neurectomy, none of whom achieved pain relief. Conclusion ACNES should be considered in children with chronic abdominal pain. Neurectomy is safe and relieves pain in around 88% of selected children. Further investigation is necessary to optimize patient selection. Level of evidence IV.

Anterior cutaneous nerve entrapment syndrome (ACNES) is increasingly diagnosed in children. Pediatric surgeons may be approached to perform a cutaneous neurectomy, the preferred operative approach, and may have no experience with the procedure. This report provides a detailed description of the operative technique used by a pediatric surgeon who has performed over 70 neurectomies for ACNES. Dissemination of this simple procedure will hopefully allow children with ACNES to undergo the procedure locally.

We sought to investigate the diagnosis, management, and outcomes of pediatric sternal fractures.We used ICD codes to search our trauma registry and Hound Dog software to search the hospital data warehouse for all cases of radiologically confirmed sternal fracture in patients21 years from January 1, 1997 to July 1, 2017. We extracted demographics, mechanism of injury, diagnostic modality, associated injuries, and clinical outcomes.We identified 65 children with sternal fractures. 46/65 (71%) were male, with median age 11 years. 34/65 (52%) presented to our emergency department (ED) and the remainder to outpatient clinics. 41/65 (63%) were diagnosed by chest X-ray, 11/65 (17%) by chest CT, 7/65 (11%) by sternal X-ray, and 5/65 (8%) by MRI. Mechanism of injury varied by age. The majority, 50/65 (77%), were isolated injuries and there were no cardiac injuries, aortic injuries or deaths. 18/33 (45%) of those who presented initially to the ED were admitted, and of these 7/18 (39%) had isolated sternal fractures.In this series, most sternal fractures were isolated with low morbidity. Sternal fracture alone should not prompt aggressive workup for intrathoracic injuries and stable patients with isolated sternal fractures can be safely followed without admission.IV.

Introduction Historically, computed tomography (CT) scans of injured children obtained at referring emergency departments were not reinterpreted by trauma center radiologists at our institution, creating a dilemma for trauma physicians: rescan, use the outside interpretation, or interpret scans themselves. In 2010, our radiologists began reinterpreting all referring hospital trauma CT scans; this study examines the effect of that change. Methods Transferred patients who had undergone an abdomen/pelvis CT (CTAP) scan between December 2010 and December 2012 were identified in our trauma registry. Pediatric radiologist reinterpretations were compared to referring hospital radiologist reports. Results We identified 168 patients transferred to our institution with a CTAP. Seventy patients were excluded owing to lack of: complete study, referring hospital interpretation, or reinterpretation. Of the remaining 98 cases, 12 new injuries were identified: 3 splenic and 3 liver injuries, 1 adrenal hematoma, 2 pelvic fractures, 1 spinal fracture, 1 duodenal hematoma and 1 jejunal perforation. Three patients had solid organ injuries upgraded (grade II to III liver laceration; 2 renal lacerations with active extravasation initially missed), and 4 patients downgraded to no injury. Conclusion Reinterpretation of referring hospital CT scans by pediatric radiologists is beneficial to appropriate management of pediatric trauma patients with concern for blunt abdominal trauma.

Most children who suffer renal trauma recover fully; however, some have long-term consequences. We sought to determine what grades of injury carry concern for complication and warrant close follow-up. Data on children with grade II or higher renal injuries from a single center over 20 years were reviewed. Demographics, presenting symptoms, lab values, clinical course, management, and follow-up data were analyzed. One hundred seventy-one children suffered renal injuries: 75% boys, aged 11.6 ± 3.5 years. Falls-54 and sports-43 were leading injury mechanisms. Presentations included pain only-61, pain and hematuria-28 and hematuria alone-11. Eight had pre-existing abnormalities. Injury grades were: grade II-88 (52%), grade III-49 (29%), grade IV-28 (16%), and grade V-6 (3%). No grades II or III patient underwent intervention or suffered sequelae. Grade IV patients underwent: stenting-5, surgery-2, embolization-1, and drainage-1. Grade V patients underwent: surgery-2, embolization-1, and drain-1. Two grade IV patients underwent late interventions: nephrectomy-1 and stenting-1. Six patients, all grades IV–V, were newly hypertensive at follow-up. Grades II and III renal injuries carry a low risk of complication and repeat imaging and close follow-up are likely not necessary. However, grades IV and V injuries carry a meaningful risk of adverse outcome and close follow-up is warranted.

Purpose The purpose of the study was to evaluate the outcome of pit-picking on adolescents with pilonidal disease. Methods Patients presenting to a Pilonidal Clinic were managed by evacuation of any un-drained collections, soaking, and as needed, hair removal. Once active inflammation resolved, they underwent pit-picking under local anesthesia. Those with > 3 pits underwent sequential pit-pickings 2 months apart. Hirsute patients also underwent laser hair epilation. Pilonidal disease was stratified by severity. Patient symptoms were collected prospectively and reviewed. Results Fifty-eight patients underwent at least one pit-picking from February 2016 to September 2017. There were 40 (69%) males with a mean age of 17.7 years (range 13–24). Thirty-seven hirsute patients (64%) underwent a series of laser epilation treatments. Patients required from 0 to 3 days of non-narcotic analgesia, and all returned promptly to pre-procedure activities. Seven patients (12%) were lost to follow-up. Of the 51 patients with follow-up data, 47 (92%) were symptom-free an average of 5.0 months (range 1–20) post-procedure. Four patients (8%) had persistent intermittent drainage. Conclusion Pit-picking is a simple office procedure that may resolve pilonidal disease in many adolescents. A longer follow-up interval is needed to determine the long-term recurrence rate. Type of study Case Series. Level of evidence Level IV.

Splenic preservation is the standard of care for hemodynamically stable children with splenic injuries. We report a 20-year single-institutional series of children with splenic injuries managed without a splenectomy.Children evaluated and treated for blunt splenic injury at Boston Children's Hospital from 1994 to 2014 were extracted from the trauma registry. Demographics, clinical characteristics, complications, and outcomes were reviewed. Three time-periods were evaluated based upon the development and modification of splenic injury clinical pathway guidelines (CPGs). Survival was defined as being discharged from the hospital alive.502 suffered isolated splenic injuries. The median AAST grade of splenic injury increased across the three CPG time periods (p0.001). No splenic-injury related mortalities occurred. Hospital length of stay decreased significantly secondary to splenic injury CPGs (p0.001). 99% of the patients were discharged home.In children managed over the last 20years for isolated splenic injury, no patient died or underwent splenectomy. Hospital length of stay decreased across time, despite an increase in the severity of splenic injuries encountered. Splenectomy has become so unusual in the management of hemodynamically stable children with a splenic injury that it may no longer be a legitimate outcome marker.

Introduction Traumatic pneumatoceles are reported to be rare in children and to have an uncertain clinical significance. We report a single institution series of traumatic pneumatoceles to better define their frequency and clinical significance. Methods After obtaining approval from the IRB, data were extracted from the trauma registry of a level 1 pediatric trauma center on children diagnosed with a pulmonary contusion (International Classification of Diseases-9th edition diagnosis codes: 861.21 to 861.31) who presented between June, 2006 and September, 2016. Patient demographics, mechanism of injury, injury severity score, diagnosis and procedure codes, length of hospital stay, outcome, imaging techniques and findings with attention to the identification of a pneumatocele, were examined. Results Of the 10,229 trauma admission, 204 children were identified as having a pulmonary contusion, 25 of whom (12.3%) were diagnosed with a pneumatocele. Their mean age was 13years (3–17). Seventy-six percent (19) were male. The most common mechanism of injury was a motor vehicle collision (10), followed by falls (6), and sports (5). Sixteen children (64%) suffered a long bone fracture, 12 (48%) an abdominal solid organ injury and 3 (12%) a traumatic brain injury. The mean Injury Severity Score was 17 (9–34). Twenty-three patients presented as transfers. There were no fatalities. The pneumatocele was identified on chest computerized tomography (CT) alone in 15 (60%), on chest CT and chest radiograph (CXR) in 3 (12%), the upper portions of an abdominal CT in 6 (24%) and on CXR alone in 1 (4%). Seven patients were found to have a solitary pneumatocele and 18 patients had 2 or more. The largest pneumatocele was 3.7cm in diameter. Ten children (40%) were admitted to the intensive care unit, 3 of whom required intubation. One patient (4%) had a respiratory complication: pneumonia. Three patients underwent chest tube placement for: pneumothorax, hemothorax and hemopneumothorax. No child underwent intervention specific to the pneumatocele. Seventeen (68%) patients were seen in follow-up in Trauma Clinic and the remainder by another practitioner ranging from 1week to 6months after injury. One child (4%) underwent a follow-up chest CT to rule out a congenital pulmonary malformation 6months after injury and this demonstrated complete resolution of the pneumatocele. Conclusion The incidence of traumatic pneumatoceles among children with a pulmonary contusion was 12.3% in this series, but is probably higher given that only 24% were visible on radiographs and a small minority of children with pulmonary contusions underwent chest CT. Pneumatoceles are common in children with pulmonary contusions, but are usually small. The majority do not appear to be clinically significant nor require follow-up imaging. Level of evidence IV.

In 2000, the American Pediatric Surgical Association (APSA) disseminated consensus practice guidelines for the management of blunt liver and splenic injury which included intensive care unit (ICU) admission for children with grade IV injuries. We sought to determine if we could better predict which children with isolated solid organ injuries (SOI) underwent an ICU-level intervention, thus necessitating ICU admission.Children with isolated liver, spleen, or kidney injuries admitted to the ICU from November 2003 to August 2015 were identified in our trauma registry, and data were extracted from the medical record. ICU-level interventions were defined as transfusion, vasopressor use, intubation, and operative/procedural intervention. Shock index and pediatric age-adjusted (SIPA) was calculated for all patients. The sensitivity and negative predictive values (NPV) were determined.133 children met inclusion criteria. 19 (14.3%) required ICU-level intervention, and 114 (85.1%) did not. 95% (n=18) of the intervention group had either an elevated SIPA or a hematocrit30% on admission compared to 22% (n=25) of patients in the no intervention group. Sensitivity was 95%, and NPV was 99%.Limiting ICU admission in children with isolated SOI to those with an elevated SIPA or hematocrit30% would reduce the ICU admission rate by two-thirds while maintaining patient safety.Diagnostic study.III.

Background/Purpose Optimal central venous catheter (CVC) tip location is necessary to decrease the incidence of complications related to their use. We sought to create a practical method to reliably predict the length of catheter to insert into the subclavian vein during CVC placement in children. Methods We performed a retrospective review of 727 chest radiographs of children who underwent either left or right subclavian CVC placement. We measured the distance from the subclavian entry site to the to the right atrium/superior vena cava (RA/SVC) junction, following the catheter's course. We analyzed the relationship between that length and patient characteristics, including: age, gender, height, weight and body surface area (BSA). Results Two derived formulas using the BSA best correlated with the optimal subclavian CVC length. For the left subclavian vein approach, the optimal catheter length was 6.5*BSA+7cm, and for the right subclavian vein approach it was 5*BSA+6. The use of these formulas correlated in CVC tip placement in a clinically proper location in 92.9% of smaller children and in 95.7% of larger children. Conclusion The optimal length of central venous catheter to insert into the subclavian vein may be determined through the use of a simple formula using the BSA.

This multiorganizational literature review was undertaken to provide an evidence base for determining whether recommendations for out-of-hospital termination of resuscitation could be made for children who are victims of traumatic cardiopulmonary arrest. Although there is increasing acceptance of out-of-hospital termination of resuscitation for adult traumatic cardiopulmonary arrest when there is no expectation of a good outcome, children are routinely excluded from state termination-of-resuscitation protocols. The decision to withhold resuscitative efforts in a child under specific circumstances (decapitation or dependent lividity, rigor mortis, etc) is reasonable. If there is any doubt as to the circumstances or timing of the traumatic cardiopulmonary arrest, under the current status of limiting termination of resuscitation in the field to persons older than 18 years in most states, resuscitation should be initiated and continued until arrival to the appropriate facility. If the patient has arrested, resuscitation has already exceeded 30 minutes, and the nearest facility is more than 30 minutes away, involvement of parents and family of these children in the decision-making process with assistance and guidance from medical professionals should be considered as part of an emphasis on family-centered care because the evidence suggests that either death or a poor outcome is inevitable.

Background. Our institution implemented an Inpatient Child Passenger Safety (CPS) program for hospitalized children to improve knowledge and compliance with the Massachusetts CPS law, requiring children less than 8 years old or 57 inches tall to be secured in a car seat when in a motor vehicle. Methods. After the Inpatient CPS Program was piloted on 3 units in 2009, the program was expanded to all inpatient units in 2010. A computerized nursing assessment tool identifies children in need of a CPS consult for education and/or car seat. Results. With the expanded Inpatient CPS Program, 3650 children have been assessed, 598 consults initiated, and 325 families have received CPS education. Car seats were distributed to 419 children; specialty car seats were loaned to 134 families. Conclusions. With a multidisciplinary approach, we implemented an Inpatient CPS Program for hospitalized children providing CPS education and car seats to families in need.

Traumatic injury has been the most common cause of morbidity and mortality in the pediatric population, but injuries to the abdominal aorta are rare. We reviewed 2 children who underwent exploratory laparotomy for blunt aortic injury in which intra-operative ultrasound guided the surgical approach. Intra-operative ultrasound allowed us to minimize resection of normal aorta and achieve primary repair. In the pediatric population, achieving primary repair is ideal, as synthetic grafts will likely need future revisions as children grow. Here we present the use of intra-operative ultrasound in maximizing the chance at primary repair of the aorta following blunt injury.

Background Computed tomography is commonly used to rule out intra-abdominal injury (IAI) in children, despite associated cost and radiation exposure. Our purpose was to derive a prediction rule to identify children at very low risk for IAI after blunt abdominal trauma (BAT) for whom a CT scan of the abdomen would be unnecessary. Study Design We prospectively enrolled children younger than 16 years of age who presented after BAT at 14 Level I pediatric trauma centers during 1 year. We excluded patients who presented more than 6 hours after injury or underwent abdominal CT before transfer. We used binary recursive partitioning to derive a prediction rule identifying children at very low risk of IAI and IAI requiring acute intervention (IAI-I) using clinical information available in the trauma bay. Results We included 2,188 children with a median age of 8 years. There were 261 patients with IAI (11.9%) and 62 patients with IAI-I (2.8%). The prediction rule consisted of (in descending order of significance): aspartate aminotransferase >200 U/L, abnormal abdominal examination, abnormal chest x-ray, report of abdominal pain, and abnormal pancreatic enzymes. The rule had a negative predictive value of 99.4% for IAI and 100.0% for IAI-I in patients with none of the prediction rule variables present. The very-low-risk population consisted of 34% of the patients and 23% received a CT scan. Computed tomography frequency ranged from 4% to 96% by center. Conclusions A prediction rule using history and physical examination, chest x-ray, and laboratory evaluation at the time of presentation after BAT identifies children at very low risk for IAI for whom CT can be avoided.

This article is designed to guide pediatric surgeons in the evaluation and stabilization of blunt head and cervical spine injuries in pediatric patients. Trauma remains the number one cause of morbidity and mortality among children, and the incidence of head injuries continues to rise. Cervical spine injuries, on the other hand, are unusual but can be devastating if missed. This article highlights the pathophysiology unique to pediatric head and cervical spine trauma as well as keys to clinical and diagnostic evaluation.

It is crucial to identify cervical spine injuries while minimizing ionizing radiation. This study analyzes the sensitivity and negative predictive value of a pediatric cervical spine clearance algorithm.We performed a retrospective review of all children21years old who were admitted following blunt trauma and underwent cervical spine clearance utilizing our institution's cervical spine clearance algorithm over a 10-year period. Age, gender, International Classification of Diseases 9th Edition diagnosis codes, presence or absence of cervical collar on arrival, Injury Severity Score, and type of cervical spine imaging obtained were extracted from the trauma registry and electronic medical record. Descriptive statistics were used and the sensitivity and negative predictive value of the algorithm were calculated.Approximately 125,000 children were evaluated in the Emergency Department and 11,331 were admitted. Of the admitted children, 1023 patients arrived in a cervical collar without advanced cervical spine imaging and were evaluated using the cervical spine clearance algorithm. Algorithm sensitivity was 94.4% and the negative predictive value was 99.9%. There was one missed injury, a spinous process tip fracture in a teenager maintained in a collar.Our algorithm was associated with a low missed injury rate and low CT utilization rate, even in children3years old.IV.

Trauma systems improve survival by directing severely injured patients to trauma centers. This study analyzes the impact of trauma systems on pediatric triage and injury mortality rates. Population-based data were collected on injured children less than 15 years who were admitted to any hospital in New England from 1996 to 2006. Data from three trauma system states were compared to three non-trauma system states. The percentages of injured children, severely injured children, and brain-injured children admitted to trauma centers were determined as well as injury hospitalization and death rates. Time trend analysis examined the pace of change between the groups. A total of 58,583 injured children were hospitalized during the study period. Injury hospitalization rates were initially similar between the two groups (with and without trauma systems) and decreased over time in both. Rates decreased more rapidly in trauma system states compared to those without, (P = 0.003). Injury death rates decreased over time in both groups with no difference between the groups, (P = 0.20). A higher percentage of injured children were admitted to trauma centers in non-trauma system states throughout the study period, and this percentage increased in both groups of states. A higher percentage of severely injured children and brain-injured children were admitted to trauma centers in non-trauma system states and both percentages increased over time. The increase was more rapid in trauma system states for children with severe injuries (P

BACKGROUND/AIM: Operative blunt duodenal injury in children is rare. The purpose of this analysis is to describe the clinical presentation, current management, and outcome of children with operative blunt duodenal injury. METHODS: The American Pediatric Surgical Association Trauma Committee solicited data from its members on children with blunt intestinal injuries identified at autopsy or operation from January 2002 through August 2006. RESULTS: Fifty-four children from 16 hospitals with operative blunt duodenal injuries were identified: 0.67 patients per hospital per year. The most common mechanisms of injury were motor vehicle crashes (35%), bicycle crashes (22%), and nonaccidental trauma (20%). Forty-nine patients (90%) had positive physical examination findings on initial presentation, including peritonitis in 18 patients (33%). Twenty-five computed tomographic (CT) scans performed demonstrated free fluid, and 13 (52%), free air. Eleven CT scans used enteral contrast, and only 2 (18%) showed extravasation. Fifty-two patients (96%) survived to operation. The overall complication rate was 42%. CONCLUSION: Operative blunt duodenal injury occurs less than once per year in the typical pediatric trauma center. Most of the patients have pertinent physical examination findings on arrival. Computed tomographic scans with enteral contrast do not seem to be helpful in diagnosis of duodenal injuries. Postoperative complications are frequent, but most children survive. Language: en

Home-related injuries are overrepresented in children from low-income households. The objectives of this study were to determine frequencies of home safety behaviors and the level of agreement between parental self-report and observed safety practices in low-income homes. In a prospective, interventional home injury prevention study of 49 low-income families with children5 years old, a trained home visitor administered baseline parental home safety behavior questionnaires and assessments. There was high agreement between caregiver self-report and home visitor observation for lack of cabinet latch (99%, 95% confidence interval [CI] = 88%-99%) and stair gate use (100%, 95% CI = 88-100%). There was lower agreement for the safe storage of cleaning supplies (62%, 95% CI = 46%-75%), sharps (74%, 95% CI = 59%-85%), and medicines/vitamins (83%, 95% CI = 69%-92%) because of the overreporting of safe practices. Self-reports of some home safety behaviors are relatively accurate, but certain practices may need to be verified by direct assessment.

Enteric duplication cysts are rare congenital anomalies of unclear etiology. While they can occur anywhere in the gastrointestinal tract, they typically occur in the ileum or ileocecal region and very rarely in the duodenum. Here, we report a case of a periampullary duodenal duplication cyst in a 13-year-old male who presented with clinical and laboratory evidence of small bowel obstruction, hepatitis, and pancreatitis. Based on radiologic imaging, the patient was thought to have a type III choledochal cyst (choledochocele) within the duodenal lumen. Intraoperative findings and postoperative pathological evaluation, however, revealed that the lesion was a duodenal duplication cyst masquerading as a choledochal cyst. Interestingly, the duplication cyst was communicating with the common bile duct, simultaneously causing biliary and small bowel obstruction.

Blunt traumatic arteriovenous fistulae of the extremities are rare in children. We report the case of a 10-year-old boy with a traumatic infrapopliteal arteriovenous fistula and concomitant pseudoaneurysm diagnosed 2 months after he was struck by a car. It was definitively managed with coil embolization. Postprocedure, the vascular anatomy of the patient's right calf was well preserved. He had complete resolution of his symptoms immediately after the intervention and continues to do well 6 months later.

BACKGROUND: Trauma is the leading cause of death and disability in Italy among patients aged between 1 year and 19 years. To transform its fragmented regional pediatric trauma system to a more organized and efficient spoke and hub model, Tuscany has developed a partnership with physicians from the United States to facilitate the process and to implement a series of strategic system changes to create the first pediatric trauma center in Italy. METHODS: After establishing a multidisciplinary and institutional task force, a rigorous needs assessment was conducted to evaluate resources and develop a strategic timeline with specific project goals. Once an intensive educational program was completed, a series of system changes were made in Tuscany to create a full-service pediatric trauma center. Once accomplished, regional changes were enacted to divert the most severely injured children to the new center. RESULTS: In

Acute appendicitis is among the most common indications for surgery in children in the Western world. The epidemiology of acute appendicitis in the United States has not been recently analyzed in a population-based cohort study.Here, we describe the epidemiology of acute appendicitis in the pediatric population in New England from 2000 to 2006.Our results show that there is clustering of perforated and nonperforated appendicitis by hospital catchment area (Moran I index 0.01 and 0.03, respectively). The overall incidence of nonperforated appendicitis decreased over our study period by 9.7% (P.05), the proportion of perforated appendicitis did not change significantly over our study period, and there was a 38% decrease in the proportion of negative appendectomies (P.05).There were trends toward increased operative volume for pediatric surgeons as well as sharp increases in the use of laparoscopy and early discharge with home health services. Our results demonstrate that the epidemiology, outcomes, and trends in treatment of acute appendicitis continue to change.

Introduction Grade of injury, serum amylase, and lipase are markers used to assess pancreatic injury. It is unclear how amylase and lipase relate to grade of injury or predict outcome. We hypothesize that serum amylase and lipase are good predictors of grade of injury and outcomes in patients with pancreatic trauma. Methods This study is a multicenter review from 9 pediatric trauma centers of all children admitted to their institution over 5 years with a pancreatic injury. Initial as well as peak amylase and lipase values were analyzed with relation to pancreatic grade, length of stay, and outcomes. Results One hundred thirty-one records were analyzed. There were 44 girls and 85 boys with an average age of 9.0 ± 0.4 years. The mean injury severity score (ISS) score was 15.5 ± 1.2 SE. The average length of stay (in days) was analyzed by grades 0 (3.93), 1 (7.73), 2 (13.4), 3 (18.4), 4 (31), and 5 (13.5). Neither initial nor peak amylase/lipase correlated with grade of injury. Neither amylase nor lipase predicted length of stay or mortality. Maximal amylase was highly predictive of developing a pseudocyst. Conclusion There seems to be limited value for repetitive routine amylase and lipase levels in the management of pediatric trauma patients with pancreatic injury.