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Purpose: We sought to determine the incidence and timing of testicular atrophy following inguinal hernia repair in children.Methods: We used the TRICARE database, which tracks care delivered to active and retired members of the US Armed Forces and their dependents, including > 3 million children. We abstracted data on male children < 12 years who underwent inguinal hernia repair (2005-2014). We excluded patients with history of testicular atrophy, malignancy or prior related operation. Our primary outcome was the incidence of the diagnosis of testicular atrophy. Among children with atrophy, we calculated median time to diagnosis, stratified by age/undescended testis.Results: 8897 children met inclusion criteria. Median age at hernia repair was 2 years (IQR 1-5). Median follow-up was 3.57 years (IQR 1.69-6.19). Overall incidence of testicular atrophy was 5.1/10,000 person-years, with the highest incidence in those with an undescended testis (13.9/10,000 person-years). All cases occurred in children [Formula: see text] 5 years, with 72% in children < 2 years. Median time to atrophy was 2.4 years (IQR 0.64-3), with 30% occurring within 1 year and 75% within 3 years.Conclusion: Testicular atrophy is a rare complication following inguinal hernia repair, with children < 2 years and those with an undescended testis at highest risk. While 30% of cases were diagnosed within a year after repair, atrophy may be diagnosed substantially later.Level Of Evidence: Prognosis Study, Level II. [ABSTRACT FROM AUTHOR]

Importance: Firearm-related injuries are the leading cause of death among children and adolescents in the US. For youths aged 10 to 19 years, 64% of firearm-related deaths are due to assault. Understanding the association between the rate of death due to assault-related firearm injury and both community-level vulnerability and state-level gun laws may inform prevention efforts and public health policy., Objective: To assess the rate of death due to assault-related firearm injury stratified by community-level social vulnerability and state-level gun laws in a national cohort of youths aged 10 to 19 years., Design, Setting, and Participants: This national cross-sectional study used the Gun Violence Archive to identify all assault-related firearm deaths among youths aged 10 to 19 years occurring in the US between January 1, 2020, and June 30, 2022., Exposure: Census tract-level social vulnerability (measured by the Centers for Disease Control and Prevention social vulnerability index [SVI]; categorized in quartiles as low [<25th percentile], moderate [25th-50th percentile], high [51st-75th percentile], or very high [>75th percentile]) and state-level gun laws (measured by the Giffords Law Center gun law scorecard rating; categorized as restrictive, moderate, or permissive)., Main Outcomes and Measures: Youth death rate (per 100 000 person-years) due to assault-related firearm injury., Results: Among 5813 youths aged 10 to 19 years who died of an assault-related firearm injury over the 2.5-year study period, the mean (SD) age was 17.1 (1.9) years, and 4979 (85.7%) were male. The death rate per 100 000 person-years in the low SVI cohort was 1.2 compared with 2.5 in the moderate SVI cohort, 5.2 in the high SVI cohort, and 13.3 in the very high SVI cohort. The mortality rate ratio of the very high SVI cohort compared with the low SVI cohort was 11.43 (95% CI, 10.17-12.88). When further stratifying deaths by the Giffords Law Center state-level gun law scorecard rating, the stepwise increase in death rate (per 100 000 person-years) with increasing SVI persisted, regardless of whether the Census tract was in a state with restrictive gun laws (0.83 in the low SVI cohort vs 10.11 in the very high SVI cohort), moderate gun laws (0.81 in the low SVI cohort vs 13.18 in the very high SVI cohort), or permissive gun laws (1.68 in the low SVI cohort vs 16.03 in the very high SVI cohort). The death rate per 100 000 person-years was higher for each SVI category in states with permissive compared with restrictive gun laws (eg, moderate SVI: 3.37 vs 1.71; high SVI: 6.33 vs 3.78)., Conclusions and Relevance: In this study, socially vulnerable communities in the US experienced a disproportionate number of assault-related firearm deaths among youths. Although stricter gun laws were associated with lower death rates in all communities, these gun laws did not equalize the consequences on a relative scale, and disadvantaged communities remained disproportionately impacted. While legislation is necessary, it may not be sufficient to solve the problem of assault-related firearm deaths among children and adolescents.

Objective: To characterize practices surrounding pediatric eCPR in the U.S. and Canada., Methods: Cross-sectional survey of U.S. and Canadian hospitals with non-cardiac eCPR programs. Variables included hospital and surgical group demographics, eCPR inclusion/exclusion criteria, cannulation approaches, and outcomes (survival to decannulation and survival to discharge)., Results: Surveys were completed by 40 hospitals in the United States (37) and Canada (3) among an estimated 49 programs (82% response rate). Respondents tended to work in >200 bed free-standing children's hospitals (27, 68%). Pediatric general surgeons respond to activations in 32 (80%) cases, with a median group size of 7 (IQR 5,9.5); 8 (20%) responding institutions take in-house call and 63% have a formal back-up system for eCPR. Dedicated simulation programs were reported by 22 (55%) respondents. Annual eCPR activations average approximately 6/year; approximately 39% of patients survived to decannulation, with 35% surviving to discharge. Cannulations occurred in a variety of settings and were mostly done through the neck at the purview of cannulating surgeon/proceduralist. Exclusion criteria used by hospitals included pre-hospital arrest (21, 53%), COVID+ (5, 13%), prolonged CPR (18, 45%), lethal chromosomal anomalies (15, 38%) and terminal underlying disease (14, 35%)., Conclusions: While there are some similarities regarding inclusion/exclusion criteria, cannulation location and modality and follow-up in pediatric eCPR, these are not standard across multiple institutions. Survival to discharge after eCPR is modest but data on cost and long-term neurologic sequela are lacking. Codification of indications and surgical approaches may help clarify the utility and success of eCPR., Competing Interests: Declaration of Competing Interest None of the authors has any conflicts of interest to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: The reported prevalence of tethered spinal cord in patients with anorectal malformations (ARMs) ranges from 9% to 64%. Practice patterns surrounding the diagnosis and management of tethered cord (TC) are suspected to vary, with consideration to the type of spine imaging, adjunct imaging modalities, what patients are offered surgical intervention, and how patients are followed after detethering. We sought to determine what consensus, if any, exists among pediatric neurosurgeons in the USA in terms of diagnosis and management of TC and, specifically, patients with TC and ARM., Methods: A survey was sent to members of the American Society of Pediatric Neurosurgeons (ASPN). Members of the ASPN received an email with a link to an anonymous REDCap survey that asked about their experience with detethering procedures, indications for surgery, diagnostic tools used, and follow-up protocols., Results: The survey was completed by 93 of the 192 ASPN members (48%). When respondents were asked about the total number of all simple filum detetherings they performed annually, 61% (N = 57) indicated they perform less than 10 for all TC patients. Ninety-three percent (N = 87) of neurosurgeons performed these procedures in patients with simple filum TC and ARM patients (TC + ARM) specifically. When asked about prophylactic detethering in those with a confirmed diagnosis of low-lying conus and with a filum fatty terminale, 59.1% (N = 55) indicated they would offer this to TC + ARM patients regardless of their age. Regarding preoperative workup for simple filum detethering, all respondents indicated they would order an MRI in both TC and TC + ARM patients, with a minority also requiring additional testing such as urodynamics, neurodevelopmental assessments, and anorectal manometry for both groups. When following patients postoperatively, almost all respondents indicated they would require clinical neurosurgical follow-up with a clinic visit (100% in all simple filum TC patients, 98.9% in fatty filum/low-lying conus TC + ARM patients), but there was wide variation in the use of other tools such as urological testing, neurodevelopmental assessment, and anorectal manometry., Discussion/conclusions: A wide variety of diagnostic criteria and indication for procedural intervention exists for management of TC patients with and without ARM. Further studies are needed to determine outcomes. Prospective protocols need to be developed and evaluated to standardize care for this patient population and determine best practices., (© 2022 S. Karger AG, Basel.)

Objectives: Distance to subspecialty surgical care is a known impediment to the delivery of high-quality healthcare. Extracorporeal life support is of benefit to pediatric patients with specific medical conditions. Despite a continued increase in the number of extracorporeal life support centers, not all children have equal access to extracorporeal life support due to geographic constraints, creating a potential disparity in healthcare. We attempted to better define the variation in geographic proximity to extracorporeal life support centers for pediatric patients using the U.S. Decennial Census., Design: A publicly available listing of voluntarily reporting extracorporeal life support centers in 2019 and the 2010 Decennial Census were used to calculate straight-line distances between extracorporeal life support zip code centroids and census block centroids. Disparities in distance to care associated with urbanization were analyzed., Setting: United States., Patients: None., Interventions: Large database review., Measurements and Main Results: There were 136 centers providing pediatric extracorporeal life support in 2019. The distribution varied by state with Texas, California, and Florida having the most centers. Over 16 million children (23% of the pediatric population) live greater than 60 miles from an extracorporeal life support center. Significant disparity exists between urban and rural locations with over 47% of children in a rural setting living greater than 60 miles from an extracorporeal life support center compared with 17% of children living in an urban setting., Conclusions: Disparities in proximity to extracorporeal life support centers were present and persistent across states. Children in rural areas have less access to extracorporeal life support centers based upon geographic distance alone. These findings may affect practice patterns and treatment decisions and are important to the development of regionalization strategies to ensure all children have subspecialty surgical care available to them, including extracorporeal life support., Competing Interests: Drs. Farr and Ricca disclosed government work. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Background: Given the rarity of pediatric surgical disease, it is important to consider available large-scale data resources as a means to better study and understand relevant disease-processes and their treatments. The Military Health System Data Repository (MDR) includes claims-based information for > 3 million pediatric patients who are dependents of members and retirees of the United States Armed Services, but has not been externally validated. We hypothesized that demographics and selected outcome metrics would be similar between MDR and the previously validated American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) for several common pediatric surgical operations., Methods: We selected five commonly performed pediatric surgical operations: appendectomy, pyeloplasty, pyloromyotomy, spinal arthrodesis for scoliosis, and facial reconstruction for cleft palate. Among children who underwent these operations, we compared demographics (age, sex, and race) and clinical outcomes (length of hospital stay [LOS] and mortality) in the MDR and NSQIP-P, including all available overlapping years (2012-2014)., Results: Age, sex, and race were generally similar between the NSQIP-P and MDR. Specifically, these demographics were generally similar between the resources for appendectomy (NSQIP-P, n = 20,602 vs. MDR, n = 4363; median age 11 vs. 12 years; female 40% vs. 41%; white 75% vs. 84%), pyeloplasty (NSQIP-P, n = 786 vs. MDR, n = 112; median age 0.9 vs. 2 years; female 28% vs. 28%; white 71% vs. 80%), pyloromyotomy, (NSQIP-P, n = 3827 vs. MDR, n = 227; median age 34 vs. < 1 year, female 17% vs. 16%; white 76% vs. 89%), scoliosis surgery (NSQIP-P, n = 5743 vs. MDR, n = 95; median age 14.2 vs. 14 years; female 75% vs. 67%; white 72% vs. 75%), and cleft lip/palate repair (NSQIP-P, n = 6202 vs. MDR, n = 749; median age, 1 vs. 1 year; female 42% vs. 45%; white 69% vs. 84%). Length of stay and 30-day mortality were similar between resources. LOS and 30-day mortality were also similar between datasets., Conclusion: For the selected common pediatric surgical operations, patients included in the MDR were comparable to those included in the validated NSQIP-P. The MDR may comprise a valuable clinical outcomes research resource, especially for studying infrequent diseases with follow-up beyond the 30-day peri-operative period.

Purpose: We aimed to describe the incidence, timing, and predictors of recurrence following inguinal hernia repair (IHR) in children., Methods: We used the TRICARE claims database, a national cohort of >3 million child dependents of members of the U.S. Armed Forces. We abstracted data on children <12y who underwent IHR (2005-2014). Our primary outcome was recurrence (ICD9-CM diagnosis codes). We calculated incidence rates for the population and stratified by age, time from repair to recurrence, and multivariable logistic regression to determine predictors., Results: Nine thousand nine hundred ninety-three children met inclusion criteria. Age at time of IHR was ≤1y in 37%, 2-3y in 23%, 4-5y in 16%, and 5-12y in 24%. Median follow-up time was 3.5y (IQR:1.6-6.1). 137 patients recurred (1.4%), with an incidence of 3.46 per 1000 person-years. Over half occurred in children 0-1y at repair (60%). The majority occurred within a year following repair (median 209 days [IQR:79-486]). Children 0-1y had 2.53 times greater odds of recurrence (compared to >5y). Children with multiple comorbidities had 5.45 times greater odds compared to those with no comorbidities., Conclusions: The incidence of recurrence following IHR is 3.46 per 1000 person-years. The majority occurred within a year of repair. Children ≤1y and those with multiple comorbidities were at increased risk., Level of Evidence: Prognosis Study, Level II., (Copyright © 2018 Elsevier Inc. All rights reserved.)