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We describe a 7-year-old boy who sustained a blunt thoracic aortic injury following a rollover motor vehicle crash where the vehicle fell 200 feet down an embankment. The chest x-ray on arrival showed widening of the superior mediastinum, a left-sided hemothorax, and first rib fracture. The screening CTA of the chest revealed bilateral pulmonary contusions, a large left hemothorax, and evidence of aortic injury with active contrast extravasation. The patient was intubated due to respiratory distress and had a left chest tube placed. The patient became hypotensive with greater than 1.5 L of blood from the chest tube, so a resuscitative thoracotomy was performed. Bleeding was controlled with a sponge stick initially and definitively with a Satinsky vascular clamp. Next the patient was transported to the hybrid OR at the adjacent adult hospital with an open chest for endovascular graft placement. The patient was admitted to the PICU post-operatively, transferred to the floor on POD 4, and discharged home on POD 9. Aortic injury after blunt trauma in pre-adolescent children is uncommon and often fatal. Endovascular repair of traumatic thoracic aortic injury in adults is currently the standard of care, but there is a paucity of clinical data to guide management of these types of injuries in pediatric patients. [ABSTRACT FROM AUTHOR]

OBJECTIVES Using available literature, our aim was to design a firearm safety counseling protocol tool for dementia patients. DESIGN We conducted a literature review on firearm safety counseling by healthcare providers using several databases to inform the creation of our evidence‐based protocol. SETTING Roughly 5.7 million Americans currently live with some form of dementia with approximately 60% of persons with dementia (PWD) owning a firearm. The mental deterioration associated with dementia creates an opportunity for firearm abuse, misuse, and injury. Patient and family safety counseling from a healthcare provider is one potential opportunity for reducing the level of danger. This literature review identifies the available clinical guidelines for firearm safety for PWD and creates a firearm safety counseling protocol based on existing literature. PARTICIPANTS: Persons with dementia and their families or care takers. MEASUREMENTS Databases were searched using variations of the terms "Firearms," "Dementia," and "Alzheimer's disease." Studies were included for review if they provided either recommendations or guidelines for healthcare provider's counseling around firearm safety for PWD or their families. RESULTS: Search terms yielded 456 articles, of which 12 met inclusion criteria. Using the available literature, we developed a firearm safety counseling protocol that provides measurable means to assess risk and offer harm mitigation strategies for patients and their families. Mitigation strategies are based on Clinical Dementia Rating scale assessment at time of patient interaction and results of risk assessment. CONCLUSION: Providing standardized and effective clinical guidelines to healthcare providers who interact with firearm‐owning PWD can act as a means to reduce firearm injury and violence. The protocol proposed in this article needs further testing and validation to determine if it will help reduce firearm‐related events in PWD. [ABSTRACT FROM AUTHOR]

Background: Peripancreatic fluid collection and pseudocyst development is a common sequela following non-operative management (NOM) of pancreatic injuries in children. Our purpose was to review management strategies and assess outcomes.Methods: A multicenter, retrospective review was conducted of children treated with NOM following blunt pancreatic injury at 22 pediatric trauma centers between the years 2010 and 2015. Organized fluid collections were called "acute peripancreatic fluid collection" (APFC) if identified < 4 weeks and "pseudocyst" if > 4 weeks following injury. Data analysis included descriptive statistics Wilcoxon rank-sum, Kruskal-Wallis and t tests.Results: One hundred patients with blunt pancreatic injury were identified. Median age was 8.5 years (range 1-16). Forty-two percent of patients (42/100) developed organized fluid collections: APFC 64% (27/42) and pseudocysts 36% (15/42). Median time to identification was 12 days (range 7-42). Most collections (64%, 27/42) were observed and 36% (15/42) underwent drainage: 67% (10/15) percutaneous drain, 7% (1/15) needle aspiration, and 27% (4/15) endoscopic transpapillary stent. A definitive procedure (cystogastrostomy/pancreatectomy) was required in 26% (11/42). Patients with larger collections (≥ 7.1 cm) had longer time to resolution. Comparison of outcomes in patients with observation vs drainage revealed no significant differences in TPN use (79% vs 75%, p = 1.00), hospital length of stay (15 vs 25 median days, p = 0.11), time to tolerate regular diet (12 vs 11 median days, p = 0.47), or need for definitive procedure (failure rate 30% vs 20%, p = 0.75).Conclusions: Following NOM of blunt pancreatic injuries in children, organized fluid collections commonly develop. If discovered early, most can be observed successfully, and drainage does not appear to improve clinical outcomes. Larger size predicts prolonged recovery.Level Of Evidence: III STUDY TYPE: Case series. [ABSTRACT FROM AUTHOR]

Guns shows are estimated to account for 4-9% of firearm sales in the US. Increased regulation of firearm sales at gun shows has been proposed as one approach to reducing firearm injury rates. This study evaluated the association between gun shows and local firearm injury rates. Data regarding the date and location of gun shows from 2017 to 2019 were abstracted from the Big Show Journal. Firearm injury rates were estimated using discharges from trauma centers serving counties within a 25-mile radius of each gun show. Clinical data were derived from the National Trauma Databank (NTDB). We used Poisson regression modeling to adjust for potential confounders including seasonality. We evaluated injury rates before and after 259 gun shows in 23 US locations using firearm injury data from 36 trauma centers. There were 1513 hospitalizations for firearm injuries pre-gun show and 1526 post-gun show. The adjusted mean 2-week rate of all-cause firearm injury per 1,000,000 person-years was 1.79 (1.16-2.76) before and 1.82 (1.18-2.83) after a gun show, with an incident rate ratio of 1.02 (0.94, 1.08). The adjusted mean 2-week rate did not vary significantly by intent after a gun show, (p = 0.24). Within two weeks after a gun show, rates of hospitalization for all-cause firearm injury do not increase significantly within the surrounding communities. The relatively small increase in available firearms after a show and the short time horizon evaluated may account for the absence of an association between gun show firearm sales and local firearm injury rates. [ABSTRACT FROM AUTHOR]

Abstract: In this paper, we describe initial studies of the structure and dynamics associated with in bulk crystalline GaAs and Ge. At low temperatures in GaAs, the amplitude of the resonance signal at indicates that a large fraction (at least ) of the Li end up in locations with cubic symmetry (i.e. the tetrahedral interstitial and substitutional sites). The linewidth of the -NMR resonance increases dramatically above 150K, reaches a maximum at about 290K, and decreases again. This suggests that the Li starts to change its location, probably from an interstitial to a substitutional site, at . Experiments in Ge are also described. In this sample, a narrow resonance is seen at low temperatures that is likely due to Li located at an interstitial site. Near room temperature, it appears that Li is converting to another site. [Copyright &y& Elsevier]

Background: Traumatic pancreatic laceration with ductal injury in children can be managed non-operatively (NOM); however, variable management affects outcomes. We hypothesized that a standardized management approach with early feeding and limited resource utilization is safe and improves outcomes., Method: Prospective, multicenter study of 13 pediatric trauma centers (2018-2022). Children with blunt pancreatic trauma with ductal injury were managed per a standard NOM pathway. Outcomes were compared to a historical NOM cohort with variable management., Results: Of 22 patients, the median age was 7.5 years (range 1-14 years). Low-fat diet was started at median 4 days [IQR 2-7] and median hospital stay was 8 days [IQR 4-10]. One patient failed NOM and underwent distal pancreatectomy. Of the rest, most (17/21, 81%) had early recovery and discharged in median 6 days [IQR 4-8.25] while 4 (19%) had prolonged recovery (median stay 24 days, IQR 19.8-30.5) and higher peri-pancreatic cyst development (early 23.5% vs prolonged 75%,p = 0.05). Pancreatic ascites at presentation correlated with cyst development (p < 0.0001). Endoscopic stent (optional) was placed in 33% and did not prevent cyst development. Delayed exocrine pancreatic insufficiency was noted in 1 patient. Compared to the historic cohort (32 patients), TPN use was lower (pre-protocol 56% vs post 23%, p = 0.02), days to diet was shorter (pre-protocol 7 vs post 4; p = 0.03), and cyst development was lower (pre-protocol 81% vs post 33%, p < 0.001)., Conclusion: Children with traumatic pancreatic ductal injury can be safely managed per the PTS NOM clinical pathway and most recover rapidly. Pancreatic ascites may predict pseudocyst formation., Levels of Evidence: IV., Study Type: therapeutic, comparative., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Lecanemab and other new amyloid-targeting immunotherapies for Alzheimer disease show notable promise but may also pose significant risk for patients., Recent Findings: To facilitate the implementation and monitoring of lecanemab infusions at our tertiary medical center, we convened an interprofessional team. The team created a number of resources including patient handouts and medical documentation templates as well as systems and processes that are likely to be useful to other clinical care settings and centers., Implications for Practice: It is our intent to widely share the resources and processes developed., Competing Interests: K.W. Turk reports research funding from the Alzheimer's association, US Department of Veterans Affairs, the Doris Duke Foundation and Vox Neuro incorporated. A.E. Budson reports Eli Lilly: Consultant, VoxNeuro: investigator initiated grant, Bristol Myers Squbb: investigator initiated grant, Oxford University Press: author royalties. Elsevier: author royalties. The other authors report no disclosures relevant to the manuscript. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.TAKE-HOME POINTS→ An interdisciplinary team was assembled to facilitate the initial rollout of disease modifying therapies for AD.→ The team developed patient-facing and internal documents to streamline initial medication roll out effectively.→ The team also developed policies, procedures, and weekly review processes for initial eligibility screening.→ The team has developed processes for ongoing imaging and clinical review of patients receiving infusions.→ Processes and resources developed are being disseminated for use and adaptation by others., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.)

Background: A US survey of surgeons found that 32% store firearms unlocked and loaded. This study explored conditions and contexts impacting personal firearm storage methods among surgeons., Methods: We conducted semi-structured interviews with English-speaking fellows of the American College of Surgeons who treated patients injured by firearms and who owned or lived in homes with firearms. Participants were recruited through email and subsequent snowball sampling from April 2022 to August 2022. All interviews were audio-recorded and transcribed verbatim. Thematic analysis was applied to transcripts to identify codes. A mixed deductive and inductive approach was used for data reduction and sorting., Results: A total of 32 surgeons were interviewed; most were male and white. Dominant themes for firearm storage practices were based on (1) attitudes; (2) perceived norms; (3) personal agency; and (4) intention of firearm use. Personal agency often conflicted with attitudes and perceived norms for surgeons owning firearms for self-defence., Conclusions: Storage practices in this sample of firearm-owning surgeons were driven by intent for firearm use, coupled with attitudes, perceived norms and personal agency. Personal agency often conflicted with attitudes and perceived norms, especially for surgeons who owned their firearm for self-defence., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To compare rates of postoperative drainage and culture profiles in children with complicated appendicitis treated with the 2 most common antibiotic regimens with and without antipseudomonal activity [piperacillin-tazobactam (PT) and ceftriaxone with metronidazole (CM)]., Background: Variation in the use of antipseudomonal antibiotics has been driven by a paucity of multicenter data reporting clinically relevant, culture-based outcomes., Methods: A retrospective cohort study of patients with complicated appendicitis (7/2015-6/2020) using NSQIP-Pediatric data from 15 hospitals participating in a regional research consortium. Operative report details, antibiotic utilization, and culture data were obtained through supplemental chart review. Rates of 30-day postoperative drainage and organism-specific culture positivity were compared between groups using mixed-effects regression to adjust for clustering after propensity matching on measures of disease severity., Results: In all, 1002 children met the criteria for matching (58.9% received CM and 41.1% received PT). In the matched sample of 778 patients, children treated with PT had similar rates of drainage overall [PT: 11.8%, CM: 12.1%; odds ratio (OR): 1.44 (OR: 0.71-2.94)] and higher rates of drainage associated with the growth of any organism [PT: 7.7%, CM: 4.6%; OR: 2.41 (95% CI: 1.08-5.39)] and Escherichia coli [PT: 4.6%, CM: 1.8%; OR: 3.42 (95% CI: 1.07-10.92)] compared to treatment with CM. Rates were similar between groups for drainage associated with multiple organisms [PT: 2.6%, CM: 1.5%; OR: 3.81 (95% CI: 0.96-15.08)] and Pseudomonas [PT: 1.0%, CM: 1.3%; OR: 3.42 (95% CI: 0.55-21.28)]., Conclusions and Relevance: The use of antipseudomonal antibiotics is not associated with lower rates of postoperative drainage procedures or more favorable culture profiles in children with complicated appendicitis., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To quantify the association between insurance and hospital admission following minor isolated extremity firearm injury., Background: The association between insurance and injury admission has not been examined., Methods: This was an observational retrospective cohort study of minor isolated extremity firearm injury captured in the Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases in 6 states (New York, Arkansas, Wisconsin, Massachusetts, Florida, and Maryland) from 2016 to 2017 among patients aged 16 years or older. The primary exposure was insurance. Admitted patients were propensity score matched to nonadmitted patients on age, extremity Abbreviated Injury Score, and Elixhauser Comorbidity Index with exact matching within hospital to adjust for selection bias. A general estimating equation logistic regression estimated the association between insurance and odds of admission in the matched cohort while controlling for sex, race, injury intent, injury type, hospital profit type, and trauma center designation with observations clustered by propensity score-matched pairs within hospital., Results: A total of 8151 patients presented to hospital with a minor isolated extremity firearm injury between 2016 and 2017 in 6 states. Patients were 88.0% male, 56.6% Black, and 71.7% aged 16 to 36 years old, and 22.1% were admitted. A total of 2090 patients were matched on propensity for admission. Privately insured matched patients had 1.70 higher adjusted odds of admission and 95% confidence interval of 1.30 to 2.22, compared with uninsured after adjusting for patient and hospital characteristics., Conclusions: Insurance was associated with hospital admission for minor isolated extremity firearm injury., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Importance: Gangrenous, suppurative, and exudative (GSE) findings have been associated with increased surgical site infection (SSI) risk and resource use in children with nonperforated appendicitis. Establishing the role for postoperative antibiotics may have important implications for infection prevention and antimicrobial stewardship., Objective: To compare SSI rates in children with nonperforated appendicitis with GSE findings who did and did not receive postoperative antibiotics., Design, Setting, and Participants: This was a retrospective cohort study using American College of Surgeons' National Surgical Quality Improvement Program (NSQIP)-Pediatric Appendectomy Targeted data from 16 hospitals participating in a regional research consortium. NSQIP data were augmented with operative report and antibiotic use data obtained through supplemental medical record review. Children with nonperforated appendicitis with GSE findings who underwent appendectomy between July 1, 2015, and June 30, 2020, were identified using previously validated intraoperative criteria. Data were analyzed from October 2022 to July 2023., Exposure: Continuation of antibiotics after appendectomy., Main Outcomes and Measures: Rate of 30-day postoperative SSI including both incisional and organ space infections. Complementary hospital and patient-level analyses were conducted to explore the association between postoperative antibiotic use and severity-adjusted outcomes. The hospital-level analysis explored the correlation between postoperative antibiotic use and observed to expected (O/E) SSI rate ratios after adjusting for differences in disease severity (presence of gangrene and postoperative length of stay) among hospital populations. In the patient-level analysis, propensity score matching was used to balance groups on disease severity, and outcomes were compared using mixed-effects logistic regression to adjust for hospital-level clustering., Results: A total of 958 children (mean [SD] age, 10.7 [3.7] years; 567 male [59.2%]) were included in the hospital-level analysis, of which 573 (59.8%) received postoperative antibiotics. No correlation was found between hospital-level SSI O/E ratios and postoperative antibiotic use when analyzed by either overall rate of use (hospital median, 53.6%; range, 31.6%-100%; Spearman ρ = -0.10; P = .71) or by postoperative antibiotic duration (hospital median, 1 day; range, 0-7 days; Spearman ρ = -0.07; P = .79). In the propensity-matched patient-level analysis including 404 patients, children who received postoperative antibiotics had similar rates of SSI compared with children who did not receive postoperative antibiotics (3 of 202 [1.5%] vs 4 of 202 [2.0%]; odds ratio, 0.75; 95% CI, 0.16-3.39; P = .70)., Conclusions and Relevance: Use of postoperative antibiotics did not improve outcomes in children with nonperforated appendicitis with gangrenous, suppurative, or exudative findings.

Background: Firearms are commonplace in the United States, and one proposed strategy to decrease risk of firearm injury is to have physicians counsel their patients about safe firearm ownership. Current rates of firearm safety counseling by surgeons who care for injured people are unknown., Methods: This study used an anonymous cross-sectional survey derived from previously published survey instruments and was piloted (n = 13) at the annual meeting of the American Association for the Surgery of Trauma (2022). The finalized survey was distributed using a quick response code during two sessions at the 2022 American College of Surgeons Clinical Congress. Eligible participants included the surgeons and surgical trainees who attended these sessions., Results: One hundred fourteen individuals completed the survey (20% response rate), and a majority were male (n = 71 [62.3%]), attending surgeons (n = 108 [94.7%]), and specialized in acute care surgery (n = 72 [63.2%]). Few participants (n = 43 [37.7%]) reported counseling patients on firearm safety as part of their routine clinical practice; however, the majority (n = 102 [89.5%]) believed that surgeons should provide firearm safety counseling. Counseling rates did not vary significantly by age, sex, surgical specialty, or region of practice, but attitudes toward counseling did differ by firearm safety counseling practices ( p = 0.03) and region of practice (0.04). Noted barriers to counseling included lack of time (n = 47 [41.2%]), perceived lack of training (n = 43 [37.7%]), and lack of firearm knowledge/experience (n = 36 [31.6%])., Conclusion: Most surgeon respondents did not provide firearm safety counseling to their patients despite the fact the majority believed they should. This suggests that counseling interventions that do not solely rely on surgeons for implementation could increase the number of patients who receive firearm safety guidance during clinical encounters., Level of Evidence: Prognostic and Epidemiological; Level III., (Copyright © 2023 American Association for the Surgery of Trauma.)

Objective: To develop a severity-adjusted, hospital-level benchmarking comparative performance report for postoperative organ space infection and antibiotic utilization in children with complicated appendicitis., Background: No benchmarking data exist to aid hospitals in identifying and prioritizing opportunities for infection prevention or antimicrobial stewardship in children with complicated appendicitis., Methods: This was a multicenter cohort study using NSQIP-Pediatric data from 16 hospitals participating in a regional research consortium, augmented with antibiotic utilization data obtained through supplemental chart review. Children with complicated appendicitis who underwent appendectomy from 07/01/2015 to 06/30/2020 were included. Thirty-day postoperative OSI rates and cumulative antibiotic utilization were compared between hospitals using observed-to-expected (O/E) ratios after adjusting for disease severity using mixed effects models. Hospitals were considered outliers if the 95% confidence interval for O/E ratios did not include 1.0., Results: 1790 patients were included. Overall, the OSI rate was 15.6% (hospital range: 2.6-39.4%) and median cumulative antibiotic utilization was 9.0 days (range: 3.0-13.0). Across hospitals, adjusted O/E ratios ranged 5.7-fold for OSI (0.49-2.80, P=0.03) and 2.4-fold for antibiotic utilization (0.59-1.45, P<0.01). Three (19%) hospitals were outliers for OSI (1 high and 2 low performers), and eight (50%) were outliers for antibiotic utilization (5 high and 3 low utilizers). Ten (63%) hospitals were identified as outliers in one or both measures., Conclusions: A comparative performance benchmarking report may help hospitals identify and prioritize quality improvement opportunities for infection prevention and antimicrobial stewardship, as well as identify exemplar performers for dissemination of best practices., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Injury from a firearm is now the leading cause of death of children and youth under age 19 in the United States (U.S.) [1] and the incidence of these deaths continues to increase each year [2]. For every death from firearm violence, there are several young people who have been injured by a bullet but not killed. As pediatric surgeons, we are on the front lines of treating these young patients. We have the unforgettable memories of delivering the horrible news to parents in "quiet rooms." [3]. As these injuries fall within our scope of practice, it is incumbent on us as professionals to work to prevent these injuries, apply best practices and work for the best pathways to recovery for our patients who do survive. There is a diverse community of pediatric surgeons tackling this public health problem in a variety of ways [4]. In a pre-meeting symposium at the APSA 2023 Annual meeting, we brought together a community of pediatric surgeons working on this critical area. The following summarizes the presentations of the symposium, with topics including Risk Factors, Injury Prevention, Treatment, Public Initiatives, and National Collaborative Efforts. TYPE OF STUDY: Review Article, Proceedings of a Symposium. LEVEL OF EVIDENCE: 1 through 4 all presented., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To evaluate whether redosing antibiotics within an hour of incision is associated with a reduction in incisional surgical site infection (iSSI) in children with appendicitis., Background: Existing data remain conflicting as to whether children with appendicitis receiving antibiotics at diagnosis benefit from antibiotic redosing before incision., Methods: This was a multicenter retrospective cohort study using data from the Pediatric National Surgical Quality Improvement Program augmented with antibiotic utilization and operative report data obtained though supplemental chart review. Children undergoing appendectomy at 14 hospitals participating in the Eastern Pediatric Surgery Network from July 2016 to June 2020 who received antibiotics upon diagnosis of appendicitis between 1 and 6 hours before incision were included. Multivariable logistic regression was used to compare odds of iSSI in those who were and were not redosed with antibiotics within 1 hour of incision, adjusting for patient demographics, disease severity, antibiotic agents, and hospital-level clustering of events., Results: A total of 3533 children from 14 hospitals were included. Overall, 46.5% were redosed (hospital range: 1.8%-94.4%, P <0.001) and iSSI rates were similar between groups [redosed: 1.2% vs non-redosed: 1.3%; odds ratio (OR) 0.84, (95%,CI, 0.39-1.83)]. In subgroup analyses, redosing was associated with lower iSSI rates when cefoxitin was used as the initial antibiotic (redosed: 1.0% vs nonredosed: 2.5%; OR: 0.38, (95% CI, 0.17-0.84)], but no benefit was found with other antibiotic regimens, longer periods between initial antibiotic administration and incision, or with increased disease severity., Conclusions: Redosing of antibiotics within 1 hour of incision in children who received their initial dose within 6 hours of incision was not associated with reduction in risk of incisional site infection unless cefoxitin was used as the initial antibiotic., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The objective was to explore the hospital-level relationship between routine pre-discharge WBC utilization (RPD-WBC) and outcomes in children with complicated appendicitis., Methods: Multicenter analysis of NSQIP-Pediatric data from 14 consortium hospitals augmented with RPD-WBC data. WBC were considered routine if obtained within one day of discharge in children who did not develop an organ space infection (OSI) or fever during the index admission. Hospital-level observed-to-expected ratios (O/E) for 30-day outcomes (antibiotic days, imaging utilization, healthcare days, and OSI) were calculated after adjusting for appendicitis severity and patient characteristics. Spearman correlation was used to explore the relationship between hospital-level RPD-WBC utilization and O/E's for each outcome., Results: 1528 children were included. Significant variation was found across hospitals in RPD-WBC use (range: 0.7-100%; p < 0.01) and all outcomes (mean antibiotic days: 9.9 [O/E range: 0.56-1.44, p < 0.01]; imaging: 21.9% [O/E range: 0.40-2.75, p < 0.01]; mean healthcare visit days: 5.7 [O/E 0.74-1.27, p < 0.01]); OSI: 14.1% [O/E range: 0.43-3.64, p < 0.01]). No correlation was found between RPD-WBC use and antibiotic days (r = +0.14, p = 0.64), imaging (r = -0.07, p = 0.82), healthcare days (r = +0.35, p = 0.23) or OSI (r = -0.13, p = 0.65)., Conclusions: Increased RPD-WBC utilization in pediatric complicated appendicitis did not correlate with improved outcomes or resource utilization at the hospital level., Level of Evidence: III., Type of Study: Clinical Research., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Esophageal button battery ingestion is a significant problem that can lead to significant complications such as tracheoesophageal fistula, esophageal perforation, and aortoesophageal fistula. Due to this, prompt recognition and treatment is integral in the care of these patients., Methods: Patients who presented to a single institution from August 2015 to April 2022 with esophageal button battery ingestion were included in this study. All esophageal button battery ingestion patients were included in a clinical algorithm for Critical Airway Response Team (CART) activation in October 2019. Time from diagnosis to treatment was compared for pre-CART clinical algorithm implementation to post-CART., Results: Data on pre-CART patients (n = 6) and post-CART patients (n = 7) was collected. Including esophageal button battery ingestions to CART activations shortened the time from chest x-ray to button battery removal from 73 ± 32 min to 35 ± 11 min (p < 0.05)., Conclusion: These data highlight the importance of implementation of a clinical care algorithm to shorten the time from diagnosis to treatment in patients with esophageal button battery ingestion., Level of Evidence: III., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The COVID-19 pandemic had numerous negative effects on the US healthcare system. Many states implemented stay-at-home (SAH) orders to slow COVID-19 virus transmission. We measured the association between SAH orders on the injury mechanism type and volume of trauma center admissions during the first wave of the COVID-19 pandemic., Methods: All trauma patients aged 16 years and older who were treated at the American College of Surgeons Trauma Quality Improvement Program participating centers from January 2018-September 2020. Weekly trauma patient volume, patient demographics, and injury characteristics were compared across the corresponding SAH time periods from each year. Patient volume was modeled using harmonic regression with a random hospital effect., Results: There were 166,773 patients admitted in 2020 after a SAH order and an average of 160,962 patients were treated over the corresponding periods in 2018-2019 in 474 centers. Patients presenting with a pre-existing condition of alcohol misuse increased (13,611 (8.3%) vs. 10,440 (6.6%), p <0.001). Assault injuries increased (19,056 (11.4%) vs. 15,605 (9.8%)) and firearm-related injuries (14,246 (8.5%) vs. 10,316 (6.4%)), p<0.001. Firearm-specific assault injuries increased (10,748 (75.5%) vs. 7,600 (74.0%)) as did firearm-specific unintentional injuries (1,318 (9.3%) vs. 830 (8.1%), p<0.001. In the month preceding the SAH orders, trauma center admissions decreased. Within a week of SAH implementation, hospital admissions increased (p<0.001) until a plateau occurred 10 weeks later above predicted levels. On regional sub-analysis, admission volume remained significantly elevated for the Midwest during weeks 11-25 after SAH order implementation, (p<0.001)., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022. Published by Elsevier Ltd.)

Importance: The clinical significance of gangrenous, suppurative, or exudative (GSE) findings is poorly characterized in children with nonperforated appendicitis., Objective: To evaluate whether GSE findings in children with nonperforated appendicitis are associated with increased risk of surgical site infections and resource utilization., Design, Setting, and Participants: This multicenter cohort study used data from the Appendectomy Targeted Database of the American College of Surgeons Pediatric National Surgical Quality Improvement Program, which were augmented with operative report data obtained by supplemental medical record review. Data were obtained from 15 hospitals participating in the Eastern Pediatric Surgery Network (EPSN) research consortium. The study cohort comprised children (aged ≤18 years) with nonperforated appendicitis who underwent appendectomy from July 1, 2015, to June 30, 2020., Exposures: The presence of GSE findings was established through standardized, keyword-based audits of operative reports by EPSN surgeons. Interrater agreement for the presence or absence of GSE findings was evaluated in a random sample of 900 operative reports., Main Outcomes and Measures: The primary outcome was 30-day postoperative surgical site infections (incisional and organ space infections). Secondary outcomes included rates of hospital revisits, postoperative abdominal imaging, and postoperative length of stay. Multivariable mixed-effects regression was used to adjust measures of association for patient characteristics and clustering within hospitals., Results: Among 6133 children with nonperforated appendicitis, 867 (14.1%) had GSE findings identified from operative report review (hospital range, 4.2%-30.2%; P < .001). Reviewers agreed on presence or absence of GSE findings in 93.3% of cases (weighted κ, 0.89; 95% CI, 0.86-0.92). In multivariable analysis, GSE findings were associated with increased odds of any surgical site infection (4.3% vs 2.2%; odds ratio [OR], 1.91; 95% CI, 1.35-2.71; P < .001), organ space infection (2.8% vs 1.1%; OR, 2.18; 95% CI, 1.30-3.67; P = .003), postoperative imaging (5.8% vs 3.7%; OR, 1.70; 95% CI, 1.23-2.36; P = .002), and prolonged mean postoperative length of stay (1.6 vs 0.9 days; rate ratio, 1.43; 95% CI, 1.32-1.54; P < .001)., Conclusions and Relevance: In children with nonperforated appendicitis, findings of gangrene, suppuration, or exudate are associated with increased surgical site infections and resource utilization. Further investigation is needed to establish the role and duration of postoperative antibiotics and inpatient management to optimize outcomes in this cohort of children.

Background: Children who survive a suicide attempt are at greater risk of later dying by suicide. Firearm screening and provision of lethal means restriction counseling may improve the safety of this high-risk cohort. Our objective was to determine firearm screening rates among children hospitalized after suicide attempts. We also assessed the effects of templating firearm screening questions into the psychiatric consultation note., Methods: This retrospective pre- and postintervention study identified children <19 years old admitted after a suicide attempt from January 1, 2016 to March 1, 2020. In mid-2017, the psychiatry consult note incorporated a previously available optional firearm screening tool as an embedded field (intervention). The intervention effect on proportion of children at high risk screened for firearm access was assessed by interrupted time series analysis., Results: Of 26 088 total admissions, 357 met inclusion criteria. The majority were teenagers (15 years old, interquartile range 14 to 16), 275 were female (77%), and 167 were White (47%). Overall, 286 (80%) of patients had firearm access screening documentation. Of the 71 (20%) without screening, 21 (30%) were discharged from the hospital; 50 (70%) were transferred to psychiatric facilities. There was no significant difference in screening rates after the intervention (Intervention shift P = .74, slope P = .85)., Conclusions: Many children were not screened for firearm access after a suicide attempt requiring hospitalization despite the screening tool integration. Multidisciplinary quality improvement efforts are needed to ensure that this critical risk reduction intervention is implemented for all patients after a suicide attempt., (Copyright © 2022 by the American Academy of Pediatrics.)

Background: Abdominal gunshot wounds (GSWs) require rapid assessment and operative intervention to reduce the risk of death and complications. We sought to determine if time to the operating room (OR) might be a useful process measure for the assessment of trauma care quality. We evaluated the facility benchmark time to OR for patients with serious injury and whether this was associated with lower rates of complications and mortality., Methods: We evaluated time to OR for adult patients with an abdominal GSW presenting in shock to American College of Surgeons Trauma Quality Improvement Program centers from 2015 to 2020. We calculated the 75th percentile time to the OR for each center and characterized centers as average, slow, or fast. We compared patient and facility characteristics across outlier status, as well as risk-adjusted complications and mortality using hierarchical multivariable logistic regression models., Results: There were 4,027 patients in 230 centers that met the inclusion criteria. Mortality was 28%. There were 61 (27%) fast and 52 (23%) slow centers. The median time for slow centers was 83 minutes (68-94 minutes) compared with fast centers, 35 minutes (32-38 minutes). Injury Severity Score and emergency department vital signs were similar across centers. Fast hospitals had higher total case volumes, more cases per surgeon, and were more likely to be Level I centers. Patients cared for in these centers had similar risk-adjusted rates of complications and mortality., Conclusion: Time to OR for patients with abdominal GSWs and shock might be a useful process measure to evaluate rapid decision making and OR access. Surgeon and center experience as measured by annual case volumes, coupled with a rapid surgical response required through Level I trauma center standards might be contributory. There was no association between outlier status and complications or mortality suggesting other factors apart from time to the OR are of greater significance., Level of Evidence: Therapeutic/care management, Level IV., (Copyright © 2022 American Association for the Surgery of Trauma.)

Purpose: Describe the experience of one institution in modifying allogeneic blood transfusion protocols for AIS surgery in response to the results of ACS-NSQIP-PEDS comparative data in a retrospective cohort study., Methods: NSQIP data demonstrated that AIS patients at our hospital had a significantly greater risk of ALBT compared to similar institutions (OR 4.1). The ALBT protocol was then revised to initiate transfusion based on Hb/Hct level, clinical hypotension and/or discussion between surgeon and anesthesiologist. A retrospective analysis of perioperative ALBT and autologous cell salvage blood transfusion (CSBT) rates was performed for patients undergoing surgery before (Group A) and after (Group B) the implementation of the revised protocol., Results: Two hundred and ninety patients constituted the study cohort, with 92 patients in Group A and 198 in Group B. Average total blood transfusion (ALBT + CSBT) per patient was significantly lower for Group B than Group A (313 ml vs. 650 ml, p < 0.01). ALBT per patient of Group B was significantly lower than Group A (85 ml vs. 324 ml, p < 0.01). 48% of patients received ALBT in Group A compared to only 18% in Group B., Conclusion: Recognition of excessive allogeneic transfusion rates in our institution through comparative data from the ACS-NSQIP-PEDS database resulted in the modification of transfusion parameters that led to a decrease in allogeneic transfusion rates for AIS patients. The current study highlights the value of a large, well-curated surgical database in optimizing clinical protocols and potentially improving overall surgical morbidity., (© 2021. Scoliosis Research Society.)

Background: Acute appendicitis in children is the most common condition requiring urgent evaluation and surgery in the emergency department. At times, despite the appendix being seen on ultrasound (US), there can be discrepancy as to whether a patient has clinical appendicitis. Secondary findings suggestive of appendicitis can be helpful in identifying and evaluating these children., Objective: The aim of this study was to determine if specific US findings and/or laboratory results are predictive of appendicitis in children with a visualized appendix on US., Methods: A prospective study was conducted on children (birth to 18 years) presenting to the pediatric emergency department with suspected appendicitis who underwent right-lower-quadrant US. Ultrasound findings analyzed appendix diameter, compressibility, increased vascularity, presence of appendicolith, inflammatory changes, right-lower-quadrant fluid near the appendix, lower abdominal fluid, tenderness during US, and lymph nodes. Diagnosis was confirmed via surgical pathology., Results: There were 1252 patients who enrolled, 60.8 (762) had their appendix visualized, and 39.1 (490) did not. In children where the appendix was seen, 35.2% (268) were diagnosed with appendicitis. Among patients with a visualized appendix, the likelihood of appendicitis was significantly greater if the appendix diameter was 7 mm or greater (odds ratio [OR], 12.4; 95% confidence interval [CI], 4.7-32.7), an appendicolith was present (OR, 3.9; 95% CI, 1.5-10.3), inflammatory changes were seen (OR, 10.2; 95% CI, 3.9-26.1), or the white blood cell (WBC) count was 10,000/μL (OR, 4.8; 95% CI, 2.4-9.7). A duration of abdominal pain of 3 days or more was significantly less likely to be associated with appendicitis (OR, 0.3; 95% CI, 0.08-0.99). The absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less had a negative predictive value of 100%., Conclusions: When the appendix is seen on US but diagnosis of appendicitis is questioned, the absence of inflammatory changes, WBC count of less than 10,000/μL, and appendix diameter of 7 mm or less should decrease suspicion for appendicitis., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction Firearm homicide is a leading cause of violence-related death in the United States.Unfortunately, more than 80% of illegal firearm discharges are never reported to police by traditional means.ShotSpotter TM  (Newark, California) is an acoustic firearm event detection system that can localize gunfire, prompting police, and subsequent emergency medical services (EMS) presence. Previously reported healthcare effects of acoustic detection are speculative in nature. We sought to investigate Hartford, Connecticut's experience with ShotSpotter​​​​​​​ TM  given its smaller size and broad coverage.  Methods The three trauma centers in Hartford (two for adults and one for pediatric) collaborated with the Hartford Police to review outcomes of victims with acoustically detected gunshots and compare them to those who went undetected. We performed a retrospective review of patients who presented with gunshot wounds (GSW) over a 30-month period, from January 1, 2016 to June 30, 2018. Victim location and acoustic detection were reconciled by the police department and hospital staff independently. Patients were individually matched for location, prehospital response, treatment durations, and hospital outcomes. Results Of 387 GSW, 157 (40.6%) presented via EMS and were included in the sample. Of these, 89 correlated to a detection event (56.7%) and 68 had no correlating event (43.3%). These two groups had no difference in prehospital treatment times, scene and transport duration, and injury severity. Further, the need for surgery or transfusion, lengths of stay, and disposition, including mortality, did not differ. Conclusions Despite limited previous reports demonstrating conferred benefits to acoustic detection of gunshots, Hartford's experience showed no benefit. The potential for such systems to act as early warning systems is evident but may depend on a city's resources, geography, and technology., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Gontarz et al.)

Background: Firearm-related injuries and deaths continue to be a substantial public health burden in the US. The purpose of this study was to describe the results of a survey of US members of the American College of Surgeons (ACS) on their practices, attitudes, and beliefs about firearms and firearm policies. The survey was designed to gain a representative understanding of the views of all US ACS members to help inform ACS positions related to firearm injury prevention., Study Design: A professional survey firm was engaged to facilitate the design of the survey and to support a web-based platform. Data collection through an anonymous survey began in July 2018, with the survey closing in September 2018. Survey data were weighted and analyses included descriptive and bivariate statistics., Results: There were 54,761 ACS members invited to participate in the survey. Of those, 11,147 respondents completed the survey, for an overall response rate of 20.4%. Respondents were questioned on firearm experience, purpose of firearm ownership, opinions on firearm ownership, and importance of ACS support for specific firearm legislation. Survey results varied by practice and training location, practice type, military experience, gender, age, presence of children in the home, level of training, and race and ethnicity. Most survey respondents were ACS fellows (n = 7,579 [68%]), male (n = 8,671 [77.8%]), and White (n = 8,639 [77.5%]). Forty-two percent of respondents keep guns in their home. Seventy-five percent of respondents believe that it is very or extremely important for the ACS to support policy initiatives to lower the incidence of firearm injury., Conclusions: There is broad support among ACS members for many initiatives related to firearm injury prevention. The degree of support for these measures varies based on both the specific initiative and demographic characteristics. The results align with the ACS strategy of healthcare professionals working together to better understand and address the root causes of violence, and simultaneously working together to make firearm ownership as safe as reasonably possible., (Copyright © 2021. Published by Elsevier Inc.)

Background: As a part of its firearm injury prevention action plan, the American College of Surgeons (ACS) surveyed the entire US ACS membership regarding individual members' knowledge, experience, attitudes, degree of support for ACS Committee on Trauma (COT) firearm programs, and degree of support for a range of firearm injury prevention policies. This survey included questions regarding members' prevalence of firearm ownership, type of firearm(s) owned, type of firearm(s) in the home, personal reasons for firearm ownership, and methods of firearm/ammunition storage., Study Design: An email invitation to participate in an anonymous, 23-item survey on firearms was sent to all US ACS members (n = 54,761) by a contracted survey research firm. Cross tabulation of questionnaire items by demographic characteristics and chi-square analyses were performed with statistical significance p < 0.05., Results: The overall response rate was 20.4% (11,147/54,761). Forty-two percent of respondents keep firearms in their home (82% long guns, 82% handguns; 32% high-capacity magazine fed, semi-automatic rifles); 75% keep guns for self-defense/protection, 73% for target shooting; 39% store firearms unlocked, and 32% store guns unlocked and loaded. Results vary by practice/training location, practice type, military experience, sex, age, presence of children in the home, level of training, and race/ethnicity., Conclusions: A significant percentage of ACS members keep firearms in their home, and nearly one-third store firearms in an unlocked and loaded fashion. Safe storage is a basic tenet of responsible firearm ownership. These data present opportunities for engaging surgeons in efforts to improve safe firearm storage., (Copyright © 2021 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2020 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Purpose: Firearm injuries continue to be a common cause of injury for American children. This pilot study was developed to evaluate the feasibility of providing guidance about firearm safety to the parents of pediatric patients using a tablet-based module in the outpatient setting., Methods: A tablet-based questionnaire that included a firearm safety message based on current best practice was administered to parents of pediatric patients at nine centers in 2018. Parents were shown a firearm safety video and then asked a series of questions related to firearm safety., Results: The study was completed by 543 parents from 15 states. More than one-third (37%) of families kept guns in their home. The majority of parents (81%, n = 438) thought it was appropriate for physicians to provide firearm safety counseling. Two-thirds (63%) of gun owning parents who do not keep their guns locked said that the information provided in the module would change the way they stored firearms at home., Conclusion: Use of a tablet based firearm safety module in the outpatient setting is feasible, and the majority of parents are receptive to receiving anticipatory guidance on firearm safety. Further data is needed to evaluate whether the intervention will improve firearm safety practices in the home., Level of Evidence: Level III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Ultrasound (US) and laboratory testing are initial diagnostic tests for acute appendicitis. A diagnostic dilemma develops when the appendix is not visualized on US. Objective: To determine if specific US findings and/or laboratory results predict acute appendicitis when the appendix is not visualized. Methods: A prospective study was conducted on children (birth-18 yrs) presenting to the pediatric emergency department with suspected acute appendicitis who underwent right lower quadrant US. Children with previous appendectomy, US at another facility, or eloped were excluded. US findings analyzed: inflammatory changes, right lower quadrant and lower abdominal fluid, tenderness during US exam and lymph nodes. Diagnoses were confirmed via surgical pathology. Results 1252 subjects were enrolled, 60.8% (762) had appendix visualized and 39.1% (490) did not. In children where the appendix was not seen, 6.7% [33] were diagnosed with appendicitis. Among patients with a non-visualized appendix, the likelihood of appendicitis was significantly greater if: inflammatory changes in the RLQ (OR 18.0, 95% CI 4.5-72.1), CRP >0.5 mg/dL (OR 2.64, 95% CI 1.0-6.8), or WBC > 10 (OR 4.36, 95% CI 1.66-11.58). Duration of abdominal pain >3 days was significantly less likely associated with appendicitis in this model (OR 0.34, 95% CI 0.003-0.395). Combined, the absence inflammatory changes, CRP < 0.5 mg/dL, WBC < 10, and pain, ≤3 days had a NPV of 94.0%. Conclusion When the appendix is not visualized on US, predictors for appendicitis include the presence of inflammatory changes in the RLQ, an elevated WBC/CRP and abdominal pain <3 days., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background/purpose: Endoscopic retrograde cholangiopancreatography (ERCP) is an adjunct for pediatric pancreatic injury management, but its use and utility in pediatric patients are unclear. We set out to evaluate the use of ERCP and its effects on outcomes., Methods: A retrospective review was performed for children who had pancreatic injuries at 22 pediatric trauma centers between 2010 and 2015. ERCP details and outcomes were collected. Analysis was performed using descriptive statistics and Wilcoxon rank-sum tests., Results: ERCP was used at 14/22 centers for 26 patients. Indications were duct evaluation, duct leak control, pseudocyst, fistula, and stricture. ERCP altered management or improved outcomes in 13/26 (50%), most commonly in patients with ERCP for duct evaluation, stricture, and fistula. In patients managed nonoperatively, those with early endoscopic intervention (within one week of injury) with stent or sphincterotomy (n=9) had similar time to regular diet [median (IQR)]: [10 (7-211) vs 7 (4-12) days; p=0.55], similar hospital days: [12 (8-20) vs 11 (6-19) days, p=0.63], and similar time on parenteral nutrition: [17 (10-40) vs 10 (6-18) days; p=0.19] compared to patients who were only observed., Conclusions: In children with blunt pancreatic injury, ERCP can be useful to diagnose duct injury and for management of late complications such as stricture and fistula. However, early endoscopic intervention for pancreatic duct disruption may not improve outcome or expedite recovery. Further study is needed., Study Type: Retrospective Study; Treatment Study., Level of Evidence: III., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background/purpose: Billing and reimbursement for pediatric surgical services is a complicated process that has not been rigorously evaluated. This study evaluates pediatric surgery billing and reimbursement and compares the process between third party payors., Methods: The authors tracked all noncapitated bills from submission to final payment for all cases performed during 1 month. Data included operation, insurance type, amount billed, and amount collected. If payments were denied, the reasons were ascertained and the appropriateness verified. Chi-square and Student's t tests were used for comparisons., Results: The billing process for all noncapitated pediatric surgical cases during May 2000, was reviewed (n = 136). The majority of bills (79%) were paid outright. Of the rejected bills, 76% were denied inappropriately. Inappropriate denial of payment was most frequent among patients insured by Medicaid. Mean time to complete payment was longest among patients insured by managed care groups. Percent of total charges reimbursed for surgical services was significantly lower for patients insured by Medicaid and Health Maintenance Organizations (HMO)., Conclusions: A significant number of bills for pediatric surgical services are rejected inappropriately. Careful analysis of one's rejected bills can recoup up to 20% of revenue. HMO's and Medicaid are more likely to deny payment inappropriately, take longer to make payments, and reimburse less for pediatric surgical services.