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IntroductionIn attempts to quell the spread of COVID-19, shelter-in-place orders were employed in most states. Increased time at home, in combination with parents potentially balancing childcare and work-from-home duties, may have had unintended consequences on pediatric falls from windows. We aimed to investigate rates of falls from windows among children during the first 6mo of the COVID-19 pandemic.MethodsPatients

Uninsured pediatric trauma patients are at increased risk of poor outcomes. The impact of the Patient Protection and Affordable Care Act (ACA) on pediatric trauma patients has not been studied. We hypothesized that the expansion of Medicaid coverage under the ACA was associated with increased insurance coverage and improved outcomes.Retrospective review of patients18 y old presenting to a level 1 pediatric trauma center 2009-2019. An interrupted time series analysis was performed to assess the impact of Medicaid expansion under the ACA in January 2014. The primary outcome was rate of insurance coverage. Secondary outcomes included in-hospital mortality, disposition, 30-day readmission, length of stay (LOS), and intensive care unit (ICU) LOS.A total of 5645 patients were evaluated, (pre-ACA n = 2,243, post-ACA n = 3402). Expansion of Medicaid was associated with minimal changes on insurance coverage. There a decrease in mortality (RR = 0.96, P = 0.0355) and a slight increase in disposition to a rehabilitation facility (RR = 1.02, P = 0.0341). There was no association with 30-day readmission (RR = 1.02, P = 0.3498). Similarly, expansion of Medicaid was not associated with change in LOS (estimate = -0.00, P = 0.8893). There was a slight decrease in ICU LOS (estimate = -0.03, P 0.0001).Medicaid expansion was associated with marginal changes in insurance coverage among pediatric trauma patients. We did not identify significant impacts on patient outcomes.

Background: Enterobius vermicularis infection of the appendix can mimic appendicitis. Limited studies exist on preoperative evaluation of pinworm positive patients. We predict pediatric patients with post-operative appendiceal pathology showing Enterobius infection are distinguishable from typical acute appendicitis using clinical, laboratory, and imaging findings. Materials and Methods: Single center retrospective review of appendectomy patients was performed. Patients with surgical pathology positive for pinworms were matched with case controls, examining symptoms, pediatric appendicitis score, physical exam, laboratory values, imaging findings and post-operative pathology. Results: Of 1153 patients, 13 had pinworms on final pathology. Compared to controls, Enterobiasis patients were more likely to present with fever (p

Management of undescended testes (UDT) has evolved over the last decade. While urologic societies in the United States and Europe have established some guidelines for care, management by North American pediatric surgeons remains variable. The aim of this systematic review is to evaluate the published evidence regarding the treatment of (UDT) in children.A comprehensive search strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Five principal questions were asked regarding imaging standards, medical treatment, surgical technique, timing of operation, and outcomes. A literature search was performed from 2005 to 2020.A total of 825 articles were identified in the initial search, and 260 were included in the final review.Pre-operative imaging and hormonal therapy are generally not recommended except in specific circumstances. Testicular growth and potential for fertility improves when orchiopexy is performed before one year of age. For a palpable testis, a single incision approach is preferred over a two-incision orchiopexy. Laparoscopic orchiopexy is associated with a slightly lower testicular atrophy rate but a higher rate of long-term testicular retraction. One and two-stage Fowler-Stephens orchiopexy have similar rates of testicular atrophy and retraction. There is a higher relative risk of testicular cancer in UDT which may be lessened by pre-pubertal orchiopexy.

IntroductionFirearms and motor vehicle collisions (MVC) are leading causes of mortality in children. We hypothesized that firearm injuries would have a higher mortality than MVCs in children and a higher level of resource utilization METHODS: Trauma patients

INTRODUCTION Identifying pediatric patients who may benefit from gastrostomy tube (GT) placement can be challenging. We hypothesized that many GTs would no longer be in use after 6 months. METHODS Inpatient GT placements in patients < 18 years old at a tertiary children's hospital from 9/2014 to 2/2020 were included. The primary outcome was GT use

Intracranial hemorrhage (ICH) can be a devastating complication of extracorporeal life support (ECLS); however, studies on the timing of ICH detection by head ultrasound (HUS) are from 2 decades ago, suggesting ICH is diagnosed by day 5 of ECLS. Given advancements in imaging and critical care, our aim was to evaluate if the timing of ICH diagnosis in infants on ECLS support has changed. Patients6 months old undergoing ECLS 2011-2020 at a tertiary care children's hospital were included. Primary outcome was timing of ICH diagnosis on HUS. Seventy-four infants underwent ECLS for cardiac (54%) or pulmonary (46%) indications. Venoarterial ECLS was most common (88%). Median ECLS duration was 6 days (range 1-26). Sixteen patients were diagnosed with ICH (21.6%), at a median of 2 days postcannulation (range 1-4). Nearly all were4 weeks old at cannulation (93.8%). In conclusion, one-fifth of infants developed ICH diagnosed by HUS while on ECLS, all within the first 4 days of ECLS, consistent with previous literature. Despite advances in critical care and imaging technology, the temporality of ICH diagnosis in infants on ECLS is unchanged.

BACKGROUND Traumatic diaphragmatic hernia (TDH) is rare in children, most often occurring following blunt thoracoabdominal trauma from high energy mechanisms, such as motor vehicle collisions (MVC). We performed a systematic review to describe injury details and management. METHODS Following PRISMA guidelines, a systematic literature search was performed to identify publications of blunt TDH in patients < 18 y old. Conflicts were resolved by consensus. Data were collected on demographics, TDH location, mechanism of injury, associated intraabdominal injuries (IAI), management, and outcomes. Denominators vary depending on number of patients with such information reported. RESULTS Fifty-eight articles were reviewed with 142 patients with TDH. The median age was seven y (range 0.25-16). Most were left-sided (85 of 126, 67.5%). MVC was the most common mechanism (66 of 142, 46.5%). IAI was present in 50.0% (57 of 114), most commonly liver injuries (25 of 57, 43.9%). Delayed diagnoses occurred in 49.6% (57 of 115, range 8 h-10 y), and were more common with right-sided TDH (76.0% versus 48.5%, P = 0.02). Chest radiography was 59.0% sensitive for TDH, while computed tomography sensitivity was 65.8%. Operative repair was performed on all surviving patients, and all underwent primary diaphragm repair. The overall mortality was 11.3% (n = 16), with four attributable to the TDH. There were no reported recurrences over a median follow-up of 12 mo. CONCLUSIONS Pediatric TDH is a rare diagnosis with a high rate of associated IAI and delayed diagnosis. Primary diaphragm repair was performed in all cases. Surgeons should maintain a high suspicion for diaphragm injury in blunt thoracoabdominal trauma.

Limited English proficiency (LEP) is associated with decreased access to healthcare. We hypothesized that LEP children with appendicitis would experience more delays in care than EP children.Retrospective review of patients18 y presenting to a tertiary pediatric hospital July 2014-July 2019 with appendicitis. LEP patients were compared to EP patients. The primary outcome was appendiceal perforation. Secondary outcomes included prior pediatrician or emergency department (ED) visits without definitive management, duration of symptoms, length of stay (LOS), initial operative or non-operative management, time from presentation to operation and return to the ED within 30 d. Multivariable regression was performed to evaluate LEP as a predictor of study outcomes.A total of 893 patients with appendicitis were identified, 15.6% (n = 140) had LEP. On multivariate regression LEP was not a significant predictor of appendiceal perforation (AOR 1.20, 95% CI 0.79, 1.80, P = 0.390). LEP was a significant predictor of a prior ED or pediatrician visit without definitive management (AOR 2.05, 95 % CI 1.05, 3.98, P= 0.034) and longer LOS (Coefficient 1.01, 95% CI 0.41, 1.61, P= 0.001). LEP was associated with a minimal increase in duration of pain prior to presentation that was not clinically significant and was not associated with initial operative or non-operative management or a significantly longer time between presentation and operation.LEP children did not experience higher rates of appendiceal perforation at our institution, but were more frequently initially evaluated by a pediatrician or at an ED and discharged without definitive management and had longer LOS.

BACKGROUND: Pediatric patients immobilized for certain procedures, such as extracorporeal membrane oxygenation (ECMO), are at high risk for developing hospital-acquired pressure injuries (HAPIs). PURPOSE: To evaluate the rate of HAPI occurrence in ECMO patients before and after implementation of prevention interventions. METHODS: Patients younger than 18 years of age who were placed on ECMO from January 2012 through March 2020 were identified, and patient data, including the development of a stage 3, 4, or unstageable pressure injuries, were abstracted. From August 2018 through December 2018, HAPI prevention interventions were implemented, which included targeted HAPI prevention and ECMO provider education, fluidized positioner provider education, and the addition of 2 wound care interventions for ECMO patients. RESULTS: Of the 120 ECMO patients identified, 5 (4.2%) developed a HAPI. All patients developed HAPI in the occipital region, and 1 patient developed an additional HAPI on their back. The median age of patients with HAPI was 1 month (interquartile range [IQR], 0.3–6.8 months). The median duration from ECMO cannulation to identification of HAPI was 9.5 days (IQR, 4.8–32.3 days). The median total run time was 4.9 days (IQR, 2.5-7.6 days): 8.5 days for patients who did develop a HAPI and 4.8 days for those who did not develop a HAPI (P = .02). The overall HAPI rate dropped from 4.8% of ECMO patients before quality improvement interventions to 0% of ECMO patients after quality improvement interventions. CONCLUSIONS: The development of stage 3, 4, or unstageable HAPIs in pediatric ECMO patients was low (4.2%) over the period studied (January 2012 through March 2020). As of the time of this writing, no HAPIs occurred after implementation of provider education in 2018.

OBJECTIVE: Long-Segment Hirschsprung Disease (LSHD) differs clinically from short-segment disease. This review article critically appraises current literature on the definition, management, outcomes, and novel therapies for patients with LSHD. METHODS: Four questions regarding the definition, management, and outcomes of patients with LSHD were generated. English-language articles published between 1990 and 2018 were compiled by searching PubMed, Scopus, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar. A qualitative synthesis was performed. RESULTS: 66 manuscripts were included in this systematic review. Standardized nomenclature and preoperative evaluation for LSHD are recommended. Insufficient evidence exists to recommend a single method for the surgical repair of LSHD. Patients with LSHD may have increased long-term gastrointestinal symptoms, including Hirschsprung-associated enterocolitis (HAEC), but have a quality of life similar to matched controls. There are few surgical technical innovations focused on this disorder. CONCLUSIONS: A standardized definition of LSHD is recommended that emphasizes the precise anatomic location of aganglionosis. Prospective studies comparing operative options and long-term outcomes are needed. Translational approaches, such as stem cell therapy, may be promising in the future for the treatment of long-segment Hirschsprung disease. LEVEL OF EVIDENCE: Level 3, 4

BackgroundTrauma is the leading cause of death in children. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides temporary hemorrhage control, but its potential benefit has not been assessed in children. We hypothesized that there are pediatric patients who may benefit from REBOA.MethodsTrauma patients

BackgroundSurgeons frequently care for children who have sustained gunshot wounds (GSWs). However, firearm safety education is not a focus in general surgery training. We hypothesised that firearm safety discussions do not routinely take place when children present to a trauma centre with a GSW.MethodA retrospective review of patients ResultsA total of 226 patients with GSWs were identified, 22% were unintentional and 63% were assault. Firearm safety discussions took place in 10 cases (4.4%). Firearm safety discussions were more likely to occur after unintentional injuries compared with other mechanisms (16.0% vs 1.3%, pConclusionAt a paediatric trauma centre, firearm safety discussions occurred in 4.4% of cases of children presenting with a GSW. There is a significant room for improvement in providing safety education interventions.

Introduction Opiates are often prescribed after pediatric operations despite safety concerns and lack of evidence confirming superiority compared to other pain control modalities. In this study, we use daily parental surveys to prospectively evaluate a strict non-opioid pain control strategy after laparoscopic appendectomy. Methods After IRB approval, children who underwent laparoscopic appendectomy for nonperforated acute appendicitis were recruited to the study. For these patients, our standard practice is to provide instructions to administer alternating acetaminophen and ibuprofen over-the-counter (OTC) postoperatively, and no opiate prescriptions are written. Parents of enrolled children received a daily RedCap survey via text message or e-mail on postoperative days (POD) 1 through 5 to prospectively assess pain control and medication usage. Trends were compared across postoperative days. Results One hundred twenty patients were enrolled in the study, and none received opiate prescriptions. Postoperative pain survey response rates were 54% on POD1, 47% on POD2, 35% on POD3, 34% on POD4, and 29% on POD5. Pain level was 4.7 ± 2.3 (out of 10) on POD1, and down-trended significantly each postoperative day to reach 0.7 ± 1.2 by POD5. On POD1, 85% of parents administered OTC medications, which reduced significantly to 14% by POD5. Parent-reported success rates to manage pain by OTC regimen were 85% on POD1, 94% on POD2, 91% on POD3, and 100% on POD4 and POD5. Conclusion Strict non-opioid pain control after appendectomy exhibits high performance based upon prospective parental surveys. This strategy should be implemented as standard of care and tested for application to other surgical conditions. Level of Evidence Level II.

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) are standard of care for pediatric choledocholithiasis. Patients typically undergo...

IntroductionThe COVID-19 pandemic has widespread effects, including enhanced psychosocial stressors and stay-at-home orders which may be associated with higher rates of child abuse. We aimed to evaluate rates of child abuse, neglect, and inadequate supervision during the COVID-19 pandemic.MethodsPatients ≤5y old admitted to a level one pediatric trauma center between 3/19/20-9/19/20 (COVID-era) were compared to a pre-COVID cohort (3/19/19-9/19/19). The primary outcome was the rate of child abuse, neglect, or inadequate supervision, determined by Child Protection Team and Social Work consultations. Secondary outcomes included injury severity score (ISS), mortality, and discharge disposition.ResultsOf 163 total COVID-era pediatric trauma patients, 22 (13.5%) sustained child abuse/neglect, compared to 17 of 206 (8.3%) pre-COVID era patients (P=0.13). The ISS was similar between cohorts (median 9 pre-COVID versus 5 COVID-era, P=0.23). There was one mortality in the pre-COVID era and none during COVID (P=0.45). The rate of discharge with someone other than the primary caregiver at time of injury was significantly higher pre-COVID (94.1% versus 59.1%, P=0.02). In addition, foster family placement rate was twice as high pre-COVID (50.0% versus 22.7%, P=0.10).ConclusionsThe rate of abuse/neglect among young pediatric trauma patients during COVID did not differ compared to pre-pandemic, but discharge to a new caregiver was significantly lower. While likely multifactorial, this data suggests that resources during COVID may have been limited and the clinical significance of this is concerning. Larger studies are warranted to further evaluate COVID-19's effect on this vulnerable population.

BackgroundThe COVID-19 pandemic has resulted in delays in presentation for other urgent medical conditions, including pediatric appendicitis. Several single-center studies have reported worse outcomes, but no state-level data is available. We aimed to determine the statewide effect of the COVID-19 pandemic on the presentation and management of pediatric appendicitis patients.Materials and methodsPatients < 18 years old with acute appendicitis at four tertiary pediatric hospitals in California between March 19, 2020 to September 19, 2020 (COVID-era) were compared to a pre-COVID cohort (March 19, 2019 to September 19, 2019). The primary outcome was the rate of perforated appendicitis. Secondary outcomes were symptom duration prior to presentation, and rates of non-operative management.ResultsRates of perforated appendicitis were unchanged (40.4% of 592 patients pre-COVID versus 42.1% of 606 patients COVID-era, P=0.17). The median symptom duration was 2 days in both cohorts (P=0.90). Computed tomography (CT) use rose from 39.8% pre-COVID to 49.4% during COVID (P=0.002). Non-operative management increased during the pandemic (8.8% pre-COVID versus 16.2% COVID-era, P < 0.0001). Hospital length of stay (LOS) was longer (2 days pre-COVID versus 3 days during COVID, P < 0.0001).ConclusionsPediatric perforated appendicitis rates did not rise during the first six months of the COVID-19 pandemic in California in this multicenter study, and there were no delays in presentation noted. There was a higher rate of CT scans, non-operative management, and longer hospital lengths of stay.

Background The need for chest X-rays (CXR) following large-bore chest tube removal has been questioned; however, the utility of CXRs following removal of small-bore pigtail chest tubes is unknown. We hypothesized that CXRs obtained following removal of pigtail chest tubes would not change management. Methods Patients Results 111 patients underwent 123 pigtail chest tube insertions; 12 patients had bilateral chest tubes. The median age was 5.8 years old. Indications were pneumothorax (n = 53), pleural effusion (n = 54), chylothorax (n = 6), empyema (n = 5), and hemothorax (n = 3). Post-pull CXRs were obtained in 121/123 cases (98.4%). The two children without post-pull CXRs did not require chest tube reinsertion. Two patients required chest tube reinsertion (1.6%), both for re-accumulation of their chylothorax. Conclusions Post-pull chest X-rays are done nearly universally following pigtail chest tube removal but rarely change management. Providers should obtain post-pull imaging based on symptoms and underlying diagnosis, with higher suspicion for recurrence in children with chylothorax.

Background Children are more likely to have urinary system injury after blunt abdominal trauma (BAT) because of anatomical vulnerabilities. Urinalysis (UA) is often performed during initial evaluation to screen for injury. The purpose of this study was to determine how often finding microscopic hematuria after BAT leads to further testing and whether this indicates a significant injury. Methods A retrospective review of children evaluated for BAT at Children's Health from 2013 to 2017 was performed. Patients included had microscopic hematuria on initial UA. Data collected included demographics, injury data, laboratory and imaging data, and outcomes. Analysis was performed using descriptive statistics, Fisher's exact, and independent t-test. Results Of 1059 patients treated for BAT during the study period, 203 (19%) exhibited microscopic hematuria on UA during the initial workup. Most UAs resulted after imaging was completed and did not impact management (158, 78%); twenty-two (14%) of these patients had urinary injury, which were diagnosed by imaging regardless of UA results. Forty-five (22%) patients were found to have microscopic hematuria that independently led to workup for urinary injury. Of these, nine patients had a urinary system injury: 6 low-grade renal and three bladder wall injuries, none of which required surgery. Those with and without urinary injury in this group underwent similar numbers of radiographic studies. Conclusions Microscopic hematuria on screening UA after BAT may lead to extensive workup, regardless of the presence of symptoms. In patients who receive cross-sectional abdominal imaging, preceding UA adds little to the clinical workup of children with BAT.

Nonaccidental trauma (NAT) is a leading cause of injury and death in early childhood. We sought to understand the association between insurance status and mortality in a national sample of pediatric NAT patients.We performed a retrospective cohort study using the 2012-2014 National Trauma Databank. We included children ≤18 y hospitalized with NAT (The International Classification of Diseases, Ninth Revision codes: E967-968). The primary exposure was insurance status (categorized as public, private, and uninsured). The primary outcome was emergency department or inpatient mortality from NAT.We identified 6389 children with NAT. Mean age was 1.6 y (standard deviation 3.7), with 41% female and 42% of an ethnic or racial minority. Most were publicly insured (77%), with 17% privately insured and 6% uninsured. Mean injury severity score (ISS) was 13.9 (standard deviation 10.3). Overall, 516 (8%) patients died following NAT. Compared to patients who survived, those who died were more likely to be younger (mean age 1.0 y versus 1.6 y; P 0.001), uninsured (13% versus 6%; P 0.001), transferred to a higher-care facility (57% versus 49%; P 0.001), and more severely injured (mean ISS 25.9 versus 12.8; P 0.001). After adjusting for age, race, transfer status, and ISS, uninsured patients had 3.3-fold (95% CI = 2.4-4.6) greater odds of death compared to those with public insurance. For every 1 point increase in ISS, children had 12% (95% CI = 11%-13%) increased adjusted odds of death.Pediatric patients without insurance had significantly greater odds of death following NAT, compared to children with public insurance. Knowledge that uninsured children comprise an especially vulnerable population is important for targeting potential interventions.

BackgroundAbusive head trauma (AHT) is a leading cause of morbidity and mortality among young children. We aimed to evaluate the long-term impact of AHT.MethodsUsing administrative claims from 2000-2018, children

BackgroundTraumatic abdominal wall hernia (TAWH) in children is an uncommon injury and most commonly occurs after blunt abdominal trauma. There is no consensus on the management of these rare cases. We performed a systematic review of the literature to describe injuries, management, and outcomes.Materials and methodsFollowing Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines, a systematic literature search of PubMed, Web of Science, Embase, and Google Scholar was performed to identify English-language publications of blunt TAWH in patients

Background There is growing concern regarding the impact of general anesthesia on neurodevelopment in children. Pre-clinical animal studies have linked anesthetic exposure to abnormal central nervous system development, but it is unclear whether these results translate into humans. The purpose of this systematic review from the American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice (OEBP) Committee was to review, summarize, and evaluate the evidence regarding the neurodevelopmental impact of general anesthesia on children and identify factors that may affect the risk of neurotoxicity. Methods Medline, Cochrane, Embase, Web of Science, and Scopus databases were queried for articles published up to and including December 2017 using the search terms “general anesthesia and neurodevelopment” as well as specific anesthetic agents. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to screen manuscripts for inclusion in the review. A consensus statement of recommendations in response to each study question was synthesized based upon the best available evidence. Results In total, 493 titles were initially identified, with 56 articles selected for full analysis and 44 included for review. Based on currently available developmental assessment tools, a single exposure to general anesthesia does not appear to have a significant effect on general neurodevelopment, although prolonged or multiple anesthetic exposures may have some adverse effects. Exposure to general anesthesia may affect different domains of development at different ages. Regional anesthetic techniques with the addition of dexmedetomidine and/or some intravenous agents may mitigate the risks of neurotoxicity. This approach may be performed safely in some patients and can be considered as an option in selected short procedures. Conclusion There is no conclusive evidence that a single short anesthetic in infancy has a detectable neurodevelopmental effect. Data do not support waiting until later in childhood to perform general anesthesia for single short procedures. With the complexities and nuances of different anesthetic methods, patients and procedures, the planning and execution of anesthesia for the pediatric patient is generally best accomplished by an anesthesiologist, ideally a pediatric anesthesiologist. Type of study Systematic review of level 1–4 studies. Level of evidence Level 1–4 (mainly level 3–4)

Objective The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations for the management of ileocolic intussusception in children. Methods The ClinicalTrials.gov, Embase, PubMed, and Scopus databases were queried for literature from January 1988 through December 2018. Search terms were designed to address the following topics in intussusception: prophylactic antibiotic use, repeated enema reductions, outpatient management, and use of minimally invasive techniques for children with intussusception. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available evidence. Results A total of 83 articles were analyzed and included for review. Prophylactic antibiotic use does not decrease complications after radiologic reduction. Repeated enema reductions may be attempted when clinically appropriate. Patients can be safely observed in the emergency department following enema reduction of ileocolic intussusception, avoiding hospital admission. Laparoscopic reduction is often successful. Conclusions Regarding intussusception in hemodynamically stable children without critical illness, pre-reduction antibiotics are unnecessary, non-operative outpatient management should be maximized, and minimally invasive techniques may be used to avoid laparotomy. Level of Evidence Level 3–5 (mainly level 3–4) Type of study Systematic Review of level 1–4 studies

BACKGROUND: Through 2015, the practice at our university based free-standing children’s hospital was to admit uncomplicated appendicitis patients for overnight observation post-operatively. Given the increasing body of evidence suggesting the safety and feasibility of same-day discharge after appendectomy for uncomplicated appendicitis, we elected to perform a prospective study evaluating the complication rates of same-day discharge compared to overnight observation at our institution, given our large volume of appendicitis. METHODS: Pediatric patients who underwent laparoscopic appendectomies for uncomplicated appendicitis in 2016 were analyzed. Data regarding demographics, admission, and discharge times and outcomes of complications, as well as readmissions, return to the emergency department, and nonscheduled clinic visits were collected and analyzing using chi-square and multivariate regression. Cost of stay data was obtained and analyzed using Mann-Whitney U test to compare non-parametric variables. RESULTS: Eight hundred and forty-nine laparoscopic appendectomies were performed for uncomplicated appendicitis during the study period, of which 382 resulted in same-day discharge and 467 in an admission for observation. Univariate analysis revealed no statistical difference between readmission rates for same day vs. observation (2 vs. 6 patients; P=0.21) or in emergency department visits within 30 days (22 vs. 27 patients; P=0.98). There was no difference in the number of surgical site infections or extra clinic visits. There was a significantly lower median cost of stay for patients discharged home the same day at 29,150 dollars (25,644, 32,276, IQR) compared to a median of 34,827 dollars (31,154, 39,457, IQR) (P

Background Tertiary referral centers provide specialty and critical care for patients presenting to hospitals that lack these resources. There is a notion among tertiary centers that outside hospitals are more likely to transfer uninsured or underinsured patients. We examined funding status of patients transferred to our tertiary pediatric hospital for surgical management of appendicitis, hypothesizing that transferred patients were more likely to have unfavorable coverage. Materials and methods The electronic medical record was queried for all cases of laparoscopic appendectomy at our hospital between 2011 and 2015. Insurance was grouped into three categories: commercial, Medicaid/Children's Health Insurance Plan, or none. Transferred patients were compared to patients who presented directly. Results A total of 5758 patients underwent laparoscopic appendectomy during the study period, of which 1683 (29.2%) were transfer patients. Transfer patients were more likely to be older, with a median age of 10.5 y versus 9.8 y in nontransferred patients (P ≤ 0.0001), and were more likely to be identified as non-Hispanic (50.0% versus 36.5%; P ≤ 0.0001). Insurance coverage was similar between groups. However, subgroup analysis of the hospitals that most frequently used our transfer services revealed a trend to transfer a higher proportion of Medicaid/Children's Health Insurance Plan patients. Conclusions Overall, pediatric patients transferred for laparoscopic appendectomy had similar insurance coverage to patients admitted directly, but subgroup analysis shows that not all centers follow this trend. Transfer patients were more frequently older and non-Hispanic. This builds upon the existing literature regarding the correlation of funding and transfer practices and highlights the need for additional research in this area.

Background Through 2015, the practice at our university based free-standing children's hospital was to admit uncomplicated appendicitis patients for overnight observation post-operatively. Given the increasing body of evidence suggesting the safety and feasibility of same-day discharge after appendectomy for uncomplicated appendicitis, we elected to perform a prospective study evaluating the complication rates of same-day discharge compared to overnight observation at our institution, given our large volume of appendicitis. Methods Pediatric patients who underwent laparoscopic appendectomies for uncomplicated appendicitis in 2016 were analyzed. Data regarding demographics, admission, and discharge times and outcomes of complications, as well as readmissions, return to the emergency department, and nonscheduled clinic visits were collected and analyzing using chi-square and multivariate regression. Cost of stay data was obtained and analyzed using Mann-Whitney U test to compare non-parametric variables. Results Eight hundred and forty-nine laparoscopic appendectomies were performed for uncomplicated appendicitis during the study period, of which 382 resulted in same-day discharge and 467 in an admission for observation. Univariate analysis revealed no statistical difference between readmission rates for same day vs. observation (2 vs. 6 patients; P=0.21) or in emergency department visits within 30 days (22 vs. 27 patients; P=0.98). There was no difference in the number of surgical site infections or extra clinic visits. There was a significantly lower median cost of stay for patients discharged home the same day at 29,150 dollars (25,644, 32,276, IQR) compared to a median of 34,827 dollars (31,154, 39,457, IQR) (P

Nonaccidental trauma (NAT) is a leading cause of pediatric mortality and disability. We examined our institution’s experience with NAT to determine if socioeconomic status is correlated with patient outcomes. NAT cases were reviewed retrospectively. Socioeconomic determinants included insurance status and race; outcomes included mortality, discharge disability and disposition. Correlations were identified using t test, Fisher’s exact test, and logistic regression. The cohort comprised of 337 patients, with an overall uninsured rate of 5.6%. This rate was achieved by insuring 64.7% of the cohort after admission. Non-survivors were more likely to have no insurance coverage (14.8% versus 4.8%, p = 0.041). Regression revealed that uninsured had 8 times (95% CI 1.7–38.7, p = 0.008) higher in-hospital mortality than those with insurance when controlling for injury severity. Additionally, injury severity score ≥ 15, transfer from outside hospital, need for ICU or operative treatment were predictive of mortality. Adjusted risk factors for severe disability at discharge did not include insurance status or race, while ISS ≥ 15 and ICU stay were predictive. There are significant associations of insurance status with pediatric NAT outcomes, highlighting that determinants other than disease severity may influence mortality and morbidity. High-risk patients should be identified to develop strategies to improve outcomes.

Diagnostic imaging in pediatric appendicitis may decrease rates of negative appendectomy and identify alternate pathologies. We compared imaging practices for children transferred from nonpediatric facilities versus directly admitted to our tertiary children's hospital for laparoscopic appendectomy, and assessed the diagnostic accuracy in each population based on final pathologic diagnosis.After institutional review board approval, all cases of laparoscopic appendectomy at our children's hospital during 2015 were reviewed. Demographic and clinical data were collected, including age, transfer status, imaging studies, and pathologic diagnosis. Imaging practices in patients transferred from adult centers were compared with those directly admitted.There were 1153 included patients who underwent laparoscopic appendectomy for acute appendicitis during the study period, with 242 (20.9%) presenting as transfers from nonpediatric facilities. Of these, 73.5% underwent preoperative computed tomography (CT), compared with 26.4% of nontransfer patients (P 0.000). All remaining patients received ultrasound (US). Despite variation in imaging strategies, rates of negative appendectomy were similar in transfer and nontransfer groups (1.7% versus 2.0%, respectively, P = 0.744). There were marginal differences in sensitivity of US and CT to detect appendix features between the transferring and referral centers.Our results show that nonpediatric facilities use CT more frequently to diagnose pediatric appendicitis. Rates of nontherapeutic surgery were equivalent between transferred and directly admitted patients, which is likely related to high performance of both imaging strategies. Transferring centers should strive to rely more heavily on US, which may require education and development of improved pediatric US capacity.

Background Mucosal appendicitis is a controversial entity that is histologically distinct from transmural appendicitis. There is mixed opinion regarding mucosal inflammation as a spectrum of appendicitis versus a negative appendectomy. The ability to distinguish these diagnoses preoperatively is of importance to prevent unnecessary surgery. We hypothesize that patients with mucosal appendicitis can be discriminated from those with transmural disease based on specific preoperative clinical and imaging findings. Materials and methods After IRB approval, all patients who underwent laparoscopic appendectomy at our institution during 2015 were reviewed in the electronic medical record. Patients with mucosal appendicitis were identified and matched 2:1 to a random cohort of nonperforated transmural appendicitis cases. Demographic and clinical data were collected, including history, examination, laboratory, and imaging findings. Preoperative factors associated with mucosal appendicitis were modeled using binomial logistic regression analysis. Results Of 1153 appendectomies performed during 2015, 103 patients had pathologic diagnosis of mucosal appendicitis. When compared with patients with mucosal infection, leukocytosis >10,000 per microliter led to 5.9 times higher likelihood of transmural pathology (P = 0.000). Noncompressibility on ultrasound was associated with 7.3 times higher likelihood of transmural disease (P = 0.015). Echogenic changes were predictive of transmural appendicitis, conferring 3.9 times the risk (P = 0.007). Presence of free fluid led to 2.3 times the rate of transmural pathology (P = 0.007). Finally, for every millimeter decrease in appendiceal diameter, patients were half as likely to exhibit transmural disease (P = 0.000). Together, these variables can successfully predict presence of mucosal appendicitis on final pathology report at a rate of 82.1%, and explain 60% of the variance in diagnosis of mucosal versus transmural appendicitis (P = 0.000). Conclusions Mucosal appendicitis remains a controversial pathologic entity, but is not associated with greater complications compared with transmural appendicitis when treated with laparoscopic appendectomy. Transmural disease can be predicted by leukocytosis, noncompressible appendix, presence of free fluid, larger appendiceal diameter and echogenicity.

Introduction: Pediatric patients are immobilized for certain procedures such as extracorporeal membrane oxygenation (ECMO). These procedures place the patient at high risk for developing hospital acquired pressure injuries (HAPI). The purpose of this quality improvement initiative was to implement HAPI prevention interventions and provider education and to evaluate the rate of HAPI occurrence in ECMO patients before and after implementation. We hypothesized that the number of ECMO patients who developed a HAPI would decrease. Methods: All …

Background Appendicitis is the most common gastrointestinal pediatric surgical emergency. With the introduction of laparoscopic techniques in the 1990s, recovery, pain, and hospital stay after laparoscopic procedures have been significantly reduced. While many laparoscopic procedures are performed as outpatient surgeries, pediatric appendectomy patients continue to be hospitalized for postoperative observation. Our goal was to evaluate the safety and feasibility of same day discharge after laparoscopic appendectomy for uncomplicated appendicitis. Methods After IRB approval, all pediatric patients undergoing laparoscopic appendectomy during 2016 for noncomplicated appendicitis were eligible for the study. Decision for same day discharge was based on surgeon preference and parental agreement. Data regarding demographics, admission and discharge times, outcomes of complications, readmissions, return to the ED, and nonscheduled clinic visits were collected. Results A total of 1321 appendectomies were performed during the study period, of which 849 were uncomplicated and 382 were discharged same day. There were 2 readmissions, 4 superficial surgical site infections, 10 patients with nausea or vomiting, and 33 patients with pain control issues, 9 of whom presented to the ED. Conclusions Same day discharge for laparoscopic noncomplicated appendectomy is a safe and feasible alternative to postoperative admission and observation. This has the potential to yield significant healthcare cost savings. Level of Evidence Level II, Prospective Cohort Study.

A previously healthy 2-year-old boy presented to the emergency department with a decreased level of consciousness. A physical examination was unremarkable except for miosis and atypical limb movements. The patient underwent an extensive workup, including the search for metabolic, infectious, neurologic, and toxicologic etiologies. An abdominal ultrasound was performed because the child continued to remain neurologically impaired with no cause identified on other investigations. The ultrasound revealed a persistent uncomplicated ileoileal intussusception. The patient was taken to the operating room for surgical reduction. The child recovered fully postoperatively. This case illustrates the rare presentation of intussusception encephalopathy, which can be a diagnostic dilemma, especially when none of the symptoms of intussusception are present. Endogenous opioid poisoning is hypothesized to be the cause of the miosis and may hint at the diagnosis and aid in early management.

Background A link between childhood radiation and future cancer risks exists, and reduction of unnecessary radiation in childhood has been recommended. Pneumothoraces, pleural effusions, and many surgical procedures require placement of a chest tube/pigtail catheter. Traditional management is daily x-rays, with an x-ray after tube removal. Our hypothesis is the "post pull" x-ray rarely results in changing clinical management of the patient. Methods With IRB approval, a 5-year retrospective chart review was performed. Inclusion criteria were chest tube or pigtail placed for any reason with complete records. Data collected were demographics, reason for and duration of placement, number of x-rays done prior to and after removal. Primary outcome was whether the "post pull" x-ray changed clinical management. Results A total of 179 episodes were evaluated. Seventeen were excluded for incomplete data, or death/transfer of the patient with the tube in situ. Forty-nine tubes/pigtails were placed for pneumothorax, 48 for pleural effusion/empyema, 9 for hemothorax, and 51 during operative procedure. A median of 5 x-rays was done post insertion. 99% of the patients (160/162) had a "post pull" x-ray performed after tube removal. In 9 cases the x-ray changed patient management. Conclusions X-ray after chest tube/pigtail removal rarely changes patient management. We recommend considering imaging if there are clinical symptoms. Level of evidence Prognosis study, level II (retrospective cohort)

Objectives The primary aim of this retrospective study was to evaluate short-term (one-to-six months) and mid-term (six-to-forty-eight months) results of aortic valve-sparing procedures. The second endpoint was to compare the results with the group of patients undergoing mechanical aortic valve replacement during the same period. Methods Between April 2008 and May 2012 at our institution, we treated 76 patients either with ascending aorta/root aneurysm/dissection or with isolated aortic regurgitation. A total of seventy-six patients undergoing aortic valve surgery. Results Analyzed parameters were divided into two parts as function of time. In the first part, i.e. during hospitalization, the mortality, duration of hospitalization, duration of extra corporeal circulation (ECC), and duration of cardiac arrest (CA) were compared and assessed. In the second part, i.e. during monitoring of the patients after their discharge from hospital (one-to-six months, and six-to-forty-eight months), the grade of postoperative AR aimed mainly at the group of aortic valve-sparing operations (subgroups A1, A2, A3), postoperative peak gradient, presence of thromboembolic and bleeding complications, postoperative endocarditis and need for reoperation or hospitalization due to cardiac reasons were analyzed. Conclusion Based on our first experience, we believe that in spite of higher technical difficulty, the aortic valve-sparing operations can be possibly performed with the same or respectively lower rate of postoperative morbidity and mortality. Presented results show that compared with the aortic valve replacement, the aortic valve-sparing operation is a promising method, and an interesting therapeutic alternative for patients. After proper indications, we consider it to be a method of choice (Tab. 6, Fig. 7, Ref. 28).

Purpose Little is known about liveborn CDH patients who die without surgery. We audited a national CDH cohort to determine whether these patients were different from patients who received CDH repair. Methods A national CDH database was analyzed (2005–2009). After excluding infants with severe physiologic instability and genetic/congenital malformations, a potential surgical candidate (PSC) subgroup was identified. PSCs were compared to the operative group (OG) and the operative non-survivor (ONS) subgroup. Standard statistical analyses were performed. Results Of 275 liveborns, 35 (13%) died without surgery. The PSC subgroup ( n =11) had a median survival of 10days (range: 3–18). Ten of 11 PSC infants were treated in ECMO centers, with 4 receiving ECMO. No differences in BW, GA, and rates of minor malformation were observed between PSC and OG patients. While neonatal illness severity (SNAP-II) predicted overall mortality, SNAP-II scores were similar between PSC and ONS groups (34 vs. 29; p =0.431). Furthermore, greater than 80% of infants with SNAP-II scores between 30 and 39 survived in the OG cohort. Conclusion Our analysis demonstrated that PSCs were similar to infants offered surgery based on illness severity and the presence of congenital malformations. We suggest that criteria for surgical ineligibility be developed to standardize the selection of surgical candidates.

Delaying surgery for infants with CDH until they achieve clinical stability is common practice. Stability, however, is inconsistently defined, and many infants fail to reach pre-established criteria. We sought to determine if infants undergoing surgery without meeting pre-established criteria could achieve meaningful survival.All infants in the CAPSNet database were analyzed (2005-2010). Patients undergoing operative repair were divided into two groups based on whether they met strict (FiO20.40, conventional ventilation, preductal saturation92%, no inotropes or vasodilators), or lenient (FiO20.60, conventional ventilation, preductal saturation88%, no vasodilators) criteria. Univariate analyses were performed comparing characteristics of those who survived after surgery (N=273) with those who did not (N=21).294 patients (85%) survived to surgery. Predictors of post-operative survival included prenatal liver position (p=0.003), preoperative oxygen requirements (p=0.008), preoperative inotropes (p0.0001), and non-conventional ventilation (p=0.004). Infants meeting strict criteria had increased survival (99%; p0.0001). Infants meeting lenient criteria constituted 70% of survivors. Nearly one-third of survivors met neither strict nor lenient criteria.Infants with CDH can achieve good survival even when criteria for pre-operative stability are not met. We suggest that all infants should be repaired even if lenient criteria for ventilatory, inotrope, or vasodilator requirements are not achieved.

Background Whether children with pancreatic trauma should be managed non-operatively or operatively is controversial. We reviewed outcomes of high-grade pancreatic injuries at two high-volume pediatric surgical centres comparing non-operative and operative management strategies. Methods All pancreatic traumas presenting from January 1993 to July 2010 were reviewed. Patients with high-grade pancreatic injuries were stratified based on early operative or non-operative therapy. Baseline characteristics and outcomes were compared. Regression analyses were performed to assess complication rates, length of stay, and TPN duration while controlling for injury severity score and associated injuries. Results Of 77 patients with pancreatic injuries, 39 were grade 3 or higher. The mean ISS was 19.2 ± 10.8. Nineteen patients (50%) had associated injuries. Fifteen patients (38%) were managed operatively. Baseline characteristics were similar between groups other than ISS (p = 0.03). Duration of hospitalization (p = 0.01), days of TPN (p = 0.003), and overall complications (p = 0.007) were higher in non-operative patients. Controlling for both ISS and any associated injury, non-operative management was associated with more complications (OR 8.11; 95% CI 1.60–41.23) and was a significant predictor of prolonged TPN (13 days longer; p = 0.024). Conclusion Primary non-operative management of high-grade pancreatic injuries is associated with a significant increase in complications and TPN dependency. Early operative intervention should be pursued whenever feasible.

Background Management of asymptomatic congenital pulmonary airway malformations remains controversial when addressing the optimal timing of surgical resection. Neonatal resection is advocated by some based on the theory that earlier lobectomy results in greater compensatory lung growth. We examined whether age at lobectomy is correlated with better pulmonary outcomes as reflected by pulmonary function and exercise testing. Methods Patients who had lobectomy for congenital pulmonary airway malformation between 1985 and 2002 were identified and underwent detailed clinical history, physical examination, pulmonary function testing (total lung capacity, forced vital capacity, forced expiratory volume in 1 second), and exercise testing (power, maximal oxygen uptake [Vo 2 max]). Results Of 87 patients identified, 47 met the inclusion criteria, and 28 were tested prospectively. Age at the time of lobectomy ranged from 3 days to 56 months. There was no correlation between age at lobectomy and pulmonary function (total lung capacity, P = .408; forced vital capacity, P = .319; forced expiratory volume in 1 second, P = .174) or maximal work capacity (power, P = .280). There was a trend toward lower Vo 2 max in patients who had undergone lobectomy at an older age (Vo 2 max, P = .055). Conclusion Most children undergoing lobectomy have normal long-term pulmonary function. We found no correlation between age at lobectomy and future pulmonary function. Cardiopulmonary exercise testing should be considered in evaluating functional outcome in these patients.

Background Controversy persists about the need to admit patients after successful reduction of intussusception. Our hypothesis is that pediatric intussusception can be managed with discharge from the emergency department (ED) after reduction without increasing morbidity, yielding significant cost savings. Methods A chart review over 10years was performed at two Canadian institutions. Data abstracted included: demographics, length of stay (LOS), initial and recurrence management. Primary outcome was early recurrence and resultant management, including LOS and need for operative intervention. Costs were calculated using hospital-specific data. Results 584 patient records were assessed: 329 patients were managed with admission after reduction, 239 as outpatients. In the admission group, 28 patients had at least one recurrence (8.5%), with 8 after discharge. In the outpatient group, 21 patients had at least one recurrence (8.8%), with 19 after discharge. The difference post-discharge was significant (p=0.004). Outcomes of recurrence did not differ, with 2 patients in each group requiring operative intervention. Average LOS in the admission group was 90h, with additional average cost of $1771 per non-operated patient. Conclusions Pediatric intussusception can be safely managed as an outpatient with reliable follow up. Discharge from the ED reduces hospital charges without increasing morbidity. This approach should be considered in managing patients with intussusception.

Purpose The purpose of this study was to compare RCDH to LCDH from the perspective of prenatal diagnosis, illness severity, treatment, and outcome. Methods A retrospective study of all cases of CDH registered in the Canadian Pediatric Surgery Network (CAPSNet) database from 2005 to 2013 was conducted. Side of defect comparisons were made by prenatal diagnostic features, birth demographic data, intensity of medical treatment, timing and type of surgery, and outcomes. Outcomes prediction with logistic regression modeling using side of defect as an exploratory covariate was performed. Results The study cohort included 498 patients, of which 84 (17%) cases had RCDH. Prenatal diagnosis was more commonly made for LCDH. No difference existed in perinatal risk factors (GA, illness severity (SNAP-II) score, associated anomalies), preoperative treatment intensity (use of vasodilators, inotropes), timing of surgery, ventilation days, need for ECMO, LOS, and overall survival. Significant differences between RCDH and LCDH were detected for patch repair rate (48.2% vs. 30.6%; p =0.036) and recurrence (4.1% vs. 0.6%; p =0.038). Stepwise regression modeling identified side of hernia as independently predictive of need for patch. Conclusions Overall, little difference exists between RCDH and LCDH in terms of prognostic factors and outcomes.