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Objective: Considerable variation in primary spontaneous pneumothorax (PSP) management exists in the pediatric population. This study aims to compare nationwide outcomes of children with PSP. Methods: The Nationwide Readmissions Database (2016 to 2018) was used to identify patients 1 to 18 years old with PSP. Trauma, secondary pneumothoraces, and elective admissions were excluded. Demographics and complications were compared among patients undergoing initial nonoperative management (NOM; observation or percutaneous drainage) or operative resection using standard statistical tests. Results: A total of 3,890 patients were identified with PSP (median age, 16 [interquartile range 14 to 17] years). Most (78%) underwent NOM, of which 17% failed requiring operative resection. Of the intent-to-treat cohort, 28% failed NOM during index admission or required repeat percutaneous drainage or operative resection on readmission. Patients treated by NOM had higher 30-day and overall readmission rates compared with operative resection (all P < 0.001). Ipsilateral recurrent pneumothorax was higher in those receiving NOM (13% vs 3%, P < 0.001). Patients from the lowest median household income quartile more frequently received NOM compared with the highest income quartile (82% vs 76%) with more readmissions. Conclusions: Patients with PSP who underwent initial NOM experienced higher readmission rates than those receiving operative resection. Furthermore, socioeconomic status was associated with the utilization of nonoperative versus operative management.

Due to the COVID-19 pandemic, numerous institutions converted medical education didactics to electronic formats including both live teleconference didactics and recorded faculty lectures. This study aims to compare the effect of recorded versus live teleconference didactic lectures on medical student examination scores during the surgery clerkship.Medical students completing the Surgery Clerkship received a weekly series of didactic lectures taught by faculty via a teleconference (2020-2021 academic year) or recorded format (2021-2022 academic year). Performance outcomes included weekly quizzes, National Board of Medical Examiners (NBME) Surgery Shelf Exam, and clerkship Objective Structured Clinical Examination (OSCE) scores.University of Miami Miller School of Medicine.All second- (MS2) and third-year (MS3) medical students completing the Surgery Clerkship over two academic years (n = 312).Students who received live teleconference lectures (n = 156) demonstrated higher average scores on weekly quizzes (89%) and the NBME shelf exam (76%) compared to those receiving recorded lectures (n = 156; 71% quiz, 70% shelf exam), both p0.001. There was a significant association with performance in the highest quartile (Q1) of weekly quiz scores and receiving live lectures (40% vs. recorded lectures 1%, p0.001). Comparing only MS3 students, mean weekly quiz scores and Q1 achievement were significantly higher (both p0.001) in the teleconference cohort with no significant difference in NBME shelf exam performance (p = 0.971). No difference in OSCE performance was observed between groups.These results suggest that synchronous teleconferences may be more effective than recorded lectures for achieving institutional learning objectives on the surgery clerkship without any negative impact on NBME shelf exam or clinical evaluation parameters. This information should be used to inform future institutional clerkship design and educational initiatives.

Gastrostomy tube (GT) placement for enteral access is one of the most common procedures for infants with numerous conditions such as congenital heart disease (CHD). Discrepancies in the literature exist regarding outcomes of newborns with CHD undergoing GT placement. This study sought to characterize postoperative outcomes and readmission complications in this patient population.The Nationwide Readmission Database was queried from 2010 to 2014 for all newborns who underwent GT placement during their index hospitalization. Newborns with or without CHD other than an isolated atrial or ventricular septal defect were compared using standard statistical tests. A propensity score-matched analysis was performed among newborns with or without CHD using100 covariates.Seven thousand seven hundred thirty six patients underwent GT placement. Newborns with CHD (27%) more frequently underwent open GT (59% versus 55%) and less frequently underwent laparoscopic (17% versus 19%) or percutaneous (24% versus 26%) GT placement compared to those without CHD, P = 0.043. GT-related complications on index admission were similar between groups (7% versus 7%, P = 0.770). Newborns with CHD had higher overall readmission rates (39% versus 31%), more GT-related readmission complications (7% versus 3%), and higher readmission costs ($35,787 versus $20,073) compared to newborns without CHD, all P 0.001. Laparoscopic GT was associated with the lowest rate of GT-related complications (0%) and overall readmission rates (27%) compared to open or percutaneous endoscopic gastrostomy (all P 0.001).Compared to newborns without CHD, newborns with CHD had higher rates of overall readmissions, readmission costs, and GT-related complications on readmission. The laparoscopic GT approach was underused despite fewer complications and readmissions.

Firearm injuries (GSW) in the pediatric population is a public health crisis. Little is known about the outcomes of damage control laparotomy (DCL) following abdominal GSW. This study aims to evaluate outcomes from abdominal GSWs in the pediatric population.The trauma registry from an urban Level 1 trauma was queried for pediatric (0-18 y) GSW was queried from September 2013 to June 2020. Demographics, clinical variables, outcomes, readmissions, and recidivism were analyzed.Abdominal GSW were identified in 83 patients (17% of all GSW). The median age was 16 [15-17], 84% were male and 86% Black. Violent intent accounted for 90% of GSW. The injury severity score was 16 [9-26] and 80% went directly from the resuscitation bay to the operating room. Laparotomy was required in 87% of patients, and surgery was not required in any patient initially managed nonoperatively. The most common complications were intraabdominal infection (20%), other infections (13%), and small bowel obstruction (8%). DCL with temporary abdominal closure was performed in 16% of laparotomies and was associated with a longer length of stay, more infections, but similar rates of readmission and mortality. Overall mortality was 13%, with all but one patient expiring in the resuscitation bay or the operating room. All patients who underwent DCL survived to discharge.Abdominal firearm injuries have high morbidity and mortality in the pediatric population. Damage control operations for abdominal GSWs are a valuable surgical option with similar outcomes to primary abdominal closure after initial injury survival.

Mycotic aneurysms are exceedingly rare in the pediatric population. The optimal surgical treatment for children with this disease is unclear as aneurysm resection and vascular reconstruction are uncommonly performed in young children. We present a unique case of a 21-month-old child with a complex cardiac history who presented with limb ischemia and was discovered to have thrombosis of the common femoral and superficial femoral artery. Groin exploration revealed a left common femoral and superficial femoral artery mycotic aneurysm that was successfully repaired with excision of the mycotic aneurysm, external iliac to profunda femoral artery vascular bypass using cryopreserved arterial allograft and femoral vein reconstruction. This case demonstrates successful vascular reconstruction can be performed in a young child with an Aspergillus mycotic aneurysm using cadaveric arterial allograft.

Motor vehicle collisions (MVCs) are the leading cause of unintentional death among children and adolescents; however, public awareness and use of appropriate restraint recommendations are perceived as deficient. We aimed to investigate the use of child safety restraints and examine outcomes in our community.We retrospectively queried a level 1 trauma registry for pediatric (0-18 y) MVC patients from October 2013 to December 2018. Demographic and clinical variables were recorded. Data regarding appropriate restraint use by age group were examined.Four hundred thirty-four cases of pediatric MVC were identified. Overall, 53% were improperly restrained or unrestrained. Sixty-two percent of car seat age and 51% of booster age children were improperly restrained or unrestrained altogether. Fifty-nine percent of back seat riding, seatbelt age were improperly restrained/unrestrained, with 26% riding in the front. Fifty-one percent of seatbelt-only adolescents were not belted. Black, non-Hispanic children were more often improperly restrained/unrestrained compared to Hispanics (63% versus 48%, P = 0.001). Improperly restrained/unrestrained children had higher injury severity (10% versus 4% Injury Severity Score25, P = 0.021), require operative/interventional radiology (33% versus 19%, P = 0.001), and be discharged to rehabilitation or skilled nursing facility (5.2% versus 1.5%, P = 0.033). Mortality in adolescents was higher among those unrestrained (5.2% versus 0.8%, P = 0.034).Although efforts to improve adherence to restraint regulations have greatly increased in the last decade, more than half of children in MVC are still improperly restrained. Injury prevention services and community outreach is essential to educate the most vulnerable populations, especially those with infants and toddlers, on adequate motor vehicle safety measures in our community.

Pyloromyotomy for hypertrophic pyloric stenosis (HPS) is one of the most common non-elective operations performed in the neonatal period. This project aims to explore outcomes of pyloromyotomy and compare differences between laparoscopic versus open pyloromyotomies in newborns diagnosed with HPS.The Nationwide Readmissions Database (NRD) from 2010 to 2014 was queried to identify patients diagnosed with HPS that underwent repair.In total, 30,915 children (18% female) underwent pyloromyotomy for HPS. Median length of stay for index admission was 2 days. A total of 212 (0.7%) patients required a redo pyloromyotomy. 127 (60%) were performed during index admission. Readmission rate at 30 days was 3% and 5% at one year, and 22% presented to a different hospital. The most common indications for readmission were feeding intolerance (24%), dehydration (10%), and malnutrition (10%). Patients from low-income households were more likely to present with malnutrition and weight loss (9% vs 4%, p0.001) and had higher readmission rates (8% vs 4%, p0.001). Laparoscopic pyloromyotomies accounted for 10% (n = 2951) of cases. Those undergoing laparoscopy were less likely to have electrolyte disturbances (41% vs 54%, p0.001) or weight loss (2% vs 11%, p0.001) on admission. The rate of open conversion was 1%. Intraoperative perforation was not more common in laparoscopic than open cases. Open pyloromyotomies had higher 30-day readmission rates and more surgical site infections.Complications from pyloromyotomies are rare. Although infrequent, the incidence of incomplete pyloromyotomy is higher than previously reported and more common with open approaches. Newborns from low-income households are more likely to present with advanced symptoms and have disproportionately higher rates of readmission.Level III TYPE OF STUDY: Treatment Study, retrospective.

Background: There are few nationwide studies comparing outcomes of open, laparoscopic (LAP), and percutaneous endoscopic (PEG) gastrostomy tube (GT) placement in the pediatric population. Materials...

Bicycle accidents are potentially preventable, and helmets can mitigate the severity of injuries. The purpose of the study it to investigate geo-demographic areas to establish prevention policies and targeted programs.From October 2013 to March 2020 all bicycle injuries at a Level 1 trauma center were collected for ages ≤18 years. Demographics, injuries, and outcomes were analyzed. Incidents were aggregated to zip codes and the Local Indicators of Spatial Association (LISA) statistic was used to test for spatial clustering of injury rates per 10,000 children.Over the 8-year time period, 77 cases were identified with an average age of 13±4 years, 83% male and 48% non-Hispanic white. The majority of patients (98%) were not wearing a helmet. Loss of consciousness was reported in 44% and 21% sustained a traumatic brain injury. Twenty-eight percent required ICU care and 36% required operative interventions. There was only 1 mortality in the cohort (1%).Injuries were more common in lower household income zip codes (Figure 1). Six zip codes encompassing several interstate exits and the connected heavy-traffic roadways comprise a statistically significant cluster of pediatric bicycle accidents (Figure 1).Low-income neighborhoods and those near major roadways held the highest risk for pediatric bicycle accidents. Use of helmets was extremely low in the patient population, with high rates of traumatic brain injury. With this information, targeted programs to address high-risk intersections, helmet access, and safety education can be implemented locally.

Purpose Congenital diaphragmatic hernia (CDH) is a congenital anomaly associated with lifelong multisystem morbidity. This study sought to identify factors contributing to hospital readmission after CDH repair. Methods The Nationwide Readmissions Database from 2010 to 2014 was used to identify patients with CDH who underwent surgical repair. Primary outcomes included all cause readmission at 30-days and 1 year and readmission for hernia recurrence. Patient and hospital factors were compared using chi-squared analysis. Results Five hundred eleven patients were identified with neonatal CDH. All repairs were performed at teaching hospitals via laparotomy in 59% (n = 303), thoracotomy in 36% (n = 183), and minimally invasive (MIS) repair in 5% (n = 25). The readmission rate within 30-days was 32% (n = 163), and 97% (n = 495) within 1 year. The most common conditions surrounding readmission were for gastroesophageal reflux (20%), CDH recurrence (17%), and surgery for gastrostomy tube and/or fundoplication (16%). Recurrence was significantly higher after MIS repair (48%) compared to those with open repair via either approach (16%), p Conclusions This is the first study to evaluate nationwide readmissions in newborns with CDH. Readmission is commonly due to CDH recurrence and reflux-associated complications. The recurrence rate is higher than previously reported and is more common after MIS and repair via thoracotomy. Level of evidence Level III treatment study.

OBJECTIVE Civilian gunshot wounds (GSWs) involving the skeletal spine and spinal cord in pediatric patients are fortunately rare. Nevertheless, their presentation mandates judicious evaluation, and their clinical outcomes remain poorly defined. Thus, the authors aimed to characterize the clinical course of this traumatic presentation in the pediatric population based on their institutional experience. METHODS A retrospective review of a level I trauma center database was performed for the period 2011–2021. Clinical data were included for patients aged ≤ 18 years who had presented with radiographic and clinical evidence of a GSW to the spine and had at least one documented follow-up at least 6 months after injury. The primary outcomes of the study were the categorization of gunshot injuries and the results of neurological and functional examinations. RESULTS A total of 13 patients satisfied the study selection criteria. The mean patient age was 15.7 ± 1.6 years, and all presentations were assault in nature. Most of the patients were male (n = 12, 92%) in gender, Black in race (n = 11, 85%), and from zip codes with a median household income below the local county average (n = 10, 77%). All patients presented with a minimum Glasgow Coma Scale score of 14. Examination at presentation revealed American Spinal Injury Association Impairment Scale (AIS) grade A in 3 cases (23%), grade B in 2 (15%), grade C in 1 (8%), grade D in 2 (15%), and grade E in 5 (38%). Gunshot injury involved all regions of the spine, most commonly the cervical and thoracic spine (n = 6 for each, 46%). In terms of skeletal injury, the most common injuries were to the facet (n = 10, 77%) and the pedicle (n = 8, 62%), with evidence of intracanal injury in 9 patients (69%). Neurosurgical intervention was pursued in 1 patient (8%). Overall, 7 patients (54%) experienced a complication during admission, and the median length of hospitalization was 12 days (range 1–88 days) without any mortality events. Within 90 days from discharge, 2 patients (15%) were readmitted to the hospital for further care. The mean follow-up was 28.9 months (range 6–74 months), by which only 1 patient (8%) had an improved AIS examination; all other patients remained at their initial AIS grade. CONCLUSIONS Pediatric GSWs involving the spine are typically nonfatal presentations, and their long-term functional outlook appears contingent on clinical examination findings at initial presentation. Although neurosurgical intervention is not necessary in most cases, judicious evaluation of radiographic and clinical examinations by a neurosurgical team is strongly recommended to optimize recovery.

Introduction Ultrasound (US) is an adjunct to history and clinical exam (CE) in the assessment of pediatric breast lesions. We sought to investigate the reliability of US and CE to predict final pathologic diameter (P). Methods A single institutional retrospective analysis of patients aged ≤18 years who underwent breast mass resection was performed. Data was collected and analyzed using SPSS. Results 88 patients met inclusion criteria with an average age at surgery of 16 ± 1.5 years. No malignancies were encountered. The largest mean diameter measured by final pathology (MPO) for all lesions was 4.1 ± 2.6 cm. Pathology encountered were fibroadenoma (83%, MPO 3.7 ± 1.7 cm), juvenile fibroadenoma (10%, MPO 7.0 ± 5.4 cm), and low-grade phyllodes tumor (3%, MPO 6.2 ± 3.8 cm). 67 patients had documented CE measurement with a mean diameter of 3.4 ± 1.8 cm. 62 patients underwent US with a mean diameter of 3.3 ± 1.6 cm. US and CE were accurate in determining P by Cronbach Alpha reliability testing. Conclusion US and CE are reliable measurements of P. The surgical utility of US when considering pediatric breast lesions is limited and should be individualized following pediatric surgical evaluation and CE.

Introduction The first COVID-19 cases occurred in the US in January of 2020, leading to the implementation of shelter in place. This study seeks to define the impact of shelter in place on the epidemiology of pediatric trauma. Methods We examined pediatric trauma admissions at 5 Level 1 and 1 Level 2 US pediatric trauma centers between January 1 and June 30, 2017–2020. Demographic and injury data were compared between pre– and post–shelter in place patient cohorts. Results A total of 8772 pediatric trauma activations were reviewed. There was a 13% decrease in trauma volume in 2020, with a nadir at 16 days following implementation of shelter in place. Injury severity scores were higher in the post–shelter in place cohort. The incidence of nonmotorized vehicle accidents and gunshot wounds increased in the post–shelter in place cohort. Conclusion We found an overall decrease in pediatric trauma volume following shelter in place. However, injuries tended to be more severe. Our findings help inform targeted injury prevention campaigns during future pandemics., Highlights • Shelter-in-place policies led to a 13% decrease in overall pediatric trauma volume. • Biggest decrease occurred in the 30 days surrounding the start of shelter in place. • Nonmotorized vehicle accidents and gunshot wounds increased with shelter in place. • Injury severity was higher among the shelter-in-place cohort compared to controls. • The incidence of nonaccidental trauma did not change with shelter in place.

Malrotation with midgut volvulus is a surgical emergency commonly encountered in pediatric surgical practice. Outcomes are excellent with timely diagnosis and treatment, but the development of bowel ischemia is associated with many negative consequences.The Nationwide Readmissions Database was used to identify patients 0-18 years (excluding newborns) with malrotation and midgut volvulus from 2010 to 2014. Demographics, procedures, and outcomes were compared by income group (highest quartile vs. lowest quartile) using standard statistical tests. Results were weighted for national estimates.Emergency surgery for midgut volvulus was performed in 572 patients. The majority (86%) underwent Ladd's procedure, while 14% required bowel resection and/or ostomy. Patients in the lowest income quartile were more likely to require bowel resection (18% vs. 8%, p = 0.03) or ostomy (9% vs. 2%, p = 0.015) compared to those in the highest income quartile. Low-income patients were more likely to experience prolonged hospital stay (8 [5-13] days vs. 6 [4-8] days, p0.001) and experience complications including infections (19% vs. 5%, p = 0.002), endotracheal intubation (18% vs. 4%, p0.001), and blood transfusions (13% vs. 3%, p = 0.003).Income disparity represents a major factor in surgical outcomes in children with midgut volvulus. A broad spectrum of clinical outcomes following surgery for midgut volvulus exists. Patients from lower-income communities are at significantly higher risk for numerous complications, negative outcomes, and higher resource utilization. These findings support additional investigations of practices to mitigate risk for low-income patients.Level III: Retrospective comparative study.

The purpose of this study was to identify the pattern of injuries that relates to abuse and neglect in children with burn injuries.The Nationwide Readmissions Database for 2010-2014 was queried for all patients aged less than 18 y admitted with burn injuries. The primary outcome was child maltreatment identified at the index admission. The secondary outcome was readmission for maltreatment. A subgroup analysis was performed on patients without a diagnosis of maltreatment during the index admission. Multivariable logistic regression was performed for each outcome.There were 57,939 admissions identified and 1960 (3.4%) involved maltreatment at the index admission. Maltreatment was associated with total body surface area burned20% (odds ratio (OR) 2.79, P 0.001) and burn of the lower limbs (OR 1.37, P 0.001). Readmission for maltreatment was found in 120 (0.2%), and the strongest risk factor was maltreatment identified at the index admission (OR 5.11, P 0.001). After excluding the patients with maltreatment identified at the index admission, 96 (0.17%) children were found to have a readmission for maltreatment that may have been present on the index admission and subsequently missed. The strongest risk factor was burn of the eye or ocular adnexa (OR 3.79, P = 0.001).This study demonstrates that a portion of admissions for burn injuries in children could involve maltreatment that was undiagnosed. Identifying these at-risk individuals is critical to prevention efforts.

This study aims to determine postoperative outcomes and readmissions in pediatric cholecystectomy with routine intraoperative cholangiogram (IOC) utilization.The Nationwide Readmissions Database 2010-2014 was queried for all pediatric cholecystectomies. A propensity score-matched analysis (PSMA) with over 30 covariates was performed between cholecystectomy alone (CCY) versus those with routine IOC (CCY + IOC, no biliary obstruction, dilatation, or pancreatitis). χ34,390 cholecystectomies were performed: 92% were laparoscopic, most were teenage females (75%, 15 years [13-17]) and did not undergo IOC (75%). Postoperative mortality rate was 0.1%. The PSMA cohort comprised of 1412 CCY and 1453 CCY + IOC. Patients with CCY alone had higher rates of 30-day (7% vs 5%), 1-year readmissions (13% vs 11%) and had higher rates of overall complications (22% vs 12%) compared with CCY + IOC, all p 0.05. Although uncommon, bile duct injuries were more prevalent in CCY (2% vs 0%, p 0.001), while there was no difference in readmissions for retained stones. Resource utilization was increased in CCY patients, likely due to increased complication rates.This nationwide PSMA suggests pediatric CCY with routine IOC is associated with decreased readmissions, overall resource utilization, complications, and bile duct injuries.Retrospective Comparative Study.Level III.

Firearm injuries (GSW) are a growing public health concern and leading cause of morbidity and mortality among children, yet predictors of injury remain understudied. This study examines the correlates of pediatric GSW within our county.We retrospectively queried an urban Level 1 trauma center registry for pediatric (0-18 years) GSW from September 2013 to January 2019, examining demographic, clinical, and injury information. We used a geographic information system to map GSW rates and perform spatial and spatiotemporal cluster analysis to identify zip code "hot spots."393 cases were identified. The cohort was 877% male, 87% African American, 10% Hispanic, and 22% Caucasian/Other. Injuries were 92% violence-related and 4% accidental, with 63% occurring outside school hours. Mortality was 12%, with 53% of deaths occurring in the resuscitation unit. Zip-level GSW rates ranged from 0 to 9 (per 1000 18 years) by incident address and 0-6 by home address. Statistically significant hot spots were in predominantly underserved African American and Hispanic neighborhoods.Geodemographic analysis of pediatric GSW injuries can be utilized to identify at-risk neighborhoods. This methodology is applicable to other metropolitan areas where targeted interventions can reduce the burden of gun violence among children.Retrospective study.Level III.

This study aims to analyze the relative risks for total thyroidectomies by comparing complication rates for total versus partial thyroidectomy in the pediatric population.We queried the Kids' Inpatient Database (KID) 1997-2012 for all cases of total (n = 3253) or partial (n = 2380) thyroidectomy. We then designed a propensity score matching model and compared total versus partial thyroidectomy based on surgical complications and outcomes.In our cohort, the median age was 16 years and 79% were females. Those treated at a specialty pediatric hospital or pediatric unit in a general hospital comprised 73% of all patients. The most common indications for surgery were malignancy (46%) and goiter (42%). The most common complications were hypocalcemia and nerve injury with an unweighted incidence of 9% (n = 174) and 3% (n = 57) respectively. When compared to partial thyroidectomy, total thyroidectomy was associated with increased rates of postoperative complications. Additionally, the median length of stay was significantly higher for total thyroidectomy patients.This is the largest analysis to date comparing outcomes for total versus partial thyroidectomy in the pediatric population. Surgeons should consider the increased rates of hypocalcemia and nerve injury complications when selecting total compared to partial thyroidectomy in children.

Fibrosarcoma is one of the most common nonrhabdomyosarcoma soft tissue sarcomas in the pediatric population. Surgical resection is the cornerstone of treatment; however, optimal factors regarding the extent of fibrosarcoma resection in localized versus regional disease is poorly understood.The Surveillance, Epidemiology, and End Results database was queried for patients who are 19 y old or younger with a diagnosis of fibrosarcoma from 1975 to 2016. Kaplan-Meier analyses were performed for disease-specific survival on clinical and pathologic variables. Multivariate analysis was performed based on significant predictors of disease-specific survival.There were 1290 patients (median age 13 [7-17] y) identified with fibrosarcoma. The overall survival rate at 20 y was 93%. Radical resection was performed on 22%, 40%, and 52% of patients with localized, regional, and distant Surveillance, Epidemiology, and End Results disease stage, respectively. Chemotherapy (P 0.001), radiation (P 0.001), histology (P 0.001), and stage (P = 0.004) were significant predictors of increased mortality using univariate Kaplan-Meier analysis. Most patients (86%) with localized or regional stage who underwent radiation had fibrosarcomas of nondermatofibrosarcoma histology (P 0.001). Dermatofibrosarcoma subtype comprised most radical resections (41%). Excluding distant stage, nondermatofibroma histology (hazard ratio 16.94, 95% confidence interval 3.77-76.01) and regional stage (hazard ratio 8.15, 95% confidence interval 2.93-22.69) were independent prognostic factors of mortality (both P 0.001). Radical resection was not a significant independent prognostic indicator of survival.Nondermatofibrosarcoma subtype is independently associated with increased mortality. Although surgery remains the mainstay of treatment, the extent of resection is not a predictor of survival for patients with the localized and regional stage of disease.

Down syndrome (DS) is the most common abnormality associated with Hirschsprung disease (HD). It has been suggested patients with HD and DS have worse outcomes, however the literature is controversial.The Kids' Inpatient Database (KID) from 2003 to 2012 was used to identify newborns with HD. Demographics, hospital characteristics, and outcomes were compared among patients with and without DS using standard statistical tests.There were 481 patients identified with HD, of which 45 (9%) had DS. Patients with DS were older at the time of first rectal biopsy (6 [3-11] days vs. 4 [3-6] days, p = 0.012). There were no differences in operative versus non-operative management in patients with and without DS (p = 0.706). Hospital length of stay was longer in the DS cohort (22 [13-33] days vs. 15 [10-24] days, p = 0.019), and patients with DS were more likely to have a concomitant diagnosis of wound infection (12% vs. 3%, p = 0.002) and necrotizing enterocolitis (14% vs. 5%, p = 0.018). The mortality rate for patients with DS was four times higher than those without DS (5% vs.0.8%, p = 0.018).In this nationwide cohort of patients with Hirschsprung disease, those with Down syndrome experienced delays in diagnosis and worse outcomes.Level III.Treatment study, retrospective comparative study.

Pediatric patients with Crohn's disease often require colectomies. The laparoscopic approach is considered safe, but there is little national data on outcomes and readmissions in this population.The Nationwide Readmissions Database was queried from 2010 to 2014 for patients ≤ 18 years who underwent colectomy for Crohn's disease during index admission. Patients were stratified by operative approach: laparoscopic versus open. Outcomes were compared with standard statistical methods.There were 2833 patients (47% female) who underwent a colectomy via laparoscopic (58%) vs. open (42%) approach. Index admissions were elective 55% of the time. Most operations were right hemicolectomy (86%), followed by total colectomy (8%). Of the study population, 489 (17%) were diverted with an ostomy. Readmission rates at 30 days and 1 year were 9% and 18%, respectively. The most common diagnoses at readmission were intra-abdominal infection (16%), small bowel obstruction (16%), and surgical site infection (9%). Laparoscopy was more commonly performed during elective admissions (63% vs. 44%), for patient with private insurance (72% vs. 39%), and for patients in the highest income quartile (66% vs. 48% in the lowest income quartile), all p0.001. Length of stay was longer on index admission for open colectomy (8[5-12] days vs. 6[4-11] days, p0.001), while cost was similar ($17,754[$12,375-$30,625] vs. $17,017[$11,219-$27,336], p = 0.104). There were no differences in readmission rate, intraabdominal infection or small bowel obstruction.In pediatric patients, laparoscopic colectomy for Crohn's disease is safe and is associated with shorter hospitalization and equivalent hospital costs compared to the open procedure. Socioeconomic disparities in laparoscopic utilization exist and warrant future investigation.Level III.

The August 30, 2018, US Food and Drug Administration advisory warned consumers to avoid eating, drinking, or handling food products prepared with liquid nitrogen (LN) (US FDA. Safety Alerts & Advisories: FDA Advises Consumers to Avoid Eating, Drinking, or Handling Food Products Prepared with Liquid Nitrogen at the Point of Sale. US Food and Drug Administration). We report on the case of a pediatric patient sustaining gastric perforation after ingestion of LN applied to food at the point of sale in the United States. "Dragon's Breath" is a popular snack of cereal puffs coated in LN giving the allusion of breathing smoke on ingestion. Instructions provided by vendors include avoidance of touching or drinking the liquid in the bottom of the cup. We report on a case of a 9-year-old girl presenting with peritonitis and gross pneumoperitoneum after consumption of Dragon's Breath with injury conferred secondary to LN ingestion. Intraoperative finding of a large perforation along the lesser curvature of the stomach was repaired primarily with an omental overlay. Her postoperative course was complicated by pneumonia and a surgical site infection. She was discharged 13 days after admission. A review of the literature of previous case reports of LN ingestion by intentional or accidental means is provided. This case report and review of the literature bring awareness of the dangers posed to pediatric patients exposed to LN applied at the point of sale.

Introduction: Surgery remains an important treatment modality for the management of pediatric Crohn's disease (CD). The objective of this study was to perform a comparative analysis of open right h...

The purpose of this study is to identify determinants of mortality and hospital readmission in infants born with esophageal atresia ± tracheoesophageal fistula.The Nationwide Readmissions Database (2010-2014) was queried for newborns with a diagnosis of esophageal atresia. Outcomes included mortality and readmissions at 30-day and 1-year.3157 patients were identified, of which 54% were male. 81% had an additional congenital anomaly, and 35% had VACTERL association. Overall mortality at index hospitalization was 11% (n = 360) and was significantly higher with additional congenital anomalies (13%), VACTERL (19%), and Spitz classification II/III (18%) vs. isolated esophageal atresia/tracheoesophageal fistula (4%), all p 0.001. After esophageal atresia repair (n = 2179), 10% (n = 212) were readmitted within 30 days and 26% (n = 563) within 1 year, with 17% admitted to different hospitals. Common diagnoses during readmission were GERD (54%), infections (42%), failure to thrive (17%), tracheomalacia (14%), and esophageal stricture (10%). Unplanned readmissions accounted for 85% of readmissions. A large number underwent operative procedures, most commonly esophageal dilation (17%) and fundoplication/gastrostomy (12%).Our study has uncovered a high likelihood of complications and unplanned readmission within the first year of life for newborns with esophageal atresia. Coordinated multidisciplinary care may help to decrease unnecessary readmissions and improve outcomes in this vulnerable population.Retrospective comparative analysis.Level III.

Pancreatic tumors are rare in children and limited data are available regarding incidence, treatment, and outcomes. We aim to describe patient and tumor characteristics and to report on survival of these diseases. Children with pancreatic tumors were queried from the National Cancer Database (2004–2014). The association between treatment and hazard of death was assessed using Kaplan–Meier method and Cox regression model. We identified 109 children with pancreatic tumors; 52% were male and median age at diagnosis was 14 years. Tumors were distributed as follows: pseudopapillary neoplasm (30%), endocrine tumors (27%), pancreatoblastoma (16%), pancreatic adenocarcinoma (16%), sarcoma (6%) and neuroblastoma (5%). Seventy-nine patients underwent surgery, of which 76% achieved R0 resection. Most patients (85%) had lymph nodes examined, of which 22% had positive nodes. Five-year overall survival by tumor histology was 95% (pseudopapillary neoplasm), 75% (neuroblastoma), 70% (pancreatoblastoma), 51% (endocrine tumors), 43% (sarcoma), and 34% (adenocarcinoma). On multivariable analysis, surgical resection was the strongest predictor of survival (HR 0.26, 95% CI 0.10–0.68, p

Background: Posterior sagittal anorectoplasty (PSARP) has been the standard for management of children with high anorectal malformations (ARMs). Recently, there has been an increase in the use of l...

Pediatric pelvic fractures are rare. The contribution of pelvic fracture pattern, risk factors for associated injuries, and mortality are poorly defined in this population.Patients aged 0-17 with pelvic fractures at a level I trauma center over a 20-y period were reviewed. Fracture patterns were classified according to the Young-Burgess classification when applicable. Fractures were analyzed for location, pubic symphysis or sacroiliac widening, and contrast extravasation.There were 163 pelvic fractures in 8758 admissions (incidence 2%). The most common associated injures were extremity fractures (60%, n = 98), abdominal solid organ (55%, n = 89), and chest (48%, n = 78), with the majority (61%, n = 99) sustaining injuries to multiple organs. Unstable fractures were associated with injures to the thorax (70% versus 40%), heart (15% versus 2%), and spleen (40% versus 18%), all P 0.05. Nonpelvic operative interventions were required in 45% (n = 73) and were more common in unstable fractures (36% versus 19%), contrast extravasation (63% versus 26%), sacroiliac widening (36% versus 20%), and sacral fractures (39% versus 13%), all P 0.05. Mortality was 13% and higher in males versus females (18% versus 5%), contrast extravasation (50% versus 3%), or sacroiliac/pubic symphysis widening (13% versus 2%) (all P 0.05). Male gender (OR 6.03), brain injury (OR 6.18), spine injury (OR 5.06), and cardiac injury (OR 35.0) were independently associated with mortality (all P 0.05).Pediatric pelvic fractures are rare but critical injuries associated with significant morbidity and need for interventions. Increasing fracture severity corresponds to injuries to other body systems and increased mortality.

Background Conjoined twins are rare developmental anomalies. There is a paucity of literature other than case reports and small case series. The aim of this study was to examine national outcomes and identify predictors of mortality in newborn conjoined twins. Methods We reviewed data on newborn conjoined twins from the Kids' Inpatient Database (1997–2012). Results A total of 240 patients were identified for a nationally weighted incidence of 1 per 100,000 live births. The majority of conjoined twins were female (n = 190 [81%]). The most commonly associated anomalies were cardiac (n = 87 [36%]), gastrointestinal (n = 41 [17%]), and abdominal wall (n = 32 [13%]) defects. Fifty-six (23%) patients underwent operative procedures, including 28 (12%) neonatal separation surgeries. The overall mortality rate was 61%; most deaths occurred within 24 hours (99 of 146 [68%]) to 48 hours (129 of 146 [88%]) after birth. Mortality was higher in female compared with male children (66% vs 38%, P = .025), premature compared with full-term children (72% vs 44%, P = .007), and in children with extremely low birth weight (95% vs 59%, P = .002). Congenital diaphragmatic hernias were seen in 15 (6%) patients and were uniformly fatal (100% vs 58%, P = .029). Mortality was highest in hospitals not designated as children’s hospitals (72%) compared with children’s hospitals (44%) (P = .007). Conclusion Conjoined twins are rare anomalies who are susceptible to extremely high perinatal mortality, especially in female children, those who are premature, or those who have low birth weight. These data support caring for these complex patients at hospitals equipped to care for this fragile population.

This study aims to compare the morbidity of open versus laparoscopic colectomy or proctocolectomy for pediatric patients with ulcerative colitis (UC) using national readmission outcomes.The 2010-2014 Nationwide Readmissions Database was used to identify patients18 years (excluding newborns) who underwent colectomy or proctocolectomy for UC. Patients with planned readmissions for staged procedures were excluded from readmission analysis. Demographics, hospital factors, and outcomes were compared by operative approach (open vs. laparoscopic) using standard statistical analysis. Results were weighted for national estimates.There were 1922 patients (51% female, age 13 ± 3 years) with UC who underwent colectomy or proctocolectomy during index admission. Most cases were performed open (54%) and as elective admissions (64%). Compared to open approach, laparoscopy was associated with shorter index hospital length of stay (8 [5-17] days vs. 9 [6-18] days, p = 0.015), fewer surgical site infections (2% vs. 2%, p = 0.022), and less post-operative gastrointestinal dysfunction (5% vs. 8%, p = 0.008). After stratifying to control for elective and unplanned index admissions, laparoscopic approach was associated with fewer small bowel obstructions during index hospitalizations in both elective (9% vs. 15%, p = 0.003) and unplanned (5% vs. 16%, p0.001) settings. Readmission for surgical site infection was also less common following laparoscopic approach in both elective (0% vs. 7%, p = 0.008) and unplanned (0% vs.7%, p = 0.017) settings.In pediatric patients with ulcerative colitis, laparoscopic colectomy or proctocolectomy is associated with shorter hospital length of stay, less post-operative complications, and improved readmission outcomes.