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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

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

IntroductionFetal myelomeningocele (MMC) repair improves lower extremity motor function. We have previously demonstrated that augmentation of fetal MMC repair with placental mesenchymal stromal cells (PMSCs) seeded on extracellular matrix (PMSC-ECM) further improves motor function in the ovine model. However, little progress has been made in improving bowel and bladder function, with many patients suffering from neurogenic bowel and bladder. We hypothesized that fetal MMC repair with PMSC-ECM would also improve bowel and bladder function.MethodsMMC defects were surgically created in twelve ovine fetuses at median gestational age (GA) 73 days, followed by defect repair at GA101 with PMSC-ECM. Fetuses were delivered at GA141. Primary bladder function outcomes were voiding posture and void volumes. Primary bowel function outcome was anorectal manometry findings including resting anal pressure and presence of rectoanal inhibitory reflex (RAIR). Secondary outcomes were anorectal and bladder detrusor muscle thickness. PMSC-ECM lambs were compared to normal lambs (n=3).ResultsEighty percent of PMSC-ECM lambs displayed normal voiding posture compared to 100% of normal lambs (p=1). Void volumes were similar (PMSC-ECM 6.1ml/kg vs. normal 8.8ml/kg, p=0.4). Resting mean anal pressures were similar between cohorts (27.0mmHg PMSC-ECM vs. normal 23.5mmHg, p=0.57). RAIR was present in 3/5 PMSC-ECM lambs that underwent anorectal manometry and all normal lambs (p=0.46). Thicknesses of anal sphincter complex, rectal wall muscles, and bladder detrusor muscles were similar between cohorts.ConclusionOvine fetal MMC repair augmented with PMSC-ECM results in near-normal bowel and bladder function. Further work is needed to evaluate these outcomes in human 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.

IntroductionCongenital diaphragmatic hernia (CDH) repair is an area of active research. Large defects requiring patches have a hernia recurrence rate of up to 50%. We designed a biodegradable polyurethane (PU)-based elastic patch that matches the mechanical properties of native diaphragm muscle. We compared the PU patch to a non-biodegradable Gore-Tex™ (polytetrafluoroethylene) patch.MethodsThe biodegradable polyurethane was synthesized from polycaprolactone, hexadiisocyanate and putrescine, and then processed into fibrous PU patches by electrospinning. Rats underwent 4mm diaphragmatic hernia (DH) creation via laparotomy followed by immediate repair with Gore-Tex™ (n=6) or PU (n=6) patches. Six rats underwent sham laparotomy without DH creation/repair. Diaphragm function was evaluated by fluoroscopy at 1 and 4 weeks. At 4 weeks, animals underwent gross inspection for recurrence and histologic evaluation for inflammatory reaction to the patch materials.ResultsThere were no hernia recurrences in either cohort. Gore-Tex™ had limited diaphragm rise compared to sham at 4 weeks (1.3mm vs 2.9mm, p=0.003), but no difference was found between PU and sham (1.7mm vs 2.9mm, p=0.09). There were no differences between PU and Gore-Tex™ at any time point. Both patches formed an inflammatory capsule, with similar thicknesses between cohorts on the abdominal (Gore-Tex™ 0.07mm vs. PU 0.13mm, p=0.39) and thoracic (Gore-Tex™ 0.3mm vs. PU 0.6mm, p=0.09) sides.ConclusionThe biodegradable PU patch allowed for similar diaphragmatic excursion compared to control animals. There were similar inflammatory responses to both patches. Further work is needed to evaluate long-term functional outcomes and further optimize the properties of the novel PU patch in vitro and in vivo.Level of evidenceLevel II, Prospective Comparative Study.

Administration of antibiotics within an hour of incision is a common quality metric for reduction of surgical site infections (SSI). Many pediatric patients who undergo surgery for an acute intraabdominal infection are already receiving treatment antibiotics. For these patients, we hypothesized that additional prophylactic antibiotic coverage would not decrease rates of SSI.Single institution retrospective review of patients18 years old undergoing appendectomy or cholecystectomy 7/2014-7/2019. Patients were categorized based on administration of an additional prophylactic antibiotic to cover gram positive bacteria within an hour of incision. The primary outcome was SSI. Secondary outcomes were Clostridium difficile colitis, intraoperative allergic reaction and readmission within 30 days due to infection.Of 363 patients, 261 received pre-operative prophylactic antibiotics and 92 received treatment antibiotics only. There was no difference in rates of organ space SSI (4.3% no prophylaxis vs 4.4% prophylaxis, p = 0.97) or superficial SSI (1.1% no prophylaxis vs. 0.7% prophylaxis, p0.999). One patient who received prophylactic antibiotics was readmitted on post-operative day 29 with C. difficile colitis. There was no difference in rates of intraoperative allergic reaction or readmission.In pediatric patients receiving treatment antibiotics for acute intraabdominal infection, additional prophylactic antibiotics may not reduce SSIs.

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

Background: The inherent morbidity associated with fetal ovine models of myelomeningocele (MMC) has created challenges for long-term survival of lambs. We aimed to develop a fetal ovine surgical spinal exposure model which could be used to evaluate long-term safety after direct spinal cord application of novel therapeutics for augmentation of in utero MMC repair. Methods: At gestational age (GA) 100–106, fetal lambs underwent surgical intervention. Laminectomy of L5–L6 was performed, dura was removed, and an experimental product was directly applied to the spinal cord. Paraspinal muscles and skin were closed and the fetus was returned to the uterus. Lambs were delivered via cesarean section at GA 140–142. Lambs were survived for 3 months with regular evaluation of motor function by the sheep locomotor rating scale. Spinal angulation was evaluated by magnetic resonance imaging at 2 weeks and 3 months. Results: Five fetal surgical intervention lambs and 6 control lambs who did not undergo surgical intervention were included. All lambs survived to the study endpoint of 3 months. No lambs had motor function abnormalities or increased spinal angulation. Conclusion: This model allows for long-term survival after fetal spinal cord exposure with product application directly onto the spinal cord.

Resection of pediatric chest wall tumors can result in large defects requiring reconstruction for function and cosmesis. Multiple reconstructive methods have been described. We performed a systematic review of the literature to describe commonly used approaches and outcomes.A systematic literature search was performed for English-language publications describing chest wall tumor resection and reconstruction using implantable materials in patients ≤21 years, excluding soft tissue resection only, sternal resection, and reconstruction by primary repair or muscle flaps alone. Data were collected on diagnoses, reconstructive method, and outcomes. Rigid chest wall reconstruction was compared to mesh reconstruction.There were 55 articles with 188 patients included. The median age was 12 years. Most tumors were malignant (n = 172, 91.5%), most commonly Ewing's sarcoma (n = 65, 34.6%), followed by unspecified sarcomas (n = 34, 18.1%), Askin's tumor (n = 16, 8.5%; a subset of Ewing's sarcoma) and osteosarcoma (n = 16, 8.5%). A median of 3 ribs were resected (range 1-12). Non-rigid meshes were most common (n = 138, 73.4%), followed by rigid prostheses (n = 50, 26.6%). There were 19 post-operative complications (16.8%) and 22.2% of patients developed scoliosis. There were no significant differences in complications (20.5% rigid vs. 10.6% non-rigid, p = 0.18) or scoliosis (22.7% vs. 14.0%, p = 0.23) by reconstruction method, but complications after rigid reconstruction were more likely to require surgery (90.0% vs. 53.9%, p = 0.09). The median follow-up duration was 24 months.In this review of the literature, there were no significant differences in overall post-operative complications or scoliosis development by reconstruction method, yet complications after rigid reconstruction were more likely to require surgical intervention.Level IV.

BackgroundWhile fetal repair of myelomeningocele (MMC) revolutionized management, many children are still unable to walk independently. Preclinical studies demonstrated that research-grade placental mesenchymal stromal cells (PMSCs) prevent paralysis in fetal ovine MMC, however this had not been replicated with clinical-grade cells that could be used in an upcoming human clinical trial. We tested clinical-grade PMSCs seeded on an extracellular matrix (PMSC-ECM) in the gold standard fetal ovine model of MMC.MethodsThirty-five ovine fetuses underwent MMC defect creation at a median of 76 days gestational age, and defect repair at 101 days gestational age with application of clinical-grade PMSC-ECM (3×105 cells/cm2, n=12 fetuses), research-grade PMSC-ECM (3×105 cells/cm2, three cell lines with n=6 (Group 1), n=6 (Group 2), and n=3 (Group 3) fetuses, respectively) or ECM without PMSCs (n=8 fetuses). Three normal lambs underwent no surgical interventions. The primary outcome was motor function measured by the Sheep Locomotor Rating scale (SLR, range 0: complete paralysis to 15: normal ambulation) at 24h of life. Correlation of lumbar spine large neuron density with SLR was evaluated.ResultsClinical-grade PMSC-ECM lambs had significantly better motor function than ECM-only lambs (SLR 14.5vs. 6.5, p=0.04) and were similar to normal lambs (14.5vs. 15, p=0.2) and research-grade PMSC-ECM lambs (Group 1: 14.5vs. 15, p=0.63; Group 2: 14.5vs. 14.5, p=0.86; Group 3: 14.5vs. 15, p=0.50). Lumbar spine large neuron density was strongly correlated with motor function (r=0.753, p

BACKGROUND Hemorrhage is a leading cause of maternal death worldwide, with increased risk in women with abnormal placentation. Aortic balloon occlusion (ABO), including resuscitative endovascular balloon occlusion (REBOA), has been used for obstetrical hemorrhage for 20 years, and is associated with decreased operative blood loss, fewer transfusions, and lower rates of hysterectomy. However, the effect of aortic occlusion on fetal/neonatal outcomes is not well known. METHODS A literature review on ABO for obstetrical or traumatic hemorrhage was performed. Cases were included if fetal/neonatal outcomes were reported. Data was collected on timing of balloon inflation (pre or post-delivery), fetal/neonatal mortality, and Apgar scores. Secondary maternal outcomes included blood loss, need for hysterectomy, ABO-related complications, and mortality. RESULTS Twenty-one reports of aortic balloon occlusion in 825 cases of obstetrical hemorrhage were reviewed (nine case reports/series and twelve comparative studies). 13.5% (111/825) had aortic occlusion prior to delivery of the fetus. Comparative cohorts included 448 patients who underwent iliac artery balloon occlusion (n = 219) or no vascular balloon occlusion (n = 229). The most common neonatal outcome reported was Apgar scores, with no difference in fetal/neonatal outcomes between ABO and non-ABO patients in any study. One neonatal mortality occurred in the sole reported case of ABO use in a pregnant trauma patient at 24 weeks gestation. One maternal mortality occurred due to aortic dissection. Five comparative studies reported significantly decreased blood loss in ABO patients compared to non-ABO patients and fourstudies reported significantly lower rates of hysterectomy in ABO patients. ABO-related complications were reported in 1.6% of patients (13/825). CONCLUSION Obstetrical hemorrhage is a devastating complication, and aortic balloon occlusion may potentially decrease blood loss and reduce the hysterectomy rate without compromising fetal and neonatal outcomes. Further research is needed to determine the safety of pre-delivery aortic occlusion as this occurred in 14% of cases. TYPE OF STUDY Review. LEVEL OF EVIDENCE IV.

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.

Trauma during pregnancy is the leading non-obstetric cause of morbidity and mortality, and accounts for five per 1000 fetal deaths. Direct fetal injury due to trauma during pregnancy is rare, and limited information is available about how to optimize fetal outcomes after injury. Early recognition and appropriate management of direct fetal trauma may improve outcomes for the fetus. There are currently no available guidelines to direct management of the injured fetus. We provide a detailed literature review of the management and outcomes of direct fetal injury following blunt and penetrating injury during pregnancy, and describe a suggested initial approach to the injured pregnant patient with a focus on evaluation for fetal injury. We identified 45 reported cases of blunt trauma resulting in direct fetal injury, with 21 surviving past the neonatal period, and 33 of penetrating trauma resulting in direct fetal injury, with 24 surviving past the neonatal period. Prenatal imaging identified fetal injury in 19 cases of blunt trauma and was used to identify bullet location relative to the fetus in 6 cases. These reports were used to develop management algorithms for the injured fetus.

Background Myelomeningocele (MMC) is the congenital failure of neural tube closure in utero, for which the standard of care is prenatal surgical repair. We developed clinical-grade placental mesenchymal stromal cells seeded on a dural extracellular matrix (PMSC-ECM), which have been shown to improve motor outcomes in preclinical ovine models. To evaluate the long-term safety of this product prior to use in a clinical trial, we conducted safety testing in a murine model. Methods Clinical grade PMSCs obtained from donor human placentas were seeded onto a 6 mm diameter ECM at a density of 3 × 105 cells/cm2. Immunodeficient mice were randomized to receive either an ECM only or PMSC-ECM administered into a subcutaneous pocket. Mice were monitored for tumor formation until two study endpoints: 4 wk and 6 mo. Pathology and histology on all tissues was performed to evaluate for tumors. Quantitative polymerase chain reaction (qPCR) was performed to evaluate for the presence of human DNA, which would indicate persistence of PMSCs. Results Fifty-four mice were included; 13 received ECM only and 14 received PMSC-ECM in both the 4-wk and 6-mo groups. No mice had gross or microscopic evidence of tumor development. A nodular focus of mature fibrous connective tissue was identified at the subcutaneous implantation pocket in the majority of mice with no significant difference between ECM only and PMSC-ECM groups (P = 0.32 at 4 wk, P > 0.99 at 6 mo). Additionally, no human DNA was detected by qPCR in any mice at either time point. Conclusions Subcutaneous implantation of the PMSC-ECM product did not result in tumor formation and we found no evidence that PMSCs persisted. These results support the safety of the PMSC-ECM product for use in a Phase 1/2a human clinical trial evaluating fetal MMC repair augmented with PMSC-ECM.

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.

BackgroundThere is little information on the effects of Pseudomonas infection on outcomes in perforated appendicitis. As Pseudomonas is not covered by many empiric appendicitis antibiotic regiments, we hypothesized that children with Pseudomonas would have worse outcomes.MethodsPatients

Optimal management of pediatric perforated appendicitis remains a topic of active investigation. Our institutional clinical practice guidelines (CPGs) were modified to discontinue antibiotics on discharge for patients with normal white blood cell count (WBC) without left shift. We hypothesized that patients would receive fewer antibiotics without increased complications.Patients18 y old with perforated appendicitis who underwent laparoscopic appendectomy between November 1, 2016 and May 31, 2021 at a tertiary care children's hospital were included. Primary outcome was adverse events: postdischarge surgical site infection (SSI), 30-day emergency department (ED) visits, or readmissions. Outcomes were compared before and after CPG modification. Multivariable regression was performed to identify factors associated with SSI.There were 113 patients pre- and 97 patients post-CPG modification. 23.1% of patients in the pre-cohort had an elevated discharge WBC or left shift compared to 18.9% of patients in the post-cohort (P = 0.48). Significantly fewer patients were prescribed antibiotics on discharge in the post-cohort (70.8% pre versus 14.4% post, P 0.0001) and for fewer days (2 pre versus 0 post, P 0.0001). Total antibiotic days decreased significantly (6.1 pre versus 4.6 post, P 0.0001). There was an increase in postdischarge SSIs on univariate analysis (1.8% pre versus 9.3% post, P = 0.03), ED visits (9.7% pre versus 19.6% post, P = 0.04), and readmissions (5.3% pre versus 11.3% post, P = 0.13). On multivariable analysis, being in the post-cohort was not significantly associated with post-discharge SSIs after adjusting for sex, symptom duration, initial WBC, and discharge antibiotic duration (OR 0.25, 95% CI 0.04-1.4, P = 0.11).Modification of a pediatric perforated appendicitis clinical practice guideline to discontinue antibiotics on discharge with a normal WBC without left shift was effective in decreasing antibiotic duration. This was associated with an increase in SSIs on univariate analysis, which did not persist on multivariable analysis and requires further investigation.

BackgroundDrowning is a leading cause of death in children ≤5 years old. Detailed data on the epidemiology of drowning in this high-risk population can inform preventative efforts. We aimed to study trends in incidence and case fatality rates (CFR) in the USA among young children hospitalised after drowning.MethodsChildren ≤5 years old hospitalised in the USA after drowning were identified from the Kids Inpatient Database 2000–2016. Incidence and CFRs by calendar year, age, sex, race/ethnicity and hospital region were calculated. Trends over time were evaluated. Factors associated with fatal drowning were assessed.ResultsAmong 30 560 804 hospitalised children ≤5 years old, 9261 drowning cases were included. Patients were more commonly male (62.3%) and white (47.4%). Two years old had the highest incidence of hospitalisation after drowning, regardless of race/ethnicity, sex and region. Overall drowning hospitalisations decreased by 49% from 2000 to 2016 (8.38–4.25 cases per 100 000 children). The mortality rate was 11.4% (n=1060), and most occurred in children ≤3 years old (83.0%). Overall case fatality decreased between 2000 and 2016 (risk ratio (RR) 0.44, 95% CI 0.25 to 0.56). The lowest reduction in incidence and case fatality was observed among Black children (Incidence RR 0.92, 95% CI 0.75 to 1.13; case fatality RR 0.80, 95% CI 0.41 to 1.58).ConclusionsHospitalisations and CFRs for drowning among children ≤5 years old have decreased from 2000 to 2016. Two years old are at the highest risk of both fatal and non-fatal drowning. Disparities exist for Black children in both the relative reduction in drowning hospitalisation incidence and case fatality. Interventions should focus on providing equitable preventative care measures to this population.

Müllerian duct anomalies are rare in the general population, occurring in less than 3% of women, but much more prevalent in female patients with anorectal malformation, occurring in up to 30% of these patients. Unicornuate uterus with a rudimentary non-communicating horn is a congenital anomaly of Müllerian development which can be seen in isolation or in conjunction with other anomalies, with several case reports described in patients with VACTERL association. These anomalies may be asymptomatic until the patient develops dysmenorrhea or devastating obstetrical complications. We describe the successful surgical management of an obstructive Müllerian anomaly in a post-pubertal female patient with anorectal malformation.

Objective The COVID-19 pandemic has disrupted graduate medical education, impacting Accreditation Council for Graduate Medical Education (ACGME)-mandated didactics. We aimed to study the utility of 2 methods of virtual learning: the daily National Surgery Resident Lecture Series (NSRLS), and weekly “SCORE School” educational webinars designed around the Surgical Council on Resident Education (SCORE) curriculum. Design and Setting: NSRLS The National Surgery Resident Lecture Series was a daily virtual educational session initially led by faculty at an individual surgical residency program. Thirty-eight lectures were assessed for number of live viewings (March 23, 2020-May 15, 2020). SCORE School Attendance at eleven weekly SCORE educational webinars was characterized into live and asynchronous viewings (May 13, 2020-August 5, 2020). Each 1-hour live webinar was produced by SCORE on a Wednesday evening and featured nationally recognized surgeon educators using an online platform that allowed for audience interaction. Results: NSRLS There were a mean of 71 live viewers per NSRLS session (range 19-118). Participation began to decline in the final 2 weeks as elective case volumes increased, but sessions remained well-attended. SCORE School There were a range of 164-3889 live viewers per SCORE School session. Sessions have most commonly been viewed asynchronously (89.8% of viewings). Live viewership decreased as the academic year ended and then rebounded with the start of the new academic year (range 4.9%-27%). Overall, the eight webinars were viewed 11,135 times. Each webinar continues to be viewed a mean of 43 times a day (range 0-102). Overall, the eleven webinars have been viewed a total of 22,722 times. Conclusions Virtual didactics aimed at surgical residents are feasible, well-attended (both live and recorded), and have high levels of viewer engagement. We have observed that careful coordination of timing and topics is ideal. The ability for asynchronous viewing is particularly important for attendance. As the COVID-19 pandemic continues to disrupt healthcare systems, training programs must continue to adapt to education via virtual platforms.

This survey study evaluates the opinions of key stakeholders regarding the need and duration of postoperative opioids for pediatric surgical patients.

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.

Purpose Prescription drug monitoring programs (PDMPs) have been established to combat the opioid epidemic, but there is no data on their efficacy in children. We hypothesized that a statewide PDMP mandate would be associated with fewer opioid prescriptions in pediatric surgical patients. Methods Patients n = 158) to 10 months post-PDMP (n = 228). Interrupted time series analysis was performed to determine the effect of the PDMP on opioid prescribing. Results Over the 20-month study period, there was an overall decrease in the rate of opioid prescriptions per month (− 3.6% change, p p = 0.4). However, PDMP implementation was associated with a reduction in opioid prescriptions of greater than 5 days’ supply (− 2.7% per month, p = 0.03). Conclusion Opioid prescriptions declined in pediatric surgical patients over the study time period. State-wide PDMP implementation was associated with a reduction in postoperative opioid prescriptions of more than 5 days’ duration.

Introduction. Translational models of myelomeningocele (MMC) are needed to test novel in utero interventions. An ideal animal model for MMC has locomotor function at birth and is low cost enough to allow for high throughput. The rat MMC model is limited by immature locomotor function at birth. The ovine MMC model is a costly surgical model. Guinea pigs are uniquely suited for an MMC model being a small animal model with locomotor function at birth. We aimed to develop a retinoic acid (RA) model of MMC in the guinea pig and to evaluate if pregnant guinea pigs could tolerate uterine manipulation. Methods. Time-mated Dunkin Hartley guinea pig dams were dosed with 60 mg/kg of RA between gestation age (GA) 12 and 15 days in the development of an RA model. Fetuses were grossly evaluated for MMC lesions at Cesarean section after GA 31 days. Evaluation of the ability of pregnant guinea pig dams to tolerate uterine surgical intervention was performed by hysterotomy of a separated group of time-mated guinea pigs at GA 45, 50, and 55. Results. Forty-two pregnant guinea pigs were dosed with RA, with a total of 189 fetuses. The fetal demise rate was 38% ( n = 71 ). A total of 118 fetuses were viable, 83% ( n = 98 ) were normal fetuses, 8% ( n = 10 ) had a neural tube defect, and 8% ( n = 10 ) had a hematoma or other anomalies. No fetuses developed an MMC defect. None of the fetuses that underwent hysterotomy survived to term. Conclusion. RA dosed at 60 mg/kg in guinea pigs between GA 12 and 15 did not result in MMC. Dunkin Hartley guinea pigs did not tolerate a hysterotomy near term in our surgical model. Further work is needed to determine if MMC can be induced in guinea pigs with alternate RA dosing.

BACKGROUND Noncompressible torso hemorrhage is a leading cause of preventable death on the battlefield. Intra-aortic balloon occlusion was first used in combat in the 1950s, but military use was rare before Operation Iraqi Freedom and Operation Enduring Freedom. During these wars, the combination of an increasing number of deployed vascular surgeons and a significant rise in deaths from hemorrhage resulted in novel adaptations of resuscitative endovascular balloon occlusion of the aorta (REBOA) technology, increasing its potential application in combat. We describe the background of REBOA development in response to a need for minimally invasive intervention for hemorrhage control and provide a detailed review of all published cases (n = 47) of REBOA use for combat casualties. The current limitations of REBOA are described, including distal ischemia and reperfusion injury, as well as ongoing research efforts to adapt REBOA for prolonged use in the austere setting. LEVEL OF EVIDENCE Level V.

Extracorporeal Life Support (ECLS) is rarely used in pediatric trauma patients due to bleeding risk, and the use of ECLS following angioembolization of traumatic hemorrhage has never been reported in a child. We report a case of a 10-year-old boy run over by a parade float resulting in severe thoracic, abdominal, and pelvic trauma, with hemorrhage from pelvic fractures requiring massive transfusion. Due to ongoing blood product requirements and contrast extravasation near the symphysis pubis, angioembolization of the internal iliac arteries was performed. Extreme hypoxemia persisted despite maximal ventilator support due to pulmonary contusions and aspiration pneumonitis. Six hours after angioembolization, venovenous ECLS was initiated. Following an initial heparin bolus, ECLS was run without anticoagulation for 12 h, but development of circuit clot required resumption of low-dose heparin. After four days, his respiratory status improved substantially and ECLS was discontinued. There were no hemorrhagic complications. The patient was discharged home in good health following inpatient rehabilitation. In this case, ECLS was successfully used in the treatment of post-traumatic respiratory failure 6 h following angioembolization of pelvic hemorrhage in a pediatric trauma patient. Further research is needed to determine the safest interval between hemorrhage control and ECLS in severely injured children.

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

BACKGROUND Trauma is the leading cause of death in children, and most deaths occur within 24 hours of injury. A better understanding of the causes of death in the immediate period of hospital care is needed. METHODS Trauma admissions younger than 18 years from 2009 to 2019 at a Level I pediatric trauma center were reviewed for deaths (n = 7,145). Patients were stratified into ages 0-6, 7-12, and 13-17 years old. The primary outcome was cause of death, with early death defined as less than 24 hours after trauma center arrival. RESULTS There were 134 (2%) deaths with a median age of 7 years. The median time from arrival to death was 14.4 hours (interquartile range, 0.5-87.8 hours). Half (54%) occurred within 24 hours. However, most patients who survived initial resuscitation in the emergency department died longer than 24 hours after arrival (69%). Traumatic brain injury was the most common cause of death (66%), followed by anoxia (9.7%) and hemorrhage (8%). Deaths from hemorrhage were most often in patients sustaining gunshot wounds (73% vs. 11% of all other deaths, p < 0.0001), more likely to occur early (100% vs. 50% of all other deaths, p = 0.0009), and all died within 6 hours of arrival. Death from hemorrhage was more common in adolescents (21.4% of children aged 13-17 vs. 6.3% of children aged 0-6, and 0% of children aged 7-12 p = 0.03). The highest case fatality rates were seen in hangings (38.5%) and gunshot wounds (9.6%). CONCLUSION Half of pediatric trauma deaths occurred within 24 hours. Death from hemorrhage was rare, but all occurred within 6 hours of arrival. This is a critical time for interventions for bleeding control to prevent death from hemorrhage in children. Analysis of these deaths can focus efforts on the urgent need for development of new hemorrhage control adjuncts in children. LEVEL OF EVIDENCE Epidemiological study, level IV.

BackgroundTraumatic brain injury (TBI) is the leading cause of death and disability in young children; however, the impact of mechanism on outcomes has not been fully evaluated. We hypothesized that children with TBI due to abuse would have a higher mortality than children with accidental TBI due to motor vehicle collisions (MVC).MethodsWe performed a retrospective review of the National Kids' Inpatient (KID) hospitalizations database of 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

The differential for neonatal hematoma sis ranges from benign etiologies to life-threatening emergencies. Neonatal gastric perforation is a rare cause of neonatal hematoma sis but is a deadly condition, requiring prompt diagnosis and treatment. The etiology is usually related to conditions predisposing to over distension of the stomach, such as positive pressure ventilation or distal obstruction, but in some cases cannot be determined. Patients generally present with abdominal distension and respiratory distress. We present a case of a 1-day old term baby girl who developed sudden onset hematoma sis and clinical deterioration, who was found to have a large proximal gastric perforation requiring emergent total gastrectomy with delayed reconstruction.

BACKGROUND: Trauma is the leading cause of death for children and adolescents. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive method of hemorrhage control used primarily in adults. We aimed to characterize REBOA use in pediatric patients. METHODS: The American Association for the Surgery of Trauma (AAST) Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry was queried for patients < 18 years old undergoing REBOA placement (2013–2020). The primary outcome was mortality. Secondary outcomes included injury severity score (ISS), additional interventions, and complications. RESULTS: Eleven patients with a median age of 17 years old had REBOA placed, with a survival rate of 30%. Inflation of the REBOA balloon resulted in a significant increase in systolic blood pressure (SBP) (median SBP pre-REBOA 53 mmHg vs. post-REBOA 110 mmHg, p = 0.0007). Patients were severely injured with a median ISS of 29 (interquartile range 16–42). There were no access-site complications. All three surviving patients had a discharge Glasgow Coma Scale of 15. CONCLUSION: REBOA is used in patients < 18 years old, but all reported patients in this registry were adolescents. No REBOA-related complications were reported. Identifying pediatric patients who may benefit from REBOA and modifying currently existing technology for this group of patients is an area of ongoing research.

BACKGROUND: A De Garengeot hernia is a femoral hernia that contains the appendix. This rare type of hernia was first described by René-Jacques Croissant De Garengeot in 1731. Numerous case reports have been published since then, yet collective analysis about the presentation, diagnosis, management, and outcomes of patients with this unique hernia is lacking. METHODS: A systematic review was performed using PubMed, Google Scholar, Embase, and Web of Science for cases of De Garengeot hernias. Keywords searched included ”De Garengeot hernia” OR “femoral appendicitis” OR “femoral hernia appendix” OR “crural hernia appendix.” To facilitate review, a classification system was created based on the gross appearance of the appendix and related structures in the femoral hernia. RESULTS: Two hundred and twenty-two cases were identified in 197 manuscripts. Cases most commonly came from Europe but have been reported worldwide. There was a female predominance (n = 180, 81.1%) and the mean age at presentation was 69.8 years. The most common presenting symptoms were a groin bulge and groin tenderness (82.4%, n = 183 and 79.7%, n = 177, respectively). A groin bulge was observed on physical exam in 95.0% (n = 211) of cases, and erythema over the hernia was present in 33.3% (n = 74). A pre-operative diagnosis of a De Garengeot hernia was established with imaging in only 31.5% (n = 70) of cases. The most common surgical approach was through a groin incision. Complications occurred in 9.5% (n = 21) of cases, most commonly surgical site infections. The most common condition of the appendix was congested/inflamed, found in 44.1% (n = 98) of cases and corresponding to class 2A in the classification system devised. CONCLUSIONS: Overall, De Garengeot hernias were found to be rare and clinically heterogeneous, as highlighted by our classification system. A systematic approach to categorizing this unique hernia may improve management decisions and help avoid complications.

Obesity is a known risk factor in adult surgical site infections (SSIs), but its significance in pediatrics is unclear. We hypothesized that overweight and obese children have increased risk for SSI.A National Surgical Quality Improvement Program-Pediatric (NSQIP-P) file and single-center reviews identified surgical patients (2-18 years) who developed SSIs. Patients were classified as underweight, normal, overweight, or obese based on body mass index (BMI). Comorbidities associated with SSI were analyzed. Sub-specialties and operations were recorded.National Surgical Quality Improvement Program-Pediatric review identified 66,671 patients and 1,380 SSIs. Seven hundred sixty-seven (767) were male and 613 female. Multivariable analysis revealed overweight and obese BMI to be risk factors for SSIs (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.06-1.43; OR 1.43, 95% CI 1.25-1.63). Most commonly, overweight and obese cohorts had superficial incisional SSIs. Pediatric general surgery (3.6%) and cardiothoracic surgery (2.5%) had the highest rates of SSIs. Single-center review identified 115 SSIs. Of these, 29.6% were overweight or obese with few other identifiable SSI risk factors. Sub-specialties with the most SSIs were pediatric surgery and pediatric orthopedics. Appendectomy was the most common procedure associated with SSIs.Herein we show elevated BMI to be a significant risk factor for SSIs. This information should be used in assessing and counseling pre-operative pediatric patients and families.

Background: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is emerging as a viable intervention for hemorrhagic shock. Training surgeons to place the device is only part of the process. We hypothesize that implementation challenges extend beyond surgical skills training and initial REBOA use should not be expected to mirror published success.Methods:All REBOA placements from January 2016-February 2017 at a level 1 trauma center were reviewed for opportunities for improvement (OFI). From September 2016-February 2017 all patients meeting highest trauma activation criteria were reviewed against our REBOA algorithm to identify patients meeting criteria for REBOA placement but not undergoing the procedure.Results:REBOA was introduced at our institution in September 2015, with first placement in January 2016. Trauma surgery, Emergency Department, and Operating Room staff underwent training. Nine patients had REBOA placed with six survivors. One patient underwent unsuccessful REBOA attempt and died. Four patients had complications from REBOA. Eight additional patients met indications but did not undergo REBOA. Conclusion:Successful REBOA use requires more than teaching surgeons indications and techniques. For a successful REBOA program, systems factors must be addressed. Systems processes must ensure equipment and procedures are standardized and familiar to all involved. Complications should be expected.