Search

AIMS AND OBJECTIVES: The purpose of this study is to describe the relationship between menopausal symptoms, physiologic health effects of cancer treatment and the physical contributors to quality of life in long-term survivors of breast cancer. BACKGROUND: The treatment of menopausal symptoms is hotly debated, especially for women with breast cancer. Common treatments for menopausal symptoms are considered to be contraindicated in women with breast cancer. DESIGN: This is a descriptive, cross-sectional study of long-term breast cancer survivors; a subset of a study that responded to a mailed survey targeting long-term cancer survivors treated at The University of Texas M.D. Anderson Cancer Center. METHODS: In 291 breast cancer patients information was available that included items that commonly relate to menopausal symptoms including hot flushes, painful sexual intercourse, inability to concentrate, fatigue and sleep disturbances. RESULTS: Ninety per cent were Caucasian American and the mean time since diagnosis was 16 +/- 8 years. All patients had been treated with surgery, (60%) with radiotherapy, (68%) with chemotherapy and (37%) with hormonal therapy. Forty-six per cent of the breast cancer survivors indicated that having breast cancer affected their overall health. Self-reported health effects were more common in those survivors who had received a combination of chemotherapy and radiotherapy. A menopausal quality of life score was determined using the items about hot flushes, ability to concentrate, painful sexual intercourse, fatigue, unhappiness and sleep disturbances. CONCLUSIONS: This study reminds us that breast cancer and menopause are independent issues. Quality of life parameters need to be rigidly defined and time sensitive. There are complex interactions between quality of life indicators and specific physiologic consequences of treatment. However, menopausal signs and symptoms may not be different for the breast cancer survivor and they should not be confused with the quality of life/psychosocial issues of the cancer survivor. RELEVANCE TO CLINICAL PRACTICE: Menopause is not a disease process but a normal developmental stage for women. It is important for nurses not only to understand the client needs of the menopausal woman, but also to be able to differentiate between quality of life issues related to menopause and to cancer treatment in order to provide holistic nursing care. [ABSTRACT FROM AUTHOR]

Epidermoid inclusion cysts are benign lesions that occasionally occur in the distal phalanges of the fingers but are less frequently identified and underreported in the toes. We describe a 55-year-old man with a history of work-related trauma followed by painful expansion of his right great toe, resulting in great anxiety. Imaging studies revealed a radiolucent lesion in the distal phalanx of his right hallux. Clinical differential diagnoses included the possibility of an intramedullary inclusion cyst and other various radiolucent lesions. During surgery, a cystic lesion that contained creamy material was discovered. Frozen section diagnosis of the lesion was an intraosseous epidermoid inclusion cyst. The lesion was removed and the patient recovered uneventfully. Although it has been reported that an unduly large number of phalangeal cysts have been treated by amputation, the judicious use of intraoperative frozen sections can prevent this scenario. [ABSTRACT FROM AUTHOR]

Background: Monitoring respiratory effort and drive during mechanical ventilation is needed to deliver lung and diaphragm protection. Esophageal pressure (∆P ES ) is the gold standard measure of respiratory effort but is not routinely available. Airway occlusion pressure in the first 100 ms of the breath (P0.1) is a readily available surrogate for both respiratory effort and drive but is only modestly correlated with ∆P ES in children. We sought to identify risk factors for P0.1 over or underestimating ∆P ES in ventilated children., Methods: Secondary analysis of physiological data from children and young adults enrolled in a randomized controlled trial testing lung and diaphragm protective ventilation in pediatric acute respiratory distress syndrome (PARDS) (NCT03266016). ∆P ES (∆P ES-REAL ), P0.1 and predicted ∆P ES (∆P ES-PRED  = 5.91*P0.1) were measured daily to identify phenotypes based upon the level of respiratory effort and drive: one passive (no spontaneous breathing), three where ∆P ES-REAL and ∆P ES-PRED were aligned (low, normal, and high effort and drive), two where ∆P ES-REAL and ∆P ES-PRED were mismatched (high underestimated effort, and overestimated effort). Logistic regression models were used to identify factors associated with each mismatch phenotype (High underestimated effort, or overestimated effort) as compared to all other spontaneous breathing phenotypes., Results: We analyzed 953 patient days (222 patients). ∆P ES-REAL and ∆P ES-PRED were aligned in 536 (77%) of the active patient days. High underestimated effort (n = 119 (12%)) was associated with higher airway resistance (adjusted OR 5.62 (95%CI 2.58, 12.26) per log unit increase, p < 0.001), higher tidal volume (adjusted OR 1.53 (95%CI 1.04, 2.24) per cubic unit increase, p = 0.03), higher opioid use (adjusted OR 2.4 (95%CI 1.12, 5.13, p = 0.024), and lower set ventilator rate (adjusted OR 0.96 (95%CI 0.93, 0.99), p = 0.005). Overestimated effort was rare (n = 37 (4%)) and associated with higher alveolar dead space (adjusted OR 1.05 (95%CI 1.01, 1.09), p = 0.007) and lower respiratory resistance (adjusted OR 0.32 (95%CI 0.13, 0.81), p = 0.017)., Conclusions: In patients with PARDS, P0.1 commonly underestimated high respiratory effort particularly with high airway resistance, high tidal volume, and high doses of opioids. Future studies are needed to investigate the impact of measures of respiratory effort, drive, and the presence of a mismatch phenotype on clinical outcome., Trial Registration: NCT03266016; August 23, 2017., (© 2024. The Author(s).)

Objectives: We sought to evaluate the association between the carbon dioxide ( co2 ) ventilatory equivalent (VEq co2 = minute ventilation/volume of co2 produced per min), a marker of dead space that does not require a blood gas measurement, and mortality risk. We compared the strength of this association to that of physiologic dead space fraction (V D /V t = [Pa co2 -mixed-expired P co2 ]/Pa co2 ) as well as to other commonly used markers of dead space (i.e., the end-tidal alveolar dead space fraction [AVDSf = (Pa co2 -end-tidal P co2 )/Pa co2 ], and ventilatory ratio [VR = (minute ventilation × Pa co2 )/(age-adjusted predicted minute ventilation × 37.5)])., Design: Retrospective cohort data, 2017-2023., Setting: Quaternary PICU., Patients: One hundred thirty-one children with acute respiratory distress syndrome., Interventions: None., Measurements and Main Results: All dead space markers were calculated at the same 1-minute timepoint for each patient within the first 72 hours of using invasive mechanical ventilation. The 131 children had a median (interquartile range, IQR) age of 5.8 (IQR 1.4, 12.6) years, oxygenation index (OI) of 7.5 (IQR 4.6, 14.3), V D /V t of 0.47 (IQR 0.38, 0.61), and mortality was 17.6% (23/131). Higher VEq co2 ( p = 0.003), V D /V t ( p = 0.002), and VR ( p = 0.013) were all associated with greater odds of mortality in multivariable models adjusting for OI, immunosuppressive comorbidity, and overall severity of illness. We failed to identify an association between AVDSf and mortality in the multivariable modeling. Similarly, we also failed to identify an association between OI and mortality after controlling for any dead space marker in the modeling. For the 28-day ventilator-free days outcome, we failed to identify an association between V D /V t and the dead space markers in multivariable modeling, although OI was significant., Conclusions: VEq co2 performs similarly to V D /V t and other surrogate dead space markers, is independently associated with mortality risk, and may be a reasonable noninvasive surrogate for V D /V t ., Competing Interests: Dr. Khemani is supported by the National Institutes of Health (NIH)/the National Heart, Lung, and Blood Institute (NHLBI) R01 HL134666. Dr. Khemani is a consultant for Nihon-Kohden OrangeMed and Bayer. Nihon-Kohdon was not involved in this study and their module for volumetric capnography was not used in this study. Dr. Bhalla is supported by the NIH/NHLBI K23 HL153756. This work was also supported by grant UL1TR001855 from the NIH/National Center for Advancing Translational Science and support from the Department of Anesthesiology and Critical Care at Children’s Hospital Los Angeles. Drs. Bhalla and Khemani’s institutions received funding from the NHLBI. Dr. Bhalla disclosed personal stock ownership. Drs. Bhalla and, Khemani received support for article research from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Aim: This study aims to identify demographic factors, area-based social determinants of health (SDOH), and clinical features associated with medical decision-making after pediatric out-of-hospital cardiac arrest (OHCA)., Methods: This is a retrospective, exploratory, descriptive analysis of patients < 18 years old admitted to the pediatric intensive care unit (ICU) after OHCA from 2011 to 2022 (n = 217) at an urban tertiary care, free-standing children's hospital. Outcomes of interest included: (1) whether a new advance care plan (ACP) (defined as a written advance directive including do not resuscitate and/or do not intubate) was ordered during hospitalization, and (2) whether the patient was discharged with new medical technology (defined as tracheostomy and/or feeding tube). Logistic regression models identified features associated with these outcomes., Results: Of the 217 patients, 78 patients (36%) had a new ACP placed during their admission. Of the survivors, 26% (27/102) were discharged home with new medical technology. Factors associated with ACP were greater change in Pediatric Cerebral Performance Category (PCPC) score (aOR = 1.49, 95% CI [1.28-1.73], p-value < 0.001) and palliative care consultation (aOR = 2.39, 95% CI [1.16-4.89], p-value 0.018). Factors associated with new medical technology were lower change in PCPC score (aOR = 0.76, 95% C.I. [0.61-0.95], p-value = 0.015) and palliative care consultation (aOR = 7.07, 95% CI [3.01-16.60], p-value < 0.001). There were no associations between area-based SDOH and outcomes., Conclusions: Understanding factors associated with decision-making related to ACP after OHCA is critical to optimize counseling for families. Multi-institutional studies are warranted to identify whether these findings are generalizable., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Virtual reality (VR) is a well-researched digital intervention that has been used for managing acute pain and anxiety in pediatric patients undergoing various medical procedures. This study focuses on investigating the role of unique patient characteristics and VR immersion level on the effectiveness of VR for managing pediatric pain and anxiety during venipuncture., Objective: The purpose of this study is to determine how specific patient characteristics and level of immersion during a VR intervention impact anxiety and pain levels for pediatric patients undergoing venipuncture procedures., Methods: This study is a secondary data analysis of 2 combined, previously published randomized control trials on 252 pediatric patients aged 10-21 years observed at Children's Hospital Los Angeles from April 12, 2017, to July 24, 2019. One randomized clinical trial was conducted in 3 clinical environments examining peripheral intravenous catheter placement (radiology and an infusion center) and blood draw (phlebotomy). Conditional process analysis was used to conduct moderation and mediation analyses to assess the impact of immersion level during the VR intervention., Results: Significant moderation was found between the level of immersion and anxiety sensitivity when predicting postprocedural anxiety (P=.01). Patients exhibiting the highest anxiety sensitivity within the standard of care yielded a 1.9 (95% CI 0.9-2.8; P<.001)-point elevation in postprocedural anxiety relative to individuals with high immersion levels. No other significant factors were found to mediate or moderate the effect of immersion on either postprocedural anxiety or pain., Conclusions: VR is most effective for patients with higher anxiety sensitivity who report feeling highly immersed. Age, location of the procedure, and gender of the patient were not found to significantly impact VR's success in managing levels of postprocedural pain or anxiety, suggesting that immersive VR may be a beneficial intervention for a broad pediatric population., Trial Registration: ClinicalTrials.gov NCT04268901; https://clinicaltrials.gov/study/NCT04268901., (©Jeffrey I Gold, Krystal M Akbar, Sandra Avila, Nhat H Ngo, Margaret J Klein. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 01.07.2024.)

Background: Craniofacial osteosarcomas (CFOS) are uncommon malignant neoplasms of the head and neck with different clinical presentation, biological behavior and prognosis from conventional osteosarcomas of long bones. Very limited genetic data have been published on CFOS., Methods: In the current study, we performed comprehensive genomic studies in 15 cases of high-grade CFOS by SNP array and targeted next generation sequencing., Result: Our study shows high-grade CFOS demonstrate highly complex and heterogenous genomic alterations and harbor frequently mutated tumor suppressor genes TP53, CDKN2A/B, and PTEN, similar to conventional osteosarcomas. Potentially actionable gene amplifications involving CCNE1, AKT2, MET, NTRK1, PDGFRA, KDR, KIT, MAP3K14, FGFR1, and AURKA were seen in 43% of cases. GNAS hotspot activating mutations were also identified in a subset of CFOS cases, with one case representing malignant transformation from fibrous dysplasia, suggesting a role for GNAS mutation in the development of CFOS., Conclusion: High-grade CFOS demonstrate highly complex and heterogenous genomic alterations, with amplification involving receptor tyrosine kinase genes, and frequent mutations involving tumor suppressor genes., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: Barriers to communication have been observed with patients and families who prefer a language other than English for medical conversations, referred to as individuals with limited English proficiency (LEP). We used the pediatric Family Satisfaction with ICU 24R (FS-ICU) survey to assess communication satisfaction for English-proficient (EP) and Spanish-speaking LEP caregivers. We added additional questions related to attendance at morning rounds, frequency of provider updates, interpreter use, and general satisfaction with communication., Methods: This was a single-center, prospective, observational cohort study in the pediatric intensive care unit (PICU) and cardiothoracic intensive care unit (CICU) of a tertiary, academic, free-standing children's hospital. Caregivers of children < 18 years old admitted for at least 48 h to the PICU or CICU between June and September 2022 were eligible for enrollment., Measurements and Main Results: 24 LEP and 74 EP caregivers completed the survey questions. The LEP group had lower household income and education levels and higher incidence of public insurance. FS-ICU scores for both LEP and EP caregivers suggested high satisfaction, without significant difference between the groups. However, qualitative analysis revealed dissatisfaction for LEP caregivers related to information, inclusion, and language barriers. EP caregivers had more positive references to information and emotional connection but indicated dissatisfaction around consistency and responsiveness. 18% of LEP caregivers reported regularly attending rounds, versus 67% of the EP group (p value < .001). 39% of LEP versus 52% of EP caregivers reported multiple daily updates, although the difference was not statistically significant. 29% of LEP respondents reported nonfluent MD/NPs using an interpreter never, rarely, or some of the time., Conclusions: There was no difference in satisfaction scores between LEP and EP caregivers. LEP caregivers had lower socioeconomic status based on public insurance and reported income and education level. Qualitative data allowed more nuanced understanding of communication satisfaction, which correlated with LEP caregivers' reported lower attendance at morning rounds, inconsistent interpreter use, and a trend toward less frequent provider updates., (© 2024. W. Montague Cobb-NMA Health Institute.)

The diagnosis of bone and soft tissue tumors is a skill which requires experience across multiple disciplines while their incidence is small. By contrast, the numbers of patients with non-tumorous diseases of bones, soft tissues, and joints dwarfs primary tumors by several orders of magnitude. The ability to successfully diagnose non-neoplastic diseases requires a knowledge of bone development, structure, remodeling, imaging, and tissue processing. This review summarizes the alterations of bones, joints, and to a lesser extent soft tissues that are encountered in the practice of everyday surgical pathology., Competing Interests: Declaration of Competing interest The author has no conflicts of interest or financial relationships to report, except for past royalties that have been received from the American Registry of Pathology., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Sclerosing epithelioid fibrosarcoma (SEF) occurring as a primary bone tumor is exceptionally uncommon. Even more rare are cases of SEF that show morphologic overlap with low-grade fibromyxoid sarcoma (LGFMS). Such hybrid lesions arising within the bone have only rarely been reported in the literature. Due to their variegated histomorphology and non-specific radiologic features, these tumors may pose diagnostic difficulties. Herein we describe three molecularly confirmed primary bone cases of sclerosing epithelioid fibrosarcoma that demonstrated prominent areas showing the features of LGFMS and with areas resembling so-called hyalinizing spindle cell tumor with giant rosettes (HSCTGR). Two patients were female and one was male aged 26, 47, and 16, respectively. The tumors occurred in the femoral head, clavicle, and temporal bone. Imaging studies demonstrated relatively well-circumscribed radiolucent bone lesions with enhancement on MRI. Cortical breakthrough and soft tissue extension were present in one case. Histologically the tumors all demonstrated hyalinized areas with SEF-like morphology as well as spindled and myxoid areas with LGFMS-like morphology. Two cases demonstrated focal areas with rosette-like architecture as seen in HSCTGR. The tumors were all positive for MUC4 by immunohistochemistry and cytogenetics, fluorescence in-situ hybridization, and next-generation sequencing studies identified EWSR1 gene rearrangements confirming the diagnosis in all three cases.Hybrid SEF is exceedingly rare as a primary bone tumor and can be difficult to distinguish from other low-grade spindled and epithelioid lesions of bone. MUC4 positivity and identification of underlying EWSR1 gene rearrangements help support this diagnosis and exclude other tumor types., (© 2023. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Objectives: To characterize the epidemiology of suicide and self-harm among adolescents admitted to PICUs during the first 2 years of the COVID-19 pandemic in the United States., Design: Descriptive analysis of a large, multicenter, quality-controlled database (Virtual Pediatric Systems [VPS]), and of a national public health dataset (U.S. Centers for Disease Control and Prevention web-based Wide-ranging ONline Data for Epidemiology Research [CDC WONDER])., Setting: The 69 PICUs participating in the VPS database that contributed data for the entire the study period, January 1, 2016, to December 31, 2021., Patients: Adolescents older than 12 years to younger than 18 years old admitted to a participating PICU during the study period with a diagnosis involving self-harm or a suicide attempt (VPS sample), or adolescent suicide deaths over the same period (CDC WONDER sample)., Interventions: None., Measurements and Main Results: We identified 10,239 suicide deaths and 7,692 PICU admissions for self-harm, including 5,414 admissions in the pre-pandemic period (Q1-2016 to Q1-2020) and 2,278 in the pandemic period (Q2-2020 to Q4-2021). Compared with the pre-pandemic period, there was no increase in the median (interquartile range) number of suicide deaths per quarter (429 [399-453] vs. 416 [390-482]) or PICU admissions for self-harm per quarter (315 [289-353] vs. 310 [286-387]) during the pandemic period, respectively. There was an increase in the ratio of self-harm PICU admissions to all-cause PICU admissions per quarter during the pandemic (1.98 [1.43-2.12]) compared with the pre-pandemic period per quarter (1.59 [1.46-1.74]). We also observed a significant decrease in all-cause PICU admissions per quarter early in the pandemic compared with the pre-pandemic period (16,026 [13,721-16,297] vs. 19,607 [18,371-20,581])., Conclusions: The number of suicide deaths and PICU admissions per quarter for self-harm remained relatively constant during the pandemic, while the number of all-cause PICU admissions per quarter decreased compared with the pre-pandemic period. The resultant higher ratio of self-harm admissions to all-cause PICU admissions may have contributed to the perception that more adolescents required critical care for mental health-related conditions early in the pandemic., Competing Interests: Dr. Rotta received funding from Elsevier, Breas US, and Vapotherm. Dr. Lin disclosed they are on the Board of Directors of the Society for Pediatric Sedation; their institution received funding from the U.S. Department of Health and Human Services (U3REP190616) (HRSA-21-104). Dr. Shein received funding from Ceribell. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Background: Adequate exposure to operative trauma is not uniform across surgical residencies, and therefore it can be challenging to achieve competency during residency alone. This study introduced the Cut Suit surgical simulator with an Advanced Surgical Skills Package, which replicates traumatic bleeding and organ injury, into surgery resident training across multiple New York City trauma centers., Methods: Trainees from 6 ACS-verified trauma centers participated in this prospective, observational trial. Groups of 3-5 trainees (post-graduate year 1-6) from 6 trauma centers within the largest public healthcare network in the U.S. participated. Residents were asked to perform various operative tasks including rescucitative thoracotomy, exploratory laprotomy, splenectomy, hepatorrhaphy, retroperitoneal exploration, and small bowel resection on a severely injured simulated patient. Pre- and post-course surveys were used to evaluate trainees' confidence performing these procedures and quizzes were used to evaluate participants' knowledge acquisition after the simulation., Results: One hundred twenty-three surgery residents participated in the evaluation. 68% of participants agreed that the simulation was similar to actual surgery. After the simulation, the percentage of residents reporting being "more confident" or "most confident" in independently managing operative trauma patients increased by 42% ( P < .01). There was a significant increase in the proportion of residents reporting being "more confident" or "most confident" managing all procedures performed. Post-activity quiz scores improved by an average of 20.4 points., Discussion: The Cut Suit surgical simulator with ASSP is a realistic and useful adjunct in training surgeons to manage complex operative trauma., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Escalating vector disease burdens pose significant global health risks, as such innovative tools for targeting mosquitoes are critical. CRISPR-Cas technologies have played a crucial role in developing powerful tools for genome manipulation in various eukaryotic organisms. Although considerable efforts have focused on utilizing class II type II CRISPR-Cas9 systems for DNA targeting, these modalities are unable to target RNA molecules, limiting their utility against RNA viruses. Recently, the Cas13 family has emerged as an efficient tool for RNA targeting; however, the application of this technique in mosquitoes, particularly Aedes aegypti , has yet to be fully realized. In this study, we engineered an antiviral strategy termed REAPER (vRNA Expression Activates Poisonous Effector Ribonuclease) that leverages the programmable RNA-targeting capabilities of CRISPR-Cas13 and its potent collateral activity. REAPER remains concealed within the mosquito until an infectious blood meal is uptaken. Upon target viral RNA infection, REAPER activates, triggering programmed destruction of its target arbovirus such as chikungunya. Consequently, Cas13-mediated RNA targeting significantly reduces viral replication and viral prevalence of infection, and its promiscuous collateral activity can even kill infected mosquitoes within a few days. This innovative REAPER technology adds to an arsenal of effective molecular genetic tools to combat mosquito virus transmission.

Due to the pervasive shortage of behavioral health (BH) specialists, collaborative partnerships between pediatric primary care practitioners (PPCPs) and BH specialists can enhance provision of BH services by PPCPs. We aimed to create a new model of collaborative care that was mostly virtual, affordable, and scalable. The pilot program was implemented in 18 practices (48 PPCPs serving approximately 150 000 patients) in 2 consecutive cohorts. Outcomes were assessed by administering pre-program and post-program surveys. Across the 18 practices, PPCPs reported significantly increased confidence in their BH knowledge and skills, and significantly increased their provision of target BH services. Barriers to BH service provision (resources, time, and staff) were unchanged. This compact, mostly virtual model of BH collaboration appears to be beneficial to PPCPs while also offering convenience to patients and affordability and scalability to the practice network., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Admissions to the ICU for children with hyperglycemic crisis (HGC, defined as diabetic ketoacidosis, hyperglycemic hyperosmolar syndrome, or hyperosmolar ketoacidosis) increased during the COVID-19 pandemic. We sought to identify if severity of illness for HGC also increased from prepandemic to pandemic years 1 and 2., Methods: Retrospective study of children aged ≤18 years hospitalized in the Pediatric Health Information System for HGC. Pre-COVID-19 years were defined as March 2017-February 2020, COVID-19 year 1 as March 2020-February 2021, and COVID-19 year 2 as March 2021-February 2022. The primary outcome was ICU admission. Secondary outcomes included mortality, length of stay, cost, and use of neurologic therapies, mechanical ventilation, or vasoactive support., Results: There were 46 425 HGC admissions to 42 hospitals, 20 045 (43.2%) of which were ICU admissions. In comparison with pre-COVID-19, children admitted in COVID-19 year 1 (odds ratio, 1.31 [95% confidence interval, 1.25-1.38], P < .0001) and year 2 (odds ratio, 1.17 [95% confidence interval, 1.11-1.22], P < .0001) had a higher odds of ICU admission in multivariable modeling after controlling for confounding variables. Severity of illness was higher during COVID-19 years when considering secondary outcomes, although these associations were not consistent across outcomes and year. There was no difference in mortality., Conclusions: Children with HGC had a higher severity of illness during the pandemic which was sustained over 2 years. Reduction in social distancing and evolving variants of SARS-CoV-2 over the 2 years of the pandemic did not significantly alter the relationship between HGC and higher requirement for ICU care., (Copyright © 2023 by the American Academy of Pediatrics.)

Background: With each succession along the surgical career pathway, from medical school to faculty, the percentage of those who identify as underrepresented in medicine (URiM) decreases. We sought to evaluate the demographic trend of surgical fellowship applicants, matriculants, and graduates over time., Study Design: The Electronic Residency Application Service and the Graduate Medical Education Survey for general surgery fellowships in colorectal surgery, surgical oncology, pediatric surgery, thoracic surgery, and vascular surgery were retrospectively analyzed (2005 to 2020). The data were stratified by race and gender, descriptive statistics were performed, and time series were evaluated. Race/ethnicity groups included White, Asian, other, and URiM, which is defined as Black/African American, Hispanic/Latino(a), Alaskan or Hawaiian Native, and Native American., Results: From 2005 to 2020, there were 5,357 Electronic Residency Application Service applicants, 4,559 matriculants, and 4,178 graduates to surgery fellowships. Whites, followed by Asians, represented the highest percentage of applicants (62.7% and 22.3%, respectively), matriculants (65.4% and 23.8% respectively), and graduates (65.4% and 24.0%, respectively). For URiMs, the applicants (13.4%), matriculants (9.1%), and graduates (9.1%) remained significantly low (p < 0.001). When stratified by both race and gender, only 4.6% of the applicants, 2.7% of matriculants, and 2.4% of graduates identified as both URiM and female compared to White female applicants (20.0%), matriculants (17.9%), and graduates (16.5%, p < 0.001)., Conclusions: Significant disparities exist for URiMs in general surgery subspecialty fellowships. These results serve as a call to action to re-examine and improve the existing processes to increase the number of URiMs in the surgery subspecialty fellowship training pathway., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Context: Hospital-based pediatric palliative care (PPC) may help optimize referrals to community-based hospice and home-based palliative care (HBPC) for children with serious illness, yet little is known about their referral practices., Objectives: To describe community-based program referrals from a PPC team, identifying factors associated with referral type, and potential misalignment between patient needs and referral received., Methods: Chart abstraction of patients seen in 2017 by the PPC team of a large, urban children's hospital, followed for at least 6 months or until death, including clinical and demographic characteristics, and referrals to hospice and HBPC., Results: Of the 302 study-eligible patients, 25% died during the hospitalization of the first 2017 visit.  Of the remaining 228 patients, 42 (18.4%) were referred to HBPC and 58 (25.4%) to hospice. Excluding patients referred to hospice care, only one-third with demographic eligibility were referred to HBPC; those seen in the ICU were least likely to be referred.  Over half of the 58 patients referred to hospice died within the study period (n = 34, 58.6%); descendants were more likely to have cancer (P = 0.002) and less likely to have a neurologic (P = 0.021) diagnosis., Conclusion: Despite demographic eligibility, a minority of patients seen by a hospital-based PPC team received referrals for hospice or HBPC.  Children discharged from an ICU and those with neurologic conditions may be at higher risk of missing referrals best aligned with their needs.  Future research should identify and address causes of referral misalignment. Advocacy for programs adaptable to patients' changing needs may also be needed., (Copyright © 2023 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Aedes aegypti mosquitoes carrying self-spreading, virus-blocking Wolbachia bacteria are being deployed to suppress dengue transmission. However, there are challenges in applying this technology in extreme environments. We introduced two Wolbachia strains into Ae. aegypti from Saudi Arabia for a release program in the hot coastal city of Jeddah. Wolbachia reduced infection and dissemination of dengue virus (DENV2) in Saudi Arabian mosquitoes and showed complete maternal transmission and cytoplasmic incompatibility. Wolbachia reduced egg hatch under a range of environmental conditions, with the Wolbachia strains showing differential thermal stability. Wolbachia effects were similar across mosquito genetic backgrounds but we found evidence of local adaptation, with Saudi Arabian mosquitoes having lower egg viability but higher adult desiccation tolerance than Australian mosquitoes. Genetic background effects will influence Wolbachia invasion dynamics, reinforcing the need to use local genotypes for mosquito release programs, particularly in extreme environments like Jeddah. Our comprehensive characterization of Wolbachia strains provides a foundation for Wolbachia-based disease interventions in harsh climates., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Ross et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: To characterize the prevalence of pediatric critical illness from multisystem inflammatory syndrome in children (MIS-C) and to assess the influence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) strain on outcomes., Design: Retrospective cohort study., Setting: Database evaluation using the Virtual Pediatric Systems Database., Patients: All children with MIS-C admitted to the PICU in 115 contributing hospitals between January 1, 2020, and June 30, 2021., Measurements and Main Results: Of the 145,580 children admitted to the PICU during the study period, 1,338 children (0.9%) were admitted with MIS-C with the largest numbers of children admitted in quarter 1 (Q1) of 2021 ( n = 626). The original SARS-CoV-2 viral strain and the D614G Strain were the predominant strains through 2020, with Alpha B.1.1.7 predominating in Q1 and quarter 2 (Q2) of 2021. Overall, the median PICU length of stay (LOS) was 2.7 days (25-75% interquartile range [IQR], 1.6-4.7 d) with a median hospital LOS of 6.6 days (25-75% IQR, 4.7-9.3 d); 15.2% received mechanical ventilation with a median duration of mechanical ventilation of 3.1 days (25-75% IQR, 1.9-5.8 d), and there were 11 hospital deaths. During the study period, there was a significant decrease in the median PICU and hospital LOS and a decrease in the frequency of mechanical ventilation, with the most significant decrease occurring between quarter 3 and quarter 4 (Q4) of 2020. Children admitted to a PICU from the general care floor or from another ICU/step-down unit had longer PICU LOS than those admitted directly from an emergency department., Conclusions: Overall mortality from MIS-C was low, but the disease burden was high. There was a peak in MIS-C cases during Q1 of 2021, following a shift in viral strains in Q1 of 2021. However, an improvement in MIS-C outcomes starting in Q4 of 2020 suggests that viral strain was not the driving factor for outcomes in this population., Competing Interests: Dr. Remy’s institution received funding from the National Institute of General Medical Sciences (K08 7K08GM129763); he received support for article research from the National Institutes of Health. Dr. Shein received funding from Hill Ward Henderson. Dr. Rotta received funding from Vapotherm, Breas US, and Elsevier. Dr. Lin’s institution received funding from University of California San Francisco subawards Department of Health and Human Services: ASPR U3REP190616 and HRSA U1I43532. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Background: Children with obstructive sleep apnea (OSA) have higher risks of post-operative respiratory complication after adenotonsillectomy. However, there is no clinical standard criteria for pediatric intensive care unit (PICU) admission following adenotonsillectomy. The purpose of this study was to identify perioperative risk factors associated with the need for PICU level care after adenotonsillectomy., Methods: We performed a retrospective chart review of children with severe OSA (apnea hypopnea index on polysomnography; AHI ≥10) and/or post-operative PICU admission at a tertiary academic center from May 2010 to September 2018. We collected demographics, pre-existing comorbidities, perioperative medications, and post-operative complications. We defined a primary outcome as escalation of airway management while in the PICU or PICU stay >48 h. Airway escalation included the need for an invasive airway, new CPAP application, increased CPAP setting, or increased supplemental oxygen., Results: Analysis included 278 children with severe OSA and/or PICU admission. Median age was 6.6 years old; 181 (65%) were admitted to the PICU, and 60 (21.5%) had the composite outcome of escalation of airway management or prolonged stay. In patients with an escalation of airway management, 28 needed intubation or mechanical ventilation. Multivariable logistic regression showed intraoperative respiratory complications, polysomnography (PSG) peak end-tidal CO 2 (EtCO 2 ) reading >60 mmHg, and the presence of neuromuscular disease as significant associated factors for escalation of airway management or prolonged PICU stay (P values < 0.01; odd ratios 3.4, 5.3, and 5.4, respectively)., Conclusion: For children following adenotonsillectomy, PSG EtCO 2  ≥ 60%, preexisting neuromuscular disease, and intraoperative complications (hypoxia, difficult airway, etc.) were independently associated with escalation of airway management or prolonged stay. AHI was not an independent predictor for PICU complication. We concluded factors should be considered for PICU admission in addition to AHI., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Patient morbidity and mortality decrease when injured patients meeting CDC Field Triage Criteria (FTC) are transported by emergency medical services (EMS) directly to designated trauma centers (TCs). This study aimed to identify potential disparities in the transport of critically injured patients to TCs by EMS., Study Design: We identified all patients in the National EMS Information System (NEMSIS) database in the National Association of EMS State Officials East region from January 1, 2018, to December 31, 2019, with a final prehospital acuity of critical or emergent by EMS. The cohort was stratified into patients transported to TCs or non-TCs. Analyses consisted of descriptive epidemiology, comparisons, and multivariable logistic regression analysis to measure the association of demographic features, vital signs, and CDC FTC designation by EMS with transport to a TC., Results: A total of 670,264 patients were identified as sustaining an injury, of which 94,250 (14%) were critically injured. Of those 94,250 critically injured, 56.0% (52,747) were transported to TCs. Among all critically injured women (n = 41,522), 50.4% were transported to TCs compared with 60.4% of critically injured men (n = 52,728, p < 0.001). In a multivariable logistic regression model, critically injured women were 19% less likely to be taken to a TC compared with critically injured men (OR 0.81, 95% CI 0.71-0.93, p = 0.003)., Conclusions: Critically injured female patients are less likely to be transported to TCs when compared with their male counterparts. Performance improvement processes that assess EMS compliance with field triage guidelines should explicitly evaluate for sex-based disparities. Further studies are warranted., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To determine the association between nationwide school closures and prevalence of common admission diagnoses in the pediatric critical care unit., Design: Retrospective cohort study., Setting: National database evaluation using the Virtual Pediatric Systems LLC database., Patients: All patients admitted to the PICU in 81 contributing hospitals in the United States., Measurements and Main Results: Diagnosis categories were determined for all 110,418 patients admitted during the 20-week study period in each year (2018, 2019, and 2020). Admission data were normalized relative to statewide school closure dates for each patient using geographic data. The "before school closure" epoch was defined as 8 weeks prior to school closure, and the "after school closure" epoch was defined as 12 weeks following school closure. For each diagnosis, admission ratios for each study day were calculated by dividing 2020 admissions by 2018-2019 admissions. The 10 most common diagnosis categories were examined. Significant changes in admission ratios were identified for bronchiolitis, pneumonia, and asthma. These changes occurred at 2, 8, and 35 days following school closure, respectively. PICU admissions decreased by 82% for bronchiolitis, 76% for pneumonia, and 76% for asthma. Nonrespiratory diseases such as diabetic ketoacidosis, status epilepticus, traumatic injury, and poisoning/ingestion did not show significant changes following school closure., Conclusions: School closures are associated with a dramatic reduction in the prevalence of severe respiratory disease requiring PICU admission. School closure may be an effective tool to mitigate future pandemics but should be balanced with potential academic, economic, mental health, and social consequences., Competing Interests: Dr. Lin’s institution received funding from the Health Resources and Services Administration and Assistant Secretary for Preparedness and Response. Dr. Klein received funding from the University Hospitals of Cleveland Linsalata Family Chair in Pediatric Critical Care and Emergency Medicine; she disclosed that she is being paid for her time as a member of the research team. Dr. Rotta received funding from Vapotherm, Breas US, and Elsevier. Dr. Remy received support for article research from the National Institutes of Health. Dr. Shein received funding from law firms for providing expert testimony and legal review. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Seventeen cases of epithelioid osteoblastoma were reviewed. The tumors most commonly arose from the vertebrae (7 cases), followed by the mandible (3), sacrum (2), bones of the foot (2), and femur, rib, and scapula (1 each). Patients' ages ranged from 5 to 33 years. The tumors measured from 2.0 to 6.5 cm in the greatest diameter (mean = 4.1 cm) and most patients presented with low-grade pain at the affected site. Imaging studies showed expansile lytic lesions with cortical thickening and a mild rim of sclerosis. Histologically all tumors were characterized by active production of bone with a fibrovascular stroma containing microtrabecular aggregates of bone matrix. The osteoblastic proliferation was atypical and showed enlarged cells with prominent nucleoli and abundant cytoplasm imparting them with a striking epithelioid appearance. Immunohistochemical studies showed variable results that caused difficulties for interpretation; 4 of 12 cases showed strong nuclear positivity for FOS, 2 of 12 cases showed strong diffuse nuclear positivity for FOSB; the remaining cases showed variable, sometimes overlapping patterns, considered to be indeterminate. Ki-67 proliferation marker showed low nuclear positivity (∼2%) in 10 cases and a slight increase (<10%) in two cases. Clinical follow-up was available in 14 patients; one patient experienced a recurrence at six months that was treated with additional curetting; the remainder of the patients were all alive and well without evidence of recurrence from 1 to 22 years (median follow up = 3 years). Epithelioid osteoblastoma is an unusual variant of osteoblastoma that has the potential for simulating a malignancy and does not appear to be associated with a more aggressive behavior., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Children with severe obstructive sleep apnea (OSA) carry a higher risk of respiratory complications after adenotonsillectomy. Their altered sensitivity to opioids may be a significant contributor to respiratory morbidity. The purpose of this study was to identify how anesthesia without opioids affects perioperative opioid demand and postoperative course., Methods: A chart review of children with severe OSA (apnea hypoxia index; AHI ≥ 10) undergoing adenotonsillectomies was performed. Comorbidities and perioperative medications were documented. Perioperative opioid doses within 48 h of procedure were calculated as morphine equivalents (mcg/kg). Pain scores, rescue medications, and postoperative complications in PICU and non-PICU settings were also documented. Anesthesia without opioid and with opioid groups were compared., Results: The analysis included 225 children. A significantly higher percentage of children received no postoperative opioids in the anesthesia without opioid group compared to those with opioid (46 of 88 children vs. 43 of 137; P < 0.05). The incidence of severe postoperative pain between the two groups was not different in PICU (P = 0.88) or non-PICU setting (P = 0.84). Perioperative opioid administration was significantly lower in anesthesia without opioid (median, Q1, Q3: 0.0, 0.0, 83.0) compared to with opioid (144.4, 72.5, 222.2; P < 0.01). Anesthesia without opioid was one of the independent factors to achieve perioperative opioid avoidance (<50mcg/kg)., Conclusions: Anesthesia without opioid for children with severe OSA for tonsillectomy significantly reduced perioperative demand for opioid and did not affect the occurrence of severe pain. Anesthesia without opioid is an effective strategy to minimalize opioid demand perioperatively for children with severe OSA for tonsillectomy., (© 2022. The Author(s).)

Importance: The lack of underrepresented in medicine physicians within US academic surgery continues, with Black surgeons representing a disproportionately low number., Objective: To evaluate the trend of general surgery residency application, matriculation, and graduation rates for Black trainees compared with their racial and ethnic counterparts over time., Design, Setting, and Participants: In this nationwide multicenter study, data from the Electronic Residency Application Service (ERAS) for the general surgery residency match and Graduate Medical Education (GME) surveys of graduating general surgery residents were retrospectively reviewed and stratified by race, ethnicity, and sex. Analyses consisted of descriptive statistics, time series plots, and simple linear regression for the rate of change over time. Medical students and general surgery residency trainees of Asian, Black, Hispanic or Latino of Spanish origin, White, and other races were included. Data for non-US citizens or nonpermanent residents were excluded. Data were collected from 2005 to 2018, and data were analyzed in March 2021., Main Outcomes and Measures: Primary outcomes included the rates of application, matriculation, and graduation from general surgery residency programs., Results: Over the study period, there were 71 687 applicants, 26 237 first-year matriculants, and 24 893 graduates. Of 71 687 applicants, 24 618 (34.3%) were women, 16 602 (23.2%) were Asian, 5968 (8.3%) were Black, 2455 (3.4%) were Latino, and 31 197 (43.5%) were White. Women applicants and graduates increased from 29.4% (1178 of 4003) to 37.1% (2293 of 6181) and 23.5% (463 of 1967) to 33.5% (719 of 2147), respectively. When stratified by race and ethnicity, applications from Black women increased from 2.2% (87 of 4003) to 3.5% (215 of 6181) (P < .001) while applications from Black men remained unchanged (3.7% [150 of 4003] to 4.6% [284 of 6181]). While the matriculation rate for Black women remained unchanged (2.4% [46 of 1919] to 2.3% [52 of 2264]), the matriculation rate for Black men significantly decreased (3.0% [57 of 1919] to 2.4% [54 of 2264]; P = .04). Among Black graduates, there was a significant decline in graduation for men (4.3% [85 of 1967] to 2.7% [57 of 2147]; P = .03) with the rate among women remaining unchanged (1.7% [33 of 1967] to 2.2% [47 of 2147])., Conclusions and Relevance: Findings of this study show that the underrepresentation of Black physicians at every stage in surgical training pipeline persists. Black men are especially affected. Identifying factors that address intersectionality and contribute to the successful recruitment and retention of Black trainees in general surgery residency is critical for achieving racial and ethnic as well as gender equity.

Importance: The incidence of pediatric diabetic ketoacidosis (DKA) increased early in the COVID-19 pandemic, but the relative contribution of behavioral changes and viral-related pathophysiology are unknown., Objective: To evaluate the relationship between school closure date and onset of increased DKA to help clarify the etiology of the increased incidence., Design: A multi-center, quality-controlled Pediatric Intensive Care Unit (PICU) database was used to identify the number of admissions to a participating PICU with DKA on each calendar day from 60 days before local school closure to 90 days after, and compared to baseline data from the same periods in 2018-2019. Interrupted time series and multiple linear regression analyses were used to identify admission rates that differed significantly between 2020 and baseline., Setting: Eighty-one PICUs in the United StatesParticipants: Children ages 29 days to 17 years admitted to a PICU with DKAExposures: Statewide school closureMain outcome/measure: Rate of admission to the PICU for DKA., Results: There were 1936 admissions for children with DKA in 2020 and 1795 admissions/year to those same PICUs in 2018-2019. Demographics and clinical outcomes did not differ before school closure, but pandemic-era patients were less often white and had longer hospital length of stay in the post-school closure period. The difference between 2020 admissions and 2018-2019 admissions was not different than zero before school closure, and significantly higher than zero after school closure, but was significantly increased in 2020 at >30 days after school closure ( p = 0.039)., Conclusions/relevance: An increase in pediatric DKA admissions began one month after school closures. Given that behavioral changes started near school closure dates and viral activity peaked weeks after, this suggests that behavioral factors may not be the primary etiology and it is possible that SARS-CoV-2 infection may have direct effects on pediatric DKA., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 McCluskey, Zee-Cheng, Klein, Scanlon, Rotta, Remy, Carroll and Shein.)

In the cranio-facial skeleton, a heterogeneous group of well characterized fibro-osseous lesions can be distinguished. Whereas fibrous dysplasia can affect any skeletal bone, ossifying fibroma and cemento-osseous dysplasia exclusively develop in the cranio-facial region, with most subtypes restricted to the tooth bearing areas of the jaws. Herein we present a series of 20 fibro-osseous lesions that developed mostly in the frontal bone and in the mandible, presenting as expansile intramedullary tumors with a unique histologic appearance and an indolent clinical course. We provide evidence that these tumors are distinct from the categories included in the WHO classification and are therefore currently unclassifiable. The definition of cemento-ossifying fibroma as an odontogenic neoplasm developing only in close proximity to teeth should be re-considered and incorporate also extragnathic lesions as shown here., (© 2021. The Author(s).)

Objectives: To characterize the epidemiology of children and adolescents admitted for deliberate self-harm to PICUs in the United States by examining patient demographics, diagnoses, modes of self-harm, and outcomes., Design: Descriptive analysis of a large, multicenter, quality-controlled database., Setting: The 137 PICUs participating in the Virtual Pediatric Systems database during the study period., Patients: Children between 6 and 18 years old admitted to a participating PICU from January 1, 2009, to December 31, 2017, with a diagnosis involving deliberate self-harm or a suicide attempt., Interventions: None., Measurements and Main Results: Of 9,197 admissions for self-harm, females accounted for 6,740 (73.3%), whereas males incurred 174 of the 284 deaths (61.3%). Admissions for self-harm doubled over the study period (0.56% in 2009 vs 1.13% in 2017), with an increase observed across every age group. After PICU care, most patients were transferred to a general care floor (51.1%) or to a psychiatric rehabilitation facility (31.8%). Intentional drug ingestion (84%) was the most common mode of self-harm but was associated with less than 1% of the fatalities. Asphyxia/hanging or firearms were a factor in 411 (4.5%) and 106 (1.2%) of the admissions but were associated with 117 (28.5%) and 55 (51.9%) of the deaths, respectively., Conclusions: PICU admissions due to self-harm increased for all age groups during the study period. Females accounted for most of these admissions, whereas males accrued most of the in-hospital deaths. Intentional drug ingestion was the most common mode of self-harm and was rarely fatal, whereas asphyxia and firearms were the mechanisms associated with the highest mortality., Competing Interests: Dr. Klein disclosed she is a statistical consultant and disclosed work for hire. Dr. Rotta received funding from Vapotherm Inc., Breas US, and Elsevier. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Objectives: To describe mechanical ventilation management and factors associated with nonadherence to lung-protective ventilation principles in pediatric acute respiratory distress syndrome., Design: A planned ancillary study to a prospective international observational study. Mechanical ventilation management (every 6 hr measurements) during pediatric acute respiratory distress syndrome days 0-3 was described and compared with Pediatric Acute Lung Injury Consensus Conference tidal volume recommendations (< 7 mL/kg in children with impaired respiratory system compliance, < 9 mL/kg in all other children) and the Acute Respiratory Distress Syndrome Network lower positive end-expiratory pressure/higher Fio2 grid recommendations., Setting: Seventy-one international PICUs., Patients: Children with pediatric acute respiratory distress syndrome., Interventions: None., Measurements and Main Results: Analyses included 422 children. On pediatric acute respiratory distress syndrome day 0, median tidal volume was 7.6 mL/kg (interquartile range, 6.3-8.9 mL/kg) and did not differ by pediatric acute respiratory distress syndrome severity. Plateau pressure was not recorded in 97% of measurements. Using delta pressure (peak inspiratory pressure - positive end-expiratory pressure), median tidal volume increased over quartiles of median delta pressure (p = 0.007). Median delta pressure was greater than or equal to 18 cm H2O for all pediatric acute respiratory distress syndrome severity levels. In severe pediatric acute respiratory distress syndrome, tidal volume was greater than or equal to 7 mL/kg 62% of the time, and positive end-expiratory pressure was lower than recommended by the positive end-expiratory pressure/Fio2 grid 70% of the time. In multivariable analysis, tidal volume nonadherence was more common with severe pediatric acute respiratory distress syndrome, fewer PICU admissions/yr, non-European PICUs, higher delta pressure, corticosteroid use, and pressure control mode. Adherence was associated with underweight stature and cuffed endotracheal tubes. In multivariable analysis, positive end-expiratory pressure/Fio2 grid nonadherence was more common with higher pediatric acute respiratory distress syndrome severity, ventilator decisions made primarily by the attending physician, pre-ICU cardiopulmonary resuscitation, underweight stature, and age less than 2 years. Adherence was associated with respiratory therapist involvement in ventilator management and longer time from pediatric acute respiratory distress syndrome diagnosis. Higher nonadherence to tidal volume and positive end-expiratory pressure recommendations were independently associated with higher mortality and longer duration of ventilation after adjustment for confounding variables. In stratified analyses, these associations were primarily influenced by children with severe pediatric acute respiratory distress syndrome., Conclusions: Nonadherence to lung-protective ventilation principles is common in pediatric acute respiratory distress syndrome and may impact outcome. Modifiable factors exist that may improve adherence., Competing Interests: Dr. Bhalla’s institution received funding from the Sainte Justine Children’s Hospital, University of Montreal; she received support for article research from the National Institutes of Health (NIH). Drs. Bhalla’s and Khemani’s institutions received funding from the Southern California Clinical Translational Science Institute. Dr. Emeriaud’s institution received funding from Fonds de recherche du Québec Santé and Maquet; he is leading a feasibility study of a new ventilator which is financially supported by Maquet Critical Care. Dr. Napolitano’s institution received funding from Drager, VERO-BIOTECH, Philips/Respironics, Aerogen, Actuated Medical, and Smiths Medical. Dr. Fernandez received funding from the Sociedad Argentina de Terapia Intesiva. Dr. Baudin received speaking fees and nonfinancial support from Maquet Critical Care. Dr. Cheifetz received funding from Philips, Medtronic, Tim Peters and Co., Up-to-Date, and NIH National Heart, Lung, and Blood Institute. Dr. Kneyber serves as a consultant for Vyaire. Dr. Newth received funding from Philips Research North America and Nihon Kohden Orange Med. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)