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While it is assumed adolescents receive comparable trauma care at pediatric trauma centers (PTC), adult trauma centers (ATC), and combined facilities (MTC), this remains understudied.We conducted a retrospective cohort study through the NTDB evaluating patients 14-18 years of age who presented to an ACS-verified level 1 or 2 trauma facility between 1/1/2016 and 12/31/2019. Multiple logistic regression analyses were performed to compare mortality risk among trauma facility verification types.91,881 adolescents presented after trauma over the four-years. Hypotension, severe TBI, firearm mechanism, and ISS15 were associated with increased mortality. Compared to PTCs, the odds of trauma-related mortality were statistically higher at MTCs (OR 1.82, p = 0.004) and ATCs (OR 1.89-2.05, p = 0.001-0.002).Injured adolescents receiving care at ATCs and MTCs have higher mortality risk than those cared for at PTCs. Further evaluation of factors associated with this observed difference is warranted and may help identify opportunities to improve outcomes in injured adolescents.

BACKGROUND: The majority of opioid overdose admissions in pediatric patients are associated with prescription opioids. Post-operative prescriptions are an addressable source of opioids in the household. This study aims to assess for sustained reduction in opioid prescribing after implementation of provider-based education at nine centers. METHODS: Opioid prescribing information was collected for pediatric patients undergoing umbilical hernia repair at nine centers between December 2018 and January 2019, one year after the start of an education intervention. This was compared to prescribing patterns in the immediate pre- and post-intervention periods at each of the nine centers. RESULTS: In the current study period, 29/127 (22.8%) patients received opioid prescriptions (median 8 doses) following surgery. There were no medication refills, emergency department returns or readmissions related to the procedure. There was sustained reduction in opioid prescribing compared to pre-intervention (22.8% vs 75.8% of patients, p

Introduction Sepsis prevention pathways, which often include blood and urine cultures, are common in children’s hospitals. Fever and tachycardia, signs often seen in patients with appendicitis, frequently trigger these pathways. We hypothesized that cultures were frequently obtained in children with appendicitis. Materials and Methods We conducted a single-center retrospective cohort study evaluating children with image-confirmed appendicitis from 4/1/2019 to 10/1/2020, coinciding with the initiation of sepsis prevention pathways. Factors associated with culture acquisition, as well as culture results, treatment, and outcomes were evaluated. Results Six hundred and fifty eight children presented with acute appendicitis during the 1.5-year period, with a median age of 10.67 years (interquartile range (IQR) 8.17-14.08). Cultures were obtained in 22.9%, including blood culture (BCx) in 8.1% and urine culture (UCx) in 17.9%. Culture acquisition decreased by 17.6% after sepsis protocol initiation. Blood culture acquisition correlated with fever ( P = .003) and younger age ( P = .03), whereas the attainment of BCx and UCx was associated with female sex ( P = .04, P < .0001), complicated appendicitis ( P = .0001, P = .03), and unknown diagnosis ( P < .0001, P < .0001). There were five positive UCx (4.24%); however, all remained asymptomatic despite a short antibiotic duration dictated by institutional appendicitis protocol. The one positive BCx (1.89%) was suspected contamination and not treated. Discussion The findings of this cohort suggest a low incidence of positive culture as well as lack of impact on clinical management in image-proven appendicitis and the initiation of a sepsis bundle without automatic culture acquisition may result in decreased culture attainment.

Analysis of peripheral venous pressure (PVP) waveforms is a novel method of monitoring intravascular volume. Two pediatric cohorts were studied to test the effect of anesthetic agents on the PVP waveform and cross-talk between peripheral veins and arteries: (1) dehydration setting in a pyloromyotomy using the infused anesthetic propofol and (2) hemorrhage setting during elective surgery for craniosynostosis with the inhaled anesthetic isoflurane. PVP waveforms were collected from 39 patients that received propofol and 9 that received isoflurane. A multiple analysis of variance test determined if anesthetics influence the PVP waveform. A prediction system was built using k-nearest neighbor (k-NN) to distinguish between: (1) PVP waveforms with and without propofol and (2) different minimum alveolar concentration (MAC) groups of isoflurane. 52 porcine, 5 propofol, and 7 isoflurane subjects were used to determine the cross-talk between veins and arteries at the heart and respiratory rate frequency during: (a) during and after bleeding with constant anesthesia, (b) before and after propofol, and (c) at each MAC value. PVP waveforms are influenced by anesthetics, determined by MANOVA: p value η2 = 0.478 for hypovolemic, and η2 = 0.388 for euvolemic conditions. The k-NN prediction models had 82% and 77% accuracy for detecting propofol and MAC, respectively. The cross-talk relationship at each stage was: (a) ρ = 0.95, (b) ρ = 0.96, and (c) could not be evaluated using this cohort. Future research should consider anesthetic agents when analyzing PVP waveforms developing future clinical monitoring technology that uses PVP.

The COVID-19 pandemic has impacted timely access to care for children, including patients with appendicitis. This study aimed to evaluate the effect of the COVID-19 pandemic on management of appendicitis and patient outcomes.A multicenter retrospective study was performed including 19 children's hospitals from April 2019-October 2020 of children (age≤18 years) diagnosed with appendicitis. Groups were defined by each hospital's city/state stay-at-home orders (SAHO), designating patients as Pre-COVID (Pre-SAHO) or COVID (Post-SAHO). Demographic, treatment, and outcome data were obtained, and univariate and multivariable analysis was performed.Of 6,014 patients, 2,413 (40.1%) presented during the COVID-19 pandemic. More patients were managed non-operatively during the COVID-19 pandemic compared to before the pandemic (147 (6.1%) vs 144 (4.0%), p0.001). Despite this change, there was no difference in the proportion of complicated appendicitis between groups (1,247 (34.6%) vs 849 (35.2%), p = 0.12). COVID era non-operative patients received fewer additional procedures, including interventional radiology (IR) drain placements, compared to pre-COVID non-operative patients (29 (19.7%) vs 69 (47.9%), p0.001). On adjusted analysis, factors associated with increased odds of receiving non-operative management included: increasing duration of symptoms (OR=1.01, 95% CI: 1.01-1.012), African American race (OR=2.4, 95% CI: 1.3-4.6), and testing positive for COVID-19 (OR=10.8, 95% CI: 5.4-21.6).Non-operative management of appendicitis increased during the COVID-19 pandemic. Additionally, fewer COVID era cases required IR procedures. These changes in the management of pediatric appendicitis during the COVID pandemic demonstrates the potential for future utilization of non-operative management.

Background Persistent gastrocutaneous fistulae frequently complicate gastrostomy tube placement. A minimally invasive technique for tract closure employing balloon catheter retraction and punch excision of the epithelized tract (PEET) was recently reported. We hypothesized the PEET technique of closure would lead to decreased complications without an increased incidence of recurrence. Methods We conducted a single-center retrospective cohort study evaluating children who underwent gastrocutaneous fistula (GCF) closure 1/1/2018–12/31/2021, comparing patients who underwent the PEET procedure to those repaired with layered closure. Procedure duration and outcomes were additionally compared to the 2018-2019 National Surgical Quality Improvement Program (NSQIP) Participant Use File (PUF) database. Results Sixty-two children underwent operative GCF closure, including 25 with PEET and 37 traditional layered closure. Procedural time was significantly decreased employing PEET (14 vs 26 minutes, P < .0001), less than half the national median by the NSQIP PUF database of 292 GCF closures (14 vs 34.5 minutes, P < .0001). Those repaired with the PEET method experienced no episodes of recurrence, surgical site infection, readmission, reoperation, or mortality within 30 days of the procedure. Conversely, in traditional closure, there was a 24.3% complication rate, including 7 surgical site infections, 1 readmission, and 2 unplanned reoperations. National procedural complication rate by NSQIP PUF was 5.5%, with a 4.8% rate of surgical site infection, .3% reoperation incidence, and .3% mortality. Discussion Our study suggests GCF closure employing the PEET procedure is a safe, more efficient method of tract closure than the traditional layered closure technique.

BACKGROUND: Pediatric trauma patients sustaining blunt abdominal trauma (BAT) with intra-abdominal injury (IAI) are frequently admitted to the intensive care unit (ICU). This study was performed to identify predictors for ICU admission following BAT. METHODS: Prospective study of children (< 16 years) who presented to 14 Level-One Pediatric Trauma Centers following BAT over a 1-year period. Patients were categorized as ICU or non-ICU patients. Data collected included vitals, physical exam findings, laboratory results, imaging, and traumatic injuries. A multivariable hierarchical logistic regression model was used to identify predictors of ICU admission. Predictive ability of the model was assessed via tenfold cross-validated area under the receiver operating characteristic curves (cvAUC). RESULTS: Included were 2,182 children with 21% (n = 463) admitted to the ICU. On univariate analysis, ICU patients were associated with abnormal age-adjusted shock index, increased injury severity scores (ISS), lower Glasgow coma scores (GCS), traumatic brain injury (TBI), and severe solid organ injury (SOI). With multivariable logistic regression, factors associated with ICU admission were severe trauma (ISS > 15), anemia (hematocrit < 30), severe TBI (GCS < 8), cervical spine injury, skull fracture, and severe solid organ injury. The cvAUC for the multivariable model was 0.91 (95% CI 0.88–0.92). CONCLUSION: Severe solid organ injury and traumatic brain injury, in association with multisystem trauma, appear to drive ICU admission in pediatric patients with BAT. These results may inform the design of a trauma bay prediction rule to assist in optimizing ICU resource utilization after BAT. STUDY DESIGN: Prognosis study. LEVEL OF EVIDENCE: 1.

OBJECTIVE To determine if risk-adjusted survival of patients with congenital diaphragmatic hernia (CDH) has improved over the last 25 years within centers that are long-term, consistent participants in the CDH Study Group (CDHSG). SUMMARY BACKGROUND DATA The CDHSG is a multicenter collaboration focused on evaluation of infants with CDH. Despite advances in pediatric surgical and intensive care, CDH mortality has appeared to plateau. Herein, we studied CDH mortality rates amongst long-term contributors to the CDHSG. METHODS We divided registry data into five-year intervals, with Era 1 (E1) beginning in 1995, and analyzed multiple variables (operative strategy, defect size, and mortality) to assess evolution of disease characteristics and severity over time. For mortality analyses, patients were risk stratified using a validated prediction score based on 5-minute Apgar (Apgar5) and birth weight. A risk-adjusted, observed to expected (O:E) mortality model was created using E1 as a reference. RESULTS 5,203 patients from 23 centers with ≥22 years of participation were included. Birth weight, Apgar5, diaphragmatic agenesis, and repair rate were unchanged over time (all p > 0.05). In E5 compared to E1, minimally invasive and patch repair were more prevalent, and timing of diaphragmatic repair was later (all p < 0.01). Overall mortality decreased over time: E1 (30.7%), E2 (30.3%), E3 (28.7%), E4 (26.0%), E5 (25.8%) (p = 0.03). Risk-adjusted mortality showed a significant improvement in E5 compared to E1 (OR 0.78, 95% CI 0.62-0.98; p = 0.03). O:E mortality improved over time, with the greatest improvement in E5. CONCLUSIONS Risk-adjusted and observed-to-expected CDH mortality have improved over time.

We implemented a protocol to evaluate pediatric patients with suspected appendicitis using ultrasound as the initial imaging modality. CT utilization rates and diagnostic accuracy were evaluated two years after pathway implementation.This was a retrospective observational study of patients18 years evaluated for suspected appendicitis. CT rates were compared before and after implementation of the protocol, and monthly CT rates were calculated to assess trends in CT utilization.CT use decreased significantly following pathway implementation from 94.2% (130/138) to 27.5% (78/284; p 0.001). Linear regression of monthly CT utilization demonstrated that CT rates continued to trend down two years after pathway implementation. Adherence to the pathway was 89.8% (255/284). Negative appendectomy rate was 2.4% (2/85) in the post-pathway period.Adherence to a pathway designed to evaluate pediatric patients with suspected appendicitis using ultrasound as the primary imaging modality has led to a sustained decrease in CT use without compromising diagnostic accuracy.

INTRODUCTION: Biliary dyskinesia (BD) is a common indication for pediatric cholecystectomy. While diagnosis is primarily based on diminished gallbladder ejection fraction (GB-EF), work-up and management in pediatrics is controversial. METHODS: We conducted a multi-institutional retrospective review of children undergoing cholecystectomy for BD to compare perioperative work-up and outcomes. RESULTS: Six hundred seventy-eight patients across 16 institutions were included. There was no significant difference in gender, age, or BMI between institutions. Most patients were white (86.3%), non-Hispanic (79.9%), and had private insurance (55.2%). Gallbladder ejection fraction (EF) was reported in 84.5% of patients, and 44.8% had an EF < 15%. 30.7% of patients were initially seen by pediatric surgeons, 31.3% by pediatric gastroenterologists, and 23.4% by the emergency department with significant variability between institutions (p < 0.001). Symptoms persisted in 35.3% of patients post-operatively with a median follow-up of 21 days (IQR 13, 34). On multivariate analysis, only non-white race and the presence of psychiatric comorbidities were associated with increased risk of post-operative symptoms. CONCLUSION: There is significant variability in evaluation and follow-up both before and after cholecystectomy for BD. Prospective research with standardized data collection and follow-up is needed to develop and validate optimal care pathways for pediatric patients with suspected BD. STUDY TYPE: Case Series, Retrospective Review. LEVEL OF EVIDENCE: Level IV.

No standard dehydration monitor exists for children. This study attempts to determine the utility of Fast Fourier Transform (FFT) of a peripheral venous pressure (PVP) waveform to predict dehydration.PVP waveforms were collected from 18 patients. Groups were defined as resuscitated (serum chloride ≥ 100 mmol/L) and hypovolemic (serum chloride100 mmol/L). Data were collected on emergency department admission and after a 20 cc/kg fluid bolus. The MATLAB (MathWorks) software analyzed nonoverlapping 10-s window signals; 2.4 Hz (144 bps) was the most demonstrative frequency to compare the PVP signal power (mmHg).Admission FFTs were compared between 10 (56%) resuscitated and 8 (44%) hypovolemic patients. The PVP signal power was higher in resuscitated patients (median 0.174 mmHg, IQR: 0.079-0.374 mmHg) than in hypovolemic patients (median 0.026 mmHg, IQR: 0.001-0.057 mmHg), (P 0.001). Fourteen patients received a bolus regardless of laboratory values: 6 (43%) resuscitated and 8 (57%) hypovolemic. In resuscitated patients, the signal power did not change significantly after the fluid bolus (median 0.142 mmHg, IQR: 0.032-0.383 mmHg) (P = 0.019), whereas significantly increased signal power (median 0.0474 mmHg, IQR: 0.019-0.110 mmHg) was observed in the hypovolemic patients after a fluid bolus at 2.4 Hz (P 0.001). The algorithm predicted dehydration for window-level analysis (sensitivity 97.95%, specificity 93.07%). The algorithm predicted dehydration for patient-level analysis (sensitivity 100%, specificity 100%).FFT of PVP waveforms can predict dehydration in hypertrophic pyloric stenosis. Further work is needed to determine the utility of PVP analysis to guide fluid resuscitation status in other pediatric populations.

Vital signs are included in the determination of shock secondary to hemorrhage; however, more granular predictors are needed. We hypothesized that fast Fourier transformation (FFT) would have a greater percent change after hemorrhage than heart rate (HR) or systolic blood pressure (SBP). Using a porcine model, nine 17 kg pigs were hemorrhaged 10% of their calculated blood volume. Peripheral venous pressure waveforms, HR and SBP were collected at baseline and after 10% blood loss. FFT was performed on the peripheral venous pressure waveforms and the peak between 1 and 3 hertz (f1) corresponded to HR. To normalize values for comparison, percent change was calculated for f1, SBP, and HR. The mean percent change for f1 was an 18.8% decrease; SBP was a 3.31% decrease; and HR was a 0.95% increase. Using analysis of variance, FFT at f1 demonstrates a statistically significant greater change than HR or SBP after loss of 10% of circulating blood volume (p = 0.0023). Further work is needed to determine if this could be used in field triage to guide resuscitation.

Blue Rubber Bleb Nevus Syndrome is a congenital rarity that manifests as vascular malformations throughout the body, including the gastrointestinal tract. With fewer than 300 cases reported, the etiology and clinical course is poorly understood; however, the literature suggests TEK mutations on chromosome 9 result in unregulated angiogenesis. We present the case of a young female treated for anemia of unknown etiology who presented in hemorrhagic shock due to gastrointestinal hemorrhage necessitating small bowel resection, with cutaneous, intestinal, hepatic, and lingual vascular malformations associated with a single somatic pathologic TEK mutation. Although uncommon, this case suggests that Blue Rubber Bleb Nevus Syndrome should be considered in the differential of a patient with persistent anemia and cutaneous lesions, carrying the potential for multiple gastrointestinal vascular malformations progressing to hemorrhage necessitating operative management. Additionally, a severe phenotype can occur without a double-hit TEK mutation.

Background Postoperative oral antibiotic management at discharge for perforated appendicitis varies by institution. A prior study at our institution led to a decrease in antibiotic therapy in patients without leukocytosis. A subsequent protocol change eliminated the white blood cell count check and oral antibiotics if discharge criteria were met by postoperative day seven. We hypothesized this change could be made without an increase in abscess or readmission rates. Methods We conducted a retrospective review of patients with perforated appendicitis over two 1-year periods after institutional review board approval (262061). In the pre-protocol group, a white blood cell count was checked at discharge and patients with leukocytosis were prescribed oral antibiotics to complete a total of 7 d. In the post-protocol group, no white blood cell count was checked and patients were discharged home without antibiotics. Results There were a total of 174 patients with complicated appendicitis in the two 1-year periods with 129 (74%) patients with perforated appendicitis discharged before postoperative day seven. The pre-protocol group included 71 children, and post-protocol included 58 children. There were no differences between mean postoperative days to discharge (2.57 versus 3, P = 0.0896), postoperative abscess rate (12.7% versus 12.1%, P = 1.0000), or readmission rate (12.7% versus 17.2%, P = 0.6184). None of the patients in the post-protocol group were discharged home with oral antibiotics compared with 22.5% in the pre-protocol group (P Conclusions For pediatric patients with perforated appendicitis discharged before postoperative day seven, stopping antibiotics at the time of discharge significantly decreased our home antibiotic use without an increase in postoperative morbidity.

BACKGROUND The purpose of this study was to determine the relationship between timing and volume of crystalloid before blood products and mortality, hypothesizing that earlier transfusion and decreased crystalloid before transfusion would be associated with improved outcomes. METHODS A multi-institutional prospective observational study of pediatric trauma patients younger than 18 years, transported from the scene of injury with elevated age-adjusted shock index on arrival, was performed from April 2018 to September 2019. Volume and timing of prehospital, emergency department, and initial admission resuscitation were assessed including calculation of 20 ± 10 mL/kg crystalloid boluses overall and before transfusion. Multivariable Cox proportional hazards and logistic regression models identified factors associated with mortality and extended intensive care, ventilator, and hospital days. RESULTS In 712 children at 24 trauma centers, mean age was 7.6 years, median (interquartile range) Injury Severity Score was 9 (2-20), and in-hospital mortality was 5.3% (n = 38). There were 311 patients(43.7%) who received at least one crystalloid bolus and 149 (20.9%) who received blood including 65 (9.6%) with massive transfusion activation. Half (53.3%) of patients who received greater than one crystalloid bolus required transfusion. Patients who received blood first (n = 41) had shorter median time to transfusion (19.8 vs. 78.0 minutes, p = 0.005) and less total fluid volume (50.4 vs. 86.6 mL/kg, p = 0.033) than those who received crystalloid first despite similar Injury Severity Score (median, 22 vs. 27, p = 0.40). On multivariable analysis, there was no association with mortality (p = 0.51); however, each crystalloid bolus after the first was incrementally associated with increased odds of extended ventilator, intensive care unit, and hospital days (all p < 0.05). Longer time to transfusion was associated with extended ventilator duration (odds ratio, 1.11; p = 0.04). CONCLUSION Resuscitation with greater than one crystalloid bolus was associated with increased need for transfusion and worse outcomes including extended duration of mechanical ventilation and hospitalization in this prospective study. These data support a crystalloid-sparing, early transfusion approach for resuscitation of injured children. LEVEL OF EVIDENCE Therapeutic, level IV.

Variation exists for postoperative antibiotics in children with complicated appendicitis. We investigated the impact of white blood count (WBC) at discharge on oral antibiotic therapy, abscess rate, and readmission rate.We conducted a two year review of children with complicated appendicitis. In the pre-protocol group, total antibiotic therapy was ten days (IV and oral) and home oral antibiotics at discharge. In the post-protocol group, children with leukocytosis were prescribed oral antibiotics to complete seven days of total antibiotic therapy and children without leukocytosis were not prescribed oral home antibiotics.There was no difference between mean hospital days after operation (3.52 vs. 3.24, p = 0.5111), means days of inpatient intravenous antibiotics (3.13 vs. 2.58, p = 0.5438), post-operative abscess rates (20.7% vs. 19.6%, p = 0.9975), or readmission rate (13.4% vs. 12.4%, p = 1.000). The post-protocol group had a shorter average total antibiotic duration (4.24 vs. 9.52 days, p 0.001) and were more likely to be discharged without oral antibiotics (71.1% vs 8.5%, p 0.001).Limiting home antibiotics at discharge to children with leukocytosis significantly decreases home antibiotic use.

Postoperative admission for acute appendicitis utilizes health care system resources. We evaluated outcomes and hospital charges for children with nonperforated appendicitis who underwent outpatient laparoscopic appendectomy.A retrospective chart review was performed for patients ≤18years old who underwent laparoscopic appendectomy for acute appendicitis in 2015. Patients were categorized into discharge from postanesthesia care unit (PACU) (outpatient), admission for24-h, and admission for24-h. Continuous variables were compared using analysis of variance and categorical variables were compared using chi-square test, with p0.05 considered significant.Of the 171 patients identified, 63 (37%) were discharged from the PACU, 94 (55%) were admitted24-h, and 14 (8%) were admitted24-h. There were no differences in postoperative emergency department/clinic visits, complications, or readmissions. Hospital charges for admission24-h and24-h were $1007 and $2237 more per patient than the PACU-discharge group, respectively. Outpatient laparoscopic appendectomies became more common over time, occurring in only 20% of patients with acute appendicitis in the first quarter of the year versus 49% of patients in the last quarter.Outpatient laparoscopic appendectomy for nonperforated appendicitis in children is a safe practice that decreases length of stay and hospital charges. Adoption of an outpatient strategy allows for better standardization of care and can lead to savings in health care resources.III (Treatment: retrospective comparative study).

There is no required competency for pediatric vascular injury in surgical training. We sought to describe changes over time for surgical specialists operating on pediatric vascular trauma injuries at a pediatric trauma center.Charts were retrospectively reviewed for vascular trauma injuries at a freestanding children's hospital between 1993 and 2015. Data were collected on mechanism, injured vessel(s), operation(s) performed, and specialists performing operation. Surgical specialists were compared over time.Ninety-four patients (median age = 12) underwent 101 pediatric vascular trauma operations. There were significant differences in frequency of types of operations (primary repairs, graft repairs, and ligations) performed by pediatric, vascular, and orthopedic surgeons (P.001). The proportion of operations performed by vascular surgeons increased and those performed by pediatric surgeons decreased significantly over time.Various surgical specialists manage pediatric vascular trauma. With expansion of integrated residency programs, surgical specialists managing these patients in the future should be trained in both pediatric and vascular surgery.

To improve opioid stewardship for umbilical hernia repair in children.An educational intervention was conducted at 9 centers with 79 surgeons. The intervention highlighted the importance of opioid stewardship, demonstrated practice variation, provided prescribing guidelines, encouraged non-opioid analgesics, and encouraged limiting doses/strength if opioids were prescribed. Three to six months of pre-intervention and 3 months of post-intervention prescribing practices for umbilical hernia repair were compared.A total of 343 patients were identified in the pre-intervention cohort and 346 in the post-intervention cohort. The percent of patients receiving opioids at discharge decreased from 75.8% pre-intervention to 44.6% (p 0.001) post-intervention. After adjusting for age, sex, umbilicoplasty, and hospital site, the odds ratio for opioid prescribing in the post- versus the pre-intervention period was 0.27 (95% CI = 0.18-0.39, p 0.001). Among patients receiving opioids, the number of doses prescribed decreased after the intervention (adjusted mean 14.3 to 10.4, p 0.001). However, the morphine equivalents/kg/dose did not significantly decrease (adjusted mean 0.14 to 0.13, p = 0.20). There were no differences in returns to emergency departments or hospital readmissions between the pre- and post-intervention cohorts.Opioid stewardship can be improved after pediatric umbilical hernia repair using a low-fidelity educational intervention.Retrospective cohort study.Level II.

Surgical wound classification (SWC) is widely utilized for surgical site infection (SSI) risk stratification and hospital comparisons. We previously demonstrated that nearly half of common pediatric operations are incorrectly classified in eleven hospitals. We aimed to improve multicenter, intraoperative SWC assignment through targeted quality improvement (QI) interventions.A before-and-after study from 2011-2014 at eleven children's hospitals was conducted. The SWC recorded in the hospital's intraoperative record (hospital-based SWC) was compared to the SWC assigned by a surgeon reviewer utilizing a standardized algorithm. Study centers independently performed QI interventions. Agreement between the hospital-based and surgeon SWC was analyzed with Cohen's weighted kappa and chi square.Surgeons reviewed 2034 cases from 2011 (Period 1) and 1998 cases from 2013 (Period 2). Overall SWC agreement improved from 56% to 76% (p0.01) and weighted kappa from 0.45 (95% CI 0.42-0.48) to 0.73 (95% CI 0.70-0.75). Median (range) improvement per institution was 23% (7-35%). A dose-response-like pattern was found between the number of interventions implemented and the amount of improvement in SWC agreement at each institution.Intraoperative SWC assignment significantly improved after resource-intensive, multifaceted interventions. However, inaccurate wound classification still commonly occurred. SWC used in SSI risk-stratification models for hospital comparisons should be carefully evaluated.

The purpose of this study was to define the hematologic response to total splenectomy (TS) or partial splenectomy (PS) in children with hereditary spherocytosis (HS) or sickle cell disease (SCD).The Splenectomy in Congenital Hemolytic Anemia (SICHA) consortium registry collected hematologic outcomes of children with CHA undergoing TS or PS to 1 year after surgery. Using random effects mixed modeling, we evaluated the association of operative type with change in hemoglobin, reticulocyte counts, and bilirubin. We also compared laparoscopic to open splenectomy.The analysis included 130 children, with 62.3% (n=81) undergoing TS. For children with HS, all hematologic measures improved after TS, including a 4.1g/dl increase in hemoglobin. Hematologic parameters also improved after PS, although the response was less robust (hemoglobin increase 2.4 g/dl, p0.001). For children with SCD, there was no change in hemoglobin. Laparoscopy was not associated with differences in hematologic outcomes compared to open. TS and laparoscopy were associated with shorter length of stay.Children with HS have an excellent hematologic response after TS or PS, although the hematologic response is more robust following TS. Children with SCD have smaller changes in their hematologic parameters. These data offer guidance to families and clinicians considering TS or PS.

This paper proposes an automatic anomaly detection and removal algorithm for peripheral venous pressure (PVP) signals, which can be used to predict intravascular volume loss in humans. PVP signal collection is a minimally invasive procedure that can be performed by using a standard peripheral intravenous (PIV) catheter and a commercial pressure-monitoring transducer. PVP signals are highly susceptible to motion and noise artifacts such as patient movements or unintended manipulation of PIV lines. Anomalies in PVP signals can corrupt useful information and seriously affect the integrity of PVP signal analysis. We propose to detect and remove such anomalies by exploiting the properties of PVP signals. Specifically, a dynamic linear model (DLM) with a Kalman filter is used to track and predict the time-domain evolution of PVP signals. The prediction residuals of the Kalman filter are then modeled with a hidden Markov model (HMM), with the normal and anomalous status of the signal modeled by using binary states of a hidden Markov chain. The HMM parameters along with the hidden states are iteratively estimated by using an unsupervised learning algorithm with a modified Baum–Welch method. The anomaly detection algorithm is applied to clinical data from a cohort of 24 pediatric patients with hypertrophic pyloric stenosis. Experimental results demonstrate that the proposed unsupervised anomaly detection algorithm can efficiently remove anomalies in PVP signals without the need of a training phase. The algorithm can also be applied to other time series signals, such as Electrocardiography (ECG) and Photoplethysmogram (PPG) signals.

A clinical prediction rule was previously developed by the Pediatric Surgery Research Collaborative (PedSRC) to identify patients at very low risk for intra-abdominal injury (IAI) and intra-abdominal injury receiving an acute intervention (IAI-I) who could safely avoid abdominal computed tomography (CT) scans after blunt abdominal trauma (BAT). Our objective was to externally validate the rule.The public-use dataset was obtained from the Pediatric Emergency Care Applied Research Network (PECARN) Intra-abdominal Injury Study. Patients 16 years of age and younger with chest x-ray, completed abdominal history and physical examination, aspartate aminotransferase (AST), and amylase or lipase collected within 6 hours of arrival were included. We excluded patients who presented greater than 6 hours after injury or missing any of the five clinical prediction variables from the PedSRC prediction rule.We included 2,435 patients from the PECARN dataset, with a mean age of 9.4 years. There were 235 patients with IAI (9.7%) and 60 patients with IAI-I (2.5%). The clinical prediction rule had a sensitivity of 97.5% for IAI and 100% for IAI-I. In patients with no abnormality in any of the five prediction rule variables, the rule had a negative predictive value of 99.3% for IAI and 100.0% for IAI-I. Of the "very low-risk" patients identified by the rule, 46.8% underwent abdominal CT imaging.A highly sensitive clinical prediction rule using history and abdominal physical examination, laboratory values, and chest x-ray was successfully validated using a large public-access dataset of pediatric BAT patients.Epidemiologic/prognostic study, level III; therapeutic care/management study, level IV.

Major health care agencies recommend real-time ultrasound (RTUS) guidance during insertion of percutaneous central venous catheters (CVC) based on studies in which CVCs were placed by nonsurgeons. We conducted a meta-analysis to compare outcomes for surgeon-performed RTUS-guided CVC insertion versus traditional landmark technique.A systematic review of the literature was performed, identifying randomized controlled trials (RCT) and prospective "safety studies" of surgeon-performed CVC insertions comparing landmark to RTUS techniques. Searches were conducted in MEDLINE, Cochrane, and Web of Science, with additional relevant articles identified through examination of the bibliographies and citations of the included studies. Two independent reviewers selected relevant studies that matched inclusion criteria, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. A meta-analysis was conducted using random effects models to compare success and complication rates.Three RCTs were identified totaling 456 patients. The RTUS guidance was associated with better first attempt success (odds ratio [OR], 4.7; 95% confidence interval [CI], 1.5-14.7, p = 0.008) and overall success (OR 6.5, 95% CI: 2.7-15.7, p0.0001). However, there were no differences in overall complication (OR 1.9 (95% CI, 0.8-4.4, p = 0.14)) or arterial puncture (OR 2.0 (95% CI, 0.7-5.6, p = 0.18) rates between the two methods.Despite many studies involving nonsurgeons, there are only three RCTs comparing RTUS versus landmark technique for surgeon-performed CVC placement. The RTUS guidance is associated with better success than landmark technique, but no difference in complication rates. No study evaluated how RTUS was implemented. Larger studies examining RTUS use during surgeon-performed CVC placements are needed.Systematic review and meta-analysis, level III.

The purpose of this technological notes paper is to describe our institution's experience collecting peripheral venous pressure (PVP) waveforms using a standard peripheral intravenous catheter in an awake pediatric patient. PVP waveforms were collected from patients with hypertrophic pyloric stenosis. PVP measurements were obtained prospectively at two time points during the hospitalization: admission to emergency department and after bolus in emergency department. Data was collected from thirty-two patients. Interference in the PVP waveforms data collection was associated with the following: patient or device motion, system set-up error, type of IV catheter, and peripheral intravenous catheter location. PVP waveforms can be collected in an awake pediatric patient and adjuncts to decrease signal interference can be used to optimize data collection.

Rapid assessment of volume status in children is often difficult. The purpose of this study was to evaluate the feasibility of surgeon-performed ultrasound to assess volume status in patients with hypertrophic pyloric stenosis. Ultrasounds were performed on admission and before operation. The diameters of the inferior vena cava (IVC) and aorta (Ao) were measured and IVC/Ao ratios were calculated. Electrolytes were measured on admission and repeated if warranted. Logistic regression was used to associate the clinical outcome, defined as CO2 ≤30 mEq/L, with IVC/Ao ratios. Predictive capacity was estimated from the logistic regression for IVC/Ao ratios. Linear regression was used to estimate associations between CO2 values and IVC/Ao ratios. Thirty-one patients were enrolled. The IVC/Ao ratio is highly associated with actual CO2 values (P

Background Surgical wound classification (SWC) is used by hospitals, quality collaboratives, and Centers for Medicare and Medicaid to stratify patients for their risk for surgical site infection. Although these data can be used to compare centers, the validity and reliability of SWC as currently practiced has not been well studied. Our objective was to assess the reliability of SWC in a multicenter fashion. We hypothesized that the concordance rates between SWC in the electronic medical record and SWC determined from the operative note review is low and varies by institution and operation. Study Design Surgical wound classification concordance was assessed at 11 participating institutions between SWC from the electronic medical record and SWC from operative note review for 8 common pediatric surgical operations. Cases with concurrent procedures were excluded. A maximum of 25 consecutive cases were selected per operation from each institution. A designated surgeon reviewed the included operative notes from his/her own institution to determine SWC based on a predetermined algorithm. Results In all, 2,034 cases were reviewed. Overall SWC concordance was 56%, ranging from 47% to 66% across institutions. Inguinal hernia repair had the highest overall median concordance (92%) and appendectomy had the lowest (12%). Electronic medical records and reviewer SWC differed by up to 3 classes for certain cases. Conclusions Surgical site infection risk stratification by SWC, as currently practiced, is an unreliable methodology to compare patients and institutions. Surgical wound classification should not be used for quality benchmarking. If SWC continues to be used, individual institutions should evaluate their process of assigning SWC to ensure its accuracy and reliability.

Purpose Pediatric surgeon performed bedside ultrasound (PSPBUS) is a targeted examination that is diagnostic or therapeutic. The aim of this paper is to review literature involving PSPBUS. Methods PSPBUS practices reviewed in this paper include central venous catheter placement, physiologic assessment (volume status and echocardiography), hypertrophic pyloric stenosis diagnosis, appendicitis diagnosis, the Focused Assessment with Sonography for Trauma (FAST), thoracic evaluation, and soft tissue infection evaluation. Results There are no standards for the practice of PSPBUS. Conclusions As the role of the pediatric surgeon continues to evolve, PSPBUS will influence practice patterns, disease diagnosis, and patient management. Type of Study Review Article. Level of Evidence Level III.

Optimal timing to begin feeds in neonates with gastroschisis remains unclear. We examined if bedside abdominal ultrasound for intestinal motility is a feasible tool to detect return of bowel function in neonates with gastroschisis.Neonates born with uncomplicated gastroschisis who underwent closure received daily ultrasound exams. Full motility was defined as peristalsis seen in all quadrants. Average length of time between abdominal wall closure and start of enteral feeds, full ultrasound motility, and clinical characteristics was compared using Student's t-tests.Seventeen patients were enrolled. No differences were found between motility on ultrasound and bowel movements, gastric residuals, or nonbilious residuals. Mean time to enteral feeds (11.82days) was significantly delayed compared to documentation of full motility on ultrasound (8.94days; p=0.012), consistent bowel movements (8.41days; p=0.006), low gastric residuals (9.47days; p0.001), and nonbilious residuals (9.18days; p0.001). In the single subject in which feeds were started before full motility was seen on ultrasound, feeds were subsequently discontinued because of emesis.Bedside abdominal ultrasound provides real-time evidence regarding intestinal motility and is a feasible tool to detect return of bowel function in neonates with gastroschisis. Future studies are needed to determine if abdominal ultrasound can shorten time to start of enteral feeds.III (diagnosis: nonconsecutive study).

The outcomes of children with congenital hemolytic anemia (CHA) undergoing total splenectomy (TS) or partial splenectomy (PS) remain unclear. In this study, we collected data from 100 children with CHA who underwent TS or PS from 2005–2013 at 16 sites in the Splenectomy in Congenital Hemolytic Anemia (SICHA) consortium using a patient registry. We analyzed demographics and baseline clinical status, operative details, and outcomes at 4, 24, and 52 weeks after surgery. Results were summarized as hematologic outcomes, short-term adverse events (AEs) (≤ 30 days after surgery), and long-term AEs (31–365 days after surgery). For children with hereditary spherocytosis, after surgery there was an increase in hemoglobin (baseline 10.1 ± 1.8 gm/dl, 52 week 12.8 ± 1.6 gm/dl; mean ± SD), decrease in reticulocyte and bilirubin as well as control of symptoms. Children with sickle cell disease had control of clinical symptoms after surgery, but had no change in hematologic parameters. There was an 11% rate of short-term AEs and 11% rate of long-term AEs. As we accumulate more subjects and longer follow-up, use of a patient registry should enhance our capacity for clinical trials and engage all stakeholders in the decision-making process.

Background Computed tomography is commonly used to rule out intra-abdominal injury (IAI) in children, despite associated cost and radiation exposure. Our purpose was to derive a prediction rule to identify children at very low risk for IAI after blunt abdominal trauma (BAT) for whom a CT scan of the abdomen would be unnecessary. Study Design We prospectively enrolled children younger than 16 years of age who presented after BAT at 14 Level I pediatric trauma centers during 1 year. We excluded patients who presented more than 6 hours after injury or underwent abdominal CT before transfer. We used binary recursive partitioning to derive a prediction rule identifying children at very low risk of IAI and IAI requiring acute intervention (IAI-I) using clinical information available in the trauma bay. Results We included 2,188 children with a median age of 8 years. There were 261 patients with IAI (11.9%) and 62 patients with IAI-I (2.8%). The prediction rule consisted of (in descending order of significance): aspartate aminotransferase >200 U/L, abnormal abdominal examination, abnormal chest x-ray, report of abdominal pain, and abnormal pancreatic enzymes. The rule had a negative predictive value of 99.4% for IAI and 100.0% for IAI-I in patients with none of the prediction rule variables present. The very-low-risk population consisted of 34% of the patients and 23% received a CT scan. Computed tomography frequency ranged from 4% to 96% by center. Conclusions A prediction rule using history and physical examination, chest x-ray, and laboratory evaluation at the time of presentation after BAT identifies children at very low risk for IAI for whom CT can be avoided.

Vascular surgeons infrequently care for pediatric patients. As such, variability in operative management and available hospital resources at free-standing children's hospitals (CHs) may exist. The study aims were (1) to determine vascular surgeon comfort level with pediatric vascular surgery and (2) to determine variations in pediatric vascular surgery practice patterns.A survey composed of clinical vignettes emailed to all members of Vascular and Endovascular Surgery Society was designed to assess operative management of pediatric vascular conditions and hospital resources. Comparisons of surgeon satisfaction between free-standing CHs and a CH within an adult general hospital were made using Wilcoxon rank-sum tests. Comparison of surgeon comfort between hospital types was made using a McNemar's test. P-values less than or equal to 0.05 indicated statistical significance.Response rate was 18% (93/525) with 96% (89/93) indicating completion of a 2 year vascular fellowship. Surgeon satisfaction with operative equipment (P = 0.002), support staff (P 0.001), and vascular laboratory availability (P = 0.01) was significantly lower at CHs. Eighty-seven percent of surgeons operated on fewer than 2 children over the preceding 3 months. For the different clinical vignettes, there was a wide variation in practice patterns with a range of 50-89% of the surgeons performing fewer than 5 cases over the preceding 10 years. There was a significant decrease in surgeon's comfort level with elective pediatric vascular operations compared to the operative management of pediatric vascular trauma (P = 0.0025).Most vascular surgeons do not feel comfortable in the operative management of pediatric vascular disease, and optimal resource availability within pediatric CHs may be lacking. Centralized care of this patient population may be warranted.

Purpose The occurrence of gastrocutaneous fistula (GCF) is a well-known complication after gastrostomy tube placement. We explore multiple factors to ascertain their impact on the rate of persistent GCF formation. Methods We retrospectively reviewed patient records for all gastrostomies (GT) constructed at our institution from 2007 to 2011. Association of GCF with method of placement, concomitant fundoplication, neurologic findings, duration of therapy, and demographics was evaluated using logistic regression. Results Nine hundred fifty patients had GTs placed, of which 148 patients had GTs removed and 47 (32%) of 148 required surgical closure secondary to persistent GCF. Laparoscopic and open procedures comprised 79 (53%) of 148 and 69 (47%) of 148, respectively. Seventeen (22%) patients in the laparoscopic group developed persistent GCF, compared to 30 (43%) in the open group ( P =0.035, OR=2.52). Seventy-one patients had concomitant Nissen fundoplication. Thirty-one (44%) developed GCF, compared to 16 (21%) without a Nissen ( P =0.002, OR=4.94). Patients with button in place for 303days had persistent GCF incidence of 23%, compared to 45% at 540days ( P P =0.011, OR=4.51). Patients with device placed at 1.8months of age were more likely to develop GCF compared to those with device placed at 8.9months of age ( P =0.017, OR=2.35). Conclusion Open operations, concurrent Nissen and younger age at placement were all statistically significant factors causing persistent GCF.

There is no consensus on optimal timing of gastroschisis repair. The 2012-2014 ACS NSQIP Pediatric Participant Use Data File was used to compare outcomes of primary versus staged gastroschisis repair.Cases were divided into primary repair (0-1day) and staged repair (4-14days). Baseline characteristics and outcomes were compared for primary versus staged closure using Fisher's exact tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. Length of stay was compared after controlling for prematurity.There were 627 subjects included, with 364 neonates in the primary group and 263 in the staged group. The primary group demonstrated shorter hospital length of stay (LOS) (5.1days; p0.001) and had less surgical site infections (OR=0.27; p=0.003), but had longer ventilator days (1.9days; p0.001). Neonates in the primary repair group were less likely to be discharged home versus transferred to another hospital (OR=0.24; p=0.006) and more likely to require nutritional support at discharge (OR=1.74; p=0.034). No significant differences were identified for mortality, readmissions, postoperative LOS, sepsis or other outcomes.Staged repair of gastroschisis has longer LOS attributed to preoperative timing, but less ventilator days. Outcomes for these closure techniques are equivocal and support surgeons performing the closure technique they are most experienced with.III (Treatment: retrospective comparative study).

Recommendations for the use of real-time ultrasonography for placement of central venous catheters in children are based on studies involving adults treated by nonsurgeons. Our purpose was to determine the frequency of use of real-time ultrasonography use by pediatric surgeons during central venous catheter placement, patient and procedure factors associated with real-time ultrasonography use, and adverse event rates.Using data gathered from 14 institutions, we performed a retrospective cohort study of patients18 years old who underwent central venous catheter placement. Patient demographics and operative details were collected. We used a logistic regression model to evaluate factors associated with real-time ultrasonography use.Real-time ultrasonography was used in 33% of attempts (N = 1,146). The subclavian vein (64%) was accessed preferentially for first site insertion. Real-time ultrasonography was less likely to be used for subclavian vein (odds ratio = 0.002; P .0001) and more likely to be used when coagulopathy (international normalized ratio1.5) was present (odds ratio = 11.1; P = .03). The rate of mechanical complications was 3.5%. Real-time ultrasonography use was associated with greater procedural success rates on first-site attempt, but also with a greater risk of hemothorax.Pediatric surgeons access preferentially the subclavian vein for central venous access, yet are less likely to use real-time ultrasonography at this site. Real-time ultrasonography was superior to the landmark techniques for the first-site procedure success, yet was associated with greater rates of hemothorax. Prospective trials involving children treated by pediatric surgeons are needed to generate more definitive data.

Creation of an animal model of necrotizing enterocolitis (NEC) allowing adjustment of severity and potential recoverability is needed to study effectiveness of prevention and treatment strategies. This study describes a novel model in preterm rabbits capable of adjusting severity of NEC-like histologic changes. Rabbit pups (n = 151) were delivered by cesarean section 2 days preterm. In the treatment groups, tissue adhesive was applied to anal openings to simulate the poor intesti- nal function and dysmotility of preterm neonates. Pups were placed into five groups: 3INT (3 day intermittent block), 4INT (4 day intermittent block), 3COM (3 day complete block), 4COM (4 day complete block), based on differences in type of anal blockage and day of life sacrificed. The fifth group, 4CON, was comprised of a control arm (n = 28) without anal block, with sacrifice of sub- jects on day 4. All pups were gavage fed with formula contaminated with Enterobacter cloacae, ranitidine, and indomethacin. Following sacrifice, the intestines were harvested for pathologic evidence of NEC. A blinded pathologist graded histologic changes consistent with NEC using a grading scale 0-4 with 4 being most severe. Fifty-seven pups (57/123) (46%) in the research arm survived to sacrifice, compared to 26/28 (93%) in the control arm of the investigation, p < 0.0001. The incidence and severity of NEC-like damage increased with the duration and completeness of the anal blockage. 44/57 (77%) of survivors revealed various degrees of NEC-like damage to large and small bowel, and 3/26 (12%) exhibited early NEC-like mucosal injury in the research and control arms, respectively. This animal model produces NEC-like pathologic changes in both small and large intestine in preterm rabbits. Because incidence and severity of damage increases with duration and completeness of intestinal dysmotility, this allows future effectiveness studies for nonsurgical treatment and prevention of NEC.

Purpose Diagnosing appendicitis may require adjunct studies such as computed tomography or ultrasound (US). Combining a clinical examination with surgeon-performed US (SPUS) may increase diagnostic accuracy and decrease radiation exposure and costs. Methods A prospective study was conducted including children with a potential diagnosis of appendicitis. A surgery resident performed a clinical examination and US to make a diagnosis. Final diagnosis of appendicitis was confirmed by operative findings and pathology. Results were compared with radiology department US (RDUS) and a large randomized trial. Analysis was performed using Fisher exact test. Results Fifty-four patients were evaluated and underwent SPUS. Twenty-nine patients (54%) had appendicitis. Overall accuracy was 89%, with accuracy increasing from 85% to 93% between the 2 halves of the study. Radiology department US was performed on 21 patients before surgical evaluation, yielding an accuracy of 81%. Surgeon-performed US on those 21 patients yielded an accuracy of 90%. No statistical differences were found between any groups ( P > .05). Conclusion Accuracy of SPUS was similar to RDUS and that of a large prospective randomized trial performed by radiologists. Furthermore, when the same clinician performs the clinical examination and US, a high level of accuracy can be achieved. With this degree of accuracy, SPUS may be used as a primary diagnostic tool and computed tomography reserved for challenging cases, limiting costs, and radiation exposure.

Objective Our institution has demonstrated the diagnostic accuracy of surgeon-performed ultrasound (US) in the diagnosis of hypertrophic pyloric stenosis (HPS). Moreover, we have also shown this modality to be accurate and reproducible through surgeon-to-surgeon instruction. The purpose of this study was to determine whether a surgical resident with experience in diagnosing HPS can teach pediatric emergency medicine (PEM) fellows, with little experience in sonography, to accurately measure the pyloric channel with bedside US. Methods A surgical resident with experience in diagnosing HPS with US-proctored 4 emergency medicine fellows for 5 bedside US examinations each. A PEM fellow, who was blinded to the results from the radiology department US, then performed bedside US and measured the pyloric channel in patients presenting to the emergency department with HPS. Results between the radiology department and the fellows were compared using the Student t test. Results In total, 18 USs were performed on 17 patients. There were no false-negative or false-positive results. There was no statistical difference between the radiology department and fellow measurement when evaluating muscle width (p = 0.21, mean deviation = 0.2 mm) or channel length (p = 0.47, mean deviation = 0.6 mm). Conclusion Bedside-performed US technique for measuring the pylorus length and width in patients with HPS is reproducible and accurate when taught to PEM providers. The learning curve for this technique is short.

Limited data exist regarding indications for resuscitative emergency thoracotomy (ETR) in the pediatric population. We attempt to define the presenting hemodynamic parameters that predict survival for pediatric patients undergoing ETR.We reviewed all pediatric patients (age18years), entered into the National Trauma Data Bank from 2007 to 2010, who underwent ETR within one hour of ED arrival. Mechanism of injury and hemodynamics were analyzed using Chi squared and Wilcoxon tests.316 children (70 blunt, 240 penetrating) underwent ETR, 31% (98/316) survived to discharge. Less than 5% of patients survived when presenting SBP was ≤50mmHg or heart rate was ≤70bpm. For blunt injuries there were no survivors with a pulse ≤80bpm or SBP ≤60mmHg. When survivors were compared to nonsurvivors, blood pressure, pulse, and injury type were statistically significant when treated as independent variables and in a logistic regression model.When ETR was performed for SBP ≤50mmHg or for heart rate ≤70bpm less than 5% of patients survived. There were no survivors of blunt trauma when SBP was ≤60mmHg or pulse was ≤80bpm. This review suggests that ETR may have limited benefit in these patients.

Historically, the majority of patients with colonic atresia have been managed by ostomy creation at the time of initial operation; conversely, we have tended to treat the atresia with resection and anastomosis. The purpose of this study is to determine the rate of concomitant Hirschsprung’s disease and to identify potential morbidity associated with primary repair. After IRB approval (#105825), charts of patients identified by ICD-9 code as having colonic atresia, who were admitted to our institution between 1993 and 2008 were, retrospectively, reviewed. Particular attention was paid to demographic data, comorbidities, operative therapy, and complications. Continuous variables were compared using an unpaired t test. A P value of

Background: Probiotic fortified diet reduces bacterial colonization and translocation in a short-term neonatal rabbit model when continuously challenged with pathogen. The purpose of this study was to determine if live probiotic diet could remain effective at decreasing colonization/translocation of pathogens in a long-term neonatal rabbit model without ill effects of the probiotic outside the gastrointestinal (GI) tract. Methods: Rabbit pups were born via cesarean delivery 1 day preterm and assigned to 2 diets: a newly formulated diet (controls) vs the same diet fortified with the live probiotic Lactoccocus lactis. Enterobacter cloacae was added to both preparations before each feed. Pups were gavage fed twice daily, and weights were recorded. Rabbits were sacrificed on day 7, and organs were harvested and cultured for target organism growth. Results: The probiotic fortified diet resulted in a significant decrease in Enterobacter translocation to the liver and decreased colonization in the stomach and lungs. There was no evidence of Lactococccus translocation or colonization outside of the GI tract. Conclusion: This probiotic fortified diet was effective at decreasing pathogenic bacteria colonization and translocation in a long-term neonatal model. The addition of L lactis to the diet resulted in appropriate growth without any colonization or translocation of the probiotic outside of the GI tract.

Background Over the past decade, pediatric patients with ruptured appendicitis (RA) have been successfully treated with IV antibiotics and an interval appendectomy. Because the treatment of acute appendicitis (AA) and RA in children is now diverging, distinguishing between these two conditions preoperatively is critical. Study Design A prospective cohort study was conducted. Clinical data were collected, and the attending surgeon's preoperative diagnosis was recorded. Accuracy of the pediatric surgeon's diagnosis was determined. Univariable and multivariable logistic regression were then used to determine independent clinical predictors of RA. Using the relative beta coefficients of these predictors, a scoring system was constructed to aid in the diagnosis of RA. Results Two hundred forty-seven patients were evaluated: 98 AA (40%), 53 RA (21%), and 97 not appendicitis (39%). Median age was 10 years old. The overall accuracy of the pediatric surgeon's preoperative diagnosis was 92%. Sensitivity and specificity for the diagnosis of RA were 96% and 83%, respectively. Multivariable regression analysis identified generalized tenderness on examination, duration of symptoms longer than 48 hours, WBC>19,400 cells/μL, abscess, and fecalith on CT scan as independent predictors for RA. A novel scoring system was developed with these variables, and, when applied to the study population, the specificity for the diagnosis of RA improved to 98%. Conclusions Pediatric surgeons differentiate AA from RA and not appendicitis preoperatively with high accuracy and sensitivity, but the specificity for diagnosing ruptured appendicitis is lower. The scoring system improved the specificity of the preoperative diagnosis. The validity and utility of this scoring system should be examined in future studies in larger patient populations.

Background No consensus has been reached on optimal timing for performing appendectomies. We compared immediate and delayed appendectomies in pediatric patients presenting with suspected acute appendicitis to determine differences in postsurgical complications and perforation rates. Methods A retrospective cohort study was performed of all children who underwent appendectomy during a 4-y period. Cutoffs used were 6, 8, and 12 h from admission to operating room (OR). The Student t -tests and chi-square tests were performed to compare continuous and categorical variables, respectively. A logistic regression model was fitted to determine predictors of appendiceal perforation. P values Results Analysis included 484 patients with mean elapsed time from admission to OR of 394 min, with 262 subjects in the immediate and 222 subjects in the delayed >6 h groups. Surgical site infections (SSIs), perforations, and small bowel obstructions were similar between groups, and no statistically significant differences were found for SSIs in the nonperforated delayed versus immediate groups ( P = 0.964). Time from admission to the OR did not predict perforation ( P = 0.921), although white blood cell count at the time of admission was a significant predictor of perforation (odds ratio, 1.08; P Conclusions For suspected acute appendicitis, delaying appendectomy after admission for >6 h demonstrated no differences in SSI or perforation rates compared with immediate appendectomy. Waiting to perform an appendectomy until the following day has equal outcomes to immediate surgical procedure and may improve overall quality of patient care by limiting surgeon fatigue.

A study previously performed at our institution demonstrated that surgeon-performed ultrasound (SPUS) was accurate compared to radiology department ultrasound (RDUS) when evaluating children with suspected appendicitis. The purpose of this study was to determine if these results were reproducible and if SPUS decreased time to definitive diagnosis.A surgery resident performed examinations and ultrasounds on children with suspected appendicitis. Final diagnosis was confirmed by pathology. Results were compared to RDUS and combined with the previous study for a final comparison with RDUS. Mean time to diagnosis was recorded. Data were analyzed using Fisher exact and Student's t test.Fifty-eight patients underwent SPUS, of these 35 had RDUS. The accuracy of SPUS alone was 93% (54/58) and RDUS accuracy was 94% (33/35) (p = 1). When SPUS was combined with clinical examination accuracy increased to 95% (55/58). When results were combined with the previous study, overall accuracy of SPUS was 90% (101/112) compared to overall RDUS accuracy of 89 % (50/56). Mean time to diagnosis for RDUS was 135 min (n = 35), whereas mean time to diagnosis for SPUS was 30 min (n = 58; p = 0.0001).SPUS is accurate and reproducible in evaluating children with suspected appendicitis. SPUS potentially decreases time to definitive therapy and emergency department wait times.