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Objective: To assess impact of participation in a positive psychology coaching program on trainee burnout and well-being., Background: Coaching using principles of positive psychology can improve well-being and reduce physician burnout. We hypothesized that participation in a coaching program would improve pediatric surgery trainee well-being., Methods: With IRB approval, a coaching program was implemented during the COVID-19 pandemic (September 2020 to July 2021) in the American Pediatric Surgical Association. Volunteer pediatric surgery trainees (n=43) were randomized to receive either one-on-one quarterly virtual coaching (n=22) from a pediatric surgeon trained in coaching skills or wellness reading materials (n=21). Participants completed prestudy and poststudy surveys containing validated measures, including positive emotion, engagement, relationships, meaning, accomplishment, professional fulfillment, burnout, self-valuation, gratitude, coping skills, and workplace experiences. Results were analyzed using the Wilcoxon rank sum test, Kruskal-Wallis test, or χ 2 test., Results: Forty trainees (93%) completed both the baseline and year-end surveys and were included in the analysis. Twenty-five (64%) were female, mean age 35.7 (SD 2.3), and 65% were first-year fellows. Coached trainees showed an improved change in positive emotion, engagement, relationships, meaning, accomplishment ( P =0.034), burnout ( P =0.024), and gratitude ( P =0.03) scores from precoaching to postcoaching compared with noncoached trainees. Coping skills also improved. More coaching sessions were associated with higher self-valuation scores ( P =0.042), and more opportunities to reflect were associated with improved burnout and self-valuation., Conclusions: Despite the stress and challenges of medicine during COVID-19, a virtual positive psychology coaching program provided benefits in well-being and burnout to pediatric surgery trainees. Coaching should be integrated into existing wellness programs to support the acquisition of coping skills that help trainees cope with the stressors they will face during their careers., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Pediatric firearm injury prevention research in younger age groups is limited. This study evaluated a large multicenter cohort of younger children with firearm injuries, focusing on injury patterns and surgical resource utilization., Methods: Children ≤15 y old sustaining firearm injuries between 2016 and 2021 and treated at 10 pediatric trauma centers in Florida were included. Individual cases were reviewed for demographics, shooting details, injury patterns, resource utilization, and outcomes. Patients were grouped by age into preschool (0-5 y), elementary school (6-10 y), middle school (11-13 y), and early high school (14-15 y). Multivariable logistic regression was used to identify predictors of death and critical resource utilization., Results: A total of 489 children (80 preschool, 76 elementary school, 92 middle school, and 241 early high school) met inclusion criteria. Demographics, injury patterns, and resource utilization were similar across age groups. Assault and self-harm increased with age. Self-harm was implicated in 5% of cases but accounted for 18% of deaths. Hand surgery (i.e., below-elbow) procedures were common at 8%. Overall mortality was 10%, but markedly higher for self-harm injuries (47%). On multivariable regression, age and demographics were not predictive of death or critical resource utilization, but self-harm intent was a strong independent risk factor for both., Conclusions: This study suggests that given the age distribution and disproportionately high impact of self-harm injuries, behavioral health resources should be available to children at the middle school level or earlier. Hand surgery may represent an overlooked but frequently utilized resource to mitigate injury impact and optimize long-term function., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Adnexal torsion requires treatment to limit ischemic injury and tissue loss. Optimal time to surgical intervention has not been established. We compared outcomes of ovarian loss amongst pediatric patients., Methods: We conducted a retrospective review of 88 patients with adnexal torsion from March 2014 through April 2021. Rates of ovarian loss were compared for patients who underwent surgery within and beyond 60 minutes from diagnosis., Results: Most patients underwent surgery more than 60 minutes from the time of diagnosis (83%; median time 116 minutes). Comparing patients with and without ovarian loss, there was no statistically significant difference in time to surgery from time of diagnosis ( P = .618). Patients with ovarian loss had a longer duration of symptoms (24 vs 96 hours; P = .017)., Conclusions: While surgical repair of adnexal torsion may be urgent, this study suggests that duration of symptoms should be considered when assessing a patient's likelihood of ovarian loss., 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.

Background: Golf carts (GCs) and all-terrain vehicles (ATVs) are popular forms of personal transport. Although ATVs are considered adventurous and dangerous, GCs are perceived to be safer. Anecdotal experience suggests increasing numbers of both GC and ATV injuries, as well as high severity of GC injuries in children. This multicenter study examined GC and ATV injuries and compared their injury patterns, resource utilization, and outcomes., Methods: Pediatric trauma centers in Florida submitted trauma registry patients age <16 years from January 2016 to June 2021. Patients with GC or ATV mechanisms were identified. Temporal trends were evaluated. Injury patterns, resource utilization, and outcomes for GCs and ATVs were compared. Intensive care unit admission and immediate surgery needs were compared using multivariable logistic regression., Results: We identified 179 GC and 496 ATV injuries from 10 trauma centers. GC and ATV injuries both increased during the study period (R 2 0.4286, 0.5946, respectively). GC patients were younger (median 11 vs 12 years, p=0.003) and had more intracranial injuries (34% vs 19%, p<0.0001). Overall Injury Severity Score (5 vs 5, p=0.27), intensive care unit (ICU) admission (20% vs 16%, p=0.24), immediate surgery (11% vs 11%, p=0.96), and mortality (1.7% vs 1.4%, p=0.72) were similar for GCs and ATVs, respectively. The risk of ICU admission (OR 1.19, 95% CI 0.74 to 1.93, p=0.47) and immediate surgery (OR 1.04, 95% CI 0.58 to 1.84, p=0.90) remained similar on multivariable logistic regression., Conclusions: During the study period, GC and ATV injuries increased. Despite their innocuous perception, GCs had a similar injury burden to ATVs. Heightened safety measures for GCs should be considered., Level of Evidence: III, prognostic/epidemiological., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Relationships between social determinants of health and pediatric trauma mechanisms and outcomes are unclear in context of COVID-19., Methods: Children <16 years old injured between 2016 and 2021 from ten pediatric trauma centers in Florida were included. Patients were stratified by high vs. low Social Vulnerability Index (SVI). Injury mechanisms studied were child abuse, ATV/golf carts, and firearms. Mechanism incidence trends and mortality were evaluated by interrupted time series and multivariable logistic regression., Results: Of 19,319 children, 68% and 32% had high and low SVI, respectively. Child abuse increased across SVI strata and did not change with COVID. ATV/golf cart injuries increased after COVID among children with low SVI. Firearm injuries increased after COVID among children with high SVI. Mortality was predicted by injury mechanism, but was not independently associated with SVI, race, or COVID., Conclusion: Social vulnerability influences pediatric trauma mechanisms and COVID effects. Child abuse and firearm injuries should be targeted for prevention., Competing Interests: Declaration of competing interest There are no conflicts of interest to disclose., (Copyright © 2023. Published by Elsevier Inc.)

Objective: The objective of this study was to explore barriers and enablers to improving the management of bacteriuria in hospitalized adults., Design: Qualitative study., Setting: Nova Scotia, Canada., Participants: Nurses, physicians, and pharmacists involved in the assessment, diagnosis, and treatment of bacteriuria in hospitalized patients., Methods: Focus groups (FGs) were completed between May and July 2019. FG discussions were facilitated using an interview guide that consisted of open-ended questions coded to the theoretical domains framework (TDF) v2. Discussions were transcribed verbatim then independently coded to the TDFv2 by two members of the research team and compared. Thematic analysis was used to identify themes., Results: Thirty-three healthcare providers from five hospitals participated (15 pharmacists, 11 nurses, and 7 physicians). The use of antibiotics for the treatment of asymptomatic bacteriuria (ASB) was the main issue identified. Subthemes that related to management of ASB included: "diagnostic uncertainty," difficulty "ignoring positive urine cultures," "organizational challenges," and "how people learn." Barriers and/or enablers to improving the management of bacteriuria were mapped to 12 theoretical domains within these subthemes. Barriers and enablers identified by participants that were most extensively discussed related to the domains of environmental context and resources, belief about capabilities , social/professional role and identity , and social influences ., Conclusions: Healthcare providers highlighted barriers and recognized enablers that may improve delivery of care to patients with bacteriuria. A wide range of barriers at the individual and organization level to address diagnostic challenges and improve workload should be considered to improve management of bacteriuria., Competing Interests: EB has received funding as a grant or contract for related work from Shoppers Drug Mart and the Canadian Institute of Health Research. EB has also received funding for unrelated work from Pfizer and the Canadian Immunization Research Network. All funding was received after completion of this project. EB has also received funding from Dalhousie University for unrelated work evaluating prescribing practices in Nova Scotia for prevention of Lyme disease. DM and MB received salary from the Research Nova Scotia, Establishment Grant. Other authors have no financial or personal relationships with commercial entities related to this work to disclose., (© The Author(s) 2024.)

Background: Sedative-hypnotic drugs are often initiated in hospital to manage insomnia and anxiety. Guidelines discourage their use, particularly in older adults, due to risks of falls, fractures, and delirium., Aim: To identify publicly available resources to decrease the use of sedative-hypnotic drugs and promote sleep in hospital., Method: An advanced Google search with 6 search strategies was conducted. Key websites were also identified and searched. Hospital- or community-based resources using non-pharmacologic measures to reduce sedative-hypnotic drug use and/or to promote sleep were included if they were publicly available in English within the past 5 years. Full text screening and data extraction was performed independently by 2 reviewers; a third reviewer resolved disagreements by consensus., Results: A total of 79 resources met inclusion criteria, with 65 (82.3%) providing education and 31 (39.2%) describing sleep hygiene strategies. Other resources included deprescribing (17, 21.5%), relaxation training (13, 16.5%), cognitive behavioural therapy for insomnia (9, 11.4%), and policies (7, 8.9%). The resources primarily targeted patients (59, 74.7%) followed by healthcare providers (9, 11.4%). There were 9 resources (11.4%) that applied to both community and hospital settings, and another 2 (2.5%) designed specifically for hospital., Conclusion: Many resources were available to patients and healthcare providers to reduce inappropriate or ineffective use of sedative-hypnotic drugs and promote better sleep. Specific resources for the hospital setting were infrequent and recommended that clinicians stop hospital-initiated sedatives when patients are discharged. Identified resources can be adapted by healthcare organizations to develop sedative-hypnotic prescribing programs and policies., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Antimicrobial resistance threatens the ability to successfully prevent and treat infections. While hospital benchmarks regarding antimicrobial use (AMU) have been well documented among adult populations, there is less information from among paediatric inpatients. This study presents benchmark rates of antimicrobial use (AMU) for paediatric inpatients in nine Canadian acute-care hospitals., Methods: Acute-care hospitals participating in the Canadian Nosocomial Infection Surveillance Program submitted annual AMU data from paediatric inpatients from 2017 and 2018. All systemic antimicrobials were included. Data were available for neonatal intensive care units (NICUs), pediatric ICUs (PICUs), and non-ICU wards. Data were analyzed using days of therapy (DOT) per 1000 patient days (DOT/1000pd)., Results: Nine hospitals provided paediatric AMU data. Data from seven NICU and PICU wards were included. Overall AMU was 481 (95% CI 409-554) DOT/1000pd. There was high variability in AMU between hospitals. AMU was higher on PICU wards (784 DOT/1000pd) than on non-ICU (494 DOT/1000pd) or NICU wards (333 DOT/1000pd). On non-ICU wards, the antimicrobials with the highest use were cefazolin (66 DOT/1000pd), ceftriaxone (59 DOT/1000pd) and piperacillin-tazobactam (48 DOT/1000pd). On PICU wards, the antimicrobials with the highest use were ceftriaxone (115 DOT/1000pd), piperacillin-tazobactam (115 DOT/1000pd), and cefazolin (111 DOT/1000pd). On NICU wards, the antimicrobials with the highest use were ampicillin (102 DOT/1000pd), gentamicin/tobramycin (78 DOT/1000pd), and cefotaxime (38 DOT/1000pd)., Conclusions: This study represents the largest collection of antimicrobial use data among hospitalized paediatric inpatients in Canada to date. In 2017/2018, overall AMU was 481 DOT/1000pd. National surveillance of AMU among paediatric inpatients is necessary for establishing benchmarks and informing antimicrobial stewardship efforts., (© 2023. The Author(s).)

Background: Benzodiazepines and sedative-hypnotic drugs (BZD/SHD) are commonly utilized in the acute care setting for insomnia and anxiety and are associated with cognitive impairment, falls, and fractures. Interventions to reduce use of BZD/SHD in hospitals are not well characterized., Objective: The objective was to conduct a scoping review to identify and characterize interventions to reduce the use of BZD/SHD by adults in the acute care setting., Methods: English language studies and abstracts that described an intervention to reduce BZD/SHD in adult hospital patients were included. Six databases (PubMed, EMBASE, CINAHL, PsycINFO, Scopus, and Web of Science) were searched up to July 2018 and updated to February 3, 2021. The grey literature (Opengrey, Grey Matters, Google Advanced) was searched up to July 2018. Titles and abstracts were screened and full-text articles were reviewed and charted by three independent reviewers. Stakeholders were consulted to inform the scoping review and collect perspectives on the findings., Results: There were 13,046 records identified and 43 studies included. The most common study designs were uncontrolled before and after (23/43, 53.5%) and randomized controlled trials (7/43, 16.3%). The majority of studies tested a single intervention (32/43, 74.4%) such as education, deprescribing, relaxation training and sleep protocols. Patients were frequently the target of relaxation training and behavior change interventions; while sleep protocols, multifaceted interventions, education and deprescribing were usually directed at healthcare providers, either alone or in combination with patients. Most studies reported positive results in decreasing BZD/SHD use (27/43, 62.8%)., Conclusions: The scoping review found a variety of interventions to decrease the utilization of BZD/SHD in hospitals. Multifaceted interventions aimed at patients and healthcare providers that include a combination of education, sleep protocols, and deprescribing may support reductions in BZD/SHD use. Stakeholders also recommended policy and system changes such as computer alerts due to feasibility and workload., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: In 2019, more than $34.5 billion was spent on prescription drugs in Canada. However, little is known about the distribution of this spending across medications and settings (outpatient and inpatient) over time. The objective of this paper is to describe the largest expenditures by medication class over time in inpatient and outpatient settings. This information can help to guide policies to control prescription medication expenditures., Methods: IQVIA's Canadian Drugstore and Hospital Purchases Audit data from January 1, 2001, to December 31, 2020, were used. In this dataset, purchasing was stratified by outpatient drugstore and inpatient hospital. Spending trajectories in both settings were compared to total expenditure over time. Total expenditure of the 25 medications with the largest expenditure were compared over time, stratified by setting. Nominal costs were used for all analysis., Results: In 2001, spending in the outpatient and inpatient settings was greatest on atorvastatin ($467.0 million) and erythropoietin alpha ($91.2 million), respectively. In 2020, spending was greatest on infliximab at $1.2 billion (outpatient) and pembrolizumab at $361.6 million (inpatient). Annual outpatient spending, although increasing, has been growing at a slower rate (5.3%) than inpatient spending (7.0%). In both settings, spending for the top 25 medications has become increasingly concentrated on biologic agents, with a reduction in the diversity of therapeutic classes of agents over time., Discussion: Identification of the concentration on spending on biologic agents is a key step in managing costs of prescription medications in Canada. Given the increases in spending on biologic agents over the last 20 years, current cost-control mechanisms may be insufficient. Future research efforts should focus on examining the effectiveness of current cost-control mechanisms and identifying new approaches to cost control for biologic agents., (© 2022. The Author(s).)

Background: Despite ample evidence of benefit, adherence to secondary prevention medication therapy after acute coronary syndrome (ACS) is often suboptimal. Hospital pharmacists are uniquely positioned to improve adherence by providing medication education at discharge., Objective: To determine whether a standardized counselling intervention at hospital discharge significantly improved patients' adherence to cardiovascular medications following ACS., Methods: This single-centre, prospective, nonrandomized comparative study enrolled patients with a primary diagnosis of ACS (January 2014 to July 2015). Patients who received standardized discharge counselling from a clinical pharmacist were compared with patients who did not receive counselling. At 30 days and 1 year after discharge, follow-up patient surveys were conducted and community pharmacy refill data were obtained. Adherence was assessed using pharmacy refill data and patient self-reporting for 5 targeted medications: acetylsalicylic acid, P2Y purinoceptor 12 (P2Y12) inhibitors, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, β-blockers, and statins. Thirty-day and 1-year medication utilization, cardiovascular readmission rates, and all-cause mortality were also assessed., Results: Of the 259 patients enrolled, 88 (34.0%) received discharge counselling. Medication data were obtained for 253 patients (97.7%) at 30 days and 242 patients (93.4%) at 1 year. At 1 year after discharge, there were no statistically significant differences between patients who did and did not receive counselling in terms of rates of nonadherence (11.9% versus 18.4%, p = 0.19), cardiovascular readmission (17.6% versus 22.3%, p = 0.42), and all-cause mortality (3.4% versus 4.2%, p > 0.99). Overall medication nonadherence was 2.8% (7/253) at 30 days and 16.1% (39/242) at 1 year., Conclusions: Discharge medication counselling provided by hospital pharmacists after ACS was not associated with significantly better medication adherence at 1 year. Higher-quality evidence is needed to determine the most effective and practical interventions to ensure that patients adhere to their medication regimens and achieve positive outcomes after ACS., Competing Interests: Competing interests: None declared., (2021 Canadian Society of Hospital Pharmacists. All content in the Canadian Journal of Hospital Pharmacy is copyrighted by the Canadian Society of Hospital Pharmacy. In submitting their manuscripts, the authors transfer, assign, and otherwise convey all copyright ownership to CSHP.)

Objective: General surgery resident (GSR) 5-year attrition rates of 12% to 20% are currently reported. This study explores the impact of full-time surgery faculty (FSF) diversity on GSR attrition., Design: Deidentified data were obtained from the Association of American Medical Colleges (AAMC) for FSF at US Liaison Committee on Medical Education (LCME)-accredited medical schools and GSR at the affiliated general surgery residency programs (2001-2016). Data included annual GSR attrition rate and the number, gender, and race of FSF and GSR. Data were analyzed using linear and logarithmic regression., Setting: The study was conducted at the University of Miami Leonard M. Miller School of Medicine in Miami, Florida., Participants: The data obtained included FSF from US LCME-accredited medical schools and GSR from those residency programs affiliated with US LCME-accredited medical schools. Data were included only if available for both FSF and GSR at a single institution. There were 107,300 annual FSF positions and 39,504 annual GSR positions from 61 U.S. LCME-accredited medical schools included in the analysis., Results: Data included 107,300 FSF positions (26% non-white; 20% female) and 39,504 GSR positions (41% non-white; 33% female) summed across 1034 institution years. Increased female FSF is associated with decreased GSR attrition (R 2  = 0.009, p = 0.002, Fig. 1). For every 1% increase in female FSF, GSR programs were 4% less likely to have an attrition rate in the top quartile (odds ratio 0.96, confidence interval 0.94-0.98)., Conclusions: Gender diversity of FSF has an impact on GSR attrition; more female FSF correlates with lower GSR attrition rates., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Ultrasound (US) is an adjunct to history and clinical exam (CE) in the assessment of pediatric breast lesions. We sought to investigate the reliability of US and CE to predict final pathologic diameter (P)., Methods: A single institutional retrospective analysis of patients aged ≤18 years who underwent breast mass resection was performed. Data was collected and analyzed using SPSS., Results: 88 patients met inclusion criteria with an average age at surgery of 16 ± 1.5 years. No malignancies were encountered. The largest mean diameter measured by final pathology (MPØ) for all lesions was 4.1 ± 2.6 cm. Pathology encountered were fibroadenoma (83%, MPØ 3.7 ± 1.7 cm), juvenile fibroadenoma (10%, MPØ 7.0 ± 5.4 cm), and low-grade phyllodes tumor (3%, MPØ 6.2 ± 3.8 cm). 67 patients had documented CE measurement with a mean diameter of 3.4 ± 1.8 cm. 62 patients underwent US with a mean diameter of 3.3 ± 1.6 cm. US and CE were accurate in determining P by Cronbach Alpha reliability testing., Conclusion: US and CE are reliable measurements of P. The surgical utility of US when considering pediatric breast lesions is limited and should be individualized following pediatric surgical evaluation and CE., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: There is no clear consensus on the optimal operative management of premature infants with surgical necrotizing enterocolitis (sNEC) or spontaneous intestinal perforation (SIP); thus, a protocol was developed to guide surgical decision making regarding initial peritoneal drainage (PD) versus initial laparotomy (LAP). We sought to evaluate outcomes after implementation of the protocol., Methods: Pre-post study including multiple urban hospitals. Premature infants with sNEC/SIP were accrued after implementation of surgical protocol-directed care (June 2014-June 2019). Patients with a birth weight of <750 g and less than 2 wk of age without pneumatosis or portal venous gas were treated with PD on perforation. PD patients received subsequent LAP for clinical deterioration or continued meconium/bilious drainage. Postprotocol characteristics and outcomes were compared with institutional historical controls. Significance set at P < 0.05., Results: Preprotocol and postprotocol cohorts comprise 35 and 73 patients, respectively. There was a statistically significant difference in age at intervention between historical control PD (14 ± 13 d) and postprotocol PD (9 ± 4 d) groups (P = 0.01), PD patient's birth weight (716 ± 212 g versus 610 ± 141 g, P = 0.02) and estimated gestational age of LAP patients (27 ± 1.7 wk versus 31 ± 4 wk, P = 0.002). PD was definitive surgery in 27% (12 of 44) of postprotocol patients compared with 13% (3 of 23) historical controls. A trend in improved survival postprotocol occurred in all PD infants (73% versus 65%), all LAP (75% versus 70%), and for initial PD and subsequent LAP (82% versus 67%)., Conclusions: Utilization of a surgical protocol in sNEC/SIP is associated with improved success of PD as definitive surgery and improved survival., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Benzodiazepines and sedative-hypnotic drugs (BZD/SHDs), such as zopiclone and the antidepressant trazodone, pose risks such as falls, fractures, and confusion, especially for older adults. Use of these drugs in the acute care setting is poorly understood., Objectives: To determine the point prevalence and characteristics of use of BZD/SHDs in hospitals in Nova Scotia, Canada., Methods: A point prevalence survey was conducted for adults admitted to all hospitals with at least 30 acute care beds between May and August 2016. Drugs administered intravenously, patients in long-term care, and patients receiving mental health services, addiction treatment, or critical care were excluded. The proportion of included patients who had received a BZD/SHD within the 24 h before the start of the survey was determined. A descriptive statistical analysis was performed., Results: Overall BZD/SHD prevalence was 34.6% (487/1409) across the 16 eligible hospitals. The average age was 70.3 years, and 150 (30.8%) of the patients were 80 years or older. Among the 585 prescriptions for these patients, commonly used drugs were zopiclone (32.0%), lorazepam (21.9%), and trazodone (21.9%). The most common indications for use were bedtime/daytime sedation (60.0%) and anxiety (12.5%). More than half of the prescriptions (55.7%) had been initiated at home, 37.6% were started in hospital, and the place of initiation was unknown for 6.7%. Benzodiazepines were prescribed more frequently to patients under 65 years than those 80 years or older (41.3% versus 22.2%, p < 0.001) whereas trazodone was more frequently prescribed to the older of these 2 age groups (52.7% versus 14.3%, p < 0.001)., Conclusions: BZD/SHDs were frequently used by hospitalized adult patients in Nova Scotia. Trazodone appears to have been substituted for benzodiazepines in the oldest age group. Pharmacists should direct their efforts toward preventing inappropriate initiation of BZD/SHDs in hospital, particularly for elderly patients., Competing Interests: Competing interests: Jennifer Isenor has received grants from Sanofi and GlaxoSmithKline for research unrelated to the work described here. No other competing interests were declared., (2020 Canadian Society of Hospital Pharmacists. All content in the Canadian Journal of Hospital Pharmacy is copyrighted by the Canadian Society of Hospital Pharmacy. In submitting their manuscripts, the authors transfer, assign, and otherwise convey all copyright ownership to CSHP.)

Background: Antimicrobial resistance is a growing threat to the world's ability to prevent and treat infections. Links between quantitative antibiotic use and the emergence of bacterial resistance are well documented. This study presents benchmark antimicrobial use (AMU) rates for inpatient adult populations in acute-care hospitals across Canada., Methods: In this retrospective surveillance study, acute-care adult hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) submitted annual AMU data on all systemic antimicrobials from 2009 to 2016. Information specific to intensive care units (ICUs) and non-ICU wards were available for 2014-2016. Data were analyzed using defined daily doses (DDD) per 1000 patient days (DDD/1000pd)., Results: Between 2009 and 2016, 16-18 CNISP adult hospitals participated each year and provided their AMU data (22 hospitals participated in ≥1 year of surveillance; 11 in all years). From 2009 to 2016, there was a significant reduction in use (12%) (from 654 to 573 DDD/1000pd, p = 0.03). Fluoroquinolones accounted for the majority of this decrease (47% reduction in combined oral and intravenous use, from 129 to 68 DDD/1000pd, p < 0.002). The top five antimicrobials used in 2016 were cefazolin (78 DDD/1000pd), piperacillin-tazobactam (53 DDD/1000pd), ceftriaxone (49 DDD/1000pd), vancomycin (combined oral and intravenous use was 44 DDD/1000pd; 7% of vancomycin use was oral), and ciprofloxacin (combined oral and intravenous use: 42 DDD/1000pd). Among the top 10 antimicrobials used in 2016, ciprofloxacin and metronidazole use decreased significantly between 2009 and 2016 by 46% (p = 0.002) and 26% (p = 0.002) respectively. Ceftriaxone (85% increase, p = 0.0008) and oral amoxicillin-clavulanate (140% increase, p < 0.0001) use increased significantly but contributed only a small component (8.6 and 5.0%, respectively) of overall use., Conclusions: This study represents the largest collection of dispensed antimicrobial use data among inpatients in Canada to date. Between 2009 and 2016, there was a significant 12% decrease in AMU, driven primarily by a 47% decrease in fluoroquinolone use. Modest absolute increases in parenteral ceftriaxone and oral amoxicillin-clavulanate use were noted but contributed a small amount of total AMU. Ongoing national surveillance is crucial for establishing benchmarks and antimicrobial stewardship guidelines.

Background: Antimicrobial use is the major factor in the development of antimicrobial resistance. Antimicrobial stewardship has been recommended as a strategy to improve antimicrobial use., Objective: To learn about health care providers' perceptions of current antimicrobial use and stewardship, including barriers and facilitators to improving antimicrobial use at acute care hospitals in Nova Scotia., Methods: This qualitative research study was conducted at acute care hospitals in Nova Scotia using focus groups and semistructured interviews. Health care providers (nurses, nurse practitioners, pharmacists, pharmacy students, and physicians) were invited to participate. Focus groups and interviews were conducted at each participant's place of employment. Interviews and focus groups were facilitated with an interview guide, audio-recorded, and transcribed verbatim. Transcripts were independently coded by 2 investigators and analyzed using thematic analysis., Results: A total of 9 focus groups and 3 individual interviews were conducted between June and August 2017. Fifty-four health care professionals and trainees (24 pharmacists and pharmacy students, 14 physicians, and 16 nurses and nurse practitioners) from 5 hospitals participated. The following themes were identified: current practices, prescribing influences, access to information, collaboration and communication, resources, and antimicrobial stewardship. Within each theme, barriers and facilitators to improving antimicrobial use were identified as subthemes., Conclusion: Participants identified current barriers to appropriate use of antimicrobials and suggested facilitators that might improve the use of these drugs. The results of this study could be used by antimicrobial stewardship teams and decision-makers to improve antimicrobial use and stewardship initiatives throughout Nova Scotia, and may be applicable to hospitals outside the province., Competing Interests: Competing interests: Other than the funding outlined above, no competing interests were declared.

Background: Unintentional injury is the leading cause of death in children and adolescents. Injuries occurring during boating and recreational water sports are poorly described in the literature. Herein, we compare injuries from water sports to those resulting from motor vehicle collisions, which are better described in existing literature., Methods: A retrospective review of 1935 consecutive pediatric trauma patients, as defined by age < 18 years, admitted to a single level-1 pediatric trauma center between January 2000 and August 2013 was performed. Patients were divided into two cohorts based on the mechanism of injury: water sports injury (WSI) or motor vehicle collision (MVC). Demographics, injury descriptors, and outcomes were reviewed for each patient. Categorical variables were compared by Chi square or Fisher's exact test, and continuous by t test or Mann-Whitney U test. Parametric data are reported as mean ± standard deviation and nonparametric as median (interquartile range). Significance was set at alpha level 0.05., Results: A total of 18 pediatric patients were admitted for WSI and 615 for MVC during the study period. Among those with WSI, mean age was 12 ± 4 years, mean Injury Severity Score (ISS) was 11 ± 10, and mean Revised Trauma Score (RTS) was 7.841(IQR 6.055-7.841). 44% of WSI occurred by personal watercraft (Jet Ski, WaveRunner), 39% by boat, and 17% by other means (e.g., diving, tubing, kite surfing). Overall, the most common WSI included skin/soft-tissue lacerations (59%), head injury/concussion (33%), tendon/ligament lacerations (28%), and extremity fractures (28%). Compared to 615 patients admitted for MVC, age, sex, race, Glasgow Coma Scale, ISS, RTS, spleen and liver laceration rates, neurosurgical consultation, ICU admission, ICU and total length of stay, and mortality were similar. Patients with WSI were more likely to be tourists (44% vs. 5%, p < 0.001). Those with WSI showed a significantly higher requirement for any surgical intervention (61% vs. 15%, p = 0.001). The rate of open fracture (28% vs. 6%, p = 0.006) and, subsequently, orthopedic procedures (39% vs. 17%, p = 0.027) were also higher in the WSI group., Conclusion: Overall, water sports injuries are similar in in-hospital mortality to motor vehicle collisions. They are more likely to result in penetrating trauma and more likely to require surgical intervention. Primary and secondary prevention strategies should specifically target personal watercraft usage and tourist populations.

The management of pediatric abdominopelvic angiosarcoma remains unclear due to limited clinical experience. Herein, we presented the first 2 pediatric patients with abdominal angiosarcoma who were treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) after neoadjuvant therapy. The first patient is alive with recurrent disease at 1-year follow-up and the second patient remains disease free after 1 year. CRS and HIPEC should be considered as a therapeutic option in the management of pediatric abdominal angiosarcomas. A multi-institutional international shared registry is needed to further evaluate the role of CRS and HIPEC in inducing remission of abdominopelvic angiosarcomas in the pediatric population.

Background: There is a paucity of literature on treatment of melanoma in children with surgical management extrapolated from adult experience. The incidence and clinical outcomes of pediatric extremity melanoma were studied., Methods: SEER registry was analyzed between 1973 and 2010 for patients <20years old with extremity melanoma. Multivariate and propensity-score matched analyses were performed to identify independent predictors of survival., Results: Overall, 917 patients were identified with an age-adjusted incidence of 0.2/100,000 persons, annual percent change 0.96. Most had localized disease (77%), histology revealing melanoma-not otherwise specified (52%). Surgical procedures performed included wide local excision (50%), excisional biopsy (32%), lymphadenectomy (LA) (28%), and sentinel lymph node biopsy (SLNB) (15%). Overall, 30-year disease specific mortality was 7% with lower survival for extremity melanoma (90%), males (89%), nodular histology (69%), and distant disease (36%) (all P<0.05). Post-treatment multivariate analysis revealed localized disease (HR 9.76; P=0.006) as an independent prognosticator of survival; earlier diagnostic years 1988-1999 (HR 2.606; P=0.017) were a negative prognosticator of survival. Propensity-score matched analysis found no difference in survival between SLNB/LA vs no sampling for regional/distant disease., Conclusions: Pediatric extremity melanoma in SEER demonstrate no survival advantage between children undergoing sampling procedures vs no sampling for regional/distant disease., Type of Study: Retrospective, prognostic study., Level of Evidence: III., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Ovarian and testicular torsions are emergencies requiring prompt surgical treatment to preserve gonadal function. However, diagnosis in females is often delayed owing to nonspecific symptoms. We sought to assess disparities in management and outcomes between males and females with torsion., Methods: The National Inpatient Sample was queried for pediatric patients with "emergent", "urgent", or "trauma center" admission and ICD-9 codes for ovarian torsion and testicular torsion. Demographic data, operative procedure, gonadal loss, length of stay (LOS), total charges (TC), and mortality were recorded., Results: There were 2254 unweighted encounters. The average age was 11.56±5.30years for males and 12.55±3.72years for females (p<0.001). Among males, 90% underwent surgery (p<0.001), of which 40% required orchiectomy. Conversely, 73% of females had surgery (p<0.001), of which 78% had oophorectomy. Subsequent analysis with only patients who underwent surgery showed that insurance status (p=0.012), race (p<0.001), and U.S. region (p<0.001) were significantly different between males and females. Gender specific analyses showed that hospital control, hospital location/teaching status, and treatment year were also significant. As such, these six factors in addition to age and gender were used for propensity score matching (PSM). PSM produced two gender cohorts of 755 encounters each. Females had longer LOS (2.44±1.84days vs. 1.28±2.27days for males, p<0.001) and had higher TC ($20,058.44±13,420.82) compared to males ($12,386.58±12,793.34), p<0.001. Logistic regression revealed that males (OR 0.163 [0.130-0.206]) and older patients (age OR 0.924 [0.903-0.946]) were less likely to undergo gonadal loss. Compared to those with private insurance, those with Medicare/Medicaid were more likely to have gonadal loss (1.401 [1.101-1.783])., Conclusion: Disparities exist in the management of torsion based on gender. Overall, females had higher charges, had longer hospitalization, and were more likely to have gonadal loss despite current data supporting gonadal preservation for nearly all cases of ovarian torsion., Clinical Study: Level III Evidence., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: There remains a paucity of literature on survival related to pediatric appendiceal tumors. The purpose of this study was to determine the incidence, surgical management, and survival outcomes of appendiceal tumors in pediatric patients., Methods: The Surveillance, Epidemiology, and End Results (SEER) Registry was analyzed for pediatric appendiceal tumors from 1973 to 2011. Parameters analyzed were: tumor type, surgical management (appendectomy vs. extensive resection), tumor size, and lymph node sampling. Chi-square analysis for categorical and Student's t test for continuous data were used., Results: Overall, 209 patients had an appendiceal tumor, including carcinoid (72%), appendiceal adenocarcinoma (16%), and lymphoma (12%). Patients undergoing appendectomy vs. extensive resection had similar 15-year survival rates (98% vs. 97%; p=0.875). Appendectomy vs. extensive resection conferred no 15-year survival advantage when patients were stratified by tumor type, including adenocarcinoma (87% vs. 89%; p=0.791), carcinoid (100% vs. 100%; p=0.863), and lymphoma (94% vs. 100%; p=0.639). There was no significant difference in 15-year survival between tumor size groups ≥2 and <2cm (both 100%) and presence or absence of lymph node sampling (96% and 97%; p=0.833) for all patients with a carcinoid tumor., Conclusion: Appendectomy may be adequate for pediatric appendiceal tumors. Extensive resection may be of limited utility for optimizing patient survival, placing patient at greater operative risk., Type of Study: Retrospective Prognostic Study., Level of Evidence: III., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Appendiceal ligation during pediatric laparoscopic appendectomy (LA) may be performed using looped suture versus stapler. Controversy regarding the utility of either method exists. Clinical outcomes and cost analysis of LA with both methods were compared., Methods: All pediatric LA were performed from fiscal years 2013 and 2014 by two pediatric surgeons. While one surgeon used looped suture, the other used stapler exclusively. chi-Square tests were performed to analyze associations., Results: Two hundred thirty-eight cases were analyzed where looped suture versus stapler LA was performed in 46% and 54% of patients, respectively. Operating room costs were $317.10 and $707.12/person for looped suture and stapler LA, respectively (P<0.0001). Difference in cost of $390.02/person was attributed solely to ligation type. On bivariate analysis, rate of in-hospital complications, length of stay, return-to-ER and readmission within 30 days did not significantly differ between groups., Conclusion: A comparative analysis of looped suture versus stapler device during LA for pediatric appendicitis revealed that postoperative complications, length of stay, ER visits and readmissions were not significantly different. Looped suture LA was significantly more cost efficient than stapler LA. In pediatric appendicitis, appendiceal ligation during LA may be performed safely and cost effectively with looped suture versus stapler., Type of Study: Cost effectiveness LEVEL OF EVIDENCE: III., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Gastric duplication cysts are an extremely rare anomaly with few reported cases in association with accessory pancreatic tissue. Diagnosis can be challenging given a presentation of recurrent pancreatitis and resemblance to pancreatic pseudocysts. We report the case of a 6-year old boy with multiple episodes of pancreatitis who was discovered to have an accessory pancreatic lobe connected to a gastric duplication cyst, successfully treated with surgical excision., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Angiosarcomas are highly aggressive malignancies of vascular origin and are very rarely found in children. We report a case of a 13-year-old girl with a history of abdominal pain and increased abdominal girth. Radiologic imaging showed significant ascites and large pelvic masses involving bilateral adnexa with abdominal spread. Microscopic examination of a biopsy revealed pleomorphic epithelioid and spindle cells with brisk mitotic activity, intracytoplasmic vacuoles, vascular channels, and large areas of hemorrhage and necrosis. Immunohistochemistry analysis showed strong and diffuse positivity for CD31, D2-40, ERG, FLI-1, and focally for CD34, vWF, and EMA. The diagnosis of metastatic angiosarcoma was rendered. The patient was treated aggressively with systemic chemotherapy, immunotherapy, cytoreductive surgery, and hyperthermic intraperitoneal chemotherapy, with a favorable response after 1-year follow-up. Angiosarcoma should be considered when encountering a vascular tumor with pleomorphism, brisk mitotic activity, and necrosis. Immunohistochemistry studies are necessary for proper diagnosis.

Background: Although firearms account for less than 5 % of all pediatric injuries, they have the highest associated case fatality rate., Methods: The registry at a Level-1 trauma center was used to identify firearm injuries (<18 years of age) from 1991 to 2011. Descriptive statistics and risk-adjusted multivariate analyses (MVA) were performed., Results: Overall, 1085 patients were identified. Immediate operations were performed in 33 % (n = 358) of patients with most having abdominal surgery (n = 214). Survival was 86 %, but higher for African Americans (OR = 1.92) than for Hispanics (p = 0.006). African Americans were more likely to sustain extremity (OR = 2.26) and less head (OR = 0.36) injuries than Hispanics (p < 0.001). Analysis by injury location showed that head (OR = 14.1) had the highest associated mortality. Other significant predictors included multiple major injury (defined by Abbreviated Injury Scale) with central nervous system involvement (OR = 7.30) and single injuries to the chest (OR = 2.68). These findings were compared to abdominal injuries as the baseline (p < 0.02). MVA demonstrated that Caucasian children had higher mortality (OR = 6.12) vs. Hispanics (p = 0.031). Children admitted with initial pH ≤ 7.15 (OR = 14.8), initial hematocrit ≤30 (OR = 3.24), or Injury Severity Score (ISS) > 15 (OR = 1.08) had higher mortality rates (p < 0.05)., Conclusion: Independent significant indicators of mortality include low initial pH or hematocrit, Caucasian race, high ISS, and those who sustain head injuries.

Introduction  This study aims to update outcomes and predictors of survival on pediatric thyroid carcinoma, specifically examining pediatric patients with nonpapillary thyroid carcinoma who underwent surgical resection. Methods  Surveillance, epidemiology, and end results database were searched for pediatric cases (< 20 years old) of surgically treated nonpapillary thyroid carcinoma diagnosed from 1973 to 2011. Demographics, clinical characteristics, and survival outcomes were analyzed using standard statistical methods. All follicular, medullary, Hürthle-cell, and nonencapsulated sclerosing carcinoma types were included. Results  A total of 493 cases were identified. The overall incidence was 0.096/100,000 persons per year. The mean age at diagnosis was 15 years and highest incidence was found in whites, females, and patients aged 15 to 19 years. Most patients had localized (60%) or regional disease (35%) and only 38% received radiation (any type). Subtotal/total thyroidectomy was the most common procedure performed (83%) and 47% had lymph node sampling. The most common histologies were follicular (54%) and medullary (28%). Most tumors were > 2cm in size (63%). Overall 30-year survival was 91% but higher for females (94%, p  = 0.02) and for local disease (92%). Disease-specific survival was highest for those with no lymph node sampling and negative lymph nodes. On multivariate analysis for medullary type only stage was an independent prognostic indicator of survival. Gender, age, tumor size, histology, and disease extent were not associated with an increased risk of mortality. Conclusions  Incidence of pediatric nonpapillary thyroid cancer is low. Females have a higher incidence but similar survival to males. Stage is the only independent prognostic indicator of survival for patients with medullary thyroid cancer., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Pharmacists have made significant contributions to patient care and have been recognized as integral members of the interprofessional team. Health care professionals differ in their opinions and expectations of clinical pharmacy services. Very little has been published about health care professionals' perspectives on advanced clinical pharmacy roles, such as prescriptive authority or administration of vaccines. In 2013, clinical pharmacy services were introduced in a vascular and general surgery ward where a pharmacist had not previously been assigned., Objectives: To explore surgical nurses' and physicians' opinions and expectations of clinical pharmacy services and to determine how these views changed over time; to compare pharmacists' views of clinical pharmacy services with those of nurses and physicians; and to develop validated survey tools., Methods: Three survey tools were created and validated, one for each profession. Surveys were distributed to nurses and physicians assigned to the general and vascular surgery ward before introduction of clinical pharmacy services and 8 months after implementation. Hospital pharmacists were invited to complete the survey at one time point., Results: Differences existed in the opinions of nurses, physicians, and pharmacists about some traditional activities. Nurses and physicians indicated stronger agreement with pharmacists participating in medication reconciliation activities than did pharmacists ( p < 0.001), whereas a greater proportion of pharmacists felt that they were the most appropriate health care professionals to provide medication discharge counselling, relative to nurses and physicians ( p = 0.001). Respondents supported advanced roles for pharmacists, such as collaborative practice agreements, but there was less support for prescribing, physical assessments, and administration of vaccines. Nurses indicated the strongest agreement with pharmacist prescribing (82% versus 69% among pharmacists and 27% among physicians; p < 0.001). Nurses and physicians expressed strong endorsements of clinical pharmacy services in the surveys' comment sections., Conclusions: The introduction of clinical pharmacy services to a surgical health care team resulted in high levels of satisfaction among nurses and physicians who responded to this survey. Differences in perceptions of traditional clinical pharmacy service activities and advanced practice roles need to be studied in more depth to better understand the factors influencing health care professionals' views.

Purpose: We sought to determine factors influencing survival and resource utilization in patients undergoing surgical resection of congenital lung malformations (CLM). Additionally, we used propensity score-matched analysis (PSMA) to compare these outcomes for thoracoscopic versus open surgical approaches., Methods: Kids' Inpatient Database (1997-2009) was used to identify congenital pulmonary airway malformation (CPAM) and pulmonary sequestration (PS) patients undergoing resection. Open and thoracoscopic CPAM resections were compared using PSMA., Results: 1547 cases comprised the cohort. In-hospital survival was 97%. Mortality was higher in small vs. large hospitals, p<0.005. Survival, pneumothorax (PTX), and thoracoscopic procedure rates were higher, while transfusion rates and length of stay (LOS) were lower, in children ≥3 vs. <3months (p<0.001). Multivariate analysis demonstrated longer LOS for older patients and Medicaid patients (all p<0.005). Total charges (TC) were higher for Western U.S., older children, and Medicaid patients (p<0.02). PSMA for thoracoscopy vs. thoracotomy in CPAM patients showed no difference in outcomes., Conclusion: CLM resections have high associated survival. Children <3months of age had higher rates of thoracotomy, transfusion, and mortality. Socioeconomic status, age, and region were independent indicators for resource utilization. Extent of resection was an independent prognostic indicator for in-hospital survival. On PSMA, thoracoscopic resection does not affect outcomes., (Copyright © 2016. Published by Elsevier Inc.)

Kaposiform hemangioendothelioma is a rare locally aggressive vascular tumor that usually manifests during early childhood. Typically the lesion presents with skin, soft tissue and bone involvement and is characterized histologically by ill-defined nodularity and the presence of spindle cells with resemblance to Kaposi's sarcoma. We report a rare neonatal case of a splenic kaposiform hemangioendothelioma associated with Kasabach-Merritt phenomenon that was diagnosed with radiographic imaging. Because of the rapid onset of thrombocytopenia and anemia, the patient required urgent splenectomy with subsequent resolution of the blood dyscrasias., (Copyright © 2016. Published by Elsevier Inc.)

Background/purpose: The purposes of this study were to identify independent predictors of venous thromboembolism (VTE), to evaluate the relative impact of adult VTE risk factors, and to identify a pediatric population at high-risk for VTE after trauma., Methods: 1934 consecutive pediatric admissions (≤ 17 years) from 01/2000 to 12/2012 at a level 1 trauma center were reviewed. Logistic regression was used to identify predictors of VTE., Results: Twenty-two patients (1.2%) developed a VTE, including 5% of those requiring orthopedic surgery, 14% of those with major vascular injury (MVI), and 36% of those with both. Most (84%) were diagnosed at the primary site of injury. 86% of those who developed a VTE were receiving thromboprophylaxis at the time of diagnosis. Independent predictors were age (odds ratio (OR): 1.59, 95% confidence interval (CI): 1.11-2.25), orthopedic surgery (OR: 8.10, CI: 3.10-21.39), transfusion (OR: 3.37, CI: 1.26-8.99), and MVI (OR: 15.43, CI: 5.70-41.76). When known risk factors for VTE in adults were adjusted, significant factors were age ≥ 13 years (OR: 9.16, CI: 1.08-77.89), indwelling central venous catheter (OR: 4.41, CI: 1.31-14.82), orthopedic surgery (OR: 6.80, CI: 2.47-18.74), and MVI (OR: 14.41, CI: 4.60-45.13)., Conclusion: MVI and orthopedic surgery are synergistic predictors of pediatric VTE. Most children who developed a VTE were receiving thromboprophylaxis at the time of diagnosis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Despite radiation concerns, computed tomography (CT) remains the favored imaging modality at many children's hospitals for appendicitis. We sought to reduce CT utilization for appendicitis in a children's hospital with an algorithm relying on 24-h ultrasound (US) as the primary imaging study., Materials and Methods: An US-based protocol for suspected appendicitis was adopted at the end of the fiscal year (FY) 2011. Data were collected for 12 mo before and 24 mo after implementation. Imaging test usage and charges were adjusted per annual number of appendectomies. Training of emergency department staff continued over 1 y after protocol implementation., Results: For FY 2011, 644 abdominal CT and 1088 appendix US were ordered, and 249 laparoscopic appendectomies (LAs) were performed. After protocol implementation, FY 2012: 535 CT, 1285 US, and 265 LA were performed; and FY 2013: 330 CT, 1235 US, and 236 LA were performed. Length of stay decreased from before to after protocol (2.57 ± 0.29 versus 2.15 ± 0.11 d), P < 0.001. CTs per appendectomy decreased 42% from FY 2011 to FY 2013 (2.43 versus 1.40, P < 0.001) and 30% from before to after protocol (2.43 versus 1.70, P < 0.001). A corresponding 27% increase in number of US before to after protocol (4.11 versus 5.20 US/appendectomy, P = 0.004) occurred. CT and US charges decreased $2253 and $6633 per appendectomy for FY 2012 and 2013, respectively., Conclusions: Protocol-driven workup with US significantly reduced CT utilization, radiation exposure, and imaging-related charges in children with suspected appendicitis. Ongoing training of emergency department staff is required to ensure protocol compliance., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: Other than automobiles, bicycles are connected to more pediatric injuries than any other consumer product. Whereas characterization of injury patterns following motor vehicle accidents has led to safety initiatives and treatment guidelines, knowledge related to bicyclist injuries is lacking. Our purpose is to identify major injury patterns and outcomes associated with pediatric bicycle accidents., Methods: From January 2000 to December 2012, 1934 consecutive pediatric admissions (≤17 years) at a level I trauma center were retrospectively reviewed for mechanism injury, demographics, and outcomes. Parametric data were analyzed with student's t test and are presented as mean ± standard deviation. Nonparametric data were analyzed with Mann-Whitney-U test and are presented as median (interquartile range). Analysis was performed to recognize injury patterns and outcomes significantly associated with bicycle related accidents., Results: 80 pediatric patients were admitted following bicycle related trauma (4% of all pediatric trauma admissions). The cohort was age 11 ± 4 years, ISS 11 ± 10, 48% black, and 81% male. Injury patterns included 21% isolated head, 21% isolated abdominal, 13% isolated extremity, and 34% multiple injuries. 5% were age 0-4 years, 35% were age 5-9 years, 45% were 10-14 years, and 15% were 15-17 years (p < 0.001). 16% required operative intervention (6% abdominal, 9% orthopedic, 1% vascular). Children under age 6 required an abdominal operation 20% of the time. Length of stay was 2 (4) days with a mortality of 2.5%., Conclusions: Pediatric bicycle accidents more commonly occur in male children aged 10-14 years. Orthopedic injury is the most frequent overall indication for surgery, yet the youngest children more often required an abdominal operation., Level of Evidence: Level III.

Background: Bronchopulmonary malformations (BPM) are rare conditions, which typically arise below the carina and can result in significant morbidity (infection and/or hemorrhage) and mortality (respiratory failure)., Materials and Methods: All children with BPM surgically treated from 2001-2014 at a tertiary care children's hospital were identified. Patient demographics, surgical indications, procedure type, estimated blood loss, pathology, perioperative complications, length of stay, and outcomes were analyzed., Results: A total of 41 BPM patients underwent surgery with 98% overall survival (one abdominal BPM expired) but 100% for thoracic lesions. Resections were performed thoracoscopically (37%), thoracoscopy converted to open (22%), and via thoracotomy (37%). Poor visualization (67%) or inability to tolerate single lung ventilation (33%) led to conversions. No conversions resulted from hemorrhage or received blood transfusions. Patients with prenatally diagnosed BPM were more likely to undergo thoracoscopic surgery (odds ratio [OR], 18.2) versus nonprenatally diagnosed, P = 0.002. Open/converted patients had longer chest tube days (6.2) versus thoracoscopic (2.9), P = 0.048. Additionally, respiratory distress was a more common indication in patients aged <4 mo (OR, 28.0) versus ≥4 mo and <6 kg (OR, 40.5) versus ≥6 kg, P < 0.001. Open resections were more common in patients aged <4 mo (OR, 26.3) versus ≥4 mo, P = 0.002. Operative time was shorter and estimated blood loss (mL/kg) was greater for <6 versus ≥6 kg, P < 0.05., Conclusions: BPM resections have high overall survival. Chest tube days are shorter among thoracoscopic patients, but conversion to thoracotomy can avoid hemorrhage and need for transfusion. Size and respiratory distress limit use of thoracoscopy in young infants with BPM., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Heterotopic gastric mucosa (HGM) is a rare, but acknowledged source of gastrointestinal pathology in pediatric patients. Sometimes clinically confused with a Meckel's diverticulum, HGM diagnosis is often made postoperatively by pathology. We present a case of jejunal HGM with a positive technetium pertechnetate scan in the right lower quadrant that resembled a Meckel's diverticulum., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Patients with suspected thiamine deficiency should receive treatment with parenteral thiamine to achieve the high serum thiamine levels necessary to reverse the effects of deficiency and to circumvent problems with absorption common in the medically ill., Objective: To quantify rates of parenteral administration of thiamine across university-affiliated hospitals and to identify factors associated with higher rates of parenteral prescribing., Design: Multicenter, retrospective observational study of thiamine prescriptions., Methods: Prescriptions for thiamine were captured from computerized pharmacy information systems across participating centers, providing information concerning dose, route, frequency, and duration of thiamine prescribed from January 2010 to December 2011., Setting: Fourteen university-affiliated tertiary care hospitals geographically distributed across Canada, including 48,806 prescriptions for thiamine provided to 32,213 hospitalized patients., Results: Parenteral thiamine accounted for a statistically significant majority of thiamine prescriptions (57.6%, P < 0.001); however, oral thiamine constituted a significant majority of the total doses prescribed (68.4%, z = 168.9; P < 0.001). Protocols prioritizing parenteral administration were associated with higher rates of parenteral prescribing (61.3% with protocol, 45.8% without protocol; P < 0.001). Patients admitted under psychiatry services were significantly more likely to be prescribed oral thiamine (P < 0.001)., Conclusions: Although parenteral thiamine accounted for a statistically significant majority of prescriptions, oral thiamine was commonly prescribed within academic hospitals. Additional strategies are needed to promote parenteral thiamine prescribing to patients with suspected thiamine deficiency., (© 2015 Society of Hospital Medicine.)

We present the case of a child who underwent a combined liver, pancreas and double kidney transplant following complications of Wolcott-Rallison syndrome (WRS) a rare genetic disorder that causes infantile insulin-dependent diabetes mellitus (IDDM) and often death in childhood from fulminant liver and concomitant kidney failure. WRS is characterized clinically through infantile IDDM, propensity for liver failure following viral infections, bone dysplasia and growth failure and developmental delay. Fewer than 60 cases with WRS are reported in the literature, mostly from consanguineous parents. Future episodes of liver failure, the main contributor to the increased mortality in WRS, may be prevented through timely liver transplantation. To the best of our knowledge, transplantation has not been utilized to manage complications of WRS prior to this report., (© Copyright 2014 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Background/purpose: The emergency department thoracotomy (EDT) is rarely utilized in children, and is thus difficult to identify survival factors. We reviewed our experience and performed a systematic review of reports of EDT in pediatric patients., Methods: Patients age ≤18 years who received an EDT from 1991 to 2012 at our institution and all published case series were reviewed. Data analyzed include age, sex, mechanism of injury (MOI), injury patterns, presence of vital signs (VS) or signs of life (SOL) in the field/ED, return of spontaneous circulation (ROSC), and survival., Results: A total of 252 patients were analyzed. 84% were male. 51% sustained penetrating injuries, and median age was 15 years. Upon arrival, 17% had VS, and 35% had SOL. After EDT, 30% experienced ROSC. The survival rate was 1.6% for blunt trauma, 10.2% for penetrating injuries, and 6.0% overall., Conclusion: Survival of pediatric patients following EDT is comparable to recent analyses in adults. Children who sustain blunt injury and are without SOL have been uniformly unsalvageable. Children who sustain penetrating trauma and have SOL or are without SOL for a short time prior to arrival have been salvageable. There are no reported EDT survivors less than 14 years of age following blunt injury., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: Initial hematocrit (Hct) is generally not considered a marker of acute blood loss because it is assumed that physiologic response of fluid conservation to hemorrhage is delayed. We challenged this idea by theorizing that admission Hct correlates with conventional signs of shock and predicts the use of blood transfusion during resuscitation of pediatric trauma patients., Methods: Data from 1928 pediatric admissions (<18 years) at a Level I trauma center (2000-2012) were compared using standard statistical analyses and logistic regression modeling to identify factors associated with blood transfusion during initial trauma resuscitation., Results: Overall mortality rate was 3.5%, with a transfusion rate of 10.7%. Factors significantly associated with transfusion were initial Hct, Glasgow Coma Score, base deficit, and injury severity score (all p<0.001). Initial Hct is a stronger predictor for transfusion (area under receiver operator curve (AUC: 0.728) compared to age-specific tachycardia (AUC: 0.689), age-specific hypotension (AUC: 0.673), and altered mental status (AUC: 0.654)). On multivariate analysis, initial Hct was an independent predictor (OR [95% CI]: 2.94 [1.56, 5.52]) along with hypotension (6.37 [2.95, 13.8]), base deficit (4.14 [1.38, 12.4]), and tachycardia (3.07 [1.62, 5.81])., Conclusions: Initial Hct correlates significantly with conventional signs of shock and is a strong independent predictor for blood transfusion with better predictability than other clinical factors., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to examine national outcomes in newborn patients with esophageal atresia and tracheoesophageal fistula (EA/TEF) in the United Sates., Methods: Kids' Inpatient Database (KID) is designed to identify, track, and analyze national outcomes for hospitalized children in the United States. Inpatient admissions for pediatric patients with EA/TEF for kids' Inpatient Database years 2000, 2003, 2006, and 2009 were analyzed. Patient demographics, socioeconomic measures, disposition, survival and surgical procedures performed were analyzed using standard statistical methods., Results: A total of 4168 cases were identified with diagnosis of EA/TEF. The overall in-hospital mortality was 9%. Univariate analysis revealed lower survival in patients with associated acute respiratory distress syndrome, ventricular septal defect (VSD), birth weight (BW) < 1500 g, gestational age (GA), time of operation within 24 h of admission, coexisting renal anomaly, imperforate anus, African American race, and lowest economic status. Multivariate logistic regression identified BW < 1500 g (odds ratio [OR] = 4.5, P < 0.001), operation within 24 h (OR = 6.9, P < 0.001), GA <28 wk (OR = 2.2, P < 0.030), and presence of VSD (OR = 3.8, P < 0.001) as independent predictors of in-hospital mortality. Children's general hospital and children's unit in a general hospital were found to have a lower mortality rate compared with not identified as a children's hospital after excluding immediate transfers (P = 0.008)., Conclusions: BW < 1500 g, operation within 24 h, GA < 28 wk, and presence of VSD are the factors that predict higher mortality in EA/TEF population. Despite dealing with more complicated cases, children's general hospital and children's unit in a general hospital were able to achieve a lower mortality rate than not identified as a children's hospital., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Patent ductus arteriosus (PDA) is a condition that commonly affects premature and low birth weight (BW) infants at times necessitating surgical intervention. We examined outcomes after surgical ligation (SL)., Materials and Methods: We analyzed the Kids' Inpatient Database for premature infants diagnosed with PDA, admitted at <8 d of age. Patient demographics, disposition, morbidity, and mortality were analyzed. All cases were weighted appropriately to project nationally representative estimates., Results: A total of 63,208 patients were identified with diagnosis of PDA. Of these, 6766 (10.7%) underwent SL. Lower gestational age (GA) and BW patients had higher incidence of PDA and rates of SL. Overall survival was 90.8% for the cohort. Survival for the SL group was 88.0% and 91.2% for the non-SL group; however, infants undergoing SL had higher survival rates up to 28 wk and 1250 g for GA and BW, respectively. GA did not affect post-SL survival adversely. Rather, lower BW was associated with extremely high mortality rates. Black infants and boys had lower survival compared with other races and girls, respectively. Larger hospitals had higher survival rates, but hospital location, teaching status, and type did not affect survival. Payer status and income quartile did not affect survival., Conclusions: PDA and SL are more common in lower BW and GA groups. Higher survival rates are found for infants with SL versus non-SL in the lowest BW and GA groups. Morbidity and mortality are not affected by SL timing. BW, rather than GA, determines survival of infants undergoing SL., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: Coagulation changes in pediatric trauma patients are not well defined. To fill this gap, we tested the hypothesis that trauma evokes a hypercoagulable response., Methods: A prospective observational study was conducted in hospitalized patients (age 8months to 14years) admitted for trauma or elective surgery. Informed consent was obtained from the parents and informed assent was obtained in patients 7years of age or older. Coagulation changes were evaluated on fresh whole blood using thromboelastography (TEG) and on stored plasma using assays for special clotting factors., Results: Forty three patients (22 trauma, median injury severity score =9; and 21 uninjured controls) were evaluated. For trauma vs control, prothrombin time (PT) was higher by about 10% (p<0.001), but activated partial thromboplastin time was not altered. TEG clotting time (R;p=0.005) and fibrin cross-linking were markedly accelerated (K time, alpha angle; p<0.001) relative to the control patients. d-Dimer, Prothrombin Fragment 1+2, and Plasminogen Activator Inhibitor-1 were all elevated, whereas Protein S activity was reduced (all p<0.01). Importantly, a large fraction of TEG values and clotting factor assays in the pediatric control group were outside the published reference ranges for adults., Conclusion: A hypercoagulable state is associated with minor trauma in children. More work is needed to determine the functional significance of these changes and to establish normal pediatric reference ranges., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: Clinical pharmacists improve the quality of patient care by reducing adverse drug events (ADEs), length of stay and mortality. This impact is currently not well described in surgery. The objective was to evaluate clinical and economic outcomes after clinical pharmacist services were added to two general surgical wards in an adult hospital., Methods: This was a prospective, observational study. All clinical interventions to resolve drug therapy problems were documented and assessed for severity, value and the probability of preventing an ADE. Cost avoidance was calculated using two methods: by avoiding additional days in hospital (CA$3593/ADE) or additional hospital costs ($7215/ADE). Two clinical pharmacy specialists and the surgical care pharmacist independently categorized the interventions; disagreements were resolved by consensus., Key Findings: The pharmacists made 1097 interventions in 6 months with a 98% acceptance rate by surgical staff. Half of the interventions were rated significant for severity (561, 51.1%) and value (559, 51.0%). One-quarter of the interventions had a 40% or greater probability of preventing an ADE (270, 24.6%). Cost avoidance was estimated to be $0.68-1.36 million or $617-1239 per intervention. Pharmacists avoided an additional 867 days in the hospital for surgical patients., Conclusion: The pharmacist's role in the management of the drug therapy needs of the post-surgical patient has the potential to improve clinical and patient outcomes and avoid healthcare costs. The inclusion of clinical pharmacists in surgical wards may result in $7 in savings for every $1 invested., (© 2013 Royal Pharmaceutical Society.)

Purpose: This study evaluates the incidence trends and clinical outcomes of children with hepatocellular carcinoma (HCC) and assesses factors predictive of patient survival., Methods: The Surveillance, Epidemiology, and End Results registry was queried from 1973 to 2009 for all patients between ages 0 and 19 with primary HCC. Demographics, tumor histology, surgical intervention, and patient survival were collected., Results: Overall, 218 patients were identified. The annual age-adjusted incidence was 0.05 cases per 100,000 in 2009. Fibrolamellar subtype tumors were exclusive to children >5years old and exhibited greater survival compared to non-fibrolamellar subtype (57% vs. 28%, respectively, p=0.002). Tumor extirpation for patients with resectable disease significantly improved overall survival at 5years compared to no surgery (60% vs. 0%, respectively, p<0.0001). Overall 5-, 10- and 20-year survival for the entire cohort was 24%, 23%, and 8%, respectively. Independent prognostic factors of lower mortality according to multivariate analysis were surgical resection (hazard ratio (HR)=0.18), non-Hispanic ethnicity (HR=0.52), and local disease at presentation (HR=0.46)., Conclusion: Over the past four decades, the incidence of HCC has remained relatively stable. Children of Hispanic ethnicity have high mortality rates. However, HCC resection for curative intent significantly improves outcomes., (© 2014.)