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Introduction: Pediatric firearm injuries are a significant public health concern in the United States. This study examines risk factors for firearm reinjury in Maryland's pediatric population., Methods: Pediatric patients (age 0-19 y) who presented to any hospital in Maryland with a firearm injury between October 1, 2015, and December 31, 2019, were identified in the Maryland Health Services Cost Review Commission database and were followed for repeat firearm injuries through March 31, 2020. Logistic regression was used to analyze risk factors for reinjury. Geospatial analysis was used to identify communities with the highest prevalence of reinjury., Results: Of 1351 index presentations for firearm injuries, 102 (7.3%) were fatal. Among children with nonfatal injuries, 40 (3.1%) re-presented with a second firearm injury, 25% of which were fatal. The median interval to reinjury was 149 d [interquartile range: 73-617]. Reinjury was more common in children aged ≥15 y (90% versus 76%), males (100% versus 87%), of Black race (90% versus 69%) or publicly insured (90% versus 68%) (all P < 0.05). Most lived in highly deprived neighborhoods of Baltimore City. No single factor was significant in multivariable models., Conclusions: Pediatric firearm reinjury is rare but highly morbid in Maryland. While prior studies have shown Black race to be independently associated with firearm reinjury, we found the effect of race was entirely attenuated after controlling for neighborhood deprivation. These findings underscore the urgent need for targeted interventions in areas identified as high risk in addition to policies to reduce youth firearm access., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Importance: The indications, safety, and efficacy of chemical venous thromboembolism prophylaxis (cVTE) in pediatric trauma patients remain unclear. A set of high-risk criteria to guide cVTE use was recently recommended; however, these criteria have not been evaluated prospectively., Objective: To examine high-risk criteria and cVTE use in a prospective multi-institutional study of pediatric trauma patients., Design, Setting, and Participants: This cohort study was completed between October 2019 and October 2022 in 8 free-standing pediatric hospitals designated as American College of Surgeons level I pediatric trauma centers. Participants were pediatric trauma patients younger than 18 years who met defined high-risk criteria on admission. It was hypothesized that cVTE would be safe and reduce the incidence of VTE., Exposures: Receipt and timing of chemical VTE prophylaxis., Main Outcomes and Measures: The primary outcome was overall VTE rate stratified by receipt and timing of cVTE. The secondary outcome was safety of cVTE as measured by bleeding or other complications from anticoagulation., Results: Among 460 high-risk pediatric trauma patients, the median (IQR) age was 14.5 years (10.4-16.2 years); 313 patients (68%) were male and 147 female (32%). The median (IQR) Injury Severity Score (ISS) was 23 (16-30), and median (IQR) number of high-risk factors was 3 (2-4). A total of 251 (54.5%) patients received cVTE; 62 (13.5%) received cVTE within 24 hours of admission. Patients who received cVTE after 24 hours had more high-risk factors and higher ISS. The most common reason for delayed cVTE was central nervous system bleed (120 patients; 30.2%). There were 28 VTE events among 25 patients (5.4%). VTE occurred in 1 of 62 patients (1.6%) receiving cVTE within 24 hours, 13 of 189 patients (6.9%) receiving cVTE after 24 hours, and 11 of 209 (5.3%) who had no cVTE (P = .31). Increasing time between admission and cVTE initiation was significantly associated with VTE (odds ratio, 1.01; 95% CI, 1.00-1.01; P = .01). No bleeding complications were observed while patients received cVTE., Conclusions and Relevance: In this prospective study, use of cVTE based on a set of high-risk criteria was safe and did not lead to bleeding complications. Delay to initiation of cVTE was significantly associated with development of VTE. Quality improvement in pediatric VTE prevention may center on timing of prophylaxis and barriers to implementation.

Background: National estimates suggest pediatric trauma recidivism is uncommon but are limited by short follow up and narrow ascertainment. We aimed to quantify the long-term frequency of trauma recidivism in a statewide pediatric population and identify risk factors for re-injury., Methods: The Maryland Health Services Cost Review Commission Dataset was queried for 0-19-year-old patients with emergency department or inpatient encounters for traumatic injuries between 2013 and 2019. We measured trauma recidivism by identifying patients with any subsequent presentation for a new traumatic injury. Univariate and multivariable regressions were used to estimate associations of patient and injury characteristics with any recidivism and inpatient recidivism., Results: Of 574,472 patients with at least one injury encounter, 29.6% experienced trauma recidivism. Age ≤2 years, public insurance, and self-inflicted injuries were associated with recidivism regardless of index treatment setting. Of those with index emergency department presentations 0.06% represented with an injury requiring inpatient admission; unique risk factors for ED-to-inpatient recidivism were age >10 years (aOR 1.61), cyclist (aOR 1.31) or burn (aOR 1.39) mechanisms, child abuse (aOR 1.27), and assault (aOR 1.43). Among patients with at least one inpatient encounter, 6.3% experienced another inpatient trauma admission, 3.4% of which were fatal. Unique risk factors for inpatient-to-inpatient recidivism were firearm (aOR 2.48) and motor vehicle/transportation (aOR 1.62) mechanisms of injury (all p < 0.05)., Conclusions: Pediatric trauma recidivism is more common and morbid than previously estimated, and risk factors for repeat injury differ by treatment setting. Demographic and injury characteristics may help develop and target setting-specific interventions., Level of Evidence: III (Retrospective Comparative Study)., Competing Interests: Conflicts of interest No conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Ultrasound (US) or magnetic resonance imaging (MRI) is recommended over computed tomography (CT) as the initial imaging modality when considering a diagnosis of appendicitis in children. This reduces unnecessary radiation exposure and has excellent accuracy. We hypothesized a significant increase in US utilization and a reduction in CT utilization in hospitals across the United States., Methods: We retrospectively reviewed NSQIP-P data from 2015 to 2021 for patients <18 years undergoing appendectomy for acute appendicitis. Rates of US, CT, and MRI usage were compared between NSQIP-P hospitals and referring non-NSQIP-P hospitals., Results: Of the 115,186 children included, 66,303 (57.6%) were imaged in NSQIP-P hospitals, 37,962 (33.0%) in non-NSQIP-P hospitals, and 7947 (6.9%) in both. US alone was used in 53.3%, followed by CT alone in 25.1%, both US + CT in 16.4%, and MRI ± CT/US in 2.6%. Non-NSIQP-P hospitals used less US than NSQIP-P centers (38.6% vs 90.8%, P < 0.0001) and more CT (74.0% vs 25.4%, P < 0.0001). From 2015 to 2021, overall US utilization increased from 68.5% to 72.3% (p < 0.0001) while CT utilization remained unchanged (43.1%-43.2%, P = 0.07). US use increased in non-NSQIP-P centers (18.8%-25.7%, P < 0.0001) but not in NSQIP-P (71.7% vs 70.9%, p = 0.28), while CT alone decreased in both (NSQIP-P: 10.1%-7.7%, P < 0.0001; non-NSQIP-P: 71.0%-59.8%, P < 0.0001)., Conclusion: US and MRI remain underutilized in diagnosing pediatric appendicitis, especially in non-NSQIP-P hospitals. Trends show modest increase in US utilization; however, CT alone remains a highly used modality in non-NSQIP-P hospitals. Adopting diagnostic strategies from NSQIP-P centers could optimize diagnostic imaging in children., Level of Evidence: III., Competing Interests: Conflicts of interest The authors have no conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: No consensus exists for the initial management of infants with gastroschisis., Methods: The American Pediatric Surgical Association (APSA) Outcomes and Evidenced-based Practice Committee (OEBPC) developed three a priori questions about gastroschisis for a qualitative systematic review. We reviewed English-language publications between January 1, 1970, and December 31, 2019. This project describes the findings of a systematic review of the three questions regarding: 1) optimal delivery timing, 2) antibiotic use, and 3) closure considerations., Results: 1339 articles were screened for eligibility; 92 manuscripts were selected and reviewed. The included studies had a Level of Evidence that ranged from 2 to 4 and recommendation Grades B-D. Twenty-eight addressed optimal timing of delivery, 5 pertained to antibiotic use, and 59 discussed closure considerations (Figure 1). Delivery after 37 weeks post-conceptual age is considered optimal. Prophylactic antibiotics covering skin flora are adequate to reduce infection risk until definitive closure. Studies support primary fascial repair, without staged silo reduction, when abdominal domain and hemodynamics permit. A sutureless repair is safe, effective, and does not delay feeding or extend length of stay. Sedation and intubation are not routinely required for a sutureless closure., Conclusions: Despite the large number of studies addressing the above-mentioned facets of gastroschisis management, the data quality is poor. A wide variation in gastroschisis management was documented, indicating a need for high quality RCTs to provide an evidence-based approach when caring for these infants., Type of Study: Qualitative systematic review of Level 1-4 studies., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: While intravenous fluid therapy is essential to re-establishing volume status in children who have experienced trauma, aggressive resuscitation can lead to various complications. There remains a lack of consensus on whether pediatric trauma patients will benefit from a liberal or restrictive crystalloid resuscitation approach and how to optimally identify and transition between fluid phases., Methods: A panel was comprised of physicians with expertise in pediatric trauma, critical care, and emergency medicine. A three-round Delphi process was conducted via an online survey, with each round being followed by a live video conference. Experts agreed or disagreed with each aspect of the proposed fluid management algorithm on a five-level Likert scale. The group opinion level defined an algorithm parameter's acceptance or rejection with greater than 75% agreement resulting in acceptance and greater than 50% disagreement resulting in rejection. The remaining were discussed and re-presented in the next round., Results: Fourteen experts from five Level 1 pediatric trauma centers representing three subspecialties were included. Responses were received from 13/14 participants (93%). In round 1, 64% of the parameters were accepted, while the remaining 36% were discussed and re-presented. In round 2, 90% of the parameters were accepted. Following round 3, there was 100% acceptance by all the experts on the revised and final version of the algorithm., Conclusions: We present a validated algorithm for intavenous fluid management in pediatric trauma patients that focuses on the de-escalation of fluids. Focusing on this time point of fluid therapy will help minimize iatrogenic complications of crystalloid fluids within this patient population., (Copyright © 2023 Elsevier Inc. All rights reserved.)

It can be difficult or impractical to refer all biliary atresia (BA) patients to high-volume centers. Our hypothesis was that a low volume center could improve outcomes with implementation of a dedicated multidisciplinary BA team. We conducted a retrospective study of patients with BA who underwent hepatic portoenterostomy at our institution from 2003 to 2020, before and after the development of a dedicated BA team. Ten consecutive patients with BA were identified following the establishment of a dedicated BA team. Since the establishment of the BA team, total bilirubin (TB) clearance (TB < 2 mg/dL) achieved by 3 and 6 months has been 60% and 60%, respectively, and survival of the native liver (SNL) at 1 and 2 years post HPE at 90% and 86%, respectively. Outcomes were markedly improved after the team was established. A dedicated BA team prioritizing communication and expeditious workup can improve outcomes at a low volume center., 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: Firearm violence is now endemic to certain US neighborhoods. Understanding factors that impact a neighborhood's susceptibility to firearm violence is crucial for prevention. Using a nationally standardized measure to characterize community-level firearm violence risk has not been broadly studied but could enhance prevention efforts. Thus, we sought to examine the association between firearm violence and the social, structural, and geospatial determinants of health, as defined by the Social Vulnerability Index (SVI)., Study Design: In this cross-sectional study, we merged 2018 SVI data on census tract with shooting incidents between 2015 and 2021 from Baltimore, Chicago, Los Angeles, New York City, and Philadelphia. We used negative binomial regression to associate the SVI with shooting incidents per 1,000 people in a census tract. Moran's I statistics and spatial lag models were used for geospatial analysis., Results: We evaluated 71,296 shooting incidents across 4,415 census tracts. Fifty-five percent of shootings occurred in 9.4% of census tracts. In all cities combined, a decile rise in SVI resulted in a 37% increase in shooting incidents (p < 0.001). A similar relationship existed in each city: 30% increase in Baltimore (p < 0.001), 50% in Chicago (p < 0.001), 28% in Los Angeles (p < 0.001), 34% in New York City (p < 0.001), and 41% in Philadelphia (p < 0.001). Shootings were highly clustered within the most vulnerable neighborhoods., Conclusions: In 5 major US cities, firearm violence was concentrated in neighborhoods with high social vulnerability. A tool such as the SVI could be used to inform prevention efforts by directing resources to communities most in need and identifying factors on which to focus these programs and policies., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Firearm-related injury in children is a public health crisis. The Social Vulnerability Index (SVI) identifies communities at risk for adverse effects due to natural or human-caused crises. We sought to determine if SVI was associated with pediatric firearm-related injury and thus could assist in prevention planning., Methods: The Centers for Disease Control and Prevention's 2018 SVI data were merged on census tract with 2015 to 2022 open-access shooting incident data in children 19 years or younger from Baltimore, Chicago, Los Angeles, New York City, and Philadelphia. Regression analyses were performed to uncover associations between firearm violence, SVI, SVI themes, and social factors at the census tract level., Results: Of 11,654 shooting incidents involving children, 52% occurred in just 6.7% of census tracts, which were on average in the highest quartile of SVI. A decile increase in SVI was associated with a 45% increase in pediatric firearm-related injury in all cities combined (incidence rate ratio, 1.45; 95% confidence interval, 1.41-1.49; p < 0.001). A similar relationship was found in each city: 30% in Baltimore, 51% in Chicago, 29% in Los Angeles, 37% in New York City, and 35% in Philadelphia (all p < 0.001). Socioeconomic status and household composition were SVI themes positively associated with shootings in children, as well as the social factors below poverty, lacking a high school diploma, civilian with a disability, single-parent household, minority, and no vehicle access. Living in areas with multi-unit structures, populations 17 years or younger, and speaking English less than well were negatively associated., Conclusion: Geospatial disparities exist in pediatric firearm-related injury and are significantly associated with neighborhood vulnerability. We demonstrate a strong association between SVI and pediatric shooting incidents in multiple major US cities. Social Vulnerability Index can help identify social and structural factors, as well as geographic areas, to assist in developing meaningful and targeted intervention and prevention efforts., Level of Evidence: Prognostic and Epidemiological; Level III., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Firearm violence in the United States is a public health crisis, but accessing accurate firearm assault data to inform prevention strategies is a challenge. Vulnerability indices have been used in other fields to better characterize and identify at-risk populations during crises, but no tool currently exists to predict where rates of firearm violence are highest. We sought to develop and validate a novel machine-learning algorithm, the Firearm Violence Vulnerability Index (FVVI), to forecast community risk for shooting incidents, fill data gaps, and enhance prevention efforts., Methods: Open-access 2015 to 2022 fatal and nonfatal shooting incident data from Baltimore, Boston, Chicago, Cincinnati, Los Angeles, New York City, Philadelphia, and Rochester were merged on census tract with 30 population characteristics derived from the 2020 American Community Survey. The data set was split into training (80%) and validation (20%) sets; Chicago data were withheld for an unseen test set. XGBoost, a decision tree-based machine-learning algorithm, was used to construct the FVVI model, which predicts shooting incident rates within urban census tracts., Results: A total of 64,909 shooting incidents in 3,962 census tracts were used to build the model; 14,898 shooting incidents in 766 census tracts were in the test set. Historical third grade math scores and having a parent jailed during childhood were population characteristics exhibiting the greatest impact on FVVI's decision making. The model had strong predictive power in the test set, with a goodness of fit ( D2 ) of 0.77., Conclusion: The Firearm Violence Vulnerability Index accurately predicts firearm violence in urban communities at a granular geographic level based solely on population characteristics. The Firearm Violence Vulnerability Index can fill gaps in currently available firearm violence data while helping to geographically target and identify social or environmental areas of focus for prevention programs. Dissemination of this standardized risk tool could also enhance firearm violence research and resource allocation., Level of Evidence: Prognostic and Epidemiological; Level IV., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Prior publications on pediatric firearm-related injuries have emphasized significant social disparities. The pandemic has heightened a variety of these societal stresses. We sought to evaluate how we must now adapt our injury prevention strategies., Patients and Methods: Firearm-related injuries in children 15 years old and under at five urban level 1 trauma centers between January 2016 and December 2020 were retrospectively reviewed. Age, gender, race/ethnicity, Injury Severity Score, situation, timing of injury around school/curfew, and mortality were evaluated. Medical examiner data identified additional deaths., Results: There were 615 injuries identified including 67 from the medical examiner. Overall, 80.2% were male with median age of 14 years (range 0-15; IQR 12-15). Black children comprised 77.2% of injured children while only representing 36% of local schools. Community violence (intentional interpersonal or bystander) injuries were 67.2% of the cohort; 7.8% were negligent discharges; and 2.6% suicide. Median age for intentional interpersonal injuries was 14 years (IQR 14-15) compared with 12 years (IQR 6-14, p<0.001) for negligent discharges. Far more injuries were seen in the summer after the stay-at-home order (p<0.001). Community violence and negligent discharges increased in 2020 (p=0.004 and p=0.04, respectively). Annual suicides also increased linearly (p=0.006). 5.5% of injuries were during school; 56.7% after school or during non-school days; and 34.3% were after legal curfew. Mortality rate was 21.3%., Conclusions: Pediatric firearm-related injuries have increased during the past 5 years. Prevention strategies have not been effective during this time interval. Prevention opportunities were identified specifically in the preteenage years to address interpersonal de-escalation training, safe handling/storage, and suicide mitigation. Efforts directed at those most vulnerable need to be reconsidered and examined for their utility and effectiveness., Level of Evidence: Level III; epidemiological study type., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Self-inflicted injuries are the second leading cause of pediatric (10-18 y old) mortality. Self-inflicted firearm trauma (SIFT) was responsible for up to half of these deaths in certain age groups. We hypothesized that SIFT prevalence has increased and is associated with specific demographics, injury patterns, and outcomes., Materials and Methods: Data were abstracted from the 2007-2018 American College of Surgeons (ACS) Trauma Quality Programs Participant Use Files (TQP-PUF). Pediatric (1-17 yold) victims of firearm violence were eligible. Age, race, gender, anatomic region, and intent were abstracted. Variables were analyzed using chi-squared tests, t-tests, and single-variate linear regression models. Temporal trends were analyzed using ANCOVA tests. Multivariate logistic regressions were conducted to identify factors influencing mortality. Significance was P < 0.05., Results: There were 41,239 pediatric firearm trauma patients (SIFT: 5.5% [n = 2272]). SIFT incidence increased over the 12-y period (2007 (n = 67) versus 2018 (n = 232), P < 0.05). SIFT was significantly associated with Caucasian race, 67% (n = 1537), teenagers, 90% (n = 2056), male gender, 87% (n = 1978), and a higher median injury severity score (ISS) than other intents of injury (SIFT: 20.0 (IQR: 9.0, 25.0) versus other: 9.0 (IQR: 1.0-13.0), P < 0.001). The SIFT mortality rate was 44% (n = 1005). On multivariate regression head gunshot wounds (OR: 21.1, 95% C.I.: 9.9-45.2, P = 0.001), and ISS (OR:1.1, 95% C.I.: 1.1-1.1, P = 0.001) were significantly associated with mortality. Compared to other intents, SIFT mortality rates increased at a higher annual rate (P < 0.001)., Conclusions: Comprehensive local and federal policy changes to reduce firearms access and increase pediatric mental health support may mitigate these injuries., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background/purpose: Controversy persists regarding the ideal surgical approach for repair of esophageal atresia with tracheoesophageal fistula (EA/TEF). We examined complications and outcomes of infants undergoing thoracoscopy and thoracotomy for repair of Type C EA/TEF using propensity score-based overlap weights to minimize the effects of selection bias., Methods: Secondary analysis of two databases from multicenter retrospective and prospective studies examining outcomes of infants with proximal EA and distal TEF who underwent repair at 11 institutions was performed based on surgical approach. Regression analysis using propensity score-based overlap weights was utilized to evaluate outcomes of patients undergoing thoracotomy or thoracoscopy for Type C EA/TEF repair., Results: Of 504 patients included, 448 (89%) underwent thoracotomy and 56 (11%) thoracoscopy. Patients undergoing thoracoscopy were more likely to be full term (37.9 vs. 36.3 weeks estimated gestational age, p < 0.001), have a higher weight at operative repair (2.9 vs. 2.6 kg, p < 0.001), and less likely to have congenital heart disease (16% vs. 39%, p < 0.001). Postoperative stricture rate did not differ by approach, 29 (52%) thoracoscopy and 198 (44%) thoracotomy (p = 0.42). Similarly, there was no significant difference in time from surgery to stricture formation (p > 0.26). Regression analysis using propensity score-based overlap weighting found no significant difference in the odds of vocal cord paresis or paralysis (OR 1.087 p = 0.885), odds of anastomotic leak (OR 1.683 p = 0.123), the hazard of time to anastomotic stricture (HR 1.204 p = 0.378), or the number of dilations (IRR 1.182 p = 0.519) between thoracoscopy and thoracotomy., Conclusion: Infants undergoing thoracoscopic repair of Type C EA/TEF are more commonly full term, with higher weight at repair, and without congenital heart disease as compared to infants repaired via thoracotomy. Utilizing propensity score-based overlap weighting to minimize the effects of selection bias, we found no significant difference in complications based on surgical approach. However, our study may be underpowered to detect such outcome differences owing to the small number of infants undergoing thoracoscopic repair., Level of Evidence: Level III., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: The American Medical Association recently declared homicides of transgender individuals an epidemic. However, transgender homicide victims are often classified as nontransgender. Our objective was to describe existing data and coding of trans (i.e., transgender) victims and to examine the risk factors for homicides of trans people relative to nontrans people across the United States., Methods: A retrospective review of the Centers for Disease Control and Prevention's National Violent Death Reporting System for the years 2003-2018 identified victims defined as transgender either through the "transgender" variable or narrative reports. Fisher's exact tests and logistic regression models were run to compare the demographics of trans victims to those not identified as trans., Results: Of the 147 transgender victims identified, 14.4% were incorrectly coded as nontrans despite clear indication of trans status in the narrative description, and 6% were coded as hate crimes. Relative to nontrans victims, trans victims were more frequently Black (54.4% versus 40.7%, P = 0.001), had a mental health condition (26.5% versus 11.3%, P < 0.001), or reported being a sex worker (9.5% versus 0.2%, P < 0.001). There were disproportionately few homicides of transgender people in the South (13.6% of trans victims versus 29.1% of nontrans victims, P < 0.001). Conversely, the West and Midwest accounted for a higher-than-expected proportion of trans victims relative to nontrans victims (23.1% of trans victims versus 16.2% of nontrans victims, P = 0.03; 24.5% of trans victims versus 16.8% of nontrans victims, P = 0.02, respectively)., Conclusions: Though the murder of transgender individuals is a known public health crisis, inconsistencies still exist in the assessment and reporting of transgender status. Further, these individuals were more likely to have multiple distinct vulnerabilities. These findings provide important information for injury and violence prevention researchers to improve reporting of transgender status in the medical record and local trauma registries., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Shock index, pediatric age adjusted (SIPA), has been widely applied in pediatric trauma but has limited precision because of the reference ranges used in its derivation. We hypothesized that a pediatric shock index (PSI) equation based on age-based vital signs would outperform SIPA., Methods: A retrospective cohort of trauma patients aged 1 to 18 years from Trauma Quality Programs - Participant Use File 2010 to 2018 was performed. A random 70% training subset was used to derive Youden index-optimizing shock index (SI) cutoffs by age for blood transfusion within 4 hours. We used linear regression to derive equations representing the PSI cutoff for children 12 years or younger and 13 years or older. For children 13 years or older, the well-established SI of 0.9 remained optimal, consistent with SIPA and other indices. For children 12 years or younger in the 30% validation subset, we compared our age-based PSI to SIPA as predictors of early transfusion, mortality, pediatric intensive care unit admission, and injury severity score of ≥25. For bedside use, a simplified "rapid" pediatric shock index (rPSI) equation was also derived and compared with SIPA., Results: A total of 439,699 patients aged 1 to 12 years met the inclusion criteria with 2,718 (1.3% of those with available outcome data) requiring transfusion within 4 hours of presentation. In the validation set, positive predictive values for early transfusion were higher for PSI (8.3%; 95% confidence interval [CI], 7.5-9.1%) and rPSI (6.3%; 95% CI, 5.7-6.9%) than SIPA (4.3%; 95% CI, 3.9-4.7%). For early transfusion, negative predictive values for both PSI (99.3%; 95% CI, 99.2-99.3%) and rPSI (99.3%; 95% CI, 99.2-99.4%) were similar to SIPA (99.4%; 95% CI, 99.3-99.4%)., Conclusion: We derived the PSI and rPSI for use in pediatric trauma using empiric, age-based SI cutoffs. The PSI and rPSI achieved higher positive predictive values and similar negative predictive values to SIPA in predicting the need for early blood transfusion and mortality., Level of Evidence: Prognostic/Epidemiological; level III., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Timely differentiation of biliary atresia (BA) from other infantile cholestatic diseases can impact patient outcomes. Additionally, non-invasive staging of fibrosis after Kasai hepatoportoenterostomy has not been widely standardized. Shear wave elastography is an ultrasound modality that detects changes in tissue stiffness. The authors propose that the utility of elastography in BA can be elucidated through meta-analysis of existing studies., Aim: To assess the utility of elastography in: (1) BA diagnosis, and (2) post-Kasai fibrosis surveillance., Methods: A literature search identified articles that evaluated elastography for BA diagnosis and for post-Kasai follow-up. Twenty studies met criteria for meta-analysis: Eleven for diagnosis and nine for follow-up post-Kasai. Estimated diagnostic odds ratio (DOR), sensitivity, and specificity of elastography were calculated through a random-effects model using Meta-DiSc software., Results: Mean liver stiffness in BA infants at diagnosis was significantly higher than in non-BA, with overall DOR 24.61, sensitivity 83%, and specificity 79%. Post-Kasai, mean liver stiffness was significantly higher in BA patients with varices than in patients without, with DOR 16.36, sensitivity 85%, and specificity 76%. Elastography differentiated stage F4 fibrosis from F0-F3 with DOR of 70.03, sensitivity 96%, and specificity 89%. Elastography also differentiated F3-F4 fibrosis from F0-F2 with DOR of 24.68, sensitivity 85%, and specificity 81%., Conclusion: Elastography has potential as a non-invasive modality for BA diagnosis and surveillance post-Kasai. This paper's limitations include inter-study method heterogeneity and small sample sizes. Future, standardized, multi-center studies are recommended., Competing Interests: Conflict-of-interest statement: There are no conflicts of interest to report., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Introduction: There has been concern that the incidence of non-accidental trauma (NAT) cases in children would rise during the COVID-19 pandemic due to the combination of social isolation and economic depression. Our goal was to evaluate NAT incidence and severity during the pandemic across multiple US cities., Methods: Multi-institutional, retrospective cohort study comparing NAT rates in children <18 y old during the COVID-19 pandemic (March-August 2020) with a recent historical data (January 2015-February 2020) and during a previous economic recession (January 2007-December 2011) at level 1 Pediatric Trauma Centers. Comparisons were made in local and national macroeconomic indicators., Results: Overall rates of NAT during March-August 2020 did not increase compared to historical data (P = 0.8). Severity of injuries did not increase during the pandemic as measured by Glasgow Coma Scale (GCS) (P = 0.97) or mortality (P = 0.7), but Injury Severity Score (ISS) slightly decreased (P = 0.018). Racial differences between time periods were seen, with increased proportions of NAT occurring in African-Americans during the pandemic (P < 0.001). NAT rates over time had low correlation (r = 0.32) with historical averages, suggesting a difference from previous years. Older children (≥3 y) had increased NAT rates during the pandemic. Overall NAT rates had low inverse correlation with unemployment (r = -0.37) and moderate inverse correlation with the stock market (r = -0.6). Significant variation between sites was observed., Conclusions: Overall NAT rates in children did not increase during the COVID-19 pandemic, but rates were highly variable by site and increases were seen in African-Americans and older children. Further studies are warranted to explore local influences on NAT rates., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The shock index is a tool for evaluating critically ill patients that is defined as the ratio of their heart rate divided by systolic blood pressure. The SI is associated with outcomes in adult trauma patients. The Shock Index Pediatric Age-adjusted was developed as a pediatric-specific tool to account for the physiologic differences of children of varying ages. There is growing interest in Shock Index Pediatric Age-adjusted, which is associated with adverse outcomes in pediatric trauma. We hypothesized that alternative shock index cutoffs based on the Advanced Trauma Life Support or the Pediatric Advanced Life Support vital sign reference ranges would outperform Shock Index Pediatric Age-adjusted., Methods: We analyzed a retrospective cohort of pediatric trauma patients (age 1 to 16 years old) in the American College of Surgeons Trauma Quality Programs Participant Use File from 2010 to 2018. The primary outcome measure was in-hospital mortality. The Shock Index Pediatric Age-adjusted was compared to an Advanced Trauma Life Support-based and a Pediatric Advanced Life Support-based shock index cutoff system. Our findings were subsequently confirmed with a separate, internal validation data set., Results: A total of 598,830 Trauma Quality Programs Participant Use File patients were included, 0.9% (n = 5,471) of whom died. For mortality, the Advanced Trauma Life Support-based system yielded the highest positive predictive value (15.8%; 95% confidence interval 15.0%-16.7%) compared with the Pediatric Advanced Life Support-based system (4.3%; 95% confidence interval 4.1%-4.5%). Both the Advanced Trauma Life Support-based and Pediatric Advanced Life Support-based systems achieved higher positive predictive values compared to Shock Index Pediatric Age-adjusted (2.6%; 95% confidence interval 2.5%-2.7%). The negative predictive values were not clinically different. Our findings were validated using a separate internal trauma database, in which the positive predictive value for mortality of the Advanced Trauma Life Support-based system was significantly higher than Shock Index Pediatric Age-adjusted (18.2% [95% confidence interval: 8.2%-32.7%] vs 2.9% [95% confidence interval: 1.6%-5.0%], P < .05)., Conclusion: Advanced Trauma Life Support and Pediatric Advanced Life Support-based shock index cutoffs achieved higher positive predictive values and similar negative predictive values compared to Shock Index Pediatric Age-adjusted for adverse outcomes in pediatric trauma., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: Management of undescended testes (UDT) has evolved over the last decade. While urologic societies in the United States and Europe have established some guidelines for care, management by North American pediatric surgeons remains variable. The aim of this systematic review is to evaluate the published evidence regarding the treatment of (UDT) in children., Methods: A comprehensive search strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Five principal questions were asked regarding imaging standards, medical treatment, surgical technique, timing of operation, and outcomes. A literature search was performed from 2005 to 2020., Results: A total of 825 articles were identified in the initial search, and 260 were included in the final review., Conclusions: Pre-operative imaging and hormonal therapy are generally not recommended except in specific circumstances. Testicular growth and potential for fertility improves when orchiopexy is performed before one year of age. For a palpable testis, a single incision approach is preferred over a two-incision orchiopexy. Laparoscopic orchiopexy is associated with a slightly lower testicular atrophy rate but a higher rate of long-term testicular retraction. One and two-stage Fowler-Stephens orchiopexy have similar rates of testicular atrophy and retraction. There is a higher relative risk of testicular cancer in UDT which may be lessened by pre-pubertal orchiopexy., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Anastomotic stricture is the most common complication after esophageal atresia (EA) repair. We sought to determine if postoperative acid suppression is associated with reduced stricture formation., Methods: A prospective, multi-institutional cohort study of infants undergoing primary EA repair from 2016 to 2020 was performed. Landmark analysis and multivariate Cox regression were used to explore if initial duration of acid suppression was associated with stricture formation at hospital discharge (DC), 3-, 6-, and 9-months postoperatively., Results: Of 156 patients, 79 (51%) developed strictures and 60 (76%) strictures occurred within three months following repair. Acid suppression was used in 141 patients (90%). Landmark analysis showed acid suppression was not associated with reduction in initial stricture formation at DC, 3-, 6- and 9-months, respectively (p = 0.19-0.95). Multivariate regression demonstrated use of a transanastomotic tube was significantly associated with stricture formation at DC (Hazard Ratio (HR) = 2.21 (95% CI 1.24-3.95, p<0.01) and 3-months (HR 5.31, 95% CI 1.65-17.16, p<0.01). There was no association between acid suppression duration and stricture formation., Conclusion: No association between the duration of postoperative acid suppression and anastomotic stricture was observed. Transanastomotic tube use increased the risk of anastomotic strictures at hospital discharge and 3 months after repair., Competing Interests: Declarations of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Firearm injury accounts for significant morbidity with high mortality among children admitted to the PICU. Understanding risk factors for PICU admission is an important step toward developing prevention and intervention strategies to minimize the burden of pediatric gunshot wound (GSW) injury., Objectives: The primary objective of this study was to characterize outcomes and the likelihood of PICU admission among children with GSWs., Design Setting and Participants: Retrospective cohort study of GSW patients 0-18 years old evaluated at the University of Chicago Comer Children's Hospital Pediatric Trauma Center from 2010 to 2017., Main Outcomes and Measures: Demographic and injury severity measures were acquired from an institutional database. We describe mortality and hospitalization characteristics for the cohort. We used logistic regression models to test the association between PICU admission and patient characteristics., Results: During the 8-year study period, 294 children experienced GSWs. We did not observe trends in overall mortality over time, but mortality for children with GSWs was higher than all-cause PICU mortality. Children 0-6 years old experienced longer hospitalizations compared with children 13-16 years old (5 vs 3 d; p = 0.04) and greater frequency of PICU admission (83.3% vs 52.9%; p = 0.001). Adjusting for severity of illness, children less than 7 years old were four-fold more likely to be admitted to the PICU than children 13-16 years old (aOR range, 3.9-4.6)., Conclusions and Relevance: Despite declines in pediatric firearm mortality across the United States, mortality did not decrease over time in our cohort and was higher than all-cause PICU mortality. Younger children with GSWs experience longer hospitalizations and require PICU care more often than older children. Our findings suggest that the youngest victims of firearm-related injury may be particularly at-risk of the long-term sequelae of critical illness and injury., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Introduction: Simulation-based medical education allows learners to refine and maintain clinical skills especially for high-stake situations such as trauma resuscitation. Despite the primary and secondary survey being its foundation, literature shows poor adherence with overall rates as low as 13%. This study evaluates the impact of rapid cycle deliberate practice (RCDP) on primary and secondary survey skill retention. We hypothesized that RCDP-trained surgery residents will have real-world clinical improvement in their survey completion in pediatric trauma resuscitations., Methods: We developed an RCDP trauma resuscitation curriculum. Videos of trauma resuscitations before and after curriculum implementation were scored by 2 blinded reviewers using a modified Pediatric Trauma Assessment Scoring Tool. Actual trauma care by residents who had received the curriculum (study group) was compared with care provided by residents who had not received the curriculum (precurriculum historical control group and a concurrent control group who provided care without receiving the curriculum)., Results: One hundred eighty-eight videos were scored with 98 in study group, 33 in concurrent control group, and 57 in historical control group. There was a significant improvement in primary survey performance between study group and historical control group (P < 0.001), but no difference between study group and concurrent control group. There was a significant improvement between study group and 2 control groups in secondary survey performance (both P < 0.001)., Conclusions: The RCDP curriculum led to significant improvement in surgical residents' trauma survey performance and had clinical impact on actual patients, which is rare in pediatric trauma simulation literature., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 Society for Simulation in Healthcare.)

Background: The equivalent Injury Severity Score (ISS) cutoffs for severe trauma vary between adult (ISS, >16) and pediatric (ISS, >25) trauma. We hypothesized that a novel injury severity prediction model incorporating age and mechanism of injury would outperform standard ISS cutoffs., Methods: The 2010 to 2016 National Trauma Data Bank was queried for pediatric trauma patients. Cut point analysis was used to determine the optimal ISS for predicting mortality for age and mechanism of injury. Linear discriminant analysis was implemented to determine prediction accuracy, based on area under the curve (AUC), of ISS cutoff of 25 (ISS, 25), shock index pediatric adjusted (SIPA), an age-adjusted ISS/abbreviated Trauma Composite Score (aTCS), and our novel Trauma Composite Score (TCS) in blunt trauma. The TCS consisted of significant variables (Abbreviated Injury Scale, Glasgow Coma Scale, sex, and SIPA) selected a priori for each age., Results: There were 109,459 blunt trauma and 9,292 penetrating trauma patients studied. There was a significant difference in ISS (blunt trauma, 9.3 ± 8.0 vs. penetrating trauma, 8.0 ± 8.6; p < 0.01) and mortality (blunt trauma, 0.7% vs. penetrating trauma, 2.7%; p < 0.01). Analysis of the entire cohort revealed an optimal ISS cut point of 25 (AUC, 0.95; sensitivity, 0.86; specificity, 0.95); however, the optimal ISS ranged from 18 to 25 when evaluated by age and mechanism. Linear discriminant analysis model AUCs varied significantly for each injury metric when assessed for blunt trauma and penetrating trauma (penetrating trauma-adjusted ISS, 0.94 ± 0.02 vs. ISS 25, 0.88 ± 0.02 vs. SIPA, 0.62 ± 0.03; p < 0.001; blunt trauma-adjusted ISS, 0.96 ± 0.01 vs. ISS 25, 0.89 ± 0.02 vs. SIPA, 0.70 ± 0.02; p < 0.001). When injury metrics were assessed across age groups in blunt trauma, TCS and aTCS performed the best., Conclusion: Current use of ISS in pediatric trauma may not accurately reflect injury severity. The TCS and aTCS incorporate both age and mechanism and outperform standard metrics in mortality prediction in blunt trauma., Level of Evidence: Retrospective review, level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Injury Severity Score (ISS) is a widely used metric for trauma research and center verification; however, it does not account for age-related physiologic parameters. We hypothesized that a novel age-based injury severity metric would better predict mortality., Methods: Adult patients (≥18 years) sustaining blunt trauma (BT) or penetrating trauma (PT) were abstracted from the 2010 to 2016 National Trauma Data Bank. Admission vitals, Glasgow Coma Scale, ISS, mechanism, and outcomes were analyzed. Patients with incomplete/non-physiologic vital signs were excluded. For each age: (1) a cut point analysis was used to determine the ISS with the highest specificity and sensitivity for predicting mortality and (2) a linear discriminant analysis was performed using ISS, ISS greater than 16, Trauma and Injury Severity Score, and Revised Trauma Scale to compare each scoring system's mortality prediction. A novel injury severity metric, the trauma component score (TCS), was developed for each age using significant (p < 0.05) variables selected from Abbreviated Injury Scale scores, Glasgow Coma Scale, vital signs, and gender. Receiver operator curves were developed and the areas under the curve were compared between the TCS and other systems., Results: There 777,794 patients studied (BT, 91.1%; PT, 8.9%). Blunt trauma patients were older (53.6 ± 21.3 years vs. 34.4 ± 13.8 years), had higher ISS scores (11.1 ± 8.5 vs. 8.5 ± 8.9), and lower mortality (2.9% vs. 3.4%) than PT patients (p < 0.05). When assessing the entire PT and BT cohort the optimal ISS cut point was 16. The optimal ISS was between 20 and 25 for BT younger than 70 years. For those older than 70 years, the optimal BT ISS steadily declined as age increased PT's cut point was 16 or less for all ages assessed. When the injury metrics were compared by area under the curve, our novel TCS more accurately predicted mortality across all ages in both BT and PT (p < 0.001)., Conclusion: Injury Severity Score is a poor mortality predictor in older patients and those sustaining penetrating trauma. The age-based TCS is a superior metric for mortality prediction across all ages., Level of Evidence: Clinical outcomes, Level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP) in pediatric patients are strongly associated with genetic mutations and lead to pan-parenchymal disease refractory to medical and endoscopic treatment. Our aim was to assess pain resolution and glucose control in patients with CP and ARP following total pancreatectomy with islet auto-transplantation (TPIAT)., Methods: We retrospectively analyzed prospectively collected clinical data of 12 children who developed CP and ARP and underwent TPIAT when 21 years old or younger at the University of Chicago between December 2009 and June 2020. Patients with recurrent or persistent abdominal pain attributed to acute or chronic pancreatic inflammation and a history of medical interventions attempted for the relief of pancreatic pain were selected by a multi-disciplinary team for TPIAT. We followed patients post-operatively and reported data for pre-TPIAT, post-operative day 75, and yearly post-TPIAT., Results: All 12 patients experienced complete resolution of pancreatic pain. The overall insulin-independence rate after 1 year was 66% (8/12) and 50% (3/6) at 4 years. Shorter duration of CP/ARP pre-TPIAT, higher mass of islets infused, and lower BMI, BMI percentile, and BSA were associated with insulin-independence post-TPIAT., Conclusions: TPIAT is a viable treatment option for pediatric patients with CP and ARP. Pediatric patients undergoing TPIAT for CP achieved resolution of pancreatic-type pain and reduced opioid requirements. The majority were able to achieve insulin-independence which was associated with lower pre-TPIAT BMI and higher islet mass transplanted (i.e., over 2000 IEQ/kg), the latter of which can be achieved by earlier TPIAT., Level of Evidence: Treatment study, Level IV., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: Long-Segment Hirschsprung Disease (LSHD) differs clinically from short-segment disease. This review article critically appraises current literature on the definition, management, outcomes, and novel therapies for patients with LSHD., Methods: Four questions regarding the definition, management, and outcomes of patients with LSHD were generated. English-language articles published between 1990 and 2018 were compiled by searching PubMed, Scopus, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar. A qualitative synthesis was performed., Results: 66 manuscripts were included in this systematic review. Standardized nomenclature and preoperative evaluation for LSHD are recommended. Insufficient evidence exists to recommend a single method for the surgical repair of LSHD. Patients with LSHD may have increased long-term gastrointestinal symptoms, including Hirschsprung-associated enterocolitis (HAEC), but have a quality of life similar to matched controls. There are few surgical technical innovations focused on this disorder., Conclusions: A standardized definition of LSHD is recommended that emphasizes the precise anatomic location of aganglionosis. Prospective studies comparing operative options and long-term outcomes are needed. Translational approaches, such as stem cell therapy, may be promising in the future for the treatment of long-segment Hirschsprung disease., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Historically, aggressive fluid resuscitation has been a cornerstone of management of hemorrhagic shock in pediatrics. Adult data suggest this strategy may be harmful. We sought to determine whether aggressive fluid resuscitation within the first hour of presentation to the emergency department in pediatric patients with trauma is associated with worse clinical outcomes., Materials and Methods: We performed a retrospective cohort study from 2012 to 2017 at a single pediatric level 1 trauma center. We defined three patient cohorts: ≤ 20 cc/kg (reference), 20-40 (20.01 to 39.99) cc/kg, and ≥40 cc/kg of intravenous fluid (IVF) given in the first in-hospital hour. Covariates included age, injury severity score, shock index (adjusted for age), and mechanism of injury and were adjusted for with multivariable regression. The primary outcome was in-hospital mortality., Results: A total of 1479 consecutive injured children were eligible for inclusion. One hundred ninety-four patients were excluded for missing IVF data, aged ≥16 y, having primary burns, or arriving pulseless. A total of 1285 patients met inclusion criteria (mean age 8.1 ± 5.5 y, male 64.5%). Higher rates of IVF administration were associated with mortality for both the 20-40 cc/kg (adjusted odds ratio (aOR) 2.96; 95% confidence interval (CI) 1.02-8.55; P = 0.045) and ≥40 cc/kg groups (aOR 6.26; 95% CI 1.79-21.83; P = 0.004). The ≥40 cc/kg group was associated with increased pediatric intensive care unit length of stay (aOR 2.20; 95% CI: 1.05-4.61; P = 0.036) and increased need for mechanical ventilation (aOR 3.79; 95% CI 1.62-8.87; P = 0.002)., Conclusions: Greater than one 20 cc/kg IVF bolus in the first emergency department hour was associated with mortality with a dose-response relationship, even after adjusting for injury severity and initial hemodynamics. These results encourage further investigation into initial resuscitation strategies for injured children., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: There is growing concern regarding the impact of general anesthesia on neurodevelopment in children. Pre-clinical animal studies have linked anesthetic exposure to abnormal central nervous system development, but it is unclear whether these results translate into humans. The purpose of this systematic review from the American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice (OEBP) Committee was to review, summarize, and evaluate the evidence regarding the neurodevelopmental impact of general anesthesia on children and identify factors that may affect the risk of neurotoxicity., Methods: Medline, Cochrane, Embase, Web of Science, and Scopus databases were queried for articles published up to and including December 2017 using the search terms "general anesthesia and neurodevelopment" as well as specific anesthetic agents. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to screen manuscripts for inclusion in the review. A consensus statement of recommendations in response to each study question was synthesized based upon the best available evidence., Results: In total, 493 titles were initially identified, with 56 articles selected for full analysis and 44 included for review. Based on currently available developmental assessment tools, a single exposure to general anesthesia does not appear to have a significant effect on general neurodevelopment, although prolonged or multiple anesthetic exposures may have some adverse effects. Exposure to general anesthesia may affect different domains of development at different ages. Regional anesthetic techniques with the addition of dexmedetomidine and/or some intravenous agents may mitigate the risks of neurotoxicity. This approach may be performed safely in some patients and can be considered as an option in selected short procedures., Conclusion: There is no conclusive evidence that a single short anesthetic in infancy has a detectable neurodevelopmental effect. Data do not support waiting until later in childhood to perform general anesthesia for single short procedures. With the complexities and nuances of different anesthetic methods, patients and procedures, the planning and execution of anesthesia for the pediatric patient is generally best accomplished by an anesthesiologist, ideally a pediatric anesthesiologist., Type of Study: Systematic review of level 1-4 studies., Level of Evidence: Level 1-4 (mainly level 3-4)., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Electrocardiographic abnormalities such as cardiac axis deviation, conduction abnormalities and ST-segment, and T &P wave abnormalities have been reported in patients with pectus excavatum. The precise determinants of these electrocardiographic abnormalities have however not been systematically evaluated. We therefore carried out this exploratory study to assess the electrocardiographic abnormalities and their determinants in children and young adults with pectus excavatum., Methods: Patients aged between 6 and 22 years with unrepaired pectus excavatum were eligible for enrollment in this preliminary hypothesis generating study, if they were seen at University of Chicago Medical Center between Jan 1, 2017 to Nov 30, 2020, and underwent an electrocardiogram during comprehensive evaluation for pectus excavatum. Pertinent data was collected from the medical charts. Unadjusted and adjusted logistic regression models were used to determine the effect of variables including age, BMI, inspiratory Haller's index, gender, right ventricular geometric distortion and FEV1/FVC (% predicted) on odds of electrocardiographic abnormalities (primary outcome variable). P-values of <0.05 were considered significant., Results: The study group (16.6 ± 2.9 years, 80% symptomatic) consisted of 28 patients [Caucasian, male (n = 24, 86% each)]. A high proportion (86%) of these patients had geometric distortion of the right ventricle on noninvasive imaging and these patients had a higher Haller's index (4.4 ± 0.95 vs 3.3 ± 0.2, p = 0.03). Approximately 60% of the patients had an abnormal electrocardiogram. Unadjusted and adjusted logistic regression models were utilized to study the determinants of these electrocardiographic abnormalities. Haller's index, BMI, age, gender, geometric distortion of the right ventricle and lung function parameters [FEV1/FEV (% predicted)] were not associated with increased odds of electrocardiographic abnormalities., Conclusions: Electrocardiographic abnormalities, particularly deviation of cardiac axis, are common in patients with pectus excavatum. In this exploratory hypothesis generating study, Haller's index and geometric distortion of the right ventricle were not associated with these abnormalities. However, systematic multicentric efforts are needed to better define electrocardiographic abnormalities in patients with pectus excavatum and elucidate their precise determinants., Competing Interests: Declaration of Competing Interest None of the authors have any relevant conflict of interest., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations for the management of ileocolic intussusception in children., Methods: The ClinicalTrials.gov, Embase, PubMed, and Scopus databases were queried for literature from January 1988 through December 2018. Search terms were designed to address the following topics in intussusception: prophylactic antibiotic use, repeated enema reductions, outpatient management, and use of minimally invasive techniques for children with intussusception. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available evidence., Results: A total of 83 articles were analyzed and included for review. Prophylactic antibiotic use does not decrease complications after radiologic reduction. Repeated enema reductions may be attempted when clinically appropriate. Patients can be safely observed in the emergency department following enema reduction of ileocolic intussusception, avoiding hospital admission. Laparoscopic reduction is often successful., Conclusions: Regarding intussusception in hemodynamically stable children without critical illness, pre-reduction antibiotics are unnecessary, non-operative outpatient management should be maximized, and minimally invasive techniques may be used to avoid laparotomy., Level of Evidence: Level 3-5 (mainly level 3-4) TYPE OF STUDY: Systematic Review of level 1-4 studies., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background/purpose: This study evaluated compliance with a multi-institutional quality improvement management protocol for Type-C esophageal atresia with distal tracheoesophageal fistula (EA/TEF)., Methods: Compliance and outcomes before and after implementation of a perioperative protocol bundle for infants undergoing Type-C EA/TEF repair were compared across 11 children's hospitals from 1/2016-1/2019. Bundle components included elimination of prosthetic material between tracheal and esophageal suture lines during repair, not leaving a transanastomotic tube at the conclusion of repair (NO-TUBE), obtaining an esophagram by postoperative-day-5, and discontinuing prophylactic antibiotics 24 h postoperatively., Results: One-hundred seventy patients were included, 40% pre-protocol and 60% post-protocol. Bundle compliance increased 2.5-fold pre- to post-protocol from 17.6% to 44.1% (p < 0.001). After stratifying by institutional compliance with all bundle components, 43.5% of patients were treated at low-compliance centers (<20%), 43% at medium-compliance centers (20-80%), and 13.5% at high-compliance centers (>80%). Rates of esophageal leak, anastomotic stricture, and time to full feeds did not differ between pre- and post-protocol cohorts, though there was an inverse correlation between NO-TUBE compliance and stricture rate over time (ρ = -0.75, p = 0.029)., Conclusions: Compliance with our multi-institutional management protocol increased 2.5-fold over the study period without compromising safety or time to feeds and does not support the use of transanastomotic tubes., Level of Evidence: Level II., Type of Study: Treatment Study., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose of Review: Traumatic injuries are a leading cause of pediatric mortality; pediatric ICUs (PICUs) are an important but potentially limited resource associated with high costs. In an era of rising healthcare costs, appropriate resource utilization is important. Here, we examine evidence-based guidelines supporting the management of pediatric traumatic injury outside of the PICU., Recent Findings: Historical management of solid organ injury and traumatic brain injury was focused on operative management. However, over the past four decades, management of solid organ injury has shifted from invasive management to nonsurgical management with a growing body of evidence supporting the safety and efficacy of this trend. The management of traumatic brain injury (TBI) has had a similar evolution to that of solid organ injury with regard to nonoperative management and management outside the critical care setting., Summary: The use of evidence-based guidelines to support expectant management in the setting of pediatric trauma has the potential to reduce unnecessary resource utilization of the PICU. In this review, we present findings that support nonoperative management and management of pediatric trauma outside of the PICU setting. In resource-poor areas, this approach may facilitate care for pediatric trauma patients. The implications are also important in resource-rich settings because of the unintended risks associated with PICU.

Background: The COVID-19 pandemic forced surgeons to reconsider concepts of "elective" operations. Perceptions about the time sensitivity and medical necessity of a procedure have taken on greater significance during the pandemic. The evolving ethical and clinical environment requires reappraisal of perioperative factors, such as personal protective equipment conservation; limiting the risk of exposure to COVID-19 for patients, families, and healthcare workers; preservation of hospital beds and ICU resources; and minimizing COVID-19-related perioperative risk to patients., Study Design: A scaffold for the complex decision-making required for prioritization of medically necessary, time-sensitive (MeNTS) operations was developed for adult patients by colleagues at the University of Chicago. Although adult MeNTS scoring can be applied across adult surgical specialties, some variables were irrelevant in a pediatric population. Pediatric manifestations of chronic diseases and congenital anomalies were not accounted for. To account for the unique challenges children face, we modified the adult MeNTS system for use across pediatric subspecialties., Results: This pediatric MeNTS scoring system was applied to 101 cases both performed and deferred between March 23 and April 19, 2020 at the University of Chicago Comer Children's Hospital. The pediatric MeNTS scores provide a safe, equitable, transparent, and ethical strategy to prioritize children's surgical procedures., Conclusions: This process is adaptable to individual institutions and we project it will be useful during the acute phase of the pandemic (maximal limitations), as well as the anticipated recovery phase., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Optimal performance of the primary and secondary survey is the foundation of Advance Trauma Life Support care. Despite its importance, not all primary surveys completed at level 1 pediatric trauma centers are performed according to established guidelines (Gala et al., Pediatr Emerg Care 32:756-762, 2016, Carter et al., Resuscitation 84:66-71, 2013). We hypothesize that rapid cycle deliberate practice (RCDP) will improve surgical residents' confidence in performing the primary and secondary survey., Methods: We developed a curriculum to teach surgical interns the principles of performing the primary and secondary survey using RCDP. Surveys distributed after each session assessed the impact of the curriculum on learner confidence and perception that this curriculum would benefit patient care. Questions were scored on a 5-point Likert scale. Sixteen surgical interns participated during intern orientation and 100% of the participants completed the post curriculum survey., Results: Thirteen (81%) of participants agreed or strongly agreed that the simulation would impact future performance in the pediatric trauma bay. The curriculum also significantly improved the confidence of our learners to perform trauma surveys (p < 0.001)., Conclusion: This curriculum improves the confidence of junior surgical residents in learning the primary and secondary survey. Most learners enjoyed the session and felt that the curriculum would positively impact their performance.

Splenic cysts are rare in the United States but more common in regions of the world where Echinococcus is endemic. Cysts are typically classified as true cysts or pseudocysts. True cysts can be parasitic or nonparasitic in origin, whereas most pseudocysts are a result of previous trauma. Recent recognition of features shared by true cysts and pseudocysts suggests the classification system may need to be revised. The prevalence of splenic cysts has increased secondary to the widespread use of abdominal imaging and successful nonoperative management of traumatic splenic injuries. Treatment previously consisted primarily of total splenectomy. However, recognition of the importance of the spleen throughout a patient's life has led to changes in the management of splenic disease. Advances in the testing and preoperative localization of splenic lesions have also led to increased efforts in splenic conservation. [Pediatr Ann. 2016;45(7):e251-e256.]., (Copyright 2016, SLACK Incorporated.)

Whereas some investigators in the surgical field advocate liver resection for the treatment of hepatocellular carcinoma (HCC), orthotopic liver transplantation (OLT) shows a significant survival advantage. Age was used to stratify survival in these groups to analyze beneficence. The Surveillance, Epidemiology, and End Results database (1998-2008) was used to identify 2355 patients who underwent either a segmentectomy, lobectomy, or extended lobectomy (resection) and 1873 patients who underwent an OLT for HCC. These patients were further stratified according to age and their relative survival was calculated. As shown in previous studies, the survival advantage is maintained in patients 40 to 59 and 60 to 79 years of age with HCC treated with OLT. However, within the 20 to 39-year-old age group, this advantage is insignificant. In this younger age group, resection patients (n = 157) have a 5-year survival rate of 50.9% whereas the OLT group (n = 40) has a 5-year survival rate of 58.9% (P = .42). Moreover, when assessing patient with lesions within the Milan criteria ages 20 to 39 years, resection shows a slight, although insignificant 4-year survival advantage: 78.2% for resection (n = 56) and 64.4% for OLT (n = 21; P = .283). This data may temper the enthusiasm for OLT in younger patients given the possibility of equivalent treatment with surgical resection., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Solid pseudopapillary tumors of the pancreas (SPTP) are very rare, and an SPTP arising in a pancreatic rest has been reported only 4 times previously and never in association with the jejunum. We report this unusual case of a 16 year old girl who presented with 4 days of intermittent, crampy abdominal pain and was found to have an SPTP arising in a pancreatic rest of the jejunum.

Background: This study aimed to analyze outcomes of surgical management for popliteal artery aneurysms (PAA)., Methods: This is a retrospective analysis of prospectively collected data regarding operations for PAA obtained from 123 United States Veterans Affairs Medical Centers as part of the National Surgical Quality Improvement Program. Univariate analyses and multivariate logistic regression were used to characterize 33 risk factors and their associations with 30-day morbidity and mortality. Survival and amputation rates, observed at one and two years after surgery, were subject to life-table and Cox regression analyses., Results: There were 583 operations for PAA in 537 patients during 1994-2005. Almost all were in men (99.8%) and median age was 69 years (range, 34 to 92 years). Most had multiple co-morbidities, 88% were ASA (American Society of Anesthesiologists) class 3 or 4, and 81% were current or past smokers (median pack-years = 50). Only 16% were diabetic. Serious complications occurred in 69 (11.8%) cases, of which 37 (6.3%) required arterial-specific reinterventions. Eight patients died within 30 days, a mortality of 1.4%. Risk factors associated with increased complications included: African-American race (odds ratio [OR] 2.8 [95% confidence interval 1.5-5.2], P = .002), emergency surgery (OR 3.8 [2.0-7.0], P < .0001), ASA 4 (OR 1.9 [1.1-3.5], P = .04), dependent functional status (OR 2.5 [1.4-4.7], P = .004), steroid use (OR 3.2 [1.2-8.7], P = .03), and need for intraoperative red blood cell transfusion of any quantity (OR 6.3 [3.5-11.2], P < .0001). Independent predictors for complications in the multivariate model were dependent functional status (adjusted OR 2.1 [1.1-4.3], P = .049) and intraoperative transfusion (adjusted OR 4.5 [2.3-8.9], P = .0002). Postoperative bleeding complications within 72 hours independently predicted early amputation (adjusted OR 25.5 [1.7-393], P = .02). Unadjusted patient survival was 92.6% at one year and 86.1% at two years. Limb salvage in surviving patients was 99.0% at 30 days, 97.6% at one year, and 96.2% at two years. Dependent preoperative functional status was the only factor predictive of worse two-year limb salvage (adjusted OR 4.6 [1.9-10.9], P = .001), but remained high at 88.2% versus 97.1% in independent patients., Conclusions: Surgical intervention for PAA is associated with low operative mortality and offers excellent two-year limb salvage, even in high-risk patients. Patients' preoperative functional status and perioperative blood transfusion requirements were the most predictive indicators of negative outcomes.

Background: The incidence of right-sided colon cancers has been increasing in recent years. It is unclear whether patient prognosis varies by tumor location. In this study, we have compared the survival of right-and left-sided colon cancers in a longitudinal population-based database., Methods: A retrospective survival analysis was performed using the Surveillance, Epidemiology, and End Results Program (SEER) database between 1988 and 2003 on subjects who underwent surgical resection for the a primary diagnosis of pathologically confirmed invasive colon adenocarcinoma. Cox proportional hazard regression analysis was used to assess long-term survival outcomes comparing right-sided (cecum to transverse colon, excluding appendix) versus left-sided (splenic flexure to sigmoid, excluding rectum) colon cancers., Results: A total of 77,978 subjects were identified with adenocarcinoma of the colon. Overall median survival was 83 months. Median survival for right-sided cancers was 78 vs. 89 months for left-sided cancers (P < .001). By Cox proportional hazard regression analysis, controlling for statistically significant confounders, including age, sex, race, marital status, tumor stage, tumor size, histologic grade, number of lymph nodes examined, and year of diagnosis, right-sided colon cancers were associated with a 5% increased mortality risk compared with left-sided colon cancers (hazard ratio, 1.04; 95% confidence interval, 1.02-1.07). These findings were consistent across subsets of subjects., Conclusion: On the basis of analysis of information from the SEER database, we found that right-sided colon cancers have a worse prognosis than left-sided colon cancers. The reason for this remains unclear but may be due to biological and/or environmental factors and may have particular bearing, given the rising incidence of right-sided colon cancers.

Objective: Lower extremity arterial injury is a rare complication following total knee (TKA) or total hip arthroplasty (THA). To date, no multi-institutional study has identified preoperative factors that may portend increased risk for these injuries. We queried a large clinical database for the incidence and predictors of arterial injury and/or compromise following lower extremity arthroplasty., Methods: Prospectively collected preoperative and postoperative data by the National Surgical Quality Improvement Program (NSQIP) of the Veterans Affairs Medical Centers were analyzed. All patients from 1996 to 2003 in the NSQIP database who underwent TKA or THA were identified via CPT codes. NSQIP defined, 30-day, postoperative outcomes were analyzed. Data were compared using bivariable analysis, as well as limited multivariable logistic regression., Results: A total of 41,633 arthroplasties (24,029 TKA, 2077 redo-TKA, 13,494 THA, 2033 redo-THA) were identified in the NSQIP database. A total of 34 (0.08%) lower extremity arterial injuries were recognized (0.08% TKA, 0.19% redo-TKA, 0.04% THA, 0.20% redo-THA). Eighteen injuries were repaired on the same day of surgery (seven intraop, 11 postop), eight between postoperative days 1 and 5, and 8 between days 6 and 30. Only two patients underwent lower extremity amputation (overall limb loss rate of 5.9% of patients who had arterial injury). Statistically significant predictors of lower extremity arterial injury identified on logistic regression analysis included redo procedure (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.2-6.0, P = .013) and African American race (OR 2.5, 95% CI 1.2-5.3, P = .02)., Conclusion: Lower extremity arterial injury was exceedingly rare after total knee or total hip arthroplasty. There is an increased incidence in African American patients and those undergoing redo arthroplasty. Among patients who sustain vascular injury, excellent limb salvage rates can be achieved with close postoperative surveillance to achieve early detection and repair of injuries.

Background: Based on data from other malignancies, the number of lymph nodes evaluated and the ratio of metastatic to examined lymph nodes (LNR) may be important predictors of survival. LNR has never been investigated in a large population-based study of patients with pancreatic adenocarcinoma., Methods: The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 4005 patients who underwent resection for pancreatic adenocarcinoma from 1988 to 2003. The effect of total lymph node count and LNR on survival was examined using univariate and multivariate analyses., Results: The median number of lymph nodes examined was seven; 390 (10.1%) patients had no lymph nodes examined. Of those patients who had at least one lymph node examined, 1507 (43.3%) had no lymph node metastases (N0) and 1971 (56.7%) had metastatic nodal disease (N1). Overall median survival was 13 months, and 5-year survival was 6.8%. N1 disease was associated with a worse 5-year survival compared with N0 disease (4.3 vs 11.3%, respectively, P < .001). Patients with N0 disease could be further stratified based on the number of lymph nodes evaluated (median survival: 1-11 nodes, 16 months vs 12 or more nodes, 23 months; P < .001). For N1 patients, LNR was one of the most powerful factors associated with survival (LNR > 0-0.2, 15 months; LNR > 0.2-0.4, 12 months; LNR > 0.4, 10 months) (P < .001)., Conclusions: Most patients have an inadequate number of lymph nodes evaluated following pancreatic surgery. N0 patients who have fewer than 12 lymph nodes examined may be understaged. In patients with N1 disease, LNR may better substratify patients with regard to prognosis.

Objective: Takayasu's arteritis (TA) is a chronic immune vasculitis that causes inflammation of the aorta and its branches and is clinically characterized by exacerbations and remissions. This study examined the quality of life (QoL) of patients with TA using the Medical Outcomes Study Short Form 36 (SF-36) Health Survey, a validated health related QoL questionnaire., Methods: Questionnaires that included the SF-36 and demographic related variables were mailed to 392 patients enrolled in the Takayasu's Arteritis Research Association. Raw SF-36 scores, as well as Physical Health Summary (PHS) and Mental Health Summary (MHS) scores, were calculated according to standard protocols. Data were analyzed for predictors of superior QoL using univariate and stepwise logistic regression analysis. SF-36 scores were also compared with those of other chronic diseases associated with peripheral vascular disease (PVD) published in the literature. Results are reported as mean +/- standard error of the mean., Results: A total of 158 patients (144 women, 14 men) with average age of 42.2 +/- 1.1 years responded to the questionnaire. Mean onset of symptoms occurred at 30.5 +/- 1.2 years, with a mean age at diagnosis of 34.7 +/- 1.2, and a median of four doctors were seen before diagnosis. The group underwent 299 TA-related surgical procedures (1.9 +/- 0.3), including coronary (38%), carotid (35%), upper extremity (30%), and lower extremity (26%) revascularization. PHS and MHS summary scores (39.2 +/- 1.0 and 44.5 +/- 1.0, respectively) were worse than mean scores for an age-matched healthy population as well as nationally reported scores for diabetes mellitus, hypertension, and coronary artery disease (all P < .0001). Multivariate predictors of better physical QoL were younger age (P = .003) and remission of the disease (P = .0002). The use of immunomodulating medications was associated with inferior physical QoL (P = .02). The sole predictor of better mental QoL was remission of disease (P = .002)., Conclusion: TA is a rare disease with profound consequences on QoL. Scores for physical and mental health are worse compared with many other chronic diseases associated with PVD. Superior physical QoL is seen in younger patients, whereas inferior physical QoL is encountered in those who take immunomodulating medications. Because the only factor to influence positively both physical and mental QoL is disease remission, every effort should be directed to attenuate disease activity.