Effect of citizenship status on access to pediatric liver and kidney transplantation.

Transplantation of non-US citizen residents remains controversial. We evaluate national trends in transplant activity among pediatric noncitizen residents (PNCR). Pediatric liver and kidney transplant data were obtained from the Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients. Data on transplanted organs, region, waitlist additions, procedures, and citizenship status were analyzed from 2012-2022. Rates of PNCR transplantation activity were compared with population rates from the US Census Bureau. On average, 713 ± 47 pediatric liver and 1039 ± 51 kidney patients were added to the waitlist, with 544 ± 32 liver and 742 ± 33 kidney transplants performed annually. Of these, PNCR comprised 1.5% and 3.3% of liver and kidney waitlist additions and 1.5% and 2.9% of liver and kidney transplant procedures, respectively. There were no significant changes in waitlist or transplant activity nationwide over the study period. There was a significant geographic variation in the percentage of waitlist additions and transplants across the United Network for Organ Sharing regions among the PNCR for liver and kidney transplantation. This is the first study to evaluate national trends in transplantation activity among PNCRs. The significant regional variation in transplantation activity for PNCR may suggest multilevel structural and systemic barriers to transplant accessibility.

Sensitivity, Specificity, and Cutoff Identifying Optic Atrophy by Macular Ganglion Cell Layer Volume in Syndromic Craniosynostosis.

PURPOSE: To determine the sensitivity, specificity, and cutoff of macular ganglion cell layer (GCL) volume consistent with optic atrophy in children with syndromic craniosynostosis and to investigate factors independently associated with reduction in GCL volume. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: Patients with syndromic craniosynostosis evaluated at Boston Children's Hospital (2010-2022) with reliable macular OCT scans. METHODS: The latest ophthalmic examination that included OCT macula scans was identified. Age at examination, sex, ethnicity, best-corrected logarithm of the minimum angle of resolution (logMAR) visual acuity, cycloplegic refraction, and funduscopic optic nerve appearance were recorded in addition to history of primary or recurrent elevation in intracranial pressure (ICP), Chiari malformation, and obstructive sleep apnea (OSA). Spectral-domain OCT software quantified segmentation of macula retinal layers and was checked manually. MAIN OUTCOME MEASURES: The primary outcome was determining sensitivity, specificity, and optimal cutoff of GCL volume consistent with optic atrophy. The secondary outcome was determining whether previously elevated ICP, OSA, Chiari malformation, craniosynostosis diagnosis, logMAR visual acuity, age, or sex were independently associated with lower GCL volume. RESULTS: Median age at examination was 11.9 years (interquartile range, 8.5-14.8 years). Fifty-eight of 61 patients (112 eyes) had reliable macula scans, 74% were female, and syndromes represented were Apert (n = 14), Crouzon (n = 17), Muenke (n = 6), Pfeiffer (n = 6), and Saethre-Chotzen (n = 15). Optimal cutoff identifying optic atrophy was a GCL volume < 1.02 mm3 with a sensitivity of 83% and specificity of 77%. Univariate analysis demonstrated that significantly lower macular GCL volume was associated with optic atrophy on fundus examination (P < 0.001), Apert syndrome (P < 0.001), history of elevated ICP (P = 0.015), Chiari malformation (P = 0.001), OSA (P < 0.001), male sex (P = 0.027), and worse logMAR visual acuity (P < 0.001). Multivariable median regression analysis confirmed that only OSA (P = 0.005), optic atrophy on fundus examination (P = 0.003), and worse logMAR visual acuity (P = 0.042) were independently associated with lower GCL volume. CONCLUSIONS: Surveillance for optic atrophy by GCL volume may be useful in a population where cognitive skills can limit acquisition of other key ophthalmic measures. It is noteworthy that OSA is also associated with lower GLC volume in this population. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Preventive Practices and Knowledge of Human Papillomavirus in Mayer-Rokitansky-Küster-Hauser Syndrome Individuals.

ABSTRACT: Mayer-Rokitansky-Küster-Hauser syndrome is a congenital disorder typified by an underdeveloped female reproductive tract. An exploratory online survey of adults with Mayer-Rokitansky-Küster-Hauser syndrome found that many did not recall receiving the human papillomavirus vaccine, and answers to knowledge questions suggested inadequate human papillomavirus counseling. However, recalled vaccine counseling was associated with improved uptake.

U.S. Attending Anesthesiologist Burnout in the Postpandemic Era.

BACKGROUND: Anesthesiologists are experiencing unprecedented levels of workplace stress and staffing shortages. This analysis aims to assess how U.S. attending anesthesiologist burnout changed since the onset of the COVID-19 pandemic and target well-being efforts. METHODS: The authors surveyed the American Society of Anesthesiologists' U.S. attending anesthesiologist members in November 2022. Burnout was assessed using the Maslach Burnout Inventory Human Services Survey with additional questions relating to workplace and demographic factors. Burnout was categorized as high risk for burnout (exhibiting emotional exhaustion and/or depersonalization) or burnout syndrome (demonstrating all three burnout dimensions concurrently). The association of burnout with U.S. attending anesthesiologist retention plans was analyzed, and associated factors were identified. RESULTS: Of 24,680 individuals contacted, 2,698 (10.9%) completed the survey, with 67.7% (1,827 of 2,698) at high risk for burnout and 18.9% (510 of 2,698) with burnout syndrome. Most (78.4%, n = 2,115) respondents have experienced recent staffing shortages, and many (36.0%, n = 970) were likely to leave their job within the next 2 yr. Those likely to leave their job in the next 2 yr had higher prevalence of high risk for burnout (78.5% [760 of 970] vs. 55.7% [651 of 1,169], P < 0.001) and burnout syndrome (24.3% [236 of 970] vs. 13.3% [156 of 1,169], P < 0.001) compared to those unlikely to leave. On multivariable analysis, perceived lack of support at work (odds ratio, 9.2; 95% CI, 7.0 to 12.1), and staffing shortages (odds ratio, 1.96; 95% CI, 1.57 to 2.43) were most strongly associated with high risk for burnout. Perceived lack of support at work (odds ratio, 6.3; 95% CI, 3.81 to 10.4) was the factor most strongly associated with burnout syndrome. CONCLUSIONS: Burnout is more prevalent in anesthesiology since early 2020, with workplace factors of perceived support and staffing being the predominant associated variables. Interventions focused on the drivers of burnout are needed to improve well-being among U.S. attending anesthesiologists.

Posterior capsule edema in adhesive capsulitis: comparison with established non-contrast MRI findings and multivariable analysis.

OBJECTIVES: To evaluate posterior glenohumeral capsule edema compared to other MRI findings in adhesive capsulitis (AC). METHODS: This study was approved by the local Institutional Review Board and it is HIPAA compliant. A retrospective search identified subjects who received fluoroscopically guided intra-articular corticosteroid injections for AC and had an MRI within 6 months prior to injection. The study group was compared with an age-, sex-, and side-matched control group who underwent the same procedures but did not have AC. MRIs were evaluated for edema of posterior capsule, anterior capsule, axillary pouch, coracohumeral ligament (CHL) and rotator interval (RI), thickness of axillary pouch and CHL, thickness of anterior capsule, RI and subcoracoid fat replacement, and teres minor atrophy and edema. Multivariable analysis was performed. RESULTS: A total of 57 subjects with AC and 57 matched controls were studied: mean age 52 ± 7 (range 31-71) years, 37 female and 20 male, 22 right and 35 left. Posterior capsule edema was more common in the AC group vs. control group (66.7 vs 17.5%, p < 0.001). Multivariable analysis showed posterior capsule edema, CHL edema, and axillary pouch (glenoid) thickness (optimum cutoff = 4 mm) were significant independent predictors of AC. Simplified analysis using these three variables had an area under the curve of 0.860 (95%CI: 0.792-0.928). With all three variables present, the sensitivity and specificity for AC were 32% and 98%, respectively. CONCLUSIONS: Posterior joint capsule edema may be helpful to confirm AC. Posterior capsule edema, CHL edema, and axillary pouch (glenoid) thickness produce a strong model for distinguishing AC from controls. CLINICAL RELEVANCE STATEMENT: Edema involving the posterior shoulder joint capsule is an imaging marker of capsulitis and is useful in differentiating patients with adhesive capsulitis from those without in conjunction with other proven MRI findings. KEY POINTS: • Posterior capsule edema has a sensitivity of 66.7% and a specificity of 82.5% for the detection of adhesive capsulitis. • Posterior capsule edema, coracohumeral ligament (CHL) edema, and axillary pouch (glenoid) thickness were significant independent predictors of adhesive capsulitis, and combining these variables together produces a very strong model for distinguishing cases from controls (AUC = 0.860). • Optimal cutoff values for CHL, axillary pouch (humeral), axillary pouch (glenoid), and axillary pouch (total) thickness were 2.5, 2.6, 4, and 6.3 mm, respectively.

To biopsy or not to biopsy: a retrospective review of presumed osteoid osteomas treated by radiofrequency ablation.

OBJECTIVE: First, to determine the frequency and spectrum of osteoid osteoma (OO)-mimicking lesions among presumed OO referred for radiofrequency ablation (RFA). Second, to compare patient sex and age, lesion location, and rates of primary treatment failure for OO based on histopathology results. MATERIALS AND METHODS: A retrospective review was performed of all first-time combined CT-guided biopsy/RFA for presumed OO at a single academic center between January 1990 and August 2023. Lesions were characterized as "biopsy-confirmed OO", "OO-mimicking", or "non-diagnostic" based on pathology results. Treatment failure was defined as residual or recurrent symptoms requiring follow-up surgery or procedural intervention. Variables of interest were compared between pathology groups using Kruskal-Wallis, Fisher's exact, and Wilcoxon rank sum tests. RESULTS: Of 643 included patients (median 18 years old, IQR: 13-24 years, 458 male), there were 445 (69.1%) biopsy-confirmed OO, 184 (28.6%) non-diagnostic lesions, and 15 (2.3%) OO-mimicking lesions. OO-mimicking lesions included chondroblastoma (n = 4), chondroma (n = 3), enchondroma (n = 2), non-ossifying fibroma (n = 2), Brodie's abscess (n = 1), eosinophilic granuloma (n = 1), fibrous dysplasia (n = 1), and unspecified carcinoma (n = 1). OO-mimicking lesions did not show male predominance (46.7% male) like biopsy-proven OO (74.1% male) (p = 0.033). Treatment failure occurred in 24 (5.4%) biopsy-confirmed OO, 8 (4.4%) non-diagnostic lesions, and 2 (13.3%) OO-mimicking lesions without a significant difference by overall biopsy result (p = 0.24) or pairwise group comparison. CONCLUSION: OO-mimicking pathology is infrequent, typically benign, but potentially malignant. OO-mimicking lesions do not exhibit male predominance. There was no significant difference in RFA treatment failure or lesion location among lesions with imaging appearances suggestive of OO. KEY POINTS: Question What is the frequency and spectrum of OO-mimicking lesions among presumed OO and what, if any, differences exist between these pathologies? Finding The study cohort included 69.1% OO, 28.6% lesions with non-diagnostic histopathology, and 2.3% OO-mimicking lesions. There was no difference in treatment failure or location among lesions. Clinical relevance Routine biopsy of presumed OO at the time of RFA identifies OO-mimicking lesions, which are rare and likely benign.

Disadvantaged Neighborhoods Continue to Bear the Burden of Gun Violence.

INTRODUCTION: Gun violence is a pervasive and dynamic public health crisis causing substantial burden on communities and healthcare systems in the United States. Risk factor and outcome analyses are crucial to develop effective interventions. The aim of this study was to assess firearm injury in a diverse community setting as it relates to neighborhood socioeconomic disadvantage and changes over time following large-scale local interventions. METHODS: All county residents with firearm injury presenting to a Level 1 Trauma Center from January 2012 to December 2021 were retrospectively reviewed. Area Deprivation Index (ADI) was used to measure neighborhood socioeconomic disadvantage based on a nine-digit zip code at patients' home address. Injuries were also stratified by 5-year time periods, 2012-2016 and 2017-2021. Demographics and clinical data were analyzed including injury severity, hospital course, and discharge location. Data were compared by ADI quintile and between time periods using chi-squared, one-way analysis of variance, and Cochran-Armitage test. RESULTS: A total of 1044 injuries were evaluated. Patients were 93% male with mean age of 29 y (standard deviation 10.2) and were concentrated in the most disadvantaged neighborhoods (74% ADI Q5). Black or African American race was greater in the most disadvantaged ADI groups (76% versus 47%-66%; P <0.001). Percentage of total injuries in the most disadvantaged ADI group rose from 71% to 78% over time (P = 0.006). Mortality occurred in 154 (15%) patients overall, while most (71%) were discharged to home. Mortality declined from 18% to 11% over time (P <0.001). Medicaid utilization rose from 42% to 77% alongside a decrease in self-pay status from 44% to 4% (P <0.001). There were no clinically significant group differences in injury severity or clinical characteristics. CONCLUSIONS: Firearm injury remains concentrated in the most socioeconomically disadvantaged neighborhoods, and this disparity is increasing over time. Medicaid utilization rose and mortality decreased in this population over time. This research presents a method to inform and monitor local gun violence interventions using ADI to address public health equity.

Immediate extubation after pediatric liver transplantation: Update on a single-center experience.

PURPOSE: Immediate extubation (IE) following liver transplantation (LT) is increasingly common in adult patients. This study reviews our center's experience with IE in children following LT to determine characteristics predictive of successful IE and its effects on post-operative outcomes. METHODS: We performed a retrospective chart review of all patients who underwent LT at our institution between January 2005 and November 2022. Patients with concomitant lung transplants and chronic ventilator requirements were excluded. RESULTS: Overall, 235 patients met study criteria. IE was achieved in 164 (69.8%) patients across all diagnoses and graft types. Of IE patients, only two required re-intubation within 3 days post-transplant. IE patients exhibited significantly shorter ICU (2 [1, 3 IQR] vs. 4 [2, 4 IQR] days, p < .001) and hospital lengths of stay (17 [12, 24 IQR] vs. 22 [14, 42 IQR] days, p = .001). Pre-transplant ICU requirement, high PELD/MELD score, intraoperative transfusion, cold ischemia time, and pressor requirements were risk factors against IE. There was no association between IE and recipient age or weight. The proportion of patients undergoing IE post-transplant increased significantly over time from 2005 to 2022 (p < .001), underscoring the role of clinical experience and transplant team learning curve. CONCLUSION: Spanning 18 years and 235 patients, we report the largest cohort of children undergoing IE following LT. Our findings support that IE is safe across ages and clinical scenarios. As our center gained experience, the rate of IE increased from 40% to 83%. These trends were associated with lower ICU and LOS, the benefits of which include earlier patient mobility and improved resource utilization.

Factors associated with D-lactic acidosis in pediatric intestinal failure: A case-control study.

BACKGROUND: D-lactic acidosis (DLA) is a serious complication of short bowel syndrome (SBS) in children with intestinal failure (IF). Malabsorbed carbohydrates are metabolized by bacteria in the intestine to D-lactate which can lead to metabolic acidosis and neurologic symptoms. METHODS: A retrospective chart review was performed in children ≤18 years old with SBS who had one of the following criteria: unexplained metabolic acidosis, neurologic signs or symptoms, history of antibiotic therapy for small bowel bacterial overgrowth, or high clinical suspicion of DLA. Cases had serum D-lactate concentration >0.25 mmol/L; controls with concentrations ≤0.25 mmol/L. RESULTS: Of forty-six children, median age was 3.16 (interquartile range (IQR): 1.98, 5.82) years, and median residual bowel length was 40 (IQR: 25, 59) cm. There were 23 cases and 23 controls. Univariate analysis showed that cases had significantly lower median bicarbonate (19 vs. 24 mEq/L, p = 0.001), higher anion gap (17 vs. 14 mEq/L, p < 0.001) and were less likely to be receiving parenteral nutrition, compared with children without DLA. Multivariable analysis identified midgut volvulus, history of intestinal lengthening procedure, and anion gap as significant independent risk factors. Midgut volvulus was the strongest independent factor associated with DLA (adjusted odds ratio = 17.1, 95% CI: 2.21, 133, p = 0.007). CONCLUSION: DLA is an important complication of pediatric IF due to SBS. Patients with IF, particularly those with history of midgut volvulus, having undergone intestinal lengthening, or with anion gap acidosis, should be closely monitored for DLA.

Fetal Vertebral Chondrostasis-Significance of Excessive Cartilage in Vertebral Bodies of Newborns.

INTRODUCTION: We describe an abnormality in fetal and neonatal vertebral bodies whose most conspicuous characteristic is an increase in cartilaginous matrix within cancellous osseous trabeculae. We have termed this finding fetal chondrostasis (FC). METHODS: We initiated a retrospective review of autopsy reports in which this condition had been prospectively diagnosed during a 36-year period. The Chalkley point counting method was applied to histologic sections of vertebral bodies to assess the relative components of cartilage, bone, and bone marrow. The results were compared to those of three control groups whose causes of death were prematurity, birth trauma, and infection. RESULTS: We found that on average, the cartilaginous content in the FC group was considerably greater in both preterm and term infants when compared to controls. FC seemed to evolve from diminished activity in the cartilaginous growth zone resulting in formation of excessively broad cartilaginous columns. These subsequently suffered from delayed resorption following their incorporation within cancellous bony trabeculae. CONCLUSION: Excess cartilage within cancellous bone of vertebral centra in newborns is merely one aspect of disturbed intrauterine osseous development but is seemingly more readily discernible than other features at this site. The most common clinical correlates for FC were multiple congenital anomalies, congenital heart disease, intrauterine growth retardation, prematurity, and certain maternal factors.

Trends in Gender of Authors of Patient Blood Management Publications.

BACKGROUND: Diverse representation in the field of patient blood management (PBM) may help bring varying perspectives to improve patient care. We assessed trends in gender of first and last authorship of recent PBM publications to evaluate diversity within the field. METHODS: Publications from 10 high-impact anesthesiology and blood transfusion medicine journals between 2017 and 2021 were reviewed using 19 keywords to identify PBM-related articles. Each publication title was reviewed independently to determine whether it met the inclusion criteria. A software program was used to identify the gender of each first and last author for the most common first names. Author gender that could not be identified through this process was determined by querying institutional websites and professional social networks (eg, ResearchGate). Any publication where the gender of the first and/or last author could not be reliably determined was excluded from the analysis. Trends over time were assessed using the Cochran-Armitage test. RESULTS: A total of 2467 publications met the inclusion criteria of the 2873 yielded by the initial search. Gender of the first and last author was identified for 2384 of these publications and included in the final analysis. Approximately 42.8% of publications featured a woman as the first author with the highest from the journals such as the Journal of the American Medical Association ( JAMA ) (48.7%) and Transfusion (48.1%) and the lowest from the journals such as the British Journal of Anaesthesia (24.1%) and Anesthesia & Analgesia (24.4%). Approximately 32.0% of the publications featured a woman as the last author with the highest being Transfusion (36.9%) and Anaesthesia (31.8%) and the lowest being Anesthesia and Analgesia (18.3%) and Anesthesiology (18.6%). Approximately 57.6% of publications had either a woman as the first or last author while 16.3% of the publications had women as both the first and last authors. Women authors comprised 32.6% of the publications with a single author. Women as the first or last authors did not change significantly over the study period ( P = .115 and P = .119, respectively). No significant difference was observed in the percentage of PBM articles with a woman as the first or last author, a woman as the first and last author, or a woman as a single author from 2017 to 2021 ( P = .089, P = .055, and P = .226, respectively). CONCLUSIONS: The percentage of women as the first and last authors in PBM publications from the 5-year period of 2017 to 2021 was <50%. Gender equity in PBM authorship was identified as an area for potential future improvement. International mentorship and sponsorship of women remain important in promoting gender equity in PBM authorship.

Central Arterial Line Placement for Pediatric Cardiac Surgery: A Single-Center Experience.

BACKGROUND: Peripheral arterial line placement is a common, low-risk procedure in pediatric patients undergoing cardiac surgery. Central arterial cannulation may be used when peripheral cannulation is not feasible. At present, there are limited data to guide central arterial-line site selection in pediatric patients. We aimed to (1) quantify the rate of complications associated with central arterial-line placement in pediatric patients undergoing cardiac surgery, (2) determine risk factors associated with central arterial-line complications, and (3) describe placement trends during the last decade. METHODS: This was a retrospective, single-center cohort study of pediatric patients who underwent intraoperative placement of an axillary or femoral arterial line for cardiac surgery between July 1, 2012 and June 30, 2022. The primary outcome studied was the incidence of complications, defined as vascular compromise, pulse loss, ultrasound-confirmed thrombus or flow abnormality, and/or positive blood cultures not attributable to another source. Patients' characteristics and perioperative factors were analyzed using univariate and multivariate analysis to examine the relationship between these factors and line-associated complications. RESULTS: A total of 1263 central arterial lines were analyzed-195 axillary arterial lines and 1068 femoral arterial lines. The overall incidences of vascular compromise and pulse loss from central arterial-line placement were 17.8% and 8.3%, respectively. Axillary lines had lower rates of vascular compromise (6.2% vs 19.9%, P < .001), pulse loss (2.1% vs 9.5%, P < .001), and ultrasound-confirmed thrombus of flow abnormalities (14.3% vs 81.1%, P = .001) than femoral lines. Complications were more common in neonates and infants. By multivariate logistic regression, femoral location (odds ratio [OR], 4.16, 95% confidence interval [CI], 1.97-8.78), presence of a genetic syndrome (OR, 1.68, 95% CI, 1.21-2.34), prematurity (OR, 1.48, 95% CI, 1.02-2.15), and anesthesia time (OR, 1.17 per hour, 95% CI, 1.07-1.27 per hour) were identified as independent risk factors for vascular compromise. Femoral location (OR, 7.43, 95% CI, 2.08-26.6), presence of a genetic syndrome (OR, 1.86, 95% CI, 1.18-2.93), prematurity (OR, 1.65, 95% CI, 1.02-2.67), and 22-G catheter size (OR, 3.26, 95% CI, 1.16-9.15) were identified as independent risk factors for pulse loss. CONCLUSIONS: Axillary arterial access is associated with a lower rate of complications in pediatric patients undergoing cardiac surgery as compared to femoral arterial access. Serious complications are rare and were limited to femoral arterial lines in this study.

Awake Supraglottic Airway Placement in Pediatric Patients for Airway Obstruction or Difficult Intubation: Insights From an International Airway Registry (PeDI).

BACKGROUND: Small case series have described awake supraglottic airway placement in infants with significant airway obstruction and difficult intubations. We conducted this study to determine outcomes when supraglottic airways were placed in awake children enrolled in the international Pediatric Difficult Intubation Registry including success of ventilation, success of tracheal intubation, and complications. METHODS: We reviewed the Pediatric Difficult Intubation Registry to identify all cases of awake supraglottic airway placement before planned tracheal intubation from August 2012 to September 2023 with subsequent review of details of awake supraglottic airway placement in the medical record. We present descriptive statistics of patient demographics, ventilation and intubation outcomes, and complications. RESULTS: A supraglottic airway was placed in an awake child in 95 of 8061 (1.2%) cases in the Pediatric Difficult Intubation Registry. Median age was 37 days (range 0-17.6 years) and median weight was 3.7 kg (1.6-46.7 kg). Sixteen (17%) cases were in patients older than 2 years and 7 (7%) were in adolescents. Adequate ventilation via a supraglottic airway was achieved in 81/95 (85%, 95% confidence interval [CI], 77%-93%) encounters. Inadequate (n = 13) or impossible (n = 1) ventilation occurred in 14/95 (15%). No complications were reported with supraglottic airway placement. For subsequent intubation, there was a 35% (33/95) first-attempt success rate and 99% (94/95) eventual success, with 1 patient awakened after failed attempts at tracheal intubation. Hypoxia occurred during the first intubation attempt in 9/95 (9%) encounters. The incidence of hypoxia was lower in encounters in which ventilation via the supraglottic airway was adequate (4/81, 5%) than in encounters in which ventilation via the supraglottic airway was inadequate or impossible (5/14, 36%). CONCLUSIONS: Although infrequently attempted, awake placement of a supraglottic airway in children with difficult airways achieved adequate ventilation and provided a conduit for oxygenation and ventilation after induction of anesthesia across a spectrum of ages.

Management Changes After Echocardiography Are Associated With Improved Outcomes in Critically Ill Children.

OBJECTIVES: To evaluate management changes and outcomes in critically ill children after formal echocardiography. DESIGN: Retrospective cohort study between January 1, 2011, and December 31, 2020. SETTING: Tertiary care children's hospital. PATIENTS: Patients from 1 to 18 years who had formal echocardiography within 72 hours of ICU admission and who were intubated and on vasoactive infusions at the time of the study. Patients were stratified into two cardiac function groups: 1) near-normal cardiac function and 2) depressed cardiac function. METHODS: Clinical variables were abstracted from the electronic medical record and placed in time sequence relative to echocardiography. Vasoactive and fluid management strategies in place before echocardiography were associated with markers of tissue perfusion and volume overload. Management changes after echocardiography were characterized and associated with outcomes. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among patients eventually found to have depressed cardiac function, the use of vasoconstrictors was associated with worse lactate clearance and oxygen extraction ratio. Use of vasoconstrictors in this cohort was also associated with a more liberal fluid management strategy, evidence of increased lung water, and a worse Sp o2 /F io2 . An echocardiogram demonstrated depressed cardiac function was likely to be followed by management changes that favored inotropes and more conservative fluid administration. Patients with depressed cardiac function who were switched to inotropes were more likely to be extubated and to wean off vasoactive support compared with those patients who remained on vasoconstrictors. CONCLUSIONS: Among patients with depressed cardiac function, alterations in management strategy after echocardiography are associated with shortened duration of intensive care interventions.

Pediatric Burn Care for Burn Injury: Outcomes by Timing of Referral Using a U.S. Single-Center Retrospective Cohort, 2005-2019.

OBJECTIVES: Burn centers offer specialized care to pediatric patients with burn injuries. However, data about outcome in relation to timing of transfer are limited. We examined these timings and outcomes among burn-injured pediatric patients. DESIGN: Single-center, retrospective cohort study of U.S. national and international practice. SETTING: Shriners ESO Trauma Burn Registry, 2005-2019. PATIENTS: Patients 0-17 years old admitted to a pediatric burn center with 10-80% total body surface area (TBSA) burn between 2005 and 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The cohort of 761 patients was subcategorized according to timing of referral: early presentation (EP) (0-7 d), delayed presentation (DP) (8-60 d), and very delayed presentation (VDP) (> 60 d). Primary outcomes included hospital length of stay (LOS), ICU LOS, percent TBSA (%TBSA)/LOS ratio, mortality, and disposition. Dichotomous outcomes were analyzed using logistic regression and continuous outcomes were compared using median regression, both utilizing multivariable analysis adjusting for a priori confounders and presented as adjusted coefficients (ACs) with 95% CI. Delayed referral (DP and VDP) was associated with higher %TBSA burn and with fewer referrals from high-income countries. Compared with EP, VDP was associated with higher LOS/%TBSA (AC, 0.2 [0.01-0.4]). On univariate analysis, in comparison with EP, DP and VDP were associated with higher ICU (DP 16 [6-29]; VDP 8 [0-18]) and hospital LOS (DP 34 [21-55]; VDP 32 [18-58]). Overall, ten of 761 patients died (1.3%), and we found no association between timing of referral and mortality. Also, in 751 survivors, 635 patients (84.6%) were discharged home without home health, and we found no association with timing of referral on multivariable analysis. CONCLUSIONS: In this report, we have reviewed our single-center, international burn-injured pediatric cohort, operating in the United States (2005-2019). We find that referral with VDP as opposed to EP was associated with increased LOS/%TBSA.

Outcomes for Pediatric Oncology and Hematopoietic Stem Cell Transplantation Patients Who Undergo Tracheostomy Placement: A Pediatric Health Information System Database Cohort Study, 2009-2020.

OBJECTIVES: To describe the epidemiology, surgical complications, and long-term outcomes after tracheostomy in pediatric oncology and/or hematopoietic stem cell transplantation (HSCT) patients in U.S. Children's Hospitals. DESIGN: Retrospective cohort from the Pediatric Health information System (PHIS) database, 2009-2020. SETTING: The PHIS dataset incorporates data from 48 pediatric hospitals in the Children's Hospital Association. PATIENTS: Patients 0-21 years old with an oncologic diagnosis and/or underwent HSCT, received a tracheostomy, and were discharged from hospital between January 1, 2009, and December 31, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 1061 patients included in the dataset, and 217 (20.5%) had undergone HSCT. The annual prevalence in tracheostomy usage did not change over the study period. The majority of patients (62.2%) underwent tracheostomy early (< 30 d) in the admission and those who underwent the procedure later (> 90 d) had a significant increase in mortality (52.6% vs. 17.6%; p < 0.001) and mechanical ventilation (MV) at discharge (51.9% vs. 24.5%; p < 0.001) compared with the early tracheostomy patients. Complications reported included tracheostomy site bleeding (< 1%) and infection (24%). The overall rate of MV at discharge was 32.6% and significantly associated with chronic lung (adjusted odds ratio [OR], 1.54; 95% CI, 1.03-2.32) and acute lung disease (OR, 2.18; 95% CI, 1.19-3.98). The overall rate of mortality was 19.6% within the cohort and significantly associated with HSCT (OR, 5.45; 95% CI, 3.88-7.70), diagnosis of sepsis (OR, 2.09; 95% CI, 1.28-3.41), and requirement for renal replacement therapy (OR, 2.76; 95% CI, 1.58-4,83). CONCLUSIONS: This study demonstrated a static prevalence of tracheostomy placement in the cohort population relative to the increasing trends in other reported groups. Regardless of underlying diagnosis, the study patients incurred substantial morbidity and mortality. However, tracheostomy specific complication rates were comparable with that of the general pediatric population and were not associated with increased odds of mortality within this population.

Difficult intubation in syndromic versus nonsyndromic forms of micrognathia in children.

BACKGROUND: We investigated how syndromic versus nonsyndromic forms of micrognathia impacted difficult intubation outcomes in children. Primary outcome was the first-attempt success rate of tracheal intubation, secondary outcomes were number of intubation attempts and complications. We hypothesized that syndromic micrognathia would be associated with lower first-attempt success rate. METHODS: In micrognathic patients enrolled in the Pediatric Difficult Intubation Registry (08/2012-03/2019) we retrospectively compared demographic and clinical characteristics between children with nonsyndromic and syndromic micrognathia using standardized mean differences (SMD) and assessed the association of the presence of syndrome with the primary and secondary outcomes using propensity score matching analysis with and without matching for airway assessment findings. RESULTS: Nonsyndromic patients (628) were less likely to have additional airway abnormalities. Syndromic patients (216) were less likely to have unanticipated difficult intubation (2% vs. 20%, SMD 0.59). First-attempt success rates of intubation were: 38% in the syndromic versus 34% in the nonsyndromic group (odds ratio [OR] 1.18; 95% confidence intervals [95% CI] 0.74, 1.89; p = .478), and 37% versus 37% (OR 0.99; 95% CI 0.66, 1.48; p = .959). Median number of intubation attempts were 2 (interquartile range [IQR]: 1, 3; range: 1, 8) versus 2 (IQR: 1, 3; range 1, 12) (median regression coefficient = 0; 95% CI: -0.7, 0.7; p = .999) and 2 (IQR: 1, 3; range: 1, 12) versus 2 (IQR: 1, 3; range 1, 8) (median regression coefficient = 0; 95% CI: -0.5, 0.5; p = .999). Complication rates were 14% versus 22% (OR 0.6; 95% CI 0.34, 1.04; p = .07) and 16% versus 21% (OR 0.71; 95% CI 0.43, 1.17; p = .185). CONCLUSIONS: Presence of syndrome was not associated with lower first-attempt success rate on intubation, number of intubation attempts, or complication rate among micrognathic patients difficult to intubate, despite more associated craniofacial abnormalities. Nonsyndromic patients were more likely to have unanticipated difficult intubations, first attempt with direct laryngoscopy.

Correlation of Transthoracic Echocardiographic Estimates of Right Ventricular Pressure with Right Ventricular Pressure Measurements on Cardiac Catheterization in Children with Pulmonary Hypertension.

OBJECTIVES: Evaluate the correlation of non-invasive echocardiographic estimates of right ventricular systolic pressure with measurements on cardiac catheterization in children with pulmonary hypertension. DESIGN: Retrospective chart review. SETTING: Quaternary academic children's hospital. PARTICIPANTS: Patients younger than 18 years with a diagnosis of pulmonary hypertension and confirmatory cardiac catheterization from 2015 to 2018. MEASUREMENTS AND MAIN RESULTS: We analyzed the correlation between measures of right ventricular systolic pressure using nonparametric Spearman rho (ρ) with statistical significance set at p < 0.05. RESULTS: Children (N = 111) with biventricular circulation, strictly defined pulmonary hypertension, and adequate tricuspid regurgitation on echocardiogram to estimate right ventricular systolic pressure using the modified Bernoulli equation. Median age and weight were 4.3 years and 14.4 kg. Median right ventricular systolic pressure estimated by tricuspid regurgitant velocity on echocardiography was 55 mmHg (IQR 45-75 mmHg) plus right atrial pressure. On cardiac catheterization, median right ventricular systolic pressure was 57 mmHg (IQR 46-75 mmHg). Echocardiographic estimates of right ventricular systolic pressure were moderately well correlated with right ventricular systolic pressure directly measured on catheterization (ρ = 0.44, 95% CI 0.27-0.6, p < 0.001) with a median difference of 4 mmHg (IQR -10 to 17). Subgroup analysis revealed that echocardiography and catheterization measurements correlated well in children with suprasystemic right ventricular pressure on cardiac catheterization (ρ = 0.75, 95% CI 0.51-0.99, p < 0.001) although catheterization measurements were a median of 26 mmHg (IQR 12-31) higher than echocardiographic estimates in this subgroup. CONCLUSIONS: In children with pulmonary hypertension, echocardiographic estimates of right ventricular pressure correlated moderately well with gold standard measurements by cardiac catheterization with stronger correlation in children with suprasystemic right ventricular pressures. This is reassuring for clinicians who must rely on echocardiography for risk stratification before anesthetizing children with pulmonary hypertension.

Organizational learning in surgery in Tanzania's health system: a descriptive cross-sectional study.

Organizational learning is critical for delivering safe, high-quality surgical care, especially in low- and middle-income countries (LMICs) where perioperative outcomes remain poor. While current investments in LMICs prioritize physical infrastructure, equipment, and staffing, investments in organizational learning are equally important to support innovation, creativity, and continuous improvement of surgical quality. This study aims to assess the extent to which health facilities in Tanzania's Lake Zone perform as learning organizations from the perspectives of surgical providers. The insights gained from this study can motivate future quality improvement initiatives and investments to improve surgical outcomes. We conducted a cross-sectional analysis using data from an adapted survey to explore the key components of organizational learning, including a supportive learning environment, effective learning processes, and encouraging leadership. Our sample included surgical team members and leaders at 20 facilities (health centers, district hospitals, and regional hospitals). We calculated the average of the responses at individual facilities. Responses that were 5+ on a 7-point scale or 4+ on a 5-point scale were considered positive. We examined the variation in responses by facility characteristics using a one-way ANOVA or Student's t-test. We used univariate and multiple regression to assess relationships between facility characteristics and perceptions of organizational learning. Ninety-eight surgical providers and leaders participated in the survey. The mean facility positive response rate was 95.1% (SD 6.1%). Time for reflection was the least favorable domain with a score of 62.5% (SD 35.8%). There was variation by facility characteristics including differences in time for reflection when comparing by level of care (P = .02) and location (P = .01), and differences in trying new approaches (P = .008), capacity building (P = .008), and information transfer (P = .01) when comparing public versus faith-based facilities. In multivariable analysis, suburban centers had less time for reflection than urban facilities (adjusted difference = -0.48; 95% CI: -0.95, -0.01; P = .046). Surgical team members reported more positive responses compared to surgical team leaders. We found a high overall positive response rate in characterizing organizational learning in surgery in 20 health facilities in Tanzania's Lake Zone. Our findings identify areas for improvement and provide a baseline for assessing the effectiveness of change initiatives. Future research should focus on validating the adapted survey and exploring the impact of strong learning environments on surgical outcomes in LMICs. Organizational learning is crucial in surgery and further research, funding, and policy work should be dedicated to improving learning cultures in health facilities.

Elongated morphology of osteoid osteoma is associated with radiofrequency ablation failure in children.

OBJECTIVE: To compare the frequency of elongated morphology of osteoid osteoma (OO) in children compared to adolescents and to determine if this elongated morphology is associated with radiofrequency ablation treatment failure. MATERIALS AND METHODS: Retrospective review of first-time CT-guided radiofrequency ablation performed for presumed OO in patients < 21 years old between 1990 and 2023. Children were considered 0 to 10 years old, and adolescents were considered 11 to 20 years old. Treatment failure was considered symptomatic recurrence requiring follow-up intervention. The largest tumor dimensions in three orthogonal planes were measured using multiplanar reformatted technology. Maximum tumor dimension, tumor volume, and eccentricity index were calculated. Elongated morphology criteria were (a) largest dimension > 10 mm and (b) eccentricity index ≥ 3. Lesion locations were recorded. Statistical analyses included the chi-square test, Fisher's exact test, nonparametric Wilcoxon rank-sum test, receiver operating characteristic analysis, and Spearman's nonparametric rank correlation. RESULTS: Of 366 included patients (median 15 years, IQR 11-18 years, 254 male), there were 86 (23.5%) children, 280 (76.5%) adolescents, and 24 (6.6%) cases of treatment failure. Elongated morphology was more common in children (19.7%) than adolescents (8.6%) (p = 0.004) and associated with younger age (p = 0.009). Elongated morphology was associated with treatment failure in children (p = 0.045) but not adolescents (p > .99) or all patients (p = 0.17). Treatment failure was not associated with age, largest dimension, eccentricity index, volume, or location. CONCLUSION: Elongated morphology of OO is associated with younger age and radiofrequency ablation treatment failure in children. Identifying this morphology may assist with counseling and treatment planning.