Still Separate, Still Not Equal: An Ecological Examination of Redlining and Racial Segregation with COVID-19 Vaccination Administration in Washington D.C.

Racial residential segregation has been deemed a fundamental cause of health inequities. It is a result of historical and contemporary policies such as redlining that have created a geographic separation of races and corresponds with an inequitable distribution of health-promoting resources. Redlining and racial residential segregation may have contributed to racial inequities in COVID-19 vaccine administration in the early stages of public accessibility. We use data from the National Archives (historical redlining), Home Mortgage Disclosure Act (contemporary redlining), American Community Survey from 1940 (historical racial residential segregation) and 2015-2019 (contemporary racial residential segregation), and Washington D.C. government (COVID-19 vaccination administration) to assess the relationships between redlining, racial residential segregation, and COVID-19 vaccine administration during the early stages of vaccine distribution when a tiered system was in place due to limited supply. Pearson correlation was used to assess whether redlining and racial segregation, measured both historically and contemporarily, were correlated with each other in Washington D.C. Subsequently, linear regression was used to assess whether each of these measures associate with COVID-19 vaccine administration. In both historical and contemporary analyses, there was a positive correlation between redlining and racial residential segregation. Further, redlining and racial residential segregation were each positively associated with administration of the novel COVID-19 vaccine. This study highlights the ongoing ways in which redlining and segregation contribute to racial health inequities. Eliminating racial health inequities in American society requires addressing the root causes that affect access to health-promoting resources.

Sexual and reproductive health education for patients with myelomeningocele.

AIM: To evaluate the sexual and reproductive health education received by patients with myelomeningocele, the most severe form of spina bifida. METHOD: A survey designed to assess the sexual and reproductive health education given by a healthcare provider to patients with myelomeningocele was offered to all English-speaking patients aged 12 years or older with a myelomeningocele clinic visit. RESULTS: In total, 67 surveys were completed. Menstruation and menstrual management were discussed at a rate of 85% in females. Few patients had discussions with a provider about fertility (42%), sexuality (37%), risk of sexually transmitted infections (45%), or had a relationship with a reproductive healthcare provider (54%). Differences by sex were observed for contraceptive education. The rate of discussions increased with age. A total of 67% of female patients and 33% of male patients requested a referral to a reproductive healthcare provider. INTERPRETATION: Sexual and reproductive health education is part of comprehensive care for all patients and those with disabilities should not be excluded. The lack of consistent education received by patients supports the need for increased attention to this topic. We encourage multidisciplinary myelomeningocele clinics to establish a process for delivering complete and patient-specific sexual and reproductive health education.

Social Determinants of Health Are Associated With Visits for Ambulatory Care Sensitive Conditions.

OBJECTIVES: Population health experts have described the link between social factors and health, but few studies link specific social needs to disease processes. Nationwide Children's Hospital implemented a universal, annual screener for social determinants of health (SDH) in 2018. Early analyses have shown that patients identifying an SDH need were more likely to have an emergency department (ED) or inpatient stay. The objective of this study is to identify links between SDH and ED presentation for ambulatory care sensitive conditions (ACSCs). METHODS: This was a retrospective observational study of children aged 0-21 years receiving care at Nationwide Children's Hospital from 2018 to 2021 that were screened for SDH. Acute care utilization within 6 months of screener completion, sociodemographic, and clinical data were collected via EPIC data extraction. Patients that completed screening tool for the first time in the ED were excluded to minimize selection bias. Logistic regression was used to analyze the association between ED presentation for ACSCs and SDH needs. RESULTS: A total of 108,346 social determinants screeners were included with 9% of screeners identifying a need. Five percent of the population expressed food needs, 4% transportation needs, 3% utility needs, and 1% housing needs. Eighteen percent of patients had an ED visit for ACSC, with the most common complaints being upper respiratory infections and asthma. Having any SDH need was associated with ED visits for ACSCs (odds ratio, 1.12; 95% confidence interval, 1.06-1.18). Needs in all domains were significantly associated with increased visits for ACSCs; however, patients with housing needs had the highest odds of utilization (odds ratio, 1.25; confidence interval, 1.11-1.41). CONCLUSIONS: The odds of ED presentation for ACSCs are higher in patients with expressed social needs. Further delineating the connections between specific SDH and health outcomes can inform timely and appropriate interventions.

Characterizing Pediatric Familial Adenomatous Polyposis in Patients Undergoing Colectomy in the United States.

OBJECTIVE: To characterize a multi-institutional cohort of pediatric patients who underwent colectomy for familial adenomatous polyposis (FAP). STUDY DESIGN: In this retrospective cohort study, diagnosis and procedure codes were used to identify patients who underwent colectomy for FAP within the Pediatric Health Information System (PHIS). The inclusion criteria were validated at 3 children's hospitals and applied to PHIS to generate a cohort of patients with FAP between 2 and 21 years who had undergone colectomy between 2009 and 2019. Demographics, clinical and surgical characteristics, and endoscopic procedure trends as identified through PHIS are described. Descriptive and comparative statistics were used to analyze data. RESULTS: Within the PHIS, 428 pediatric patients with FAP who underwent colectomy were identified. Median age at colectomy was 14 years (range 2-21 years); 264 patients (62%) received an ileal pouch anal anastomosis and 13 (3%) underwent ileorectal anastomosis. Specific anastomotic surgical procedure codes were not reported for 151 patients (35%). Endoscopic assessment at the surgical institution occurred in 40% of the cohort before colectomy and in 22% of the cohort following colectomy. CONCLUSIONS: In this cohort, colectomy took place at an earlier age than suggested in published guidelines. Ileal pouch anal anastomosis is the predominant procedure for pediatric patients with FAP who underwent colectomy in US pediatric centers. Endoscopic assessment trends before and after surgery suggest that the surgical institution plays a limited role in the care of this population.

Implementation of a Level 1 Neuro Trauma Activation at a Tertiary Pediatric Trauma Center.

INTRODUCTION: Timely management improves outcomes in patients with traumatic brain injury (TBI), especially those requiring operative intervention. We implemented a "Level 1 Neuro" (L1N) trauma activation for severe TBI, aiming to decrease times to intervention. METHODS: We evaluated whether an L1N activation was associated with shorter times to operating room (OR) incision and pediatric intensive care unit (PICU) admission using multivariable regression models. Trauma patients with severe TBI undergoing operative intervention or PICU admission from January 2008-October 2020 met inclusion. The L1N cohort included patients meeting our institution's L1N criteria. The L1 and L2 cohorts included head injury patients with hAIS ≥3 and an L1 or L2 activation, respectively. RESULTS: Median hAIS, GCS, Rotterdam CT score, and ISS were 4.5 (4-5), 8 (3-15), 2 (1-3), and 17 (11-26), respectively. We demonstrate clinically shorter times to OR incision among L1N traumas (93.3 min) compared to L1 (106.7 min; P = 0.73) and L2 cohorts (133.5 min; P = 0.03). We also demonstrate clinically shorter times to anesthesia among L1N traumas (51.9 min) compared to L1 (70.1 min; P = 0.13) and L2 cohorts (101.3 min; P < 0.01). Median GCS, ISS and hAIS in the PICU patients were 10 (IQR:3-15), 17 (11-26), and 4 (3-4), respectively. We demonstrate clinically shorter times to PICU among L1N traumas (82.1 min) and the L2 cohort (154.7 min; P < 0.01). CONCLUSIONS: An L1N activation is associated with shorter times to anesthesia and OR management. Enhancing communication with standardized neurotrauma activation has the potential to improve timeliness of care in severe pediatric TBI.

Disparities in the Management of Pediatric Breast Masses.

INTRODUCTION: Disparities in surgical management have been documented across a range of disease processes. The objective of this study was to investigate sociodemographic disparities in young females undergoing excision of a breast mass. METHODS: A retrospective study of females aged 10-21 y who underwent surgery for a breast lesion across eleven pediatric hospitals from 2011 to 2016 was performed. Differences in patient characteristics, workup, management, and pathology by race/ethnicity, insurance status, median neighborhood income, and urbanicity were evaluated with bivariate and multivariable regression analyses. RESULTS: A total of 454 females were included, with a median age of 16 y interquartile range (IQR: 3). 44% of patients were nonHispanic (NH) Black, 40% were NH White, and 7% were Hispanic. 50% of patients had private insurance, 39% had public insurance, and 9% had other/unknown insurance status. Median neighborhood income was $49,974, and 88% of patients resided in a metropolitan area. NH Whites have 4.5 times the odds of undergoing preoperative fine needle aspiration or core needle biopsy compared to NH Blacks (CI: 2.0, 10.0). No differences in time to surgery from the initial imaging study, size of the lesion, or pathology were observed on multivariable analysis. CONCLUSIONS: We found no significant differences by race/ethnicity, insurance status, household income, or urbanicity in the time to surgery after the initial imaging study. The only significant disparity noted on multivariable analysis was NH White patients were more likely to undergo preoperative biopsy than were NH Black patients; however, the utility of biopsy in pediatric breast masses is not well established.

Characteristics Associated with Homeless Pregnant Women in Columbus, Ohio.

INTRODUCTION: The effects of homelessness on pregnant women are substantial. We aim to identify key characteristics of a group of women identified as homeless and pregnant in order to understand their history of housing, family composition, health, and demographics as a first step for future intervention. METHODS: We present cross-sectional survey data on a sample of 100 women reporting homelessness and pregnancy in the prior year in Columbus, Ohio, identified through social service and housing not for profit agencies. Our analysis uses data collected from a survey of health behaviors, housing, employment status, and demographics. Continuous measures are described with means and standard deviations, and categorical variables are described with percentages. RESULTS: The majority (81%) of the women identified as African American. Over 95% of the women were single, and 74 women reported a prior pregnancy. Almost half of the women reported being behind on rent at least one time in the last 6 months, and 43% indicated that they had lived in more than three places in the last year. Approximately 34% of the sample reported cigarette use during pregnancy, while 12% and 30% reported alcohol and illicit drug use, respectively. DISCUSSION: Women who were pregnant and experiencing homelessness in our study reported a multitude of complex and severe problems ranging from high rates of substance use, longstanding housing insecurity and financial stress. Programs hoping to successfully support women will need to address a variety of service needs while recognizing the resilience of many women.

Computational Fluid Dynamic Modeling Reveals Nonlinear Airway Stress during Trachea Development.

Normative trachea dimensions and aerodynamic information during development was collected to establish clinical benchmarks and showed that airway development seems to outpace respiratory demands. Infants and toddlers' trachea exhibit higher aerodynamic stress that significantly decreases by teenage years. This implies large airway pathology in younger children may have a more substantial clinical impact.

Management of Pediatric Breast Masses: A Multi-institutional Retrospective Cohort Study.

BACKGROUND: The objective of our study was to describe the workup, management, and outcomes of pediatric patients with breast masses undergoing operative intervention. MATERIALS AND METHODS: A retrospective cohort study was conducted of girls 10-21 y of age who underwent surgery for a breast mass across 11 children's hospitals from 2011 to 2016. Demographic and clinical characteristics were summarized. RESULTS: Four hundred and fifty-three female patients with a median age of 16 y (IQR: 3) underwent surgery for a breast mass during the study period. The most common preoperative imaging was breast ultrasound (95%); 28% reported the Breast Imaging Reporting and Data System (BI-RADS) classification. Preoperative core biopsy was performed in 12%. All patients underwent lumpectomy, most commonly due to mass size (45%) or growth (29%). The median maximum dimension of a mass on preoperative ultrasound was 2.8 cm (IQR: 1.9). Most operations were performed by pediatric surgeons (65%) and breast surgeons (25%). The most frequent pathology was fibroadenoma (75%); 3% were phyllodes. BI-RADS scoring ≥4 on breast ultrasound had a sensitivity of 0% and a negative predictive value of 93% for identifying phyllodes tumors. CONCLUSIONS: Most pediatric breast masses are self-identified and benign. BI-RADS classification based on ultrasound was not consistently assigned and had little clinical utility for identifying phyllodes.

Factors Associated with Torsion in Pediatric Patients with Ovarian Masses.

BACKGROUND: Management of ovarian torsion has evolved toward ovarian preservation regardless of ovarian appearance during surgery. However, patients with torsion and an ovarian neoplasm undergo a disproportionately high rate of oophorectomy. Our objectives were to identify factors associated with ovarian torsion among females with an ovarian mass and to determine if torsion is associated with malignancy. METHODS: A retrospective review of females aged 2-21 y who underwent an operation for an ovarian cyst or neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariate logistic regression was used to assess factors associated with torsion. Imaging data were assessed for sensitivity, specificity, and predictive value in identifying ovarian torsion. RESULTS: Of 814 girls with an ovarian neoplasm, 180 (22%) had torsion. In risk-adjusted analyses, patients with a younger age, mass size >5 cm, abdominal pain, and vomiting had an increased likelihood of torsion (P < 0.01 for all). Patients with a mass >5 cm had two times the odds of torsion (odds ratio: 2.1; confidence interval: 1.2, 3.6). Imaging was not reliable at identifying torsion (sensitivity 34%, positive predictive value 49%) or excluding torsion (specificity 72%, negative predictive value 87%). The rates of malignancy were lower in those with an ovarian mass and torsion than those without torsion (10% versus 17%, P = 0.01). Among the 180 girls with torsion and a mass, 48% underwent oophorectomy of which 14% (n = 12) had a malignancy. CONCLUSIONS: In females with an ovarian neoplasm, torsion is not associated with an increased risk of malignancy and ovarian preservation should be considered.

Comparison of Perioperative Outcomes and Parental Satisfaction Outcomes of Strip Craniectomy with Postoperative Helmet versus Spring-Mediated Remodeling in Sagittal Craniosynostosis.

INTRODUCTION: We sought to compare outcomes and parental satisfaction between 2 approaches for sagittal craniosynostosis: strip craniectomy with spring-mediated skull remodeling (SMSR) and strip craniectomy with postoperative helmet (SCH). METHODS: Perioperative and outcome data for SMSR or SCH patients between September 2010 and July 2019 were retrospectively reviewed. A telephone survey was administered to parents of children who underwent both procedures. RESULTS: A total of 62 children were treated for sagittal craniosynostosis by either SMSR (n = 45) or SCH (n = 17). The SCH group had a lower estimated blood loss (27 vs. 47.06 mL, p = 0.021) and age at surgery (13.0 vs. 19.8 weeks) than the SMSR group. Three patients underwent early springs removal due to trauma or dislodgement, all of whom converted to helmeting. Of the 62 children initially identified, 59 were determined to have an adequate follow-up time to assess long-term outcomes. The mean follow-up time was 30.1 months (n = 16) in the SCH group and 32.0 months in the SMSR group (n = 43, p = 0.39). Two patients in the SCH group and one in the SMSR group converted to open cranial vault reconstruction. Thirty parents agreed to respond to the satisfaction survey (8 SCH, 22 SMSR) based on a Likert scale of responses (0 being most dissatisfied possible, 4 most satisfied possible). Average satisfaction was 3.86/4.0 in the SCH group and 3.45/4.0 in the SMSR group. No parents in the SCH group would change to SMSR, while 3 of the 22 SMSR survey responders would have changed to SCH. CONCLUSIONS: Perioperative outcomes and average parental satisfaction were similar in both groups. Importance of helmet wear compliance and risk of spring dislodgement should be discussed with parents.

Racial, ethnic and language disparities in healthcare utilization in pediatric patients following tonsillectomy.

IMPORTANCE: Tonsillectomy is one of the most common surgical procedures performed in the United States. However, there is little known about the intersectionality of race, ethnicity, and language and how these factors influence post-tonsillectomy outcomes such as ED utilization and hospital readmission rates. OBJECTIVE: To examine disparities in emergency department (ED) utilization and hospital readmissions for post-tonsillectomy complications based on insurance status, patient race, ethnicity and language spoken. DESIGN: This was retrospective cohort over four years. SETTING: Tertiary Care Children's Hospital. PARTICIPANTS: All children (n = 10,215) who underwent tonsillectomy or adenotonsillectomy at a tertiary children's hospital from January 2015 to December 2018 were identified and included. There were no exclusion criteria. EXPOSURE: The exposure of interest was tonsillectomy. MAIN OUTCOMES AND MEASURES: Outcomes and variables of interest were defined prior to data collection. The primary outcome of this study was emergency department (ED) utilization defined as any ED or urgent care visit within 21 days of the tonsillectomy for surgery-related concerns. The secondary outcome of this study was readmissions following tonsillectomy. RESULTS: A total of 10215 pediatric patients (median age, 6 years; 5096 [50 %] male) who underwent tonsillectomy were included in the analysis. 13 % of patients presented to the ED with surgery-related complaints. Among English proficient patients, multi-racial patients were the only group with an elevated odds of ED utilization (OR:1.5, 95 % CI: 1.2, 1.9). Non-English language preference (NELP) patients of Black, Hispanic, Asian, and American Indian/Alaskan Native race/ethnicity also had elevated odds of ED use post-tonsillectomy compared to non-Hispanic White English proficient patients. Six percent of all patients had an unplanned hospital readmission. Asian patients with non-English language preference had 2.1 times the odds of readmission (95 % CI: 1.2, 3.6); and were disproportionately admitted for post-tonsillectomy hemorrhage. CONCLUSIONS: and Relevance: Language disparities in ED use and readmission persist after adjusting for risk factors. Non-English language preference populations have a higher rate of ED utilization, especially for minor complications. Disparities may result from differential health literacy or predispositions to complications. Future directions include additional research on mechanisms and targeted interventions to increase education and access to language-appropriate resources.

Does preoperative calcium and 1, 25 OH vitamin D supplementation impact postoperative hypocalcemia and length of stay following pediatric thyroidectomy?

OBJECTIVE: To investigate whether perioperative calcium and 1,25 OH vitamin D supplementation (PCDS) influences the rates of postoperative hypocalcemia and length of stay (LOS) following pediatric thyroidectomy. STUDY DESIGN: Retrospective Cohort Review. SETTING: Tertiary children's hospital. METHODS: 94 patients who underwent completion or total thyroidectomy with or without concomitant neck dissection from 2010 to 2020 at a single institution were included. Patients with pre-existing hypocalcemia or preoperative vitamin D insufficiency were excluded. Rates of postoperative hypocalcemia and LOS were compared for patients receiving PCDS to those receiving no supplementation. RESULTS: Thirty percent of patients with PCDS had documented postoperative hypocalcemia compared to 64% of patients without PCDS (p = 0.01). Patients with PCDS had a median LOS of 30 h compared to 36 h (p = 0.002). Multivariable analyses confirmed that patients with PCDS had lower odds of postoperative hypocalcemia (OR: 0.32, CI: 0.11, 0.89) and shorter LOS by 17 h (SE: 8, p = 0.04) after adjustment for confounders. CONCLUSION: PCDS is associated with significantly lower risk of hypocalcemia and shorter LOS. Standardizing preoperative care for pediatric patients undergoing thyroidectomy may decrease variability and improve outcomes following surgery.

Diagnostic Performance of Magnetic Resonance Imaging for Pediatric Ovarian Neoplasms: A Multi-Institutional Review.

STUDY OBJECTIVE: To assess the diagnostic performance of MRI to predict ovarian malignancy alone and compared with other diagnostic studies. METHODS: A retrospective analysis was conducted of patients aged 2-21 years who underwent ovarian mass resection between 2009 and 2021 at 11 pediatric hospitals. Sociodemographic information, clinical and imaging findings, tumor markers, and operative and pathology details were collected. Diagnostic performance for detecting malignancy was assessed by calculating sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for MRI with other diagnostic modalities. RESULTS: One thousand and fifty-three patients, with a median age of 14.6 years, underwent resection of an ovarian mass; 10% (110/1053) had malignant disease on pathology, and 13% (136/1053) underwent preoperative MRI. MRI sensitivity, specificity, PPV, and NPV were 60%, 94%, 60%, and 94%. Ultrasound sensitivity, specificity, PPV, and NPV were 31%, 99%, 73%, and 95%. Tumor marker sensitivity, specificity, PPV, and NPV were 90%, 46%, 22%, and 96%. MRI and ultrasound concordance was 88%, with sensitivity, specificity, PPV, and NPV of 33%, 99%, 75%, and 94%. MRI sensitivity in ultrasound-discordant cases was 100%. MRI and tumor marker concordance was 88% with sensitivity, specificity, PPV, and NPV of 100%, 86%, 64%, and 100%. MRI specificity in tumor marker-discordant cases was 100%. CONCLUSION: Diagnostic modalities used to assess ovarian neoplasms in pediatric patients typically agree. In cases of disagreement, MRI is more sensitive for malignancy than ultrasound and more specific than tumor markers. Selective use of MRI with preoperative ultrasound and tumor markers may be beneficial when the risk of malignancy is uncertain. CONCISE ABSTRACT: This retrospective review of 1053 patients aged 2-21 years who underwent ovarian mass resection between 2009 and 2021 at 11 pediatric hospitals found that ultrasound, tumor markers, and MRI tend to agree on benign vs malignant, but in cases of disagreement, MRI is more sensitive for malignancy than ultrasound.

Maternal infant bonding in tracheostomy dependent infants: A cross sectional study.

OBJECTIVES: To report the current state of maternal infant bonding (MIB) in mothers of tracheostomy-dependent infants and identify demographic factors associated with MIB. METHODS: A cross-sectional study was conducted at a pediatric tertiary care hospital. Mothers of tracheostomy-dependent children below the age of two, seen during the 24 months prior to June 2021, were recruited to participate. The exclusion criteria consisted of clinical instability of the infant at the time of recruitment or lack of custody. The Maternal Infant Bonding Questionnaire (MIBQ) was administered to biological mothers. The possible range of scores was 0-24 with higher scores indicating poorer bonding. Mean MIBQ scores, as well as elevated MIBQ scores (greater than 0), were evaluated with respect to patient demographic and clinical characteristics. RESULTS: Of 46 eligible participants, the response rate was 6 7% (n = 31). The median maternal age was 30 (IQR:8.5), and the median infant age was 15 months (IQR: 7.5). The mean MIBQ score in the tracheostomy-dependent infant population was 1.38 (SD: 1.96), and 45% had a score greater than 0. The mean MIBQ of our cohort was not statistically different from the control group of healthy infants. Elevated MIBQ scores signaling poorer bonding were seen in caregivers of infants with bronchopulmonary dysplasia and older caregivers. Preliminary evidence suggests that caregivers of infants with mechanical ventilation and neurologic comorbidities may have improved bonding compared to other tracheostomized infants. MIBQ scores were not associated with other sociodemographic or clinical characteristics, such as gestational age at birth, previous history of psychiatric illness, admission status or sociodemographic characteristics. CONCLUSION: We observe a mean MIBQ score of 1.38 in mothers of tracheostomy-dependent infants. Efforts to improve bonding may aid infant development and maternal affect.

Assessing the Relationship Between Infection Frequency and Risk of Post-Tonsillectomy Hemorrhage.

OBJECTIVE: To determine the relationship between frequency of tonsillitis and the risk of post-tonsillectomy hemorrhage (PTH) in pediatric patients undergoing tonsillectomy for recurrent tonsillitis. METHODS: After obtaining IRB approval from Nationwide Children's Hospital, charts for all patients who underwent a total tonsillectomy in 2017 for recurrent or chronic tonsillitis were retrospectively reviewed (n = 424). Patients were divided into 2 cohorts based on the frequency of tonsillitis prior to surgery: those meeting the 1-year criteria with 7 or more infections in the past year (n = 100), and those who did not meet criteria defined as those with fewer than 7 infections in the past year (n = 324). The primary outcome of interest was PTH. Comparison of cohorts and frequency of PTH were assessed using bivariate analyses. Kaplan-Meier curves were used to compare time to onset of hemorrhage between primary vs. secondary PTH. Generalized mixed and logistic regression models were used to evaluate risk of hemorrhage following tonsillectomy. RESULTS: Among a total cohort of 424 patients undergoing tonsillectomy, 23.58% (n = 100) met criteria while 76.42% (n = 324) did not. A total of 8.73% (n = 37) patients experienced PTH. Compared to those who did not meet criteria, those who met criteria had a higher odds of developing PTH; however, this was not significant (OR: 1.42 [95% CI: 0.67, 2.98], P = .3582). Estimated probability of developing PTH for those who met criteria was 11% [95% CI: 6.19, 18.81] compared to 8.03% [95% CI: 5.52, 11.54] for those who did not meet criteria. Among all PTH cases, 5.41% (n = 2) were primary hemorrhage while 94.59% (n = 35) were secondary hemorrhage with 50% of those with secondary PTH having experienced hemorrhage within 6 days [95% CI: 5, 7] of tonsillectomy. Patients with neuromuscular conditions had significantly higher odds of PTH (OR: 4.75 [95% CI: 1.19, 18.97], P = .0276). CONCLUSION: Patients who met the 1-year criteria for tonsillectomy did not have a significantly higher odds of PTH. Further research is needed to better evaluate the relationship between infection frequency and risk of PTH.

Association of Vibrotactile Biofeedback With Reduced Ergonomic Risk for Surgeons During Tonsillectomy.

Importance: Work-related musculoskeletal disorders are common among otolaryngologists and can be associated with decreased productivity, missed workdays, and reduced quality of life. Ergonomic risk for surgeons is elevated during common otolaryngology procedures; current ergonomic interventions lack the ability to provide real-time feedback. The ability to quantify and mitigate ergonomic risk during surgery may reduce work-related musculoskeletal disorders. Objective: To quantify the association of vibrotactile biofeedback with intraoperative ergonomic risk to surgeons during tonsillectomy. Design, Setting, and Participants: This cross-sectional study was conducted between June 2021 and October 2021 at a freestanding tertiary care children's hospital and included 11 attending pediatric otolaryngologists. Data analysis was conducted from August to October 2021. Interventions: Real-time quantification of ergonomic risk during tonsillectomy and the use of a vibrotactile biofeedback posture monitor. Main Outcomes and Measures: Association of vibrotactile biofeedback with objective measures of ergonomic risk. Assessment tools included the Rapid Upper Limb Assessment, craniovertebral angle, and time spent in an at-risk posture. Results: Eleven surgeons (mean [SD] age 42 [7] years; 2 women [18%]) performed 126 procedures with continuous posture monitoring in the presence (80 [63%]) and absence (46 [37%]) of vibrotactile biofeedback. No complications or delays associated with the device were reported. Intraoperative vibrotactile biofeedback was associated with improved Rapid Upper Limit Assessment neck, trunk, and leg scores by 0.15 (95% CI, 0.05-0.25), improved craniovertebral angle by 1.9 (95% CI, 0.32-3.40), and decreased overall time spent in an at-risk posture by 30% (95% CI, 22%-39%). Conclusions and Relevance: The results of this cross-sectional study suggest that use of a vibrotactile biofeedback device to quantify and mitigate ergonomic risk for surgeons is feasible and safe while performing surgery. Vibrotactile biofeedback was associated with reduced ergonomic risk during tonsillectomy and may have a role in improving surgical ergonomics and preventing work-related musculoskeletal disorders.

Recurrence Rates for Pediatric Benign Ovarian Neoplasms.

STUDY OBJECTIVE: To examine the recurrence rates of pediatric benign ovarian neoplasms METHODS: A retrospective review of females up to 21 years of age who underwent surgery for a benign ovarian neoplasm at 8 pediatric hospitals from January 2010 through December 2016 was conducted. Data include primary operation details, follow-up imaging, and reoperation details. RESULTS: Four hundred and twenty-six females were included in our cohort, with a median age of 15 years at the time of the primary operation. Of the patients, 69% had a mature teratoma, 18% had a serous cystadenoma, and 8% had a mucinous cystadenoma. Two-thirds of patients underwent ovarian-sparing surgery. There were 11 pathologically confirmed recurrences (2.6%) at a median follow-up of 12.8 months. The pathologically confirmed recurrence was 10.5 per 100 person-months at 12 months (SE = 5.7) for mucinous cystadenomas and 0.4 months (SE = 0.4) for mature teratomas (P = .001). For half of the patients, the pathologically confirmed recurrences occurred by 12.8 months, and for 75%, they occurred by 23.3 months. There were no differences in reoperation or recurrence on the basis of initial procedure (ovary-sparing surgery vs oophorectomy). CONCLUSION: We measured the pathologically confirmed recurrence rate for pediatric benign ovarian neoplasms in a large cohort. Oophorectomy was not protective against recurrence. Mucinous cystadenomas were at a greater risk of pathologically confirmed recurrence.

Hospital Case-Volume and Patient Outcomes Following Pediatric Brain Tumor Surgery in the Pediatric Health Information System.

BACKGROUND: Markers of quality of care in various surgical specialties have been shown to correlate with hospital volumes. This study investigates the effect of hospital volume and patient-related factors on the outcomes of children undergoing brain tumor resection. METHODS: We examined the data within the Pediatric Health Information System (PHIS) for children aged zero to 17 years undergoing brain tumor resection between 2016 and 2020. Length of hospital stay (LOS), costs, and reoperation rates were analyzed for associations with hospital case-volume, patient factors, and other hospital-related factors. RESULTS: A total of 2568 patients were included in this PHIS analysis. After adjusting for covariates, care provided by high-case-volume hospitals led to shorter LOS (P = 0.01). The effect of hospital case-volume on median cost was present on univariate analysis (US $63,845 at low-volume hospital versus US $54,909 at high-volume hospital, P = 0.002); this finding was attenuated by LOS. A trend was observed between reoperation rates and hospital case-volume, with lowest quartile volume hospitals having higher odds of reoperation than hospitals with volumes in the highest quartile (P = 0.06). Racial and ethnic minorities, medical comorbidities, and other sociodemographic factors were associated with poorer outcomes following surgery. CONCLUSIONS: Centering care around high-case-volume hospitals can potentially lead to shorter hospital stays and decreased costs for children with brain tumors. This PHIS article highlights the association of the studied outcomes with certain sociodemographic factors and illustrates that inequalities in pediatric health care still exist. Further efforts are required to understand and eliminate these potentially harmful differences.

Using the Craniovertebral Angle to Quantify Intraoperative Ergonomic Risk.

OBJECTIVE: To measure the craniovertebral angle during tonsillectomy, assess the interrater reliability of our methodology, and investigate the correlations of the Rapid Upper Limb Assessment and the craniovertebral angle to quantify ergonomic risk. STUDY DESIGN: Prospective, observational study. SETTING: Tertiary care pediatric institution. METHODS: Neck posture was evaluated for 92 images with 7 surgeons. Lateral images of the surgeon were captured every minute in a standardized method. Images were assessed by 3 raters, measuring the craniovertebral angle, defined as the angle between a horizontal line through the C7 vertebrae and another line through C7 and the tragus of the ear. Interrater reliability of the craniovertebral angle was evaluated using the κ statistic. Per prior publications, reports of neck pain were frequent when the craniovertebral angle value was <50°; thus, we defined an abnormal posture if the craniovertebral angle was <50°. RESULTS: Mean (SD) craniovertebral angle during tonsillectomy was 26.0° (11.3°). One hundred percent of procedures had at least 1 assessment of abnormal posture. The lowest interrater reliability was 0.77 (CI: 0.67-0.87). Rapid Upper Limb Assessment and craniovertebral angle (CA) correlation was -0.12 (P = .27) and, therefore, null. CONCLUSION: Poor posture during tonsillectomy places otolaryngologists at intraoperative ergonomic risk. The craniovertebral angle is a predictor of future neck pain, and a pathologic neck position during tonsillectomy was identified. Given the high interrater reliability, our approach to assessing intraoperative surgical ergonomics was validated. Overall, RULA and the CA are not a substitute for one another but complementary.