Cervical seatbelt sign is not associated with blunt cerebrovascular injury in children: A review of the national trauma databank.

BACKGROUND: Blunt cerebrovascular injury (BCVI) is a rare consequence of blunt trauma. There appears to be benefit to an aggressive approach to screening for BCVI due to catastrophic sequelae of unrecognized injury. However, screening for BCVI carries extensive cost and oncologic risk to young patients. Foundational BCVI studies examined adults primarily, leaving question to the effectiveness of these criteria in children. We sought to evaluate BCVI screening criteria developed in primarily adult populations using a nationally representative pediatric dataset. METHODS: We queried the 2008-2014 National Trauma Data Bank for patients with BCVI. Patients were stratified by age (adults>18yrs, pediatric≤18yrs). Screening factors from the Modified Denver Criteria and Modified Memphis Criteria (GCS≤8, C1C3 cervical fracture, cervical subluxation, seatbelt sign, basilar skull fracture, mid-facial fracture, mandibular fracture, significant blood loss, coma, stroke, and hanging) were examined using univariate analysis and backwards-stepwise logistic regression to verify predictors of BCVI. RESULTS: Blunt injury occurred in 2,174,244 adults and 422,181 children; 5970 adults and 809 children sustained BCVI. In univariate analysis, all screening factors correlated with BCVI in both groups (p < 0.001). When comparing BCVI patients, children more commonly experienced GCS≤8, seatbelt sign, basilar skull fracture, mid-facial fracture, mandibular fracture, and coma (p < 0.05). In multivariable analysis, seatbelt sign was not associated with pediatric BCVI. CONCLUSION: Many adult-associated BCVI risk factors apply to children. Although children more commonly experience seatbelt sign, it does not independently cause increased BCVI risk. Given the rarity of pediatric BCVI, prospective multi-institutional studies are warranted to establish screening criteria specific to children.

Racial/ethnic differences in necrotizing enterocolitis incidence and outcomes in premature very low birth weight infants.

BACKGROUND: As advances in neonatal intensive care increase the survival of extremely premature infants, the at-risk population for necrotizing enterocolitis (NEC) continues to rise. Although racial health disparities in preterm births have been well documented, large-scale studies exploring racial differences in NEC outcomes are lacking. Here, we conduct a study of racial health disparities in NEC using a nationally representative multicenter cohort. STUDY DESIGN: Infants ≤1500 g birth weight and ≤30 weeks gestational age admitted in the first week after birth to neonatal intensive care units in the Pediatrix Medical group from 1997 to 2015 were included. Multivariable logistic regression was used to determine the adjusted odds ratio (AOR) of risk factors related to NEC and associated mortality. RESULTS: Of the 126,089 (45% non-Hispanic White, 27% non-Hispanic Black, and 19% Hispanic) infants who met the inclusion criteria, 8796 (7%) developed NEC. On multivariable analysis, non-Hispanic Black and Hispanic infants had higher odds of developing NEC (AOR 1.31, 95% confidence interval (CI) [1.24-1.39], p < 0.001 and AOR 1.30 [1.21-1.39], p < 0.001, respectively). Among infants with NEC, mortality was higher in non-Hispanic Black and Hispanic infants compared to non-Hispanic White infants (AOR 1.35 [1.15-1.58], p < 0.001 and AOR 1.31 [1.09-1.56], p = 0.003, respectively). CONCLUSION: Our study demonstrates that non-Hispanic Black and Hispanic infants are significantly more likely to be diagnosed with NEC. In addition, non-Hispanic Black and Hispanic infants have higher odds of death after NEC compared to non-Hispanic White infants. Further studies are necessary to investigate the etiology of these health disparities and to test interventions to improve these health outcomes.

Comparing oncologic outcomes after minimally invasive and open surgery for pediatric neuroblastoma and Wilms tumor.

BACKGROUND: Minimally invasive surgery (MIS) has been widely adopted for common operations in pediatric surgery; however, its role in childhood tumors is limited by concerns about oncologic outcomes. We compared open and MIS approaches for pediatric neuroblastoma and Wilms tumor (WT) using a national database. METHODS: The National Cancer Data Base from 2010 to 2012 was queried for cases of neuroblastoma and WT in children ≤21 years old. Children were classified as receiving open or MIS surgery for definitive resection, with clinical outcomes compared using a propensity matching methodology (two open:one MIS). RESULTS: For children with neuroblastoma, 17% (98 of 579) underwent MIS, while only 5% of children with WT (35 of 695) had an MIS approach for tumor resection. After propensity matching, there was no difference between open and MIS surgery for either tumor for 30-day mortality, readmissions, surgical margin status, and 1- and 3-year survival. However, in both tumors, open surgery more often evaluated lymph nodes and had larger lymph node harvest. CONCLUSION: Our retrospective review suggests that the use of MIS appears to be a safe method of oncologic resection for select children with neuroblastoma and WT. Further research should clarify which children are the optimal candidates for this approach.

A multi-institution analysis of predictors of timing of inguinal hernia repair among premature infants.

PURPOSE: Inguinal hernias are common in premature infants, but there is substantial variation with regards to timing of repair. We sought to quantify and explain this variation. METHODS: Cohort study of infants <34weeks gestation diagnosed with an inguinal hernia and discharged from one of 329 neonatal intensive units between 1998 and 2012. Multivariable logistic regression clustered by site was used to evaluate demographic, clinical, maternal, and socioeconomic variables associated with pre-discharge repair. RESULTS: A total of 8037 infants met study criteria, and 3230 (40%) received a pre-discharge repair. The frequency of pre-discharge repair varied by site from 9% to 84%, and increased over the study period from 20% in 1998 to 45% in 2012. Concurrent gastrostomy or fundoplication and lower socioeconomic status were associated with an increased odds of receiving a pre-discharge repair. CONCLUSION: There is substantial variation with regards to the timing of repair of inguinal hernias in premature infants, with an increasing number of infants receiving repair prior to hospital discharge over time. Concurrent gastrostomy or fundoplication and socioeconomic status are associated with timing of repair. LEVEL OF EVIDENCE: IV.

Outcomes following elective resection of congenital pulmonary airway malformations are equivalent after 3 months of age and a weight of 5 kg.

PURPOSE: Resection of congenital pulmonary airway malformations (CPAMs) is often performed to reduce the risk of recurrent infection and malignant transformation. However, there is substantial variation in the timing of resection. This study was performed to determine the association of age and weight on outcomes following elective resection of CPAMs. METHODS: The American College of Surgeons National Surgical Quality Improvement Program-Pediatric database from 2012 to 2014 was queried for infants undergoing elective resection of a CPAM. Infants were categorized based on age (0-3months, 3-6months, 6-9months, 9-12months, and >12months) and weight (0-5kg, 5-10kg, and >10kg). Groups were compared for baseline characteristics and outcomes including a morbidity composite of pneumonia, reintubation, ventilator days >0, reoperation, readmission, hospital length of stay >7days, and mortality. RESULTS: A total of 311 infants met study criteria. The morbidity composite was significantly more common among infants <3months of age compared to infants >3months of age (31.3% vs. 15.6%, p=0.01) and among infants <5kg as compared to infants >5kg (37.5% vs. 15.8%, p<0.01). CONCLUSIONS: Infants should be observed until three months of age and a weight of five kilograms prior to elective resection of CPAMs. LEVEL OF EVIDENCE: Level III.

Extracorporeal life support use in pediatric trauma: a review of the National Trauma Data Bank.

PURPOSE: As the role of extracorporeal life support (ECLS) continues to evolve in the adult and pediatric populations, smaller studies and case reports have described successful use of ECLS in specific groups of pediatric trauma patients. To further define the role of ECLS in pediatric trauma, we examined indications and outcomes for use of ECLS in injured children using a large national database. METHODS: All trauma patients ≤18years old were identified from the 2007 to 2011 National Trauma Data Bank. We collected patient demographics, mechanism of injury, injury severity, use of ECLS, and survival to discharge. Children undergoing ECLS were compared to those who did not undergo ECLS, using a 3:1 propensity matched analysis to compare outcomes between ECLS and non-ECLS patients with similar injury patterns. RESULTS: Of 589,895 pediatric trauma patients identified, 36 patients underwent ECLS. Within the ECLS cohort, 21/36 (58%) survived, and 10/36 (28%) were discharged directly home. Most ECLS patients were between 15 and 18years 20/36 (56%). Mechanisms of injury (MOI) resulting in ECLS use included: motor vehicle collision (MVC) 16/36 (44%), gunshot wound (GSW) 6/36 (17%), burns 6/36 (17%), and drowning/suffocation (D/S) 5/36 (14%). Among the ECLS cohort, survival varied by MOI from 75% in D/S to 56% in MVC and 33% in GSW and was 55% in patients with significant head injuries. Using propensity analysis for matched injury patterns, survival for ECLS and non-ECLS patients was similar (58% vs. 65%, p=0.61). CONCLUSIONS: In the largest study to date of ECLS support in pediatric trauma patients, we found encouraging survival rates to discharge, comparable to patients not undergoing ECLS with similar injuries. These results support further use and focused research of ECLS in pediatric trauma, including drowning, burn, and MVC victims and those with significant head injuries. LEVEL OF EVIDENCE: Level III; treatment study.

Influence of weight at enterostomy reversal on surgical outcomes in infants after emergent neonatal stoma creation.

PURPOSE: Neonates after emergent enterostomy creation frequently require reversal at low weight because of complications including cholestasis, dehydration, dumping, failure to thrive, and failure to achieve enteral independence. We investigated whether stoma reversal at low weight (< 2.5kg) is associated with poor surgical outcomes. METHODS: Patients who underwent enterostomy reversal from 2005 to 2013 at less than 6months old were identified in our institutional database. Only patients who underwent emergent enterostomy creation (i.e. for necrotizing enterocolitis or spontaneous perforation) were included. Demographics, disease process, comorbidities, stoma type, reversal indication, operative details, and complications were examined. Patients were categorized by weight at reversal of less than 2kg, 2.01-2.5kg, 2.51-3.5kg, and greater than 3.5kg. Data were analyzed using univariable and multivariable regression with significance level of p<0.05. The primary outcome examined was major morbidity, defined as the presence of anastomotic leak, obstruction, hernia, EC fistula, perforation, wound infection, sepsis, or death. RESULTS: Eighty-nine patients met inclusion criteria. Demographics (sex, ethnicity, surgical disease process, reversal indication, and ASA score) were similar. The lowest weight group had lower gestational age (p<0.001) and birth weight (p=0.005), and contained a higher proportion of jejunostomies to ileostomies (p=0.013). On univariable analysis, only incisional hernia was significantly different as a complication between weight groups. On multivariable analysis controlling for gestational age and ASA, there was no significant difference in odds of major operative morbidity between groups. CONCLUSIONS: Enterostomy reversal at lower weight may not be associated with increased risk of perioperative complications. Early stoma reversal may be acceptable when required for progression of neonatal care. LEVEL OF EVIDENCE: Level III, Treatment Study (Retrospective comparative study).

Current use and outcomes of helicopter transport in pediatric trauma: a review of 18,291 transports.

PURPOSE: The role of helicopter emergency medical services (HEMS) in pediatric trauma remains controversial. We examined its use in pediatric trauma and its effectiveness in children with moderate/severe injuries. METHODS: All blunt/penetrating trauma patients ≤18years old in the National Trauma Data Bank were evaluated for use of HEMS and in-hospital mortality. In a comparative effectiveness study, only patients treated at level I/II pediatric centers with injury severity score (ISS)≥9 were included. RESULTS: Of 127,489 included patients, 18,291 (14%) arrived via HEMS, compared to 56% by ground ambulance and 29% by private vehicle/walk-in. HEMS patients had more severe injuries (ISS≥25; 28% vs. 14%) and altered mental status (GCS≤8; 29% vs. 11%), but also contained many patients with only minor injuries or no major physiologic derangements. In unadjusted analysis, HEMS was associated with increased mortality (OR: 1.6; 95% CI: 1.4-1.7). However, it had decreased mortality by regression (0.5; 0.4-0.6) and propensity analysis (0.7; 0.6-0.8) to adjust for confounders. CONCLUSION: We found multiple indicators for overuse of HEMS, with nearly 40% of children having only minor injuries. In moderate/severe injuries, HEMS is associated with decreased mortality, potentially saving one life for every 47 flights. Research is needed to determine appropriate criteria for helicopter triage. COMPARATIVE STUDY/LEVEL OF EVIDENCE: III.

Predictors of nodal metastasis in pediatric differentiated thyroid cancer.

BACKGROUND/PURPOSE: There are limited data identifying risk factors for nodal metastasis in children with differentiated thyroid cancer. METHODS: The 1998-2011 Surveillance, Epidemiology, and End Results Program database was queried for patients ≤18years of age diagnosed with differentiated thyroid cancer who underwent nodal examination. Patients were grouped by absence or presence of nodal metastasis. Multivariable logistic regression methods were used to identify independent risk factors for nodal metastasis. RESULTS: In total, 1075 children met study criteria: 734 (68%) had nodal metastases, while 341 (32%) did not. After adjustment, risk factors for nodal metastasis included larger tumor size (1.1-2cm: odds ratio [OR] 2.02, 95% confidence interval [CI] 1.22-3.34, p=0.006; 2.1-4cm: OR 3.37, 95% CI 2.03-5.60, p<0.001; > 4cm: OR 3.39, 95% CI 1.69-6.81, p=0.001), extrathyroidal extension (OR 7.28, 95% CI 4.07-13.01, p<0.001), and multifocal disease (OR 1.94, 95% CI 1.33-2.84, p=0.001). CONCLUSIONS: Increasing tumor size, extrathyroidal extension, and multifocal disease are independent factors associated with nodal metastases in pediatric differentiated thyroid cancer. If these risk factors are present, children with differentiated thyroid cancer should undergo careful preoperative evaluation for evidence of lateral cervical lymph node metastases, and the central compartment should be evaluated intraoperatively, with consideration of central lymphadenectomy. LEVEL OF EVIDENCE: Level III.

Diagnostic evaluation of ovarian torsion: An analysis of pediatric patients using the Nationwide Emergency Department Sample.

BACKGROUND: Ultrasonography (US) is the diagnostic modality of choice during work-up for ovarian torsion, although computed tomography (CT) may be used. We examined the utilization of CT in girls with ovarian torsion, and determined which patients are most likely to undergo this study. METHODS: The Nationwide Emergency Department Sample dataset was searched for patients <18 years who presented with ovarian torsion from 2006 to 2012. Hospitals were categorized by the volume of pediatric patients seen. RESULTS: A total of 1279 patients were identified. Seven hundred twelve (56%) were seen at adult hospitals, 154 (12%) at pediatric privileged, and 413 (32%) at pediatric hospitals. Patients cared for in a pediatric or pediatric privileged hospital had more US alone performed to diagnose ovarian torsion (p < 0.01). CONCLUSIONS: Girls seen at pediatric hospitals are more likely to undergo US for work-up of ovarian torsion.

Management of blunt pancreatic trauma in children: Review of the National Trauma Data Bank.

PURPOSE: This study aims to examine the current management strategies and outcomes after blunt pancreatic trauma in children using a national patient registry. METHODS: Using the National Trauma Data Bank (NTDB) from 2007-2011, we identified all patients ≤18years old who suffered blunt pancreatic trauma. Patients were categorized as undergoing nonoperative pancreatic management (no abdominal operation, abdominal operation without pancreatic-specific procedure, or pancreatic drainage alone) or operative pancreatic management (pancreatic resection/repair). Patient characteristics, operative details, clinical outcomes, and factors associated with operative management were examined. RESULTS: Of 610,402 pediatric cases in the NTDB, 1653 children (0.3%) had blunt pancreatic injury and 674 had information on specific location of pancreatic injury. Of these 674 cases, 514 (76.3%) underwent nonoperative pancreatic management. The groups were similar in age, gender, and race; however, pancreatic injury grade>3, moderate to severe injury severity, and bicycle accidents were associated with operative management in multivariable analysis. Children with pancreatic head injuries or GCS motor score<6 were less likely to undergo pancreatic operation. Overall morbidity and mortality rates were 26.5% and 5.3%, respectively. Most outcomes were similar between treatment groups, including mortality (2.5% vs. 6.7% in operative vs. nonoperative cohorts respectively; p=0.07). CONCLUSION: Although rare, blunt pancreatic trauma in children continues to be a morbid injury. In the largest analysis of blunt pancreatic trauma in children, we provide data on which to base future prospective studies. Operative management of pancreatic trauma occurs most often in children with distal ductal injuries, suggesting that prospective studies may want to focus on this group.

Gastrostomy tube placement in infants with congenital diaphragmatic hernia: Frequency, predictors, and growth outcomes.

BACKGROUND: Gastrostomy tube (G-tube) placement is a common intervention for newborns with severe feeding difficulties. Infants with congenital diaphragmatic hernia (CDH) are at high risk for feeding problems. Prevalence of G-tube placement and consequent nutritional outcomes of infants with CDH and G-tubes has not been described. AIMS: Determine factors associated with G-tube placement and growth in infants with congenital diaphragmatic hernia. STUDY DESIGN: Retrospective cohort study of infants with CDH to evaluate the association of G-tube placement with risk factors using logistic regression. We also assessed the association between growth velocity and G-tube placement and other risk factors using linear regression. SUBJECTS: The subjects of the study were infants with CDH treated at Duke University Medical Center from 1997 to 2013. OUTCOME MEASURES: Weight gain in infants with CDH that had G-tube placement compared to those infants with CDH that did not. RESULT: Of the 123 infants with CDH, 85 (69%) survived and G-tubes were placed in 25/85 (29%) survivors. On adjusted analysis, extracorporeal membrane oxygenation (OR=11.26 [95% CI: 1.92-65.89]; P=0.01) and proton pump inhibitor use (OR=17.29 [3.98-75.14], P≤0.001) were associated with G-tube placement. Infants without G-tubes had a growth velocity of 6.5g/day (95% CI: 2.5-10.4) more than infants with G-tubes. CONCLUSION: Survivors with more complex inpatient courses were more likely to receive G-tubes. Further investigation is needed to identify optimal feeding practices for infants with CDH.

Laparoscopy Is Safe in Infants and Neonates with Congenital Heart Disease: A National Study of 3684 Patients.

PURPOSE: Concerns have been raised about the use of laparoscopic surgery (LS) in infants with congenital heart disease (CHD) due to their unique physiology. Prior studies on the safety and effectiveness of laparoscopy in children with CHD are limited in scope and cohort size. MATERIALS AND METHODS: We identified children <1 year of age with CHD who underwent abdominal surgery in the 2012-2013 American College of Surgeons National Surgical Quality Improvement Project Pediatric database. Patients were stratified by surgical approach: open surgery (OS) versus LS. We then compared postoperative complications, postoperative length of stay, and 30-day mortality by using multivariable regression methods. RESULTS: In total, 3684 patients met study criteria: 2502 underwent OS while 1182 underwent LS. Infants who underwent LS were older (98 days versus 36 days), larger by weight (4.2 kg versus 3.2 kg), and more likely to require nutritional support preoperatively (74.7% versus 60.5%) (all P < .001). After multivariable adjustment, LS was associated with lower overall complication rate (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.34-0.52, P < .001) and shorter postoperative length of stay (effect size -1.8 days, 95% CI -1.8-1.2, P < .001). LS and OS demonstrated similar 30-day mortality (OR 0.71, 95% CI 0.38-1.32, P = .28). CONCLUSIONS: Laparoscopy can be performed safely in infants with CHD who need abdominal surgery. Although further studies may be useful in determining which infants with congenital cardiac disease benefit the most from use of laparoscopy, minimally invasive techniques can be applied to routine and complex abdominal procedures.

Understanding parental refusal of permission for child participation in surgical prospective trials.

PURPOSE: The success of prospective randomized trials relies on voluntary participation, which has been perceived as a barrier for successful trials in children who rely on parental permission. We sought to identify the reasons parents decline child participation to understand potential limitations in the consent process. METHODS: A prospective observational study was conducted in 92 patients asked to participate in prospective randomized trials between 2012 and 2015. Parental reasons for refusal were documented. RESULTS: The 92 refusals were distributed between studies investigating the management of circumcision, gastroschisis, pectus excavatum, appendicitis, pyloric stenosis, undescended testicles, abdominal abscess and gastroesophageal reflux. Reasons for refusal included preference of treatment path (37 %), inability to follow up (21 %), unspecified resistance to participate in research (18 %), preference to maintain independent surgeon decision (16 %), and desire for historically standard treatment (8 %). Of the families who opted to pursue a specific treatment arm rather than randomization, 35 % had prior experience with that treatment, 32 % had researched the procedure, 18 % wished to pursue the minimal intervention and 15 % did not specify. CONCLUSIONS: Parental preference of therapy is the most common reason for refusal of study participation. This variable could be influenced with more effective explanation of study rationale and existing equipoise.

Necrotizing enterocolitis and the use of loop diuretics in very low birth weight neonates.

BACKGROUND: Necrotizing enterocolitis (NEC) is a gastrointestinal disease of premature, very low birth weight neonates resulting in sepsis and death. Loop diuretics are widely used in neonates as a treatment for pulmonary fluid retention. An association between diuretic use and NEC has not been explored. METHODS: The medical records of all neonates admitted to Duke Children's Hospital between 2007 and 2012 with a birth weight ≤1,500 grams were reviewed. RESULTS: Using multivariable logistic regression analysis, we found that loop diuretic administration was not a risk factor for the development of NEC. On subanalysis, 75% of medical NEC infants had prior exposure to loop diuretics, compared with 100% of surgical NEC infants (P = .004). CONCLUSIONS: Loop diuretics do not increase the risk of development of NEC in very low birth weight neonates. However, on diagnosis of NEC, administration of loop diuretics may be associated with the progression of NEC severity from medical NEC to surgical NEC.

Factors associated with survival in pediatric adrenocortical carcinoma: An analysis of the National Cancer Data Base (NCDB).

PURPOSE: Adrenocortical carcinoma (ACC) is a rare tumor in children with important distinctions from the adult disease. We reviewed the National Cancer Data Base (NCDB) to determine factors associated with long-term survival. METHODS: The NCDB was queried for patients less than 18 years of age who were diagnosed with ACC between 1998 and 2011. Kaplan-Meier analysis was utilized to determine factors significantly associated with overall survival. RESULTS: A total of 111 patients were included (median age: 4 years, 69% female). ACC was more common in the youngest cohort, with 48% of cases occurring in children younger than the age of 3. Median tumor size was 9.5 cm (IQR: 6.5-13.0), and 87% of patients underwent some form of surgical resection. Among children with available data, 19 of 62 presented with metastases. Overall 1- and 3-year survival was 70% and 64%, respectively. Age, tumor size, extension of tumor into surrounding tissue, and metastatic disease were all found to be significantly associated with survival. Among patients who underwent a surgical procedure, margin status was also found to be significantly associated with survival. CONCLUSION: Age, tumor size, extension of tumor, metastatic disease, and margin status are significantly associated with long-term survival in children with adrenocortical carcinoma.

Comparative effectiveness of treatment strategies for severe splenic trauma in the pediatric population.

BACKGROUND: Splenic angioembolization (SAE) is increasingly used in the management of splenic injuries in adults, although its value in pediatric trauma is unclear. We sought to assess outcomes related to splenectomy vs SAE. METHODS: The National Trauma Data Bank was queried for patients 0 to 15 years of age from 2007 to 2011. Subgroup analysis of splenectomy vs SAE was performed for high-grade injuries using propensity analysis and inverse probability weighting. RESULTS: Of 11,694 children presenting with splenic trauma, over 90% were treated nonoperatively. Adjusted analysis of high-grade injuries included 265 children who underwent splenectomy and 199 who underwent SAE. The Injury Severity Score, number of transfusions, and complications rates were not significantly different between the 2 groups. Overall adjusted mortality for children with high-grade injuries was 13.4% following splenectomy and 10.0% following SAE (P = .31) CONCLUSION: Patients undergoing SAE for high-grade splenic trauma have comparable morbidity and mortality with splenectomy.

Saline vs Tissue Plasminogen Activator Irrigations after Drain Placement for Appendicitis-Associated Abscess: A Prospective Randomized Trial.

BACKGROUND: Emerging data suggest instillation of tissue plasminogen activator (tPA) is safe and potentially efficacious in the treatment of intra-abdominal abscess. To date, prospective comparative data are lacking in children. Therefore, we conducted a randomized trial comparing abscess irrigation with tPA and irrigation with saline alone. STUDY DESIGN: After IRB approval, children with an abscess secondary to perforated appendicitis who had a percutaneous drain placed for treatment were randomized to twice-daily instillation of 13 mL 10% tPA or 13 mL normal saline. All patients were treated with once-daily dosing of ceftriaxone and metronidazole throughout their course. The primary end point variable was duration of hospitalization after drain placement. Using a power of 0.8 and an α of 0.05, a sample size of 62 patients was calculated. RESULTS: Sixty-two patients were enrolled between January 2009 and February 2013. There were no differences in demographics, abscess size, abscess number, admission WBC, or duration of symptoms. Duration of hospitalization after drainage was considerably longer with the use of tPA. There was no difference in total duration of hospitalization, days of drainage, or days of antibiotics. However, medication charges were higher with tPA. CONCLUSIONS: There are no advantages to routine tPA flushes in the treatment of abdominal abscess secondary to perforated appendicitis in children.

Inequalities in the use of helmets by race and payer status among pediatric cyclists.

BACKGROUND: Despite nationwide campaigns to increase the use of helmets among pediatric cyclists, many children continue to be injured while riding without a helmet. To determine where programs and policies intended to promote helmet use should be directed, we surveyed a large national dataset to identify variables associated with helmet use. METHODS: The National Trauma Data Bank was queried during the years 2007, 2010, and 2011 for children younger than the age of 16 years who were involved in a bicycle accident. Children were grouped based on whether they had a helmet on during the accident. A multivariable logistic mixed-effects model was utilized to determine factors associated with helmet use. RESULTS: Of the 7,678 children included in the analysis, 1,695 (22.1%) were wearing a helmet during their accident. On unadjusted analysis, nonhelmeted riders were more likely to be older (median age 11 years vs 10 years, P < .001), black (10.1% vs 3.7%, P < .001) or insured by Medicaid (32.8% vs 14.3%, P < .001). After adjustment, black children were still less likely to have had worn a helmet compared with white children (adjusted odds ratio 0.38, 95% confidence interval 0.28-0.50). Children on Medicaid were also less likely to have been wearing a helmet compared to children with private insurance (adjusted odds ratio 0.33, 95% confidence interval 0.28-0.39). CONCLUSION: Children who are black or who are on Medicaid are less likely to be wearing a helmet when involved in a bicycle accident than white children or children with private insurance, respectively. Future efforts to promote helmet use should be directed towards these groups.