Primary Anastomosis Versus Stoma for Surgical Necrotizing Enterocolitis in US Children's Hospitals.

INTRODUCTION: Multiple studies have documented the safety of intestinal anastomosis after resection for necrotizing enterocolitis (NEC). We sought to evaluate a large population of infants with surgical NEC and assess outcomes after primary anastomosis versus enterostomy. METHODS: The Pediatric Health Information System database was used to identify infants with Bell Stage 3 NEC who underwent an intestinal resection for acute disease between 2016 and 2021. Demographics and preoperative physiology were assessed, and nutritional, infectious, and surgical outcomes were analyzed. RESULTS: Two hundred twenty-two infants at 38 children's hospitals were included. Thirty-five (15.8%) were managed with a primary anastomosis. Among infants who underwent a resection within 10 d of their first operative intervention and survived for at least 3 d, a primary anastomosis was used in 26 (13.7%). These patients were older but had similar weight and physiological status at the time of resection as those managed with an enterostomy. The incidence of wound and infectious complications, duration of parenteral nutrition and length of stay were similar after anastomosis or enterostomy. CONCLUSIONS: In a large, geographically heterogenous population of infants with NEC, only 15.8% were managed with a primary anastomosis after intestinal resection. Survivors who underwent resection within 10 d were demographically and physiologically comparable to those who underwent enterostomy and had similar surgical outcomes. While there are clearly indications for enterostomy in some infants with NEC, these data confirm the conclusions of smaller, single-center studies that a primary anastomosis should be considered more frequently.

Frequency and predictors of concurrent complications in multi-suture release for syndromic craniosynostosis.

PURPOSE: Understanding the complication profile of craniosynostosis surgery is important, yet little is known about complication co-occurrence in syndromic children after multi-suture craniosynostosis surgery. We examined concurrent perioperative complications and predictive factors in this population. METHODS: In this retrospective cohort study, children with syndromic diagnoses and multi-suture involvement who underwent craniosynostosis surgery in 2012-2020 were identified from the National Surgical Quality Improvement Program-Pediatric database. The primary outcome was concurrent complications; factors associated with concurrent complications were identified. Correlations between complications and patient outcomes were assessed. RESULTS: Among 5,848 children identified, 161 children (2.75%) had concurrent complications: 129 (2.21%) experienced two complications and 32 (0.55%) experienced ≥ 3. The most frequent complication was bleeding/transfusion (69.53%). The most common concurrent complications were transfusion/superficial infection (27.95%) and transfusion/deep incisional infection (13.04%) or transfusion/sepsis (13.04%). Two cardiac factors (major cardiac risk factors (odds ratio (OR) 3.50 [1.92-6.38]) and previous cardiac surgery (OR 4.87 [2.36-10.04])), two pulmonary factors (preoperative ventilator dependence (OR 3.27 [1.16-9.21]) and structural pulmonary/airway abnormalities (OR 2.89 [2.05-4.08])), and preoperative nutritional support (OR 4.05 [2.34-7.01]) were independently associated with concurrent complications. Children who received blood transfusion had higher odds of deep surgical site infection (OR 4.62 [1.08-19.73]; p = 0.04). CONCLUSIONS: Our results indicate that several cardiac and pulmonary risk factors, along with preoperative nutritional support, were independently associated with concurrent complications but procedural factors were not. This information can help inform presurgical counseling and preoperative risk stratification in this population.

Percutaneous Pigtail Catheter Drainage of Spontaneous Intestinal Perforation in Premature Infants.

INTRODUCTION: Peritoneal drainage is an established management strategy for spontaneous intestinal perforation (SIP) in premature infants. We sought to evaluate the safety and efficacy of percutaneous pigtail catheter placement as an alternative to drain insertion via a lower quadrant incision. METHODS: Patients less than 32 weeks gestational age who underwent peritoneal drain placement for SIP at two neonatal intensive care units between 2011 and 2022 were identified. Incisional drainage (ID) or percutaneous pigtail catheter drainage (PD) was used based upon the usual practices of the surgeons. ID (n = 19) was performed via a 5-mm right lower quadrant incision into which a one-fourth-inch Penrose or red rubber catheter was placed. PD (n = 18) was accomplished using a Seldinger technique by which a 6.0 or 8.5 F pigtail catheter was passed through the left lower quadrant. Demographics and physiological parameters at the time of drainage were recorded and short-term and long-term outcomes were evaluated. RESULTS: Thirty seven infants were identified. There were no differences in demographics or physiological derangement between the groups. Patients who underwent ID had more frequent stool drainage, a greater transfusion requirement, and a longer time to full feedings (60.6 v 37.7 d, P = 0.04). Incisional hernias (n = 3, 16%) only developed after ID. The duration of drain placement, length of stay, and time to resolution of pneumoperitoneum were similar with ID and PD as was the incidence of premature drain dislodgement and subsequent laparotomy. CONCLUSIONS: Percutaneous drain placement provided effective drainage in infants with SIP and was associated with more rapid feeding advancement and no incidence of incisional hernia.

Trauma and Critical Care Military-Civilian Publications Increased After the COVID-19 Pandemic: A Literature Review.

INTRODUCTION: There continues to be a growing demand for military-civilian partnerships (MCPs) in research collaborations developing medical trauma care in domestic and international affairs. The objective of this comprehensive review is to investigate the difference in the quantity of MCP trauma and critical care publications before and after the COVID-19 pandemic. METHODS: A systematic literature review was performed for the calendar years 2018 and 2021 utilizing MEDLINE, Cochrane, and EMBASE databases. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a three-tiered review of 603 English language articles to identify trauma-related military and/or civilian partners and describe the changes in geographical relationships. RESULTS: A total of 96 (2018) and 119 (2021) articles met screening criteria for trauma and critical care studies and were used for final data extraction. Ultimately, 59 (2018) and 71 (2021) papers met the inclusion criteria of identifying trauma/critical care MCPs and identified both military and civilian partners. There was also an increase from 10 (2018) to 17 (2021) publications that mentioned advocacy for MCP. Using the author affiliations, four regional MCP types were recorded: of 2018 articles, locoregional (3.4%), US-national (47.5%), single international country (42.4%), and between multiple countries (6.8%); of 2021 articles, locoregional (15.5%), US-national (38%), single international country (29.6%), and between multiple countries (16.9%). There has been an increase in the number of locoregional and multinational MCPs and an overall increase in the number of collaborative trauma publications and MCP advocacy papers. A national geographical heat map was developed to illustrate the changes from 2018 to 2021. CONCLUSIONS: There has been an increase in the number of recorded trauma and critical care MCP publications post-pandemic. The growth in the number of manuscripts in more regions post-pandemic suggests an increase in the recognition of collaborations that contribute not only to conflict readiness but also advancements in trauma and surgical care.

Emerging From the Pandemic: How Has Academic Surgery Changed?

Academic surgery has changed along with the rest of the world in response to the COVID pandemic. With increasing rates of vaccination against COVID over the past 2 y, we have slowly but steadily made progress toward controlling the spread of the virus. Surgeons, academic surgery departments, health systems, and trainees are all attempting to establish a new normal in various domains-clinical, research, teaching, and in their personal lives. How has the pandemic changed these areas? At the 2022 Academic Surgical Congress Hot Topics session, we attempted to address these issues.

Benchmarking rectal cancer care: institutional compliance with a longitudinal checklist.

BACKGROUND: In 2012, the American Society of Colon and Rectal Surgeons published the Rectal Cancer Surgery Checklist, a consensus document listing 25 essential elements of care for all patients undergoing radical surgery for rectal cancer. The authors herein examine checklist adherence in a mature, multisurgeon specialty academic practice. MATERIALS AND METHODS: A retrospective medical record review of patients undergoing elective radical resection for rectal adenocarcinoma over a 23-mo period was conducted. Checklists were completed post hoc for each patient, and these results were tabulated to determine levels of compliance. Subgroup analyses by compliance and experience levels of the treating surgeon were performed. RESULTS: A total of 161 patients underwent resection, demonstrating a median completion rate of 84% per patient. Poor compliance was noted consistently in documenting baseline sexual function (0%), multidisciplinary discussion of treatment plans (16.8%), pelvic nerve identification (8.7%) and leak testing (52.9%), and radial margin status reporting (57.5%). Junior surgeons achieved higher rates of compliance and were more likely to restage after neoadjuvant therapy (67.9% versus 29.4%, P < 0.001), discuss patients at tumor board (31.3% versus 13.2%, P = 0.014), and document leak testing (86.7% versus 47.2%, P = 0.005) compared with senior surgeons. CONCLUSIONS: Checklist compliance within a high-volume, specialty academic practice remains varied. Only surgeon experience level was significantly associated with high checklist compliance. Junior surgeons achieved greater compliance with certain items, particularly those that reinforce decision-making. Further efforts to standardize rectal cancer care should focus on checklist implementation, targeted surgeon outreach, and assessment of checklist compliance correlation to clinical outcomes.

Disruption of retinoblastoma protein expression in the intestinal epithelium impairs lipid absorption.

We previously demonstrated increased villus height following genetic deletion, or knockout, of retinoblastoma protein (Rb) in the intestinal epithelium (Rb-IKO). Here we determined the functional consequences of augmented mucosal growth on intestinal fat absorption and following a 50% small bowel resection (SBR). Mice with constitutively disrupted Rb expression in the intestinal epithelium (Rb-IKO) along with their floxed (wild-type, WT) littermates were placed on a high-fat diet (HFD, 42% kcal fat) for 54 wk. Mice were weighed weekly, and fat absorption, indirect calorimetry, and MRI body composition were measured. Rb-IKO mice were also subjected to a 50% SBR, followed by HFD feeding for 33 wk. In separate experiments, we examined intestinal fat absorption in mice with conditional (tamoxifen-inducible) intestinal Rb (inducible Rb-IKO) deletion. Microarray revealed that the transcriptional expression of lipid absorption/transport genes was significantly reduced in constitutive Rb-IKO mice. These mice demonstrated greater mucosal surface area yet manifested paradoxically impaired intestinal long-chain triglyceride absorption and decreased cholesterol absorption. Despite attenuated lipid absorption, there were no differences in metabolic rate, body composition, and weight gain in Rb-IKO and WT mice at baseline and following SBR. We also confirmed fat malabsorption in inducible Rb-IKO mice. We concluded that, despite an expanded mucosal surface area, Rb-IKO mice demonstrate impaired lipid absorption without compensatory alterations in energy homeostasis or body composition. These findings underscore the importance of delineating structural/functional relationships in the gut and suggest a previously unknown role for Rb in the regulation of intestinal lipid absorption.

Acute coagulopathy in pediatric trauma.

PURPOSE OF REVIEW: To summarize our current understanding of the pathophysiology, diagnosis, and management of acute traumatic coagulopathy in children. RECENT FINDINGS: Traumatic coagulopathy is a complex process that leads to global dysfunction of the endogenous coagulation system and results in worse outcomes and increased mortality. Although the cause is multifactorial, it is common in severely injured patients and is driven by significant tissue injury and hypoperfusion. Viscoelastic coagulation tests have been established as a rapid and reliable method to assess traumatic coagulopathy. Additionally, massive transfusion protocols have improved outcomes in adults, but limited studies in pediatrics have not shown any difference in mortality. SUMMARY: Prospective studies are needed to determine how to best diagnose and manage acute traumatic coagulopathy in children.

Race Does Not Affect Rates of Surgical Complications at Military Treatment Facility.

INTRODUCTION: Racial minorities have been found to have worse health care outcomes, including perioperative adverse events. We hypothesized that these racial disparities may be mitigated in a military treatment facility, where all patients have a military service connection and are universally insured. MATERIALS AND METHODS: This is a single institution retrospective review of American College of Surgeons National Surgical Quality Improvement Program data for all procedures collected from 2017 to 2020. The primary outcome analyzed was risk-adjusted 30-day postoperative complications compared by race. RESULTS: There were 6,941 patients included. The overall surgical complication rate was 6.9%. The complication rate was 7.3% for White patients, 6.5% for Black patients, 12.6% for Asian patients, and 3.4% for other races. However, after performing patient and procedure level risk adjustment using multivariable logistic regression, race was not independently associated with surgical complications. CONCLUSIONS: Risk-adjusted surgical complication rates do not vary by race at this military treatment facility. This suggests that postoperative racial disparities may be mitigated within a universal health care system.

Perceptions of general surgery residents at military treatment facilities: Excellent training with crisis of confidence.

BACKGROUND: The declining operative volume at Military Treatment Facilities (MTFs) has resulted in Program Directors finding alternate civilian sites for resident rotations. The continued shift away from MTFs for surgical training is likely to have unintended negative consequences. METHODS: An anonymous survey was generated and sent to the program directors of military general surgery training programs for distribution to their residents. RESULTS: A total of 42 residents responded (response rate 21%) with adequate representation from all PGY years. Ninety-five percent of residents believed that their programs provided the training needed to be a competent general surgeon. However, when asked about career choices, only 30.9% reported being likely/extremely likely to remain in the military beyond their initial service obligation, while 54.7% reported that it was unlikely/extremely unlikely and 19% reported uncertainty. Eighty-eight percent reported that decreasing MTF surgical volume directly influenced their decision to stay in the military, and half of respondents regretted joining the military. When asked to assess their confidence in the military to provide opportunities for skill sustainment as a staff surgeon, 90.4% were not confident or were neutral. CONCLUSION: Although military surgical residents have a generally positive perception of their surgical training, they also lack confidence in their future military surgical careers. Our findings suggest that declining MTF surgical volume will likely negatively impact long-term retention of military surgeons and may negatively impact force generation for Operational Commander. LEVEL OF EVIDENCE: Prognostic and Epidemiological, Level IV.

Assessing the Impact of Neighborhood and Built Environment on Pediatric Perioperative Care: A Systematic Review of the Literature.

CONTEXT: Neighborhood and built environment encompass one key area of the Social Determinants of Health (SDOH) and is frequently assessed using area-level indices. OBJECTIVE: We sought to systematically review the pediatric surgery literature for use of commonly applied area-level indices and to compare their utility for prediction of outcomes. DATA SOURCES: A literature search was conducted using PubMed, Ovid MEDLINE, Ovid MEDLINE Epub Ahead of Print, PsycInfo, and an artificial intelligence search tool (1/2013-2/2023). STUDY SELECTION: Inclusion required pediatric surgical patients in the US, surgical intervention performed, and use of an area-level metric. DATA EXTRACTION: Extraction domains included study, patient, and procedure characteristics. RESULTS: Area Deprivation Index is the most consistent and commonly accepted index. It is also the most granular, as it uses Census Block Groups. Child Opportunity Index is less granular (Census Tract), but incorporates pediatric-specific predictors of risk. Results with Social Vulnerability Index, Neighborhood Deprivation Index, and Neighborhood Socioeconomic Status were less consistent. LIMITATIONS: All studies were retrospective and quality varied from good to fair. CONCLUSIONS: While each index has strengths and limitations, standardization on ideal metric(s) for the pediatric surgical population will help build the inferential power needed to move from understanding the role of SDOH to building meaningful interventions towards equity in care. TYPE OF STUDY: Systematic Review. LEVEL OF EVIDENCE: Level III.

A Comparative Study of Laparoscopic versus Open Management of Index Small Bowel Obstruction in Children.

INTRODUCTION: There is limited literature on the optimal approach to treat adhesive small bowel obstruction (ASBO) in children. We sought to compare rates and outcomes of laparoscopic (LAP) and open (OPEN) surgery for pediatric ASBO. METHODS: A California statewide database was used to identify children (<18 years old) with an index ASBO from 2007 to 2020. The primary outcome was the type of operative management: LAP or OPEN. Secondary outcomes were hospital characteristics, patient demographics, and postoperative complications. We excluded patients treated non-operatively. RESULTS: Our study group had 545 patients. 381 (70%) underwent OPEN and 164 (30%) LAP during the index admission. Over the study period, there was increasing use of laparoscopic surgery, with higher use in older children (p < 0.001). LAP was associated with fewer overall complications (65.2% vs. 81.6%, p < 0.001), with a decreasing trend in complications over time (p < 0.001). The LAP group had significantly lower rates of bowel resection (4.9% vs. 17.1%, p < 0.001), length of stay (LOS) (17 vs. 23 days, p < 0.001), and TPN use (12.2% vs. 29.1%, p < 0.001). Mortality rates were equivalent. Although the LAP group had lower readmission rates (22.6% vs. 37.3%, p < 0.001), the length of time between discharge and readmission was similar (171 vs. 165 days, p = 0.190). DISCUSSION: The use of laparoscopic surgery for index ASBO increased over the study period. However, it was less commonly utilized in younger children. LAP had fewer overall complications as well as shorter LOS, decreased TPN use, and fewer readmissions. The benefits and risks of each approach must be weighed. LEVEL OF EVIDENCE: III.

Frequency and predictors of complication clustering within 30 days of spinal fusion surgery: a study of children with neuromuscular scoliosis.

PURPOSE: There is limited information on the clustering or co-occurrence of complications after spinal fusion surgery for neuromuscular disease in children. We aimed to identify the frequency and predictive factors of co-occurring perioperative complications in these children. METHODS: In this retrospective database cohort study, we identified children (ages 10-18 years) with neuromuscular scoliosis who underwent elective spinal fusion in 2012-2020 from the National Surgical Quality Improvement Program-Pediatric database. The rates of co-occurring complications within 30 days were calculated, and associated factors were identified by logistic regression analysis. Correlation between a number of complications and outcomes was assessed. RESULTS: Approximately 11% (709/6677 children with neuromuscular scoliosis undergoing spinal fusion had co-occurring complications: 7% experienced two complications and 4% experienced ≥ 3. The most common complication was bleeding/transfusion (80%), which most frequently co-occurred with pneumonia (24%) and reintubation (18%). Surgical time ≥ 400 min (odds ratio (OR) 1.49 [95% confidence interval (CI) 1.25-1.75]), fusion ≥ 13 levels (1.42 [1.13-1.79]), and pelvic fixation (OR 1.21 [1.01, 1.44]) were identified as procedural factors that independently predicted concurrent complications. Clinical risk factors for co-occurring complications included an American Society of Anesthesiologist physical status classification ≥ 3 (1.73 [1.27-2.37]), structural pulmonary/airway abnormalities (1.24 [1.01-1.52]), impaired cognitive status (1.80 [1.41-2.30]), seizure disorder (1.36 [1.12-1.67]), hematologic disorder (1.40 [1.03-1.91], preoperative nutritional support (1.34 [1.08-1.72]), and congenital malformations (1.20 [1.01-1.44]). Preoperative tracheostomy was protective against concurrent complications (0.62 [0.43-0.89]). Significant correlations were found between number of complications and length of stay, non-home discharge, readmissions, and death. CONCLUSION: Longer surgical time (≥ 400 min), fusion ≥ 13 levels and pelvic fixation are surgical risk factors independently associated with co-occurring complications, which were associated with poorer patient outcomes. Recognizing identified nonmodifiable risk factors might also be important for preoperative planning and risk stratification of children with neuromuscular scoliosis requiring spinal fusion. LEVEL OF EVIDENCE: Level IV evidence.

Surgical outcomes in children with Trisomy 13: An ACS NSQIP - Pediatric review.

BACKGROUND: Trisomy 13 is a rare genetic condition with a characteristic set of severe congenital abnormalities. Traditionally, the standard of care was to provide palliative care only. However, there has been a recent shift towards life-prolonging care, including surgery. This study seeks to describe surgical outcomes in patients with trisomy 13 and compare them to comorbidity-matched controls. METHODS: Using the ACS NSQIP Pediatric 2012-2019 Participant Use Data Files, patients with trisomy 13 were identified and described. A nearest-neighbor 10:1 propensity score match was performed using demographics, comorbidities, and procedural details. This yielded 254 patients with trisomy 13 and 2,422 controls. Risk ratios for morbidity and mortality by trisomy 13 status were determined using modified Poisson regression. The primary outcomes were thirty-day mortality and the occurrence of any morbidity. RESULTS: The median age of patients with trisomy 13 was 16 months (IQR 87 months). 126 were male (49.6%) and 128 were female (50.4%). There were no differences in overall morbidity compared to controls (31.8% vs. 29.7%, RR 1.06, 95%CI 0.87-1.28, p = 0.554), but patients with trisomy 13 had markedly higher mortality (7.9% vs. 1.8%, RR 4.43, 95%CI 2.28-8.61, p<0.001). CONCLUSIONS: We conclude that patients with trisomy 13 undergoing surgery have frequent morbidity and an elevated although not prohibitive risk of death. Compared to patients with similar comorbidities, they have similar rates of morbidity but a markedly higher risk of mortality. Parents of children with trisomy 13 require thorough counseling on these risks before deciding on surgery.

Impact of COVID on surgical case volume at military treatment facilities with surgical residencies.

INTRODUCTION: The Military Health System (MHS) is tasked with the dual mission of providing medical care to beneficiaries while ensuring medical readiness. MHS provides care through a combination of military treatment facilities (MTF) ("direct care"; DC) & off-base civilian facilities ("purchased care"; PC). Given recent concerns regarding low surgical volume at MTFs, we sought to evaluate COVID's impact on elective and non-elective case volume at MTFs with surgical residencies. METHODS: Retrospective review of 2017-2021 M2 database was performed on Tricare beneficiaries who underwent bariatric surgery or major colorectal surgery in the DC or PC market at, or, surrounding MTFs with surgical residencies. Procedures were identified using ICD-10 procedure codes and Medicare severity-diagnosis related groups. A detailed analysis was then performed on changes in case volume in the DC and PC markets. RESULTS: 5,698 bariatric and 5,517 major colorectal procedures were performed during the study period. There was an 84% vs 20% quarterly decrease in elective bariatric surgeries completed in the DC and PC markets from Q1 to Q2 2020. Pre to post-COVID (Q1 2017 - Q1 2020 vs Q3 2020 - Q4 2021) there was a decrease in the percentage of bariatric surgeries completed in the DC market (74.1% vs 55.0%, p = 0.001). Meanwhile, major colorectal surgery quarterly case volume remained unchanged in the DC (137 vs 125, p = 0.18) and PC (146 v 137, p = 0.13) markets, pre- and post-COVID. DISCUSSION: Bariatric surgical case volume at MTFs disproportionately decreased during COVID when compared to the PC market and major colorectal cases. Bariatric case volume has rebounded in PC markets surpassing pre-COVID levels while DC case volume remains depressed. Further attention is warranted regarding decreased elective surgical case volume at MTFs.

Tumor or Inflammatory Myofibroblastic Reaction in an Adolescent With an Abdominal Lymphatic Malformation?

We report the case of a 17-year-old male who presented with intractable nausea and vomiting. Cross-sectional imaging revealed a large retrogastric abdominal mass. Fine needle aspiration done via endoscopic ultrasound (EUS) was nondiagnostic. Exploratory laparotomy revealed a large inflammatory mass densely adherent to the stomach and retroperitoneum. Incisional biopsy frozen section revealed spindle cells, and subsequent resection of the mass with en-bloc subtotal gastrectomy with Roux-en-y gastrojejunostomy reconstruction was performed. Final pathology demonstrated a lymphatic malformation with reactive myofibroblastic proliferation. Inflammatory abdominal lymphatic malformations are especially rare and not well described in the literature. These masses may present diagnostic challenges until the specimen is sent for pathologic analysis.

Mixed reality surgical mentoring of combat casualty care related procedures in a perfused cadaver model: Initial results of a randomized feasibility study.

BACKGROUND: Most telemedicine modalities have limited ability to enhance procedural and operative care. We developed a novel system to provide synchronous bidirectional expert mixed reality-enabled virtual procedural mentoring. In this feasibility study, we evaluated mixed reality mentoring of combat casualty care related procedures in a re-perfused cadaver model. METHODS: Novices received real-time holographic mentoring from experts using augmented reality via Hololens (Microsoft Inc, Redmond, WA). The experts maintained real-time awareness of the novice's operative environment using virtual reality via HTC-Vive (HTC Corp, Xindian District, Taiwan). Additional cameras (both environments) and novel software created the immersive, shared, 3-dimensional mixed reality environment in which the novice and expert collaborated. The novices were prospectively randomized to either mixed reality or audio-only mentoring. Blinded experts independently evaluated novice procedural videos using a 5-point Likert scale-based questionnaire. Nonparametric variables were evaluated using the Wilcoxon rank-sum test and comparisons using the χ2 analysis; significance was defined at P < .05. RESULTS: Surgeon and nonsurgeon novices (14) performed 69 combat casualty care-related procedures (38 mixed reality, 31 audio), including various vascular exposures, 4-compartment lower leg fasciotomy, and emergency neurosurgical procedures; 85% were performed correctly with no difference in either group. Upon video review, mixed reality-mentored novices showed no difference in procedural flow and forward planning (3.67 vs 3.28, P = .21) or the likelihood of performing individual procedural steps correctly (4.12 vs 3.59, P = .06). CONCLUSION: In this initial feasibility study, our novel mixed reality-based mentoring system successfully facilitated the performance of a wide variety of combat casualty care relevant procedures using a high fidelity re-perfused cadaver model. The small sample size and limited variety of novice types likely impacted the ability of holographically mentored novices to demonstrate improvement over the audio-only control group. Despite this, using virtual, augmented, and mixed reality technologies for procedural mentoring demonstrated promise, and further study is needed.

Air transportation over-utilization in pediatric trauma patients.

BACKGROUND: Air transportation can be a life-saving transfer modality for trauma patients. However, it is also costly and carries risk for air-crews and patients. We sought to examine the incidence of air transportation among pediatric trauma patients as well as the rate of over-triage in utilizing this intervention. METHODS: We conducted a single-institution retrospective review of all pediatric trauma patients who utilized air transportation, either from scene to hospital or hospital to hospital Emergency Department (ED) transfers, between 2013 and 2018. RESULTS: There were 348 pediatric trauma patients who utilized air transport. More than half of all patients (n = 186, 55.9%) were discharged from the hospital within 48 h, 121 (36.3%) were discharged within 24 h, and 34 (10.2%) were discharged home from the ED. The mean ISS was 11.2 ±â€¯0.5 while only 31% had an ISS ≥15. There were 97 patients (27.9%) with elevated age adjusted shock index, and 101 patients (29.0%) who required time sensitive interventions. More than half of patients (59.3%) were initially taken to an outside hospital (OSH) and were then transferred to our facility by air while 40.4% were transported directly from scene to our institution by air. Patients who were transferred from an OSH were younger (6.8 ±â€¯0.4 vs 11.2 ±â€¯0.4, p < 0.01) and had a higher incidence of an elevated age-adjusted shock index (32.4% vs 19.1%, p = 0.006) as well as mortality (6.3% vs 1.4%, p = 0.03). However, ultimately there were no differences in ISS, rates of operative intervention, PICU utilization, or time sensitive intervention. Both groups had similarly high rates of discharge within 48 h, 24 h, and from the ED. CONCLUSIONS: Air transportation among pediatric trauma patients from scene to hospital and hospital to hospital is over-utilized based on multiple metrics including low rates of ISS ≥15, elevated age-adjusted shock indexes, low rates of time sensitive intervention, as well as high rates of discharge within 24 and 48 h. LEVEL OF EVIDENCE: III TYPE OF STUDY: Clinical Research-retrospective review.

Pediatric firearm injuries: A Midwest experience.

INTRODUCTION: Firearm injuries remain a significant public health concern. As a Level 1 Pediatric Trauma Center with a wide and diverse catchment, we sought to define our own experience as well as identify the affected patient population. METHODS: A retrospective review was conducted utilizing our institution's trauma registry including all pediatric patients (age ≤ 17 years) who presented with a firearm injury between 2012 and 2017. Patients were stratified by age group as well as by geographic location. Outcomes as well as circumstances of the shooting were measured. RESULTS: A total of 236 patients were included. One hundred thirteen patients (47.9%) were ≤12 years while 123 (52.1%) were between the ages of 13 and 17 years. The younger group had a 52.2% operative intervention rate while the older group had a 37.2% operative intervention rate (p = 0.005) while there was no difference in mortality rate. Patients in the younger group tended to be injured by someone who was known to the patient (self: 22.1%, family/friend: 44.3%) as an accidental shooting (61.9%) while patients in the older group were usually injured by a stranger (58.5%) as an assault (61.8%). When stratified by location, the majority of patients were from large cities. However, after adjusting for population, the firearm injury rate was the highest in the small cities. The majority of the shootings in these small cities were accidental, even after stratifying by age (young group: 81.4% small cities vs 50% large cities, p = 0.0008%; older group: 62.5% small cities vs 25.2% large cities, p = 0.0005). CONCLUSIONS: Although gun violence in the pediatric population is traditionally viewed as an "urban" problem among teens, our research shows that young children also suffer the consequences of firearm injuries and that rural areas are afflicted particularly by accidental firearm discharges. This may represent a new targeted audience for outreach. LEVEL OF EVIDENCE: III.

Mentoring Pediatric Victims of Interpersonal Violence Reduces Recidivism.

Pediatric interpersonal violence is a public health crisis resulting in morbidity and mortality and recidivism. St. Louis City and surrounding areas have the highest rates of youth interpersonal violence nationally. St. Louis Children's Hospital (SLCH) Social Work in conjunction with Pediatric Emergency Medicine established a novel emergency department (ED)-initiated program to determine whether co-location of services followed by outpatient mentoring reduced the rate of morbidity, mortality, and recidivism in youths experiencing interpersonal violence. SLCH developed the "Empowering Youth Through Interpersonal Violence Prevention Program," co-locating initial social work services and emergency medical services in the pediatric ED. Youths, ages 8 to 17 years, presenting for interpersonal violence were approached for immediate social work counseling and subsequent individualized outpatient mentoring, developed from national best practices and model programs. A prospective 2:1 randomized, controlled pilot study assessing for youth morbidity, mortality, and recidivism was conducted for program service feasibility from 2012 to 2014. The study was followed by a 1-year retrospective analysis of program service integration as a hospital standard-of-care evaluating the same outcome measures. Of the 24 youths who participated in the pilot study and received the intervention, there was a 4% rate of morbidity and recidivism. Conversely, there was a 3.4% rate of mortality, 6.7% rate of morbidity, and 11.8% recidivism rate in those who refused to participate in services. EYIPP was offered as a service from 2014 to 2015 and 57 youths participated with a 3.5% rate of both morbidity and recidivism. During this time, 78 eligible youths declined services with a 1.1% rate of morbidity, and 2.3% recidivism rate. This novelprogram reduces recidivism, morbidity, and mortality in youths presenting to SLCH for interpersonal violence-related injuries suggesting that co-location of social services in the ED, followed by individualized mentoring may be important for engagement.