Risk of Injury-Related Readmission Varies by Initial Presenting-Hospital Type Among Children at High Risk for Physical Abuse.

OBJECTIVES: Children experiencing physical abuse may initially present to hospitals with underappreciated minor injuries, only to experience more severe injuries in the future. The objectives of this study were to 1) describe young children presenting with high-risk diagnoses for physical abuse, 2) characterize the hospitals to which they initially presented, and 3) evaluate associations of initial presenting-hospital type with subsequent admission for injury. METHODS: Patients aged younger than 6 years from the 2009-2014 Florida Agency for Healthcare Administration database with high-risk diagnoses (codes previously associated with >70% risk of child physical abuse) were included. Patients were categorized by the hospital type to which they initially presented: community hospital, adult/combined trauma center, or pediatric trauma center. Primary outcome was subsequent injury-related hospital admission within 1 year. Association of initial presenting-hospital type with outcome was evaluated with multivariable logistic regression, adjusting for demographics, socioeconomic status, preexisting comorbidities, and injury severity. RESULTS: A total of 8626 high-risk children met inclusion criteria. Sixty-eight percent of high-risk children initially presented to community hospitals. At 1 year, 3% of high-risk children had experienced subsequent injury-related admission. On multivariable analysis, initial presentation to a community hospital was associated with higher risk of subsequent injury-related admission (odds ratio, 4.03 vs level 1/pediatric trauma center; 95% confidence interval, 1.83-8.86). Initial presentation to a level 2 adult or combined adult/pediatric trauma center was also associated with higher risk for subsequent injury-related admission (odds ratio, 3.19; 95% confidence interval, 1.40-7.27). CONCLUSIONS: Most children at high risk for physical abuse initially present to community hospitals, not dedicated trauma centers. Children initially evaluated in high-level pediatric trauma centers had lower risk of subsequent injury-related admission. This unexplained variability suggests stronger collaboration is needed between community hospitals and regional pediatric trauma centers at the time of initial presentation to recognize and protect vulnerable children.

Outcomes of Pediatric Central Venous Access Device Placement With Concomitant Surgical Procedures.

BACKGROUND: Children frequently undergo placement of a tunneled central venous catheter or port (CVAD) concomitantly with other surgical procedures (CVAD-CP), but the risk factors for early CVAD complications with this practice are unclear. METHODS: Children undergoing CVAD-CP were identified from the National Surgical Quality Improvement Program-Pediatric 2012-2016 database. Predictor variables included demographics, CP characteristics, malignancy, and CVAD type. Outcome variables were CVAD-associated bloodstream infection (CLABSI) or new deep venous thrombosis (nDVT) within 30 d. Patients with and without CLABSI or nDVT were compared, and the temporal relationship of nDVT and CLABSI was investigated. Multivariable logistic regression modeling was used to assess independent risk factors for CLABSI. RESULTS: Of 2036 patients included, median age was 1.5 y, 35% had malignancy, and 40% had a clean concomitant procedure. Overall, 1.3% developed CLABSI and 0.7% developed nDVT. Multivariable regression modeling revealed higher risk of CLABSI with clean CPs (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.06-5.34, P = 0.035), tunneled catheters (OR 3.2, 95% CI 1.18-8.56, P = 0.022), and longer anesthesia duration (OR 1.02 per 10 min, 95% CI 1.00-1.04, P = 0.042). nDVT was strongly associated with CLABSI (21% CLABSI among those with DVT, 0.5% among those without, P ≤ 0.0001). In all cases of nDVT with CLABSI, the diagnosis of DVT preceded diagnosis of CLABSI, by a median of 7 d. CONCLUSIONS: The type of CVAD and characteristics of the concomitant procedure influence early CLABSI after CVAD-CP. The unexpected finding of higher CLABSI rates among clean concomitant procedures suggests that perioperative prophylactic antibiotics should not be withheld in this setting, but requires prospective validation. nDVT is frequently diagnosed prior to CLABSI, suggesting a possible role for antibiotics in the treatment of postoperative DVT after CVAD placement.

30-Day Outcomes Following Esophageal Replacement in Children: A National Surgical Quality Improvement Project Pediatric Analysis.

INTRODUCTION: The optimal method of esophageal replacement remains controversial. The aim of this study was to evaluate 30-d outcomes of children in the National Surgical Quality Improvement Project Pediatric (NSQIP-P) database who underwent esophageal replacement from 2012 to 2018. METHODS: Demographics, comorbidities, and procedural technique was identified in NSQIP-P and reviewed. Thirty-day outcomes were assessed and stratified by gastric pull-up or tube interposition versus small bowel or colonic interposition. Categorical and continuous variables were assessed by Pearson's chi-square, Fisher's exact, and Wilcoxon rank-sum tests, respectively. Multivariate logistic regression was performed to estimate the effects of procedure technique and clinical risk factors on patient outcomes. RESULTS: Of the 99 cases of esophageal replacement included, 52 (52.5%) utilized a gastric conduit, whereas 47 (47.5%) involved small bowel/colonic esophageal interposition. Overall risk of complications was 52.5%, the most common of which were perioperative transfusion (30.3%), surgical site infection (11.1%), and sepsis (9.1%). Risk of unplanned reoperation was 17.2%, and risk of mortality was 3.0%. Risk for complications, reoperation, and readmission did not differ significantly between those who underwent gastric esophageal replacement and those who underwent small bowel or colonic interposition. Median operative time was shorter in the gastric esophageal replacement group (5.2 versus 8.1 h, P = 0.009). CONCLUSIONS: Among children in NSQIP-P who underwent esophageal replacement from 2012 to 2018, the risk of 30-d complications, unplanned reoperation, and mortality was relatively frequent and was similar across operative techniques. Opportunities exist to improve preoperative optimization, utilization of blood transfusion services, and infectious complications in the perioperative period irrespective of operative technique. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Predicting Morbidity and Mortality in Neonates Born With Gastroschisis.

BACKGROUND: Gastroschisis is an increasingly common congenital abdominal wall defect. Due to advances in neonatal critical care and early surgical management, mortality from gastroschisis and associated complications has decreased to less than 10% in most series. However, it has been recognized that the outcome of gastroschisis has a spectrum and that the disorder affects a heterogeneous cohort of neonates. The goal of this study is to predict morbidity and mortality in neonates with gastroschisis using clinically relevant variables. METHODS: A multicenter, retrospective observational study of neonates born with gastroschisis was conducted. Neonatal characteristics and outcomes were collected and compared. Prediction of morbidity and mortality was performed using multivariate clinical models. RESULTS: Five hundred and sixty-six neonates with gastroschisis were identified. Overall survival was 95%. Median hospital length of stay was 37 d. Sepsis was diagnosed in 107 neonates. Days on parenteral nutrition and mechanical ventilation were considerable with a median of 27 and 5 d, respectively. Complex gastroschisis (atresia, perforation, volvulus), preterm delivery (<37 wk), and very low birth weight (<1500 g) were associated with worse clinical outcomes including increased sepsis, short bowel syndrome, parenteral nutrition days, and length of stay. The composite metric of birth weight, Apgar score at 5 min, and complex gastroschisis was able to successfully predict mortality (area under the curve, 0.81). CONCLUSIONS: Clinical variables can be used in gastroschisis to distinguish those who will survive from nonsurvivors. Although these findings need to be validated in other large multicenter data sets, this prognostic score may aid practitioners in the identification and management of at-risk neonates.

Effectiveness of a collaborative, student-run campaign to increase safety belt use among adolescents.

BACKGROUND: MVCs are the leading cause of death among adolescents. Seat belts have been shown to decrease MVC-related death. The purpose of this retrospective cohort study was to evaluate the effectiveness of a community-supported, student-run campaign to increase safety belt use among adolescents in Southwest Florida. METHODS: We reviewed results of campaigns at 14 high schools from 2012 to 2018. The primary outcome was change in rates of student-driver seat belt use over the course of each campaign. Secondary outcomes included trends in seat belt use and MVC-related fatalities over the study period. Wilcoxon signed-rank test was used to compare rates of seat belt use before and after each intervention and over the course of the study period. Multivariate logistic regression was used to estimate the independent effects of demographic covariates on outcomes. RESULTS: Altogether, 85 campaigns were reviewed. A total of 8500 preintervention and 8500 postintervention observations of student seat belt use were assessed. The median rate of seat belt use increased from 82% prior to the intervention to 87% following the intervention (p<0.001). We did not detect a sustained trend in seat belt use or MVC-related fatalities over the study period. On multivariate analysis, schools with a higher proportion of minority students were less likely to experience a substantial increase in seat belt use following the intervention (OR=0.17, 95% CI 0.03 to 0.84, p=0.030). CONCLUSION: This collaborative campaign resulted in a modest, short-term increase in seat belt use among high school students. Future studies should evaluate which interventions are most effective and how short-term increases in seat belt use can be sustained.

Short-term Outcomes After Pectus Excavatum Repair in Adults and Children.

BACKGROUND: Pectus excavatum is a common congenital chest wall deformity often repaired during adolescence, although a subset of patients undergo repair as adults. The goal of our study was to determine the effects of age at repair and repair technique on short-term surgical outcomes. MATERIALS AND METHODS: We performed a cohort study of patients in the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Project pediatric (age<18 y) and adult databases who underwent pectus excavatum repair. The primary outcome was the incidence of 30-d complications. Secondary outcomes included length of stay, reoperation, and readmission. Multivariable logistic regression was used to estimate the independent effects of patient age and type of repair on postoperative outcomes. RESULTS: Of the 2268 subjects included, 2089 (92.1%) were younger than 18 y. Overall, 3.4% of patients suffered a 30-d complication, and the risk was similar between age groups (risk ratio [RR], 0.69; 95% confidence interval [CI], 0.08-5.03; P = 0.731). Steroid therapy was an independent risk factor for complications (RR, 8.0; 95% CI, 1.9-19.7; P = 0.006). Median length of stay was 4 d (interquartile range, 3-5) and was similar between age groups. Risk for readmission and reoperation were 2.8% and 1.5%, respectively, and were similar for pediatric and adult patients. When comparing minimally invasive repair with and without thoracoscopy, risk for 30-d complications was lower among patients repaired with thoracoscopy (RR, 0.56; CI, 0.32-0.96; P = 0.034). CONCLUSIONS: Pediatric and adult patients experience comparable rates of postoperative complications, readmission, and reoperation after pectus excavatum repair. Use of thoracoscopy during minimally invasive repair is associated with lower risk of complications. These findings suggest that thoracoscopy should be used routinely for minimally invasive repair of pectus excavatum.

To Scan or Not to Scan: Overutilization of Computed Tomography for Minor Head Injury at a Pediatric Trauma Center.

BACKGROUND: Degree of compliance with Pediatric Emergency Care Applied Research Network (PECARN) recommendations for radiographic evaluation following minor head injury in children is not well understood. The aim of this study was to assess PECARN compliance at a pediatric trauma center. The secondary aim was to determine whether children with indeterminate history of loss of consciousness (LOC) are at greater risk for clinically important traumatic brain injury (ciTBI) than those with no LOC. MATERIALS AND METHODS: We identified children aged 0-17 y who presented <24 h after minor head injury with Glasgow Coma Scale ≥14 in our institutional trauma registry. Predictor variables for ciTBI (TBI resulting in admission ≥2 nights, intubation ≥24 h, neurosurgery, or death) were reviewed. Simple and multivariate logistic regressions were performed to estimate the independent effects of demographic and clinical characteristics on the outcome of ciTBI. RESULTS: We included 739 children. Incidence of ciTBI was 5.4%. Only 5.6% did not undergo computed tomography (CT). PECARN compliance was 92.6% overall, but only 23.0% in those for whom CT was not indicated. Among those for whom either CT or observation was acceptable, 93.7% underwent CT. LOC history was indeterminate in 8.5%. On multivariate analysis, indeterminate LOC was not a risk factor for ciTBI. Vomiting and presence of occipital/parietal/temporal scalp hematoma were independent risk factors for ciTBI. CONCLUSIONS: CT is overutilized in pediatric trauma patients presenting to our institution after minor head injury when compared to PECARN criteria. Indeterminate LOC history was not a risk factor for ciTBI. Education of parents and clinicians regarding the risk to benefit ratio of CT in trauma patients with minor head injury is needed.

Implications of non-accidental trauma on resource utilization and outcomes.

PURPOSE: The purpose was to compare the resource utilization and outcomes between patients with suspected (SUSP) and confirmed (CONF) non-accidental trauma (NAT). METHODS: The institutional trauma registry was reviewed for patients aged 0-18 years presenting from 2007 to 2012 with a diagnosis of suspicion for NAT. Patients with suspected and confirmed NAT were compared. RESULTS: There were 281 patients included. CONF presented with a higher heart rate (142 ± 27 vs 128 ± 23 bpm, p < 0.01), lower systolic blood pressure (100 ± 18 vs 105 ± 16 mm Hg, p = 0.03), and higher Injury Severity Score (15 ± 11 vs 9 ± 5, p < 0.01). SUSP received fewer consultations (1.6 ± 0.7 vs 2.4 ± 1.1, 95% CI - 0.58 to - 0.09, p < 0.01) and had a shorter length of stay (1.6 ± 1.3 vs 7.8 ± 9.8 days, 95% CI - 4.58 to - 0.72, p < 0.01). SUSP were more often discharged home (OR 94.22, 95% CI: 21.26-417.476, p < 0.01). CONF had a higher mortality rate (8.2 vs 0%, p < 0.01). CONCLUSIONS: Patients with confirmed NAT present with more severe injuries and require more hospital resources compared to patients in whom NAT is suspected and ruled out.

Helicopter Transport From the Scene of Injury: Are There Improved Outcomes for Pediatric Trauma Patients?

BACKGROUND: There is conflicting data to support the routine use of helicopter transport (HT) for the transfer of trauma patients. The purpose of this study was to evaluate outcomes for trauma patients transported via helicopter from the scene of injury to a regional pediatric trauma center. METHODS: The institutional trauma registry was queried for trauma patients presenting from January 2000 through March 2012. Of 9119 patients, 1709 patients who presented from the scene were selected for further evaluation. This cohort was stratified into HT and ground transport (GT) for analysis. Associations between mode of transport and outcomes were estimated using odds ratios and 95% confidence intervals from multivariable logistic regression models. RESULTS: Seven hundred twenty-five patients (42.4%) presented via HT, whereas 984 (57.6%) presented via GT. Patients arriving by HT had a higher Injury Severity Score, lower Glasgow Coma Scale, were less likely to undergo surgery within 3 hours, more likely to present after motorized trauma, and had longer intensive care unit (ICU) and hospital length of stay (LOS). Multivariate analysis controlling for Injury Severity Score, Glasgow Coma Scale, mechanism of injury, scene distance, and time to arrive to the hospital revealed that patients arriving by HT were more likely to have longer hospital LOS compared with those arriving by GT (odds ratios = 2.3, 95% confidence interval = 1.00-5.28, P = 0.049). However, no statistically significant association was observed for prehospital intubation, surgery within 3 hours, ICU admissions, or ICU LOS. CONCLUSIONS: Although patients arriving by helicopter are more severely injured and arrive from greater distances, when controlling for injuries, scene distance, and time to hospital arrival, only hospital LOS was significantly affected by HT.

Enhancing recovery after minimally invasive repair of pectus excavatum.

PURPOSE: There are variations in the perioperative management of patients who undergo minimally invasive repair of pectus excavatum (MIRPE). The purpose is to analyze the change in resource utilization after implementation of a standardized practice plan and describe an enhanced recovery pathway. METHODS: A standardized practice plan was implemented in 2013. A retrospective review of patients who underwent MIRPE from 2012 to 2015 was performed to evaluate the trends in resource utilization. A pain management protocol was implemented and a retrospective review was performed of patients who underwent repair before (2010-2012) and after (2014-2015) implementation. RESULTS: There were 71 patients included in the review of resource utilization. After implementation, there was a decrease in intensive care unit length of stay (LOS), and laboratory and radiologic studies ordered. There were 64 patients included in the pain protocol analysis. After implementation, postoperative morphine equivalents (3.3 ± 1.4 vs 1.2 ± 0.5 mg/kg, p < 0.01), urinary retention requiring catheterization (33 vs 14%, p = 0.07), and LOS (4 ± 1 vs 2.8 ± 0.8 days, p < 0.01) decreased. CONCLUSION: The implementation of an enhanced recovery pathway is a feasible and effective way to reduce resource utilization and improve outcomes in pediatric patients who undergo minimally invasive repair of pectus excavatum.

Obesity and single-incision laparoscopic appendectomy in children.

BACKGROUND: Single-incision laparoscopic appendectomy (SILA) has emerged as a less-invasive alternative to conventional laparoscopy. The purpose of this study was to assess the impact of body habitus on outcomes after SILA in the pediatric population. METHODS: A retrospective review of 413 patients who underwent SILA from 2012 to 2015 was performed. Body mass index (BMI) was calculated, and the BMI percentile was obtained per Center for Disease Control guidelines. Standard definitions for overweight (BMI 85th-94th percentile) and obese (BMI > 95th percentile) were used. General demographic and outcome data were analyzed. RESULTS: SILA was performed in 413 patients during the study period, of which 66.3% were normal weight, 16% were overweight, and 17.7% were obese. There were no significant differences in age at presentation, time to diagnosis, or intraoperative classification of appendicitis. There were no significant differences in operative time (27.0 ± 9.1 versus 27 ± 9.8 versus 28.4 ± 9.4 min, P = 0.514), postoperative length of stay (0.97 ± 1.65 versus 1.53 ± 4.15 versus 1.14 ± 2.27 d, P = 0.214), 30-d surgical site infections (6.9% versus 12.1% versus 8.2%, P = 0.377), emergency department visits (8.4% versus 10.6% versus 11%, P = 0.726), or readmissions (4.7% versus 4.1% versus 4.5%, P = 0.967) among normal, overweight, and obese groups. CONCLUSIONS: Our results indicate that obesity does not significantly impact outcomes after SILA. SILA can be performed in overweight and obese children with no significant difference in operative time, length of stay, or incidence of surgical site infection. SILA should continue to be offered to overweight and obese children.

The role of chest radiography following pectus bar removal.

PURPOSE: Surgical correction of pectus excavatum (PE) via a minimally invasive approach involves placement of a steel bar, which is subsequently removed. The purpose of our study was to evaluate the incidence of pneumothorax and the role for chest radiography (CXR) in patients undergoing pectus bar removal. METHODS: A retrospective review of 84 patients who underwent pectus bar removal from 2006 to 2014 was performed. Results of postoperative CXR, repeat imaging, need for chest thoracostomy tube placement, and complications were analyzed. RESULTS: Mean Haller index prior to correction was 4.3 ± 0.9. The mean time between PE repair and bar removal was 2.3 ± 0.6 years. Sixty-one patients (72.6 %) had a postoperative CXR. Thirty-one (50.8 %) had no acute findings, 20 (32.8 %) had findings of atelectasis or subcutaneous emphysema, and 10 (16.4 %) had a pneumothorax. One patient (1.6 %) had a second postoperative CXR for a small pneumothorax and rib fractures. There were two complications (2.4 %). No chest tubes were placed for pneumothorax, and 95 % of patients were discharged the day of surgery. CONCLUSION: Postoperative CXR following pectus bar removal is unnecessary given the low incidence of postoperative pneumothorax requiring intervention. Patients can be safely discharged the day of surgery without the need for routine postoperative chest imaging.

Admission patterns in pediatric trauma patients with isolated injuries.

BACKGROUND: Pediatric trauma patients presenting with stable, isolated injuries are often admitted to the trauma service for initial management. The purpose of this study was to evaluate admission patterns in trauma patients with isolated injuries and compare outcomes based on admitting service. METHODS: The institutional trauma registry was retrospectively reviewed for patients presenting from January 2007-December 2012. A total of 3417 patients were admitted to a surgical service and further reviewed. Patients with isolated injuries were further stratified by admission to the general trauma service (GTS, n = 738) versus admission to the subspecialty surgical trauma service (STS, n = 2251). RESULTS: When compared to patients admitted to GTS, patients admitted to STS with isolated injuries were significantly younger, were more likely to present with injury severity scores ranging from 9-14, Glasgow coma scale ≥ 13, had shorter emergency room length of stay, were more likely to undergo surgery within 24 h, and had fewer computed tomography scans performed. There were no missed injuries in patients with isolated injuries admitted to STS (with 5% having a GTS consult) compared with one missed injury in those admitted to GTS. Patients with isolated injuries admitted to an STS were found to have significantly lower complication rates (0.6% versus 2.2%, P < 0.01). CONCLUSIONS: Pediatric trauma patients presenting with stable, isolated injuries may be efficiently and safely managed by nontrauma services without an increase in missed injuries or complications.

Repeat computed tomography scans after pediatric trauma: results of an institutional effort to minimize radiation exposure.

BACKGROUND: Many pediatric trauma patients are initially evaluated at non-pediatric, non-trauma centers where they undergo CT prior to transfer to a pediatric trauma center. The purpose of this study is to quantify the number of repeat CT and assess the risk of delayed or missed injuries. METHODS: The institutional pediatric trauma registry was queried for patients evaluated from January 2001 to March 2012. All patients who underwent repeat CT within 24 h after transfer were included. General admission, demographic, and outcome data were analyzed. RESULTS: A total of 6041 patients were transferred from a referring hospital after undergoing CT scans. Five percent of patients underwent repeat CT with a mean age of 6.3 ± 5.7 years. Patients who underwent repeat CT scans had significantly higher Injury Severity Scores and lower Glasgow Coma Scale. CT head was the most commonly repeated. Comparing results of referring CT scans to repeated scans, there was good agreement between results for head CT (κ = 0.69) and moderate agreement for abdominopelvic CT (κ = 0.59). The overall incidence of delayed diagnosis of injuries was 0.7%. CONCLUSION: The low incidence of missed or delayed injuries justifies limiting additional radiation exposure to pediatric trauma patients based on clinical status.

Endoscopic closure of persistent gastrocutaneous fistula in children.

PURPOSE: The incidence of persistent gastrocutaneous fistula (GCF) after removal of gastrostomy tubes in pediatric patients is estimated to be up to 44 %. Our aim was to review the outcomes of GCF closure by an endoscopic technique that utilizes cautery and endoclips. METHODS: A retrospective analysis of patients who underwent endoscopic treatment for persistent GCF from January 2010 to September 2013 was performed. This technique utilized esophagogastroduodenoscopy with cauterization of the fistula track and endoclipping of the gastric mucosa. RESULTS: Sixteen patients underwent endoscopic treatment for persistent GCF. Mean age at time of endoscopy was 7.5 ± 5.5 (1.1-17) years. Gastrostomy tubes were in place for mean of 5.4 ± 5.2 (0.5-14.2) years prior to removal. The average time from gastrostomy tube removal to first endoscopic clipping was 6.7 ± 9 (0.1-28.9) months. Seven patients (44 %) had successful closure after one endoclipping procedure. Six patients underwent a second endoclipping procedure, with three successful closures. Four patients (25 %) required surgical closure for persistent fistulas and 2 (13 %) have continued drainage. CONCLUSIONS: While endoscopy with cautery and endoclipping proves to be safe, many patients require multiple procedures and may require surgical closure. Patient selection and refinement of this technique may improve outcomes.

A simple thoracoscopic plication technique for diaphragmatic eventration in neonates and infants: technical details and initial results.

PURPOSE: Existing minimal-access surgical approaches for correction of symptomatic diaphragmatic eventration may be technically difficult in neonates and infants. We report technical details and initial outcomes of a novel, simple thoracoscopic repair technique. METHODS: The technique uses one 3-mm camera port, a 3-mm instrument incision without a port, and an 18-gauge spinal needle, which is passed through the chest wall into the pleural space. The excess diaphragm is first plicated over the needle, after which a non-absorbable suture is passed through the needle and tied extracorporeally. The needle is passed repeatedly until the desired degree of tension is achieved. A retrospective review was performed for all patients undergoing repair by this technique. RESULTS: Nine patients have undergone thoracoscopic plication at a median age of 3 months (range 0.2-13.2 mos.) and a median weight of 4.5 kg (range 2.3-8.2 kg). No organ injuries or conversions to thoracotomy occurred. Median operative time was 60 min. Patients repaired beyond the neonatal period were extubated in the operating room. There were two post-operative pneumothoraces. No recurrences have been seen at a mean follow-up of 17 months. CONCLUSION: This technique of thoracoscopic diaphragm plication is safe, effective, and technically straightforward in neonates and infants.

Risk factors for prolonged hospitalization and readmission after total thyroidectomy in children: Associations with surgical subspecialty.

BACKGROUND: Total thyroidectomy (TT) in children is performed by pediatric general surgeons (P-GS), pediatric otolaryngologists (P-ENT), or adult GS/ENT. This study evaluated short-term pediatric TT outcomes, focusing on surgical subspecialties. METHODS: Pediatric (<18 years) TT with/without central limited lymph node dissection (CLND) between 2015 and 2020 were obtained from the National Surgical Quality Improvement Program-Pediatric database. Risk factors for prolonged hospitalization (PH,>2 days) and 30-day readmission were investigated with multivariate logistic regression. RESULTS: Of 1535 patients, 14% had PH and 2% were readmitted. PH rates for P-ENT vs. P-GS vs. adult were 21% vs. 11% vs. 10%, respectively. Adjusted risk of PH was higher for P-ENT (OR 1.70, p = 0.003) but similar for P-GS/adult. There was no difference for risk of readmission by subspecialty. CONCLUSION: PH is more likely after pediatric TT performed by P-ENT, as compared to P-GS or adult surgeons. While TT may be performed safely by individual subspecialties, collaboration across specialties may further optimize outcomes.

Language Differences by Race on Letters of Recommendation for the Pediatric Surgery Match.

OBJECTIVE: This study aims to evaluate if there is any significant linguistic difference in LoR based on applicant's race/ethnicity. DESIGN: Retrospective review of applications to pediatric surgery fellowship at a single institution (2016-2020). Race was self-reported by applicants. LoR were analyzed via the Linguistic Inquiry and Word Count (LIWC) software program. SETTING: Johns Hopkins All Children's Hospital, St. Petersburg, Florida USA. A free-standing tertiary pediatric hospital. PARTICIPANTS: Pediatric surgery fellowship applicants from 2016 to 2020. RESULTS: A total of 1086 LoR from 280 applicants (52% female) were analyzed. Racial distribution was Caucasians 62.1%, Asian 12.1%, Hispanics 7.1%, multiracial 6.4% African Americans 5%, and other/unknown 7.1%. Letter writers were largely male (84%), pediatric surgeons (63%) and professors (57%). There was no difference in LoR word count across races. LoR for female multiracial candidates contained higher use of affiliation and negative emotion terms compared to Hispanic females (p = 0.002 and 0.048, respectively), and past focus terms when compared to Caucasian and Asian female applicants (p < 0.001 and p = 0.003, respectively). Religion terms were more common in LoR for Asian females when compared to Caucasian females (p < 0.001). CONCLUSION: This study demonstrates linguistic differences in LoR for pediatric surgery training programs based on applicant race/ethnicity. While differences are present, these do not suggest overt bias based on applicants race or ethnicity.

Examining Implicit Bias Differences in Pediatric Surgical Fellowship Letters of Recommendation Using Natural Language Processing.

OBJECTIVE: We analyzed the prevalence and type of bias in letters of recommendation (LOR) for pediatric surgical fellowship applications from 2016-2021 using natural language processing (NLP) at a quaternary care academic hospital. DESIGN: Demographics were extracted from submitted applications. The Valence Aware Dictionary for sEntiment Reasoning (VADER) model was used to calculate polarity scores. The National Research Council dataset was used for emotion and intensity analysis.  The Kruskal-Wallis H-test was used to determine statistical significance.  SETTING: This study took place at a single, academic, free standing quaternary care children's hospital with an ACGME accredited pediatric surgery fellowship. PARTICIPANTS: Applicants to a single pediatric surgery fellowship were selected for this study from 2016 to 2021. A total of 182 individual applicants were included and 701 letters of recommendation were analyzed. RESULTS: Black applicants had the highest mean polarity (most positive), while Hispanic applicants had the lowest.  Overall differences between polarity distributions were not statistically significant.   The intensity of emotions showed that differences in "anger" were statistically significant (p=0.03).  Mean polarity was higher for applicants that successfully matched in pediatric surgery. DISCUSSION: This study identified differences in LORs based on racial and gender demographics submitted as part of pediatric surgical fellowship applications to a single training program. The presence of bias in letters of recommendation can lead to inequities in demographics to a given program. While difficult to detect for humans, natural language processing is able to detect bias as well as differences in polarity and emotional intensity. While the types of emotions identified in this study are highly similar among race and gender groups, the intensity of these emotions revealed differences, with "anger" being most significant. CONCLUSION: From this work, it can be concluded that bias in LORs, as reflected as differences in polarity, which is likely a result of the intensity of the emotions being used and not the types of emotions being expressed.   Natural language processing shows promise in identification of subtle areas of bias that may influence an individual's likelihood of successful matching.

Pediatric Cervical Spine Injury Following Blunt Trauma in Children Younger Than 3 Years: The PEDSPINE II Study.

Importance: There is variability in practice and imaging usage to diagnose cervical spine injury (CSI) following blunt trauma in pediatric patients. Objective: To develop a prediction model to guide imaging usage and to identify trends in imaging and to evaluate the PEDSPINE model. Design, Setting, and Participants: This cohort study included pediatric patients (<3 years years) following blunt trauma between January 2007 and July 2017. Of 22 centers in PEDSPINE, 15 centers, comprising level 1 and 2 stand-alone pediatric hospitals, level 1 and 2 pediatric hospitals within an adult hospital, and level 1 adult hospitals, were included. Patients who died prior to obtaining cervical spine imaging were excluded. Descriptive analysis was performed to describe the population, use of imaging, and injury patterns. PEDSPINE model validation was performed. A new algorithm was derived using clinical criteria and formulation of a multiclass classification problem. Analysis took place from January to October 2022. Exposure: Blunt trauma. Main Outcomes and Measures: Primary outcome was CSI. The primary and secondary objectives were predetermined. Results: The current study, PEDSPINE II, included 9389 patients, of which 128 (1.36%) had CSI, twice the rate in PEDSPINE (0.66%). The mean (SD) age was 1.3 (0.9) years; and 70 patients (54.7%) were male. Overall, 7113 children (80%) underwent cervical spine imaging, compared with 7882 (63%) in PEDSPINE. Several candidate models were fitted for the multiclass classification problem. After comparative analysis, the multinomial regression model was chosen with one-vs-rest area under the curve (AUC) of 0.903 (95% CI, 0.836-0.943) and was able to discriminate between bony and ligamentous injury. PEDSPINE and PEDSPINE II models' ability to identify CSI were compared. In predicting the presence of any injury, PEDSPINE II obtained a one-vs-rest AUC of 0.885 (95% CI, 0.804-0.934), outperforming the PEDSPINE score (AUC, 0.845; 95% CI, 0.769-0.915). Conclusion and Relevance: This study found wide clinical variability in the evaluation of pediatric trauma patients with increased use of cervical spine imaging. This has implications of increased cost, increased radiation exposure, and a potential for overdiagnosis. This prediction tool could help to decrease the use of imaging, aid in clinical decision-making, and decrease hospital resource use and cost.