Association of pediatric firearm injury with neighborhood social deprivation in Philadelphia.

Background: Firearm-related injury is the leading cause of death among children and adolescents. There is a need to clarify the association of neighborhood environment with gun violence affecting children. We evaluated the relative contribution of specific social determinants to observed rates of firearm-related injury in children of different ages. Methods: This was a population-based study of firearm injury in children (age <18 years) that occurred in Philadelphia census tracts (2015-2021). The exposure was neighborhood Social Deprivation Index (SDI) quintile. The outcome was the rate of pediatric firearm injury due to interpersonal violence stratified by age, sex, race, and year. Hierarchical negative binomial regression measured the risk-adjusted association between SDI quintile and pediatric firearm injury rate. The relative contribution of specific components of the SDI to neighborhood risk of pediatric firearm injury was estimated. Effect modification and the role of specific social determinants were evaluated in younger (<15 years old) versus older children. Results: 927 children were injured due to gun violence during the study period. Firearm-injured children were predominantly male (87%), of black race (89%), with a median age of 16 (IQR 15-17). Nearly one-half of all pediatric shootings (47%) occurred in the quintile of highest SDI (Q5). Younger children represented a larger proportion of children shot in neighborhoods within the highest (Q5), compared with the lowest (Q1), SDI quintile (25% vs 5%; p<0.007). After risk adjustment, pediatric firearm-related injury was strongly associated with increasing SDI (Q5 vs Q1; aRR 14; 95% CI 6 to 32). Specific measures of social deprivation (poverty, incomplete schooling, single-parent homes, and rented housing) were associated with significantly greater increases in firearm injury risk for younger, compared with older, children. Component measures of the SDI explained 58% of observed differences between neighborhoods. Conclusions: Neighborhood measures of social deprivation are strongly associated with firearm-related injury in children. Younger children appear to be disproportionately affected by specific adverse social determinants compared with older children. Root cause evaluation is required to clarify the interaction with other factors such as the availability of firearms and interpersonal conflict that place children at risk in neighborhoods where gun violence is common. Level of evidence: Level III - Observational Study.

Guidance for Pediatric Pituitary MRI Ordering: A Single Institution Improvement Initiative.

We identified inconsistencies in the pituitary MRI ordering practices at our pediatric institution. We used an interdepartmental collaboration to develop a pituitary MRI ordering guide based on available evidence and local expertise. The initiative has led to an improvement in the appropriate use of intravenous gadolinium-based contrast agents for pediatric pituitary MRI studies.

Custom injury prevention priority scoring: Local ranking procedures to assess unique community needs: Local Pediatric Injury Prevention Priority Scoring.

BACKGROUND: Trauma is the leading cause of morbidity and mortality in children. Many traumatic injuries are preventable and trauma centers play a major role in directing population-level injury prevention strategies. Given the constraint of finite resources, calculating priorities for injury prevention at an institutional level is essential. The Injury Prevention and Priority Score (IPPS) is a widely applicable tool that is more robust than simple prevalence rankings and considers injury severity - an important factor when developing prevention strategies. We developed an adapted-IPPS methodology to define our local injury prevention priorities using our institution's patient population. METHODS: The institution-specific trauma registry was used, which includes patients presenting to a level 1 pediatric trauma center July 2018 - June 2022. Causes of injury were categorized into injury mechanisms based on external cause codes. Mechanisms of injury were ranked by frequency and severity (based on mean Injury Severity Score, ISS). An IPPS was calculated for each of the injury mechanisms, which were then ranked from highest to lowest priority injury mechanism. RESULTS: In ranking injury mechanisms by IPPS, "falls" remain the top priority mechanism despite their relatively low severity, given their overwhelming frequency (n = 1993, mean ISS = 5.9). The injury mechanisms "motor vehicle" (n = 434, mean ISS = 10.9) and "pedestrian" (n = 13, mean ISS = 15), become higher priority given their injury severity, despite lower frequency. "Pedestrian" includes non-traffic incidents such as patients run over by cars in driveways or rural settings. CONCLUSIONS: Computing the IPPS for each injury mechanism, using data collected routinely for trauma registries, enables trauma centers to use local data to inform injury prevention efforts in their communities. Calculating rankings based on an injury mechanism's relative frequency and severity allows a more robust understanding of their impact. LEVEL OF EVIDENCE: IV.

Pediatric thoracic cage fractures-Mind the sternum: A retrospective analysis of the ACS-TQIP database.

BACKGROUND: The thoracic cage is an anatomical entity formed by the thoracic spine, ribs, and sternum. As part of this osteoligamentous complex, the sternum contributes substantially to the stability of the thoracic spine. This study investigates the influence of a concomitant sternal fracture (SF) on the treatment and hospital course of pediatric patients with a thoracic vertebral fracture (TVF). METHODS: The Trauma Quality Improvement Program data sets from 2016 to 2020 were reviewed. Patients aged 0 year to 19 years with TVF with or without SF following blunt trauma were identified using the Abbreviated Injury Scale codes and selected for further data collection. Patients with transverse or spinous process fractures or incomplete data were excluded. Data collected included demographics, mechanisms of injury, clinical variables, procedures, intensive care unit admission and length of stay, total length of stay and in-hospital mortality. Continuous variables were analyzed with Wilcoxon rank sum test, categorical variables with χ 2 test. RESULTS: A total of 13,434 patients were identified, of which 10,292 had isolated TVF (TVF), 788 TVF and concomitant SF (TVF + SF), 2,225 isolated SF (excluded), and 126 incomplete data (excluded). Motor vehicle collisions were the most common mechanism of injury in both groups (TVF, 75%; TVF + SF, 88%), followed by falls (TVF: 23%, TVF + SF: 12%). Spinal cord injuries were more common among TVF + SF patients (6.4% vs. 4%). Median injury severity score (17 vs. 12), age (17 vs. 15 years), LOS (5 vs. 3 days), and mortality (5.6% vs. 2.3%) were significantly higher and the need for operative treatment (69% vs. 56%) and ICU admission (53% vs. 36%) significantly more frequent in patients with TVF + SF. CONCLUSION: Concomitant SF occur in 7% of all pediatric patients with TVF and are associated with increased morbidity and mortality. This combination of injuries is likely the result of greater energy transmission and injury potential. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Embolization for pediatric trauma.

BACKGROUND: The management of pediatric trauma with trans-arterial embolization is uncommon, even in level 1 trauma centers; hence, there is a dearth of literature on this subject compared to the adult experience. OBJECTIVE: To describe a single-center, level 1 trauma center experience with arterial embolization for pediatric trauma. MATERIALS AND METHODS: A retrospective review was performed to identify demographics, transfusion requirements, pre-procedure imaging, procedural details, adverse events, and arterial embolization outcomes over a 19-year period. Twenty children (age 4.5 months to 17 years, median 13.5 years; weight 3.6 to 108 kg, median 53 kg) were included. Technical success was defined as angiographic resolution of the bleeding-related abnormality on post-embolization angiography or successful empiric embolization in the absence of an angiographic finding. Clinical success was defined as not requiring additional intervention after embolization. RESULTS: Seventy-five percent (n=15/20) of patients required red blood cell transfusions prior to embolization with a mean volume replacement 64 ml/kg (range 12-166 ml/kg) and the median time from injury to intervention was 3 days (range 0-16 days). Technical success was achieved in 100% (20/20) of children while clinical success was achieved in 80% (n=16/20). For the 4 children (20%) with continued bleeding following initial embolization, 2 underwent repeat embolization, 1 underwent surgery, and 1 underwent repeat embolization and surgery. Mortality prior to discharge was 15% (n=3). A post-embolization mild adverse event included one groin hematoma, while a severe adverse event included one common iliac artery pseudoaneurysm requiring open surgical ligation. CONCLUSIONS: In this single-center experience, arterial embolization for hemorrhage control in children after trauma is feasible but can be challenging and the clinical failure rate of 20% in this series reflects this complexity. Standardization of pre-embolization trauma assessment parameters and embolic techniques may improve outcomes.

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.

Trends in Histrelin Implantation at a Pediatric Tertiary Care Center.

INTRODUCTION: Determine procedural outcomes and identify changing trends of utilization among patients undergoing histrelin implantation at a large pediatric tertiary care center over 15 y. METHODS: Retrospective review of all patients undergoing histrelin implantation between January 2008 and April 2022. RESULTS: A total of 746 patients underwent 1794 unique procedures (1364 placements/replacements, 430 removals). Procedures were performed in the clinic (1071, 60%), sedation unit (630, 35%), and operating room (93, 5%). A total of 14 (0.8%) complications were identified, including two patients that required early implant removal and one patient requiring antibiotics. Implants were placed for central precocious puberty (CPP, 579) or gender dysphoria (GD, 167). Cohort included 25.9% males and 74.1% females with mean age of implantation of 9.48 y (SD: 2.34, range: 1.05-17.34). The GD group is comprised of 52.4% males and 47.6% females, compared to 18.3% males and 81.7% females in the CPP. Significant difference was identified for mean age at placement by indication (CPP 8.65 y versus GD 12.34, P < 0.001). New patient referrals and implant procedures increased significantly over 14 y. Yearly frequency of patients receiving implants for CPP and GD increased significantly (P < 0.001), with proportion of GD patients increasing from 7% to 32%. CONCLUSIONS: Histrelin procedures have increased in frequency overall with the greater increase noted in the GD cohort. The development of a streamlined process and a dedicated team have enabled histrelin procedures to be safely performed in the clinic setting for most, with a very low complication rate.

Variability in firearm injury among major pediatric trauma centers across the USA.

Objectives: In 2020, firearm injuries surpassed automobile collisions as the leading cause of death in US children. Annual automobile fatalities have decreased during 40 years through a multipronged approach. To develop similarly targeted public health interventions to reduce firearm fatalities, there is a critical need to first characterize firearm injuries and their outcomes at a granular level. We sought to compare firearm injuries, outcomes, and types of shooters at trauma centers in four pediatric health systems across the USA. Methods: We retrospectively extracted data from each institution's trauma registry, paper and electronic health records. Study included all patients less than 19 years of age with a firearm injury between 2003 and 2018. Variables collected included demographics, intent, resources used, and emergency department and hospital disposition. Descriptive statistics were reported using medians and IQRs for continuous data and counts with percentages for categorical data. χ2 test or Fisher's exact test was conducted for categorical comparisons. Results: Our cohort (n=1008, median age 14 years) was predominantly black and male. During the study period, there was an overall increase in firearm injuries, driven primarily by increases in the South (S) site (ß=0.11 (SE 0.02), p=<0.001) in the setting of stable rates in the West and decreasing rates in the Northeast and Mid-Atlantic sites (ß=-0.15 (SE 0.04), p=0.002; ß=-0.19 (SE0.04), p=0.001). Child age, race, insurance type, resource use, injury type, and shooter type all varied by regional site. Conclusion: The incidence of firearm-related injuries seen at four sites during 15 years varied by site and region. The overall increase in firearm injuries was predominantly driven by the S site, where injuries were more often unintentional. This highlights the need for region-specific data to allow for the development of targeted interventions to impact the burden of injury.Level of Evidence: II, retrospective study.

Firearm Death Rates in Rural vs Urban US Counties.

This cross-sectional study examines the variability in firearm mortality risk by county type across the full rural-urban continuum in the US.

A proposed clinical pathway for the patients with Borderline Personality Disorder presenting to Emergency Departments.

OBJECTIVE: Emergency Department (ED) care of repeated self-injury, intensive affective lability, and interpersonal dysfunction associated with borderline personality disorder (BPD) is challenging. We propose an evidence-based acute clinical pathway for people with BPD. CONCLUSION: Our standardised evidence-based short-term acute hospital treatment pathway includes structured ED assessment, structured short-term hospital admission when clinically indicated, and immediate short-term (4-sessions) clinical follow-up. This approach could be adopted nationally to reduce iatrogenic harm, acute service overdependence and negative healthcare system impacts of BPD.

Transgender Youth Experiences with Implantable GnRH Agonists for Puberty Suppression.

This descriptive study reports caregiver experiences with GnRH agonist implants among a cohort of youth followed in a pediatric hospital-based gender clinic. We administered a survey to 36 of 55 eligible caregivers ascertaining demographics and satisfaction, with a medical record review of any surgical complications. The overwhelming majority (97.1%) reported satisfaction with the procedure and would undergo the implant procedure again (94.4%). The most frequent challenges noted were about affordability (39.8%) and insurance denials (39.8%). Implantable GnRH agonist can be used successfully in pediatric patients with gender dysphoria. Future policy should seek to address concerns regarding insurance approval and reimbursement.

Gastroduodenal artery embolization for peptic ulcer hemorrhage refractory to endoscopic intervention: A single-center experience.

Objective: To determine the efficacy of gastroduodenal artery embolization (GDAE) for bleeding peptic ulcers that failed endoscopic intervention. To identify incidence and risk factors for failure of GDAE. Materials and Methods: A retrospective review of patients who underwent GDAE for hemorrhage from peptic ulcer disease refractory to endoscopic intervention were included in the study. Refractory to endoscopic intervention was defined as persistent hemorrhage following at least two separate endoscopic sessions with two different endoscopic techniques (thermal, injection, or mechanical) or one endoscopic session with the use of two different techniques. Demographics, comorbidities, endoscopic and angiographic findings, significant post-embolization pRBC transfusion, and index GDAE failure were collected. Failure of index GDAE was defined as the need for re-intervention (repeat embolization, endoscopy, or surgery) for rebleeding or mortality within 30 days after GDAE. Multivariate analyzes were performed to identify independent predictors for failure of index GDAE. Results: There were 70 patients that underwent GDAE after endoscopic intervention for bleeding peptic ulcers with a technical success rate of 100%. Failure of index GDAE rate was 23% (n = 16). Multivariate analysis identified ≥2 comorbidities (odds ratio [OR]: 14.2 [1.68-19.2], P = 0.023), days between endoscopy and GDAE (OR: 1.43 [1.11-2.27], P = 0.028), and extravasation during angiography (OR: 6.71 [1.16-47.4], P = 0.039) as independent predictors of index GDAE failure. Endoscopic Forrest classification was not a significant predictor for the failure of index GDAE (P > 0.1). Conclusion: The study demonstrates safety and efficacy of GDAE for hemorrhage from PUD that is refractory to endoscopic intervention. Days between endoscopy and GDAE, high comorbidity burden, and extravasation during angiography are associated with increased risk for failure of index GDAE.

Surgical insights and management in patients with the 22q11.2 deletion syndrome.

PURPOSE: 22q11.2 deletion syndrome (22q11.2DS) can present with a variety challenges to patients and their caregivers, many of which require surgical evaluation and intervention. Surgical needs can also extend long into adulthood, prompting evaluation and intervention throughout development and beyond. Here, we identify common concerns and patient needs associated with the 22q11.2DS from a general surgery perspective, their management, and typical management based on our institution's experience with 1263 patients. METHODS: 1263 patients evaluated and treated at the 22q And You Center at the Children's Hospital of Philadelphia were enrolled and included in the study, from January 1992 to May 2017 Co-morbidities, procedures, and imaging studies performed were quantified and assessed via descriptive analysis. RESULTS: Gastroesophageal reflux disease (GERD) and feeding difficulties were the most common surgical issues identified, while gastrostomy tube placement, anorectal procedures, and hernia repairs were the most common surgical interventions performed by general surgeons. CONCLUSIONS: General surgical procedures are commonly needed in this population and are part of the complex needs these patients and their surgeons may encounter in the setting of a 22q11.2DS diagnosis. These findings will help to inform a well-coordinated, multidisciplinary approach to care.

Settling the Score: Injury Severity Score Fails to Capture Nuances in Pediatric Trauma.

OBJECTIVES: Recent work has questioned the accuracy of the Injury Severity Score (ISS) and the Abbreviated Injury Scale (AIS) in the pediatric population. We sought to determine mortality rates in pediatric trauma patients at ISSs considered "severe" in adults and whether mortality would vary substantially between adults and children sustaining injuries with the same AIS. METHODS: Univariate logistic regression was used to generate mortality rates associated with ISS scores, for children (<16 years of age) and adults, using the 2016 National Trauma Data Bank. Mortality rates at an ISS of 15 were calculated in both groups. We similarly calculated ISS scores associated with mortality rates of 10%, 25%, and 50%. Receiver operating characteristic curves were constructed to compare the discriminative ability of ISS to predict mortality after blunt and penetrating injuries in adults and children. Mortality rates associated with 1 or more AIS 3 injuries per body region were defined. RESULTS: There were 855,454 cases, 86,414 (10.1%) of which were children. The ISS associated with 10%, 25%, and 50% mortality were 35, 44, and 53, respectively, in children; they were 27, 38, and 48 in adults. At an ISS of 15, pediatric mortality was 1.0%; in adults, it was 3.1%. A 3.1% mortality rate was not observed in children until an ISS of 25. On receiver operating characteristic analysis, the ISS performed better in children compared with adults (area under the curve, 0.965 vs 0.860 [P < 0.001]). Adults consistently suffered from higher mortality rates than did children with the same number of severe injuries to a body region, and mortality varied widely between specific selected AIS 3 injuries. CONCLUSIONS: Although the ISS predicts mortality well, children have lower mortality than do adults for the same ISS, and therefore, the accepted definition of severe injury is not equivalent between these 2 cohorts. Mortality risk is highly dependent on the specific nature of the injury, with large variability in outcomes despite identical AIS scores.

All body region injuries are not equal: Differences in pediatric discharge functional status based on Abbreviated Injury Scale (AIS) body regions and severity scores.

PURPOSE: Functional outcomes have been proposed for assessing quality of pediatric trauma care. Outcomes assessments often rely on Abbreviated Injury Scale (AIS) severity scores to adjust for injury characteristics, but the relationship between AIS severity and functional impairment is unknown. This study's primary aim was to quantify functional impairment associated with increasing AIS severity scores within body regions. The secondary aim was to assess differences in impairment between body regions based on AIS severity. METHODS: Children with serious (AIS≥ 3) isolated body region injuries enrolled in a multicenter prospective study were analyzed. The primary outcome was functional status at discharge measured using the Functional Status Scale (FSS). Discharge FSS was compared (1) within each body region across increasing AIS severity scores, and (2) between body regions for injuries with matching AIS scores. RESULTS: The study included 266 children, with 16% having abnormal FSS at discharge. Worse FSS was associated with increasing AIS severity only for spine injuries. Abnormal FSS was observed in a greater proportion of head injury patients with a severely impaired initial Glasgow Coma Scale (GCS) (GCS< 9) compared to those with a higher GCS score (43% versus 9%; p < 0.01). Patients with AIS 3 extremity and severe head injuries had a higher proportion of abnormal FSS at discharge than AIS 3 abdomen or non-severe head injuries. CONCLUSIONS: AIS severity does not account for variability in discharge functional impairment within or between body regions. Benchmarking based on functional status assessment requires clinical factors in addition to AIS severity for appropriate risk adjustment. LEVEL OF EVIDENCE: 1 (Prognostic and Epidemiological).

Development and validation of machine learning models for the prediction of blunt cerebrovascular injury in children.

BACKGROUND: Blunt cerebrovascular injury (BCVI) is a rare finding in trauma patients. The previously validated BCVI (Denver and Memphis) prediction model in adult patients was shown to be inadequate as a screening option in injured children. We sought to improve the detection of BCVI by developing a prediction model specific to the pediatric population. METHODS: The National Trauma Databank (NTDB) was queried from 2007 to 2015. Test and training datasets of the total number of patients (885,100) with complete ICD data were used to build a random forest model predicting BCVI. All ICD features not used to define BCVI (2268) were included within the random forest model, a machine learning method. A random forest model of 1000 decision trees trying 7 variables at each node was applied to training data (50% of the dataset, 442,600 patients) and validated with test data in the remaining 50% of the dataset. In addition, Denver and Memphis model variables were re-validated and compared to our new model. RESULTS: A total of 885,100 pediatric patients were identified in the NTDB to have experienced blunt pediatric trauma, with 1,998 (0.2%) having a diagnosis of BCVI. Skull fractures (OR 1.004, 95% CI 1.003-1.004), extremity fractures (OR 1.001, 95% 1.0006-1.002), and vertebral injuries (OR 1.004, 95% CI 1.003-1.004) were associated with increased risk for BCVI. The BCVI prediction model identified 94.4% of BCVI patients and 76.1% of non-BCVI patients within the NTDB. This study identified ICD9/ICD10 codes with strong association to BCVI. The Denver and Memphis criteria were re-applied to NTDB data to compare validity and only correctly identified 13.4% of total BCVI patients and 99.1% of non BCVI patients. CONCLUSION: The prediction model developed in this study is able to better identify pediatric patients who should be screened with further imaging to identify BCVI. LEVEL OF EVIDENCE: Retrospective diagnostic study-level III evidence.