Trends and Outcomes of Pediatric Vascular Injuries in the United States: An Analysis of the National Trauma Data Bank.

BACKGROUND: According to the Center for Disease Control and Prevention, trauma is the leading cause of death in children aged >1 year in the United States (US). Although vascular injuries occur in only 0.6-1% of pediatric patients with trauma, they are a major mortality contributor. This study aims to examine epidemiology and outcomes after pediatric vascular injuries (PedVIs) in the US. METHODS: The National Trauma Data Bank (2002-2012) was queried to identify children (0-16) with PedVIs. Patients were categorized based on their demographics, location, and mechanism and presenting trauma severity (injury severity score [ISS] and shock). Study was divided into two 5-year periods (P1: 2002-2006; P2: 2007-2012) to study the trends in pediatric vascular trauma presentation and outcomes (hospital death and extended length of stay [LOS > 8 days]) using adjusted analyses. RESULTS: Analyses were performed on 3,408 cases; who were male (73.7%) and Caucasian (52.8%) with a mean age of 10.5 ± 4.5 years. The Southern region of the US saw the highest increase in PedVIs (P2 versus P1: 38.3% vs. 25.0%, P < 0.05). Blunt injuries constituted most of these injuries (57%). Firearm (36.9%) and motor vehicle crash (MVC) (34%) were the most common lethal mechanisms of injury. Despite the significant decrease in MVC rates (P2 versus P1: 17.4% vs. 22.6%, P < 0.05), firearm rates were unchanged. Upper extremity injuries were the most common anatomically (34.9%). ISS and shock were significantly decreased during P2. Mortality occurred in 7.9% of patients, which significantly decreased (P2 versus P1: 6.3% vs. 10.9%, P < 0.001) without a significant change in LOS. Odds of mortality decreased by 32% during P2 (P = 0.08) and was independently associated with penetrating mechanism of injury (odds ratio [OR]: 1.97; 95% confidence interval [CI]: 1.22-3.19, P = 0.006), shock at presentation (OR: 5.48; 95% CI: 3.55-8.46, P < 0.001); ISS (OR: 1.08; 95% CI: 1.06-1.27, P < 0.001), and Glasgow Coma Score < 9 (OR: 11.21; 95% CI: 7.18-17.49, P < 0.001). CONCLUSIONS: We observed a significant decrease in the overall severity of injury and in-hospital mortality concurrent with the observation of a significant decrease in the rates of pediatric MVC vascular injuries. Public health policies directed toward firearm safety may further decrease PedVIs and mortality among this vulnerable population.

Acute Gastric Volvulus in a 16-Year-Old Male Adolescent: A Case Report.

OBJECTIVE: We described a case of acute mesenteroaxial gastric volvulus in a male adolescent who presented to the pediatric emergency department (ED). CASE: A previously healthy male adolescent presented to the pediatric ED with gradual onset of epigastric pain, emesis, and a soft and nondistended abdomen. After evaluation, management, and resolution of the pain, the patient was discharged home with a primary care follow-up plan. Approximately 5 hours after discharge, the patient returned to the pediatric ED with worsening abdominal pain, the inability to tolerate oral intake, and a firm and distended abdomen. Subsequent evaluation identified an acute mesenteroaxial gastric volvulus. Pediatric surgeons performed an exploratory laparotomy, reduction of the gastric volvulus, and gastropexy, and the patient was discharged after a brief hospitalization. CONCLUSIONS: Acute gastric volvulus can present with symptoms similar to benign abdominal etiologies. Timely diagnosis and intervention are key to improved outcomes for patients.

Medicare Facility Diagnosis-Related Groups Have Outpaced Individual Physician Payment.

BACKGROUND: We set out to compare the rates of Medicare reimbursement to physicians versus hospitals for several major vascular procedures over a period of 5 years. METHODS: We queried the Wolters Kluwer MediRegs database to collect Medicare reimbursement data from fiscal years 2011 to 2015. We surveyed reimbursements for carotid endarterectomy, carotid angioplasty and stenting, femoropopliteal bypass, and lower extremity fem-pop revascularization with stenting. Based on data availability, we surveyed physician reimbursement data on the national level and in both medically overserved and underserved areas. Hospital reimbursement rates were examined on a national level and by hospitals' teaching and wage index statuses. RESULTS: We found that for all 4 vascular procedures, Medicare reimbursements to hospitals increased by a greater percentage than to physicians. By region, underserved areas had lower physician reimbursements than the national average, while the opposite was true for overserved areas. Additionally, for hospital Medicare reimbursements, location in a high wage index accounted for a significant increase in reimbursement over the national average, with teaching status contributing to this increase in a smaller extent. CONCLUSIONS: These data on Medicare reimbursements indicate that payments to hospitals are increasing more significantly than to physicians. This disparity in pay changes affects both independent and academic vascular surgeons. Medicare should consider pay increases to independent providers in accordance to the hospital pay increase.