Improving Accuracy of Administrative Data for Perforated Appendicitis Classification.

INTRODUCTION: Reliance on International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes may misclassify perforated appendicitis with resultant research, fiscal, and public health implications. We aimed to improve the accuracy of administrative data for perforated appendicitis classification relying on ICD-10-CM codes from 2015 to 2018. METHODS: We conducted a retrospective study of randomly sampled patients aged ≤18 years diagnosed with acute appendicitis from eight children's hospitals. Patients were identified using the Pediatric Health Information System, and true perforation status was determined by medical record review. We developed two algorithms by leveraging Pediatric Health Information System data elements and data mining (DM) approaches. The two developed algorithm performance was compared against algorithms that exclusively relied on ICD-10-CM codes using area under the curve and other measures. RESULTS: Of 1051 clinically validated encounters that were included, 383 (36.4%) patients were identified to have perforated appendicitis. The two algorithms developed using DM approaches primarily leveraged ICD-10-CM codes and length of stay. DM-developed algorithms had a significantly higher accuracy than algorithms relying exclusively on ICD-10-CM (P value < 0.01): sensitivity and specificity for DM-developed algorithms were 0.86-0.88 and 0.95-0.97, respectively, which were overall higher than algorithms that relied on only ICD-10-CM. CONCLUSIONS: This study provides an algorithm that can improve the accuracy of perforated appendicitis classification using commonly available elements in administrative data. We recommend that this algorithm is used in future appendicitis classification to ensure valid reporting, hospital-level benchmarking, and fiscal or public health assessments.

Management of complex pediatric and adolescent liver trauma: adult vs pediatric level 1 trauma centers.

PURPOSE: Management of high-grade pediatric and adolescent liver trauma can be complex. Studies suggest that variation exists at adult (ATC) vs pediatric trauma centers (PTC); however, there is limited granular comparative data. We sought to describe and compare the management and outcomes of complex pediatric and adolescent liver trauma between a level 1 ATC and two PTCs in a large metropolitan city. METHODS: A retrospective review of pediatric and adolescent (age < 21 years) patients with American Association for the Surgery of Trauma (AAST) Grade 4 and 5 liver injuries managed at an ATC and PTCs between 2016 and 2022 was performed. Demographic, clinical, and outcome data were obtained at the ATC and PTCs. Primary outcomes included rates of operative management and use of interventional radiology (IR). Secondary outcomes included packed red blood cell (pRBC) utilization, intensive care unit (ICU) length of stay (LOS), and hospital LOS. RESULTS: One hundred forty-four patients were identified, seventy-five at the ATC and sixty-nine at the PTC. The cohort was predominantly black (65.5%) males (63.5%). Six injuries (8.7%) at the PTC and forty-five (60%) injuries at the ATC were penetrating trauma. Comparing only blunt trauma, ATC patients had higher Injury Severity Score (median 37 vs 26) and ages (20 years vs 9 years). ATC patients were more likely to undergo operative management (26.7% vs 11.0%, p = 0.016) and utilized IR more (51.9% vs 4.8%, p < 0.001) compared to the PTC. The patients managed at the ATC required higher rates of pRBC transfusions though not statistically significant (p = 0.06). There were no differences in mortality, ICU, or hospital LOS. CONCLUSION: Our retrospective review of high-grade pediatric and adolescent liver trauma demonstrated higher rates of IR and operating room use at the ATC compared to the PTC in the setting of higher Injury Severity Score and age. While the PTC successfully managed > 95% of Grade 4/5 liver injuries non-operatively, prospective data are needed to determine the optimal algorithm for management in the older adolescent population. LEVEL OF EVIDENCE: Level IV.

Management of Fibrous Hamartoma of Infancy: A Contemporary Series.

BACKGROUND: Fibrous hamartoma of infancy (FHI) is a rare, benign, soft tissue mass that may be locally infiltrative. Primary excision is the mainstay of treatment; however, given the infiltrative nature, margin negativity can be difficult to achieve. The management of residual disease in the setting of positive margins after primary excision is not well described. METHODS: All patients undergoing FHI excision from 2012 to 2022 were included. Demographics, operative data, margin status, recurrence, and post-operative follow-up data were obtained via retrospective chart review. RESULTS: Nine patients were identified who underwent FHI excision. The median age at time of excision was 9 months (IQR 16). Seven (78%) were male, and the majority (78%) were white. Seven (78%) underwent preoperative imaging via ultrasound or MRI, and 4 (44%) had a preoperative biopsy to confirm diagnosis. Common locations included upper extremity (n = 4, 44%) and lower extremity/inguinal region (n = 4, 44%). Six patients (67%) had positive margins on pathology - 3 (33%) on the upper extremity, 2 (22%) on the lower extremity/inguinal region, and one (11%) on the flank. One patient (11%) had a local recurrence which did not undergo re-excision. CONCLUSIONS: FHI remains a rare diagnosis. There is a high margin positivity rate; however, local clinically significant mass recurrence remains uncommon. With low rates of clinically significant mass development coupled with the benign nature of disease, a "watch and wait" approach may be appropriate for patients with positive histologic margins after complete gross excision to avoid reoperation and need for complex reconstructions. LEVEL OF EVIDENCE: Level 4.

The Association of Social Determinants of Health With Short Term Pediatric Gastrostomy Tube Outcomes.

INTRODUCTION: Social determinants of health (SDH) have been found to be important contributors to postoperative outcomes, especially those related to procedures that require significant postoperative resources. The association between short-term gastrostomy tube (GT) outcomes and SDH in the pediatric population is unknown. METHODS: A retrospective review was performed of all patients less than 18 y old who received a GT between January 2018 and December 2020 at a single institution. Data including demographics, area deprivation index (ADI), and perioperative information were collected. Patient characteristics were compared in those that did and did not have an unexpected emergency department (ED) visit within 6 wk of discharge from GT placement. Statistical analysis was performed using Wilcoxon sum-rank, Chi-squared test, and Fisher's exact test where applicable, and univariable and multivariable logistic regression. RESULTS: Of the 541 children who underwent GT placement, 112 (20.7%) returned to the ED within 6 wk postdischarge. In univariable analysis, Black children had 1.64 the odds of an unexpected ED visit compared to White children (95% confidence interval [CI] 1.04-2.60, P = 0.03). When controlling for ethnicity, primary language, insurance, ADI and comorbidities, Black children had 1.80 the odds of an unexpected ED visit compared to White children (95% CI 1.10-2.97, P = 0.02). Final model fit which added a race by ADI interaction term revealed Black children had 2.52 the odds of an unexpected ED visit compared to White children in the low (1-6) ADI group (95% CI 1.41-4.60, P = 0.002). Within advantaged neighborhoods (ADI 1-6), the probability of unplanned ED visits for White children was 17.3% (95%CI 8.9% - 31.1%), which was significantly lower than that for Black children (34.6%, 95% CI 18.8% - 54.7%; P value = 0.006). CONCLUSIONS: Race and neighborhood disadvantage can be associated with unexpected ED visits within 6 wk of discharge from GT placement in the pediatric population. For procedures that require significant postdischarge resources it is important to study the effect of SDH on return to the healthcare system as they can be an important driver of disparities in outcomes.

Concurrent use of continuous kidney replacement therapy during extracorporeal membrane oxygenation: what pediatric nephrologists need to know-PCRRT-ICONIC practice points.

Extracorporeal membrane oxygenation (ECMO) provides temporary cardiorespiratory support for neonatal, pediatric, and adult patients when traditional management has failed. This lifesaving therapy has intrinsic risks, including the development of a robust inflammatory response, acute kidney injury (AKI), fluid overload (FO), and blood loss via consumption and coagulopathy. Continuous kidney replacement therapy (CKRT) has been proposed to reduce these side effects by mitigating the host inflammatory response and controlling FO, improving outcomes in patients requiring ECMO. The Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup and the International Collaboration of Nephrologists and Intensivists for Critical Care Children (ICONIC) met to highlight current practice standards for ECMO use within the pediatric population. This review discusses ECMO modalities, the pathophysiology of inflammation during an ECMO run, its adverse effects, various anticoagulation strategies, and the technical aspects and outcomes of implementing CKRT during ECMO in neonatal and pediatric populations. Consensus practice points and guidelines are summarized. ECMO should be utilized in patients with severe acute respiratory failure despite the use of conventional treatment modalities. The Extracorporeal Life Support Organization (ELSO) offers guidelines for ECMO initiation and management while maintaining a clinical registry of over 195,000 patients to assess outcomes and complications. Monitoring and preventing fluid overload during ECMO and CKRT are imperative to reduce mortality risk. Clinical evidence, resources, and experience of the nephrologist and healthcare team should guide the selection of ECMO circuit.

Comparison of preoperative and intraoperative surgeon diagnosis and pathologic findings in spontaneous intestinal perforation vs necrotizing enterocolitis.

OBJECTIVE: To investigate the accuracy of preoperative and intraoperative diagnosis via comparison to pathologic diagnosis in spontaneous intestinal perforation (SIP) vs. necrotizing enterocolitis (NEC). STUDY DESIGN: A retrospective review of neonates <1500 g treated for pneumoperitoneum between 07/2004-09/2022 was conducted. Patients treated for NEC medically prior to diagnosis and those treated with drain only were excluded. Fleiss' Kappa analysis assessed agreement between all three diagnoses: preoperative, intraoperative, and pathologic. RESULT: Overall, 125 patients were included with mean birthweight 834.2 g (SD:259.2) and mean gestational age 25.8 weeks (SD:2.2). Preoperative and intraoperative diagnoses agreed in 90.3%, intraoperative and pathologic agreed in 71.1%, and preoperative and pathologic agreed in 75.2% of patients. Fleiss' Kappa was 0.55 (95% CI:0.43,0.68), indicating moderate agreement between the three diagnoses. CONCLUSION: Our study shows moderate agreement between preoperative, intraoperative, and pathologic diagnoses. Further studies investigating the clinical characteristics of SIP and NEC are needed to improve diagnostic accuracy and management.

Transcystic Laparoscopic Common Bile Duct Exploration for Pediatric Patients with Choledocholithiasis: A Multi-Center Study.

BACKGROUND: Patients with choledocholithiasis are often treated with endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Upfront LC, intraoperative cholangiogram (IOC), and possible transcystic laparoscopic common bile duct exploration (LCBDE) could potentially avoid the need for ERCP. We hypothesized that upfront LC + IOC ± LCBDE will decrease length of stay (LOS) and the total number of interventions for children with suspected choledocholithiasis. METHODS: A multicenter, retrospective cohort study was performed on pediatric patients (<18 years) between 2018 and 2022 with suspected choledocholithiasis. Demographic and clinical data were compared for upfront LC + IOC ± LCBDE and possible postoperative ERCP (OR1st) versus preoperative ERCP prior to LC (OR2nd). Complications were defined as postoperative pancreatitis, recurrent choledocholithiasis, bleeding, or abscess. RESULTS: Across four centers, 252 children with suspected choledocholithiasis were treated with OR1st (n = 156) or OR2nd (n = 96). There were no differences in age, gender, or body mass index. Of the LCBDE patients (72/156), 86% had definitive intraoperative management with the remaining 14% requiring postoperative ERCP. Complications were fewer and LOS was shorter with OR1st (3/156 vs. 15/96; 2.39 vs 3.84 days, p < 0.05). CONCLUSION: Upfront LC + IOC ± LCBDE for children with choledocholithiasis is associated with fewer ERCPs, lower LOS, and decreased complications. Postoperative ERCP remains an essential adjunct for patients who fail LCBDE. Further educational efforts are needed to increase the skill level for IOC and LCBDE in pediatric patients with suspected choledocholithiasis. LEVEL OF EVIDENCE: Level III.

Lower Extremity Vascular Injury in the Pediatric Trauma Patient: Management and Outcomes at an Adult Level I Trauma Center.

BACKGROUND: Traumatic vascular injuries of the lower extremity in the pediatric population are uncommon but can result in significant morbidity. The objective of this study is to demonstrate our experience with these injuries by describing patterns of traumatic vascular injury, the initial management, and data regarding early outcomes. METHODS: In total, 506 patients presented with lower extremity vascular injury between January 1, 2009 and January 1, 2021 to Grady Memorial Hospital, an urban, adult Level I trauma center in Atlanta, Georgia. Thirty-two of the 506 patients were aged less than 18 years and were evaluated for a total of 47 lower extremity vascular injuries. To fully elucidate the injury patterns and clinical course in this population, we examined patient demographics, mechanism of injury, type of vessel injured, surgical repair performed, and early outcomes and complications. RESULTS: The median (interquartile range) age was 16 (2) years (range, 3-17 years), and the majority were male (n = 29, 90.6%). Of the vascular injuries identified, 28 were arterial and 19 were venous. Of these injuries, 14 patients had combined arterial-venous injuries. The majority of injuries were the result of a penetrating injury (n = 28, 87.5%), and of these, all but 2 were attributed to gunshot wounds. Twenty-seven vascular interventions were performed by nonpediatric surgeons: 11 by trauma surgeons, 13 by vascular surgeons, 2 by orthopedic surgeons, and 1 by an interventional radiologist. Two patients required amputation: 1 during the index admission and 1 delayed at 3 months. Overall survival was 96.9%. CONCLUSIONS: Vascular injuries as the result of trauma at any age often require early intervention, and we believe that these injuries in the pediatric population can be safely managed in adult trauma centers with a multidisciplinary team composed of trauma, vascular, and orthopedic surgeons with the potential to decrease associated morbidity and mortality from these injuries.

Pediatric ECLS Neurologic Management and Outcomes.

Neurologic complications associated with extracorporeal life support (ECLS), including seizures, ischemia/infarction, and intracranial hemorrhage significantly increase morbidity and mortality in pediatric and neonatal patients. Prompt recognition of adverse neurologic events may provide a window to intervene with neuroprotective measures. Many neuromonitoring modalities are available with varying benefits and limitations. Several pre-ECLS and ECLS-related factors have been associated with an increased risk for neurologic complications. These may be patient- or circuit-related and include modifiable and non-modifiable factors. ECLS survivors are at risk for long-term neurological sequelae affecting neurodevelopmental outcomes. Possible long-term outcomes range from normal development to severe impairment. Patients should undergo a neurological evaluation prior to discharge, and neurodevelopmental assessments should be included in each patient's structured, multidisciplinary follow-up. Safe pediatric and neonatal ECLS management requires a thorough understanding of neurological complications, neuromonitoring techniques and limitations, considerations to minimize risk, and an awareness of possible long-term ramifications. With a focus on ECLS for respiratory failure, this manuscript provides a review of these topics and summarizes best practice guidelines from international organizations and expert consensus.

Transfusion in Neonatal Extracorporeal Membrane Oxygenation: A Best Practice Review.

Extracorporeal Membrane Oxygenation (ECMO) is an important tool for managing critically ill neonates. Bleeding and thrombotic complications are common and significant. An understanding of ECMO physiology, its interactions with the unique neonatal hemostatic pathways, and appreciation for the distinctive risks and benefits of neonatal transfusion as it applies to ECMO are required. Currently, there is variability regarding transfusion practices, related to changing norms and a lack of high-quality literature and trials. This review provides an analysis of the neonatal ECMO transfusion literature and summarizes available best practice guidelines.

Increases in adolescent firearm injuries were associated with school closures during COVID-19.

BACKGROUND: Mitigation measures, including school closures, were enacted to protect the public during the COVID-19 pandemic. However, the negative effects of mitigation measures are not fully known. Adolescents are uniquely vulnerable to policy changes since many depend on schools for physical, mental, and/or nutritional support.  This study explores the statistical relationships between school closures and adolescent firearm injuries (AFI) during the pandemic. METHODS: Data were drawn from a collaborative registry of 4 trauma centers in Atlanta, GA (2 adult and 2 pediatric). Firearm injuries affecting adolescents aged 11-21 years from 1/1/2016 to 6/30/2021 were evaluated. Local economic and COVID data were obtained from the Bureau of Labor Statistics and the Georgia Department of Health. Linear models of AFI were created based on COVID cases, school closure, unemployment, and wage changes. RESULTS: There were 1,330 AFI at Atlanta trauma centers during the study period, 1,130 of whom resided in the 10 metro counties. A significant spike in injuries was observed during Spring 2020. A season-adjusted time series of AFI was found to be non- stationary (p = 0.60). After adjustment for unemployment, seasonal variation, wage changes, county baseline injury rate, and county-level COVID incidence, each additional day of unplanned school closure in Atlanta was associated with 0.69 (95% CI 0.34- 1.04, p < 0.001) additional AFIs across the city. CONCLUSION: AFI increased during the COVID pandemic. This rise in violence is statistically attributable in part to school closures after adjustment for COVID cases, unemployment, and seasonal variation. These findings reinforce the need to consider the direct implications on public health and adolescent safety when implementing public policy.

Implementation of enhanced recovery protocols reduces opioid use in pediatric laparoscopic cholecystectomy surgery.

PURPOSE: Enhanced recovery protocols [ERPs] standardize care and have been demonstrated to improve surgical quality in adults. We retrospectively compared outcomes before and after implementation of ERPs in children undergoing elective laparoscopic cholecystectomy [ELC] surgery. METHODS: A pediatric-specific ERP was implemented for children undergoing ELC at one [C1] of the two Pediatric Surgical Centers in July 2016. We retrospectively reviewed 606 patients undergoing ELC between July 2014 and December 2019. Of these, 206 patients underwent ELC prior to ERP implementation [Pre-ERP] were compared to 400 patients undergoing ELC managed in the post-ERP implementation period (between January 2017 and December 2019), 21 of which were managed by enhanced recovery protocol. Primary Outcomes included immediate peri-operative and post-operative narcotic use in mean morphine equivalents [MME], narcotics at discharge, complications, nurse calls and returns to system [RTS]. RESULTS: There was a significant decrease in opioid use both post-operatively and at time of discharge in the ERP managed cohort. The MME use during the post-operative period was 0.85 in the in ERP-compliant patients compared to 6.40 in the non-compliant group (p < 0.027). Eighty-six percent of ERP-compliant patients in the study required no narcotics at discharge, which was statistically significant when compared to ERP non-compliant cohort (p < 0.0001). There was also no change in RTS, nurse calls or complications. In addition, in the post-ERP period (2017-2019), a dominant proportion of patients at C1 partially complied with the ERP, resulting in a statistically significantly decrease of opioid use between sites in the post-op period (6.54 vs 10.57 MME) post-ERP (p < 0.001). Similar effects were noted in discharge narcotics. CONCLUSION: The use of pediatric-specific ERP in children undergoing ELC is safe, effective, and provides compassionate pain control while leading to a reduction in opioid use peri-operatively and at discharge. This improvement occurred without changes in RTS, nursing calls or complications. LEVEL OF EVIDENCE: Level III; Retrospective study.

Excellence and duty: Dr. James F. Densler, the first black pediatric surgeon in the United States.

Dr. James F. Densler is a remarkable figure in pediatric surgery for both his pioneering of pediatric operations and, perhaps more importantly, shattering racial barriers. Despite growing up in the segregated South, being barred admission to his initial medical school of choice and experiencing a racially motivated bombing while in medical school, Densler persevered with the desire to fulfill the need he saw in his community, becoming the first practicing Black pediatric surgeon in the United States. His continued devotion to service later led him become a critical figure in the education of students at the newly formed Morehouse School of Medicine in Atlanta, Georgia. Through an extensive literature review and personal interviews with Dr. Densler and his colleagues, this paper outlines Dr. James Densler's life, surgical career, and the indelible mark he leaves behind.

Implementation of enhanced recovery protocols reduces opioid use in pediatric laparoscopic Heller myotomy surgery.

BACKGROUND: Enhanced recovery protocols (ERPs) are effective means of standardizing and improving the quality of surgical care in adults. Our purpose was to retrospectively compare outcomes before and after implementation of ERPs in children undergoing laparoscopic Heller myotomy for achalasia. METHODS: A pediatric-specific ERP was used for children undergoing laparoscopic Heller myotomy starting July 2017 at two pediatric surgery centers within a single metropolitan healthcare system. A retrospective review of 8 patients undergoing Heller myotomies between July 2014 and July 2017 was performed as a control. This cohort was compared to 14 patients managed post-ERP implementation (2017-2020). Outcomes of interest investigated included opioid use during admission, narcotics at discharge, time to regular diet, length of stay (LOS), and readmissions. RESULTS: There was a significant decrease in opioid use both while in the hospital and at time of discharge. Mean morphine equivalent use was 4.50 mg in the pre-ERP cohort and 1.97 mg in the post-ERP cohort. Furthermore, 8 out of 14 (57%) patients in the post-ERP cohort received no opioids during the admission compared with only 2 out of 8 (25%) patients in the pre-ERP cohort. Only 1 out of 14 (7.14%) patients in the post-ERP cohort was discharged with a prescription for opioid medication while 6 out of 8 (75%) in the pre-ERP cohort were discharged with an opiate prescription. CONCLUSIONS: The use of ERP in children undergoing laparoscopic Heller myotomy surgery is safe and effective and leads to a reduction in opioid use during admission and at discharge. LEVELS OF EVIDENCE: Level III.