Neighborhood child opportunity is associated with hospital length of stay following pediatric burn injury.

INTRODUCTION: Pediatric burns are associated with socioeconomic disadvantage and lead to significant morbidity. The Child Opportunity Index (COI) is a well-validated measure of neighborhood characteristics associated with healthy child development. We sought to evaluate the relationship between COI and outcomes of burn injuries in children. METHODS: We performed a single-institution retrospective review of pediatric (<16 years) burn admissions between 2015 and 2019. Based on United States residential zip codes, patients were stratified into national COI quintiles. We performed a multivariate Poisson regression analysis to determine the association between COI and increased length of stay. RESULTS: 2095 pediatric burn admissions occurred over the study period. Most children admitted were from very low (n = 644, 33.2 %) and low (n = 566, 29.2 %) COI neighborhoods. The proportion of non-Hispanic Black patients was significantly higher in neighborhoods with very low (44.5 %) compared to others (low:28.8 % vs. moderate:11.9 % vs. high:10.5 % vs. very high:4.3 %) (p < 0.01). Hospital length of stay was significantly longer in patients from very low COI neighborhoods (3.6 ± 4.1 vs. 3.2 ± 4.9 vs. 3.3 ± 4.8 vs. 2.8 ± 3.5 vs. 3.2 ± 8.1) (p = 0.02). On multivariate regression analysis, living in very high COI neighborhoods was associated with significantly decreased hospital length of stay (IRR: 0.51; 95 % CI: 0.45-0.56). CONCLUSION: Children from neighborhoods with significant socioeconomic disadvantage, as measured by the Child Opportunity Index, had a significantly higher incidence of burn injuries resulting in hospital admissions and longer hospital length of stay. Public health interventions focused on neighborhood-level drivers of childhood development are needed to decrease the incidence and reduce hospital costs in pediatric burns. TYPE OF STUDY: Retrospective study LEVEL OF EVIDENCE: Level III.

Postoperative Antibiotics, Outcomes, and Resource Use in Children With Gangrenous Appendicitis.

Importance: Gangrenous, suppurative, and exudative (GSE) findings have been associated with increased surgical site infection (SSI) risk and resource use in children with nonperforated appendicitis. Establishing the role for postoperative antibiotics may have important implications for infection prevention and antimicrobial stewardship. Objective: To compare SSI rates in children with nonperforated appendicitis with GSE findings who did and did not receive postoperative antibiotics. Design, Setting, and Participants: This was a retrospective cohort study using American College of Surgeons' National Surgical Quality Improvement Program (NSQIP)-Pediatric Appendectomy Targeted data from 16 hospitals participating in a regional research consortium. NSQIP data were augmented with operative report and antibiotic use data obtained through supplemental medical record review. Children with nonperforated appendicitis with GSE findings who underwent appendectomy between July 1, 2015, and June 30, 2020, were identified using previously validated intraoperative criteria. Data were analyzed from October 2022 to July 2023. Exposure: Continuation of antibiotics after appendectomy. Main Outcomes and Measures: Rate of 30-day postoperative SSI including both incisional and organ space infections. Complementary hospital and patient-level analyses were conducted to explore the association between postoperative antibiotic use and severity-adjusted outcomes. The hospital-level analysis explored the correlation between postoperative antibiotic use and observed to expected (O/E) SSI rate ratios after adjusting for differences in disease severity (presence of gangrene and postoperative length of stay) among hospital populations. In the patient-level analysis, propensity score matching was used to balance groups on disease severity, and outcomes were compared using mixed-effects logistic regression to adjust for hospital-level clustering. Results: A total of 958 children (mean [SD] age, 10.7 [3.7] years; 567 male [59.2%]) were included in the hospital-level analysis, of which 573 (59.8%) received postoperative antibiotics. No correlation was found between hospital-level SSI O/E ratios and postoperative antibiotic use when analyzed by either overall rate of use (hospital median, 53.6%; range, 31.6%-100%; Spearman ρ = -0.10; P = .71) or by postoperative antibiotic duration (hospital median, 1 day; range, 0-7 days; Spearman ρ = -0.07; P = .79). In the propensity-matched patient-level analysis including 404 patients, children who received postoperative antibiotics had similar rates of SSI compared with children who did not receive postoperative antibiotics (3 of 202 [1.5%] vs 4 of 202 [2.0%]; odds ratio, 0.75; 95% CI, 0.16-3.39; P = .70). Conclusions and Relevance: Use of postoperative antibiotics did not improve outcomes in children with nonperforated appendicitis with gangrenous, suppurative, or exudative findings.

Utility of a Benchmarking Report for Balancing Infection Prevention and Antimicrobial Stewardship in Children with Complicated Appendicitis.

OBJECTIVE: To develop a severity-adjusted, hospital-level benchmarking comparative performance report for postoperative organ space infection and antibiotic utilization in children with complicated appendicitis. BACKGROUND: No benchmarking data exist to aid hospitals in identifying and prioritizing opportunities for infection prevention or antimicrobial stewardship in children with complicated appendicitis. METHODS: This was a multicenter cohort study using NSQIP-Pediatric data from 16 hospitals participating in a regional research consortium, augmented with antibiotic utilization data obtained through supplemental chart review. Children with complicated appendicitis who underwent appendectomy from 07/01/2015 to 06/30/2020 were included. Thirty-day postoperative OSI rates and cumulative antibiotic utilization were compared between hospitals using observed-to-expected (O/E) ratios after adjusting for disease severity using mixed effects models. Hospitals were considered outliers if the 95% confidence interval for O/E ratios did not include 1.0. RESULTS: 1790 patients were included. Overall, the OSI rate was 15.6% (hospital range: 2.6-39.4%) and median cumulative antibiotic utilization was 9.0 days (range: 3.0-13.0). Across hospitals, adjusted O/E ratios ranged 5.7-fold for OSI (0.49-2.80, P=0.03) and 2.4-fold for antibiotic utilization (0.59-1.45, P<0.01). Three (19%) hospitals were outliers for OSI (1 high and 2 low performers), and eight (50%) were outliers for antibiotic utilization (5 high and 3 low utilizers). Ten (63%) hospitals were identified as outliers in one or both measures. CONCLUSIONS: A comparative performance benchmarking report may help hospitals identify and prioritize quality improvement opportunities for infection prevention and antimicrobial stewardship, as well as identify exemplar performers for dissemination of best practices.

Health Literacy and Health-care Resource Utilization Following Gastrostomy Tube Placement in Pediatric Patients.

INTRODUCTION: Parental health literacy and neighborhood socioeconomic disadvantage are associated with adverse health outcomes and increased health-care resource utilization in children. We sought to evaluate the association between community-level health literacy and neighborhood socioeconomic disadvantage and their relationships with outcomes of pediatric patients undergoing gastrostomy tube (GT) placement. METHODS: Pediatric patients who underwent GT placement from 2000 to 2019 were identified using the IBM MarketScan Research database. Claims data were merged with the health literacy index (HLI) and area deprivation index (ADI), measures of community-level health literacy and neighborhood socioeconomic disadvantage, respectively. We used multivariate logistic regression to estimate factors associated with postoperative 30- and 90-day ED visits (EVs) and 30-day readmissions. RESULTS: A total of 4374 pediatric patients underwent GT placement. In this cohort, 6.1% and 11.4% had 30-day and 90-day EV; and 30-day readmissions in 19.75%. HLI was lower in those with 30-(244.6 ± 6.1 versus 245.4 ± 6.1; P = 0.0482) and 90-(244.5 ± 5.8 versus 245.5 ± 6.1; P = 0.001) day EV, and 30-day readmission (244.5 ± 5.56 versus 245.4 ± 6.1; P = 0.001) related to GT. ADI was lower in those with 90-day EV (55.1 ± 13.1 versus 55.9 ± 14.6; P = 0.0244). HLI was associated with decreased odds of 30- (adjusted odds ratio: 0.968; 95% confidence interval: 0.941-0.997) and 90-day (adjusted odds ratio: 0.975; 95% confidence interval: 0.954-0.998) EV following GT placement. ADI was also significantly associated with 30 and 90-day EV following GT placement. CONCLUSIONS: In pediatric patients undergoing GT placement, higher ecologically-measured health literacy and neighborhood socioeconomic disadvantage are associated with decreased health-care resource utilization, as evidenced by decreased ED visits. Future studies should focus on the role of individual parental health literacy in outcomes of pediatric surgical patients.

Central Line-Associated Bloodstream Infection Risk Factors in a Pediatric Population.

BACKGROUND: Central venous line (CVL) placement in children is often necessary for treatment and may be complicated by central line-associated bloodstream infection (CLABSI). We hypothesize that line type and clinical and demographic factors at line placement impact CLABSI rates. METHODS: This is a single-institution case-control study of pediatric patients (≤18 years old) admitted between January 1, 2015, and December 31, 2019. Case patients had a documented CLABSI. Control patients had a CVL placed during the study period and were matched by sex and age in a 2:1 ratio. Bivariate and multivariate logistic regression analysis was performed. RESULTS: We identified 78 patients with a CLABSI and 140 patients without a CLABSI. After controlling for pertinent covariates, patients undergoing tunneled or non-tunneled CVL had higher odds of CLABSI than those undergoing PICC (OR 2.51, CI 1.12-5.64 and OR 3.88, CI 1.06-14.20 respectively), and patients undergoing port placement had decreased odds of CLABSI compared to PICC (OR .05, CI 0.01-.51). There were lower odds of CLABSI when lines were placed for intravenous medications compared to those placed for solid tumor malignancy (OR .15, CI .03-.79). Race and age were not statistically significant risk factors. DISCUSSION: Central lines placed for medication administration compared to solid tumors, PICC compared to tunneled and non-tunneled central lines, and ports compared to PICC were associated with lower odds of CLABSI. Future improvement efforts should focus on PICC and port placement in appropriate patients to decrease CLABSI rates.

Use of Antipseudomonal Antibiotics is not Associated with Lower Rates of Postoperative Drainage Procedures or More Favorable Culture Profiles in Children with Complicated Appendicitis: Results from a Multicenter Regional Research Consortium.

OBJECTIVE: To compare rates of postoperative drainage and culture profiles in children with complicated appendicitis treated with the two most common antibiotic regimens with and without antipseudomonal activity (piperacillin-tazobactam [PT] and ceftriaxone with metronidazole [CM]). SUMMARY OF BACKGROUND DATA: Variation in use of antipseudomonal antibiotics has been driven by a paucity of multicenter data reporting clinically relevant, culture-based outcomes. METHODS: Retrospective cohort study of patients with complicated appendicitis (7/2015-6/2020) using NSQIP-Pediatric data from 15 hospitals participating in a regional research consortium. Operative report details, antibiotic utilization, and culture data were obtained through supplemental chart review. Rates of 30-day postoperative drainage and organism-specific culture positivity were compared between groups using mixed effects regression to adjust for clustering after propensity matching on measures of disease severity. RESULTS: 1002 children met criteria for matching (58.9% received CM and 41.1% received PT). In the matched sample of 778 patients, children treated with PT had similar rates of drainage overall (PT: 11.8%, CM: 12.1%; OR 1.44 [OR:0.71-2.94]) and higher rates of drainage associated with growth of any organism (PT: 7.7%, CM: 4.6%; OR 2.41 [95%CI:1.08-5.39]) and Escherichia coli (PT: 4.6%, CM: 1.8%; OR 3.42 [95%CI:1.07-10.92]) compared to treatment with CM. Rates were similar between groups for drainage associated with multiple organisms (PT: 2.6%, CM: 1.5%; OR 3.81 [95%CI:0.96-15.08]) and Pseudomonas (PT: 1.0%, CM: 1.3%; OR 3.42 [95%CI:0.55-21.28]). CONCLUSIONS AND RELEVANCE: Use of antipseudomonal antibiotics is not associated with lower rates of postoperative drainage procedures or more favorable culture profiles in children with complicated appendicitis.

Injury Patterns, Imaging Usage, and Disparities Associated With Car Restraint Use in Children.

BACKGROUND: Motor vehicle collision (MVC) is a leading cause of accidental death in children. Despite effective forms of child safety restraint (eg, car seat and booster seat), studies demonstrate poor compliance with guidelines. The goal of this study was to delineate injury patterns, imaging usage, and potential demographic disparities associated with child restraint use following MVC. METHODS: A retrospective review of the North Carolina Trauma Registry was performed to determine demographic factors and outcomes associated with improper restraint of children (0-8 years) involved in MVC from 2013 to 2018. Bivariate analysis was performed by the appropriateness of restraint. Multivariable Poisson regression identified demographic factors for the relative risk of inappropriate restraint. RESULTS: Inappropriately restrained patients were older (5.1 years v. 3.6 yrs, P < .001) and weighed more (44.1 lbs v. 35.3 lbs, P < .001). A higher proportion of African American (56.9% v. 39.3%, P < .001) and Medicaid (52.2% v. 39.0%, P < .001) patients were inappropriately restrained. Multivariable Poisson regression showed that African American patients (RR 1.43), Asian patients (RR 1.51), and Medicaid payor status (RR 1.25) were associated with a higher risk of inappropriate restraint. Inappropriately restrained patients had a longer length of stay, but injury severity score and mortality were no different. DISCUSSION: African American children, Asian children, and Medicaid insurance payor status patients had an increased risk of inappropriate restraint use in MVC. This study describes unequal restraint patterns in children, which suggests opportunity for targeted patient education and necessitates research to further delineate the underlying etiology of these differences.

Difference in Postoperative Outcomes and Perioperative Resource Utilization Between General Surgeons and Pediatric Surgeons: A Systematic Review.

Background: Both general surgeons (GS) and pediatric surgeons (PS) perform a high volume of appendectomies in pediatric patients, but there is a paucity of data on these outcomes based on surgeon training. We performed a systematic review and meta-analysis to compare postoperative outcomes and perioperative resource utilization for pediatric appendectomies.Methods: We searched PubMed to identify articles examining the association between surgeon specialization and outcomes for pediatric patients undergoing appendectomies. Study selection, data extraction, risk of bias assessment, and quality assessment were performed by one reviewer, with another reviewer to resolve discrepancies.Results: We identified 4799 articles, with 98.4% (4724/2799) concordance after initial review. Following resolution of discrepancies, 16 studies met inclusion criteria. Of the studies that reported each outcome, GS and PS demonstrated similar rates of readmission within 30 days (pooled RR 1.61 95% CI 0.66, 2.55) wound infections (pooled RR 1.07, 95% CI .55, 1.60), use of laparoscopic surgery (pooled RR 1.87, 95% CI .21, 3.53), postoperative complications (pooled RR 1.40, 95% CI .83, 1.97), use of preoperative imaging (pooled RR .98,95% CI .90, 1.05), and intra-abdominal abscesses (pooled RR .80, 95% CI .03, 1.58). Patients treated by GS did have a significantly higher risk of negative appendectomies (pooled RR 1.47, 95% CI 1.10, 1.84) when compared to PS.Discussion: This is the first meta-analysis to compare outcomes for pediatric appendectomies performed by GS compared to PS. Patient outcomes and resource utilization were similar among PS and GS, except for negative appendectomies were significantly more likely with GS.

The Effect of an Enhanced Recovery Protocol on Pediatric Colorectal Surgical Patient Outcomes at a Single Institution.

INTRODUCTION: Enhanced recovery protocols (ERP) have been associated with fewer postoperative complications in adult colorectal surgery patients, but there is a paucity of data on pediatric patients. Our aim is to describe the effect of an ERP, compared to conventional care, on pediatric colorectal surgical complications. MATERIALS AND METHODS: We performed a single institution, retrospective cohort study (2014-2020) on pediatric (≤18 years old) colorectal surgery patients pre- and post-implementation of an ERP. Bivariate analysis and logistic regression were used to assess the effect of an ERP on return visits to the emergency room, reoperation, and readmission within 30-days. RESULTS: There were 194 patients included in this study, with 54 in the control cohort and 140 in the ERP cohort. There was no significant difference in the age, BMI, primary diagnosis, or use of laparoscopic technique between the cohorts. The ERP cohort had a significantly shorter foley duration, postoperative stay, and had nerve blocks performed. After controlling for pertinent covariates, the ERP cohort experienced higher odds of reoperation within 30 days (OR 5.83, P = .04). There was no significant difference in the other outcomes analyzed. CONCLUSION: In this study, there was no difference in the odds of overall complications, readmission or return to the ER within 30-days of surgery. However, although infrequent, there were higher odds of returns to the OR within 30 days. Future studies are needed to analyze how adherence to individual components may influence patient outcomes to ensure patient safety during ERP implementation.

Outcomes in Pediatric Burn Patients With Additional Trauma-Related Injuries.

The addition of trauma to burn injuries may result in higher morbidity and mortality. The purpose of this study was to evaluate the outcomes of pediatric patients with a combination of burn and trauma injuries, and included all pediatric Burn only, Trauma only, and combined Burn-Trauma patients admitted between 2011 and 2020. Mean length of stay, ICU length of stay, and ventilator days were highest for the Burn-Trauma group. The odds of mortality were almost 13 times higher for the Burn-Trauma group when compared to the Burn only group (P = .1299). After using inverse probability of treatment weighting, the odds of mortality were almost 10 times higher for the Burn-Trauma group in comparison to the Burn only group (P < .0066). Thus, the addition of trauma to burn injuries was associated with increased odds of mortality, as well as longer ICU and overall hospital length of stay in this patient population.

Costs and recurrence of inguinal hernia repair in premature infants during neonatal admission.

BACKGROUND: Timing of inguinal hernia repair (IHR) in premature infants remains variable, yet the impact of IHR timing on procedure costs and recurrence is unclear. We sought to compare cost and recurrence rates of IHR in premature infants based on timing of repair. METHODS: We performed a retrospective cohort study using MarketScan insurance claims data from 2007 to 2018 to evaluate IHR occurring within 365 days of birth in preterm infants (gestational age [GA]<37 weeks at birth). Patients were stratified based on timing of IHR: those occurring during and after neonatal discharge. Hernia recurrences within one year following IHR were identified. Patient demographic characteristics and costs were compared between groups. Time to recurrence and cumulative recurrence hazards were estimated using Kaplan Meier analysis and Cox proportional hazards regression. RESULTS: We identified 3,662 preterm infants with IHR within 365 days of birth; 1,054(28.8%) occurred early. Infants with IHR during NICU stay were more likely to have GA at birth≤32 weeks (74.7% vs. 37.2%; p<0.01) and birthweight<1500 g (83.0% vs. 40.3%; p<0.01) compared to post-NICU IHR. The hernia recurrence rate was higher and total procedure costs lower in early IHR. Early IHR (HR:1.86, 95% CI: 1.56-2.22), incarcerated/strangulated hernia (HR:1.86, 95% CI:1.49-2.32), GA≤32 weeks (HR: 1.40, 95% CI: 1.19-1.65), and congenital anomalies (HR: 1.32, 95% CI: 1.12-1.57) were predictors of hernia recurrence. CONCLUSION: Using insurance claims data, IHR performed during initial neonatal admission was associated with lower cost, but higher recurrence rate, when compared to delayed repairs in preterm infants. TYPE OF STUDY: Retrospective study LEVEL OF EVIDENCE: Level III.

Cost of Pediatric Trauma: A Comparison of Non-Accidental and Accidental Trauma in Pediatric Patients.

BACKGROUND: Nonaccidental trauma (NAT) affects >100,000 children in the United States every year and is associated with significant mortality and morbidity. Little is known about the financial burden of NAT, particularly in comparison to accidental trauma (AT). We sought to compare hospital charges and outcomes between children presenting with NAT and AT. METHODS: Pediatric (<16 y) trauma hospitalizations from 2006 to 2018 were identified using the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and Kid's Inpatient Sample (KID) databases. Hospitalizations were identified as NAT or AT based on ICD codes. Discharge weights were used to obtain national estimates and standardize them across the different sampling structures. Outcomes (hospital charges, length of stay (LOS), and mortality) were compared, and multivariate regression analyses were used to assess independent predictors of hospital charges and mortality. RESULTS: Fifty-eight Thousand Two Hundred Seventy-five pediatric hospitalizations were included with 17,954 (0.3%) categorized as NAT. Children with NAT were younger, more female, less likely to identify as White, and more under public insurance than those with AT. Hospital charges were significantly higher in patients with NAT ($27,100 versus $19,900, P < 0.0001). Mortality (4.9% versus 0.0%, P < 0.0001) and LOS (3.2 d versus 1.5 d, P < 0.0001) were significantly higher among patients with NAT. Multivariable regression analyses identified NAT as a predictor of higher hospital charges, mortality, and LOS. CONCLUSIONS: Nonaccidental trauma in pediatric patients is associated with significantly higher hospital charges, mortality, and LOS than accidental trauma. Ongoing research focused on the relative impact of known risk factors and resource utilization is needed.

Appendectomy by Pediatric Surgeons in North Carolina is Associated With Higher Charge Than General Surgeons.

INTRODUCTION: The delivery of pediatric surgical care for acute appendicitis involves general surgeons (GS) and pediatric surgeons (PS), but the differences in clinical practice are primarily undescribed. We examined charge differences between GS and PS for the treatment of pediatric acute appendicitis. METHODS: We performed a retrospective review of the North Carolina hospital discharge database (2013-2017) in pediatric patients (≤18 y) who had surgery for appendiceal pathology (acute or chronic appendicitis and other appendiceal pathology). We performed a bivariate analysis of surgical charges over the type of surgical providers (GS, PS, other specialty, and unassigned surgeons). RESULTS: Over the study period, 21,049 patients had appendicitis or other diseases of the appendix, and 15,230 (72.4%) underwent appendectomy. Patients who were operated on by PS were younger (10 y, interquartile range (IQR): 6-13 versus 13 y, IQR: 9-16, P < 0.001). Acute appendicitis was diagnosed in 2860 (44.3%) and 3173 (49.2%) of the PS and GS cohorts, respectively, P = 0.008. PS compared to GS performed a higher percentage of laparoscopic (n = 2,697, 89.4% versus n = 2,178, 65.5%) than open appendectomies (n = 280, 9.3% versus n = 1,118, 33.6%), P < 0.001. The overall hospital charges were $28,081 (IQR: $21,706-$37,431) and $24,322 (IQR: $17,906-$32,226) for PS and GS, respectively, P < 0.001. Surgical charges where higher for PS than GS, $12,566 (IQR: $9802-$17,462) and $8051 (IQR: $5872-$2331), respectively. When controlling for diagnosis, surgical approach, emergent status, age, and surgical cost of appendiceal surgery, and hospital charges following appendiceal surgery were $4280 higher for PS than GS (95% CI: 3874-4687). CONCLUSIONS: The total charge for operations for appendiceal disease is significantly higher for PS compared to GS. Pediatric surgeons had increased surgical charges compared to GS but decreased radiology charges. The specific reasons for these differences are not clearly delineated in this data set and persist after controlling for relevant covariates. However, these data demonstrate that increasing value in pediatric appendicitis may require specialty-based targets.

Association of Gangrenous, Suppurative, and Exudative Findings With Outcomes and Resource Utilization in Children With Nonperforated Appendicitis.

Importance: The clinical significance of gangrenous, suppurative, or exudative (GSE) findings is poorly characterized in children with nonperforated appendicitis. Objective: To evaluate whether GSE findings in children with nonperforated appendicitis are associated with increased risk of surgical site infections and resource utilization. Design, Setting, and Participants: This multicenter cohort study used data from the Appendectomy Targeted Database of the American College of Surgeons Pediatric National Surgical Quality Improvement Program, which were augmented with operative report data obtained by supplemental medical record review. Data were obtained from 15 hospitals participating in the Eastern Pediatric Surgery Network (EPSN) research consortium. The study cohort comprised children (aged ≤18 years) with nonperforated appendicitis who underwent appendectomy from July 1, 2015, to June 30, 2020. Exposures: The presence of GSE findings was established through standardized, keyword-based audits of operative reports by EPSN surgeons. Interrater agreement for the presence or absence of GSE findings was evaluated in a random sample of 900 operative reports. Main Outcomes and Measures: The primary outcome was 30-day postoperative surgical site infections (incisional and organ space infections). Secondary outcomes included rates of hospital revisits, postoperative abdominal imaging, and postoperative length of stay. Multivariable mixed-effects regression was used to adjust measures of association for patient characteristics and clustering within hospitals. Results: Among 6133 children with nonperforated appendicitis, 867 (14.1%) had GSE findings identified from operative report review (hospital range, 4.2%-30.2%; P < .001). Reviewers agreed on presence or absence of GSE findings in 93.3% of cases (weighted κ, 0.89; 95% CI, 0.86-0.92). In multivariable analysis, GSE findings were associated with increased odds of any surgical site infection (4.3% vs 2.2%; odds ratio [OR], 1.91; 95% CI, 1.35-2.71; P < .001), organ space infection (2.8% vs 1.1%; OR, 2.18; 95% CI, 1.30-3.67; P = .003), postoperative imaging (5.8% vs 3.7%; OR, 1.70; 95% CI, 1.23-2.36; P = .002), and prolonged mean postoperative length of stay (1.6 vs 0.9 days; rate ratio, 1.43; 95% CI, 1.32-1.54; P < .001). Conclusions and Relevance: In children with nonperforated appendicitis, findings of gangrene, suppuration, or exudate are associated with increased surgical site infections and resource utilization. Further investigation is needed to establish the role and duration of postoperative antibiotics and inpatient management to optimize outcomes in this cohort of children.

Extracorporeal Membrane Oxygenation for COVID-19-Associated Multisystem Inflammatory Syndrome in a 5-year-old.

Severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) is associated with multisystem inflammatory syndrome in children (MIS-C) that ranges from mild symptoms to cardiopulmonary collapse. A 5-year-old girl presented with shock and a rapid decline in left ventricular function requiring intubation. SARS-CoV-2 was diagnosed by viral Polymerase Chain Reaction (PCR), and she received remdesivir and COVID-19 convalescent plasma. Initial echocardiogram (ECHO) demonstrated low normal left ventricular function and mild left anterior descending coronary artery dilation. She remained hypotensive, despite high-dose epinephrine and norepinephrine infusions as well as stress-dose hydrocortisone. Admission SARS-CoV-2 IgG assay was positive, meeting the criteria for MIS-C. An ECHO 9 hours after admission demonstrated a severe decline in left ventricular function. Due to severe cardiogenic shock, she was cannulated for venoarterial extracorporeal support (ECMO). During her ECMO course, she was treated with remdesivir, intravenous methylprednisolone, intravenous immunoglobulin, and anakinra. She was decannulated on ECMO day 7, extubated the following day, and discharged home 2 weeks later without respiratory or cardiac support. The use of ECMO for cardiopulmonary support for pediatric patients with MIS-C is feasible and should be considered early as part of the treatment algorithm for patients with severe cardiopulmonary dysfunction.

Implementation of Electronic Clinical Decision Support Tools for Antibiotic Stewardship in Pediatric Appendicitis.

BACKGROUND: The efficacy of clinical decision support (CDS) tools to promote antibiotic stewardship in pediatric appendicitis remains poorly understood. Here, we developed an electronic order panel (OP) to assist with decreased utilization of extended spectrum antibiotics. METHODS: Retrospective review of patients (≤18 years) at a single institution from May 2018 to October 2019 treated with ≥1 dose of preferred (narrow) or nonpreferred (broad-spectrum) antibiotics was performed, and they were categorized as pre- (PIC) or postimplementation cohorts (PISC). RESULTS: Of 234 encounters, 170 (73%) and 107 (46%) received preferred and nonpreferred antibiotics, respectively. Postimplementation cohort encounters had a sustained 50% increase in preferred antibiotic use compared to PIC (92% vs 42%, P = .014). Order panel utilization accounted for 31% of overall encounters and 44% of PISC encounters. CONCLUSION: Despite sustained improvement in antibiotic stewardship, OP utilization remains low. The use of CDS tools may not be a good process measure for quality improvement.

Factors associated with inguinal hernia repair in premature infants during neonatal admission.

INTRODUCTION: Timing of inguinal hernia repair (IHR) in premature infants is variable and influenced by surgeon preference and complication profile. The purpose of this study was to evaluate factors related to early IHR, defined as hernia repair during initial neonatal admission, in premature infants. METHODS: Neonatal hospitalizations of premature infants (gestational age at birth < 37 weeks and ≤ 28 days old at admission), with a diagnosis of inguinal hernia from 2010 to 2017 in HCUP National Inpatient Sample and Kid's Inpatient Sample databases were evaluated. Multivariable Cox proportional hazard models was used to estimate associations between demographics, additional procedures, hospital characteristics, and early IHR. RESULTS: Overall, 30,298 neonatal hospitalizations of premature infants with inguinal hernia were identified; 13,228 (43.3%) underwent early IHR. Early IHR was more likely with older gestational age at birth (35-36 weeks vs < 24 weeks, HR 6.05, 95% CI 4.17, 8.79), female sex (HR 1.20, 95% CI 1.07, 1.34), and undergoing concomitant gastrostomy (HR 2.51, 95% CI 1.72, 3.66). Non-Hispanic Black infants (HR 0.84, 95% CI 0.75, 0.95), infants at urban non-teaching hospitals (HR 0.15, 95% CI 0.07, 0.33), and infants at rural hospitals (HR 0.81, 95% CI 0.70, 0.97) were less likely to undergo early IHR. CONCLUSIONS: Using a nationally representative database, early IHR in premature neonates was more commonly performed in non-Hispanic White, female neonates and at urban teaching hospitals. Patient race and hospital type were determinants of early IHR in premature neonates. There is a need to further evaluate the impact of race and socioeconomic factors on outcomes of common pediatric operations like inguinal hernia repairs. LEVEL OF EVIDENCE: Level III.

The Impact of General Surgeons on Pediatric Surgical Practice in North Carolina: The Reality of Pediatric Surgical Care Delivery.

OBJECTIVE: The aim of this study was to define the training background of the actual surgical workforce providing care to pediatric patients in North Carolina (NC). BACKGROUND: Due to database limitations, pediatric surgical workforce studies have not included general surgeons (GS) who operate on children. Defining the role of GS in care delivery affects policy for clinical care and general and pediatric surgical training. METHODS: We performed a retrospective review of the NC Hospital Discharge Database (2011-2017), including pediatric patients (<18 years) undergoing the most frequent general surgery procedures. Descriptive and correlational analysis over surgical provider [Pediatric Surgeon (PS), GS], and other specialties (OSS), was performed using logistic regression modeling to identify factors associated with surgery by a PS. RESULTS: Of the 57,265 discharges analyzed, pediatric, general, and other specialty surgeons operated on 25,514 (44.6%), 18,581 (32.5%), and 9049 (15.8%), respectively. In a logistic regression model, PS had lower odds of operating on older patients [odds ratio (OR) 0.9, 95% confidence interval (CI) 0.90-0.91]. However, PS were more likely to operate on female patients (OR 1.58, 95% CI 1.53-1.65), Black (OR 1.49, 95% CI 1.43-1.56), and other minority patients (OR 1.23, 95% CI 1.17-1.29) when compared to white patients. PS were also more likely to operate on patients with private insurance (OR 1.38, 95% CI 1.33-1.43) compared to government insurance, and patients undergoing emergency surgery (OR 1.44, 95% CI 1.38-1.50). CONCLUSION: In NC, general surgeons performed a third of the operations on children. After controlling for covariates, pediatric surgeons in NC are more likely to operate on minority and emergency surgery patients, and this is the first study to describe this important practice pattern.

Intravenous Delivery of Lung-Targeted Nanofibers for Pulmonary Hypertension in Mice.

Pulmonary hypertension is a highly morbid disease with no cure. Available treatments are limited by systemic adverse effects due to non-specific biodistribution. Self-assembled peptide amphiphile (PA) nanofibers are biocompatible nanomaterials that can be modified to recognize specific biological markers to provide targeted drug delivery and reduce off-target toxicity. Here, PA nanofibers that target the angiotensin I-converting enzyme and the receptor for advanced glycation end-products (RAGE) are developed, as both proteins are overexpressed in the lung with pulmonary hypertension. It is demonstrated that intravenous delivery of RAGE-targeted nanofibers containing the targeting epitope LVFFAED (LVFF) significantly accumulated within the lung in a chronic hypoxia-induced pulmonary hypertension mouse model. Using 3D light sheet fluorescence microscopy, it is shown that LVFF nanofiber localization is specific to the diseased pulmonary tissue with immunofluorescence analysis demonstrating colocalization of the targeted nanofiber to RAGE in the hypoxic lung. Furthermore, biodistribution studies show that significantly more LVFF nanofibers localized to the lung compared to major off-target organs. Targeted nanofibers are retained within the pulmonary tissue for 24 h after injection. Collectively, these data demonstrate the potential of a RAGE-targeted nanomaterial as a drug delivery platform to treat pulmonary hypertension.