Golf cart injuries have similar severity to all-terrain vehicle injuries in children: a multicenter comparison over a 5-year period.

Background: Golf carts (GCs) and all-terrain vehicles (ATVs) are popular forms of personal transport. Although ATVs are considered adventurous and dangerous, GCs are perceived to be safer. Anecdotal experience suggests increasing numbers of both GC and ATV injuries, as well as high severity of GC injuries in children. This multicenter study examined GC and ATV injuries and compared their injury patterns, resource utilization, and outcomes. Methods: Pediatric trauma centers in Florida submitted trauma registry patients age <16 years from January 2016 to June 2021. Patients with GC or ATV mechanisms were identified. Temporal trends were evaluated. Injury patterns, resource utilization, and outcomes for GCs and ATVs were compared. Intensive care unit admission and immediate surgery needs were compared using multivariable logistic regression. Results: We identified 179 GC and 496 ATV injuries from 10 trauma centers. GC and ATV injuries both increased during the study period (R2 0.4286, 0.5946, respectively). GC patients were younger (median 11 vs 12 years, p=0.003) and had more intracranial injuries (34% vs 19%, p<0.0001). Overall Injury Severity Score (5 vs 5, p=0.27), intensive care unit (ICU) admission (20% vs 16%, p=0.24), immediate surgery (11% vs 11%, p=0.96), and mortality (1.7% vs 1.4%, p=0.72) were similar for GCs and ATVs, respectively. The risk of ICU admission (OR 1.19, 95% CI 0.74 to 1.93, p=0.47) and immediate surgery (OR 1.04, 95% CI 0.58 to 1.84, p=0.90) remained similar on multivariable logistic regression. Conclusions: During the study period, GC and ATV injuries increased. Despite their innocuous perception, GCs had a similar injury burden to ATVs. Heightened safety measures for GCs should be considered. Level of evidence: III, prognostic/epidemiological.

Identifying Injuries Suggestive of Child Physical Abuse: An Innovative Application of the Trauma Quality Improvement Program.

BACKGROUND: Child physical abuse (CPA) carries high risk of morbidity and mortality. Screening for CPA may be limited by subjective risk criteria and racial and socioeconomic biases. This study derived, validated, and compared age-stratified International Classification of Diseases, 10th revision (ICD-10) diagnosis codes indicating high risk of CPA. METHODS: Injured children age < 6 years from the Trauma Quality Improvement Program (TQIP) database were included; years 2017-18 were used for derivation and 2019 for validation. Confirmed CPA was defined as a report of abuse plus discharge with alternate caregiver. Patients were classified as high vs. low CPA risk by three methods: 1) abuse-specific ICD-10 codes, 2) previously validated high-risk ICD-9 codes crosswalked to equivalent ICD-10 codes, and 3) empirically-derived ICD-10 codes from TQIP. These methods were compared with respect to sensitivity, specificity, area under the receiver-operator curve (AUROC), and uniformity across race and insurance strata. RESULTS: A total of 122,867 children were included (81,347 derivation cohort, 41,520 validation cohort). Age-stratified high-risk diagnoses derived from TQIP consisted of 40 unique codes for age 0-2, 30 codes for age 3-4, and 20 codes for age 5-6. In the validation cohort, 890 children (2.1%) had confirmed CPA. On comparison with abuse-specific and crosswalked ICD-9 codes, TQIP-derived codes had the highest sensitivity (70% vs. 19% vs. 54%) and the highest AUROC (0.74 vs. 0.59 vs. 0.68, p < 0.0001) for confirmed abuse across all age groups. Age-based risk stratification using TQIP-derived codes demonstrated low variability by race (25% White vs. 25% Hispanic vs. 28% Black patients considered high-risk) and insurance status (23% privately insured vs. 26% uninsured). CONCLUSIONS: High-risk CPA injury codes empirically derived from TQIP produced the best diagnostic characteristics and minimized some disparities. This approach, while requiring further validation, has the potential to improve CPA injury surveillance and decrease bias in screening protocols.Level of Evidence/Study Typelevel 3, diagnostic test/criteria.

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

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

Social determinants of health in pediatric trauma: Associations with injury mechanisms and outcomes in the context of the COVID-19 pandemic.

BACKGROUND: Relationships between social determinants of health and pediatric trauma mechanisms and outcomes are unclear in context of COVID-19. METHODS: Children <16 years old injured between 2016 and 2021 from ten pediatric trauma centers in Florida were included. Patients were stratified by high vs. low Social Vulnerability Index (SVI). Injury mechanisms studied were child abuse, ATV/golf carts, and firearms. Mechanism incidence trends and mortality were evaluated by interrupted time series and multivariable logistic regression. RESULTS: Of 19,319 children, 68% and 32% had high and low SVI, respectively. Child abuse increased across SVI strata and did not change with COVID. ATV/golf cart injuries increased after COVID among children with low SVI. Firearm injuries increased after COVID among children with high SVI. Mortality was predicted by injury mechanism, but was not independently associated with SVI, race, or COVID. CONCLUSION: Social vulnerability influences pediatric trauma mechanisms and COVID effects. Child abuse and firearm injuries should be targeted for prevention.

Defining Pediatric Trauma Center Resource Utilization: Multidisciplinary Consensus-Based Criteria from the Pediatric Trauma Society.

BACKGROUND: Pediatric trauma triage and transfer decisions should incorporate the likelihood that an injured child will require pediatric trauma center (PTC) resources. Resource utilization may be a better basis than mortality risk when evaluating pediatric injury severity. However, there is currently no consensus definition of PTC resource utilization that encompasses the full scope of PTC services. METHODS: Consensus criteria were developed in collaboration with the Pediatric Trauma Society (PTS) Research Committee using a modified Delphi approach. An expert panel was recruited representing the following pediatric disciplines: prehospital care, emergency medicine, nursing, general surgery, neurosurgery, orthopedics, anesthesia, radiology, critical care, child abuse, and rehabilitation medicine. Resource utilization criteria were drafted from a comprehensive literature review, seeking to complete the following sentence: "Pediatric patients with traumatic injuries have used PTC resources if they..." Criteria were then refined and underwent three rounds of voting to achieve consensus. Consensus was defined as agreement of 75% or more panelists. Between the second and third voting rounds, broad feedback from attendees of the PTS annual meeting was obtained. RESULTS: The Delphi panel consisted of 18 members from 15 institutions. Twenty initial draft criteria were developed based on literature review. These criteria dealt with airway interventions, vascular access, initial stabilization procedures, fluid resuscitation, blood product transfusion, abdominal trauma/solid organ injury management, intensive care monitoring, anesthesia/sedation, advanced imaging, radiologic interpretation, child abuse evaluation, and rehabilitative services. After refinement and panel voting, 14 criteria achieved the >75% consensus threshold. The final consensus criteria were reviewed and endorsed by the PTS Guidelines Committee. CONCLUSIONS: This study defines multidisciplinary consensus-based criteria for PTC resource utilization. These criteria are an important step toward developing a gold standard, resource-based, pediatric injury severity metric. Such metrics can help optimize system-level pediatric trauma triage based on likelihood of requiring PTC resources. LEVEL OF EVIDENCE/STUDY TYPE: Level II, diagnostic test/criteria.

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

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

Balanced resuscitation with whole blood versus component therapy in critically injured pre-adolescent children: getting there faster with fewer exposures.

PURPOSE: Balanced blood product resuscitation with red blood cells, plasma, and platelets can be achieved using whole blood (WB) or component therapy (CT). However, balanced resuscitation of younger children with severe traumatic hemorrhage may be complicated by delays in delivering all blood components and concerns regarding multiple product exposures. We hypothesized that WB achieves balanced resuscitation faster than CT, with fewer product exposures and improved clinical outcomes. METHODS: Children <12 years old receiving balanced resuscitation within four hours of arrival were identified from the 2017-2019 Trauma Quality Improvement Program database. Time to balanced resuscitation was defined as the time of initiation of WB or all three components. Patient characteristics, resuscitation details, and outcomes were compared between WB and CT groups. Time to balanced resuscitation was compared using Kaplan-Meier analysis and Cox regression modeling to adjust for covariates. Additional multivariable regression models compared number of transfusion exposures, intensive care unit (ICU) length of stay, and mortality. RESULTS: There were 390 patients (109 WB, 281 CT) with median age 7 years, 12% penetrating mechanism, 42% severe TBI, and 49% in-hospital mortality. Time to balanced resuscitation was shorter for WB vs. CT (median 28 vs. 87 minutes, hazard ratio [HR] 2.93, 95% confidence interval [CI] 2.31-3.72, p < 0.0001). WB patients received fewer transfusion exposures (mean 3.2 vs. 3.9, adjusted incidence rate ratio 0.82, 95% CI 0.72-0.92, p = 0.001) and lower total product volumes (50 vs. 85 mL/kg, p = 0.01). ICU stays trended shorter for WB vs. CT (median 10 vs. 12 days; adjusted HR 1.32, 95% CI 0.93-1.86), while in-hospital mortality was similar (50% vs. 45%, adjusted odds ratio 1.11, 95% CI 0.65-1.88). CONCLUSIONS: In critically injured pre-adolescent children receiving emergent transfusion, WB was associated with faster time to balanced resuscitation, fewer transfusion exposures, lower blood product volumes, and a trend toward shorter ICU stays than CT.Study TypeOriginal Research. LEVEL OF EVIDENCE: 3, retrospective.

Association of blood product ratios with early mortality in pediatric trauma resuscitation: A time-dependent analysis from the National Trauma Databank.

BACKGROUND: Injured children with severe hemorrhage often receive blood product transfusions with ratios of plasma and platelets to packed red blood cells (PRBCs) approaching 1:1:1. Whether blood product ratios vary during pediatric resuscitation is unknown. This study (1) described precise timing of pediatric blood product administration, (2) characterized changes in blood product ratios over time, and (3) evaluated the association of blood products with early mortality while incorporating time-varying factors. METHODS: Pediatric (younger than 18 years) trauma patients receiving high-volume transfusion (>40 mL/kg total products or >2 U PRBC or whole blood, during first 4 hours) were obtained from the 2017 to 2019 Trauma Quality Improvement Program database. The time of each individual product transfusion was recorded, along with demographics, injury details, and times of death. Patients were assigned to blood product groups at 15-minute intervals: high plasma/PRBC ratio (>1:1) with platelets, high plasma/PRBC ratio (>1:1) without platelets, low plasma/PRBC ratio (<1:1), PRBC only, and whole blood. Cox proportional hazards modeling for 24-hour mortality was performed, including blood product group as a time-varying variable and adjusting for relevant covariates. RESULTS: Of 1,152 included patients (median age, 15 years; 32% penetrating, 28% severe traumatic brain injury [sTBI]), 18% died within 24 hours. During the resuscitation period, the number of patients in high-ratio groups increased over time, and patients switched blood product groups up to six times. There was no significant difference in mortality by blood product group. Among patients with sTBI, there was a strong trend toward lower mortality among high plasma/PRBC without platelets versus high plasma/PRBC with platelets (hazard ratio, 0.55; p = 0.07). CONCLUSION: No significant association of high ratios or whole blood with mortality was seen when time-varying factors were incorporated. The impact of balanced resuscitation strategies, particularly platelet transfusion, may be greatest among patients with sTBI. Optimizing balanced resuscitation for children requires appropriately designed prospective studies. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

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

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

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

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

Financial and Safety Impact of Simulation-based Clinical Systems Testing on Pediatric Trauma Center Transitions.

Simulation offers multiple tools that apply to medical settings, but little is known about the application of simulation to pediatric trauma workflow changes. Our institution recently underwent significant clinical changes in becoming an independent pediatric trauma center. We used a simulation-based clinical systems testing (SbCST) approach to manage change-associated risks. The purpose of this study was to describe our SbCST process, evaluate its impact on patient safety, and estimate financial costs and benefits. Methods: SbCST consisted of the following steps: (1) change-based needs assessment, in which stakeholders developed relevant simulation scenarios; (2) scenario implementation; and (3) postsimulation failure mode and effects analysis (FMEA) to identify latent safety threats (LSTs). LSTs were prioritized for mitigation based on the expected probability and severity of adverse event occurrences. We calculated the costs associated with the simulation process. We conservatively estimated SbCST cost savings using 3 approaches: (1) FMEA-based avoidance of adverse events; (2) avoidance of trauma readmissions; and (3) avoidance of medical liability lawsuits. Results: We implemented 2 simulation scenarios prechange. FMEA revealed 49 LSTs, of which 9 were highest priority (catastrophic severity and high likelihood of occurrence). These were prioritized and mitigated using the hospital's quality/safety framework. Cost-benefit analysis based on FMEA event avoidance demonstrated net cost savings to the institution ranging from $52,000-227,000 over the 3-month postchange period. Readmission-based and liability-based estimates also produced favorable results. Conclusions: The SbCST approach identified multiple high-impact safety risks and financially benefited the institution in managing significant pediatric trauma clinical process changes.

The International Classification of Disease Critical Care Severity Score demonstrates that pediatric burden of injury is similar to that of adults: Validation using the National Trauma Databank☆.

BACKGROUND/PURPOSE: Resource-based severity of injury (SOI) measures, such as the International Classification of Disease (ICD) Critical Care Severity Score (ICASS), may characterize traumatic burden better than standard mortality-based measures. The purpose of this study was to validate the ICASS in a representative national-level trauma cohort and compare SOI measures between children and adults. METHODS: The National Trauma Databank was used to derive (2008-12) and validate (2013-15) ICASS and ICD Injury Severity Scores (ICISS, standard mortality-based SOI measure). SOI metrics and outcomes were compared between pediatric, adult, and elderly age groups. Logistic regression modeling evaluated predictors of critical care resource utilization. RESULTS: Derivation and validation cohorts consisted of 3.90 and 1.97 million patients, respectively. ICASS strongly predicted actual critical care utilization (OR 1.04, 95% CI 1.04-1.04, p<0.0001). Mean ICASS was 24.4 for children and 33.0 for adults (ratio 0.74), indicating predicted critical care utilization in children was three-quarters that of adults. In contrast, predicted pediatric mortality was less than half that of adults. CONCLUSIONS: Mortality-based SOI measures underestimate pediatric burden of injury. This study validates ICASS and demonstrates that pediatric resource-based SOI is more similar to that of adults. ICASS is easily calculated without a trauma registry and complements mortality-based measures. Level of evidence III, retrospective comparative study.

A real-world study of wearable sensors in Parkinson's disease.

Most wearable sensor studies in Parkinson's disease have been conducted in the clinic and thus may not be a true representation of everyday symptoms and symptom variation. Our goal was to measure activity, gait, and tremor using wearable sensors inside and outside the clinic. In this observational study, we assessed motor features using wearable sensors developed by MC10, Inc. Participants wore five sensors, one on each limb and on the trunk, during an in-person clinic visit and for two days thereafter. Using the accelerometer data from the sensors, activity states (lying, sitting, standing, walking) were determined and steps per day were also computed by aggregating over 2 s walking intervals. For non-walking periods, tremor durations were identified that had a characteristic frequency between 3 and 10 Hz. We analyzed data from 17 individuals with Parkinson's disease and 17 age-matched controls over an average 45.4 h of sensor wear. Individuals with Parkinson's walked significantly less (median [inter-quartile range]: 4980 [2835-7163] steps/day) than controls (7367 [5106-8928] steps/day; P = 0.04). Tremor was present for 1.6 [0.4-5.9] hours (median [range]) per day in most-affected hands (MDS-UPDRS 3.17a or 3.17b = 1-4) of individuals with Parkinson's, which was significantly higher than the 0.5 [0.3-2.3] hours per day in less-affected hands (MDS-UPDRS 3.17a or 3.17b = 0). These results, which require replication in larger cohorts, advance our understanding of the manifestations of Parkinson's in real-world settings.

Does speed matter? A look at NSQIP-P outcomes based on operative time.

BACKGROUND: Appendicitis is a common pediatric surgical condition, comprising a large burden of healthcare costs. We aimed to determine if prolonged operative times were associated with increased 30-day complication rates when adjusting for pre-operative risk factors. METHODS: Patients <18 years old, diagnosed intraoperatively with acute uncomplicated appendicitis and undergoing laparoscopic appendectomy were identified from the NSQIP-P 2012-2018 databases. The primary outcome, "infectious post-operative complications", is a composite of sepsis, deep incisional surgical site infections, wound disruptions, superficial, and organ space infections within 30-days of the operation. Secondary outcomes included return to the operating room and unplanned readmissions within 30 days. Logistic regression models were used to assess associations between operative time and each outcome. A Receiver Operating Characteristic (ROC) curve was generated from the predicted probabilities of the multivariate model for infectious post-operative complications to examine operative times. RESULTS: Between 2012 and 2018, 27,763 pediatric patients with acute uncomplicated appendicitis underwent a laparoscopic appendectomy. Over half the population was male (61%) with a median operative time of 39 min (IQR 29-52 min). Infectious post-operative complication rate was 2.8% overall and was highest (8%) among patients with operative time ≥ 90 min (Fig. 1). Unplanned readmission occurred in 2.9% of patients, with 0.7% returning to the operating room. Each 30-min increase in operating time was associated with a 24% increase in odds of an infectious post-operative complication (OR=1.24, 95% CI=1.17-1.31) in adjusted models. Operative time thresholds predicted with ROC analysis were most meaningful in younger patients with higher ASA class and pre-operative SIRS/Sepsis/Septic shock. Longer operative times were also associated with higher odds of unplanned readmission (OR=1.11, 95% CI=1.05-1.18) and return to the operating room (OR=1.13, 95% CI=1.02-1.24) in adjusted models. CONCLUSION: There is a risk-adjusted association between prolonged operative time and the occurrence of infectious post-operative complications. Infectious postoperative complications increase healthcare spending and are currently an area of focus in healthcare value models. Future studies should focus on addressing laparoscopic appendectomy operative times longer than 60 min, with steps such as continuation of antibiotics, shifting roles between attending and resident surgeons, and simulation training. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Letters of recommendation for pediatric surgery fellowship: Analysis of linguistic differences based on gender of the applicant.

BACKGROUND: Gender bias in letters of recommendation (LOR) has been reported for candidate selection in academic medicine, typically with females frequently described with communal terms (e.g. helpful, kind, interpersonal) and males described more with agentic terms (e.g. assertive, intellectual, ambitious). This study examined the presence of linguistic gender differences in LOR for Pediatric Surgery Fellowship. METHODS: LOR submitted to a single pediatric surgery fellowship program between 2014 and 2018 were retrospectively reviewed and analyzed using a previously validated Linguistic Inquiry and Word Count Software (LIWC) program. Descriptive statistics and bivariate analysis were employed in our analysis. Multivariable logistic regression models were built to assess independent association of LIWC variables with applicant gender, LOR writer gender, and applicant-writer gender concordance. RESULTS: 1264 LOR from 325 applicants (51% female) were analyzed. Of the letter writers, 83% were male, 57% were professors, and 7.6% were Pediatric Surgery Fellowship Program Directors. The overall median average word count was 518 words, with no significant difference in LOR word count between applicant genders. Compared to male applicants, female applicants were described significantly more with work words (e.g. excellent, work; p = 0.04). Male LOR writers used authentic words (e.g. honest, humble; p = 0.006) and home words (e.g. family, house; p = 0.04) significantly more than female LOR writers. There were no significant differences in the use of agentic and communal words between genders. CONCLUSION: While there are linguistic differences in LOR for candidates in the Pediatric Surgery match based on gender, previously described overt gender bias was not seen in this study. Interestingly, female candidates were described more with work words, like excellent; a reversal of previously described gender bias in academic medicine. These findings may be due to the unique interpersonal and multidisciplinary skills required in pediatric surgery and may represent a unique form of gender bias that warrants further study.

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

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

Risk factors for complications after abdominal surgery in children with sickle cell disease.

BACKGROUND: Abdominal surgery in children with sickle cell disease (SCD) carries an increased risk of postoperative complications. Preoperative transfusions are frequently given to decrease the risk of vasoocclusive events. However, risk factors for postoperative complications are not well-defined in the pediatric population. METHODS: Pediatric patients with SCD undergoing common abdominal operations were identified from the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database from 2012 to 2018. Outcomes of interest were the incidence rates of 1) any complication or readmission, and 2) serious SCD-related complications (stroke, new onset seizure, ventilator support >24 h postoperatively, or readmission with SCD crisis within 30 days of surgery). Patients were categorized by transfusion approach (transfusion within 48 h before surgery vs. no transfusion) and preoperative hematocrit (<21.0, 21.0-23.9, 24.0-26.9, 27.0-29.9, ≥30.0). Stratified bivariate analyses and multivariable logistic regression were used to identify independent risk factors for complications. RESULTS: A total of 813 patients met inclusion criteria. There were 470 cholecystectomy, 251 splenectomy, 39 appendectomy, and 53 combination procedures; 13% of cases were urgent or emergent. Preoperative hematocrit levels were <21.0 in 3%, 21.0-23.9 in 10%, 24.0-26.9 in 17%, 27.0-29.9in 30%, and ≥30.0 in 41% of patients; 52% received perioperative transfusion. The 30-day incidences of any complication/readmission and SCD-related complications were 12% and 4%, respectively. On bivariate analyses, urgent/emergent case status was the only significant predictor of complications, carrying risk of 20% and 8% for overall and SCD-related complications, respectively; this finding persisted on multivariable logistic regression (OR 1.83, 95% CI 1.0.2-3.29, p = 0.04). Neither preoperative transfusion nor preoperative hematocrit level was associated with complication risk, although there was a trend toward higher SCD-related complications in patients with preoperative hematocrit <21.0 (p = 0.07). CONCLUSION: In this large cohort of pediatric SCD patients undergoing abdominal surgery, there was no clear association between postoperative complications and the transfusion approach or the preoperative hematocrit level within the range above 21.0. Urgent/emergent surgical procedures carried a nearly two-fold higher complication risk compared to elective procedures. Future studies should prospectively evaluate preoperative transfusion approaches and compare immediate and delayed operative management to nonoperative management in this population. LEVEL OF EVIDENCE: III Retrospective review.

A perioperative bivalirudin anticoagulation protocol for neonates with congenital diaphragmatic hernia on extracorporeal membrane oxygenation.

INTRODUCTION: There is little published data regarding bivalirudin anticoagulation for surgical neonates on extracorporeal membrane oxygenation (ECMO). This study described our perioperative anticoagulation protocol and evaluated the relationship of bivalirudin dose to activated partial thrombin time (aPTT) and thromboelastography reaction time (TEG-R) monitoring assays. MATERIALS AND METHODS: Neonates with congenital diaphragmatic hernia (CDH) on ECMO and single-agent bivalirudin anticoagulation at our institution from 2016 to 2018 were included. Bivalirudin infusion rates, laboratory results, transfusions, and clinical events during the initial (cannulation to repair) and postoperative (up to 60 h post-repair) periods were recorded. RESULTS: Forty-two neonates met inclusion criteria. Bivalirudin was started at 0.16 mg/kg/h and titrated in 10-20% increments to target aPTT of 70-85 s and TEG-R of 9-12 min. All patients achieved target anticoagulation levels within the first 12 h on doses ranging from 0.12-0.36 mg/kg/h. Postoperatively, bivalirudin increased to median 0.16 (range 0.08-0.40), 0.22 (0.08-0.60), and 0.39 (0.08-0.80) mg/kg/h by 6, 24, and 60 h, respectively. On multivariable regression, no significant association of aPTT (p = 0.09) or TEG-R (p = 0.22) with bivalirudin dose was seen. Hemoglobin decrease ≥2 g/dL in 24 h occurred in 39%, but there were no reoperations, deaths, or circuit changes for thrombosis. CONCLUSIONS: This standardized perioperative bivalirudin protocol achieved target anticoagulation level quickly. Postoperative bleeding was managed without significant morbidity. Consistent dose-response relationships between bivalirudin and aPTT or TEG-R were not seen, but gradually increasing doses were needed to maintain therapeutic anticoagulation.

External caliper-based measurements of the modified percent depth as an alternative to cross-sectional imaging for assessing the severity of pectus excavatum.

BACKGROUND: Cross-sectional imaging (CSI) may be clinically unnecessary in the evaluation of pectus excavatum (PE). The purpose of our study was to prospectively evaluate the accuracy and reliability of the modified percent depth (MPD), derived from caliper-based external measurements, in identifying PE. METHODS: Children 11-21 years old presenting for evaluation of PE or to obtain thoracic cross-sectional imaging for other indications were measured to derive the Modified Percent Depth. The Haller Index (HI) and Correction Index (CI) were calculated from CSI. Receiver-Operator Characteristic (ROC) analysis was used to compare the sensitivity and specificity of MPD, HI, and CI. Interrater reliability was assessed using Spearman's correlation coefficient and Cohen's Kappa coefficient. RESULTS: Of 199 patients, 76 (38%) had severe PE. Median age was 16 years (range = 11-21). The median Modified Percent Depth was 21.4% (IQR = 16.2-26.3) among those with PE versus 4.1% (IQR = 1.7-6.4) in those without (p < 0.001). MPD ≥ 11% exhibited similar sensitivity and specificity to HI ≥ 3.25 and CI ≥ 10 for identifying PE (ROC 0.98 vs. 0.97 vs. 0.98, respectively, p = 0.41). With respect to interrater reliability, independent clinicians' caliper measurements exhibited 87% agreement when identifying MPD ≥ 11% (p < 0.001) with excellent correlation (Spearman's ρ > 0.71, p < 0.001). CONCLUSION: Caliper-based, physical examination measurements of the Modified Percent Depth reliably identify pectus excavatum and represent an alternative to CSI-based measurements for the assessment of PE. TYPE OF STUDY: Diagnostic test. LEVEL OF EVIDENCE: Level II.

Patient-reported impact of symptoms in Huntington disease: PRISM-HD.

OBJECTIVE: To determine the frequency and relative importance of symptoms experienced by adults with Huntington disease (HD) and to identify factors associated with a higher disease burden. METHODS: We performed 40 qualitative interviews (n = 20 with HD, n = 20 caregivers) and analyzed 2,082 quotes regarding the symptomatic burden of HD. We subsequently performed a cross-sectional study with 389 participants (n = 156 with HD [60 of whom were prodromal], n = 233 caregivers) to assess the prevalence and relative importance (scale 0-4) of 216 symptoms and 15 symptomatic themes in HD. Cross-correlation analysis was performed based on sex, disease duration, age, number of CAG repeats, disease burden, Total Functional Capacity score, employment status, disease status, and ambulatory status. RESULTS: The symptomatic themes with the highest prevalence in HD were emotional issues (83.0%), fatigue (82.5%), and difficulty thinking (77.0%). The symptomatic themes with the highest relative importance to participants were difficulty thinking (1.91), impaired sleep or daytime sleepiness (1.90), and emotional issues (1.81). High Total Functional Capacity scores, being employed, and having prodromal HD were associated with a lower prevalence of symptomatic themes. Despite reporting no clinical features of the disease, prodromal individuals demonstrated high rates of emotional issues (71.2%) and fatigue (69.5%). There was concordance between the prevalence of symptoms reported by manifest individuals and caregivers. CONCLUSIONS: Many symptomatic themes affect the lives of those with HD. These themes have a variable level of importance to the HD population and are identified both by those with HD and by their caregivers.