Opportunity for Reduction of Intensive Care Unit Resource Utilization in Pediatric Blunt Liver and Spleen Injuries: A National Trauma Data Bank Analysis.

INTRODUCTION: Guidelines for blunt liver and spleen injury (BLSI) by the Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium (ATOMAC) emphasize hemodynamic stability over injury grade when considering non-operative management (NOM). In this study, we examined rates of intensive care unit (ICU) admission for children with isolated low-risk BLSI among US hospitals. METHODS: The National Trauma Data Bank (NTDB) was queried for patients ages 1-15 admitted between 2017 and 2019 with BLSI. Patients with penetrating injuries and/or concomitant non-abdominal injuries with AIS score ≥3 were excluded. Isolated BLSI was considered low-risk if the patient had normal admission vitals and did not require operative intervention. Primary outcomes measured were ICU admission, ICU length of stay (LOS), and overall LOS. RESULTS: 5777 patients ages 15 and under presented with isolated BLSI during the study period. 2031/5777 (35.2%) were considered low-risk. Low-risk patients had lower rates of ICU admission compared to high-risk patients (30.9% vs. 41.6%, p < 0.001) and had shorter ICU LOS (median 2 days vs. 2, p < 0.001) and shorter overall LOS (median 41 h vs. 54, p < 0.001). Pediatric verified and non-pediatric verified trauma centers had similar rates of ICU admission (36.8% vs. 38.9%, p = 0.11). CONCLUSION: Further work is needed to capture opportunities for reduction in ICU utilization in isolated BLSI. LEVEL OF EVIDENCE: III.

Pediatric Peripheral Vascular Trauma: Incidence and Outcomes.

Peripheral vascular trauma (PVT) is rare in children, with an incidence estimated below 1%. We studied pediatric PVT and risk factors for major amputation by accessing the 2019 National Trauma Data Bank (NTDB). Demographics, injury type and location, trauma center capability, injury severity score (ISS), length of stay (LOS), and major amputation rates were evaluated. Statistical analysis included chi-square testing for categorical variables and t-tests for continuous variables. Of 130,554 pediatric trauma patients, 1196 (.9%) had 1460 upper extremity (UE) and lower extremity (LE) PVT. Patients were predominantly male (n = 933, 78%) with a mean age of 14 years. Most patients suffered penetrating injury (n = 744, 62.2%). The most common vessels injuries were radial (n = 198, 13.6%) and femoral (n = 196, 13.4%). Major amputation occurred in 2.6% of patients (n = 31). Patients who suffered blunt injury (OR, 3.3; 95% CI, 1.5-7.5; P = .004) and lower limb PVT (OR, 11.1; 95% CI, 3.3-37.9, P = .0001) had higher odds of amputation.

The Obesity Paradox in the Pediatric Trauma Patient.

BACKGROUND: Obesity is a chronic disease that adversely impacts patient outcomes and increasingly affecting the pediatric population. According to the CDC, in 2020 the prevalence of obesity among children and adolescents was estimated to be as high as 19.7%. The obesity paradox is the increased survival for overweight and obese adult trauma patients when compared to patients with healthy weights. The aim of this study was to analyze the impact of BMI and outcomes in the pediatric trauma population. METHODS: Trauma patients in the 2-18 years age group and reported to the 2017-2019 National Trauma Data Bank were identified. CDC growth charts and z-scores were calculated to categorize patients into four subgroups: underweight (<5th percentile), healthy weight (5th-85th percentile), overweight (85th-95th percentile), and obesity (>95th percentile). Primary outcome studied was the mortality rate. Secondary outcomes included injury severity score (ISS), hospital length of stay (LOS), ICU LOS, and number of days on a ventilator. Continuous and categorical data were analyzed using ANOVA and Chi-squared test, respectively, using the healthy BMI category as reference group. P < 0.05 was considered significant. RESULTS: A total of 161,458 patients [Underweight: 9148 (6%), Healthy weight: 88,009 (55%), Overweight: 26,740 (17%), and Obese: 37,561 (23%)] were included. The mean age was 11 years (SD:5.1). Total mortality for the patient set was 1825 (1.13%). The lowest mortality rate was in the obese group. The ISS was lowest in the obese group, while ICU LOS and days on ventilator were no different than control patients. Hospital LOS and transfer to rehabilitation rates were higher in the obese population. CONCLUSION: Obesity appears to have a protective effect on mortality and significantly better secondary outcomes in the pediatric trauma population. Further study is necessary to evaluate the interplay between body weight and outcomes in pediatric trauma and disease states. LEVEL OF EVIDENCE: III.

Pediatric Melanoma: Geographic Trends in Incidence, Stage, and Mortality in the United States.

INTRODUCTION: Pediatric melanoma is the most commonly diagnosed skin cancer in children, with the annual incidence recently increasing by an average of 2% each year. Ultraviolet (UV) radiation from excessive sun exposure is an important carcinogenic risk factor, with penetration varying greatly throughout the country. Consequently, an individual's geographic location may play a role in how much exposure to high UV index rays they receive throughout their lifetime. The objective of this study was to use the surveillance, epidemiology, and end results SEER database to study geographic trends in incidence, staging, and mortality of pediatric melanoma between 2009 and 2019 and determine their relation to UV index in the United States. MATERIALS AND METHODS: A retrospective analysis of pediatric patients from 0 to 19 years in the surveillance, epidemiology, and end results 22 registries incidence database (17 states) and 17 registries incidence-based mortality database (12 states) was conducted from 2009 to 2019 based on a diagnosis of melanoma of the skin using the International Classification of Childhood Cancer codes for malignant melanoma. Data regarding patient demographics and incidence, staging, and mortality per state were extracted. Incidence data were geographically mapped and mean UV index distribution from www.epa.gov was superimposed. RESULTS: Incidence of pediatric melanoma was stratified regionally, with a total of 1665 new cases from 2009 to 2019. The Northeast had 393 new cases, with 244 (62.1%) localized cases, 55 (14.0%) lymph node-invasive and metastatic (advanced) cases, and 6/146 (4.1%) cases of mortality. The Midwest had 209 new cases, with 123 (58.9%) localized cases, 29 (13.9%) advanced cases, and 1/57 (1.8%) case of mortality. The South had 487 new cases, with 224 (46.0%) localized cases, 104 (21.4%) advanced cases, and 8/232 (3.4%) cases of mortality. The West had 576 new cases, with 364 (63.2%) localized cases, 82 (14.2%) advanced cases, and 23/551 (4.2%) cases of mortality. Mean UV index was 4.4 in the Northeast, 4.8 in the Midwest, 7.3 in the South, and 5.5 in the West from 2006 to 2020. The regional difference in incidence was not statistically significant. There was a statistically significant increased number of advanced cases in the South as compared to the Northeast (P = 0.005), West (P = 0.002), and Midwest (P = 0.02), with a significant correlation coefficient of 0.7204 between advanced cases and mean UV index in the South. CONCLUSIONS: There is a statistically significant increased incidence of lymph node-invasive and metastatic pediatric melanoma cases in the South as compared to the West, Northeast, and Midwest regions of the United States. There is also a significant correlation between the incidence of lymph node-invasive and metastatic pediatric melanoma cases and UV index. In the pediatric population, there is no statistically significant association between total incidence and mortality of melanoma and geographic region. There is an increased prevalence of pediatric melanoma seen in White and female patients. This suggests that an individual's geographic location in the United States during childhood may play a role in their likelihood of malignant melanoma development, advanced-stage melanoma development, and mortality.

Pediatric cerebrovascular trauma: Incidence, management, and outcomes.

BACKGROUND: Pediatric cerebrovascular trauma (CVT) is rare. There is an increasing use of endovascular management in vascular trauma. We studied the incidence, management, and outcomes of CVT in the pediatric population using the NTDB (National Trauma Data Bank). METHODS: The NTDB was queried for CVT in patients less than 18 years of age over a recent three-year period (2017-2019). Demographics, injury mechanism, type and location, Glasgow Coma Score (GCS), length of stay (LOS), surgical approach (open vs endovascular), and morbidity/mortality were evaluated. Statistical analysis included χ2 and student's t-tests or Fisher's exact tests where appropriate. RESULTS: Of 386,918 pediatric trauma cases, 1536 (0.4%) suffered 1821 CVT. Blunt trauma accounted for 69.3%. Patients were predominantly male (65.4%) and white (57.5%), with an mean age of 14 years. There were 998 (55%) carotid artery injuries, including 846 common/internal carotid and 145 external carotid. Other vessel injuries included 141 (11%) intracranial carotid, 571 (31%) vertebral artery and 252 (14%) jugular vein. Mean number of vessels injured was 1.2. Motor vehicle trauma was most common (49.3%) followed by firearm injury (21%). The mean GCS was 11, and mean total LOS was 11.3 days. Majority of interventions were performed in an open fashion (65.7%), whereas 29.7% were performed endovascularly. Stroke rate was 3.1%. Patients with multiple vascular injuries had an overall mortality of 29% (p<0.0001). CONCLUSION: While not accorded as much importance as blunt injury, penetrating CVT comprises of 30% of injuries. Nearly 1/3rd of all cases needing surgical intervention were managed with endovascular techniques. LEVEL OF EVIDENCE: III.

Nephron sparing surgery outcomes in Wilms' tumor: is it ready for primetime?

PURPOSE: Radical nephrectomy is the gold standard in Wilms tumor (WT) treatment and is combined with adjuvant treatment in early stage disease or performed after neo adjuvant therapy in advanced disease. With the development of novel adjuvant and neoadjuvant therapeutic strategies, there is increasing interest in organ preserving procedures in several adult malignancies. Potential long-term complications of living with a single kidney include hyperfiltration syndrome, hypertension, and fluid retention. If NSS (Nephron Sparing Surgery) were to be adopted for the treatment of WT it would be necessary to preserve the gains in Overall Survival (OS) seen with current treatment protocols. With this in mind we undertook a study of outcomes of NSS performed in the USA using a large population-based registry. METHODS: We retrospectively queried the SEER Research Plus 18-registries Database 2010-2018 for patients 18 years old or younger with Wilms tumor as determined by ICD-O-3 code 8960. Clinical and demographic data was extracted, and statistical analysis was performed in GraphPad PRISM 9 with bivariate analysis and log-rank analysis to determine survival. RESULTS: 1087 patients with Wilms tumor were identified. 73 (6.72%) underwent nephron-sparing surgery. The final cohort consisted of 45 patients (64%) who underwent unilateral NSS and 25 patients (36%) who underwent bilateral NSS. Three were excluded from analysis due to non-renal origin of tumor. Mean age was 3.214 years (std dev 3.807). Demographics were similar between the groups, apart from younger age associated with bilateral tumor (p = 0.0441). No differences were found between radiation use (p = 0.4280), chemotherapy use (p = 0.5479), tumor size (p = 0.2186), positive regional lymph nodes (p = 0.707). Log-rank analysis demonstrated that cancer-specific survival was not significantly different between unilateral and bilateral NSS or radical nephrectomy (p = 0.4539). CONCLUSION: NSS may preserve renal function long-term, an important consideration in the pediatric population. Prospective study is necessary to select the appropriate patient subsets who may benefit from NSS in WT.

Pediatric firearm injury trends in the United States: A national trauma data bank (NTDB) analysis.

AIM OF STUDY: Firearm injuries are the second leading cause of injury-related death in the USA in children less than 18. We compared overall and intent-specific firearm hospitalizations across age group and race to understand recent trends. METHODS: A retrospective cohort of 20,083 children from the national trauma data bank involved in incidences of firearm discharges from 2013 to 2017 was divided by race, discharge intent, gun type, and four age groups: infants (ages 0-2), toddlers (3-6), children (7-12), and adolescents (13-18). Discharge intent and gun type were determined by ICD-9-CM and ICD-10-CM External Causes of Injury codes. Injury severity score (ISS), hospital discharge disposition, and length of stay (LOS) were used as predictors for morbidity and mortality. RESULTS: From 2013 to 2017, there were on an average 4016 firearm injuries reported to the NTDB (n = 20,083). 71% (n = 14,313) of the incidents were assaults. Victims who identified as African American and Caucasian made up 60% (n = 11,890) and 26% (n = 5162) of the total victims, respectively, and were predominantly male (86%, n = 17,202). Victims who identified as Caucasian made up 70% of suicides (n = 819), while African Americans made up 70% of assaults (n = 9733). 87% (n = 17,525) of the patient population were adolescents. The number of accidental firearm discharges compared to firearm assaults was greater for toddlers, while the opposite was true for infants, children, and adolescents. Average LOS by age group varied each year, though children had the highest total average LOS.  Average ISS was highest for infants and adolescents (11.5 and 10.4) and American Indians and Caucasians (10.1 and 11.1). Overall mortality rate was 6% (n = 1220) and had no significant differences between years. Mortality rate was highest for infants (7%, n = 25). CONCLUSIONS: Adolescent males and African Americans were disproportionately affected by overall and assault-specific firearm discharges. Firearm injury prevention legislation is critical to prevent these injures.

A nationwide database analysis of demographics and outcomes related to Extracorporeal Membrane Oxygenation (ECMO) in congenital diaphragmatic hernia.

PURPOSE: The aim of the study was to understand the use of Extracorporeal Membrane Oxygenation (ECMO) in congenital diaphragmatic hernia (CDH) and its outcomes. METHODS: The 2016 Kid's Inpatient Database (KID) obtained from the national Healthcare Cost and Utilization Project (HCUP) was used to obtain CDH birth, demographic, and outcome data associated with ECMO use. Categorical variables were analyzed and odds ratios (OR) with 95% confidence intervals (CI) are reported for variables found to have significance (p < 0.05). Appropriate regressions were used for comparing categorical and continuous data using SPSS 25 for Macintosh. RESULTS: The database contained 1189 cases of CDH, of which 133 (11.2%) received ECMO. The overall mortality of neonates with CDH was 18.9% (225/1189). Newborns with CDH on ECMO had a survival of 46% (61/133) compared to 85.5% without ECMO (903/1056) (OR 6.966, p < 0.001, 95% CI 4.756-10.204). ECMO increased length of stay from 24.6 to 69.8 days (OR 2.834, p < 0.001, 95% CI 2.768-2.903) and average cost from $375,002.20 to $1641,586.83 (OR 4.378, p < 0.001, 95% CI 3.341-5.735). CONCLUSIONS: Increased length of stay, costs, and outcomes with ECMO use in CDH should prompt an examination of criteria necessitating ECMO.

Regional variation in gastroschisis: a nationwide database review of demographics and outcomes.

BACKGROUND: Gastroschisis is an index neonatal malformation with an increasing incidence from earlier decades. The aim of this study was to investigate regional variations in patient demographics, outcomes, and costs in gastroschisis. MATERIALS AND METHODS: The 2016 kid's inpatient database (KID) obtained from the Healthcare Cost and Utilization Project (HCUP) was used to obtain gastroschisis birth, demographic, and outcome data across four U.S. geographical regions: Northeast, Midwest, South, and West. Categorical variables were analyzed with Pearson's Chi-squared test. Odds ratios (OR) with 95% confidence intervals (CI) were reported for variables with significance (p < 0.05). Appropriate logistic regressions were used for comparing categorical, cardinal, and continuous data. RESULTS: 2043 gastroschisis cases were obtained from the 2016 KID database with a weighted incidence of 5.1 per 10,000 live births. Incidence of gastroschisis across regions was similar when controlling for a number of hospitals reporting to KID. Prematurity was common, with 59% (1204) of neonates with gastroschisis born at less than 37 weeks. 52% (N = 1067) of gastroschisis infants were male. 46% (955) were White, 9% (178) African American, 22% (450) Hispanic, and 8% (155) other. The overall mortality of gastroschisis in this database was 3.6% (75). The average length of stay was 39 days and average cost of treatment was $357,436. Though without significant differences in mortality, there were significant differences in demographics, costs, and lengths of stay between regions. CONCLUSIONS: There has been a significant increase in gastroschisis incidence over the last three decades. This significant increase appears to be related to an increase in socioeconomic inequality and an alteration in the population demographics in the United States. Further study of regional variations will facilitate the development of best practice guidelines that benefit all.

Study of social disparities in pediatric laparoscopic appendectomy outcomes and cost.

PURPOSE: There is an increasing focus on racial and social disparities in health care. There have been several studies that have documented disparities in outcome between racial groups in the adult literature. Not much is known about disparities in outcomes after surgical procedures in children. The purpose of this study was to investigate the effect of race on complications (outcomes) and costs after laparoscopic appendectomy. METHODS: This study is a single-center retrospective chart review of 248 pediatric patients who underwent appendectomies for uncomplicated acute appendicitis from 2015 to 2017. Patients were divided into minority (Africa American or Hispanic) and non-minority groups, and length of stay, preoperative and postoperative factors, and total costs were compared. RESULTS: Of 185 eligible patients, 45.9% (n = 85) were of Hispanic or African American ethnicity and 54.1% (n = 100) were Caucasian. About 11.8% of minority patients had comorbidities and 12% of majority patients had comorbidities (p = 1). Readmission rate for minority group patients was 3.5% (n = 3) and 2% (n = 2) for majority patients (p = 0.7). The average cost of hospital stay for minority patients was $30,900 and for majority patients was $31,111 (p = 0.59). CONCLUSIONS: Standardization of care protocols has reduced social/racial disparities in surgical outcomes. In the most common pediatric surgery emergency procedure, laparoscopic appendectomy, there were no differences in outcomes or costs between minority (Hispanic/Africa American) and Caucasian ethnic groups. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Clinical Study.

Pediatric Nonaccidental Trauma: Experience at a Level 1 Trauma Center.

INTRODUCTION: Pediatric nonaccidental trauma (NAT) is difficult to diagnose. Several isolated injuries in NAT could happen in the setting of accidental trauma (AT), and having a high index of suspicion is important to correctly identify abuse. NAT has a significant mortality rate if the sentinel event is not adequately diagnosed, and the infant is not separated from the perpetrator. Level 1 pediatric trauma centers (PTC) see a significant number of NAT. We evaluated the injury patterns of NAT admissions at our level 1 PTC. METHODS: Retrospective analysis of all cases of NAT for children under the age of two admitted at an ACS level 1 pediatric trauma center between the years of 2016 and 2018. Charts were queried for demographic data, injury patterns, mortality, and disposition. Correlation between disposition status and injury patterns was performed. The Fisher Exact test and student t-test were used to study the significance of differences in categorical and continuous data, respectively. RESULTS: 32/91 (35%) trauma patients under the age of two years were diagnosed as NAT in the three-year study period. 21/32 (39%) male and 11/26 (42%) female admissions were confirmed NAT (p = NS). 20 were under 1 year of age, and 12 were aged between 1 and 2 years (p = NS). 13 (41%) were Caucasian, 6 (19%) were Hispanic/Latino, 11 (34%) were Black, and 2(6%) were of unknown ethnicity (p = NS). Facial, torso, lower extremity, retinal, and internal organ injury were significantly more common with NAT. Medicaid coverage was noted in 31/32 (97%) NAT patients. 20/32 (62.5%) patients were legally displaced as a result of the NAT. CONCLUSION: 1/3rd of all admissions at a pediatric level 1 trauma center were identified as NAT. A high index of suspicion is necessary to not miss NAT, as injury patterns are variable. Nearly 1/3rd of all victims go back to the same environment where they sustained NAT increasing their susceptibility to future NAT.

Central line associated blood stream infections in gastroschisis patients: A nationwide database analysis of risks, outcomes, and disparities.

PURPOSE: The aim of this study was to determine the risk of central line associated blood-stream infections (CLABSI) in neonatal gastroschisis patients, risk factors, outcomes, and financial implications. METHODS: The 2016 Healthcare Cost and Utilization Project (HCUP)'s kid's inpatient database (KID), a national database of pediatric inpatient admissions across the United States, was used to obtain a large sample of gastroschisis admissions. Incidence of CLABSI in the gastroschisis patient population was compared to the incidence of CLABSI in the database. To further study the factors influencing CLABSI in gastroschisis, demographic and clinical features of patients were analyzed. Categorical variables were analyzed using Fisher's exact test or Pearson's chi-squared test. Odds ratios (OR) with 95% confidence intervals (CI) for variables found to have significance (p < 0.05) were calculated. FINDINGS: Incidence of CLABSI in this database for pediatric inpatients was 4449 out of 298,862 central line insertions [1.48%] and was 81 out of 2032 [3.9%] (OR 2.83, 95% CI 2.26-3.54, p < 0.001) in the gastroschisis cohort. African American neonates had a significantly higher risk of CLABSI with gastroschisis. Prematurity and low birth-weight in gastroschisis were protective from CLABSI, along with patients from suburban areas or admitted in the Southern USA. Average costs were greater in gastroschisis patients with CLABSI, increasing from $281,779 to $421,970 (p = 0.008). The average length of stay increased from 31 days to 38 days with a CLABSI (p < 0.001). CONCLUSIONS: In gastroschisis patients, CLABSI incidence is high and adds great morbidity and expense. For uncertain reasons, premature and low birth weight babies appear to be protected. LEVEL OF EVIDENCE: Level III.

Trending Weight Loss Patterns in Obese and Super Obese Adolescents: Does Laparoscopic Sleeve Gastrectomy Provide Equivalent Outcomes in both Groups?

BACKGROUND: Many factors, including preoperative weight, may determine final weight loss after bariatric surgery; however, their proportional contribution is unclear. To such end, we evaluated weight loss patterns among obese adolescents. METHODS: We evaluated 57 adolescents who underwent laparoscopic sleeve gastrectomy from 2011 to 2017. Data collection included demographics, anthropometrics, and comorbidities and was done over a 3-year follow-up period. Statistical analysis was performed using Student's t test and repeated measures ANOVA. RESULTS: In the morbidly obese (MO) group, 82% were female, while 52% were male in the super obese (SMO) group (P < 0.0059). While 13/34 patients in the obese group achieved > 60% percent excess body weight loss (%EBWL), only 3/23 super obese patients achieved > 60% EBWL (P = 0.0695). %EBWL at 1-year follow-up significantly differed between the obese and super obese groups, 61.7 ± 14.6% and 47.7 ± 14.9% respectively (P = 0.035). The average BMI in the obese group was 29.8 at 1 year and 41.3 in the super obese group. There was a significant difference in the rate of excess weight loss (%EBWL/month) between the two groups (P < 0.01). There was good comorbidity resolution (about 70%) in both groups after surgery. CONCLUSION: Comorbidity resolution after sleeve gastrectomy is excellent in the adolescent population irrespective of initial BMI. Consideration should be given to earlier bariatric intervention in SMO adolescents to facilitate return to near normal BMI. Focus on education of referral sources, such as community pediatricians and family practitioners to facilitate early bariatric evaluation should be considered. Weight loss in postsurgical SMO patients should be carefully monitored and adjunctive interventions should be considered.

Enhanced recovery after surgery (ERAS) protocols in neonates should focus on the respiratory tract.

BACKGROUND/PURPOSE: Enhanced recovery after surgery (ERAS) protocols have shown significant benefits in terms of patient outcomes and institutional cost savings in colorectal and bariatric surgery. This has not, however, been tried in the neonatal setting. One of the major barriers to developing ERAS protocols in the neonatal intensive care unit (NICU) is the often-prolonged intubation of neonates after surgery. To this end, we evaluated our institutional data to determine if prolonged intubation post-operatively is associated with adverse events. METHODS: This is a retrospective cohort study of neonates who were intubated for a surgical procedure from January 2012 to December 2016. Documented data included pre-operative intubation status, timing of post-operative extubation: immediate (< 24 h) or delayed (> 24 h), and adverse respiratory events. The Fisher exact test and Student's t test were used to study differences amongst categorical and continuous variables, respectively. RESULTS: 58 surgical procedures were identified, where the patient was intubated specifically for the surgical intervention, of which 28 were extubated immediately and 30 were extubated in a delayed fashion. The overall incidence of adverse respiratory events was increased in the delayed extubation group (P = 0.03). CONCLUSIONS: Healthcare providers should encourage early extubation after neonatal surgery. Consideration should be given to implementing ERAS protocols in NICUs. LEVEL OF EVIDENCE: Prognosis study-level II.

Characterizing Bariatric Surgery Utilization and Complication Rates in the Adolescent Population.

INTRODUCTION: Bariatric surgery is an increasingly common treatment of morbid obesity in the United States and has demonstrated effective weight loss and improvement of comorbidities. We used the National Surgical Quality Improvement Program (NSQIP) data to characterize bariatric surgery utilization and complication rates in the adolescent population. METHODS: Demographics, surgical procedures, comorbidities, and 30-day outcomes of 2625 adolescents ages 18-21 who underwent bariatric surgery were analyzed from NSQIP data-bank from 2005 to 2015. RESULTS: 79.5% of patients were females. Majority of patients identified as Caucasian or Black/African American (BAA) at 66.7% (73% of US population) and 15.5% (12.6% of US population), respectively. 15.9% identified as Hispanic. Comorbidities included diabetes in 9.3% (7.8% NIDDM), hypertension (9.5%), and dyspnea on moderate exertion (13.2%). Sleeve Gastrectomy, Laparoscopic Roux-En-Y (RY) and Adjustable Gastric Banding (AGB) were the three most common procedures performed during the study period. There has been a sharp trend towards SG in recent years (11.4% in 2010, to 66.6% in 2015), while RY utilization declined (47.4% in 2010 to 28.6% in 2015). Surgical complications were 2.4%, with the most common being superficial surgical site infection (0.7%), UTI (0.7%), and organ-space infection (0.4%). Reoperation and readmission rates within 30-days post-operation were 1.5% and 4.1%, respectively. Those with complications had longer length-of-stays (2.7 vs. 1.8 days, P < 0.001), greater reoperation rates (OR = 9.6, P < 0.001) and readmission rates (OR = 11.8, P < 0.001). CONCLUSION: Morbid obesity is associated with significant comorbidity. SG is increasingly the most utilized form of bariatric surgery. While complications are low, they are associated with greater hospital length-of-stay, readmission, and reoperation rates. LEVEL OF EVIDENCE: Treatment Study, Level III.

Facilitating factors in same-day discharge after pediatric laparoscopic appendectomy.

BACKGROUND: Appendicitis has been cited to be the most common abdominal disorder that requires acute care surgery in the pediatric population. Enhanced Recovery After Surgery protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. Such pathways have been found to enhance quality of care for surgical patients as well as improve recovery and shorten hospital stays. The purpose of this study was to determine the key factors that facilitate same-day discharge (SDD) and early return to normal activities after laparoscopic appendectomies in children. METHODS: This is a single-center retrospective chart review of pediatric patients (<18 y old) who underwent appendectomies for acute appendicitis from January 2015 to April 2017. The patient population was divided into two groups: those with SDD and those who were discharged one or more days after surgery. SDD was defined as discharge less than 24 h of surgical admission. Patient factors, including prehospital, preoperative, perioperative, and postoperative factors, were compared and analyzed between the two groups and statistically evaluated using Fisher's exact test for categorical data and student t-test for continuous variables. RESULTS: Two hundred forty eight patients were found under International Classification of Diseases-9 and International Classification of Diseases-10 codes for acute appendicitis. Of these, 63 were excluded due to perforated appendicitis, nonoperative management, interval appendectomies, or misdiagnosis. The remaining 185 had laparoscopic appendectomies; 59.5% (n = 110) were SDDs and 40.5% (n = 75) stayed more than one day. No significant difference was found for time between emergency room arrival and surgical admission (5.27 versus 5.4 h; P = 08.) but SDD patients had a significantly shorter time between surgical admission and operation (5.8 versus 11.4 h; P <0.001). SDD patients and non-SDD patients had no significant difference in rate of complications (0% versus 1.3%; P = 0.4). There was no significant difference in readmission rates between the two groups (2.7% versus 2.7%; P = 1). Total hospital charges, which indirectly reflect costs, were significantly less for SDD ($29,195 versus $33,703; P <0.001). CONCLUSIONS: Surgical leadership can be effective in facilitating SDD without increasing readmission rates or complications and helps reduce hospital costs, decreases chances of nosocomial infection, and increases patient and family satisfaction.

Chromosomal Microarray Testing in NEC: A Case Report.

Necrotizing enterocolitis (NEC) remains the most common reason for emergent surgery in the neonatal intensive care unit. The common pathophysiology in all NEC involves alteration in gut microflora, abnormal blood supply to the intestine, and uncontrolled cytokine release. We report a full-term neonate who developed NEC. The neonate had surgical resection of approximately 120cms of bowel. After an initial proximal jejunostomy she underwent a successful jejuno-ileal anastomosis with preservation of her ileocolic valve at 6 weeks of age. A little more than one year of age, she is being weaned off her parenteral nutrition (PN) as her bowel adaptation continues. A chromosomal microarray analysis (CMA) resulted in the identification of a 15q13.3 microdeletion.

We thought we would be perfect: medication errors before and after the initiation of Computerized Physician Order Entry.

BACKGROUND: Because the Institute of Medicine demanded health care improvement, electronic medical records have been implemented with the hopes of eliminating iatrogenic injury caused by avoidable mistakes. Electronic orders and electronic medical records survived its initial slow adoption and have since had a myriad of identifiable flaws as it becomes incorporated nationally. MATERIALS AND METHODS: This retrospective study at a university teaching hospital analyzed all medication order errors (OEs) for the 26 wk of paper-order entries before computer physician order entry (CPOE) and 26 weeks after CPOE was initiated. All OEs were included and documented by month as well as severity using standard taxonomy. RESULTS: Results indicated that CPOE yielded a significant increase in overall medication OE with five of six severity categories remaining the same or increasing in OE. Severity categories A and E saw a significant increase once CPOE began (P < 0.01). Pre-CPOE OEs were 1741, whereas Post-CPOE OEs were 2226, showing an increase in overall medication errors (P < 0.01). After CPOE began, the cumulative successive errors recorded were 112, 290, 267, 307, 412, 399, and 439 with an R(2) value of 0.849 and a P value of 0.003 in the analysis of variance to test regression relation. CONCLUSIONS: As CPOE adapts for its real-world applications, it may eventually prove useful in reducing errors; however, perfection and error free order entry will not be achieved unless objective data analysis guides its evolution.

Pediatric appendectomy: optimal surgical timing and risk assessment.

Appendicitis is one of the most common pediatric surgical problems. In the older surgical paradigm, appendectomy was considered to be an emergent procedure; however, with changes to resident work hours and other economic factors, the operation has evolved into an urgent and deliberately planned intervention. This paradigm shift in care has not necessarily seen universal buy-in by all stakeholders. Skeptics worry about the higher incidence of complications, particularly intra-abdominal abscess (IAA), associated with the delay to appendectomy with this strategy. Development of IAA after pediatric appendectomy greatly burdens the healthcare system, incapacitates patients, and limits family functionality. The risk factors that influence the development of IAA after appendectomy were evaluated in 220 children admitted to a large urban teaching hospital over a recent 1.5-year period. Preoperative risk factors included in the study were age, sex, weight, ethnicity, duration and nature of symptoms, white cell count, and ultrasound or computed tomography scan findings (appendicolith, peritoneal fluid, abscess, phlegmon), failed nonoperative management, antibiotics administered, and timing. Intraoperative factors included were timing of appendectomy, surgical and pathological findings of perforation, open or laparoscopic procedure, and use of staple or Endoloop to ligate the appendix. Postoperative factors included were duration and type of antibiotic therapy. There were 94 (43%) perforated and 126 (57%) nonperforated appendicitis during the study period. The incidence of postoperative IAA was 4.5 per cent (nine of 220). Children operated on after overnight antibiotics and resuscitation had a significantly lower risk of IAA as compared with children managed by other strategies (P < 0.0003). Of the preoperative factors, only the presence of a fever in the emergency department (P < 0.001) and identification of complicated appendicitis on imaging (P < 0.0001) were significant risk factors for postoperative abscess development. Perforated appendicitis carries a higher risk of development of IAA that is not reduced by an emergent operative or delayed nonoperative management strategy. The timing of appendectomy appears to be an extremely important factor in reducing the incidence of IAA after all presentations of appendectomy. The role of resuscitation and antibiotics in limiting the effects of the inflammatory cascade and development of laboratory markers that accurately measure the latter need to be the focus of further research in this field.