Presence of Microscopic Hematuria Does Not Predict Clinically Important Intra-Abdominal Injury in Children.

OBJECTIVE: Screening for blunt intra-abdominal injury in children often includes directed laboratory evaluation that guides need for computed tomography. We sought to evaluate the use of urinalysis in identifying patients with clinically important intraabdominal injury (ci-IAI). METHODS: A retrospective chart review was performed for all patients less than 18 years who presented with blunt mechanisms at a level I trauma center between 2016 and 2019. Exclusion criteria included transfer from an outside facility, physical abuse, and death within thirty minutes of arrival. Demographics, physical exam findings, serum chemistries, urinalysis, and imaging were reviewed. Clinically important intraabdominal injury was defined as injury requiring ≥2 nights admission, blood transfusion, angiography with embolization, or therapeutic surgery. RESULTS: Two hundred forty patients were identified. One hundred sixty-five had a completed urinalysis. For all patients an abnormal chemistry panel and abnormal physical exam had a sensitivity of 88.9% and a negative predictive value of 99.3%. Nine patients had a ci-IAI. Patients with a ci-IAI were more likely to have abdominal pain, tenderness on exam, and elevated hepatic enzymes. When patients were stratified by the presence of an abnormal chemistry or physical exam with or without microscopic hematuria, urinalysis did not improve the ability to identify patients with a ci-IAI. In fact, presence of microscopic hematuria increased the rate of false positives by 12%. CONCLUSIONS: Microscopic hematuria was not a useful marker for ci-IAI and may lead to falsely assuming a more serious injury.

Pediatric Train Injuries: A 10-Year Review From the Pennsylvania Trauma Outcomes Study Database.

OBJECTIVES: Trains can cause severe injuries in pediatric patients requiring significant resource utilization. We sought to review train injuries in Pennsylvania to determine the burden of these injuries on the pediatric trauma system. METHODS: We queried the Pennsylvania Trauma Outcomes Study Database to identify patients younger than 18 years injured by trains between 2007 and 2016. Demographics, hospital course, outcomes, and resource utilization were reviewed. RESULTS: Thirty-five children from 17 Pennsylvania counties were included. Three counties accounted for 48.6% of injured children. The median age was 15.0 years, and most patients were White (60.0%) and male (77.1%). The median length of stay was 8.0 days and overall mortality 8.6%. Intensive care unit admission was required for 65.7%. The median Injury Severity and Functional Status at Discharge scores were 14.0 and 18.0, respectively. Major orthopedic injuries (fracture or amputation) were the most common (57.1%) followed by traumatic brain injury (45.7%), pneumothorax (14.3%), and solid organ injury (14.3%). Operative management was common with 65.7% undergoing surgery. CONCLUSIONS: Injuries caused by trains can be severe and are most commonly orthopedic or traumatic brain injuries. Targeted safety interventions may be possible given the common mechanisms and geographic clustering of these injuries.

Reducing Phlebotomy, Length of Stay, Cost: Development of a Blunt Abdominal Trauma Pathway in a Level I, Pediatric Trauma Center.

OBJECTIVES: Blunt abdominal trauma (BAT) is a leading cause of morbidity in children with higher hemodynamic stabilities when compared with adults. Pediatric patients with BAT can often be managed without surgical interventions; however, laboratory testing is often recommended. Yet, laboratory testing can be costly, and current literature has not identified appropriate pathways or specific tests necessary to detect intra-abdominal injury after BAT. Therefore, the present study evaluated a proposed laboratory testing pathway to determine if it safely reduced draws of complete blood counts, coagulation studies, urinalysis, comprehensive metabolic panels, amylase and lipase levels orders, emergency department (ED) length of stay, and cost in pediatric BAT patients. METHODS: A retrospective review of levels I, II, and III BAT pediatric patients (n = 329) was performed from 2015 to 2018 at our level I, pediatric trauma center. Patients were then grouped based on pre-post pathway, and differences were calculated using univariate analyses. RESULTS: After implementation of the pathway, there was a significant decrease in the number of complete blood counts, coagulation studies, urinalysis, comprehensive metabolic panels, amylase, and lipase levels orders ( P < 0.05). Postpathway patients had lower average ED lengths of stay and testing costs compared with the pre pathway patients ( P < 0.05). There was no increase in rates of return to the ED within 30 days, missed injuries, or readmissions of patients to the ED. CONCLUSIONS: Results displayed that the adoption of a laboratory testing pathway for BAT patients reduced the number of laboratory tests, ED length of stay, and associated costs pediatric patients without impacting quality care.

Using Weather, Lunar Cycles, and Time of Year to Predict Trauma Incidents in an Urban, Level I Pediatric Trauma Center.

BACKGROUND: Trauma patterns in adults are influenced by weather conditions, lunar phases, and time of year. The extent to which these factors contribute to pediatric trauma is unclear. OBJECTIVE: The present study aimed to review patients from a single Level I pediatric trauma center to determine the influence of weather, the lunar cycle, and time of year on trauma activity. METHODS: A retrospective review of trauma activations (n = 1,932) was conducted from 2015 to 2017. Injury type and general demographics were collected. Weather data and lunar cycles were derived from historical databases. RESULTS: Days with no precipitation increased the total number of injuries of all types compared with those with precipitation (p < .001). Blunt and penetrating injuries were more likely to occur during full moons, whereas burn injuries were significantly higher during new moons (p < .001). Blunt trauma was significantly higher in September than all other months, F(11, 1,921) = 4.25, p < .001, whereas January had a significantly higher number of burns than all other months (p < .001). CONCLUSIONS: Pediatric trauma trends associated with external factors such as weather, lunar cycles, and time of year can inform hospital staffing decisions in anticipation of likely injuries and help direct injury prevention efforts.

A Standardized Protocol for Cervical Spine Evaluation in Children Reduces Imaging Utilization: A Pilot Study of the Pediatric Cervical Spine Clearance Working Group Protocol.

BACKGROUND: Cervical spine injuries (CSI) have the potential to cause severe morbidity in children. Multiple imaging studies are used during evaluation of CSIs but come at a cost, both financially and in radiation exposure. To reduce resource utilization and radiation exposure, we implemented the Pediatric Cervical Spine Clearance Working Group (PCSCWG) standardized protocol (SP) for evaluating CSIs in children. METHODS: Children below 18 years old presenting with concern for CSI at a level 1 pediatric trauma center were reviewed before (July 2015 to May 2016) and after (November 2017 to June 2018) protocol implementation. Demographics, injuries, and imaging utilization were extracted. The primary outcomes were the proportion of patients cleared with clinical exam, and the proportion undergoing x-ray, computed tomography, or magnetic resonance image. The secondary outcome was the estimated difference in imaging charges based on the annual reduction in radiographic studies. RESULTS: During the study 359 children were evaluated for CSIs (248 pre-SP, 111 post-SP). Patients were similar with respect to age, injury severity score, and mechanism of injury. Protocol adherence was 87.4%. The prevalence of CSI was similar in the preprotocol and postprotocol cohorts (2.8% vs. 1.8%, P=0.567). Children treated after protocol implementation were significantly more likely to be cleared by clinical exam (15.3% vs. 43.2%, P<0.001). Significantly fewer children had x-rays (70.2% vs. 55.0%, P=0.005) and computed tomography scans (14.5% vs. 5.4%, P=0.013) in the postprotocol period. There was no difference in the utilization of magnetic resonance image (6.9% vs. 7.2%, P=0.904) or the proportion of children discharged with a cervical collar (10.1% vs. 12.6%, P=0.476). No patients in either group were found to have a previously undiagnosed injury at follow-up. The reduction in radiographic studies translates to an estimated annual reduction in imaging charges of $396,476. CONCLUSIONS: The PCSCWG protocol for evaluating CSIs reduced the number of radiographic studies performed and estimated imaging charges while reliably identifying CSIs.

Admission of Pediatric Concussion Injury Patients: Is It Necessary?

BACKGROUND: Currently there is no consensus on the management of patients with a concussion and negative computed tomography (CT) of the head. This study examined the necessity of admitting pediatric patients with concussive symptoms. The purpose of this study was to determine if pediatric patients evaluated in the emergency department (ED) for concussion with a negative head CT scan require routine hospital admission. MATERIALS AND METHODS: A retrospective chart review of pediatric trauma patients admitted to the hospital for a concussion from 2010 to 2017 was conducted after IRB approval (1709005621). Only patients with a negative head CT were included. Demographic information, ED evaluation, and hospital course were reviewed. RESULTS: A total of 90 patients (Mage = 10 y; 72.2% male) were included in the analysis. The average Glasgow coma scale was 14.6 (range 9-15). Loss of consciousness was reported by 36.7% (n = 33) of patients. Reported symptoms included nausea/emesis in 35.5% (n = 32) and altered mental status in 40% (n = 36). Following admission, 94.4% of patients were discharged within 24 h of admission. Of the four patients (4.4%) that stayed longer than 24 h, only two hospitalizations were related to the concussion (inability to tolerate diet). One patient had a fever unrelated to the concussion and one stayed because of social issues. Average length of stay for these patients was 2.75 d (range 2-4 d). There was no difference in Glasgow coma scale in comparison to patients who were discharged within 24 h. CONCLUSIONS: Although there are a large number of pediatric patients evaluated in the ED for concussion injuries, very few of these patients require any further care. Our study suggests that patients with concussion and a negative head CT who tolerate a diet can be safely discharged home.

Cohorting Trauma Patients in a Medical/Surgical Unit at a Level I Pediatric Trauma Center to Enhance Interdisciplinary Collaboration and Documentation.

Medical errors are a significant issue in health care that may be avoided through enhanced communication and documentation. This study examines interdisciplinary communication and compliance with trauma standards of care demonstrated through following the implementation of cohorting trauma patients to one medical/surgical unit and instituting daily interdisciplinary trauma patient rounds. Potential benefits include enhanced communication, improved nursing satisfaction, and increased compliance with trauma standards of care demonstrated through documentation, which the literature suggests improves quality of care. Pre- and postcohorting surveys related to safety attitudes, comfort with caring for trauma patients, and the efficacy of cohorting were administered to the nursing staff. As a marker for increased compliance with trauma standards of care, medical records were reviewed for completion of substance abuse screening upon admission and Functional Independence Measure screening at discharge. The results were compared after the cohorting initiative with 2 years prior. The rate of compliance with substance abuse screening increased from an average of 62.5% in 2015 and 2016 to 84% in 2017. Functional Independence Measure compliance increased from an average of 72.5% in 2015 and 2016 to 94% in 2017 following the cohorting intervention. Nursing perceptions of teamwork, safety climate, and staff support significantly improved (p < .05) from pre- to postcohorting surveys. Improvements were noted in comfort with performing tasks associated with caring for trauma patients but were not statistically significant. Cohorting trauma patients to one medical/surgical unit resulted in positive perceptions of professional relationships, improved communication, and compliance with trauma standards of care for documentation.

Anterior vertebral body tethering for immature adolescent idiopathic scoliosis: one-year results on the first 32 patients.

PURPOSE: This retrospective chart review evaluates the clinical and radiographic outcomes of anterior vertebral body tethering (VBT) at 1-year follow-up. Anterior VBT offers a fusionless treatment option for skeletally immature patients with adolescent idiopathic scoliosis. It is a growth-modulation technique, which utilizes patients' growth to attain progressive scoliosis correction. Numerous animal models support its promise; however, clinical data remain sparse. METHODS: Clinical and radiographic data were retrospectively analyzed. We reviewed 32 patients who underwent thoracic VBT with a minimum one-year follow-up. Pertinent clinical and radiographic data were collected. ANOVA, Student's t test and Fisher's exact test were utilized to compare different time points. RESULTS: 32 patients with thoracic idiopathic scoliosis (72 % female) with a minimum one-year follow-up were identified; mean age at surgery was 12 years. All patients were considered skeletally immature pre-operatively; mean Risser score 0.42, mean Sanders score 3.2. Patients underwent tethering of an average of 7.7 levels (range 7-11). Median blood loss was 100 cc. The mean pre-operative thoracic curve magnitude was 42.8° ± 8.0° which corrected to 21.0° ± 8.5° on first erect and 17.9° ± 11.4° at most recent. The pre-operative lumbar curve of 25.2° ± 7.3° demonstrated progressive correction (first erect = 18.0° ± 7.1°, 1 year = 12.6° ± 9.4°, p < 0.00001). Thoracic axial rotation measured 13.4° pre-operatively and 7.4° at the most recent measurement (p < 0.00001). One patient experienced prolonged atelectasis which required a bronchoscopy; otherwise, no major complications were observed. CONCLUSIONS: Our early results indicate that anterior VBT is a safe and potentially effective treatment option for skeletally immature patients with idiopathic scoliosis. These patients experienced an improvement of their scoliosis with minimal major complications. However, longer term follow-up of this cohort will reveal the true benefits of this promising technique. LEVEL OF EVIDENCE: IV.

Establishing technical performance norms for general surgery residents.

BACKGROUND: Surgery residents are required to achieve performance milestones to advance in their residency. Level-specific, technical performance norms that could be used as milestones, however, do not currently exist. Our aim was to develop level-specific, technical performance norms for general surgery residents on select simulated tasks across multiple institutions. STUDY DESIGN: An IRB-approved, prospective, multi-institutional collaborative study with voluntary participation of residents was undertaken at the start of the 2011-2012 academic year. General surgery residents (PGY I-V) from seven institutions were tested on three laparoscopic and five open simulated surgical tasks, and their performance was assessed based on task time and errors. Means and standard deviations of performance for each resident level were calculated and compared. Residents with performance 1 standard deviation below the mean were considered outliers. RESULTS: A total of 147 residents were evaluated. Mean resident age was 28 ± 3 years; 42 % were female; and they had attended 74 different medical schools. Senior residents (PGY III-V) had more clinical and simulator experience than junior residents (PGY I-II) (p < 0.001). Resident performance scores progressively increased in all tasks reaching a plateau at a lower PGY level for open tasks. Depending on the task, 0-18 % of residents were outliers. When surveyed, 66 % of residents agreed that national performance norms for residents should exist. CONCLUSIONS: Performance norms were established for select tasks in a representative sample of US surgery residents. Such performance norms allow a more informed assessment of resident skill through comparison to national data and enable the identification of outliers who may benefit from additional training.

The Impact of Anterior Vertebral Body Tethering on Pulmonary Function.

STUDY DESIGN: Retrospective, single-center study. OBJECTIVE: To examine pulmonary function tests (PFTs) in patients undergoing anterior vertebral body tethering (AVBT). SUMMARY OF BACKGROUND DATA: The effect of AVBT on pulmonary status remains unclear. MATERIALS AND METHODS: The authors examined preoperative and postoperative PFTs following AVBT in a retrospective, single-center cohort of patients. Outcomes were compared using percent predicted values as continuous and categorical variables (using 10% change as significant) and divided into categorical values based on the American Thoracic Society standards. RESULTS: Fifty-eight patients with adolescent idiopathic scoliosis were included, with a mean age of 12.5±1.4 years and a follow-up of 4.2±1.1 years. The mean thoracic curve was 47°±9°, which improved to 21°±12°. At baseline, the mean forced expiratory volume in one second (FEV1%) and forced vital capacity (FVC%) values were 79% and 82%, respectively. Four patients had normal FEV1% (≥100%), 67% had mild restrictive disease (70%-99%) and the rest had worse FEV1%. Mean FEV1 improved from 2.2 to 2.6 L ( P <0.05) and FVC improved from 2.5 to 3.0 L ( P <0.05); however, % predicted values remained unchanged (FEV1%: 79%-80%; FVC%: 82-80%, P >0.05) with mean postoperative PFTs at 37±12 months postoperative. The use of miniopen thoracotomy was not associated with worsening PFTs, but extension of the lowest instrumented vertebra below T12 was correlated with decreasing FEV1% in the bivariate analysis ( P <0.05). Patients with worse preoperative FVC% (80±13% vs. 90±11%, P =0.03) and FEV1% (77±17% vs. 87±12%, P =0.06) also had a greater likelihood of declining postoperative FEV1%. CONCLUSION: Pulmonary function in most patients undergoing AVBT remained stable (76%) or improved (14%); however, a subset may worsen (10%). Further studies are needed to identify the risk factors for this group, but worse preoperative PFTs and extension below T12 may be risk factors for worsening pulmonary function.

Knowing Your Patient Population: Techniques to Capture Infants at High Risk for Physical Abuse in a Trauma Registry.

BACKGROUND: Physical abuse is a major public health concern and a leading cause of morbidity and mortality in infants. Clinical decision tools derived from trauma registries can facilitate timely risk-stratification. The Trauma Quality Improvement Program (TQIP) database does not report age for children <1 year who are at highest risk for abuse. We report a method to capture these infants despite the missing age. METHODS: Patients ≤17 years were identified from TQIP (2017-2019). The primary outcomes included injuries resulting from confirmed or suspected child abuse captured by diagnosis codes or report/investigation of physical abuse, or different caregiver at discharge available in TQIP. We used two methods to select infants within TQIP. In the first, World Health Organization (WHO) growth standards for stature or length-for-age and weight-for-age were selected to capture children younger than 1 year. In the second, a K-means machine learning algorithm was used to cluster patients by weight and height. We compared outcome and injury data with and without patients <1 year. RESULTS: Using the WHO growth standard 19,916 children <1 year were identified. A total of 20,513 patients had a report of physical abuse filed, and 9393 were infants <1 year. Increased age-adjusted odds ratios [95% CI] were seen for fractures of the upper limb (1.28 [1.22-1.34]), vertebrae (1.89 [1.68-2.13]), ribs (5.2 [4.8-5.63]), and spinal cord (3.39 [2.85-4.02]) and head injuries (1.55 [1.5-1.6]) with infants included. CONCLUSIONS: In a nationwide trauma registry, WHO growth standards can be used to capture patients under one year who are more adversely impacted by maltreatment. TYPE OF STUDY: Retrospective, Cross-sectional. LEVEL OF EVIDENCE: Level III, Diagnostic.

Clinical Outcomes in Neurologically Intact Children With Small Intracranial Bleeds and Simple Skull Fractures.

Introduction Children with minor intracranial hemorrhage (ICH) and/or simple skull fractures are often hospitalized for monitoring; however, the majority do not require any medical, surgical, or critical care interventions. Our purpose was to determine the rate of significant clinical sequela (SCS) and identify associated risk factors in neurologically intact children with close head trauma. Methods This is a retrospective observational study. Children (≤ 3 years of age) admitted with closed head trauma, documented head injuries (ICH ≤ 5mm and/or simple skull fracture), and a Glasgow Coma Scale (GCS) score of ≥14, between January 2015 and January 2020, were included. We collected demographics, resource utilization, and patient outcomes variables. SCS was defined as any radiologic progression, and/or clinically important medical or neurological deterioration. Results A total of 205 patients were enrolled in the study (65.4% male, mean age 7.7 months). Repeat neuroimaging was obtained in 41/205 patients (20%) with radiologic progression noted in 5/205 (2.4%). Thirteen out of 205 patients (6.3%) experienced SCS. Patients with SCS were more likely to be males (92.3% vs 63.5% in females, P=0.035) to have had a report filed with child protective services due to a concern for abuse/neglect (92.3% vs 61.5% in females, P=0.025), and to have had a non-linear skull fracture (P<0.001). No other factors were shown to be predictive of SCS with enough statistical significance. Conclusion Neurologically intact children with traumatic closed head injury are at low risk for developing SCS. This study suggests that most of these children may not need ICU monitoring. This study also showed that a certain subset might be at an increased risk of developing SCS.

Obesity is not associated with increased resource utilization or morbidity in patients undergoing appendectomy.

BACKGROUND: Obesity is a growing public health concern that places patients at risk of morbidity and mortality following surgery. We sought to determine whether obesity influences our resource utilization and postoperative outcomes for patients who present with appendicitis. METHODS: Charts were reviewed for patients age 1-18 years identified from a prospective registry who presented with a diagnosis of appendicitis from 2017 to 2020. Patients who underwent appendectomy were eligible. Charts were reviewed for demographics, imaging studies, laboratory studies, length of stay, operative times and thirty-day postoperative adverse events defined as return to the emergency room, re-admission, postoperative abscess or return to the operating room. A multivariate logistic regression analysis was performed to identify differences in resource utilization and outcome. RESULTS: A total of 451 patients were identified. There were 126 obese patients (27.9%). Obese patients were not more likely to present with perforated appendicitis and were not more likely to undergo computed tomography scans. All patients underwent laparoscopic appendectomy. Although intraoperative times were significantly longer for Black patients and older patients, BMI did not influence length of surgery. Length of stay was significantly higher for younger patients (p = 0.019). Adverse events were seen in 38 patients (8.4%). There was no association between BMI and adverse events. CONCLUSIONS: Within our standardized management pathway, obesity does not influence management or patient outcomes for the treatment of appendicitis. Furthermore, obese patients did not require additional resource utilization. LEVEL OF EVIDENCE: III.

Pain After Anterior Vertebral Body Tethering: Incidence, Risk Factors, and Timing.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To examine the incidence and risk factors for postoperative pain following anterior vertebral body tethering (AVBT) for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Up to 78% of patients with AIS report preoperative pain; it is the greatest patient concern surrounding surgery. Pain significantly decreases following posterior spinal fusion, but pain following AVBT is poorly understood. MATERIALS AND METHODS: We retrospectively reviewed 279 patients with a two-year follow-up after AVBT for AIS. We collected demographic, radiographic, and clinical data pertinent to postoperative pain at each time interval of preoperative and postoperative visits (6 wk, 6 mo, 1 y, and annually thereafter). RESULTS: Within our cohort, 68.1% of patients reported preoperative pain. Older age ( P =0.014) and greater proximal thoracic ( P =0.013) and main thoracic ( P =0.002) coronal curve magnitudes were associated with preoperative pain. Pain at any time point > 6 weeks postoperatively was reported in 41.6% of patients; it was associated with the female sex ( P =0.032), need for revision surgery ( P =0.019), and greater lateral displacement of the apical lumbar vertebrae ( P =0.028). The association between preoperative and postoperative pain trended toward significance ( P =0.07). At 6 months postoperatively, 91.8% had pain resolution; the same number remained pain-free at the time of last follow-up. The presence of a postoperative complication was associated with new-onset postoperative pain that resolved ( P =0.009). Only 8.2% had persistent pain, although no risk factors were found to be associated with persistent pain. CONCLUSION: In our cohort of 279 patients with a minimum 2-year follow-up after AVBT, 68.1% reported preoperative pain. Nearly 42% reported postoperative pain at any time point, but only 8.2% had persistent pain. Postoperative pain after AVBT was associated with female sex, revision surgery, and Lenke lumbar modifier. AVBT is associated with a significant reduction in pain, and few patients report long-term postoperative pain.

Updated APSA Guidelines for the Management of Blunt Liver and Spleen Injuries.

BACKGROUND: Non-operative management of blunt liver and spleen injuries was championed initially in children with the first management guideline published in 2000 by the American Pediatric Surgical Association (APSA). Multiple articles have expanded on the original guidelines and additional therapy has been investigated to improve care for these patients. Based on a literature review and current consensus, the management guidelines for the treatment of blunt liver and spleen injuries are presented. METHODS: A recent literature review by the APSA Outcomes committee [2] was utilized as the basis for the guideline recommendations. A task force was assembled from the APSA Committee on Trauma to review the original guidelines, the literature reported by the Outcomes Committee and then to develop an easy to implement guideline. RESULTS: The updated guidelines for the management of blunt liver and spleen injuries are divided into 4 sections: Admission, Procedures, Set Free and Aftercare. Admission to the intensive care unit is based on abnormal vital signs after resuscitation with stable patients admitted to the ward with minimal restrictions. Procedure recommendations include transfusions for low hemoglobin (<7 mg/dL) or signs of ongoing bleeding. Angioembolization and operative exploration is limited to those patients with clinical signs of continued bleeding after resuscitation. Discharge is based on clinical condition and not grade of injury. Activity restrictions remain the same while follow-up imaging is only indicated for symptomatic patients. CONCLUSION: The updated APSA guidelines for the management of blunt liver and spleen injuries present an easy-to-follow management strategy for children. LEVEL OF EVIDENCE: Level 5.

Derivation and Validation of a Machine Learning Algorithm for Predicting Venous Thromboembolism in Injured Children.

BACKGROUND: Venous thromboembolism (VTE) causes significant morbidity in pediatric trauma patients. We applied machine learning algorithms to the Trauma Quality Improvement Program (TQIP) database to develop and validate a risk prediction model for VTE in injured children. METHODS: Patients ≤18 years were identified from TQIP (2017-2019, n = 383,814). Those administered VTE prophylaxis ≤24 h and missing the outcome (VTE) were removed (n = 347,576). Feature selection identified 15 predictors: intubation, need for supplemental oxygen, spinal injury, pelvic fractures, multiple long bone fractures, major surgery (neurosurgery, thoracic, orthopedic, vascular), age, transfusion requirement, intracranial pressure monitor or external ventricular drain placement, and low Glasgow Coma Scale score. Data was split into training (n = 251,409) and testing (n = 118,175) subsets. Machine learning algorithms were trained, tested, and compared. RESULTS: Low-risk prediction: For the testing subset, all models outperformed the baseline rate of VTE (0.15%) with a predicted rate of 0.01-0.02% (p < 2.2e-16). 88.4-89.4% of patients were classified as low risk by the models. HIGH-RISK PREDICTION: All models outperformed baseline with a predicted rate of VTE ranging from 1.13 to 1.32% (p < 2.2e-16). The performance of the 3 models was not significantly different. CONCLUSION: We developed a predictive model that differentiates injured children for development of VTE with high discrimination and can guide prophylaxis use. LEVEL OF EVIDENCE: Prognostic, Level II. TYPE OF STUDY: Retrospective, Cross-sectional.

What Happens After a Vertebral Body Tether Break? Incidence, Location, and Progression With Five-year Follow-up.

STUDY DESIGN: Retrospective review. OBJECTIVE: To study risk factors for anterior vertebral body tether (VBT) breakage. SUMMARY OF BACKGROUND DATA: VBT is used to treat adolescent idiopathic scoliosis in skeletally immature patients. However, tethers break in up to 48% of cases. MATERIALS AND METHODS: We reviewed 63 patients who underwent thoracic and/or lumbar VBT with a minimum five-year follow-up. We radiographically characterized suspected tether breaks as a change in interscrew angle >5°. Demographic, radiographic, and clinical risk factors for presumed VBT breaks were evaluated. RESULTS: In confirmed VBT breaks, the average interscrew angle change was 8.1°, and segmental coronal curve change was 13.6°, with a high correlation ( r =0.82). Our presumed VBT break cohort constituted 50 thoracic tethers, four lumbar tethers, and nine combined thoracic/lumbar tethers; the average age was 12.1±1.2 years and the mean follow-up was 73.1±11.7 months. Of 59 patients with thoracic VBTs, 12 patients (20.3%) had a total of 18 breaks. Eleven thoracic breaks (61.1%) occurred between two and five years postoperatively, and 15 (83.3%) occurred below the curve apex ( P <0.05). The timing of thoracic VBT breakage moderately correlated with more distal breaks ( r =0.35). Of 13 patients who underwent lumbar VBT, eight patients (61.5%) had a total of 12 presumed breaks. Six lumbar breaks (50%) occurred between one and two years postoperatively, and seven (58.3%) occurred at or distal to the apex. Age, sex, body mass index, Risser score, and curve flexibility were not associated with VBT breaks, but the association between percent curve correction and thoracic VBT breakage trended toward significance ( P =0.054). Lumbar VBTs were more likely to break than thoracic VBTs ( P =0.016). Seven of the patients with presumed VBT breaks (35%) underwent revision surgery. CONCLUSIONS: Lumbar VBTs broke with greater frequency than thoracic VBTs, and VBT breaks typically occurred at levels distal to the curve apex. Only 15% of all patients required revision. LEVEL OF EVIDENCE: 3.

Thoracoscopic intercostal to phrenic nerve transfer for diaphragmatic reanimation in a child with tetraplegia.

Context: To describe for the first time a novel technique of thoracoscopic intercostal nerve mobilization and intercostal to phrenic nerve transfer in the setting of tetraplegia with the goal of reanimating the diaphragm and decreasing ventilator dependence.Findings: A 5-year-old female on 24 h ventilator support secondary to traumatic tetraplegia was evaluated for possible phrenic nerve pacing. Left-sided phrenic nerve stimulation did not result in diaphragmatic contraction indicating a lower motor neuron injury. The patient underwent thoracoscopic mobilization of the left phrenic nerve and 10th intercostal nerve while positioned in the left lateral decubitus position using four 5 mm trocars. The mobilized intercostal nerve was transected close to its distal anterior termination and coapted without tension to the cut end of the terminal phrenic nerve using fibrin sealant. Lastly, phrenic nerve pacer leads and battery were implanted in the chest wall and connected to the electrode placed on the intercostal nerve. One year following the procedure, the patient was tolerating phrenic pacing during the day while requiring ventilation overnight. Currently, the patient is 2 years post-operative from this procedure and does not require ventilator support.Conclusion/clinical relevance: We have shown for the first time a novel approach of thoracoscopic nerve mobilization and phrenic to intercostal nerve transposition to be both safe and effective for restoring innervation of the diaphragm in a child. This minimally invasive procedure is recommended as the preferred approach to reanimate the diaphragm.

Utility of skull radiographs in infants undergoing 3D head CT during evaluation for physical abuse.

BACKGROUND: Clinical practice guidelines recommend performing head CT and skull radiographs (SR) when evaluating infants for physical abuse. We compared the accuracy of 3-dimensional CT (3DCT) and SR for detecting skull fractures. METHODS: We reviewed children <12 months evaluated for physical abuse undergoing 3DCT and SR between January 2017 and December 2018. 3DCT and SR images were blindly read by 2 radiologists. Interrater reliability (IRR) was calculated. Diagnostic accuracy was compared using McNemar's test. RESULTS: 158 infants with a mean age of 5.0 months underwent 3DCT and SR. Consensus reading identified 46 fractures (29.1%) on 3DCT and 40 fractures (25.3%) on SR. IRR was higher for 3DCT (κ = 0.95) than for SR (=0.65). 11 fractures were identified on 3DCT but not SR. 5 fractures were identified on SR but not 3DCT. There was no difference in the diagnostic accuracy of 3DCT and SR (χ2 = 1.56, p = 0.211). CONCLUSIONS: We found no difference in the accuracy of 3DCT and SR for detecting skull fractures in infants. Because 3DCT has better IRR and evaluates for both bony and intracranial injuries it is superior to SR. Omitting SRs may be acceptable if a 3DCT is performed, and would reduce radiation exposure without compromising diagnostic accuracy.

A Standardized Protocol for Nonoperative Management of Complicated Appendicitis in Children Reduces Resource Utilization.

INTRODUCTION: To standardize care and reduce resource utilization, we implemented a standardized protocol (SP) for the nonoperative treatment of complicated appendicitis. MATERIALS AND METHODS: We conducted a prospective, historically controlled, study of patients <21 years with complicated appendicitis managed nonoperatively using an SP from January 2017 to November 2018. The primary outcomes included length of stay (LOS), antibiotic days, peripheral inserted central catheter (PICC) utilization, discharge on intravenous antibiotics, and predischarge imaging. Secondary outcomes were protocol adherence and the rates of adverse events (AE) including return to emergency department (ED), readmission, failure of nonoperative treatment, and interval appendectomy complications. RESULTS: Protocol adherence was 67.9%. In total, 741 children were treated for appendicitis of which 58 (30 pre-SP and 28 post-SP) were treated nonoperatively for complicated appendicitis at presentation. Patients were well matched for age, admission white blood cell, sex, body mass index, race, and the proportion requiring percutaneous drainage. After implementing the SP, fewer children had PICCs (100.0 vs. 57.1%, p ≤ 0.001), fewer were discharged on intravenous antibiotics (90.0 vs. 42.9%, p < 0.001), and total antibiotic days were reduced (14.0 vs. 10.0, p = 0.006). There was no difference in LOS (5.5 vs. 6.0 days, p = 0.790) or the proportion undergoing ultrasound (36.7 vs. 39.3%, p = 0.837) or computed tomography scan (16.7 vs. 3.6%, p = 0.195) prior to discharge. There were nonsignificant trends toward reduced AEs (46.7 vs. 35.7%, p = 0.397), returns to ED (40.0 vs. 28.6%, p = 0.360), and readmissions (26.7 vs. 17.9%, p = 0.421). The proportion failing nonoperative treatment (10.0 vs. 3.6%, p = 0.612) and experiencing complications of interval appendectomy (3.3 vs. 3.6%, p = 0.918) were not significantly different. CONCLUSION: Implementing an SP for treating complicated appendicitis nonoperatively reduced resource utilization without negatively affecting clinical outcomes.