Growing Up After Adolescent Bariatric Surgery.

This study investigates the effects of adolescent bariatric surgery among young adults approximately 10 years post-surgery. Participants were recruited from a hospital-based bariatric registry. We used an exploratory, qualitatively-driven mixed methods design. Findings were integrated with medical chart data and the SF-36, Body QoL, and the Transition Readiness Assessment Questionnaire. Of the 22 participants who completed surveys (14 females and 8 males), 20 participants also completed a phone interview. Median participant age was 25 years (range = 19-30). Median weight-loss was 23% (6.0%‒58%). Four themes emerged: taking control, weight loss challenges, body image adjustment, and growing up. Participants reported physical benefits of surgery yet were challenged by eating habits, body image, and interpersonal relationships. Participants were indifferent to preventative healthcare, despite the potential for vitamin deficiencies and the return of weight-related comorbidities. Clinicians can facilitate the transition to young adulthood by providing continued mental support, education, and medical monitoring.

The Impact of Bullying Victimization and Sexual Orientation on the Severity of Suicidal Behavior.

Background: Lesbian, gay, and bisexual youth face a disproportionate risk of suicidal ideation and attempt compared to heterosexual counterparts. Escalation from ideation to attempt can occur quickly, and youth who survive suicide attempts are likely to pursue subsequent, riskier attempts. This study examines the effects of bullying and sexual orientation on suicidal outcomes. Methods: Data came from the national, school-administered 2017 Youth Risk Behavior Survey (N = 14,765). Bivariate associations, binomial logistic regressions, and ordinal logistic regressions were performed. Results: Lesbian/gay, bisexual, and unsure youth reported greater odds of ideation and attempts compared to heterosexual youth. For ideation, increased effects were inconsistent across bullying types and significant interactions were found for bisexual youth who were bullied in school, and for lesbian/gay youth who were cyberbullied. Conclusion: These results underscore the need to understand bullying victimization for lesbian, gay, and bisexual youth. Awareness of increasing cyberbullying and creating school environments of no-bullying tolerance in the post-pandemic era are among the challenges ahead.

Learning from suicide deaths in Harris County, Texas.

This study examined individual and community demographic characteristics surrounding suicides in one of the most populous counties in the United States. We paired medical examiner records with U.S. Census data and analyzed them using geospatial software. The majority of decedents were non-Hispanic, white males who died primarily of gunshot wounds. Salient age characteristics included interpersonal violence and depression among ages younger than 40. Despite lower incomes and education levels, areas with higher population density and racial/ethnic minorities had fewer suicides. Additional research should address depression among males and the elderly, interpersonal violence, firearm access, and culture.

The American Academy of Pediatrics firearm safety infographic improves firearm safety guidance: A qualitative study.

PURPOSE: Approximately 800 children annually suffer unintentional firearm injuries and deaths from unsecured firearms in the United States. These injuries are preventable, and may be avoided by providing parents with firearm safety guidance (FSG). The purpose of this study was to evaluate the experience of pediatric providers in delivering FSG following incorporation of the American Academy of Pediatrics (AAP) infographic. METHODS: Qualitative study completed July 2019-December 2019. Community pediatricians in Houston, Texas were provided the AAP firearm safety infographic and encouraged to provide FSG routinely during well-child visits with firearm-owning parents. Efficacy, feasibility of use and barriers to FSG were assessed via focus groups. Content analysis was utilized to identify emergent themes from provider experiences. RESULTS: Forty-four pediatricians across eight clinics delivered FSG using the AAP infographic. Of these, thirty-four participated in focus groups discussing their experience. Only 34% of those in the focus groups had routinely provided FSG prior to the study. The AAP infographic was a useful tool because of its visibility, valuable information, and assistance with broaching the topic of firearm safety with parents. Three themes were identified from qualitative analysis: methods of successful delivery of FSG (62%), patient responses to FSG (25%), and barriers to delivery of FSG (13%). Parents were generally receptive to the guidance. CONCLUSIONS: The AAP firearm safety infographic, which is free and publicly available, can be a valuable and satisfactory tool for delivery of firearm safety guidance by pediatric providers, including surgeons. Further study is needed to assess whether the guidance changes parental storage behaviors. LEVEL OF EVIDENCE: Level VI.

Physician-driven or self-directed safe firearm storage guidance: Which one is best?

BACKGROUND/PURPOSE: Access to firearms is a preventable cause of unintentional injury and suicide in children. Pediatric physicians provide injury prevention guidance, but firearm safety may not routinely be included. The purpose of this pilot study was to evaluate the effectiveness of firearm safety guidance (FSG) provided by a physician. METHODS: Prospective, randomized-controlled, trial assessing physician-delivered FSG at two pediatric clinics in Houston, Texas. Firearm-owning parents were randomized to physician guidance (PG) versus control (CG) groups. The CG received a handout with firearm safety facts and a free cable lock. The PG additionally received FSG by a physician. Pre- and post-intervention surveys were conducted. Results were analyzed using descriptive statistics and Chi square analysis. RESULTS: Thirty-two families participated; most (70%) were satisfied with the guidance. Pre-intervention safe firearm storage was high in both groups, and the intervention did not lead to improved habits in either group [PG: Pre 93% vs. Post 89%, p = 0.7 and CG: Pre 82% vs. 78%, p = 0.7].There was no difference in use of the free cable lock among groups (44% vs. 22%, p = 0.9). The PG demonstrated improved knowledge of the state child access protection law (PG: Pre 60% vs. Post 100% vs. CG: Pre 29% vs. Post 67%; p = 0.02). CONCLUSIONS: For firearm-owning parents, physician-delivered safe storage guidance may not be more effective than self-directed guidance provided by a handout. A larger trial is underway to confirm the findings of this pilot study.

Virtual learning experiences in population health nursing course during the COVID-19 pandemic.

AIM: To discuss the virtual learning strategies used in population health nursing course during the coronavirus disease 2019 (COVID-19) pandemic. BACKGROUND: The School of Nursing faculty in a South Central University in the United States quickly combined innovation with digital resources and transitioned a course in population health during the COVID-19 pandemic. Nursing faculty were challenged to develop student nursing objectives in assessment, planning, intervention and evaluation of vulnerable populations in the community through a virtual environment. REFLECTIONS OF POPULATION HEALTH NURSING CLINICAL EDUCATION: The experiences of five clinical groups are described, covering adults with disabilities, older people, patients with COVID-19 and youth populations. DISCUSSION: The course objectives were met through use of a digital environment. Collaborative interventions were designed and implemented with community stakeholders while maintaining social distancing policies. Successes included increased frequency of communication and learning opportunities for students and the community, and student satisfaction. Barriers to student learning were not related to the digital learning environment, although the older adults required modifications to use electronic devices. CONCLUSION: Virtual classrooms are a viable platform to teach population health nursing and to benefit vulnerable populations. IMPLICATIONS FOR NURSING PRACTICE: Virtual learning offers benefits within academia and the community. Technology offers the possibility to improve mental health among older people and enhance knowledge among the general population. Students are better able to connect with clinical faculty and stakeholders through digital platforms. IMPLICATIONS FOR NURSING POLICY: Nurses play a vital role in improving population health and can collaborate with community stakeholders to implement innovative and sustainable solutions to nursing education, practices and policy. Digital platforms can enhance the involvement of students through these collaborations during and after the pandemic.

Keeping Children Safe at Home: Parent Perspectives to Firearms Safety Education Delivered by Pediatric Providers.

OBJECTIVES: The aims of this study were to assess parent acceptance of firearms education delivered by clinical providers, determine whether parents engage in firearms safety dialog with their children, and evaluate reasons for ownership and storage behaviors. METHODS: The parents of children ages 0 to 18 years completed surveys while in a pediatric inpatient setting in Texas. Demographics, acceptability, current behaviors, and storage practices were queried. Responses between firearms owners and nonowners were analyzed using the Fisher exact and χ2 tests. RESULTS: Of the 115 parents who completed surveys, 41% reported owning firearms. Most parents were likely or highly likely to follow their pediatrician's gun safety advice (67%), were accepting of safety videos in waiting rooms (59%), and accepted firearms locks distributed by clinical providers (69%). Nonowners were less likely than owners to have spoken to their children about gun safety (P = 0.004). Parents owned firearms for self-protection and recreation (50%), self-protection only (38%), or recreation only (12%). Owners stored them unloaded (75%), used safety devices (95%), and stored them in the closet of the master bedroom (54%). CONCLUSIONS: Talking about firearms safety in a healthcare setting was not a contentious issue in the majority of our sample. Parents were accepting of provider-led firearms guidance regardless of ownership status. This provides an opportunity for providers to focus on effective messaging and time-efficient delivery of firearms safety education.

Effectiveness of a clinical pathway for pediatric complex appendicitis based on antibiotic stewardship principles.

PURPOSE: Outcomes and resource utilization were evaluated after implementing a novel complex appendicitis (CA) pathway limiting postoperative antibiotics based on clinical parameters. METHODS: Children with intraoperative CA (gangrenous, perforated, or abscess) were treated with intravenous antibiotics postoperatively until clinical criteria were met, without utilizing CBC or oral antibiotics at discharge. An interrupted time series (pre-intervention, transition, post-intervention) was used to assess outcomes. Hospital length of stay (LOS) was analyzed using segmented regression. Intra-abdominal abscess and readmission rates were analyzed using non-inferiority and multivariate logistic regression. RESULTS: Five hundred ten children were included with a median age of 10 [IQR7-12] years. There were no differences in postoperative LOS (slope - 0.008; p = 0.855), intra-abdominal abscess rate (5% vs. 8%; p = 0.135), or readmission rate (12% vs. 8%; p = 0.113) across time periods which remained true when adjusting for age, gender, and intraabdominal disease severity. Post-intervention outcomes were not inferior to pre-intervention, abscess rate (p = 0.002), or readmission rate (p < 0.001). Intraoperative findings of perforation (OR9.0; 95% CI1-71; p = 0.044) and perforation with abscess (OR18.2; 95% CI2-36; p = 0.005) were associated with a greater likelihood of postoperative abscess compared to gangrenous appendicitis. CONCLUSION: A CA protocol based on clinical parameters is safe and effective, resulting in similar intra-abdominal abscess and readmission rates compared to more resource-intense regimens. LEVEL OF EVIDENCE: III TYPE OF RESEARCH: Interrupted Time Series.

An assessment of provider satisfaction with the use of a standardized visual aid for informed consent for appendectomy in children.

PURPOSE: We previously validated a visual aid for the use in the consent process for an appendectomy showing improved parental satisfaction and understanding. In this study, we evaluated provider satisfaction and perceived value of using the visual aid. METHODS: An IRB approved survey was developed assessing provider experience with use of the visual aid. This was distributed and analyzed via Research Electronic Data Capture (RedCap) Database. RESULTS: We administered 58 surveys (45% response rate). Participants included faculty (n = 2), fellows (n = 1), residents (n = 6), and physician assistants (n = 17). The visual aid was used >10 times by 50% of providers. The most common reason for not using the visual aid was not remembering it was available. Nearly half (40%) did not feel the visual aid added any time. 9/20 (45%) felt it added a small amount of time. Slightly over half of providers (52%) felt using the visual aid significantly increased family ability to give informed consent and made the consenting process easier for both providers and families. CONCLUSION: Using a visual aid in consenting families for appendectomy does not add significant time and subjectively improves the process for providers and increases provider perception of parental understanding. LEVEL OF EVIDENCE: Cost effectiveness, Level IV.

Cost-Effectiveness Analysis of the Surgical Management of Infants Less than One Year of Age with Feeding Difficulties.

BACKGROUND: We compared the cost-effectiveness of the common surgical strategies for the management of infants with feeding difficulty. METHODS: Infants with feeding difficulty undergoing gastrostomy alone (GT), GT and fundoplication, or gastrojejunostomy (GJ) tube were enrolled between 2/2017 and 2/2018. A validated GERD symptom severity questionnaire (GSQ) and visual analog scale (VAS) to assess quality of life (QOL) were administered at baseline, 1 month, and every 6 months. Data collected included demographics, resource utilization, diagnostic studies, and costs. VAS scores were converted to quality adjusted life months (QALMs), and costs per QALM were compared using a decision tree model. RESULTS: Fifty patients initially had a GT alone (71% laparoscopically), and one had a primary GJ. Median age was 4 months (IQR 3-8 months). Median follow-up was 11 months (IQR 5-13 months). Forty-three did well with GT alone. Six (12%) required conversion from GT to GJ tube, and one required a fundoplication. Of those with GT alone, six (14%) improved significantly so that their GT was removed after a mean of 7 ±â€¯3 months. Overall, the median GSQ score improved from 173 at baseline to 18 after 1 year (p < 0.001). VAS scores also improved from 70/100 at baseline to 85/100 at 1 year (p < 0.001). ED visits (59%), readmissions (47%), and clinic visits (88%) cost $58,091, $1,442,139, and $216,739, respectively. GJ tube had significantly higher costs for diagnostic testing compared to GT (median $8768 vs. $1007, p < 0.001). Conversion to GJ tube resulted in costs of $68,241 per QALM gained compared to GT only. CONCLUSIONS: Most patients improved with GT alone without needing GJ tube or fundoplication. GT and GJ tube were associated with improvement in symptoms and QOL. GJ tube patients reported greater gains in QALMS but incurred higher costs. Further analysis of willingness to pay for each additional QALM will help determine the value of care. STUDY AND LEVEL OF EVIDENCE: Cost-effectiveness study, Level II.

A Multicenter Evaluation of a Firearm Safety Intervention in the Pediatric Outpatient Setting.

PURPOSE: Firearm injuries continue to be a common cause of injury for American children. This pilot study was developed to evaluate the feasibility of providing guidance about firearm safety to the parents of pediatric patients using a tablet-based module in the outpatient setting. METHODS: A tablet-based questionnaire that included a firearm safety message based on current best practice was administered to parents of pediatric patients at nine centers in 2018. Parents were shown a firearm safety video and then asked a series of questions related to firearm safety. RESULTS: The study was completed by 543 parents from 15 states. More than one-third (37%) of families kept guns in their home. The majority of parents (81%, n = 438) thought it was appropriate for physicians to provide firearm safety counseling. Two-thirds (63%) of gun owning parents who do not keep their guns locked said that the information provided in the module would change the way they stored firearms at home. CONCLUSION: Use of a tablet based firearm safety module in the outpatient setting is feasible, and the majority of parents are receptive to receiving anticipatory guidance on firearm safety. Further data is needed to evaluate whether the intervention will improve firearm safety practices in the home. LEVEL OF EVIDENCE: Level III.

Do Ventriculoperitoneal Shunts Increase Complications After Laparoscopic Gastrostomy in Children?

BACKGROUND: In patients requiring gastrostomies, ventriculoperitoneal (VP) shunts are a frequently encountered comorbidity. The objective of this study is to evaluate the postoperative management of children with VP shunts that undergo laparoscopic gastrostomy placement and determine their incidence of complications. MATERIALS AND METHODS: Children 18 y old or younger who underwent laparoscopic gastrostomy placement at a freestanding academic children's hospital between January 2014 and October 2016 were reviewed. Data collected included demographics, management, and outcomes. Patients were compared based on their presence of a VP shunt before laparoscopic gastrostomy. Statistical analysis was performed using chi square, Fisher's exact, and Wilcoxon rank-sum tests. RESULTS: We reviewed the medical records of 270 children that underwent laparoscopic gastrostomy placement by 15 pediatric surgeons. Of these, 9% (25) had a previously placed VP shunt. In comparing patients with a VP shunt with those without a VP shunt, there was no significant difference in median age (4 versus 3 y, P = 0.92), gender (48% versus 51% males, P = 0.80), body mass index (15 versus 16, P = 0.69), preoperative diet (48% versus 47% nasogastric tube dependent, P = 0.60), or procedure time (43 versus 42 min, P = 0.37). The postoperative management of these children was similar: day of initiation of postoperative feeds (84% versus 73% on postoperative day #1, P = 0.70), method of initiation of feeds (60% versus 55% continuous, P = 0.25), and type of initial feeds (83% versus 71% Pedialyte, P = 0.24). Similarly, there was no difference in hospital length of stay, return to the emergency department, or postoperative complications within 90 d (P > 0.05). CONCLUSIONS: Children with ventriculoperitoneal shunts do not have a higher rate of immediate complications after laparoscopic gastrostomy placement and may be managed similar to other children in the postoperative period.

Evaluating quality of life of extracorporeal membrane oxygenation survivors using the pediatric quality of life inventory survey.

PURPOSE: This study assesses the impact of extracorporeal membrane oxygenation (ECMO) associated morbidities on long-term quality of life (QOL) outcomes. METHODS: A single center, retrospective review of neonatal and pediatric non-cardiac ECMO survivors from 1/2005-7/2016 was performed. The 2012 Pediatric Quality of Life Inventory™ (PedsQL™) survey was administered. Clinical outcomes and QOL scores between groups were compared. RESULTS: Of 74 patients eligible, 64% (35 NICU, 12 PICU) completed the survey. Mean time since ECMO was 5.5±3years. ECMO duration for venoarterial (VA) and venovenous (VV) were similar (median 9 vs. 7.5days, p=0.09). VA ECMO had higher overall complication rate (64% vs. 36%, p=0.06) and higher neurologic complication rate (52% vs. 9%, p=0.002). ECMO mode and ICU type did not impact QOL. However, patients with neurologic complications (n=15) showed a trend towards lower overall QOL (63/100±20 vs. 74/100±18, p=0.06) compared to patients without neurologic complications. A subset analysis of patients with ischemic or hemorrhagic intracranial injuries (n=13) had significantly lower overall QOL (59/100±19 vs. 75/100±18, p=0.01) compared to patients without intracranial injuries. CONCLUSION: Neurologic complication following ECMO is common, associated with VA mode, and negatively impacts long-term QOL. Given these associations, when clinically feasible, VV ECMO may be considered as first line ECMO therapy. TYPE OF STUDY: Retrospective review. LEVEL OF EVIDENCE: II.

Injury patterns of child abuse: Experience of two Level 1 pediatric trauma centers.

PURPOSE: This study examines non-accidental trauma (NAT) fatalities as a percentage of all injury fatalities and identifies injury patterns in NAT admissions to two level 1 pediatric trauma centers. METHODS: We reviewed all children (<5years old) treated for NAT from 2011 to 2015. Patient demographics, injury sites, and survival were obtained from both institutional trauma registries. RESULTS: Of 4623 trauma admissions, 557 (12%) were due to NAT. However, 43 (46%) of 93 overall trauma fatalities were due to NAT. Head injuries were the most common injuries sustained (60%) and led to the greatest increased risk of death (RR 5.1, 95% CI 2.0-12.7). Less common injuries that increased the risk of death were facial injuries (14%, RR 2.9, 95% CI 1.6-5.3), abdominal injuries (8%, RR 2.8, 95% CI 1.4-5.6), and spinal injuries (3%, RR 3.9, 95% CI 1.8-8.8). Although 76% of head injuries occurred in infants <1year, children ages 1-4years old with head injuries had a significantly higher case fatality rate (27% vs. 6%, p<0.001). CONCLUSION: Child abuse accounts for a large proportion of trauma fatalities in children under 5years of age. Intracranial injuries are common in child abuse and increase the risk of death substantially. Preventing NAT in infants and young children should be a public health priority. TYPE OF STUDY: Retrospective Review. LEVEL OF EVIDENCE: II.