Surgical Management of Secondary and Tertiary Hyperparathyroidism.

Secondary hyperparathyroidism (SHPT) often arises from kidney disease and is characterized by elevated parathyroid hormone (PTH) levels. The reported optimal PTH level to balance the compensatory physiologic response in SHPT with the pathologic morbidity and mortality has changed over time with our evolving understanding. Parathyroidectomy for kidney-related hyperparathyroidism requires consideration of the patient's dialysis status, potential for kidney transplantation, and medical history. Extent of parathyroidectomy and intraoperative decision-making requires consideration to maximize cure with the risk of permanent hypoparathyroidism. Parathyroidectomy for kidney-related hyperparathyroidism can provide a reduction in morbidity, mortality, and improved kidney allograft function and survival.

Povidone-iodine intra-abdominal irrigation versus no irrigation in pediatric perforated appendicitis: A secondary economic analysis of a Bayesian randomized controlled trial.

BACKGROUND: A pilot randomized controlled trial (RCT) conducted in children (2-17 â€‹y) with perforated appendicitis demonstrated an 89% probability of reduced intra-abdominal abscess (IAA) rate with povidone-iodine (PVI) irrigation, compared with no irrigation (NI). We hypothesized that PVI also reduced 30-day hospital costs. METHODS: We conducted a retrospective economic analysis of a pilot RCT. Hospital costs, inflated to 2019 U.S. dollars, were obtained for index admissions and 30-day emergency visits and readmissions. Cost differences between groups were assessed using frequentist and Bayesian generalized linear models. RESULTS: We observed a 95% Bayesian probability that PVI reduced 30-day mean total hospital costs ($16,555 [PVI] versus $18,509 [NI]; Bayesian cost ratio: 0.90, 95% CrI, 0.78-1.03). The mean absolute difference per patient was $1,954 less with PVI (95% CI, -$4,288 to $379). CONCLUSIONS: PVI likely reduced the IAA rate and 30-day hospital costs, suggesting the intervention is both clinically superior and cost saving.

Older Patients With Asymptomatic Primary Hyperparathyroidism: Should Criteria for Surgery Be Expanded?

Context: Patients with primary hyperparathyroidism (PHPT) can present with variable signs, symptoms, and end-organ effects. Clinical practice guidelines influence referral for consideration of parathyroidectomy. Objective: This study compared the demographic, biochemical, and symptom profile and examine indications for surgery in patients older than 50 years who underwent parathyroidectomy to determine how changes to current guidelines may affect recommendations for parathyroidectomy. Methods: A retrospective review was conducted of patients age 50 years or older who underwent initial parathyroidectomy for sporadic PHPT from 2012 to 2020. Patients were classified by indications for surgery per guideline criteria (classic, asymptomatic, and no criteria met) and age group (AG): 50 to 59 years; 60 to 69 years; 70 years or older. Patients were treated at a high-volume tertiary medical center by endocrine surgeons. Results: Of 1182 patients, 367 (31%) classic and 660 (56%) asymptomatic patients met the criteria for surgery. The most common indications for surgery were extent of hypercalcemia (51%), osteoporosis (28%), and nephrolithiasis (27%). Of the 155 (13%) patients who did not meet the criteria, neurocognitive symptoms (AG1: 88% vs AG2: 81% vs AG3: 70%; P = .14) and osteopenia (AG1: 53% vs AG2: 68% vs AG3: 68%; P = .43) were frequently observed regardless of patient age. If the age threshold of younger than 50 years was expanded to 60, 65, or 70 years, an additional 61 (5%), 99 (8%), and 124 (10%) patients in the entire cohort would have met the guideline criteria for surgery, respectively. Conclusion: Expanding current guidelines for PHPT to include a broader age range, osteopenia, and neurocognitive symptoms may allow for earlier surgical referral and evaluation for definitive treatment.

Healthcare Utilization Among Infants Discharged From the Neonatal Intensive Care Unit: A Descriptive Cost Analysis.

The cost of readmissions of neonatal intensive care unit (NICU) graduates within 6 months and a year of their life is well-studied. However, the cost of readmissions within 90 days of NICU discharge is unknown. This study's objective was to estimate the overall and mean cost of healthcare use for unplanned hospital visits of NICU graduates within 90 days of discharge A retrospective review of all infants discharged between 1/1/2017 and 03/31/2017 from a large hospital system NICUs was conducted. All unplanned hospital visits (readmissions or stand-alone emergency department (ED) visits) occurring within 90 days post NICU discharge were included. The total and mean cost of unplanned hospital visits were computed and adjusted to 2021 US dollars. The total cost was estimated to be $785 804 with a mean of $1898 per patient. Hospital readmissions accounted for 98% ($768 718) of the total costs and ED visits for 2% ($17 086). The mean cost per readmission and stand-alone ED visit were $25 624 and $475 respectively. The highest mean total cost of unplanned hospital readmission was noted in extremely low birth weight infants ($25 295). Interventions targeted to reduce hospital readmissions after NICU discharge have the potential to significantly reduce healthcare costs for this patient population.

Surgical treatment of adrenal tumors during pregnancy.

While most adrenal tumors are identified incidentally and are non-functional, hormone-secreting tumors can cause morbidity and mortality. Hemodynamic lability and hypertension in pregnancy are associated with worse maternal and fetal outcomes. Achieving a diagnosis of hormone excess due to adrenal tumors can be clinically more difficult in the gravid patient due to normal physiologic alterations in hormones and symptoms related to pregnancy. This review focuses on some nuances of the diagnostic work-up, perioperative care, and surgical management of adrenally-mediated cortisol excess, primary aldosteronism, and pheochromocytoma and paraganglioma in the pregnant patient.

Barriers to Transition to Home From the Neonatal Intensive Care Unit: A Qualitative Perspectives of Parents and Healthcare Providers.

The objective of this study was to explore the challenges faced by parents of former neonatal intensive care unit (NICU) patients in transitioning home from parents' and healthcare providers' perspective. We conducted semistructured individual and group interviews with parents of former NICU patients and healthcare providers. Themes from the individual interviews framed the group interviews' contents. The group interviews were recorded and transcribed, and thematic analysis was performed to identify themes. We conducted individual and group interviews with 16 parents and 33 inpatient and outpatient providers from November 2017 to June 2018. Individual interview participants identified several barriers experienced by parents when transitioning their infant home from the NICU including parental involvement and engagement during NICU stay and during the discharge process. Further exploration within group interviews revealed opportunities to improve discharge communication and processes, standardization of parental education that was lacking due to NICU resource constraints, support for parents' emotional state, and use of technology for infant care in the home. Parents of NICU patients face serious emotional, logistical, and knowledge challenges when transitioning their infant home from the NICU. Understanding and mitigating the challenges of transitioning infants from NICU to home require multistakeholder input from both parents and providers.

Medullary thyroid carcinoma: recent advances in identification, treatment, and prognosis.

Medullary thyroid carcinoma (MTC) is a neuroendocrine tumor that represents <5% of all thyroid malignancies and is generally more aggressive than differentiated thyroid cancer. The aim of this study is to provide an update, through review of clinical studies of patients with MTC published between January 1, 2016, and June 1, 2021, on recent advances in the diagnosis and treatment of MTC. This review focuses on updates in biochemical testing, imaging, hereditary disease, surgical management, adjuvant therapies, and prognosis. Recent advances reviewed herein have sought to diagnose MTC at earlier stages of disease, predict when patients with a hereditary syndrome may develop MTC, use functional imaging to assess for distant metastases, perform optimal initial surgery with appropriate lymphadenectomy, employ targeted systemic therapies for patients with progressive metastatic disease, and better predict patient-specific outcomes.

Impact of facility type on survival after pancreatoduodenectomy for small pancreatic adenocarcinoma (≤ 2 cm).

BACKGROUND: Previous studies have demonstrated that even small pancreatic cancers are associated with poor survival. The role of facility type on survival in this setting is unknown. STUDY DESIGN: The National Cancer Database (NCDB) was utilized. Patients who underwent pancreatoduodenectomy for adenocarcinoma ≤ 2 cm in Academic/Research Cancer Programs (ACPs) were compared to Non-Academic Cancer Programs (NACPs). RESULTS: A total of 4672 patients were identified. Surgery at ACPs was associated with a lower rate of positive margins (14% vs 17%,P < .0001) and a higher rate of lymphadenectomy ≥15 nodes (49.6% vs 36.3%,P < .0001). Over 75% of the ACPs facilities were high volume vs 25.5% among NACPs. There was no difference in the odds of delivering chemotherapy in the neoadjuvant or adjuvant setting between ACPs and NACPs. The median survival at ACPs was 29.4 months vs 25.7 months at NACPs (Log-rank test:P < .0001). ACPs were associated with improved survival, adjusted Hazard Ratio: 0.88, 95%CI:0.81-0.96. CONCLUSION: Pancreatoduodenectomy for small pancreatic cancers at ACPs is associated with improved survival compared to NACPs.

The Influence of Obesity on Outcomes After Pediatric Reduction Mammaplasty: A Retrospective Analysis of the Pediatric National Surgical Quality Improvement Program-Pediatric Database.

BACKGROUND: Symptomatic macromastia causes negative physical and psychosocial effects, which support the need for early intervention, even in the adolescent population (Plast Reconstr Surg 2012;130:785-789). Reduction mammaplasty is a proven treatment that reliably addresses symptoms from macromastia. The National Surgical Quality Improvement Program-Pediatric is the leading nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care (Pediatrics 2012;130:e339-e346). In adults, obesity is associated with increased early postoperative complications after mammaplasty (Pediatrics 2017;140(5)). We hypothesized that obesity would increase the incidence of postoperative complications in pediatric patients undergoing reduction mammaplasty. METHODS: The National Surgical Quality Improvement Program-Pediatric database was queried for female patients 18 years or younger who underwent reduction mammaplasty from January 2012 to December 2017 using Current Procedural Terminology code 19318. Demographic, clinical, and outcomes data were abstracted from the database. A composite postoperative adverse events variable was created from a list of 21 individual adverse events. Patients were stratified by presence of obesity (body mass index ≥30 kg/m) on univariate analyses. Multivariable logistic regression was used to determine factors associated with any postoperative adverse events. RESULTS: A total of 542 female patients underwent reduction mammaplasty, with 48% of the cohort being obese. Patients were similar in age (median, 17 years) and comorbidities between obese and nonobese groups. Obese patients were more likely to be African American, have higher American Society of Anesthesiologists class, and endure longer operations. Composite adverse event rates were significantly higher in the obese group (7% vs 2%, P = 0.013). Individual adverse events were similar between groups, with the exception of 30-day readmissions, which was higher in the obese group (3% vs 1%, P = 0.04). On multivariable logistic regression, obesity increased the odds of having a postoperative adverse event by 3-fold after adjusting for operative duration. CONCLUSIONS: Obesity was significantly associated with greater postoperative adverse events in obese adolescent females after reduction mammaplasty compared with their nonobese counterparts. Although recorded rates of adverse events after reduction mammaplasty were low, preoperative weight loss programs may further improve outcomes for obese pediatric populations undergoing reduction mammaplasty.

Povidone-iodine Irrigation for Pediatric Perforated Appendicitis May Be Protective: A Bayesian Pilot Randomized Controlled Trial.

OBJECTIVES: A randomized controlled trial was conducted to test the hypothesis that povidone-iodine (PVI) irrigation versus no irrigation (NI) reduces postoperative intra-abdominal abscess (IAA) in children with perforated appendicitis. METHODS: A 100 patient pilot randomized controlled trial was conducted. Consecutive patients with acute perforated appendicitis were randomized (1:1) to PVI or NI from April 2016 to March 2017 and followed for 1 year. Patients and postoperative providers were blinded to allocation. The primary endpoint was 30-day image-confirmed IAA. Secondary outcomes included initial and total 30-day length of stay (LOS), emergency department (ED) visits, and readmissions. Intention-to-treat analyses were performed to estimate the probability of clinical benefit using Bayesian regression models (an optimistic prior for the primary outcome and neutral priors for secondary outcomes). Frequentist statistics were also used. RESULTS: Baseline characteristics were similar between treatment arms. The PVI arm had 12% postoperative IAA versus 16% in the NI arm (relative risk 0.72, 95% credible interval 0.38-1.23). Bayesian analysis estimates 89% probability that PVI reduces IAA. High probability of benefit was seen in all secondary outcomes for the PVI arm: fewer ED visits and readmissions, and shorter initial and total 30-day LOS. The probability of benefit in reduction of total 30-day LOS in PVI patients was 96% and was significant (P = 0.05) on frequentist analysis. CONCLUSIONS: PVI irrigation for perforated appendicitis in children demonstrated a strong probability of reduction in postoperative IAA with a high probability of decreased LOS. With the favorable probability of benefit in all outcomes, this pilot study serves as evidence to continue a definitive trial.

Factors Associated With Surgical Management for Pediatric Facial Fractures at a Level One Trauma Center.

Pediatric facial fractures present and are managed differently than the adult population. This study describes the pattern and mechanism of facial fractures in children and identifies factors associated with need for surgical management. An IRB-approved retrospective chart analysis of all pediatric patients age ≤ 18 years diagnosed with facial fractures at our level 1 trauma center over a 10-year period (January 2006-December 2015) was performed. Demographics, fracture location, mechanism of injury, concomitant head and neck injuries, and surgical management were reviewed. Statistical analysis was then performed comparing surgical and nonsurgical cohorts using univariate and multivariate analyses. One thousand two hundred seventy-four patients were diagnosed with facial fractures. Five hundred seventeen (40.6%) underwent surgical management. Two thousand one hundred seventy-two total facial fractures were recorded. Orbit fractures (29%) were the most commonly recorded, observed in 49% of patients presenting. Increased age was associated with increased odds of surgical management (OR 1.13; 95% CI 1.09-1.16). Mandible (OR 9.28; 95% CI 6.88-12.51) and Le Fort fractures (OR 19.73; 95% CI 9.78-39.77) had increased odds of surgical management. Patients with traumatic brain injury had reduced odds (OR 0.54; 95% CI 0.35-0.83) of surgical management for their facial fractures. Older pediatric patients may be more likely to require surgical management of their facial fractures, especially those with mandible or Le Fort fractures. Patients with traumatic brain injury are likely to sustain life threatening injuries, deferring repair of their facial fractures. Patient education and counseling, as well as predictive models, can be improved to reflect these data.

The Trends of Pediatric Facial Fractures Due to Violence in a Level One Trauma Population.

INTRODUCTION: Pediatric facial fractures due to intentionally violent mechanisms represent a unique subset of facial fractures. The objective of our research is to identify how violence affects patterns of facial fractures and their management in pediatric patients. METHODS: An IRB approved, retrospective study of our institution's pediatric patients ≤18 years of age who presented with ≥1 facial fracture due to violence from January 2006 to December 2015 was performed. Violence was defined as trauma intended to hurt another or self. Demographics, fractures, mechanism, concomitant injuries, and management were analyzed. RESULTS: The 1274 patients were diagnosed with facial fractures, with 235 of these due to violence (18%). These patients of violence (POV) had 332 fractures, with an average fracture per patient of 1.4 ±â€Š.0.8. The majority (86%) were male, Non-Hispanic African American (35%), and the average age was 15.9 ±â€Š2.8 years. The most common fracture was the mandible (50% of patients) and most common mechanism was assault (76%). The POV were older, male, and of minority race/ethnic groups when compared to patients of non-violence (PONV) (P <0.01). The POV presented with fewer concomitant injuries, were less likely to be admitted to the intensive care unit, and more often surgically managed when compared to the PONV (P <0.01). CONCLUSION: This study represents the largest US, single institution, Level 1 trauma center study of pediatric facial fractures. Pediatric patients with facial fractures due to a violent mechanism represent a distinct category of trauma patients with a unique profile of injuries.

Variability in perioperative evaluation and resource utilization in pediatric patients with suspected biliary dyskinesia: A multi-institutional retrospective cohort study.

INTRODUCTION: Biliary dyskinesia (BD) is a common indication for pediatric cholecystectomy. While diagnosis is primarily based on diminished gallbladder ejection fraction (GB-EF), work-up and management in pediatrics is controversial. METHODS: We conducted a multi-institutional retrospective review of children undergoing cholecystectomy for BD to compare perioperative work-up and outcomes. RESULTS: Six hundred seventy-eight patients across 16 institutions were included. There was no significant difference in gender, age, or BMI between institutions. Most patients were white (86.3%), non-Hispanic (79.9%), and had private insurance (55.2%). Gallbladder ejection fraction (EF) was reported in 84.5% of patients, and 44.8% had an EF <15%. 30.7% of patients were initially seen by pediatric surgeons, 31.3% by pediatric gastroenterologists, and 23.4% by the emergency department with significant variability between institutions (p < 0.001). Symptoms persisted in 35.3% of patients post-operatively with a median follow-up of 21 days (IQR 13, 34). On multivariate analysis, only non-white race and the presence of psychiatric comorbidities were associated with increased risk of post-operative symptoms. CONCLUSION: There is significant variability in evaluation and follow-up both before and after cholecystectomy for BD. Prospective research with standardized data collection and follow-up is needed to develop and validate optimal care pathways for pediatric patients with suspected BD. STUDY TYPE: Case Series, Retrospective Review. LEVEL OF EVIDENCE: Level IV.

Impact of Cardiac Risk Factors on Complications Following Cranial Vault Remodeling: Analysis of the 2012 to 2016 National Safety Quality Improvement Program-Pediatric Database.

Congenital cardiac malformations have been reported in 8% of patients with craniosynostosis undergoing cranial vault remodeling (CVR), but associations with surgical outcomes are unknown. This study evaluated postoperative complications in patients who underwent CVR for craniosynostosis with or without cardiac risk factors (CRF) using the National Safety Quality Improvement Program-Pediatric (NSQIP-P) database. NSQIP-P database was queried for patients <2 years with craniosynostosis who underwent CVR from 2012 to 2016 based on diagnosis and procedure codes. The primary outcome was a composite of available NSQIP-P complications. Analysis compared patients with craniosynostosis based on the presence or absence of CRF. Univariate and multiple logistic regression identified risk factors associated with postoperative complications. A total of 3293 patients met inclusion criteria (8% with CRF). Two-thirds of patients experienced at least 1 complication, though patients with CRF experienced a greater proportion (74% vs 66%, P = 0.001). Univariate analysis identified associations between post-operative complications and age, ASA class, supplemental oxygen, neuromuscular disorders, preoperative nutritional supplementation, interventricular hemorrhage, and CRF. On multivariate regression, only older age (OR 1.17, 95% CI 1.01-1.36) and longer operative duration (OR 1.01, 95% CI 1.01-1.01) were associated with greater odds of postoperative complications. The most common complication in patients with craniosynostosis who undergo CVR is bleeding requiring transfusion. Older age and longer operative duration were associated with postoperative complications. Although patients with CRF have more postoperative complications, CRF was not a risk factor on adjusted analysis.

Let the right one in: High admission rate for low-acuity pediatric burns.

BACKGROUND: The purpose of this study was to characterize emergency pediatric burn care triage at a tertiary children's hospital to identify targets for quality improvement. METHODS: A retrospective review of patients <18 years with primary burn injuries who presented to a children's emergency department in 2016 was conducted. Demographic and injury characteristics were recorded. Low acuity was defined by size (<5% total body surface area burn), depth (not third degree), and no need for conscious sedation for debridement. Multiple logistic regression was used for analysis. RESULTS: A total of 309 pediatric burn patients were triaged in the emergency department. Patients were typically young (median 3.3 years), male (59%), Hispanic (47%), publically insured (77%), and transferred in (65%). Scalding was the most common mechanism (59%). Though most burns were small (median 2% total body surface area), not deep (

Room for "quality" improvement? Validating National Surgical Quality Improvement Program-Pediatric (NSQIP-P) appendectomy data.

INTRODUCTION: Accurate data are essential for the validity of clinical registries. This study aimed to validate NSQIP-P data, assess representativeness, and evaluate risk-adjusted predictive ability at a single institution. METHODS: A prospective appendectomy-specific pediatric surgery research database (RD) maintained by clinical researchers was compared to the NSQIP-P data for appendectomies performed in 2016 at a tertiary children's hospital. NSQIP-P sampled data collected by trained surgical clinical reviewers (SCRs) were compared to matched RD patients. Both datasets used NSQIP-P definitions. Using χ2, datasets were compared by patient demographics, disease severity (simple vs. complicated), and outcomes. RESULTS: 458 appendectomies for acute appendicitis were performed in 2016, of which 250 (55%) were abstracted by SCRs and matched to RD patients. Patient demographics were similar between datasets. Disease severity (NSQIP-P:50% complicated vs RD:31% complicated) and composite morbidity (NSQIP-P:6.0% vs RD:14.4%) were significantly different (both p < 0.01). Demographics and outcomes were similar between matched (n = 250) and unsampled patients in the RD (n = 208). NSQIP-P's risk-adjusted predicted morbidity was significantly lower than morbidity observed in all (n = 458) RD patients (NSQIP-P:9.9% vs RD:14.2%, p < 0.01). CONCLUSIONS: Though constituting a representative sample, NSQIP-P appendectomy data were inconsistent with department data. Discrepancies appear to be the result of underreporting of outcome variables and disease misclassification. TYPE OF STUDY: Retrospective comparative review. LEVEL OF EVIDENCE: Level III.

Hospital type predicts computed tomography use for pediatric appendicitis.

BACKGROUND: Evidence-based guidelines recommend ultrasound (US) over computed tomography (CT) as the primary imaging modality for suspected pediatric appendicitis. Continued high rates of CT use may result in significant unnecessary radiation exposure in children. The purpose of this study was to evaluate variables associated with preoperative CT use in pediatric appendectomy patients. METHODS: A retrospective cohort study of pediatric patients who underwent appendectomy for acute appendicitis in 2015-2016 at National Surgical Quality Improvement Program for Pediatrics (NSQIP-P) hospitals was conducted. Pediatric (<18 years old) patients who underwent appendectomy for acute appendicitis in an NSQIP-P hospital from 2015 to 2016 were included. Patients were excluded if they underwent interval or incidental appendectomy or did not have a final diagnosis of appendicitis. Variables associated with imaging evaluation, including age, body mass index (BMI), race/ethnicity, gender and hospital of presentation (NSQIP-P vs. non-NSQIP-P hospital) were evaluated. The primary outcome was receipt of preoperative CT. Secondary outcomes include reimaging practices and trends over time. RESULTS: 22,333 children underwent appendectomies, of which almost all were imaged preoperatively (96.5%) and 36% of whom presented initially to a non-NSQIP-P hospital. Overall, US only was the most common imaging modality (52%), followed by CT only (27%), US+CT (16%), no imaging (3%), MRI +/- CT/US (1%) and MRI only (<1%). On regression, older age (>11 years), obesity (BMI >95th percentile for age), and female gender were associated with increased odds of receiving a CT scan. However, initial presentation to a non-NSQIP-P hospital was the strongest predictor of CT use (OR 9.4, 95% CI 8.1-10.8). Reimaging after transfer was common, especially after US and MRI at a non-NSQIP-P hospital. CT use decreased between 2015 and 2016 in non-NSQIP-P hospitals but remained the same (25%) in NSQIP-P facilities. CONCLUSIONS: Though patient characteristics were associated with different imaging practices, presentation at a referral, nonchildren's hospital is the strongest predictor of CT use in children with appendicitis. NSQIP-P hospitals frequently reimage transferred patients and have not reduced their CT use. Novel strategies are required for all hospital types in order to sustain reduction in CT use and mitigate unnecessary imaging. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Retrospective comparative study.

Tunneled central venous catheters in pediatric intestinal failure: a single-center experience.

BACKGROUND: Parenteral nutrition for intestinal failure (IF) often requires a tunneled central venous catheter (CVC). The purpose of this study was to characterize complications after CVC placement and contributors to line loss in pediatric IF patients. METHODS: An institutional review board-approved retrospective review of pediatric (<18 y) IF patients who had a silicone tunneled CVC newly inserted or exchanged from 2012 to 2016 in an IF center was conducted. Patient demographics, procedure service (surgery versus interventional radiology), procedure type (new versus exchange), vessel, and complications related to CVCs were evaluated. Complications included dislodgement, infection, break, occlusion/malfunction, and others. An ethanol-lock protocol for silicone CVCs in IF patients was instituted in January 2012. RESULTS: Twenty-nine IF patients with tunneled CVCs were identified with 182 lines and 18,534 line d. Median age at line insertion was 17.1 mo (interquartile range [IQR] 7.6-31.5) with a median of five catheters (IQR 2-8) per patient. There were 19.2 complications per 1000 line d. Occlusions/malfunctions were the most common complication (6.0/1000 line d) followed by breaks (5.6/1000 line d). Median life of catheters was 51.5 d (IQR 21-129). On regression, adjusting for age, insertion service, and procedure type, shorter line life was associated with younger age (P = 0.04) and placement by interventional radiology (P < 0.01). Dislodgement was associated with newly placed lines relative risk 6.5 (95% CI 2.2-28.8). CONCLUSIONS: CVCs in pediatric IF patients have frequent complications and short line lifetimes. Dislodgement of CVC was an unexpectedly common complication with loss of access in newly placed lines. There may be modifiable processes to mitigate CVC complications.

Too much of a bad thing: Discharge opioid prescriptions in pediatric appendectomy patients.

BACKGROUND: Opioid misuse is a public health crisis in the United States. This study aimed to evaluate the discharge opioid prescription practices for pediatric simple appendectomy patients. METHODS: A retrospective review of pediatric appendectomy patients at a tertiary children's hospital was conducted from October 2016 to January 2018. Only patients with simple appendicitis were included. Written opioid prescriptions were found in the electronic medical record (EMR) or through a statewide prescription monitoring database. All dosing data were converted to oral morphine equivalents (OMEs). Analysis of variance and logistic regression were used. RESULTS: During the study, 590 patients underwent appendectomy, of which 371 (62.9%) were diagnosed as having simple acute appendicitis. The majority of patients were prescribed an opioid analgesic (62.5%). Demographics were similar between those who received opioids and those who did not. The OME prescribed per day (range 0.2 to 3.4 mg/kg/day) was highly variable as was duration of prescription (1 to 30 days). Odds of emergency department visit were 3.3 times higher (95% CI 1.3-8.2) in those who received opioids. CONCLUSION: Postdischarge prescription practices for pediatric appendectomy are highly variable. Two-thirds of patients who received narcotics had a higher rate of complications. Greater scrutiny is required to optimize opioid stewardship. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Enhanced neonatal surgical site infection prediction model utilizing statistically and clinically significant variables in combination with a machine learning algorithm.

BACKGROUND: Machine-learning can elucidate complex relationships/provide insight to important variables for large datasets. This study aimed to develop an accurate model to predict neonatal surgical site infections (SSI) using different statistical methods. METHODS: The 2012-2015 National Surgical Quality Improvement Program-Pediatric for neonates was utilized for development and validations models. The primary outcome was any SSI. Models included different algorithms: full multiple logistic regression (LR), a priori clinical LR, random forest classification (RFC), and a hybrid model (combination of clinical knowledge and significant variables from RF) to maximize predictive power. RESULTS: 16,842 patients (median age 18 days, IQR 3-58) were included. 542 SSIs (4%) were identified. Agreement was observed for multiple covariates among significant variables between models. Area under the curve for each model was similar (full model 0.65, clinical model 0.67, RF 0.68, hybrid LR 0.67); however, the hybrid model utilized the fewest variables (18). CONCLUSIONS: The hybrid model had similar predictability as other models with fewer and more clinically relevant variables. Machine-learning algorithms can identify important novel characteristics, which enhance clinical prediction models.