Population-Based Intraoperative Disease Severity Criteria for Pediatric Appendicitis.

Importance: A standardized severity assessment approach is needed in children with appendicitis for postoperative adverse event estimation and severity adjustment for hospital-level comparative performance reporting. Objective: To examine the association between the presence and number of National Surgical Quality Improvement Program (NSQIP) Pediatric-defined intraoperative criteria for complicated appendicitis and outcomes in a population-based sample of children. Design, Setting, and Participants: This cohort study used data from the American College of Surgeons NSQIP Pediatric Appendectomy Procedure Targeted Participant Use Data File and General Participant Use Data File for children younger than 18 years who underwent appendectomy from January 1, 2019, through December 31, 2022, at 148 hospitals participating in NSQIP Pediatric. Exposure: The presence of NSQIP Pediatric intraoperative criteria for complicated appendicitis (ie, visible perforation, intraperitoneal abscess, extraluminal fecalith, and diffuse fibrinopurulent exudate). Main Outcomes and Measures: Adverse event outcomes included postoperative rates of any surgical site infection (incisional or organ space), percutaneous drainage, sepsis, and reoperation. Resource use outcomes included operative duration and hospital length of stay, and rates of postoperative imaging, parenteral nutrition use, and revisits. Multivariable regression was used to explore the influence of individual and combinations of intraoperative criteria on outcomes after adjusting for patient characteristics. Results: Of 82 950 patients included, 23 221 (27.9%) had at least 1 finding of complicated appendicitis. Compared with cases without any criteria present, the presence of each finding of complicated appendicitis was independently associated with higher rates of any adverse events; adjusted odds ratios (AORs) by finding were 5.57 (95% CI, 5.04-6.15) for visible hole, 4.83 (95% CI, 4.17-5.59) for diffuse fibrinopurulent exudate, 7.06 (95% CI, 5.77-8.63) for abscess, and 6.62 (95% CI, 4.78-9.15) for fecalith. An increasing number of criteria was associated with a stepwise increase in risk of any adverse events; AOR by number of criteria met were 5.55 (95% CI, 5.09-6.05) for 1 criterion, 8.86 (95% CI, 8.16-9.62) for 2 criteria, and 16.65 (95% CI, 15.10-18.35) for ≥3 criteria. Similar patterns in criteria-specific and cumulative implications for outcomes were observed with each individual adverse event and resource use measure. Conclusions and Relevance: This cohort study found that postoperative complications and increased resource use are associated with the presence and number of NSQIP Pediatric criteria for complicated appendicitis. These criteria should be considered the gold standard, evidence-based severity assessment framework for estimating risk of adverse events and resource use in children with appendicitis.

Real-World Vein Mapping Practice Patterns Before Endovascular Treatment of Limb Ischemia.

INTRODUCTION: The Best Endovascular versus Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) trial results suggest that in patients with chronic limb-threatening ischemia (CLTI) and adequate single-segment great saphenous vein (SSGSV) by preoperative duplex ultrasonography, a surgical-first treatment strategy is superior to an endovascular-first strategy. However, the utilization of vein mapping prior to endovascular-first revascularization for CLTI in actual clinical practice is not known. METHODS: Data from a multicenter clinical data warehouse (2008-2019) were linked to Medicare claims data for patients undergoing endovascular-first treatment of infra-inguinal CLTI. Only patients who would have otherwise been eligible for enrollment in BEST-CLI were included. Adequate SSGSV was defined as healthy vein >3.0 mm in diameter from the groin through the knee. Logistic regression was used to estimate associations between preprocedure characteristics and vein mapping. Survival methods were used to estimate the risk of major adverse limb events and death. RESULTS: A total of 142 candidates for either surgical or endovascular treatment underwent endovascular-first management of CLTI. Ultrasound assessment for SSGSV was not performed in 76% of patients prior to endovascular-first revascularization. Of those who underwent preprocedure vein mapping, 44% had adequate SSGSV for bypass. Within one year postprocedure, 12.0% (95% confidence interval 7.4-18.0%) of patients underwent open surgical bypass and 54.7% (95% confidence interval 45.3-62.4%) experienced a major adverse limb event or death. CONCLUSIONS: In a real-world cohort of BEST-CLI-eligible patients undergoing endovascular-first intervention for infra-inguinal CLTI, three-quarters of patients had no preprocedure ultrasound assessment of great saphenous vein conduit. Practice patterns for vein conduit assessment in the real-world warrant reconsideration in the context of BEST-CLI trial results.

Variations by State in Firearm Suicide Among US Children and Young Adults, 2016-2021.

This cross-sectional study examines variations by state in firearm suicide rates in US children and young adults from 2016 to 2021 using data from the Centers for Disease Control and Prevention.

Impact of Nutritional Deficiencies on Children and Young Adults with Crohn's Disease Undergoing Intraabdominal Surgery.

PURPOSE: We examined the impact of comorbidities on length of stay and total hospital charges for children and young adults with Crohn's Disease (CD) undergoing surgery. METHODS: Patients (<21 years) were identified with a diagnosis of CD and an intraabdominal surgery in the Kids' Inpatient Database for the years 2006, 2009 and 2012. Length of stay (LOS) and total hospital charges (THC; USD$) were stratified by anemia, anxiety, depression and nutritional deficiency. National estimates were obtained using case weighting and multivariable linear regression was performed. RESULTS: We identified 3224 CD admissions with an intraabdominal surgery. The population was predominantly male, non-Hispanic white, and high school aged. There was an increase in LOS and THC for nutritional deficiency in all study years, and for depression and anemia in specific years. Multivariable linear regression revealed a 3.3-5.5 day increase in LOS associated with a comorbid diagnosis of nutritional deficiency. However, no increase in THC was seen for any comorbidity under evaluation. CONCLUSIONS: Behavioral health and, particularly, nutritional status have a significant impact on the care of children and young adults with CD. Nutritional deficiency, anemia, and depression resulted in increased LOS for those undergoing surgery. Improved presurgical management of comorbidities may reduce LOS for these patients. LEVEL OF EVIDENCE: III.

Risk Factors for Venous Thromboembolism in Children and Young Adults With Inflammatory Bowel Disease.

BACKGROUND: Both adult and pediatric patients with inflammatory bowel disease (IBD) are at increased risk of developing venous thromboembolism (VTE) when compared with those without IBD. The risk factors for VTE in pediatric IBD patients, including those undergoing major surgery, have not been previously determined. MATERIALS AND METHODS: Patients (aged <21 y) were identified with an International Classification of Diseases, Ninth Revision (ICD-9), diagnosis of IBD (555.X or 556.X) or Crohn's Disease (CD; 555.X) in the Kids' Inpatient Database for the years 2006-2012. Procedure and ICD-9 diagnosis codes were scrutinized. VTE was defined by ICD-9 codes. National estimates were obtained using case weighting. Multivariable logistic regression was performed. RESULTS: A total of 44,554 and 28,132 patients were identified with IBD and CD, respectively. During their hospital admission, 456 (1.01%) IBD and 205 (0.72%) CD patients developed VTE. The oldest patients, those having increased length of stay, a major surgical procedure, or a hypercoagulable diagnosis had the highest rate of VTE with both IBD and CD. After performing adjusted logistic regression, undergoing a major surgical procedure was associated with 1.98 and 2.24 times greater odds of developing VTE for IBD and CD patients, respectively. A hypercoagulable diagnosis was associated with increasing the odds of VTE by 7.39 and 6.91 times in IBD and CD, respectively. CONCLUSIONS: Pediatric patients with IBD are at increased risk of VTE. Our study demonstrates undergoing a major surgical procedure or having a hypercoagulable diagnosis additionally increases the risk for VTE. Given these findings, VTE prophylaxis for this population should be further investigated. LEVEL OF EVIDENCE: III.

The Role of Race and Economic Characteristics in the Presentation and Survival of Patients With Surgically Resected Non-Small Cell Lung Cancer.

BACKGROUND: Little is understood regarding the inter-relation between economic, marital, and racial/ethnic differences in presentation and survival of surgically resected lung cancer patients. Our investigation will assess these differences in addition to known therapeutic, patient, and histopathologic factors. METHODS: A retrospective review of the Surveillance Epidemiology and End Reporting database was conducted through the years 2007-2012. The population was split into nine different ethnic groups. Population differences were assessed via chi-square testing. Multivariable analysis (MVA) were used to detect overall survival (OS) differences in the total surgical population (TS, N = 35,689) in an ear (T1-T2 < 4 cm N0) surgical population [early-stage resectable (ESR), N = 17,931]. Lung cancer-specific survival (LCSS) was assessed in the ESR. RESULTS: In the TS population, as compared to Whites, Blacks, and Hispanics presented with younger age, more adenocarcinomas, lower rates of marriage, lower rates of insurance, less stage I tumors, and had less nodes examined, but their type of surgical procedures and OS/LCSS were the same. MVA demonstrated that lower OS and LCSS were associated with males, single/divorced/widowed partnership, lower income (TS only), and Medicaid insurance. MVA also found that Blacks and Hispanics had a similar OS/LCSS to Whites and that all ethnic groups were associated with a similar or better outcomes. The 90-day mortality and positive nodes were correlated with not having insurance and not being married, but they were not associated with ethnicity. CONCLUSION: In TS and ESR groups, OS was not different in the two largest ethnic groups (Black and Hispanic) as compared to Whites, but was related to single/widowed/divorced status, Medicaid insurance, and income (TS group only). Nodal positivity was associated with patients who did not have a married partner or insurance suggesting that these factors may impact disease biology. Economic and psychosocial variables may play a role in survival of ear lung cancer in addition to standard histopathologic and treatment variables.