Pediatric traumatic brain injury: Resource utilization and outcomes at adult versus pediatric trauma centers.

INTRODUCTION: Traumatic brain injury is the leading cause of trauma-related death in children. We hypothesized that children with isolated traumatic brain injury would experience differential outcomes when treated at pediatric versus adult or combined trauma centers. METHODS: After institutional review board approval, the 2015 National Trauma Data Bank was queried for children up to age 16 years with isolated traumatic brain injury. Demographics and clinical outcomes were collected. Univariable and multivariable analyses were conducted to assess for predictors of in-hospital mortality and complications. Kaplan-Meier survival analysis was conducted. RESULTS: A total of 3,766 children with isolated traumatic brain injury were identified; 1,060 (28%) were treated at pediatric trauma centers, 1,909 (51%) at adult trauma centers, and 797 (21%) at combined trauma centers. Subjects were 5 years old (median, interquartile range 1-12 years), 63% male, and 64% white. Higher blood pressure and lower injury severity score were associated with reduced mortality (P < .05). Increasing injury severity score was associated with higher mortality by multivariable logistic regression (odds ratio 1.57, P < .0001). There were no survival differences among hospital types (P = .88). CONCLUSION: Outcomes for children with isolated traumatic brain injury appear equal across different types of designated trauma centers. These findings may have implications for prehospital transport and triage guidelines.

Reducing Underdiagnosis of Hirschsprung-Associated Enterocolitis: A Novel Scoring System.

BACKGROUND: Hirschsprung-Associated Enterocolitis (HAEC) is a life-threatening and difficult to diagnose complication of Hirschsprung Disease (HSCR). The goal of this study was to evaluate existing HAEC scoring systems and develop a new scoring system. METHODS: Retrospective, multi-institutional data collection was performed. For each patient, all encounters were analyzed. Data included demographics, symptomatology, laboratory and radiographic findings, and treatments received. A "true" diagnosis of HAEC was defined as receipt of treatment with rectal irrigations, antibiotics, and bowel rest. The Pastor and Frykman scoring systems were evaluated for sensitivity/specificity and univariate and multivariate logistic regression performed to create a new scoring system. RESULTS: Four centers worldwide provided data on 200 patients with 1450 encounters and 369 HAEC episodes. Fifty-seven percent of patients experienced one or more episodes of HAEC. Long-segment colonic disease was associated with a higher risk of HAEC on univariate analysis (OR 1.92, 95% CI 1.43-2.57). Six variables were significantly associated with HAEC on multivariate analysis. Using published diagnostic cutoffs, sensitivity/specificity for existing systems were found to be 38.2%/96% for Pastor's and 56.4%/86.9% for Frykman's score. A new scoring system with a sensitivity/specificity of 67.8%/87.9% was created by stepwise multivariate analysis. The new score outperformed the existing scores by decreasing underdiagnosis in this patient cohort. CONCLUSIONS: Existing scoring systems perform poorly in identifying episodes of HAEC, resulting in significant underdiagnosis. The proposed scoring system may be better at identifying those underdiagnosed in the clinical setting. Head-to-head comparison of HAEC scoring systems using prospective data collection may be beneficial to achieve standardization in the field.

Resection margin histology may predict intermediate-term outcomes in children with rectosigmoid Hirschsprung disease.

INTRODUCTION: Recent studies suggest that some of the post-surgical morbidity in Hirschsprung disease (HSCR) is due to enteric nervous system structural defects in the proximal, ganglionated bowel that remains after surgery. We hypothesized that resection margin histology would predict intermediate-term outcomes in HSCR patients. METHODS: Following IRB approval, HSCR patients with rectosigmoid disease born between 2009 and 2016 were reviewed and tissue blocks were obtained for new analyses. Proximal resection margins were analyzed for ganglion size, Hu + neurons/ganglion, and % nitric oxide synthase (NOS) neurons/ganglion as compared to control (non-HSCR) patient samples. Chart reviews were performed for 1- and 2-year outcomes. Patients were contacted for survey to determine Rintala bowel function score. RESULTS: 45 patients had recto-sigmoid disease and were further analyzed. HSCR patients had significantly smaller individual ganglion size (4533 µm2, range 1744-16,287 vs. 6492 µm2, range 1932-30,838, p = 0.0192) and fewer HuC/D + neurons per ganglion (15, range 5.2-34 vs. 21, range 5.2-6.7, p = 0.0214). HSCR patients demonstrated a markedly increased percentage of NOS (relaxation neurotransmitter) neurons (50, range 22-85 vs. 37, range 16-80, p = 0.0266). None of the histology measures correlated with presence/absence of constipation at 1-2 year follow-up (p = NS). However, smaller ganglion size and higher percentage of NOS neurons correlated with decreased patient-reported quality of life (r = 0.3838, r = - 0.1809). CONCLUSION: 1-2 year follow-up may be insufficient to determine if resection margin histology correlates with outcomes. Patient-reported quality of life surveys, although limited in number, suggest that neurotransmitter imbalance at the resection margin may predict poor outcomes in HSCR patients. This study supports the concept that the ganglionated portion of the remaining colon post-surgery may not sustain normal bowel function.

Pediatric trauma triage: A Pediatric Trauma Society Research Committee systematic review.

BACKGROUND: Significant variability exists in the triage of injured children with most systems using mechanism of injury and/or physiologic criteria. It is not well established if existing triage criteria predict the need for intervention or impact morbidity and mortality. This study evaluated existing evidence for pediatric trauma triage. Questions defined a priori were as follows: (1) Do prehospital trauma triage criteria reduce mortality? (2) Do prehospital trauma scoring systems predict outcomes? (3) Do trauma center activation criteria predict outcomes? (4) Do trauma center activation criteria predict need for procedural or operative interventions? (5) Do trauma bay pediatric trauma scoring systems predict outcomes? (6) What secondary triage criteria for transfer of children exist? METHODS: A structured, systematic review was conducted, and multiple databases were queried using search terms related to pediatric trauma triage. The literature search was limited to January 1990 to August 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was applied with the methodological index for nonrandomized studies tool used to assess the quality of included studies. Qualitative analysis was performed. RESULTS: A total of 1,752 articles were screened, and 38 were included in the qualitative analysis. Twelve articles addressed questions 1 and 2, 21 articles addressed question 3 to 5, and five articles addressed question 6. Existing literature suggest that prehospital triage criteria or scoring systems do not predict or reduce mortality, although selected physiologic parameters may. In contrast, hospital trauma activation criteria can predict the need for procedures or surgical intervention and identify patients with higher mortality; again, physiologic signs are more predictive than mechanism of injury. Currently, no standardized secondary triage/transfer protocols exist. CONCLUSION: Evidence supporting the utility of prehospital triage criteria for injured children is insufficient, while physiology-based trauma system activation criteria do appropriately stratify injured children. The absence of strong evidence supports the need for further prehospital and secondary transfer triage-related research. LEVEL OF EVIDENCE: Systematic review study, level II.

Guidelines for synoptic reporting of surgery and pathology in Hirschsprung disease.

BACKGROUND/PURPOSE: Synoptic, or standardized, reporting of surgery and pathology reports has been widely adopted in surgical oncology. Patients with Hirschsprung disease may experience morbidity related to surgical factors or underlying pathology and often undergo multiple operations. Our aim is to improve the postoperative outcome and care of patients with Hirschsprung disease by proposing a standardized set of data that should be included in every surgery and pathology report. METHODS: Members of the American Pediatric Surgical Association Hirschsprung Disease Interest Group and experts in pediatric pathology of Hirschsprung disease participated in group discussions, performed literature review and arrived at expert consensus guidelines for surgery and pathology reporting. RESULTS: The importance of accurate operative and pathologic reports and the implications of inadequate documentation in patients with Hirschsprung disease are discussed and guidelines for standardizing these reports are provided. CONCLUSIONS: Adherence to the principles of reporting for operations and surgical pathology may improve outcomes for Hirschsprung disease patients and will facilitate identification of correlations among morphology, function, genetics and outcomes, which are required to improve the overall management of these patients. LEVEL OF EVIDENCE: V.

Neutropenia at the time of subcutaneous port insertion may not be a risk factor for early infectious complications in pediatric oncology patients.

BACKGROUND: The risk of infection associated with subcutaneous port (SQP) placement in patients with neutropenia remains unclear. We reviewed the rate of early infectious complications (<30 days) following SQP placement in pediatric oncology patients with or without neutropenia [absolute neutrophil count (ANC) <500/mm3]. METHODS: Baseline characteristics and infectious complications were compared between groups using univariate and multivariate analyses. RESULTS: A total of 614 SQP were placed in 542 patients. Compared to nonneutropenic patients, those with neutropenia were more likely to have leukemia (n = 74, 94% vs n = 268, 50%), preoperative fever (n = 17, 22% vs n = 25, 5%), recent documented infection (n = 15, 19% vs n = 47, 9%), and were younger (81 vs 109 months) (p values <0.01). After adjusting for fever and underlying-disease, there was a nonsignificant association between neutropenia and early postoperative infection (OR 2.42, 95% CI 0.82-7.18, p = 0.11). Only preoperative fever was a predictor of infection (OR 6.09, 95% CI 2.08-17.81, p = 0.001). CONCLUSION: SQP placement appears safe in most neutropenic patients. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Lack of disparities in screening for associated anomalies in children with anorectal malformations.

INTRODUCTION: Patients with anorectal malformations (ARM) often have associated congenital anomalies and should undergo several screening exams in the first year of life. We hypothesized that racial and socioeconomic disparities exist in the screening processes for these patients. METHODS: After IRB approval, a retrospective review of patients with ARM born between 2005 and 2016 was performed at a quaternary care children's hospital. Demographics including gender, race, insurance, and zip code were collected. Zip code was used as a surrogate for median income. Chart review was performed to identify anomaly type and whether Vertebral defects, Anorectal malformations, Cardiac defects, Tracheo-Esophageal fistula, Renal anomalies, and Limb abnormalities screening was performed within 1 y of age. Descriptive statistics and chi square analyses were performed. RESULTS: One hundred patients (59% male, 68% low malformation) were identified. African American and Caucasian subjects represented 41% and 40% of the population, respectively. Overall, 68 of 100 patients had at least one screening test for each of the Vertebral defects, Anorectal malformations, Cardiac defects, Tracheo-Esophageal fistula, Renal anomalies, and Limb abnormalities associations. Although some minor differences were noted (more African Americans received skeletal survey than Caucasians, 80.5% versus 60%, P = 0.00335), no pattern of systematic bias in the receipt or timing of screening was evident based on race, insurance, or income. CONCLUSIONS: There do not appear to be racial or socioeconomic disparities in screening for associated anomalies in patients with ARM. However, overall gaps in screening still exist, and work must be carried out to appropriately screen all patients for associated anomalies.

Impaired growth outcomes in children with congenital colorectal diseases.

BACKGROUND: Cloaca, Hirschsprung disease, and anorectal malformations (CHARM) are congenital anomalies of the hindgut. Small series have suggested that children suffering from one of these anomalies may be at risk for growth impairment. We sought to expand on these findings in a comprehensive cohort, hypothesizing that patients with Medicaid insurance or African-American (AA) race would be at higher risk for poor growth. METHODS: Following Institutional Review Board (IRB) approval, single-institution retrospective review of children with CHARM anomalies was performed (2009-2016). Body mass index (BMI) value Z-scores were obtained using the 2006 World Health Organization (age 0-24 mo) and 2000 Centers for Disease Control (CDC) (age >2 y) growth charts and calculators (statistical analysis system). Patient factors and BMI Z-scores were analyzed with descriptive statistics and Fisher's exact test. RESULTS: One hundred sixty-six patients (Cloaca n = 16, Hirschsprung disease [HD] n = 71, anorectal malformation [ARM] n = 79) were identified. The BMI Z-score distribution for the entire CHARM cohort was lower than controls (P < 0.0001). HD and ARM BMI Z-scores were also lower versus controls (P < 0.0007, P < 0.0037). Requiring more or less than the average number of surgeries did not impact BMI Z-score [P = non-significant (NS)]. Patients with Medicaid had lower Z-scores versus private or commercial insurance (P < 0.0001). AA race BMI Z-score distribution was lower than controls (P < 0.0002), but there was no statistical difference in BMI Z-scores when comparing AA versus non-AA CHARM patients (P = NS). CONCLUSIONS: Patients born with CHARM anomalies are at risk for impaired growth. Furthermore study is warranted to identify modifiable risk factors contributing to this impairment. Longitudinal follow-up should include interventions to mitigate these risks.

Using Bradford's law of scattering to identify the core journals of pediatric surgery.

BACKGROUND: Bradford's law of scattering defines an exponentially diminishing return when extending a search for references in journals and can be used to identify the "core" journals in a field. The purpose of this study was to identify the core journals of pediatric surgery. METHODS: With Institutional Review Board approval, we developed bibliometric profiles for the top academically productive pediatric surgeons in the United States. These profiles included the total number of publications, journals in which those authors published their manuscripts, and identification of all articles cited by those surgeons, along with the journals those references were drawn from. Bradford's law of scattering was applied to identify the core journals of pediatric surgery. RESULTS: We identified n = 69 pediatric surgeons (10 ± 0.2 5-year h-index). These authors published 10,031 articles (145 ± 90 per surgeon), which were cited 250841 times (3635 ± 413 per surgeon). Pediatric surgeons' articles contained 199507 references (2891 ± 176 per surgeon). We analyzed 58,310 references (top 20 journals) cited by pediatric surgeons. Bradford's Law identified a single core journal for p = 3-10 zones, with P = 3, providing the best correlation between predicted and actual values (Rˆ2 = 0.9996). The core journal for pediatric surgery is Journal of Pediatric Surgery. CONCLUSIONS: We used Bradford's Law to identify the core journals of pediatric surgery. These core journals include the two leading pediatric surgery-specific journals and the highest impact factor journals in surgery (Annals of Surgery) and medicine (NEJM). These findings can help busy pediatric surgeons focus their reading to stay updated in a rapidly evolving field.

Using bibliometrics to analyze the state of academic productivity in US pediatric surgery training programs.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements state that faculty must establish and maintain an environment of inquiry and scholarship. Bibliometrics, the statistical analysis of written publications, assesses scientific productivity and impact. The goal of this study was to understand the state of scholarship at Pediatric Surgery training programs. METHODS: Following IRB approval, Scopus was used to generate bibliometric profiles for US Pediatric Surgery training programs and faculty. Statistical analyses were performed. RESULTS: Information was obtained for 430 surgeons (105 female) from 48 US training programs. The mean lifetime h-index/surgeon for programs was 14.4 +/- 4.7 (6 programs above 1 SD, 9 programs below 1 SD). The mean 5-yearh-index/surgeon for programs was 3.92 +/- 1.5 (7 programs above 1 SD, 8 programs below 1 SD). Programs accredited after 2000 had a lower lifetime h-index than those accredited before 2000 (p=0.0378). Female surgeons had a lower lifetime h-index (p<0.0001), 5-yearh-index (p=0.0049), and m-quotient (p<0.0001) compared to males. Mean lifetime h-index increased with academic rank (p<0.0001), with no gender differences beyond the assistant professor rank (p=NS). CONCLUSION: Variability was identified based on institution, gender, and rank. This information can be used for benchmarking the academic productivity of faculty and programs and as an adjunct in promotion/tenure decisions. TYPE OF STUDY: Original Research. LEVEL OF EVIDENCE: n/a.

Proposed clinical pathway for nonoperative management of high-grade pediatric pancreatic injuries based on a multicenter analysis: A pediatric trauma society collaborative.

BACKGROUND: Guidelines for nonoperative management (NOM) of high-grade pancreatic injuries in children have not been established, and wide practice variability exists. The purpose of this study was to evaluate common clinical strategies across multiple pediatric trauma centers to develop a consensus-based standard clinical pathway. METHODS: A multicenter, retrospective review was conducted of children with high-grade (American Association of Surgeons for Trauma grade III-V) pancreatic injuries treated with NOM between 2010 and 2015. Data were collected on demographics, clinical management, and outcomes. RESULTS: Eighty-six patients were treated at 20 pediatric trauma centers. Median age was 9 years (range, 1-18 years). The majority (73%) of injuries were American Association of Surgeons for Trauma grade III, 24% were grade IV, and 3% were grade V. Median time from injury to presentation was 12 hours and median ISS was 16 (range, 4-66). All patients had computed tomography scan and serum pancreatic enzyme levels at presentation, but serial enzyme level monitoring was variable. Pancreatic enzyme levels did not correlate with injury grade or pseudocyst development. Parenteral nutrition was used in 68% and jejunal feeds in 31%. 3Endoscopic retrograde cholangiopancreatogram was obtained in 25%. An organized peripancreatic fluid collection present for at least 7 days after injury was identified in 59% (42 of 71). Initial management of these included: observation 64%, percutaneous drain 24%, and endoscopic drainage 10% and needle aspiration 2%. Clear liquids were started at a median of 6 days (IQR, 3-13 days) and regular diet at a median of 8 days (IQR 4-20 days). Median hospitalization length was 13 days (IQR, 7-24 days). Injury grade did not account for prolonged time to initiating oral diet or hospital length; indicating that the variability in these outcomes was largely due to different surgeon preferences. CONCLUSION: High-grade pancreatic injuries in children are rare and significant variability exists in NOM strategies, which may affect outcomes and effective resource utilization. A standard clinical pathway is proposed. LEVEL OF EVIDENCE: Therapeutic/care management, level V (case series).

Bevacizumab-induced transient sixth nerve palsy in ovarian cancer: A case report.

We report a case of transient sixth nerve palsy after systemic administration of bevacizumab. Two days after systemic administration of bevacizumab in conjunction with gemcitabine and carboplatin in a 67-year-old woman with recurrent primary ovarian cancer, the patient developed sixth nerve palsy. After bevacizumab was stopped, the complete left sixth nerve palsy resolved spontaneously over the course of 3 months. This is the first reported case of bevacizumab-induced cranial sixth nerve palsy in the treatment of gynecologic malignancy.

Hospital roommates and development of health care-onset Clostridium difficile infection.

There is potential for person-to-person transmission in Clostridium difficile outbreak settings. A limited number of studies have examined the role of hospital roommates in the development of nosocomial infections. This retrospective cohort study evaluated room cooccupancy and duration of exposure to roommates as predictors of health care-onset C difficile infection (CDI). Among roommates of patients with CDI, duration of room cooccupancy was significantly longer in those developing CDI.