CONTEXT.—:Surgery for Hirschsprung disease includes resection of the aganglionic bowel and adjacent transition zone (ganglionic bowel with partial circumferential aganglionosis, myenteric hypoganglionosis, and/or submucosal nerve hypertrophy). Pathology practices, including intraoperative frozen sections and sampling of resection specimens and accurate recognition and reporting of transition zone histopathology, are necessary to both prevent and diagnose incomplete resection. OBJECTIVE.—:To identify opportunities to improve pathology practice related to Hirschsprung disease. DESIGN.—:Surgical pathology reports and histology slides from Hirschsprung disease resections performed on 35 patients (25 institutions) were reviewed. Data included what type of analyses were performed on proximal resection margins (eg, intraoperative frozen section), how resections were sampled for histology, and how the results were reported. Slides were assessed for features of transition zone histology and the findings compared with those in the original surgical pathology reports. RESULTS.—:The length of the resected ganglionic bowel was stated or calculable in 18 of 35 cases (51%) and most pathology reports did not address the presence or absence of transitional zone histology at the proximal surgical margin. Intraoperative frozen section evaluations of the proximal margin were performed in 8 of 35 cases (23%); 1 or more features of transition zone were present in 3 of these but not documented. Among the remaining 27 patients, transition zone histology was present in 9 (33%) but not reported. CONCLUSIONS.—:Pathologists need to understand transition zone histology and to implement methods to enhance accurate and timely diagnosis. Specific recommendations are provided here to achieve these goals.

OBJECTIVE:Consensus on functional outcomes for anorectal malformations (ARM) is hindered by the heterogeneity of the available literature. Optimal patient counseling includes discussion of short- and long-term outcomes for bowel and urinary continence, sexual and psychosocial function, transitional care, and quality of life. This systematic review examines and summarizes the current literature available related to functional outcomes for children with ARM. METHODS:The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee drafted consensus-based questions regarding anorectal malformations. Pertinent articles from 1985 to 2021 were reviewed. RESULTS:More than 10,843 publications were reviewed with 109 being included in the final recommendations. Recommendations are primarily based on C-D levels of evidence. Continence and constipation rates were higher in patients with perineal fistula and rectovestibular fistula, although symptoms tended to improve as patients got older. Urological anomalies are common and longer term urologic surveillance protocols for patients with ARM need to be further outlined. Sexual and psychosocial issues are common, but ARM patients can have a good quality of life when gastrointestinal symptoms are minimized. Many of the problems associated with ARM can persist into adulthood, supporting structured care plans as patients transition to adult care. CONCLUSIONS:Evidence to support best practices and achieve optimal outcomes for patients with ARM is lacking for many aspects of care. Multi-institutional registries have begun to address management and prognosis for these patients. Prospective and comparative studies are needed to improve care and provide consensus guidelines for this complex patient population. LEVEL OF EVIDENCE: 4:

BACKGROUND AND OBJECTIVES:Historically, cholecystectomy was infrequently performed in children. Lifestyle changes, delays in health care access, and increases in childhood obesity occurred during the COVID-19 pandemic. The impact of these shifts on need for cholecystectomy are poorly understood. We evaluate trends in cholecystectomy case volume among children during the COVID-19 pandemic. METHODS:A multi-institutional retrospective cohort study was conducted for children ages 18 years and younger who underwent cholecystectomy from January 1, 2016, to July 31, 2022, at 10 children's hospitals. Differences in cholecystectomy case mix and volume before and during the pandemic were identified using bivariate comparisons and interrupted time series analysis. RESULTS:Overall, 4282 children were identified: 2122 before the pandemic and 2160 during the pandemic. Most were female (74.2%) with a median age of 15 years (IQR, 13.0-16.0 years). The proportion of Hispanic (55.0% vs 60.1%; P = .01) patients, body mass index (BMI) (26.0 vs 27.1; P < .001), and obesity (BMI > 30) (30.8% vs 37.4%; P < .001) increased during the pandemic. Predicted monthly case volume increased from 40 to 100 during the pandemic. Patients transferred from an outside hospital increased (21.3% vs 28.5%; P < .001). Significant increases in acute cholecystitis (12.2% vs 17.3%; P < .001), choledocholithiasis (12.8% vs 16.5%; P = .001), gallstone pancreatitis (10.6% vs 12.4%; P = .064), and chronic cholecystitis (1.4% vs 3.2%; P < .001) also occurred. On interrupted time series analysis, change in month-to-month case count significantly increased during the pandemic (Figure 1; P < .001), which persisted after exclusion of transferred patients. CONCLUSIONS:Pediatric cholecystectomy case volume and complexity increased during the COVID-19 pandemic. These findings may be secondary to changes in childhood health, transfer patterns, and shifts in access, highlighting an increased health care burden on children's hospitals.

We present the case of a newborn male with congenital amniotic band syndrome and a constriction band involving the right inguinal crease, scrotum and perineum. He was diagnosed prenatally and referred to our institution after developing a right femoral nerve palsy. Surgical management included excision of the constriction band and Z-plasty closure. We discuss the considerations for safe and cosmetic surgical outcomes in this rare presentation of amniotic band syndrome. A multidisciplinary approach to management is essential during workup and surgical intervention.

A premature infant with a prenatal diagnosis of cloacal exstrophy was born at 32 weeks of gestation. She was delivered via cesarean section due to fetal decelerations and concern for fetal distress. She was Twin B of a twin pregnancy, and her sister was healthy. At delivery, her appearance, pulse, grimace, activity, and respiration (APGAR) scores were 2 and 8 at one and five minutes, respectively. Her birth weight was 1.7 kg.

Objective: Tobacco use and obesity are leading causes of preventable death in the U.S. E-cigarette use is on the rise; however, obesity prevalence among e-cigarette users is unknown. The present study characterized obesity prevalence among e-cigarette and tobacco users in a national sample of U.S. adults. Method: Data were obtained from the 2018 Behavioral Risk Factor Surveillance System. Approximately 249,726 participants provided data on e-cigarette and tobacco use, height, weight, and demographics, and were categorized as follows: Ever vaped, ever smoked; Ever vaped, never smoked; Never vaped, ever smoked; Never vaped, never smoked. Results: Obesity prevalence (BMI >= 30 kg/m2) differed significantly across groups: 33.0% (ever vaped, ever smoked); 27.7% (ever vaped, never smoked); 33.1% (never vaped, ever smoked); 32.1% (never vaped, never smoked), p < .001. Groups also differed demographically. Logistic regressions adjusted for demographics revealed subjects in the never vaped, ever smoked group were significantly more likely to have obesity relative to those in the never vaped, never smoked group (p < 0.001) with vaping status having no main effect. Secondary analyses using never smokers as the reference found current smokers were less likely to have obesity and former smokers were more likely to have obesity, p < .001. Discussion: The present study is the first to characterize U.S. obesity prevalence among e-cigarette and tobacco users. Obesity prevalence was lower in the ever vaped, never smoked group; however, this finding appears to be attributable to demographic variables. As e-cigarette use becomes more common, future research should examine the development and maintenance of obesity among users.

Introduction Smoking for weight control is a well-documented behavior. There is emerging evidence to suggest electronic cigarettes (e-cigarettes) may be used for similar motivations yet measure development for the use of e-cigarettes for weight control has received less attention. The objective of the current study was to adapt and explore the psychometric properties of The Smoking-Related Weight and Eating Episodes Test (SWEET) for e-cigarette users. Methods Young adult (N=1875) current cigarette, e-cigarette, and dual users completed the original SWEET (SWEET-C) and/or adapted SWEET for e-cigarette use (SWEET-EC) based on current tobacco product use. Demographics, associated e-cigarette characteristics, nicotine dependence, outcome expectancies, and eating disorder behaviors were also assessed. Participants were recruited online and measures were completed via self-report. Results Four exploratory factor analyses using principal components extraction and direct oblimin rotation methods were run to explore the SWEET-C and SWEET-EC. A one-factor solution explaining 66 % of the variance was retained for the SWEET-C, and a one-factor solution explaining 73 % of the variance was retained for the SWEET-EC. Both measures exhibited excellent internal consistency. Higher SWEET-EC scores were observed among dual users, and were associated with daily e-cigarette use, JUUL use, self-reported vaping for weight control, older age, higher body mass index, and problematic eating behaviors. Conclusion Our findings support the adaptation of the SWEET-EC to measure e-cigarette use for weight control. The SWEET-EC will help to better understand how individuals use e-cigarettes to curb eating behavior and for weight control.

Introduction While most lymphatic malformations (LMs) are treated by percutaneous sclerotherapy, intra-abdominal LMs may be difficult to access percutaneously due to their anatomic location. Case Presentation An 11-year-old otherwise healthy boy presented with abdominal pain and cross-sectional imaging (including CT scan and MRI) identified an intra-abdominal LM located in the lesser sac, bordered by the stomach, spleen, and pancreas. An attempt to access the lesion percutaneously was made, however this was unsuccessful due to overlying viscera. Given the morbidity associated with an open surgical approach, the patient underwent laparoscopic-guided doxycycline sclerosant injection. After the LM was exposed laparoscopically, a pigtail catheter was placed into the lesion using the Seldinger technique. Doxycycline sclerosant was instilled three times over the course of three days and the pigtail catheter was removed after the third instillation. The LM completed resolved in addition to the abdominal pain the patient was experiencing. After more than one year of follow up, the LM has not recurred. Conclusion Abdominal LMs may be safely treated with a laparoscopic-guided doxycycline sclerosant injection when surgical excision would be exceedingly morbid and there is no safe percutaneous entry site.

Purpose The purpose of the study was to determine if antegrade continence enema (ACE) alone is an effective treatment for patients with severe functional constipation and segmental colonic dysmotility. Methods A retrospective study of patients with functional constipation and segmental colonic dysmotility who underwent ACE as their initial means of management. Data was collected from six participating sites in the Pediatric Colorectal and Pelvic Learning Consortium. Patients who had a colonic resection at the same time as an ACE or previously were excluded from analysis. Only patients who were 21 years old or younger and had at least 1-year follow-up after ACE were included. All patients had segmental colonic dysmotility documented by colonic manometry. Patient characteristics including preoperative colonic and anorectal manometry were summarized, and associations with colonic resection following ACE were evaluated using Fisher's exact test and Wilcoxon rank-sum test. p -Values of less than 0.05 were considered significant. Statistical analyses and summaries were performed using SAS version 9.4 (SAS Institute Inc., Cary, North Carolina, United States). Results A total of 104 patients from 6 institutions were included in the study with an even gender distribution (males n = 50, 48.1%) and a median age of 9.6 years (interquartile range 7.4, 12.8). At 1-year follow-up, 96 patients (92%) were successfully managed with ACE alone and 8 patients (7%) underwent subsequent colonic resection for persistent symptoms. Behavioral disorder, type of bowel management, and the need for botulinum toxin administered to the anal sphincters was not associated with the need for subsequent colonic resection. On anorectal manometry, lack of pelvic floor dyssynergia was significantly associated with the need for subsequent colonic resection; 3/8, 37.5% without pelvic dyssynergia versus 1/8, 12.5% ( p = 0.023) with pelvic dyssynergia underwent subsequent colonic resection. Conclusion In patients with severe functional constipation and documented segmental colonic dysmotility, ACE alone is an effective treatment modality at 1-year follow-up. Patients without pelvic floor dyssynergia on anorectal manometry are more likely to receive colonic resection after ACE. The vast majority of such patients can avoid a colonic resection.

Objective: Tobacco use is elevated among individuals with eating disorders (EDs). Yet, further research is needed to understand associations between cigarette and e-cigarette use patterns and ED symptomatology. To gain a more comprehensive understanding of tobacco use and EDs, this study characterized ED symptomatology and tobacco use patterns, including exclusive cigarette use, e-cigarette use, dual use, and nonuse. Method: Young adults aged 18-24 years who self-reported exclusive cigarette, e-cigarette, dual, or nonuse (N = 2500) were recruited via Lucid, an online survey management company. Participants completed questionnaires assessing body dissatisfaction, global ED psychopathology, binge eating and self-induced vomiting frequency, and demographics. ED diagnostic groups included: anorexia nervosa (AN), bulimia spectrum eating disorders (BSED), atypical AN, and night eating syndrome (NES). Results: Multinomial logistic models revealed those with AN were more likely to be dual users, those with atypical AN were more likely to be exclusive e-cigarette users, and participants with a BSED or NES were more likely to be exclusive e-cigarette or dual users, compared to those without an ED. General linear models suggested body dissatisfaction and global ED psychopathology were higher among exclusive e-cigarette and dual users, while binge eating and self-induced vomiting frequencies were greater among all tobacco use groups compared to nonusers. Discussion: Our findings suggest young adults with ED symptomatology were more likely to be users of e-cigarettes exclusively or dual users. It will be necessary to examine how these associations manifest using longitudinal and clinical populations in future research.

E-cigarette use has increased among young adults, and emerging research suggests a subset of young adults report using e-cigarettes for appetite control/weight loss. The current article examined the association of e-cigarette weight control beliefs with subsequent e-cigarette initiation. Data were collected via online surveys from a prospective cohort study of young adults in Southern California (N = 1,368) at baseline (May-October 2020; M [SD]age = 21.2 [0.4]) and 6 months later (January-May 2021). Binary logistic regression models were used to evaluate the association of e-cigarette weight control beliefs (i.e., perceptions that e-cigarettes help people lose weight and satisfy hunger and desire to eat unhealthy foods) with new onset e-cigarette use at follow-up. All models were adjusted for sociodemographic characteristics. Among individuals who had never used e-cigarettes at baseline, those who agreed (vs. disagreed) that e-cigarettes help people lose weight had more than three times the odds of initiating e-cigarette use by follow-up (OR [95% CI]: 3.24 [1.52, 6.62]). Similarly, those who agreed (vs. disagreed) that vaping certain e-cigarette flavors help satisfy hunger and desire to eat unhealthy foods had more than twice the odds of initiating e-cigarette use by follow-up (OR [95% CI]: 2.40 [1.15, 4.82]). Findings highlight that e-cigarette weight control beliefs are an important risk factor for vaping initiation. Future interventions and policies aiming to prevent vaping among young adults should address e-cigarette weight control beliefs and long-term health consequences from related use. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Background/Purpose: A small number of Hirschsprung disease (HD) patients develop inflammatory bowel disease (IBD)-like symptoms after pullthrough surgery. The etiology and pathophysiology of Hirschsprung-associated IBD (HD-IBD) remains unknown. This study aims to further characterize HD-IBD, to identify potential risk factors and to evaluate response to treatment in a large group of patients. Methods: Retrospective study of patients diagnosed with IBD after pullthrough surgery between 2000 and 2021 at 17 institutions. Data regarding clinical presentation and course of HD and IBD were reviewed. Effectiveness of medical therapy for IBD was recorded using a Likert scale. Results: There were 55 patients (78% male). 50% (n = 28) had long segment disease. Hirschsprung-associated enterocolitis (HAEC) was reported in 68% (n = 36). Ten patients (18%) had Trisomy 21. IBD was diagnosed after age 5 in 63% (n = 34). IBD presentation consisted of colonic or small bowel inflammation resembling IBD in 69% (n = 38), unexplained or persistent fistula in 18% (n = 10) and unexplained HAEC >5 years old or unresponsive to standard treatment in 13% (n = 7). Biological agents were the most effective (80%) medications. A third of patients required a surgical procedure for IBD. Conclusion: More than half of the patients were diagnosed with HD-IBD after 5 years old. Long segment disease, HAEC after pull through operation and trisomy 21 may represent risk factors for this condition. Investigation for possible IBD should be considered in children with unexplained fistulae, HAEC beyond

You have accessJournal of UrologyCME1 Apr 2023MP53-20 INITIAL UROLOGIC EVALUATION FOR ANORECTAL MALFORMATIONS: A PCPLC RETROSPECTIVE Jennifer Ahn, Caitlin Smith, Samuel Rice-Townsend, Lauren Nicassio, Jeffery Avansino, Megan Durham, Jason Frischer, Casey Calkins, Rebecca Rentea, Matthew Ralls, Megan Fuller, Richard Wood, Michael Rollins, Justin Lee, Ron Reeder, Belinda Dickie, Payam Saadai, Mark Cain, and Paul Merguerian Jennifer AhnJennifer Ahn More articles by this author , Caitlin SmithCaitlin Smith More articles by this author , Samuel Rice-TownsendSamuel Rice-Townsend More articles by this author , Lauren NicassioLauren Nicassio More articles by this author , Jeffery AvansinoJeffery Avansino More articles by this author , Megan DurhamMegan Durham More articles by this author , Jason FrischerJason Frischer More articles by this author , Casey CalkinsCasey Calkins More articles by this author , Rebecca RenteaRebecca Rentea More articles by this author , Matthew RallsMatthew Ralls More articles by this author , Megan FullerMegan Fuller More articles by this author , Richard WoodRichard Wood More articles by this author , Michael RollinsMichael Rollins More articles by this author , Justin LeeJustin Lee More articles by this author , Ron ReederRon Reeder More articles by this author , Belinda DickieBelinda Dickie More articles by this author , Payam SaadaiPayam Saadai More articles by this author , Mark CainMark Cain More articles by this author , and Paul MerguerianPaul Merguerian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003301.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urologic anomalies such as hydronephrosis, solitary kidney, and vesicoureteral reflux are common in individuals with anorectal malformations (ARM). These can lead to renal damage if not detected and managed appropriately. Optimal detection and surveillance strategies have not yet been established. We aim to evaluate current urologic evaluation practices in individuals with anorectal malformation utilizing a multi-center registry. METHODS: We performed a multicenter retrospective study of children with ARM evaluated at sites participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). We included all subjects with ARM who had a colostomy or PSARP within 12 months of birth and were also seen at a PCPLC site within 3 months of birth or ARM diagnosis. The primary outcome was the proportion of subjects undergoing urologic evaluation within 12 months of ARM diagnosis. The secondary outcome was proportion of screened subjects with urologic anomalies. We evaluated associations between urologic evaluation and clinical and sociodemographic characteristics. p-value <0.05 was considered significant. RESULTS: A total of 427 subjects with ARM from 13 institutions were included, and only 22% (93/427) of subjects had a recorded urologic evaluation within 12 months of ARM diagnosis. For imaging studies performed within 12 months of ARM diagnosis, 25% (112/427) underwent renal ultrasound, 8% (34/427) had a voiding cystourethrogram (VCUG), and 1% had a renal scan performed. Kidney anomalies were reported in 58 subjects, with hydronephrosis seen most commonly, followed by horseshoe kidney and ectopic kidney. Vesicoureteral reflux was detected in 20 subjects, comprising 59% of those who had a VCUG performed. On univariate analysis, having a renal ultrasound performed within 12 months of ARM diagnosis was not associated with clinical characteristics, such as ARM complexity or spine/sacrum status. It was associated with Hispanic ethnicity (OR 1.73, CI 1.04, 2.84, p=0.034). CONCLUSIONS: Timely urologic evaluation was recorded only 25% of the time, with a high proportion yielding expected anomalies such as hydronephrosis and vesicoureteral reflux. This suggests many potentially harmful conditions may be going undetected or unrecorded, and routine early evaluation should be standardized. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e720 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jennifer Ahn More articles by this author Caitlin Smith More articles by this author Samuel Rice-Townsend More articles by this author Lauren Nicassio More articles by this author Jeffery Avansino More articles by this author Megan Durham More articles by this author Jason Frischer More articles by this author Casey Calkins More articles by this author Rebecca Rentea More articles by this author Matthew Ralls More articles by this author Megan Fuller More articles by this author Richard Wood More articles by this author Michael Rollins More articles by this author Justin Lee More articles by this author Ron Reeder More articles by this author Belinda Dickie More articles by this author Payam Saadai More articles by this author Mark Cain More articles by this author Paul Merguerian More articles by this author Expand All Advertisement PDF downloadLoading ...

This study examined baseline patient characteristics as predictors of early weight loss, defined as any weight loss within the first month of treatment, among patients receiving adjunctive behavioural treatments for loss-of-control (LOC) eating about 6 months after bariatric surgery. Participants were 126 patients in a treatment trial for LOC-eating (roughly 6 months postoperatively) categorized by early weight change following 1 month of treatment. Early weight-loss, defined as any weight loss following 1 month of treatment, and weight-gain, defined as any weight gain, groups were compared on sociodemographic and clinical variables assessed using a battery of reliably administered diagnostic and clinical interviews and established self-report measures, and on surgery-related variables (time since surgery, percent total [%TWL], and percent excess weight loss). Most patients (n = 99; 78.6%) lost weight after the first month of adjunctive treatments. Black patients (n = 24; 61.5%) were significantly less likely to achieve early weight loss compared to patients identifying as White (n = 60; 83%) or 'other' (n = 15; 100%) which was not predicted by any other sociodemographic variable. Severity of eating-disorder psychopathology, psychiatric comorbidity, and a broad range of psychosocial measures were not significantly predictive of early weight changes. Duration since surgery and percent weight loss from time of surgery to study enrolment 6-months post-surgery differed by early weight-loss and weight-gain groups. Findings suggest that among post-bariatric surgery patients receiving adjunctive behavioural treatments for LOC-eating, baseline patient characteristics, aside from race and surgery-related variables, do not predict early weight loss.

Background: Adnexal torsion is the sixth most common pediatric surgical emergency, and one that requires high clinical suspicion and prompt surgical intervention in order to preserve ad-nexal function. Patients presenting with one or more additional acute medical concerns during an episode of torsion must be managed carefully and effectively to ensure both safe perioperative care and expeditious surgical management.Case Presentation: We review a case of adnexal torsion in a seventeen-year-old female who was found incidentally to have severe hyponatremia, with serum sodium concentration 117 mEq/L. Further workup was initiated for this significant electrolyte derangement. This demonstrated low serum osmolality and high urine osmolality, consistent with syndrome of inappropriate an-tidiuretic hormone (SIADH). This case represents the first case report of SIADH in the setting of adnexal torsion. Optimizing surgical management was uniquely challenging in this case. In or-der to preserve fertility in this young patient, urgent detorsion was needed. This had to be bal-anced with aggressive but safe preoperative normalization of sodium to minimize intraopera-tive risk. Although serum sodium improved with medical management, it only returned to nor-mal range after the patient underwent surgical detorsion of the adnexa, and resolution of her pain.Conclusions: Although this represents the first reported case of SIADH in the setting of adnexal torsion, the linkage between pain afferents and SIADH has been well documented, suggesting that patients with severe pain from torsion may be at risk for hyponatremia via this mechanism. As such, providers should be aware of the management of SIADH, as well as potential periopera-tive risks. This case, along with our review of the literature, supports surgical intervention as in-tegral to the definitive coffection of hyponatremia in patients with adnexal masses resulting in SIADH.

The purpose of this study was to investigate factors impacting transplant-free survival among infants with biliary atresia. A multi-institutional, retrospective cohort study was performed at nine tertiary-level children’s hospitals in the United States. Infants who underwent Kasai portoenterostomy (KP) from January 2009 to May 2017 were identified. Clinical characteristics included age at time of KP, steroid use, surgical approach, liver pathology, and surgeon experience. Likelihood of transplant-free survival (TFS) was evaluated using logistic regression, adjusting for patient and surgeon-level factors. Secondary outcomes at 1 year included readmission, cholangitis, reoperation, mortality, and biliary clearance. Overall, 223 infants underwent KP, and 91 (40.8%) survived with their native liver. Mean age at surgery was 63.9 days (± 24.7 days). At 1 year, 78.5% experienced readmission, 56.9% developed cholangitis, 3.8% had a surgical revision, and 5 died. Biliary clearance at 3 months was achieved in 76.6%. Controlling for patient and surgeon-level factors, each additional day of age toward operation was associated with a 2% decrease in likelihood of TFS (OR 0.98, 95% CI 0.97–0.99). Earlier surgical intervention by Kasai portoenterostomy at tertiary-level centers significantly increases likelihood for TFS. Policy-level interventions to facilitate early screening and surgical referral for infants with biliary atresia are warranted to improve outcomes.

BACKGROUND There is wide variation in opioid prescribing after appendectomy in children and adolescents, with recent increases noted in opioid-related pediatric deaths from prescription and illicit opioids. The goal of this project was to minimize opioid prescribing at the time of discharge for children undergoing appendectomy by using Quality Improvement (QI) methodology. STUDY DESIGN Children (18 years of age or less) who underwent appendectomy were evaluated from January to December 2019 using NSQIP-Pediatric at 10 children's hospitals within the Western Pediatric Surgery Research Consortium. Before project initiation, 5 hospitals did not routinely prescribe opioids after appendectomy (protocol). At the remaining 5 hospitals, prescribing was not standardized and varied by surgeon (no-protocol). A prospective multi-institutional QI project was used to minimize outpatient opioid prescriptions for children after appendectomy. The proportion of children at each hospital receiving an opioid prescription at discharge was compared for 6 months before and after the intervention using chi-square analysis. RESULTS Overall, 1,524 children who underwent appendectomy were evaluated from January to December 2019. After the QI intervention, overall opioid prescribing decreased from 18.2% to 4.0% (p < 0.001), with significant decreases in protocol hospitals (2.7% vs 0.8%, p = 0.038) and no-protocol hospitals (37.9% vs 8.8%, p < 0.001). The proportion of 30-day emergency room visits did not change after the QI intervention (8.9% vs 9.9%, p = 0.54) and mean postintervention pain management satisfaction scores were high. CONCLUSION Opioid prescribing can be minimized in children after appendectomy without increasing emergency room visits or decreasing patient satisfaction. Furthermore, NSQIP-Pediatric can be used as a platform for multi-institutional collaboration for successful implementation of QI projects.

Purpose: Those with chronic cardiac and pulmonary diseases are predisposed to several psychosocial disorders. Tailored rehabilitation programs have been shown to improve physiological and psychosocial well-being. The purpose of this study was, first, to assess the psychosocial improvements among patients with cardiac and pulmonary diseases who have finished cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) programs; second, to assess the differences in psychosocial factors among those patients based on smoking status at the beginning and end of these programs. Methods: The CR and PR programs in hospital settings were retrospectively analyzed from 2013-2018. Before and after, all patients completed the sociodemographic characteristics along with the Psychosocial Risk Factor Survey that measures total distress, depression, anxiety, hostility, and social isolation. Results: There were 355 patients with cardiac and 244 patients with pulmonary disease who completed 6- to 12-wk CR or PR programs. There were significant improvements in all psychosocial symptoms among cardiac patients. Patients with pulmonary disease exhibited significant improvements in all psychosocial factors except for social isolation. Moreover, current smokers in the CR group reported elevated symptoms of several psychosocial scores. Conclusion: These findings provide critical information about the effects of tailored rehabilitation programs among patients with chronic cardiac and pulmonary diseases on psychosocial levels. By using the Psychosocial Risk Factor Survey, we have found that total distress, depression, anxiety, and hostility were reduced among patients who completed the CR or PR programs. Current smokers exhibited the elevated mean scores on psychosocial symptoms in the cardiac group that may be a target for smoking cessation program. The advantages of tailored rehabilitation programs are significant, which may be of benefit for physical, social, behavioral, and psychological well-being.