INTRODUCTION:No universally accepted surgical management of spontaneous intestinal perforation (SIP) and surgical necrotizing enterocolitis (NEC) exists in low birth weight premature infants. In 2014, our institution implemented a protocol stratifying infants with surgical NEC or SIP to peritoneal drain (PD) insertion or laparotomy (LAP). This study aimed to identify factors associated with conversion from PD to LAP. METHODS:We conducted a retrospective review of infants who underwent PD (CPT 49020) between June 2014 and October 2024. Per protocol, infants ≥750 g, ≥14 d old, or with pneumatosis or portal venous gas on X-ray underwent LAP. All others received PD, with standard postoperative management including antibiotics, and drain removal on day 7. Conversion from PD to LAP occurred for persistent clinical deterioration. Demographic, clinical, and treatment variables were analyzed to identify predictors of progression to LAP. RESULTS:Sixty-six infants underwent primary peritoneal drainage, with protocol nonadherence in 38% due to birth weight >750 g (21%) or postnatal age >14 d (17%). Blood transfusion within 7 d of intervention was more common among infants who progressed to exploratory LAP compared with those managed without LAP (96.4% versus 57.1%, P = 0.003). In contrast, preoperative NeoProfen exposure was less frequent among infants requiring LAP than among those who did not progress to LAP (10.7% versus 42.9%, P = 0.017). CONCLUSIONS:In this single institutional review of patients with surgical NEC or SIP who underwent protocol driven intervention, blood transfusion within 7 d of diagnosis was associated with progression from PD to LAP, while NeoProfen administration was negatively associated. These modifiable factors may inform future refinements of protocol-based management for surgical NEC and SIP.

Objective: To update and add to the first report commissioned by the Blue Ribbon Committee (BRC) about 20 years prior. Background: Following a summit in late 2022 commissioned by the American Board of Surgery regarding competency-based reforms in surgical education and through a partnership with the American College of Surgeons and other stakeholders, a BRC-II on surgical education was formed. The BRC-II would have 7 subcommittees. This paper details the work of the Medical Student Subcommittee within the BRC-II. Methods: The subcommittee’s work, supported by staff from the American College of Surgeons, entailed a thorough literature review, which involved collating and aggregating the findings, identifying key challenges and opportunities, and committing to draft recommendations. These recommendations were then presented and refined through discussions with the BRC at large in multiple virtual and in-person settings. Results: The subcommittee’s work is detailed below and further summarized in table format. The section below elucidates the medical student education continuum and discusses the pertinent topics of recruitment, surgical engagement in medical student training and the surgical image, training for the current surgical practice model, trainee selection for graduate medical education, and optimizing the transition from undergraduate medical education to graduate medical education. Conclusions: The last 2 decades have shown significant changes and shifts in medical education and surgical practice. The findings of BRC-II in this manuscript help to structure the current and future necessary improvements, focusing on different aspects of medical student education.

INTRODUCTION:Dr. Asa G. Yancey published a surgical technique describing a pull - through of normal colon through a cuff of aganglionic colon to treat Hirschsprung disease in 1952, 12 y before Dr. Franco Soave whose name is attached to the procedure. Yancey and his pioneering operation went unrecognized for over half a century because of discriminatory segregation in the publishing practices of academic medicine dating back to the 1950s. MATERIALS AND METHODS:We performed a literature review on the surgical therapies for Hirschsprung disease. This history was supplemented with first-hand accounts provided by Yancey's children. Further information by leaders of the American Pediatric Surgical Association Hirschsprung interest group regarding the future of surgical nomenclature for the endorectal pull-through procedure was acquired through interviews. RESULTS:A review of the literature revealed that Yancey's description of the pull-through technique for Hirschsprung disease was published 12 y prior to Soave's publication and yet, Yancey received little to no recognition for his work. Yancey's children describe a surgeon who was persistent in his endeavor to create a more inclusive field of academic surgery as well as a man who prioritized his family and the education of future surgeons. Conversations with the American Pediatric Surgical Association Hirschsprung interest group suggest active changes to give posthumous credit to Yancey, including renaming the procedure to the Yancey - Soave pull-through technique. CONCLUSIONS:Here, we provide a historical review of Yancey's career as well as insights on the man behind the surgery and how he persevered in academic surgery despite experiencing discrimination during the civil rights movement.

From the Leonard M Miller School of Medicine, Don Soffer Clinical Research Center, University of Miami, Miami, FL. Received November 28, 2023; Accepted November 28, 2023. Disclosure Information: Nothing to disclose. Presented at the American College of Surgeons Clinical Congress, Boston, MA, October 2023. Correspondence address: Henri R Ford, MD, MHA, FACS, MAMSE, FRCS(Eng), FAAP, Leonard M Miller School of Medicine, Don Soffer Clinical Research Center, University of Miami, 1120 NW 14th St, Suite 360S, Miami, FL 33136. email: [email protected]

OBJECTIVE:To update and add to the first report commissioned by the Blue Ribbon Committee (BRC) about 20 years prior. BACKGROUND:Following a summit in late 2022 commissioned by the American Board of Surgery regarding competency-based reforms in surgical education and through a partnership with the American College of Surgeons and other stakeholders, a BRC-II on surgical education was formed. The BRC-II would have 7 subcommittees. This paper details the work of the Medical Student Subcommittee within the BRC-II. METHODS:The subcommittee's work, supported by staff from the American College of Surgeons, entailed a thorough literature review, which involved collating and aggregating the findings, identifying key challenges and opportunities, and committing to draft recommendations. These recommendations were then presented and refined through discussions with the BRC at large in multiple virtual and in-person settings. RESULTS:The subcommittee's work is detailed below and further summarized in table format. The section below elucidates the medical student education continuum and discusses the pertinent topics of recruitment, surgical engagement in medical student training and the surgical image, training for the current surgical practice model, trainee selection for graduate medical education, and optimizing the transition from undergraduate medical education to graduate medical education. CONCLUSIONS:The last 2 decades have shown significant changes and shifts in medical education and surgical practice. The findings of BRC-II in this manuscript help to structure the current and future necessary improvements, focusing on different aspects of medical student education.

Background: Pediatric pedestrian injuries (PPI) are a major public health concern. This study utilized geospatial analysis to characterize the risk and injury severity of PPI. Methods: A retrospective chart review of PPI patients (age < 18) from a level 1 trauma center was performed (2013-2020). A geographic information system geocoded injury location to home and other public landmarks. Incidents were aggregated to zip codes and the Local Indicators of Spatial Association statistic tested for spatial clustering of injury rates per 10,000 children. Predictors for increased injury severity were assessed by logistic regression. Results: PPI encompassed 6% (n = 188) of pediatric traumas. Most patients were black (54%), male (58%), >13 years (56%), and with Medicaid insurance (68%). Nine zip codes comprised a statistically significant cluster of PPI. Nearly half (40%) occurred within a quarter mile of home; 7% occurred at home. Most (65%) PPI occurred within 1 mile of a school, and 45% occurred within a quarter mile of a park. Nearly all (99%) PPI occurred within a quarter mile of a major intersection and/or roadway. Using admission to ICU as a marker for injury severity, farther distance from home (OR 1.060, 95% CI 1.001-1.121, p = 0.045) and age <13 years (3.662, 95% CI 1.854-7.231, p < 0.001) were independent predictors of injury severity. Conclusions: There are significant sociodemographic disparities in PPI. Most injuries occur near patients' homes and other public landmarks. Multidisciplinary injury prevention collaboration can help inform policymakers, direct local safety programs, and provide a model for PPI prevention at the national level. Level of Evidence: Level IV. (c) 2023 Elsevier Inc. All rights reserved.

Necrotizing Enterocolitis (NEC) is a devastating disease that primarily affects the premature neonatal intestine, leading to necrosis, sepsis and death. Although the pathophysiology of NEC is incompletely understood, inflammatory mediators, such as TNF-α, along with an immature intestinal barrier and bacterial pathogens play a crucial role in the development of NEC. The presentation may include non-specific findings, such as irritability, feeding intolerance and abdominal distention, and it can quickly progress to pneumoperitoneum and peritonitis. The modified Bell’s staging system is a tool to assist with the diagnosis of NEC, based on systemic, abdominal and radiographic signs. Most infants with NEC are treated with medical management; however, approximately 30–50% of these will go on to require surgical intervention. Despite advancements in prevention, mortality rates of infants diagnosed with NEC remain high, at approximately 35% in surgical and 20% in medical NEC. Among survivors, long-term complications include short bowel syndrome, strictures and neurodevelopmental delay. Despite advances in the care of premature infants, NEC continues to be one of the deadliest diseases of neonates.

Background: Motor vehicle collisions (MVCs) are the leading cause of unintentional death among children and adolescents; however, public awareness and use of appropriate restraint recommendations are perceived as deficient. We aimed to investigate the use of child safety restraints and examine outcomes in our community. Methods: We retrospectively queried a level 1 trauma registry for pediatric (0-18 y) MVC patients from October 2013 to December 2018. Demographic and clinical variables were recorded. Data regarding appropriate restraint use by age group were examined. Results: Four hundred thirty-four cases of pediatric MVC were identified. Overall, 53% were improperly restrained or unrestrained. Sixty-two percent of car seat age and 51% of booster age children were improperly restrained or unrestrained altogether. Fifty-nine percent of back seat riding, seatbelt age were improperly restrained/unrestrained, with 26% riding in the front. Fifty-one percent of seatbelt-only adolescents were not belted. Black, non Hispanic children were more often improperly restrained/unrestrained compared to Hispanics (63% versus 48%, P = 0.001). Improperly restrained/unrestrained children had higher injury severity (10% versus 4% Injury Severity Score > 25, P = 0.021), require operative/ interventional radiology (33% versus 19%, P = 0.001), and be discharged to rehabilitation or skilled nursing facility (5.2% versus 1.5%, P = 0.033). Mortality in adolescents was higher among those unrestrained (5.2% versus 0.8%, P = 0.034). Conclusions: Although efforts to improve adherence to restraint regulations have greatly increased in the last decade, more than half of children in MVC are still improperly restrained. Injury prevention services and community outreach is essential to educate the most vulnerable populations, especially those with infants and toddlers, on adequate motor vehicle safety measures in our community. (c) 2021 Elsevier Inc. All rights reserved.

Objective: To determine the role of race and gender in the career experience of Black/AA academic surgeons and to quantify the prevalence of experience with racial and gender bias stratified by gender. Summary of Background Data: Compared to their male counterparts, Black/African American women remain significantly underrepresented among senior surgical faculty and department leadership. The impact of racial and gender bias on the academic and professional trajectory of Black/AA women surgeons has not been well-studied. Methods: A cross-sectional survey regarding demographics, employment, and perceived barriers to career advancement was distributed via email to faculty surgeon members of the Society of Black American Surgeons (SBAS) in September 2019. Results: Of 181 faculty members, 53 responded (29%), including 31 women (58%) and 22 men (42%). Academic positions as a first job were common (men 95% vs women 77%, P = 0.06). Men were more likely to attain the rank of full professor (men 41% vs women 7%, P = 0.01). Reports of racial bias in the workplace were similar (women 84% vs men 86%, not significant); however, reports of gender bias (women 97% vs men 27%, P < 0.001) and perception of salary inequities (women 89% vs 63%, P = 0.02) were more common among women. Conclusions and Relevance: Despite efforts to increase diversity, high rates of racial bias persist in the workplace. Black/AA women also report experiencing a high rate of gender bias and challenges in academic promotion.

A well-respected surgical professor is the invited speaker for a conference at a large academic surgical department. As part of the events, there is a meet-and-greet to allow residents, fellows, and faculty speak with the professor. Dr. Z is a junior surgeon second-generation American citizen of Ecuadorean descent. The professor turns to Dr. Z and says, “you know, I told my fellow Mohammad to change his name to Matt so he could get a chief job.” The group of residents appear uncomfortable, but no one says anything in response.

High levels of PGE2 have been implicated in the pathogenesis of intestinal inflammatory disorders such as necrotizing enterocolitis (NEC) and peritonitis. However, PGE2 has a paradoxical effect: its low levels promote intestinal homeostasis, whereas high levels may contribute to pathology. These concentration-dependent effects are mediated by four receptors, EP1-EP4. In this study, we evaluate the effect of blockade of the low affinity pro-inflammatory receptors EP1 and EP2 on expression of COX-2, the rate-limiting enzyme in PGE(2) biosynthesis, and on gut barrier permeability using cultured enterocytes and three different models of intestinal injury. PGE(2) upregulated COX-2 in IEC-6 enterocytes, and this response was blocked by the EP2 antagonist PF-04418948, but not by the EP1 antagonist ONO-8711 or EP4 antagonist E7046. In the neonatal rat model of NEC, EP2 antagonist and low dose ofCOX-2 inhibitor Celecoxib, but not EP1 antagonist, reduced NEC pathology as well as COX-2 mRNA and protein expression. In the adult mouse endotoxemia and cecal ligation/puncture models, EP2, but not EP1 genetic deficiency decreased COX-2 expression in the intestine. Our results indicate that the EP2 receptor plays a critical role in the positive feedback regulation of intestinal COX-2 by its end-product PGE(2) during inflammation and may be a novel therapeutic target in the treatment of NEC.

Hurricane Dorian's ensemble of extreme winds, wave action, and pelting rains laid waste to exquisitely vulnerable human settlements throughout the Abaco islands in northwest Bahamas. Dorian, the strongest hurricane ever to impact the Bahamas, pulled a towering storm surge onshore. Combined with 20 inches of rain, vast expanses of Abaco islands were submerged. The system's forward movement slowed to near standstill, creating one of the longest-duration population exposures to a hurricane in history [[1]Shultz J.M. Sands D.E. Kossin J.P. Galea S Double environmental injustice — climate change, Hurricane Dorian, and the Bahamas.New Engl J Med. 2020; 328: 1-3https://doi.org/10.1056/NEJMp1912965Crossref Scopus (17) Google Scholar]. Atmospheric scientists are observing that, in the era of climate change, Atlantic storms are becoming stronger, wetter, and slower moving as they come over land; Dorian matched this evolving profile, three-for-three [2Knutson T. Camargo S.J. Chan J.C.L. et al.Tropical cyclones and climate change assessment: part I. Detection and attribution.Bull Am Meteor Soc. 2019; 100: 1987-2007Crossref Scopus (102) Google Scholar, 3Hall T.M. Kossin J.P. Hurricane stalling along the North American coast and implications for rainfall.Clim Atmos Sci. 2019; 2: 17https://doi.org/10.1038/s41612-019-0074-8Crossref Scopus (29) Google Scholar, 4Shultz J.M. Kossin J.P. Shepherd J.M. et al.Risks, health consequences, and response challenges for small-island-based populations: observations from the 2017 Atlantic hurricane season.Disaster Med Public Health Prep. 2019; 13: 5-17Crossref PubMed Scopus (29) Google Scholar]. Dorian produced catastrophic damage to the Abaco islands' fragile built environment, pummelling a population of 17,500 Bahamian citizens and permanent residents, plus thousands more persons with work permits and nondocumented individuals. Hardest hit were shanty towns situated on the waterfront, with names like The Mudd and Pigeon Peas [[1]Shultz J.M. Sands D.E. Kossin J.P. Galea S Double environmental injustice — climate change, Hurricane Dorian, and the Bahamas.New Engl J Med. 2020; 328: 1-3https://doi.org/10.1056/NEJMp1912965Crossref Scopus (17) Google Scholar]. These collections of unregulated structures, pieced together from scavenged materials like plywood and sheets of corrugated iron, did not meet Bahamas' stringent building codes. Although slated for demolition, these dwellings were occupied when Dorian moved through. Rickety construction offered scant protection. Ramshackle habitats collapsed onto their occupants or disintegrated into projectile debris, contributing to the severity of injuries sustained [[1]Shultz J.M. Sands D.E. Kossin J.P. Galea S Double environmental injustice — climate change, Hurricane Dorian, and the Bahamas.New Engl J Med. 2020; 328: 1-3https://doi.org/10.1056/NEJMp1912965Crossref Scopus (17) Google Scholar]. In the aftermath, the shattered landscape drew analogies to war zones. Marsh Harbour, the major population centre, was home to about 7000 residents. As Dorian approached, locals filled Marsh Harbour's primary community shelter to overflowing. Others hunkered down in their dwellings, only to witness their homes being destroyed by Dorian's ferocious winds. Flimsy structures blew apart, directly exposing residents to the ravaging forces of Dorian [[1]Shultz J.M. Sands D.E. Kossin J.P. Galea S Double environmental injustice — climate change, Hurricane Dorian, and the Bahamas.New Engl J Med. 2020; 328: 1-3https://doi.org/10.1056/NEJMp1912965Crossref Scopus (17) Google Scholar]. Sixty Abaco islanders were killed during Dorian's assault; countless others were swept away in floodwaters and remain unfound months afterward. Remarkably, Marsh Harbour Medical Centre (MHMC), remained operational during and after Dorian's passage. In the immediate aftermath, MHMC was swarmed with hundreds of displaced survivors seeking shelter. A skeleton crew of physician and nursing staff saw 30 critical patients requiring evacuation. As winds died down, a massive patient surge – estimated at 1000 – flooded into MHMC. Patient flow, consisting mainly of lower-acuity injuries and illnesses, was punctuated by the sporadic arrival of severe medical trauma cases. Staff treated lacerations, fractures, blunt trauma from flying debris, amputating and crush injuries from structural collapse, and aspiration injuries from near drownings. In the immediate aftermath, Project Hope and Americares provided volunteer health professionals. Direct Relief supplied pharmaceuticals. Bahamas Ministry of Health staffed medical facilities, but damage to housing stock and infrastructure prevented these personnel from filling more permanent onsite positions. The University of Miami Miller School of Medicine (UM) is providing intermediate medical and psychiatric support to MHMC and clinics in Abaco islands. UM staff are observing three salient patterns. First, medical trauma during Dorian's landfall was unusually severe compared to most Atlantic hurricanes. This is attributed to extreme storm hazards colliding with an exceptionally vulnerable population – and then stalling. Rarely has a hurricane so completely devastated the built environment, leaving many residents exposed, mid-storm, to the fury of the elements [[1]Shultz J.M. Sands D.E. Kossin J.P. Galea S Double environmental injustice — climate change, Hurricane Dorian, and the Bahamas.New Engl J Med. 2020; 328: 1-3https://doi.org/10.1056/NEJMp1912965Crossref Scopus (17) Google Scholar]. Currently, as the islands repopulate, and recovery efforts are underway, a new wave of medical trauma is occurring with steep increases in construction and motor vehicle injuries, some requiring advanced emergency care and evacuation. Second, storm damage – compounded by loss of electrical power – crippled healthcare services, impeding access to providers, medications, and vital treatments. Consequently, months after Dorian's passage, patients flowing through MHMC are presenting with inadequately managed chronic disease symptoms. Uncontrolled hypertension, type 2 diabetes, and cardiovascular disease are especially prominent. Needs for higher level care, including hospitalization and life-sustaining treatments like renal dialysis, require relocation of patients to Nassau. Third, almost universally, patients present with a psychological overlay to their medical conditions. New-onset, hurricane-related psychopathology is prevalent [[5]Espinel Z. Kossin J.P. Galea S. Richardson A.S. Shultz J.M Forecast: increasing mental health consequences from Atlantic hurricanes throughout the 21st century.Psychiatr Serv. 2019; 70: 1165-1167https://doi.org/10.1176/appi.ps.201900273Crossref PubMed Scopus (8) Google Scholar,[6]Espinel Z. Galea S. Kossin J.P. Caban-Aleman C. Shultz J.M Climate-driven Atlantic hurricanes pose rising threats for psychopathology.Lancet Psychiatry. 2019; 6: 721-723Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar]. Complaints of distress and sleep disorders are common. Patients spontaneously recount terrifying, life-threatening ("I thought I was going to die") experiences during Dorian's impact. Some describe the day-long, body-shaking "freight train" roar of Dorian's winds [[1]Shultz J.M. Sands D.E. Kossin J.P. Galea S Double environmental injustice — climate change, Hurricane Dorian, and the Bahamas.New Engl J Med. 2020; 328: 1-3https://doi.org/10.1056/NEJMp1912965Crossref Scopus (17) Google Scholar]. Survivors who lost home and possessions are at elevated risk for major depression [[5]Espinel Z. Kossin J.P. Galea S. Richardson A.S. Shultz J.M Forecast: increasing mental health consequences from Atlantic hurricanes throughout the 21st century.Psychiatr Serv. 2019; 70: 1165-1167https://doi.org/10.1176/appi.ps.201900273Crossref PubMed Scopus (8) Google Scholar,[6]Espinel Z. Galea S. Kossin J.P. Caban-Aleman C. Shultz J.M Climate-driven Atlantic hurricanes pose rising threats for psychopathology.Lancet Psychiatry. 2019; 6: 721-723Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar]. Islanders who lost a loved one grapple with complicated grief and traumatic bereavement. Others continue searching for still-missing family members. There is urgent need for mental health support [[5]Espinel Z. Kossin J.P. Galea S. Richardson A.S. Shultz J.M Forecast: increasing mental health consequences from Atlantic hurricanes throughout the 21st century.Psychiatr Serv. 2019; 70: 1165-1167https://doi.org/10.1176/appi.ps.201900273Crossref PubMed Scopus (8) Google Scholar,[6]Espinel Z. Galea S. Kossin J.P. Caban-Aleman C. Shultz J.M Climate-driven Atlantic hurricanes pose rising threats for psychopathology.Lancet Psychiatry. 2019; 6: 721-723Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar]. UM clinicians express concern for the well-being of their Bahamian counterparts who are staffing MHMC and area clinics. These professionals endured the stress of working shifts as Dorian tore apart their homes and communities. They treated an overwhelming patient surge that included uncharacteristically severe medical trauma. Post-impact, working under such austere conditions and unrelenting duress cannot be sustained without respite. Professionals who continue to serve, while trying to paste their own homes and lives back together, do so with astonishing resilience. Along with the patients they treat, these professionals are re-experiencing traumatic memories of Dorian, not sleeping well, and dealing with irreplaceable losses. Beyond intermediate clinical support, UM is committed to long-term capacity building, pulling from multiple disciplines and a network of partners to build back resilient healthcare services. One component involves structuring a stepped-care approach for mental health and psychosocial support [[7]Inter-Agency Standing Committee (IASC)IASC guidelines on mental health and psychosocial support in emergency settings. IASC, Geneva2007Google Scholar,[8]Shultz J.M. Verdeli H. Gomez Ceballos A.M. et al.A pilot study of a stepped-care brief intervention to help psychologically-distressed women displaced by conflict in Bogotá, Colombia.Global Mental Health. 2019; 6 (1–12): e28https://doi.org/10.1017/gmh.2019.26Crossref Google Scholar]. Community outreach, screening for common mental disorders, psychoeducation, and evidence-based mental health interventions can be provided once a structure is in place. Regarding workforce protection for Bahamas clinical and public health professionals on the front lines, development of stress management and team resilience training is underway [[9]Pfefferbaum B. Van Horn R.L. Pfefferbaum R A conceptual framework to enhance community resilience using social capital.Clin Soc Work J. 2017; 45: 102-110Crossref Scopus (23) Google Scholar]. Authors declare no conflict of interest.

Necrotizing enterocolitis (NEC) NEC Necrotizing enterocolitis (NEC) is the predominant intestinal inflammatory disorder affecting the newborn infant. Risk factors for NEC include prematurityPrematurity , formula feeding, and bacterial colonization of the gastrointestinal (GI) tract. The number of neonates at risk of developing NEC continues to rise due to recent advances in neonatology that have resulted in increased survival of extremely premature infants. Clinical features of NEC are often nonspecific and include evidence of physiologic instability, feeding intolerance, abdominal distention, and hematochezia. A cluster of key clinical and radiographic findings, known as the Bell staging system, has been used to characterize disease severity. Despite aggressive management strategies, morbidity and mortality from NEC remain high. Thus, this vexing disease will likely remain a major contributor to healthcare costs and may, one day, become the leading cause of death among premature infants. Optimal preventive strategies are needed to avert the devastating consequences of NEC.

Purpose: Firearm injuries (GSW) are a growing public health concern and leading cause of morbidity and mortality among children, yet predictors of injury remain understudied. This study examines the correlates of pediatric GSW within our county. Methods: We retrospectively queried an urban Level l trauma center registry for pediatric (0-18 yea rs) GSW from September 2013 to January 2019, examining demographic, clinical, and injury information. We used a geographic information system to map GSW rates and perform spatial and spatiotemporal duster analysis to identify zip code "hot spots." Results: 393 cases were identified. The cohort was 877% male, 87% African American, 10% Hispanic, and 22% Caucasian/Other. Injuries were 92% violence-related and 4% accidental, with 63% occurring outside school hours. Mortality was 12%, with 53% of deaths occurring in the resuscitation unit. Zip-level GSW rates ranged from 0 to 9 (per 1000 < 18 years) by incident address and 0-6 by home address. Statistically significant hot spots were in predominantly underserved African American and Hispanic neighborhoods. Conclusions: Geodemographic analysis of pediatric GSW injuries can be utilized to identify at-risk neighborhoods. This methodology is applicable to other metropolitan areas where targeted interventions can reduce the burden of gun violence among children. (C) 2020 Elsevier Inc. All rights reserved.

Background: Simulation-based training (SBT) for pediatric trauma resuscitation can improve team performance. The purpose of this study was to describe the nationwide trend in SBT use and barriers to SBT implementation. Methods: Trauma centers that participated in ACS TQIP Pediatric in 2016 (N = 125) were surveyed about SBT use. Center characteristics and reported implementation barriers were compared between centers using and not using SBT. Results: Survey response rate was 75% (94/125) with 78% (73/94) reporting SBT use. The frequency of pediatric SBT use increased from 2014 to 2016 (median 5.5 vs 6.5 annual sessions, p < 0.01). Funding barriers were negatively associated with number of annual SBT sessions (r < -0.34, p <0.05). Centers not using SBT reported lack of technical expertise (p = 0.01) and lack of data supporting SBT (p = 0.03) as significant barriers. Conclusions: Simulation use increased from 2014 to 2016, but significant barriers to implementation exist. Strategies to share resources and decrease costs may improve usage. (C) 2018 Elsevier Inc. All rights reserved.

Newborn emergencies that occur in the delivery room are frequently the result of life-threatening congenital anomalies that can result in death or severe disability if not treated in the immediate postnatal period. Prompt recognition and treatment of such disorders are paramount to ensuring the wellbeing of the infant. As congenital anomalies are frequently being diagnosed earlier due to improved prenatal detection, the coordination of planned interventions for life-threatening malformations is also becoming more common. This article serves as a guide for the presentation and initial management of the most common non-cardiac, newborn surgical emergencies.