Ultrasound (US) use within pediatric surgery is expanding rapidly. While US guidance for central line placement has been common practice for many years now, advances in the quality of images, portability of US machines, and a lack of radiation associated with imaging has led to broader application in many other aspects of surgery, ranging from diagnostics to performing operations under the direction of point-of-care ultrasound (POCUS). The relatively short learning curve for providers along with excellent image quality in children due to their small size provides an easy, effective imaging modality with diverse applications. Discussed here is a broad overview of the spectrum of US use within current pediatric surgical practices.

Abstract Introduction The United States continues to suffer from a serious epidemic of opioid use. Exposure to opioids is a known risk factor for long-term use and dependence. This is of particular importance to burn care, as opioids are frequently essential to manage the pain associated with burn injuries. The purpose of this study was to characterize opioid use among burn patients after hospitalization and to identify any risk factors for long-term dependence. Methods All patients admitted to a burn center during a single year period (2/1/2020-2/1/21) were examined. Patients who died were excluded. A controlled substance reporting system was utilized to determine opioid use over a time period from 6 months prior to injury and up to 12 months post-hospital discharge. Reporting to this database is mandated by law and therefore includes all prescriptions regardless of prescriber, insurance, location, etc. Duration of opioid use was recorded for all patients in the study. Long-term use was defined as having an active opioid prescription at 12 months post-hospital discharge. Patient demographic information, burn injury characteristics, operative interventions, and hospital course were examined to determine risk factors for long-term opioid use following burn injury. Results A total of 185 patients were included in the study. Patients were predominantly male (76.2%) and had an average age of 47.5 years old. Patients had an average TBSA burn of 9.5% and a length of stay of 6.7 days. A total of 54.7% of patients received an opioid prescription at discharge. Only 17 patients (9.7%) had persistent opioid use at 1 year. The only independent risk factor identified for long term opioid use was pre-injury use (p< 0.001). Among the 17 patients still on opioids at 1 year, 16 had filled 3 or more opioid prescriptions in the 6 months prior to injury. The solitary patient without a pre-existing opioid history had multiple readmissions and delayed operative interventions after their initial hospital course. Conclusions A majority of burn patients received opioids for pain control following hospital discharge. However, the duration of therapy was generally short among opioid naïve patients. Burn injury was not associated with long term opioid use among patients in the study. Applicability of Research to Practice When used judiciously and with caution, opioids can be safely prescribed to burn patients without fear of long-term opioid dependence.

OBJECTIVES:Disparities in pediatric health outcomes are widespread. It is unclear whether rurality negatively impacts outcomes of infants with surgical congenital diseases. This study compared outcomes of rural versus urban infants requiring complex surgical care at children's hospitals in the United States.METHODS:Rural and urban infants (aged <1 year) receiving surgical care at children's hospitals from 2016 to 2019 for esophageal atresia, gastroschisis, Hirschsprung's disease, anorectal malformation, and congenital diaphragmatic hernia were compared over a 1-year postoperative period using the Pediatric Health Information System. Generalized linear mixed effects models compared outcomes of rural and urban infants.RESULTS:Among 5732 infants, 20.2% lived in rural areas. Rural infants were more frequently white, lived farther from the hospital, and lived in areas with lower median household income compared with urban infants (all P < .001). Rural infants with anorectal malformation and gastroschisis had lower adjusted hospital days over 1 year; rural infants with esophageal atresia had higher adjusted odds of 30-day hospital readmission. Adjusted mortality, hospital days, and readmissions were otherwise similar between the 2 groups. Outcomes remained similar when comparing urban infants to rural infant subgroups with the longest hospital travel distance (≥60 miles) and lowest median household income (<$35 000).CONCLUSIONS:Despite longer travel distances and lower financial resources, rural infants with congenital anomalies have similar postoperative outcomes to urban infants when treated at children's hospitals. Future work is needed to examine outcomes for infants treated outside children's hospitals and to determine whether efforts are necessary to increase access to children's hospitals.

After completing this article, readers should be able to: Understand the epidemiology of firearm injury and mortality in the United States.Recognize risk factors associated with firearm injury and mortality.Define the role that pediatric providers have in screening for firearm injury risk among patients and families and counseling about firearm safety when appropriate.Understand provider-level barriers to firearm safety counseling and how to overcome these barriers (education, stakeholder buy in, collaborations with gun owners and community-based organizations to increase cultural competence).Develop strategies to build cultural competence in advising patients and families with firearms.Compared with other high-income countries, the United States has the highest rate of firearm-related injury and mortality in the world. (1) In 2016, the rate of firearm deaths in children and adolescents in the United States was 36.5 times higher than the rate in other high-income countries and 5 times higher than the rate in middle-income countries. (2) According to 2016 death certificate data collected by the Centers for Disease Control and Prevention (CDC), the second leading cause of death among children and adolescents (age 1–19 years) in the United States was firearm injury. (3)(4) International studies indicate that 91% of firearm deaths in children aged 0 to 14 years in high-income countries worldwide occur in the United States. (5) According to data from the National Trauma Data Bank from 2010 to 2016, 13% of firearm injuries occurred in children younger than 15 years and 50% occurred in 18- and 19-year-olds. (3) Of all injuries and illnesses in children, firearm injuries have one of the highest case fatality rates, particularly if intent is self-harm. (5)(6) Surprisingly, the rates of firearm injury across the country during the COVID-19 pandemic have increased, and 2020 was the deadliest year on record, with more than 40,000 Americans killed by firearms. (7)One-third of homes in the United States in which children reside have at least 1 gun in the household, and a surge in firearm purchases among Americans during the past 2 years has resulted in a significantly higher number of firearms in households across the country. (8) Although the safest way to store a gun is locked and unloaded, (9)(10) many are stored unlocked and loaded. (11)(12)(13) During the past 2 decades, the safe storage of weapons in homes has declined, with 21% of homes storing firearms unlocked and loaded in 2015 compared with only 8% in 2002. (13)(14) As a result, at least 4.6 million American children live in a home with an unlocked and loaded gun. (13) Interestingly, the most common reason for owning a firearm among Americans is the perceived belief that it makes the home safer, with 35% of Americans saying it makes the household safer in 2000 and 63% with this same belief in 2014. (13) However, guns in the home do not correlate with safety, (15) with the odds of firearm-related homicide, suicide, or accidental injury being higher in gun-owning homes. (13)Deaths and injuries related to firearms are considered unintentional or intentional. Unintentional injuries from firearms are more common in children, whereas intentional injuries, such as suicide or homicide, are more likely seen in adolescents. (2) Unintentional firearm-related deaths in children commonly occur when a child happens upon a loaded and unsecured firearm in their household and shoots a sibling or themselves. (6) Suicide accounts for most firearm-related deaths in the United States (>55%), followed by homicides. (5)(7) In the pediatric population, homicides are the leading cause of firearm-related deaths. (6) Younger children are more likely to be shot by adults they know and in the house in which they live, whereas adolescents aged 13 to 17 years are more likely to be killed by someone similar in age as the victim and are equally as likely to die in a home or in the streets. Although homicide rates in children and adolescents have been decreasing, firearm suicide rates in the pediatric population have had the opposite trend with a rapid increase, and firearm-related suicide is now one of the leading causes of death in adolescents. (4) In 2019, suicide was the 10th leading cause of death in the United States among all Americans, and about half of all suicides were by firearms. (4) Most suicides are completed with handguns; however, long gun use for suicides is higher in rural counties and in adolescents. (16) Regardless of the intention, overall, firearm injury has one of the highest case fatality rates of any illness or injury in pediatrics. (3)Firearm injury and mortality vary across the country by geographic location and across states. From 2010 to 2014, Louisiana and the District of Columbia had the highest rates of child firearm mortality in the nation (4.5 and 4.2 per 100,000, respectively). (6) In addition, firearm-related homicide deaths are more prevalent in southern and midwestern states. (6) This variability may be in part due to varying firearm safety legislation by state, as there has been an association between strict firearm safety laws (safe storage, background checks) and lower rates of childhood and all-age resident firearm-related deaths. (17)Firearm injury and violence disproportionally affects Americans based on their race, sex, age, and socioeconomic status. In the United States, African Americans, males, and adolescents aged 13 to 17 years are particularly at risk. (6) From 2012 to 2014, firearm-related homicides primarily affected African Americans, whereas firearm-related suicide primarily affected White and American Indian children. (6) In addition, males and adolescents are also more likely to experience nonfatal firearm injuries. (6) Firearm injury trends also show that young African American children (<5 years) have firearm mortality rates 3 times as high as young White children. (18) Given these disparities, gun violence has to be addressed via a community-based approach with emphasis placed on neighborhood- and hospital-based violence interrupter programs. (19)(20) Efforts to develop more hospital-based violence intervention programs and other important community-based organizations should be considered.Policies and laws geared toward safe storage have been shown to improve firearm safety in the household. Child access prevention (CAP) laws requiring safe storage of weapons within the household have been associated with lower rates of firearm-associated suicide (21) and reduced self-inflicted injuries and unintentional firearm injuries in youth. (17)(22) Background checks have been shown to decrease violent crime, whereas stand-your-ground laws have resulted in higher rates of homicide. Extreme risk protection orders (ERPOs), also known as red flag laws, are important means that empower families and law enforcement to temporarily restrict firearm access for loved ones who are at risk for harm to self or others. After implementation in Indiana and Connecticut, it is estimated to have prevented at least 1 suicide for every 10 to 20 ERPOs issued, with 7.5% and 13.7% reductions in suicides, respectively. (23) For pediatricians providing guidance to patients and families on firearm safety, an understanding of state firearm safety laws such as ERPOs and CAP laws empowers practitioners to provide families information on these lifesaving resources during counseling.Most health-care providers believe that discussing firearm safety with their patients is important and that implementing already existing evidence-based firearm injury and mortality prevention strategies into health-care settings can be impactful. Most pediatric providers believe that counseling on firearm safety is beneficial and that firearm injury prevention should be discussed with all families. (24)(25) Despite widespread belief that counseling is necessary to prevent injuries, few health-care providers routinely screen and counsel patients about firearm safety. In a survey conducted in the 1990s, 33% of providers reported ever having counseled about gun safety and 20% reported actively performing firearm safety counseling, despite 80% finding it beneficial. (23) In a more recent survey of pediatric residents, most (96%) believed that physicians have a duty to counsel on firearm risks; however, 63% never provide counseling during health supervision visits, and of those who did, most report that they provided it less than 5% of the time. (26) Of the respondents, most (85%) felt uncomfortable with counseling on safety storage devices. In a survey from outpatient pediatric practices in St Louis, Missouri, only 0.5% of parents reported that their firearm safety education was received through a pediatrician; yet, 75% of the respondents thought that pediatricians should advise about safe firearm storage. (27)Both gun-owning and non–gun-owning parents underestimate how much their kids know about where guns are stored or whether the child has ever handled a gun. (28) A survey found that 39% of parents who reported that their children did not know the location of the firearm in the home were contradicted by their children, and 40% of children who reported having handled a firearm were not identified by their parents as having done so. (28)Although some physicians are concerned about the legality of confidentially screening and counseling patients on firearm injury risk, there are no federal or state laws that prohibit physicians from asking about firearms in the home. (29) Parental willingness to engage in discussions with providers about firearm safety is also important to consider. Several studies have shown parental willingness to hear advice from their pediatrician on this topic. One study found that 75% of parents thought that pediatricians should advise about safe storage of firearms and two-thirds thought that pediatricians should screen for guns in the home. (27) Although gun owners were less likely to feel that their physician should ask about firearms in the home compared with non–gun owners, still, most agree that it would be appropriate to do so. (27)(30)(31) Furthermore, most gun owners reported that physicians should advise about safe gun storage (71%), despite fewer feeling that physicians should ask. (27) By approaching screening and counseling about firearm safety in the context of injury prevention as part of routine care, concurrently with discussions about other injury prevention topics, such as motor vehicle safety and drowning avoidance, providers can help normalize conversations around firearm injury prevention in the health-care setting.There are gaps in knowledge in our understanding of the most effective approach for pediatric providers to screen and counsel patients and families on firearm injury prevention, highlighting the need for further research. However, several studies to date do provide valuable insights into a variety of approaches. (32)(33)(34)(35) In 2000, a national study on the effectiveness of a 1-time, 1-minute counseling session on firearm safety and safe storage was found to have no effect on gun acquisition, removal of firearms, or use of safe storage devices. (32) Although this trial did not find significant differences in removal of firearms from the home, there was a moderate increase in the purchase of gun safety locks after this short 1-minute counseling intervention. More recent studies found that firearm safety intervention significantly increases the use of safer storage practices. (33)(34)(35) In a randomized controlled trial in a large health-care setting, pediatricians administered an intervention to at-risk families termed the Safety Check that involves screening for firearm access, counseling on safe storage and motivational interviewing, and providing a gun lock. Patients and families who received the Safety Check had a 21.4% increase in storing their firearms locked, unloaded, and separately from ammunition. (33) Based on this study, the Safety Check is a common evidence-based approach that is used in health-care settings. (33) Differences in the intervention of this latter study included screening for exposure, assessing parents' interest and openness to changing their child's exposure, and providing a physical tool (ie, the cable lock) compared with previous studies, which consisted of only scripted counseling dialogue and a brochure. (32)(33) Another study found that a clinical team member–administered firearm safety intervention, which included safe storage counseling, a brochure, and a free gun safety lock, among families with access to a firearm resulted in a 61% increase in the safe storage of firearms compared with 26% in the control group. (35) These studies suggest that a more nuanced approach in discussing firearm safety rather than screening all patients, counseling based on individual risk factors, and providing physical preventive tools—such as gun safety locks—may be the most effective in improving safe storage practices and promoting positive behavior change.For pediatric providers, where the focus is on child safety, in addition to the safety of everyone in the household, safe storage counseling should clearly emphasize that the safest way to store a gun is locked, unloaded, and separately from ammunition. (9)(10) Context for screening is important; hence, questions about firearm access inside or outside of the household and subsequent counseling can be incorporated into broader discussions about injury prevention that are already part of routine care, such as counseling pertaining to motor vehicle safety, helmet use, and drowning avoidance. (31) A simple technique to start the screening is to ask "Are any firearms kept in or around your home?" within the context of questions about home safety hazards. (31) If the answer is yes, a strategy that adult providers use for follow-up questions includes use of the 5 Ls: Locked, Loaded, Little children, feeling Low, Learned owner, many of which can be applied to children as well. (29)(31) These screening questions can prompt deeper discussions on education about safe storage practices, provisions of resources such as gun locks and firearm safety courses, referrals for underlying health risk factors such as mental health or substance use, and community resources. (36) Ideally, discussions should be had in the context of a physician–patient relationship (29); however, if a physician is encountering a patient who is at particularly high risk for firearm violence (harm to self or others) it is important to intervene regardless of the previously established relationship—hence why screening is important especially for acute care physicians seeing patients in emergency care settings. Table 1 outlines a variety of other firearm safety measures that can be used as part of provider-administered counseling, and Table 2 outlines a list of additional resources that can be offered to patients.All patients and families are potentially at risk for firearm injury, particularly those with access to firearms within or outside of the household (eg, family or friend's house); hence, the importance of universally screening all patients cannot be understated. Yet, in addition to screening for firearm access, concomitant screening for health risk factors that pose a heightened risk of firearm injury and mortality and may require more targeted intervention is critical. (37) Patients with suicidal or homicidal ideation, previous substance abuse or active substance use, or a history of violence have a higher risk of firearm-related injury and mortality. (29)(38) Sixty percent of firearm-related deaths are suicides (39); hence, suicidal ideation warrants particular attention. Despite the elevated risk of firearm injury in patients with suicidal or homicidal ideation, pediatricians rarely document screening for firearm access in these high-risk patients. (40) It is imperative that behavioral health professionals are involved for patients with suicidal ideation to provide lethal means counseling, which is an intervention that includes education about the lethality of guns in the setting of suicides and routine counseling on removal of access to firearms for patients deemed to be at higher risk for suicide. (5) Other risk factors for firearm injury and mortality, such as a history of violence, alcohol or drug abuse, or a history of other mental illnesses, are important to screen for as well. (29) One recent study in a pediatric trauma center found that firearm safety discussions were held in only 10% of patients after presenting with gunshot wounds, (41) despite this being a risk factor for future gun violence. Screening for these additional risk factors will allow for specialty behavioral health and substance use referrals as needed, as well as the provision of community resources such as violence interrupter programs. (31) Although particular health risk factors as listed previously herein can increase one's risk of firearm injury, it is critical to reemphasize that screening for firearm injury risk should be universal and nontargeted, particularly when it comes to firearm access, because all children and family members are potentially at risk regardless of associated health risk factors.Another important consideration is the effect of firearm-related violence on the mental health of children who witness it. Exposure to firearm-related violence generally is also related to mental health in the development of posttraumatic stress. (42) In addition, as mass shootings are becoming more commonplace, the mental health toll taken on survivors of the mass shooting, the families and friends of the victims, and the community of the event has led to posttraumatic stress disorders, depression, and other psychological symptoms. (43) However, there are a significant number of factors involved in the development of mental health disorders following violence and in particular gun-related violence. Significantly more research is required to better understand the effects of firearm injury and mortality on survivors, although, it does highlight the importance and need to involve mental health professionals for children who witness gun violence in their communities.Studies have identified several provider-level barriers with respect to having conversations related to firearm injury prevention with patients and families, including lack of comfort, education, knowledge, and time and fear of offending or harming the doctor–patient relationship. It is important that clinicians are aware of these potential barriers because education in itself can serve to overcome many of these barriers to the implementation of firearm injury and mortality prevention strategies. The most common reason cited for lack of firearm safety counseling during office visits is unfamiliarity with firearms and safety devices. (26)(44) Another review reported that clinicians who lacked formal training or felt that their patients were unlikely to follow their advice were least likely to provide firearm safety counseling. (45) Given the impact that firearm safety counseling has on improving safe storage practices and thereby preventing firearm injury, it is imperative that providers are educated on this topic to feel comfortable discussing firearm safety with their patients. (24)(25)(32)(33)(34) Studies demonstrate that education does improve clinical team members' ability to counsel on firearm safety. Workshop courses can be especially effective in increasing rates of firearm safety counseling among providers and trainees. Until recently, data on the effectiveness of educating providers on firearm injury and mortality prevention screening and counseling has been limited, with a systematic review in 2016 finding only 4 papers pertaining to this. (46) However, 2 institutions recently published their findings with respect to the effectiveness of educational workshops on improving resident comfort with firearm safety counseling. (47)(48)(49) One residency program found that after implementing a firearm safety counseling training session with their pediatrics residents they were 5 times more likely to discuss firearm safety than previously at 6-month follow-up. (47) This course consisted of training from a police officer on safe handling of firearm devices with videos and demonstrations, didactic discussion on the epidemiology of firearm injuries in children, and principles of counseling with role play practice scenarios. (47) The interactive nature of this workshop is especially helpful as the residents learn directly about guns and safety measures to improve their knowledge and comfort with the topic. Another institution completed a similar workshop course with didactics on epidemiology, lessons on firearm parts and safety features, and an interactive workshop. Residents report an increase in knowledge and skill, and there is significant improvement in documented counseling in office visits. Surveys of residencies in pediatrics, psychiatry, and family medicine report low rates of actual training for their residents, (45) indicating a need for more training and better resources. However, recent papers on quality improvement strategies such as recurrent resident education via noon conferences and grand rounds (49) and electronic medical record prompts (50) have shown that these strategies resulted in a better rate of firearm screening among pediatric residents at their hospitals. Hence, education can certainly serve to improve provider comfort in screening and counseling for firearm injury prevention.For providers to become confident in screening and counseling those at risk for firearm injury and violence, the acquisition of a new skill set of cultural competence around firearm-related injury prevention is also necessary. To build on this level competence, it is critical that health-care providers engage gun owners and community leaders throughout the process of educating and developing and implementing firearm injury prevention strategies. Collaboration with gun owners to learn effective storage strategies for different types of guns may help build physician confidence in counseling, encourage better rapport with gun-owning patients, and help promote change in patient behavior with credible suggestions. (5)(35)(38) Increased knowledge on the types of firearms, how they are operated, and how safety devices are used will undoubtedly increase provider comfort and confidence in talking about firearm safety. Similarly, engaging community voices, including schools, faith-based organizations, and members from communities that experience high rates of firearm violence, is a crucial component of developing the cultural competence necessary to talk to patients about firearm safety and firearm injury prevention. (51) Community-based collaborations serve to empower and educate clinical team members on how to have conversations with patients about gun violence while also serving to ensure that appropriate bridges are built to provide at-risk patients with community resources they may need.Although health-care–driven screening and counseling to prevent firearm injury and mortality is critical, it is only 1 piece of a much larger strategy involving health-care organizations and communities of physicians, clinicians, patients, and advocates to address this public health issue. Important steps in approaching firearm injury prevention as a health-care issue include surveillance, the identification of risk and protective factors, the implementation of preventive strategies, and their subsequent evaluation. (52) The benefit of framing firearm injury and violence as a public health issue is that it allows for a clear framework to study this epidemic, the implementation of preventive strategies that improve community health as a whole, and a multipronged approach to this crisis from an apolitical, harm reduction viewpoint focused solely on injury prevention and safety.Many large medical associations have published position statements on firearm injury and mortality prevention, emphasizing the importance of approaching this as a health-care issue. (5) In 2012 the American Academy of Pediatrics updated its policy statement on firearm-related injuries to children, (53) and in 2018 the American Pediatric Surgical Association updated its position statement. (54) Both organizations provide statements on governmental policies and regulations as well as statements focusing on empowering physicians to address firearm-related injury and mortality as an injury prevention health-care issue and strategies to do so. These statements are summarized in Table 3.For the first time in decades, federal funding for research on firearm injury and mortality prevention is available. This presents a unique opportunity for pediatric providers to conduct firearm injury prevention research to address the many knowledge gaps that exist with respect to risk factors for firearm injury, the effectiveness of preventive strategies, and facilitators and barriers to the implementation of firearm injury and mortality prevention strategies in health-care settings. Although research priorities are wide reaching, a focus on the study of implementation of firearm-related injury and mortality prevention strategies concurrently with evaluating outcomes and effectiveness of evidence-based strategies is paramount.Research is required to further evaluate the effectiveness of safe storage counseling and other health-care firearm injury prevention strategies with respect to not only positive behavior change but also downstream reductions in firearm injuries. A multicenter safety intervention by pediatric surgeons showed that 63% of parents who viewed a firearm safety module would change the way they stored their firearm. (12) Studies comparing firearm storage practices across regions that rigorously evaluate how these practices correlate with firearm-related injury rates are lacking and would help inform best practices.There is also an opportunity to screen patients for their firearm and interpersonal violence risk using violence risk prediction models such as the SaFETy (serious fighting, friend weapon carrying, community environment, and firearm threats) score. (55) One study found that 59% of assaulted drug-using adolescents and young adults (age 14–24 years) who received care in an emergency department reported firearm aggression, victimization, or injury within 2 years of the initial visit. (56) Implementing brief intervention techniques during their initial hospital encounter that focus on mental health, drug use, and violence prevention may deter future events associated with firearms.Immediate actionable steps for pediatricians include awareness of the health issue of firearm injury and its incorporation into their practice to learn about prevention strategies and counseling. Physicians can, and should, educate themselves on their role in firearm injury prevention with their individual patients. Medical governing organizations, academic hospitals, and residency training programs can develop teaching and coaching for physicians to be able to better incorporate firearm safety into their daily practice. Importantly, common sense policy measures will be critical to achieve long-term success in preventing firearm injuries as part of a holistic public health approach. Further evaluation of the effectiveness of CAP laws and ERPOs to promote firearm safety and prevent firearm injury would lend further weight to having these policies be a part of the education offered to patients.Integrate screening for firearm access and firearm injury risk into your routine practice by incorporating this conversation into home safety hazard and injury prevention discussions about risk factors such as motor vehicle safety, drowning avoidance, and helmet wearing.Use the 5 Ls—locked, loaded, little children, feeling low, and learned owner—to guide counseling on firearm safety.Approach all discussions about firearms empathetically and without judgment to encourage open discussion with patients.Attend workshops and training programs to learn more about firearm injury and mortality prevention, firearm safe storage practices, and firearm safety counseling tips.Work collaboratively with colleagues and stakeholders in the health-care setting to improve chances for successful implementation.Collaborate with community members, such as gun owners and members from communities at risk, in developing the culturally competent education needed to increase provider comfort in talking to patients about firearm injury prevention. This will also allow for the provision of community resources to those at risk.You can find the teaching slides that accompany this article on the Views>Supplementary Data option in the online article toolbar.

Objective To determine whether procedure-specific provider volume is associated with outcomes for patients undergoing repair of pectus excavatum at tertiary care children's hospitals. Study design We performed a cohort study of patients undergoing repair of pectus excavatum between January 1, 2013 and December 31, 2019, at children's hospitals using the Pediatric Health Information System database. The main exposures were the pectus excavatum repair volume quartile of the patient's hospital and the pectus excavatum repair volume category of their surgeon. Our primary outcome was surgical complication, identified using International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, Clinical Modification codes from Pediatric Health Information System. Secondary outcomes included high-cost admission and extended length of stay. Results In total, 7183 patients with an average age of 15.2 years (SD 2.0), 83% male, 74% non-Hispanic White, 68% no comorbidities, 72% private insurance, and 82% from metro areas were analyzed. Compared with the lowest-volume (<= 10 cases/year) quartile of hospitals, patients undergoing repair of pectus excavatum at hospitals in the second (>10-18 cases/year), third (>18-26 cases/year), and fourth (>26 cases/year) volume quartiles had decreased odds of complication of OR 0.52 (CI 0.34-0.82), 0.51 (CI 0.33-0.78), and 0.41 (CI 0.27-0.62), respectively. Patients with pectus excavatum who underwent repair by surgeons in the second (>1-5 cases/year), third (>5-10 cases/year), and fourth (>10 cases/year) volume categories had decreased odds of complication of OR 0.91 (CI 0.68-1.20), OR 0.73 (CI 0.51-1.04), and OR 0.55 (CI 0.39-0.76), respectively, compared with the lowest-volume (<= 1 case/year) category of surgeons. Conclusions Procedure-specific case volume is an important factor when considering providers for elective surgery, even among specialized centers providing comprehensive patient care.

Background: There is wide variability and considerable controversy regarding the classification of appendicitis and the need for postoperative antibiotics. This study aimed to assess interrater agreement with respect to the classification of appendicitis and its influence on the use of postoperative antibiotics amongst surgeons and surgical trainees. Methods: A survey comprising 15 intraoperative images captured during appendectomy was distributed to surgeons and surgical trainees. Participants were asked to classify severity of disease (normal, inflamed, purulent, gangrenous, perforated) and whether they would prescribe postoperative antibiotics. Statistical analysis included percent agreement, Krippendorff's alpha for interrater agreement, and logistic regression. Results: In total, 562 respondents completed the survey: 206 surgical trainees, 217 adult surgeons, and 139 pediatric surgeons. For classification of appendicitis, the statistical interrater agreement was highest for categorization as gangrenous/perforated versus nongangrenous/nonperforated (Krippendorff's alpha = 0.73) and lowest for perforated versus nonperforated (Krippendorff's alpha = 0.45). Fourteen percent of survey respondents would administer postoperative antibiotics for an inflamed appendix, 44% for suppurative, 75% for gangrenous, and 97% for perforated appendicitis. Interrater agreement of postoperative antibiotic use was low (Krippendorff's alpha = 0.28). The only significant factor associated with postoperative antibiotic utilization was 16 or more years in practice. Conclusions: Surgeon agreement is poor with respect to both subjective appendicitis classification and objective utilization of postoperative antibiotics. This survey demonstrates that a large proportion (59%) of surgeons prescribe antibiotics after nongangrenous or nonperforated appendectomy, despite a lack of evidence basis for this practice. These findings highlight the need for further consensus to enable standardized research and avoid overtreatment with unnecessary antibiotics. (C) 2021 Elsevier Inc. All rights reserved.

INTRODUCTION:Intraabdominal abscesses (IAA) are a common complication following appendectomy. Empiric antibiotic regimens may fail to prevent IAA due to changes in bacterial resistance. We aim to describe the bacteriology of pediatric patients requiring drainage of an IAA after an appendectomy for appendicitis. METHODS:We performed a retrospective study of patients ≤18 years who underwent percutaneous drainage of an IAA following appendectomy a single U.S. children's hospital between 2015 and 2018. Patient demographics, appendicitis characteristics, antibiotic regimens, and culture data were collected. RESULTS:In total, 71 patients required drainage of an IAA of which 48 (67%) were male, the average age was 9.81 (SD 3.31) years and 68 (95.7%) having complicated appendicitis. Ceftriaxone/metronidazole was the most common empiric regimen prior to IAA drainage occurring in 64 (90.1%) patients. IAA cultures isolated organisms in 34 (47.9%) patients. Of those with positive cultures, 17 (50%) cases demonstrated an antimicrobial resistant organism. Most notably, 20% of Escherichia coli was resistant to the empiric regimen. Empiric antimicrobial regimens did not appropriately cover 92.3% of Pseudomonas aeruginosa cultures or 100% of Enterococcus species cultures. Antimicrobial regimens were changed following IAA drainage in 30 (42.2%) instances with 23 (32.4%) instances due to resistance in culture results or lack of appropriate empiric antimicrobial coverage. CONCLUSIONS:IAA culture data following appendectomy for appendicitis frequently demonstrates resistance to or lack of appropriate coverage by empiric antimicrobial regimens. These data support close review of IAA culture results to identify prevalent resistant pathogens along with local changes in resistance. LEVEL OF EVIDENCE:Level III.

McMahon, Maxwell BS; Ott, Katherine MD; Vacek, Jonathan MD, MS; Hu, Andrew MBBS; De Boer, Chris MD; Linton, Samuel MD; Bouchard, Megan E. MD; Hu, Yue-Yung MD, MPH; Raval, Mehul V. MD, MS; Goldstein, Seth D. MD, MPhil Author Information

Background: In 2012, the American Academy of Pediatrics (AAP) concluded the health benefits of circumcision during the neonatal period outweigh the risks, a shift from its 1999 statement. The national trends for circumcisions since 2012 are unclear. Herein, we describe trends in male circumcision in US pediatric hospitals. Methods: Using the …

Background: Burn injuries are a major cause of morbidity and mortality within lowand middle-income countries (LMICs). The World Health Organization developed the Global Burn Registry to centralize data collection for the guidance of burn prevention programs. This study analyzed the epidemiologic and hospital-specific factors associated with burn injury outcomes in LMICs and high-income countries (HICs). Methods: A retrospective review was performed using the Global Burn Registry over 3 y. Patients were stratified by income region. Bivariate analyses and stepwise regressions were performed to evaluate patient and hospital demographics and variables associated with injury patterns and outcomes. Outcomes of interest included mortality and length of stay. Results: Over the study period, data were collected on 1995 patients from 10 LMICs (20 hospitals) and four HICs (four hospitals). Significantly higher mortality was seen in LMICs compared with HICs (17% versus 9%; P < 0.001). There was no significant difference between income regions for injury patterns (P = 0.062) or total body surface area of the burn injury (P = 0.077). Of the LMIC hospitals in this data set, 11% did not have reliable access to an operating theater. Conclusions: HICs had a lower overall mortality even with higher rates of concurrent injuries, as well as longer length of stay. LMIC hospitals had fewer resources available, which could explain increased mortality, given similar total body surface area. This study highlights how investing in health care infrastructure could lead to improved outcomes for patients in low-resource settings. (c) 2020 Elsevier Inc. All rights reserved.

BACKGROUND:Preoperative physical activity (PA) is an important reference point to evaluate recovery, yet is not attainable for emergent surgical admissions. We investigated the validity of PA of healthy children recruited from within the same community as surgical patients and a nationally representative sample as alternative baseline PA for pediatric surgical patients. METHODS:Patients undergoing an elective operation were matched to community-recruited healthy controls (CRHC) on sex, age, and weight, and their PA was assessed using an Actigraph accelerometer. National Health and Nutrition Examination Survey (NHANES) Actigraph PA data were used as a nationally representative match for baseline PA. Surgical patients wore the accelerometer for 2 days preoperatively, CRHC for 2 days, and NHANES participants for 7 days. PA was categorized as light (LPA) or moderate vigorous (MVPA). Means were compared between the 3 groups. RESULTS:Thirty patients were matched with 80 CRHC and 3147 NHANES participants. LPA was similar between surgical patients and CRHC. However, CRHC averaged 19 min/day more MVPA than surgery patients (p = 0.04), and both groups averaged 58 min and 67 min/day higher MVPA than the matched NHANES sample, respectively (p < 0.01). CONCLUSIONS:CRHC LPA was similar to preoperative LPA in surgical patients and may be an alternative. LEVEL OF EVIDENCE:Level II.

Background: Symptoms including chest pain and palpitations are commonly described by pediatric patients with pectus deformity. Cardiac anomalies are thought to be less common in patients with pectus carinatum (PC) than those in patients with pectus excavatum; however, no literature supports this presumption. Echocardiogram (echo) assesses heart structure and function. We hypothesized that a screening echo would 1) determine the relationship between symptoms and echo findings and 2) define the incidence of cardiac defects in patients with PC. Materials and methods: This is an institutional review boardeapproved retrospective review of all patients with PC who received an echo from 2015 to 2019 at a tertiary care children's hospital. Echo findings and patient-reported symptoms were collected from electronic health records. Descriptive statistics were used to assess correlation between findings. Results: We identified 155 patients with PC who received an echo with complete data available for analysis. Of these, 44 (28.4%) reported chest pain and 13 (8.4%) reported palpitations. Echo results showed that five patients (3.2%) had mitral valve prolapse and 11 (7.1%) had aortic root dilation. Patient-reported symptoms were not significantly associated with abnormal echo findings. Conclusions: Chest pain and palpitations frequently occur in the PC population but may not be related to abnormal echo findings. We recommend screening echo in patients with PC regardless of symptoms. (C) 2020 Elsevier Inc. All rights reserved.

BackgroundEnhanced recovery protocols (ERPs) have been used to improve patient outcomes and resource utilization after surgery. These evidence-based interventions include patient education, standardized anesthesia protocols, and limited fasting, but their use among pediatric populations is lagging. We aimed to determine baseline recovery practices within pediatric surgery departments participating in an ERP implementation trial for elective inflammatory bowel disease (IBD) operations.MethodsTo measure baseline ERP adherence, we administered a survey to a staff surgeon in each of the 18 participating sites. The survey assessed demographics of each department and utilization of 21 recovery elements during patient encounter phases. Mixed-methods analysis was used to evaluate predictors and barriers to ERP element implementation.ResultsThe assessment revealed an average of 6.3 ERP elements being practiced at each site. The most commonly practiced elements were using minimally invasive techniques (100%), avoiding intraabdominal drains (89%), and ileus prophylaxis (72%).The preoperative phase had the most elements with no adherence including patient education, optimizing medical comorbidities, and avoiding prolonged fasting. There was no association with number of elements utilized and total number of surgeons in the department, annual IBD surgery volume, and hospital size. Lack of buy-in from colleagues, electronic medical record adaptation, and resources for data collection and analysis were identified barriers.ConclusionsHigher intervention utilization for IBD surgery was associated with elements surgeons directly control such as use of laparoscopy and avoiding drains. Elements requiring system-level changes had lower use. The study characterizes the scope of ERP utilization and the need for effective tools to improve adoption.Level of evidenceLevel III.Type of studyMixed-methods survey.

Objective: To examine the association between prolonged in-hospital time to appendectomy (TTA) and the risk of complicated appendicitis. Summary Background Data: Historically, acute appendicitis was treated with emergency appendectomy. More recently, practice patterns have shifted to urgent appendectomy, with acceptable in-hospital delays of up to 24 hours. However, the consequences of prolonged TTA remain poorly understood. Herein, we present the largest individual analysis to date of outcomes associated with prolonged in-hospital delay before appendectomy in children. Methods: Data from patients who underwent appendectomy within 24 hours of hospital presentation were obtained from the American College of Surgeons Pediatric National Surgical Quality Improvement Program Procedure Targeted Appendectomy database from 2016 to 2018. Appendectomy within 16 hours of presentation was considered early, whereas those between 16 to 24 hours were defined as late. The primary outcome was operative findings of complicated appendicitis. Secondary outcomes included 30-day complications and resource utilization. Results: This study consisted of 18,927 patients, with 20.6% undergoing late appendectomy. The rate of complicated appendicitis was significantly higher in the late group (Early: 26.3%, Late: 30.3%, P < 0.05). Additionally, the late group had longer operative times, increased need for postoperative percutaneous drainage, antibiotics at discharge, parenteral nutrition, and an extended hospital length of stay (P < 0.05). On multivariate analysis, late appendectomy remained a predictor of complicated disease (odds ratio 1.17 [95% confidence interval, 1.08–1.27]). Conclusions: A significant proportion of pediatric patients with acute appendicitis experience prolonged in-hospital delays before appendectomy, which are associated with modestly increased rates of complicated appendicitis. Although this does not indicate appendectomy needs to be done emergently, prolonged in-hospital TTA should be avoided whenever possible.

Vacek, Jonathan MD; Rizeq, Yazan K. BS; Many, Benjamin T. MD; Raval, Mehul V. MD, FACS; Abdullah, Fizan MD, FACS; Goldstein, Seth MD Author Information

Background: There is an increasing national trend toward initial venovenous (VV) extracorporeal membrane oxygenation (ECMO) for infants and children with respiratory disease; however, some proportion of patients initiated on VV ECMO will ultimately require conversion to venoarterial (VA) support for circulatory augmentation. The purpose of this work is to describe patients who required conversion from VV to VA ECMO and to highlight the increased mortality in this population. Materials and methods: Demographic and disease-specific data on children who underwent VV-to-VA ECMO conversion were extracted from the Extracorporeal Life Support Organization registry. Survival comparisons to age-matched patients undergoing unconverted ECMO runs were made using the 2016 Extracorporeal Life Support Organization International Summary report. The relative risk (RR) of death associated with VV-to-VA conversion was calculated, and statistical analysis of survival was performed using a chi-squared test with P < 0.05 for significance. Results: This study cohort consisted of 1382 patients who required VV-to-VA conversion. The overall hospital survival rate for neonates requiring conversion was 60%, compared with 83% for unconverted VV runs and 64% for unconverted VA runs (RR 1.23; 95% confidence interval, 1.14-1.34). Similarly, the survival of older children requiring conversion was 46% compared with 66% and 51%, respectively (RR 1.16; 95% confidence interval, 1.06-1.27). Conclusions: VV-to-VA conversion does occur and is associated with increased mortality. The need for conversion from VV to VA ECMO may represent an early failure to recognize physiologic parameters or disease severity that would be better managed with initial VA support. Further research is needed to pinpoint the cause of increased mortality and to identify predictors of VV failure to optimize initial mode selection. (C) 2019 Elsevier Inc. All rights reserved.