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We analyzed the impact of treating center designation and case volume of penetrating trauma on outcomes after pediatric penetrating thoracic injuries (PTI).PTI patients18 years were identified from the National Trauma Data Bank (2013-2016). Centers were categorized by type (Pediatric or Adult) and designation status (Level I, Level II, and other). Performance was calculated as the difference between observed and expected mortality and standardized using the total penetrating trauma volume per center. Expected mortality was calculated using the Trauma Mortality Prediction Model. Pearson correlation and linear mixed-effects models evaluated the association between variables and performance.We identified 4,134 PTI patients treated at 596 trauma centers: 879 (21%) at Adult Level I, 608 (15%) at Adult Level II, 531 (13%) at Pediatric Level I, 320 (8%) at Pediatric Level II, and 1,796 (43%) at other centers. Primary injury mechanisms were firearm-related (58%) and cut/piercing (42%). Overall mortality was 16% and median predicted mortality was 3.6% (IQR: 1.5% - 11.2%). Among patients with thoracic firearm-related injuries, centers with lower penetrating case volume and total trauma care demonstrated significantly worse outcomes. Multivariable analysis revealed Adult Level I centers had superior outcomes compared with all other non-Level I centers. There was no difference in mortality between Pediatric and Adult Level I centers.Adult Level I trauma center designation and annual case volume of penetrating thoracic trauma are associated with improved mortality after pediatric firearm-related thoracic injuries. Further study is needed to identify factors in higher volume centers that improve outcomes.Level III.

To identify patient factors associated with improper restraint usage and worse trauma outcomes for pediatric patients involved in motor vehicle collisions (MVCs).Retrospective study performed at a Level I pediatric trauma center for patients (≤18 yr) evaluated after MVC between 2008 and 2018. The Area Deprivation Index (ADI) was used to measure neighborhood socioeconomic disadvantage (NSD) levels based on the patient's home address. Trauma registry data was correlated to ADI and used to analyze appropriate restraint usage by NSD. Proper restraint practices were defined based on national guidelines and state laws. Demographics and clinical outcomes were also analyzed. Chi-square analysis with Bonferroni corrections was used to assess the association of ADI, race, and ethnicity with proper restraint usage.Among 1152 patients included, approximately 50% were male, the median age was 7 years [IQR 4-10], and 53% were of Hispanic ethnicity. Hispanic patients comprised 73% of children in ADI quintile 5 (greatest NSD), yet only 26% of children in ADI quintile 1 (least NSD). No differences were observed across clinical data and outcomes. Hispanic children8 yr were significantly less likely to be in a car seat/booster seat compared to non-Hispanic children (OR 0.69, 95% CI 0.50-0.95, p = 0.025). Furthermore, those with greatest NSD (ADI quintile 5) had the largest proportion of unrestrained patients (21%, see Fig. 1).Hispanic children, especially those who require infant or booster seats (8 yr), and children living in areas with greater neighborhood socioeconomic disadvantage demonstrated poorer restraint practices. ADI can successfully identify high-risk groups for targeted injury prevention programs and improved compliance in the most vulnerable neighborhoods.Retrospective Study.

Electronic cigarettes (e-cigarettes) are handheld, battery-powered vaporizing devices. It is estimated that more than 25% of youth have used these devices recreationally. While vaping-associated lung injury is an increasingly recognized risk, little is known about the risk of traumatic injuries associated with e-cigarette malfunction.A multi-institutional retrospective study was performed by querying the electronic health records at nine children's hospitals. Patients who sustained traumatic injuries while vaping from January 2016 through December 2019 were identified. Patient demographics, injury characteristics, and the details of trauma management were reviewed.15 children sustained traumatic injuries due to e-cigarette explosion. The median age was 17 y (range 13-18). The median injury severity score was 2 (range 1-5). Three patients reported that their injury coincided with their first vaping experience. Ten patients required hospital admission, three of whom required intensive care unit admission. Admitted patients had a median length of stay of 3 d (range 1-6). The injuries sustained were: facial burns (6), loss of multiple teeth (5), thigh and groin burns (5), hand burns (4), ocular burns (4), a radial nerve injury, a facial laceration, and a mandible fracture. Six children required operative intervention, one of whom required multiple operations for a severe hand injury.In addition to vaping-associated lung injury, vaping-associated traumatic injuries are an emerging and worrisome injury pattern sustained by adolescents in the United States. This report highlights another means by which e-cigarettes pose an increasing risk to a vulnerable youth population.

The purpose of this work was to obtain an elastic composite material from polymer powders (polyurethane and polypropylene) with the addition of BaTiO3 until 35% with tailored dielectric and piezoelectric features. The filament extruded from the composite material was very elastic but had good features to be used for 3D printing applications. It was technically demonstrated that the 3D thermal deposition of composite filament with 35% BaTiO3 was a convenient process for achieving tailored architectures to be used as devices with functionality as piezoelectric sensors. Finally, the functionality of such 3D printable flexible piezoelectric devices with energy harvesting features was demonstrated, which can be used in various biomedical devices (as wearable electronics or intelligent prosthesis), generating enough energy to make such devices completely autonomous only by exploiting body movements at variable low frequencies.

Introduction The purpose of this study was to evaluate the use of a cadaveric teaching model for needle compression of pneumothorax simulated by thoracoscopy. Materials and methods A standardized didactic instruction was provided to medical personnel participants at a single institution tertiary medical center. A thoracoscope was inserted into cadavers and insufflated to 20 mm Hg for simulation of a tension pneumothorax. The study participants performed six needle decompressions (3 anterior, 3 lateral), which were all directly observed thoracoscopically. Demographic data and post-surveys were obtained. The primary endpoint was participant assessment of this teaching model for a simulated pneumothorax. Secondary endpoints were successful decompression of the pneumothorax, perceived success of each attempt, and injury to intrathoracic structures. Results Forty participants completed 240 attempted decompressions. Participants reported that 43% had taken ATLS, and 63% had performed a needle decompression on a simulated patient prior to this study. The rate of successful decompressions was 85.86%. Participants reported a perceived successful completion rate of 82%. 73.7% performed this safely, while 88.5% perceived that they performed it safely. 85.7% stated that they felt more confident and capable after the study. Conclusion A simulated model is essential for adequate teaching. Our use of a thoracoscopic cadaveric model provides a realistic simulation of the pneumothorax used for training. Participants had similar rates of actual completion and perceived completion including higher rates of perceived safety. Further use of this model as a teaching tool will potentially improve the success of this life-saving procedure.

Dielectric properties for nanocomposites with metallic fillers inside a polymer matrix were determined using CST STUDIO SUITE—Electromagnetic field simulation software followed by the free-space Nicolson–Ross–Weir procedure. The structure is randomly generated to simulate the intrinsic non-uniformity of real nanomaterials. Cubic insertions were equated to corresponding spherical particles in order to provide either the same volume index or the same exterior surface index. The energy concentration around the inserts and within the entire material was determined as useful information in practice in order to design materials tailored to avoid exceeding the field/temperature limit values. The paper successfully associated the dialectic measurements with the results from the computer simulations, which are mainly based on energetic effects in electromagnetic applications. The experimental results are comparable with the software simulation in terms of precision. The conclusions outline the practical applications of the method for both electromagnetic shielding and microwave domain/telecommunications applications.

The California-Mexico border region is a high-volume trauma area with populations of widely disparate socioeconomic status. This work analyzed differences in demographics and mechanism of injury in children using the Area Deprivation Index (ADI), a composite measure of 17 markers of neighborhood socioeconomic disadvantage.A retrospective review was performed of pediatric patients evaluated at the regional Level I Pediatric Trauma Center between 2008 and 2018. Collected data included patient demographics and injury characteristics. Patient addresses were correlated to neighborhood disadvantage level using ADI quintiles, with a higher quintile representing greater socioeconomic disadvantage.A total of 9,715 children were identified, of which 4,307 (44%) were Hispanic. Hispanic children were more likely to live in more disadvantaged neighborhoods than non-Hispanic children (p0.001). There were markedly different injury mechanisms in neighborhoods with greater socioeconomic disadvantage (higher ADI) compared with those with less socioeconomic disadvantage. Sports-related and nonmotorized vehicular trauma predominated in less disadvantaged neighborhoods, while higher ADI quintiles were strongly associated with pedestrian versus automobile, motorized vehicle accidents/collisions, and nonaccidental injuries (p0.001).This analysis represents the first study to characterize pediatric traumatic injury patterns based upon the neighborhood ADI metric. Area Deprivation Index can be a useful resource in identifying disparities in pediatric trauma and children at increased risk for vehicular and abusive injury who may benefit from increased resource allocation, social support, and prevention programs.Prognostic and epidemiological, Level III.

Background Pediatric surgeons are often asked to treat clinical problems for which little high-quality data exist. For adults with adhesive small bowel obstruction (ASBO), water soluble contrast-based protocols are used to guide management. Little is known about their utility in children. We aimed to better understand key factors in clinical decision-making processes and integration of adult based data in pediatric surgeon's approach to ASBO. Methods We administered a web-based survey to practicing pediatric surgeons at institutions comprising the Western Pediatric Surgery Research Consortium. Results The response rate was 69% (78/113). Over half of respondents reported using contrast protocols to guide ASBO management either routinely or occasionally (n = 47, 60%). Common themes regarding the incorporation of adult-based data into clinical practice included the need to adapt protocols for pediatric patients, the dearth of pediatric specific data, and the quality of the published adult evidence. Conclusions Our findings demonstrate that pediatric surgeons use contrast-based protocols for the management of ASBO despite the paucity of pediatric specific data. Furthermore, our survey data help us understand how pediatric surgeons incorporate adult based evidence into their practice.

An institution's programs, activities, initiatives, and other institutionally-related undertakings would be transformed into the most renowned globally-acknowledged worldwide standards in light of the vision-mission. The survey on the awareness and acceptability of the University's Revised Vision-Mission, as well as the College of Teacher Education and Graduate School Program Goals and Program Objectives and Outcomes, demonstrates the awareness and acceptability of the University's Vision, Mission, Goals, and Objectives, as well as the University Core Values. It also includes translations of the new vision and mission from English to Vietnamese, Korean, Filipino, Ilocano, and Ibanag by the statekholders of the new vision and purpose. Significantly, by translating the VGMO, the university is expanding worldwide, emphasizing the importance of academic and community effort as it materializes the programs that will propel the institution forward.

BackgroundSurgical care is an important, yet often neglected component of child health in low- and middle-income countries (LMICs). This study examines the potential impact of scaling up surgical care at first-level hospitals in LMICs within the first 20years of life.MethodsEpidemiological data from the global burden of disease 2019 Study and a counterfactual method developed for the disease control priorities; 3rd Edition were used to estimate the number of treatable deaths in the under 20year age group if surgical care could be scaled up at first-level hospitals. Our model included three digestive diseases, four maternal and neonatal conditions, and seven common traumatic injuries.ResultsAn estimated 314,609 (95% UI, 239,619-402,005) deaths per year in the under 20year age group could be averted if surgical care were scaled up at first-level hospitals in LMICs. Most of the treatable deaths are in the under-5year age group (80.9%) and relates to improved obstetrical care and its effect on reducing neonatal encephalopathy due to birth asphyxia and trauma. Injuries are the leading cause of treatable deaths after age 5years. Sixty-one percent of the treatable deaths occur in lower middle-income countries. Overall, scaling up surgical care at first-level hospitals could avert 5·1% of the total deaths in children and adolescents under 20years of age in LMICs per year.ConclusionsImproving the capacity of surgical services at first-level hospitals in LMICs has the potential to avert many deaths within the first 20years of life.

The researchers are interested in finding out the correlation of online learning and academic achievement of First Year Bachelor of Secondary Education (BSEd) Major in English of Mindoro State University (MinSU), specifically the students’ level of performance of students in online learning in terms of: quizzes, major examinations, performance tasks, and recitation. The data revealed that the level of writing skills of first year BSED Majors who used the pen-and-paper method in terms of spelling, vocabulary, and sentence structure was high, all with average scores of 11. On the other hand, the results showed that the level of writing skills of first year BSED Majors who used Microsoft Teams was very high in terms of spelling, with an average score of 14, and high in terms of vocabulary and sentence structure, with both average scores of 12. The computed p-value between the Microsoft Teams spelling and pen-and-paper method spelling was 0.001. In terms of Microsoft Teams vocabulary and pen-and-paper method vocabulary, the p-value was 0.004. Lastly, the computed pvalue between the Microsoft Teams sentence structure and pen-and-paper method sentence structure was 0.002. Based on the results, the computed p values of the three variables were less than the critical value at the 0.05 level of significance. Therefore, the null hypothesis of no significant difference was rejected. The findings revealed that there was a significant difference in the level of writing skills between first year BSED Majors who used the pen-andpaper method and those who used Microsoft Teams in terms of spelling, vocabulary, and sentence structure.

In this paper, the obtaining and characterization of five experimental models of novel polymer composite materials with ferrite nano-powder are presented. The composites were obtained by mechanically mixing two components and pressing the obtained mixture on a hot plate press. The ferrite powders were obtained by an innovative economic co-precipitation route. The characterization of these composites consisted of physical and thermal properties: hydrostatic density, scanning electron microscopy (SEM), and TG DSC thermal analyses, along with functional electromagnetic tests in order to demonstrate the functionality of these materials as electromagnetic shields (magnetic permeability, dielectric characteristics, and shielding effectiveness). The purpose of this work was to obtain a flexible composite material, applicable to any type of architecture for the electrical and automotive industry, necessary for protection against electromagnetic interference. The results demonstrated the efficiency of such materials at lower frequencies, but also in the microwave domain, with higher thermal stability and lifetime.

A major challenge in developing biomimetic, high-performance, and sustainable products is the accurate replication of the biological materials' striking properties, such as high strength, self-repair, and stimuli-responsiveness. The rationalization of such features on the microscopic scale, together with the rational design of synthetic materials, is currently hindered by our limited understanding of the sequence-structure-property relationship. Here, employing state-of-the-art nuclear magnetic resonance (NMR) spectroscopy, we link the atomistic structural and dynamic properties of an artificial bioinspired tandem repeat protein TR(1,11) to its stunning macroscopic properties including high elasticity, self-healing capabilities, and record-holding proton conductivity among biological materials. We show that the hydration-induced structural rearrangement of the amorphous Gly-rich soft segment and the ordered Ala-rich hard segment is the key to the material's outstanding physical properties. We found that in the hydrated state both the Ala-rich ordered and Gly-rich disordered parts contribute to the formation of the nanoconfined β-sheets, thereby enhancing the strength and toughness of the material. This restructuring is accompanied by fast proline ring puckering and backbone cis-trans isomerization at the water-protein interface, which in turn enhances the elasticity and the thermal conductivity of the hydrated films. Our in-depth characterization provides a solid ground for the development of next-generation materials with improved properties.

BACKGROUND: Surgical care is an important, yet often neglected component of child health in low- and middle-income countries (LMICs). This study examines the potential impact of scaling up surgical care at first-level hospitals in LMICs within the first 20 years of life. METHODS: Epidemiological data from the global burden of disease 2019 Study and a counterfactual method developed for the disease control priorities; 3rd Edition were used to estimate the number of treatable deaths in the under 20 year age group if surgical care could be scaled up at first-level hospitals. Our model included three digestive diseases, four maternal and neonatal conditions, and seven common traumatic injuries. RESULTS: An estimated 314,609 (95% UI, 239,619-402,005) deaths per year in the under 20 year age group could be averted if surgical care were scaled up at first-level hospitals in LMICs. Most of the treatable deaths are in the under-5 year age group (80.9%) and relates to improved obstetrical care and its effect on reducing neonatal encephalopathy due to birth asphyxia and trauma. Injuries are the leading cause of treatable deaths after age 5 years. Sixty-one percent of the treatable deaths occur in lower middle-income countries. Overall, scaling up surgical care at first-level hospitals could avert 5·1% of the total deaths in children and adolescents under 20 years of age in LMICs per year. CONCLUSIONS: Improving the capacity of surgical services at first-level hospitals in LMICs has the potential to avert many deaths within the first 20 years of life.

IntroductionData examining rates of postoperative complications among SARS-CoV-2 positive children are limited. The purpose of this study was to evaluate the impact of symptomatic and asymptomatic SARS-CoV-2 positive status on postoperative respiratory outcomes for children.MethodsThis retrospective cohort study included SARS-CoV-2 positive pediatric patients across 20 hospitals who underwent general anesthesia from March to October 2020. The primary outcome was frequency of postoperative respiratory complications, including: high-flow nasal cannula/non invasive ventilation, reintubation, pneumonia, Extracorporeal Membrane Oxygenation (ECMO), and 30-day respiratory-related readmissions or emergency department (ED) visits. Univariate analyses were used to evaluate associations between patient and procedure characteristics and stratified analyses by symptoms were performed examining incidence of complications.ResultsOf 266 SARS-CoV-2 positive patients, 163 (61.7%) were male, and the median age was 10 years (interquartile range 4-14). The majority of procedures were emergent or urgent (n=214, 80.5%). The most common procedures were appendectomies (n=78, 29.3%) and fracture repairs (n=40,15.0%). 13 patients (4.9%) had preoperative symptoms including cough or dyspnea. 26 patients (9.8%) had postoperative respiratory complications, including 15 requiring high-flow oxygen, 8 with pneumonia, 4 requiring non invasive ventilation, 3 respiratory ED visits, and 2 respiratory readmissions. Respiratory complications were more common among symptomatic patients than asymptomatic patients (30.8% vs. 8.7%, p=0.01). Higher ASA class and comorbidities were also associated with postoperative respiratory complications.ConclusionsPostoperative respiratory complications are less common in asymptomatic versus symptomatic SARS-COV-2 positive children. Relaxation of COVID-19-related restrictions for time-sensitive, non urgent procedures in selected asymptomatic patients may be reasonably considered. Additionally, further research is needed to evaluate the costs and benefits of routine testing for asymptomatic patients.Level of evidenceIii, Respiratory complications.

Surgical care is an important, yet often neglected component of child health in low- and middle-income countries (LMICs). This study examines the potential impact of scaling up surgical care at first-level hospitals in LMICs within the first 20 years of life.Epidemiological data from the global burden of disease 2019 Study and a counterfactual method developed for the disease control priorities; 3rd Edition were used to estimate the number of treatable deaths in the under 20 year age group if surgical care could be scaled up at first-level hospitals. Our model included three digestive diseases, four maternal and neonatal conditions, and seven common traumatic injuries.An estimated 314,609 (95% UI, 239,619-402,005) deaths per year in the under 20 year age group could be averted if surgical care were scaled up at first-level hospitals in LMICs. Most of the treatable deaths are in the under-5 year age group (80.9%) and relates to improved obstetrical care and its effect on reducing neonatal encephalopathy due to birth asphyxia and trauma. Injuries are the leading cause of treatable deaths after age 5 years. Sixty-one percent of the treatable deaths occur in lower middle-income countries. Overall, scaling up surgical care at first-level hospitals could avert 5·1% of the total deaths in children and adolescents under 20 years of age in LMICs per year.Improving the capacity of surgical services at first-level hospitals in LMICs has the potential to avert many deaths within the first 20 years of life.

For the emergence of life, the abiotic synthesis of RNA from its monomers is a central step. We found alkaline, uncatalysed drying conditions in bulk and at heated air-water interfaces where 2´,3´-cyclic nucleotides polymerised, forming up to 10-mers within a day. The polymerisation proceeded at a pH range of 7-12 at temperatures between 40-80 °C and was marginally enhanced by K+ ions. Among the canonical ribonucleotides, cGMP polymerised most efficiently. Quantification was performed using HPLC coupled to ESI-TOF by fitting the isotope distribution to the mass spectra. Our study suggests a polymerisation mechanism where cGMP aids the incorporation of the relatively unreactive nucleotides C, A and U. The 2´,3´-cyclic nucleotides are byproducts of prebiotic phosphorylation, nucleotide syntheses and RNA hydrolysis, indicating direct recycling pathways. The simple reaction condition offers a plausible entry point for RNA to the evolution of life on early Earth.

The purpose of this study was to identify clinical and traffic factors that influence pediatric pedestrian versus automobile collisions (P-ACs) with an emphasis on health care disparities.A retrospective review was performed of pediatric (18 years or younger) P-ACs treated at a Level I pediatric trauma center from 2008 to 2018. Demographic, clinical, and traffic scene data were analyzed. Area deprivation index (ADI) was used to measure neighborhood socioeconomic disadvantage (NSD) based on home addresses. Traffic scene data from the California Statewide Integrated Traffic Records System were matched to clinical records. Traffic safety was assessed by the streetlight coverage, the proximity of the collision to home addresses, and sidewalk coverage. Descriptive statistics and univariate analysis for key variables and outcomes were calculated using Kruskal-Wallis, Wilcoxon, χ 2 , or Fisher's exact tests. Statistical significance was attributed to p values of0.05.Among 770 patients, the majority were male (65%) and Hispanic (54%), with a median age of 8 years (interquartile range, 4-12 years). Hispanic patients were more likely to live in more disadvantaged neighborhoods than non-Hispanic patients (67% vs. 45%, p0.01). There were no differences in clinical characteristics or outcomes across ADI quintiles. Using the Statewide Integrated Traffic Records System (n = 272), patients with more NSD were more likely injured during dark streetlight conditions (15% vs. 4% least disadvantaged; p = 0.04) and within 0.5 miles from home ( p0.01). Pedestrian violations were common (65%). During after-school hours, 25% were pedestrian violations, compared with 12% driver violations ( p = 0.02).A larger proportion of Hispanic children injured in P-ACs lived in neighborhoods with more socioeconomic disadvantage. Hispanic ethnicity and NSD are each independently associated with P-ACs. Poor streetlight conditions and close proximity to home were associated with the most socioeconomically disadvantaged neighborhoods. This research may support targeted prevention programs to improve pedestrian safety in children.Prognostic/Epidemiological; Level IV.

Introduction For over 30 years, the USNS Mercy hospital ship has provided surgical care on multiple humanitarian aid and disaster relief missions. During these missions, surgical support varies according to host nation needs, and the operative treatment of cancer patients remains controversial. We report the number of incidentally discovered surgical oncologic cases treated aboard the USNS Mercy on four missions and discuss challenges regarding oncologic care on these missions. Materials and Methods Between 2008 and 2016, operative cases and surgical pathology results from four multinational humanitarian missions were analyzed according to organ system, patient’s geographic location, and diagnosis. Primary outcomes were total number and proportion of malignant cases, analyzed yearly and over all four missions. Secondary outcomes were malignant diagnoses by organ system and host nation health capacities (based on indicators from the WHO). Results A total of 2,767 operations were performed during 18 port visits in 8 countries in Southeast Asia. In total, 1,193 pathology specimens (surgical biopsies, fine needle aspirations, etc.) were obtained. Overall malignancy rate across all organ systems was 9%. Yearly malignancy rates ranged from 2% to 13%. The highest malignancy rates were found in thyroid (33%), breast (20%), and parotid and salivary gland cases (19%). All host nations had operational strategies for cancer in place (n = 8, 100%), but few had national infrastructures to treat noncommunicable diseases (n = 2, 25%). Conclusions Despite current policies to screen out cancer patients on USNS Mercy missions, 9% of surgical biopsies were malignant. Cancer management during these missions presents a unique challenge because of limited resources for surgery, chemoradiotherapy, and follow-up care. Contingency plans must be considered to provide completion of care for these patients whose cancers are discovered incidentally. Furthermore, an understanding of host nation capabilities in relation to medical and surgical care is crucial to providing treatment in resource-limited areas.

IntroductionDisease Control Priorities, 3rd Edition (DCP3) is an evidence-based, published resource that outlines essential procedures recommended for developing health care systems. These systems must consider various populations and the incidence of certain surgical conditions that require treatment. In relation to pediatric patients, the prevalence of certain surgical conditions encountered remains unclear in several low- and middle-income countries. Over the past 15 years, the USNS Mercy, one of the U.S. Navy’s large hospital ships, has led the Pacific Partnership missions, which provide large-scale humanitarian aid throughout Southeast Asia. The data collected during these missions provide an opportunity to analyze the scope of pediatric operations performed in resource-limited countries. This analysis may assist in future planning for specific needs during military humanitarian missions.Materials and MethodsSurgical case data were prospectively collected during the six Pacific Partnership missions from 2006 to 2018. Demographic data were analyzed for all patients ≤8 years of age who underwent an operation. These data were retrospectively reviewed and all case logs were categorized by mission year, procedure-type, and host nation. Operations were classified based on 44 essential operations delineated in DCP3. Primary outcome was incidence of DCP3 essential operations. Secondary outcomes were perioperative complications. Standard statistical methods were performed for descriptive analysis.ResultsA total of 3,209 major and minor operations were performed during 24 port visits in nine countries. Pediatric cases represented 1,117 (38%) of these procedures. Pediatric surgeons performed 291 (26%) of these cases. Based on DCP3 criteria, 789 pediatric operations (71%) were considered essential procedures. The most common DCP3-aligned procedures were cleft lip repair (432, 57%), hernia repair (207, 27%), and hydrocelectomy (60, 8%). Operative volume for pediatric surgery was highest during the 2008 mission (522 cases), when two pediatric surgeons were deployed, and lowest during the 2018 mission (five cases), when the mission focus was on education rather than surgical procedures and lack of pediatric cases referred by the host nation. Overall complication rate for pediatric cases was 1%.ConclusionsThis study represents the largest known analysis of military humanitarian assistance. Pediatric operations represented over one-third of the surgical volume during Pacific Partnership missions from 2006 to 2018. The majority of cases were DCP3-aligned and associated with a low complication rate. Future humanitarian aid missions and host nations should allocate appropriate medical and educational resources to treat DCP3 pediatric surgical diseases in low- and middle-income countries to support long-term capacity building while maintaining optimal surgical outcomes.

Background Emergency department thoracotomy (EDT) for pediatric patients is uncommon, and practice patterns have not been evaluated. We examined the indications and outcomes for EDT by trauma center designation using a nationwide database. Methods Patients 16 years or younger who underwent EDT within 30 minutes of arrival from 2013 to 2016 were identified in the American College of Surgeons National Trauma Data Bank. Patient demographic information, indications for EDT, and outcomes were analyzed. Outcomes were compared between centers with and without pediatric trauma center designation. Results A total of 114 patients were identified for analysis with a mean ± SD age of 10.3 ± 4.7 years. Patients were predominantly male (69%) with a median Injury Severity Score of 26 (interquartile range, 18-42). Penetrating trauma occurred in 56%. Overall, mortality was 90% and was similar in penetrating and blunt trauma (88% vs. 94%; p = 0.34). There were no survivors among the 53 patients (46%) who arrived with no signs of life. Among the 11 patients (10%) who survived, median length of stay was 26 days (interquartile range, 6-28 days). Overall, 8% of EDT was performed at free-standing pediatric trauma centers, 45% at adult centers, and 47% at combined trauma centers. Mortality rates and indications were similar among trauma centers regardless of designation status. Conclusion In a national population-based data set, the mortality after pediatric EDT is high, and many of these procedures are performed at nonpediatric trauma centers. Regardless of injury mechanism, EDT is not appropriate in children without signs of life on arrival. Pediatric guidelines are needed to increase awareness of the poor outcomes and limited indications for EDT. Level of evidence Therapeutic, level IV.

Background Humanitarian surgeons face many ethical challenges. Despite increasing resident participation during humanitarian activities, minimal literature exists describing premission ethics training. Methods A systematic literature review was conducted to identify publications on humanitarian surgery. A 3-tiered review was performed assessing for ethical conflicts and guidelines. A Humanitarian Ethics Curriculum (HEC) was developed based on these findings and administered to residents prior to a humanitarian mission. Postmission essays were assigned to describe an ethical dilemma they encountered. The HEC's value was evaluated by identifying the ACGME core competencies represented in the essays. Results 49 eligible publications were identified. Several areas of consensus were found. Controversies identified included: trainee involvement, surgical innovation, and operating on patients with dismal prognosis. All residents stated that the HEC was vital. 61% of ethical dilemmas involved surgical patients. Core competencies emphasized included systems-based practice, patient care, professionalism, interpersonal/communication skills, and medical knowledge. Conclusions There is consensus regarding ethical principles that surgeons should follow during humanitarian activities. However, areas of controversy persist. Premission HEC should be administered to residents participating in humanitarian missions.

New aspects concerning the photodegradation (PD) of ampicillin are reported by photoluminescence (PL), Raman scattering and FTIR spectroscopy. The exposure of ampicillin in the absence (AM) and in the presence of the excipient (AMP) to UV light leads to an intensity diminution of the photoluminescence excitation (PLE) and photoluminescence (PL) spectra and the emergence of a new IR band at 3450 cm−1. The photoluminescence studies demonstrate that the AM PD is amplified in the presence of excipients and an alkaline medium. In this last case, the PD process of AM involves the emergence of new compounds, whose presence is highlighted by: (i) the emergence of the isosbestic point at 300 nm in the UV-VIS spectra; (ii) a change in the ratio between the absorbance of IR bands situated in the spectral ranges 1200–1660 and 3250–3450 cm−1; and (iii) a change in the ratio between the intensities of the Raman lines localized in the spectral ranges 1050–1800 and 2750–3100 cm−1. A chemical mechanism of the PD processes of AM in an alkaline medium is proposed.

For the emergence of life, the abiotic synthesis of RNA from its monomers is a central challenge. We found alkaline drying conditions in bulk and at heated air-water interfaces where 2 ́,3 ́-cyclic nucleotides reacted to form copolymers up to 10-mers. The polymerisation proceeded at a pH range of 7-12, temperatures between 40-80 °C and was enhanced by K+ ions. Among the canonical nucleotides, cGMP polymerised most efficiently. Our study suggests a polymerisation mechanism where cGMP polymerises first to form a polymorphic scaffold into which the other relatively unreactive nucleotides copolymerise. The 2 ́,3 ́-cyclic monomers are often products in prebiotic phosphorylation, nucleotide syntheses and recyclable intermediates of RNA hydrolyses. The plausible abiotic availability and the simple dry polymerisation conditions, combined with hydrolytic recycling offers an appealing minimal entry point for RNA-based molecular evolution on early Earth.

We report the case of a 17-year-old male who presented with intractable nausea and vomiting. Cross-sectional imaging revealed a large retrogastric abdominal mass. Fine needle aspiration done via endoscopic ultrasound (EUS) was nondiagnostic. Exploratory laparotomy revealed a large inflammatory mass densely adherent to the stomach and retroperitoneum. Incisional biopsy frozen section revealed spindle cells, and subsequent resection of the mass with en-bloc subtotal gastrectomy with Roux-en-y gastrojejunostomy reconstruction was performed. Final pathology demonstrated a lymphatic malformation with reactive myofibroblastic proliferation. Inflammatory abdominal lymphatic malformations are especially rare and not well described in the literature. These masses may present diagnostic challenges until the specimen is sent for pathologic analysis.

Background Economic, social, and psychologic stressors are associated with an increased risk for abusive injuries in children. Prolonged physical proximity between adults and children under conditions of severe external stress, such as witnessed during the COVID-19 pandemic with “shelter-in-place orders”, may be associated with additional increased risk for child physical abuse. We hypothesized that child physical abuse rates and associated severity of injury would increase during the early months of the pandemic as compared to the prior benchmark period. Methods We conducted a nine-center retrospective review of suspected child physical abuse admissions across the Western Pediatric Surgery Research Consortium. Cases were identified for the period of April 1-June 30, 2020 (COVID-19) and compared to the identical period in 2019. We collected patient demographics, injury characteristics, and outcome data. Results There were no significant differences in child physical abuse cases between the time periods in the consortium as a whole or at individual hospitals. There were no differences between the study periods with regard to patient characteristics, injury types or severity, resource utilization, disposition, or mortality. Conclusions Apparent rates of new injuries related to child physical abuse did not increase early in the COVID-19 pandemic. While this may suggest that pediatric physical abuse was not impacted by pandemic restrictions and stresses, it is possible that under-reporting, under-detection, or delays in presentation of abusive injuries increased during the pandemic. Long-term follow-up of subsequent rates and severity of child abuse is needed to assess for unrecognized injuries that may have occurred.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potential adjunct in pediatric trauma patients with noncompressible truncal and pelvic hemorrhage; however, there are little data evaluating the anatomic considerations of REBOA in children. We evaluated the vascular dimensions and anatomic limitations of using REBOA in children.Computed tomography scans of pediatric patients performed between February 2016 and October 2019 were retrospectively reviewed by two investigators. Vascular measurements included diameters of aorta zones I and III, common iliac arteries, external iliac arteries, and common femoral arteries (CFAs), and distances between access site (CFA) and aorta zones I and III. Measurements were grouped within Broselow categories, based upon patient height. Interrater reliability for measurements was determined using intraclass correlation coefficients. Vascular dimensions were correlated with the patient's height, weight, and body mass index using linear regression analysis.A total of 557 computed tomography scans met the inclusion criteria and were reviewed. Measurements of vessel diameter and distance from the CFA to aorta zones I and III were determined and grouped by Broselow category. Patient age ranged from 0 to 18 years, with a male to female ratio of 1:1. Overall interrater reliability of vessel measurements was good (average intraclass correlation coefficient, 0.90). Vessel diameter had greatest correlation with height (R2 = 0.665, aorta zone I; R2 = 0.611, aorta zone III) and poorly correlated with body mass index (R2 = 0.318 and R2 = 0.290, respectively).This study represents the largest compilation of REBOA-related pediatric vessel diameter measurements and the first to provide data on distance between access site and balloon deployment zones. Based on our findings, the 7-Fr REBOA catheter would be appropriate for the Black, Green, and Orange Broselow categories, and a 4-Fr REBOA catheter would be warranted for Yellow, White, and Blue Broselow categories.Prognostic and epidemiological, level III.

Laparoscopic gastrostomy tube (GT) placement carries the risk of early tube dislodgement and is often modified with absorbable subcutaneously-tunneled transabdominal tacking sutures that can aid in tube replacement. However, these buried sutures may increase the risk of surgical site infection (SSI). This study sought to evaluate SSI rates associated with different types of transabdominal tacking sutures used in modified laparoscopic GT placement.A single-institution, retrospective review was performed of all patients ≤18 years-old undergoing modified laparoscopic GT placement between September 2016 and March 2020. Patients were stratified into three groups by suture type used, and the primary outcome was SSI within six weeks of surgery. Demographic and perioperative data were analyzed by chi-square or Fisher's exact test.A total of 113 modified laparoscopic GT placements were performed at a median age of 9 months (interquartile range 3 months to 3 years). Prophylactic antibiotic use was similar between groups. Eleven patients (10%) developed an SSI, and all were treated with antibiotics alone. No SSIs were observed with the use of poliglecaprone suture (n = 46), and higher SSI rates were observed with use of polyglactin (n = 17) and polydioxanone (n = 51) suture (18% polyglactin vs. 16% polydioxanone vs. 0% poliglecaprone, p0.05). No differences were observed in rates of early postoperative dislodgement, leakage, or granulation tissue.Absorbable braided and long-lasting monofilament transabdominal tacking sutures may increase risk of SSI following modified laparoscopic gastrostomy tube placement. In this cohort, the use of poliglecaprone (Monocryl) suture was associated with no SSIs and similar rates of postoperative dislodgement, leakage, and granulation tissue.Treatment Study, Level III.

There is a paucity of data to describe how neighborhood socioeconomic disadvantage (NSD) correlates with childhood injuries and outcomes. This study assesses the relationship of NSD to bicycle safety and trauma outcomes among pediatric bicycle versus automobile injuries.Between 2008 and 2018, patients ≤18 y old with bicycle versus automobile injuries from a Level I pediatric trauma center were evaluated. Area Deprivation Index (ADI) was used to measure NSD. Patient demographics, injury, clinical data characteristics, and bike safety were analyzed. Traffic scene data from the Statewide Integrated Traffic Records System were matched to clinical records. Multivariate logistic regression was used to assess demographic characteristics related to helmet usage.Among 321 patients, 84% were male with a median age of 12 y [interquartile range 9-13], and 44% were of Hispanic ethnicity. Hispanic ethnicity was greater in the most disadvantaged ADI groups (P 0.001). Mortality occurred in two patients, and most (96%) were discharged home. Of Statewide Integrated Traffic Records System matched traffic records, 81% were at locations without a bike lane. No differences were found in GCS, intensive care unit admission, or length of stay by ADI. Hispanic ethnicity and the highest deprivation group were independently associated with lower odds of wearing a helmet (AOR 0.35, 95% confidence interval 0.1-0.9, P = 0.03; AOR 0.33 95% confidence interval 0.17-0.62; P = 0.001), while patient age and sex were unrelated to helmet usage.Outcomes for bike versus auto trauma remains similar across ADI groups. However, bike helmet usage is significantly lower among Hispanic children and those from neighborhoods with greater socioeconomic disadvantage.

Introduction Since 2006, the U.S. Navy has conducted six Pacific Partnership (PP) missions throughout Southeast Asia on board the U.S. Naval Ship Mercy (T-AH 19). This study describes trends in overall and surgical specialty operative volumes to better understand the burden of surgical disease treated during these humanitarian and civic assistance (HCA) operations. This information can assist medical planners and surgical leaders involved in future humanitarian missions. Materials and Methods Following approval from the Naval Medical Center San Diego Institutional Review Board, a retrospective review of surgical case data was performed for the six PP missions from 2006 to 2018. Data collected included patient demographics, Current Procedural Terminology codes, and surgical specialty. The primary outcome was surgical case volume per specialty. Secondary outcomes included surgical staffing per mission and overall trends in operative volume. Results A total of 3,826 operative procedures were performed during the study period. Mission years in which case volume for both general surgery and ophthalmology were below their respective medians were associated with the least total surgical services to host nations (HNs). The number of active duty Navy surgeons varied with each mission; however, the staffing for a PP mission generally included at least two general surgeons, one ophthalmologist, one plastic surgeon, one pediatric surgeon, one orthopedic surgeon, one otolaryngologist, one oral surgeon, one urologist, and one obstetrician–gynecologist. Case volume per surgeon was highest in 2006 (50 cases per surgeon) and decreased after 2006, reaching an all-time low during the 2018 PP mission (10 cases per surgeon). Pediatric surgery and plastic surgery had the highest average case volumes per surgeon at 58 and 46 cases per surgeon, respectively, while oromaxillofacial surgery and neurosurgery had the lowest average case volumes per surgeon at 9 and 14 cases per surgeon, respectively. Conclusions Operative volume on military HCA missions is greatly influenced by the priorities of the HN, the mission focus, the number of individuals from the HN that present for screening, and the availability of personnel and resources available on the hospital ship. Future mission planning should optimize general surgery and ophthalmology staffing and essential equipment, as total mission case volumes were highly dependent upon the productivity of these two specialties. Careful determination of the surgical needs of HNs should serve as a guide for the selection of subspecialists to maximize effectiveness in future military HCA missions.

The purpose of this study was to analyze a nationwide database of malpractice lawsuits involving pediatric surgical patients to identify contributing factors in liability claims.Using the CRICO (Controlled Risk Insurance Company Strategies' Comparative Benchmarking System) database, malpractice claims involving patients ≤18 y old were reviewed from 2008 to 2017. Data were analyzed using descriptive statistics and logistic regression.Of the 844 claims, 76% of the patients were older than age 5. While the average total indemnity paid was $544,325, cases with claimants1-year-old accounted for 24% of the total indemnity paid, with an average of $1,135,240 per claimant. The most frequently named responsible services were Orthopedics (34%), General Surgery (15%), and Otolaryngology (11%). Fracture or dislocation, appendectomy, skin/breast surgery, arthroscopy, and tonsillectomy/adenoidectomy were among the frequently involved procedures for the cohort of cases. The most common contributing factors for the top procedures involve issues surrounding patient assessment, technical performance, and communication. Cases with a contributing factor of failure to appreciate and reconcile relevant sign/symptom/test results were associated with a higher likelihood of payment (OR 6.6, P 0.05). Issues surrounding the selection of therapy also led to an increased likelihood of an indemnity payment (OR 2.8, P 0.05).Malpractice claims related to pediatric surgical procedures involve a wide range of specialties. Patient evaluations, technical performance, and communication are modifiable factors to improve surgical care in children. The contributing factors assigned to each procedure may represent an opportunity for focused improvement to improve patient outcomes.

In this work, improved fracture toughness of tetra-functional epoxy polymer was obtained using two-dimensional (2H polytype) molybdenum disulfide (MoS2) nano-platelets as a filler. Simultaneous in-situ exfoliation and functionalization of MoS2 were achieved in the presence of cetyltrimethylammonium bromide (CTAB) via sonication. The aim was to improve the dispersion of MoS2 nanoplatelets in epoxy and enhance the interfacial interaction between nanoplatelets and epoxy matrix. Epoxy nanocomposites with CTAB functionalized MoS2 (f-MoS2) nanoplatelets, ranging in content from 0.1 wt% up to 1 wt%, were fabricated. Modified MoS2 improved the fracture properties (81%) of tetrafunctional epoxy nanocomposites. The flexural strength and compressive strength improved by 64% and 47%, respectively, with 0.25 wt% loading of f-MoS2 nanoplatelets compared to neat epoxy. The addition of f-MoS2 nanoplatelets enhanced the thermomechanical properties of epoxy. This work demonstrated the potential of organically modified MoS2 nanoplatelets for improving the fracture and thermal behavior of tetrafunctional epoxy nanocomposites.

Introduction Quality in medical care must be measured in order to be improved. Trauma management is part of health care, and by definition, it must be checked constantly. The only way to measure quality and outcomes is to systematically accrue data and analyze them. Material and methods A systematic revision of the literature about quality indicators in trauma associated to an international consensus conference Results An internationally approved base core set of 82 trauma quality indicators was obtained: Indicators were divided into 6 fields: prevention, structure, process, outcome, post-traumatic management, and society integrational effects. Conclusion Present trauma quality indicator core set represents the result of an international effort aiming to provide a useful tool in quality evaluation and improvement. Further improvement may only be possible through international trauma registry development. This will allow for huge international data accrual permitting to evaluate results and compare outcomes.

Virtual health (VH) may enhance mentorship to remote first responders. We evaluated the feasibility of synchronous bidirectional VH to mentor life-saving procedures performed by deployed novice providers.Video teleconferencing (VTC) was established between the USNS Mercy (T-AH 19) underway in the Pacific Ocean to Naval Medical Center San Diego using surgeon teleconsultation. The adult simulated clinical vignette included injuries following a shipboard explosion with subsequent fire. The pediatric simulated vignette included injuries that resulted from an improvised explosive device (IED) blast. Using VTC, augmented reality (AR) goggles, and airway simulation equipment, corpsmen (HMs) received visual cues to perform advanced life-saving procedures.In adult scenarios, 100% of novice hospital HMs performed tasks on first attempt (n = 12). Mean time for tourniquet placement was 46 seconds (standard deviation [SD], 19 seconds); needle thoracostomy, 70 seconds (SD, 67 seconds); tube thoracostomy, 313 seconds (SD, 152 seconds); and cricothyroidotomy, 274 seconds (SD, 82 seconds). In pediatric scenarios, 100% of novice HMs performed tasks on first attempt (n = 5). Mean time for tube thoracostomy completion was 532 seconds (SD, 109 seconds).VH can enhance the training and delivery of trauma care during prolonged field care in resource-limited settings.

Since their development in 1908, surgical staplers have been used as a method of “mechanical suturing” in efforts to divide hollow viscera and create anastomoses in an efficient and sterile manner. The concept for the surgical stapler was first developed by Humér Hultl, a Hungarian professor and surgeon, and designed by Victor Fischer, a Hungarian businessman and designer of surgical instruments. The design was highly acclaimed; however, it was bulky, cumbersome, and expensive to manufacture. In 1920, Aladár Petz, a student of Hultl, incorporated two innovations to the Fischer-Hultl stapler to create a more lightweight model, which was named the Petz clamp. In 1934, Friedrich of Ulm designed what would be the predecessor to the modern-day linear stapler. In the 1950s, Russian and American staplers began to emerge. Throughout the 1960s, a variety of stapling instruments were developed in the United States, manufactured by the United States Surgical Corporation. In the 1970s, Johnson & Johnson Ethicon brand joined the market. The United States Surgical Corporation was later bought by Tyco Healthcare and became Covidien in 2007. Through the collaboration of Felicien Steichen, Mark Ravitch, and Leon Hirsch, surgical staplers were further modified to incorporate interchangeable cartridges with various designs. With the advent of minimally invasive surgery began production of laparoscopic surgical staplers. Since its inception, the surgical stapler has provided a means to efficiently create safe and effective visceral and vascular anastomoses. The surgical stapler design continues to evolve while still maintaining the basic principles that were implemented in the original design.

An incidental appendectomy is performed by some surgeons during operative treatment for intussusception to eliminate future appendicitis as a diagnostic consideration. However, an appendectomy can increase the risk of infection and other noninfectious complications making an incidental appendectomy controversial. We examined outcomes for surgical intervention for intussusception with appendectomy (SWA) compared to surgical reduction alone (SRA).The Pediatric Health Information System database, 8/2008-9/2015, was retrospectively analyzed for patients under the age of five who required an operative intervention for intussusception without bowel resection. Demographic data and postoperative outcomes were analyzed. Available data included need for postoperative enema, subsequent small bowel obstruction, recurrent intussusception, length of stay (LOS), and adjusted total cost (ATC).Fifty-seven percent (748/1312) of patients had appendectomy performed during surgical reduction, 564 (43%) did not. ATC ($10,594 vs. $8939, p 0.001) and LOS (3.0 vs. 2.48, p 0.001) are higher in the SWA group. Rates of readmission are similar, but post-operative small bowel obstruction may be higher in the SWA group (1.3% vs. 0.35%, p = 0.06).There is a higher mean LOS and ATC in the SWA group. This study suggests that appendectomy during surgery for uncomplicated intussusception should be reconsidered and requires further investigation.retrospective comparative study.III.

Superior mesenteric artery (SMA) syndrome is a rare condition in which the third portion of the duodenum is compressed between the SMA anteriorly and the aorta posteriorly. The resulting duodenal obstruction is often due to rapid weight loss and commonly resolves with distal tube feeds. Occasionally, patients fail this medical management, and require a surgical bypass. We present the case of a male adolescent who presented with SMA syndrome and underwent laparoscopic duodenojejunostomy using a retroperitoneal technique that avoids crossing of the transverse colon and does not create a duodenal diverticulum proximal to the mesenteric root.

Background Older aged adults and those with pre-existing conditions are at highest risk for severe COVID-19 associated outcomes. Methods Using a large dataset of genome-wide RNA-seq profiles derived from human dermal fibroblasts (GSE113957) we investigated whether age affects the expression of pattern recognition receptor (PRR) genes and ACE2, the receptor for SARS-CoV-2. Results Extremes of age are associated with increased expression of selected PRR genes, ACE2 and four genes that encode proteins that have been shown to interact with SAR2-CoV-2 proteins. Conclusions Assessment of PRR expression might provide a strategy for stratifying the risk of severe COVID-19 disease at both the individual and population levels.

BACKGROUND Ventriculoperitoneal shunt (VPS) placement into the reoperative abdomen can be challenging due to intraperitoneal adhesions. Laparoscopic guidance may provide safe abdominal access and identify an area for optimal cerebrospinal fluid drainage. The study aim was to compare laparoscopic-assisted VPS placement to an "open" approach in patients with prior abdominal surgery. MATERIALS AND METHODS A retrospective review was performed of children undergoing VPS placement into a reoperative abdomen from 2009-2019. Clinical data were collected, and patients undergoing laparoscopy (LAP) were compared to those undergoing an open approach (OPEN). RESULTS A total of 120 children underwent 169 VPS placements at a median age of 8 y (IQR 2-15 y), and a mean number of two prior abdominal operations (IQR 1-2). Laparoscopy was used in 24% of cases. Shunt-related complications within 30 d were lower in the LAP group (0% versus 19%, P = 0.001), as were VPS-related postoperative emergency department visits (0% versus 13%, P = 0.003) and readmissions (0% versus 13%, P = 0.013). Shunt malfunction rates were higher (42% OPEN versus 25% LAP, P = 0.03) and occurred sooner in the OPEN group (median 26 versus 78 wk, P = 0.01). The LAP group demonstrated shorter operative times (63 versus 100 min, P < 0.0001), and the only bowel injury. Time to feeds, length of stay, and mortality were similar between groups. CONCLUSIONS Laparoscopic guidance during VPS placement into the reoperative abdomen is associated with a decrease in shunt-related complications, longer shunt patency, and shorter operative times. Prospective study may clarify the potential benefits of laparoscopy in this setting.

The purpose of this study was to evaluate the characteristics of neonates with congenital diaphragmatic hernia (CDH) undergoing enteral access procedures (gastrostomy or jejunostomy) during their initial hospitalization, and establish a clinical scoring system based on these characteristics.Data were obtained from the multicenter, multinational CDH Study Group database (CDHSG Registry) between 2007 and 2019. Patients were randomly partitioned into model-derivation and validation subsets. Weighted scores were assigned to risk factors based on their calculated β-coefficients after logistic regression.Of 4537 total patients, 597 (13%) underwent gastrostomy or jejunostomy tube placement. In the derivation subset, factors independently associated with an increased risk for enteral access included oxygen requirement at 30-days, chromosomal abnormalities, gastroesophageal reflux, major cardiac anomalies, ECMO requirement, liver herniation, and increased defect size. Based on the devised scoring system, patients could be stratified into very low (0-4 points;10% risk), low (5-6 points; 10-20% risk), intermediate (7-9 points; 30-60% risk), and high risk (≥10 points; 70% risk) groups for enteral access.This study identifies risk factors associated with enteral access procedures in neonates with congenital diaphragmatic hernia and establishes a novel scoring system that may be used to guide clinical decision making in those with poor oral feeding.Prognosis study.