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Introduction: Our objective was to perform a feasibility study using real-world data from a learning health system (LHS) to describe current practice patterns of wound closure and explore differences in outcomes associated with the use of tissue adhesives and other methods of wound closure in the pediatric surgical population to inform a potentially large study., Methods: A multi-institutional cross-sectional study was performed of a random sample of patients <18 y-old who underwent laparoscopic appendectomy, open or laparoscopic inguinal hernia repair, umbilical hernia repair, or repair of traumatic laceration from January 1, 2019, to December 31, 2019. Sociodemographic and operative characteristics were obtained from 6 PEDSnet (a national pediatric LHS) children's hospitals and OneFlorida Clinical Research Consortium (a PCORnet collaboration across 14 academic health systems). Additional clinical data elements were collected via chart review., Results: Of the 692 patients included, 182 (26.3%) had appendectomies, 155 (22.4%) inguinal hernia repairs, 163 (23.6%) umbilical hernia repairs, and 192 (27.8%) traumatic lacerations. Of the 500 surgical incisions, sutures with tissue adhesives were the most frequently used (n = 211, 42.2%), followed by sutures with adhesive strips (n = 176, 35.2%), and sutures only (n = 72, 14.4%). Most traumatic lacerations were repaired with sutures only (n = 127, 64.5%). The overall wound-related complication rate was 3.0% and resumption of normal activities was recommended at a median of 14 d (interquartile ranges 14-14)., Conclusions: The LHS represents an efficient tool to identify cohorts of pediatric surgical patients to perform comparative effectiveness research using real-world data to support medical and surgical products/devices in children., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Limited English proficiency (LEP) is linked to lower health care access and worse clinical outcomes. This study aims to explore the potential role of LEP on clinical outcomes of pediatric burn patients., Methods: We conducted a single-institution retrospective study of burn patients presenting at a tertiary pediatric burn referral program between January 2016 and December 2020. Patient demographics, burn mechanism, severity, interventions, and primary patient language were abstracted from the electronic health record. Clinical outcomes (length of stay [LOS], clinic follow-up, and 30-day readmission) of patients with LEP were compared to patients with English as primary language (EPL)., Results: Thirty-five (4.2%) patients with LEP were identified of 840 total patients. On univariate analysis, there was no difference in mean total body surface area (6.5% versus 6.1%), report of physical abuse (2.9% versus 8.9%), or need for grafting (14.3% versus 15.0%) comparing patients with LEP to those with EPL. Patients with LEP were more likely to have a scald burn (68.6% versus 48.9%, P = 0.025) and less likely to have a flame/fire burn (20.0% versus 37.6%, P = 0.047). On multivariate analysis, there was no difference between patients with LEP compared to patients with EPL for LOS (2.9 versus 3.5 d), 30-day readmissions (5.6% versus 5.7%), or clinic follow-up (80.6% versus 75.0%). In patients with >10% total body surface area, patients with LEP had a longer emergency department LOS (277 min versus 145 min, P = 0.06) but no difference in outcome measures., Conclusions: Pediatric patients with LEP were not found to have worse burn outcomes compared to EPL patients in our patient sample. However, a true association is difficult to determine given the small sample size of LEP patients and the potential underestimation of language discordancy as recorded in the electronic medical record. Further research is needed to better explore the role of primary language and health communication as a social determinant of health in pediatric burn patients., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Among premature infants, the incidence of inguinal hernias is reported to be as high as 30%. Despite being one of the most commonly performed procedures, the optimal setting of inguinal hernia repair (IHR) that is inpatient versus outpatient remains debatable. We sought to compare the 30-day outcomes of each approach by querying the National Surgical Quality Improvement Program-Pediatric database., Materials and Methods: A retrospective cohort study comparing inpatient versus outpatient IHR using the National Surgical Quality Improvement Program-Pediatric database from 2013 to 2019 was performed. Demographic and clinical data were initially compared using univariate analysis. Continuous variables are presented as median and interquartile range and categorical variables are presented as n (%). Subsequently, cohorts were propensity matched using clinically and statistically significant patient characteristics., Results: 928 patients underwent IHR, 634 (68.3%) while inpatient, 294 (31.7%) following hospital discharge. Inpatient IHR was associated with lower age at the time of surgery (120 versus 147 d; P < 0.0001), younger gestational age (27 versus 33 wk; P < 0.0001), decreased probability of repair in elective setting (87.2% versus 97.3%; P < 0.0001), and increased preoperative supplemental oxygen need (42% versus 4.4%; P < 0.0001). Comparison of propensity matched cohorts revealed that inpatient IHR was associated with increased procedure time (82 versus 51 min; P < 0.0001) and anesthetic duration (146 versus 102 min; P < 0.0001), wound infection rates (3.8% versus 0%; P = 0.007), blood transfusions (4.2% versus 0.5%; P = 0.036), unplanned intubations (2.8% versus 0%; P = 0.03), ventilator days (0 versus 0; range [0,30 versus 0,2]; P = 0.002), reoperation rate (5.6% versus 0%; P < 0.001), postoperative hospital length of stay (4 versus 1 d; P < 0.0001), and unplanned readmissions (8.9% versus 0.9%; P = 0.002)., Conclusions: Inpatient IHR in premature neonates were associated with different postoperative outcomes than outpatient IHR. At least in the elective setting among premature infants, outpatient IHR can be considered safe in select patients while we await higher quality prospective data., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Coronavirus disease 2019 (COVID-19) has been shown to affect outcomes among surgical patients. We hypothesized that COVID-19 would be linked to higher mortality and longer length of stay of trauma patients regardless of the injury severity score (ISS)., Methods: We performed a retrospective analysis of trauma registries from two level 1 trauma centers (suburban and urban) from March 1, 2019, to June 30, 2019, and March 1, 2020, to June 30, 2020, comparing baseline characteristics and cumulative adverse events. Data collected included ISS, demographics, and comorbidities. The primary outcome was time from hospitalization to in-hospital death. Outcomes during the height of the first New York COVID-19 wave were also compared with the same time frame in the prior year. Kaplan-Meier method with log-rank test and Cox proportional hazard models were used to compare outcomes., Results: There were 1180 trauma patients admitted during the study period from March 2020 to June 2020. Of these, 596 were never tested for COVID-19 and were excluded from the analysis. A total of 148 COVID+ patients and 436 COVID- patients composed the 2020 cohort for analysis. Compared with the 2019 cohort, the 2020 cohort was older with more associated comorbidities, more adverse events, but lower ISS. Higher rates of historical hypertension, diabetes, neurologic events, and coagulopathy were found among COVID+ patients compared with COVID- patients. D-dimer and ferritin were unreliable indicators of COVID-19 severity; however, C-reactive protein levels were higher in COVID+ relative to COVID- patients. Patients who were COVID+ had a lower median ISS compared with COVID- patients, and COVID+ patients had higher rates of mortality and longer length of stay., Conclusions: COVID+ trauma patients admitted to our two level 1 trauma centers had increased morbidity and mortality compared with admitted COVID- trauma patients despite age and lower ISS. C-reactive protein may play a role in monitoring COVID-19 activity in trauma patients. A better understanding of the physiological impact of COVID-19 on injured patients warrants further investigation., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: While many factors influence medical student career choice, interactions with attending and resident physicians during clinical rotations are particularly important. To evaluate the influence of attending and resident physicians on medical students' career choices, particularly for those pursuing surgical careers, we quantified their respective influence in the context of other known influences., Methods: Rising fourth-year medical students and new graduates were given an IRB-exempt, 14-item online survey. Descriptive statistics were performed on the demographic information. Chi-square analysis was used, as were Kruskal-Wallis and Mann-Whitney analyses on the Likert responses (α = 0.05)., Results: Survey response was 24%. Students pursuing general surgery rated residents greater than or equal to attendings on 7 of 8 key mentoring characteristics. Of students choosing a different specialty than the one they intended to pursue upon entering medical school, the influence of residents was cited by 100% of the students pursuing general surgery, compared to 59% of the entire cohort. Identification of a role model and perceived personality fit were significantly more important than other factors (P < 0.0001). Students pursuing general surgery rated the importance of identifying a role model and perceived personality fit greater than their peers., Conclusions: Residents have greater influences on medical students' career choice compared to attendings. Students pursuing a surgical specialty, particularly general surgery, considered the influence of role models and perceived personality fit to be the most important factors in their specialty decision. These findings provide valuable insights to improve student experiences and career recruitment in surgical specialties, particularly general surgery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Trauma is the leading cause of death in pediatric patients over 1 y of age. Controversy exists regarding prehospital airway management for these patients, with some studies suggesting that endotracheal intubation in the field or at a referring hospital is associated with increased mortality and complication rate. These studies were largely performed at urban centers, and it is unclear whether the results apply to suburban/rural networks with longer transport times and more stops at referring hospitals. The purpose of this study is to evaluate differential outcomes in pediatric trauma patients who underwent endotracheal intubation at the scene of injury, referring hospital, or pediatric trauma center in a predominantly rural/suburban setting., Materials and Methods: A retrospective review was performed evaluating trauma patients age 18 y or younger at a single institution over 10 y (2004-2014). Patients were selected who underwent endotracheal intubation and were classified based on location of intubation (scene, referring hospital, or trauma center). Fischer's exact test and t-tests were performed for comparison. Univariate and multivariate regression analyses were performed., Results: 288 patients were identified. 155 (53.8%) were intubated at the scene of injury, 55 (19.1%) at a referring hospital, and 72 (25%) at the trauma center. Overall mortality was 21.9%, which was highest in the scene intubation group (29.7%) compared with the referring hospital (20%) and trauma center (5.6%) groups (P < 0.01). Patients intubated at the scene had higher Injury Severity Scores and lower Glasgow Coma Scale scores (P < 0.01). Duration of intubation was lowest in the trauma center group (P < 0.01). Complication rate was highest in the referring hospital group (P < 0.05). Multivariate analysis revealed that age, injury severity, and neurologic status were the key drivers of mortality rather than location of intubation., Conclusions: Mortality and duration of intubation were lowest in trauma patients intubated at a pediatric trauma center. However, location of intubation was not a significant independent predictor of mortality or complications on multivariate analysis, suggesting that age, injury severity, and neurologic status are the main indicators of prognosis in severe pediatric trauma., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Gastroschisis is an increasingly common congenital abdominal wall defect. Due to advances in neonatal critical care and early surgical management, mortality from gastroschisis and associated complications has decreased to less than 10% in most series. However, it has been recognized that the outcome of gastroschisis has a spectrum and that the disorder affects a heterogeneous cohort of neonates. The goal of this study is to predict morbidity and mortality in neonates with gastroschisis using clinically relevant variables., Methods: A multicenter, retrospective observational study of neonates born with gastroschisis was conducted. Neonatal characteristics and outcomes were collected and compared. Prediction of morbidity and mortality was performed using multivariate clinical models., Results: Five hundred and sixty-six neonates with gastroschisis were identified. Overall survival was 95%. Median hospital length of stay was 37 d. Sepsis was diagnosed in 107 neonates. Days on parenteral nutrition and mechanical ventilation were considerable with a median of 27 and 5 d, respectively. Complex gastroschisis (atresia, perforation, volvulus), preterm delivery (<37 wk), and very low birth weight (<1500 g) were associated with worse clinical outcomes including increased sepsis, short bowel syndrome, parenteral nutrition days, and length of stay. The composite metric of birth weight, Apgar score at 5 min, and complex gastroschisis was able to successfully predict mortality (area under the curve, 0.81)., Conclusions: Clinical variables can be used in gastroschisis to distinguish those who will survive from nonsurvivors. Although these findings need to be validated in other large multicenter data sets, this prognostic score may aid practitioners in the identification and management of at-risk neonates., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Pectus excavatum is a common chest wall deformity with no known cause. A common hypothesis is that in patients with pectus excavatum, there is an overgrowth of costal cartilage relative to healthy individuals., Materials and Methods: We obtained radiological curvilinear three-dimensional measurements of the fourth to eighth costal cartilage and associated ribs in 16 patients with pectus excavatum and 16 age- and gender-matched controls between the ages of 6 and 32 y. An analysis of variance was used to compare bone length, cartilage length, and their ratios between patients and controls., Results: Relative to bone length, patients with pectus excavatum overall had shorter costal cartilage lengths (P < 0.001), especially on the left side (P < 0.05). We were unable to localize this observation to specific ribs during post hoc analysis., Conclusions: This is the first study to empirically test the overgrowth hypothesis of pectus excavatum for ribs 4 through 8. Although we and others have found no evidence to support this hypothesis, we surprisingly found the alternate hypothesis to be true: patients with pectus excavatum tend to have shorter costal cartilages. Future studies should expand on these results with larger sample sizes and consider volumetric measurements longitudinally during thoracic development., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Sepsis is the systemic inflammatory response to an infection. Generation of reactive oxygen species represents an important part of the inflammatory cascade in sepsis. Dysregulation of iron homeostasis can further promote the generation of radicals and amplify the damage caused by systemic immune activation. This can potentially be suppressed or prevented by iron chelation. Therefore, this study was designed to examine the effects of a novel iron chelator (DIBI) with or without standard antibiotic treatment in colon ascendens stent peritonitis (CASP)-induced experimental sepsis., Methods: Six groups of animals (n = 7-10) were included in the study: sham surgery; untreated CASP animals; CASP and subcutaneous (sc) or intraperitoneal DIBI administration, respectively; CASP and imipenem sc; and combination of DIBI and imipenem sc., Results: We observed a 55% reduction in leukocyte adhesion in V1 venules after sc administration of DIBI and a 40% reduction after imipenem treatment, when compared to untreated CASP animals (P < 0.05). A further reduction in the number of adherent leukocytes in V1 venules has been observed after combined treatment with DIBI and imipenem (66%). A significant decrease in bacterial count was observed from 2200 (150-64,000) to 100 (1-420) colony forming units per milliliter in blood in the sc DIBI and imipenem combination group (P = 0.0065). The bacterial count in the peritoneal lavage fluid was also significantly reduced in the sc imipenem group and the sc DIBI and imipenem combination group (P = 0.0021 and P = 0.0001, respectively) when compared to untreated CASP animals., Conclusions: These findings suggest a potential role of iron chelators in the treatment of sepsis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Pediatric electrical and chemical burns are rare injuries, and the care of these patients varies significantly. We reviewed our experience in management of electrical and chemical burns to analyze the clinical course, management, and outcomes., Methods: A retrospective review was conducted on children with chemical and electrical burns presenting to two large regional pediatric burn centers over a 10-y period (2002-2012). Clinical data including patient demographics, nature of burns, management, and outcomes were collected and analyzed., Results: There were 50 cases, 25 chemical and electrical burns each. Overall, the mean±standard deviation age was 6.2±5.6 y, and the mean total body surface area burn was 4.3±3.2%. Chemical burns were larger, had less depth, and shorter length of stay, whereas electrical burns were smaller, deeper, and had a longer length of stay. Two chemical burns and six electrical burns required grafting. Twelve percent of electrical burns required rehabilitation, and 20% required compression garments for hypertrophic scars. Six percent required late surgeries., Conclusions: Pediatric electric and chemical burns are rare and require specialized care. Graft rates are not high but are mostly noted in electrical burns., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The significance of meconium plug syndrome (MPS) is unclear but has been associated with Hirschsprung's disease and magnesium tocolysis. We reviewed our experience to attempt to identify any potential association with these conditions and to review our outcomes., Methods: Using the International Classification of Diseases, Ninth revision, code for meconium obstruction, patient charts were identified during the 1998-2008 period. A total of 61 cases of MPS were found, after excluding 7 of meconium ileus. Data regarding the hospital course and outcomes were collected and analyzed., Results: Approximately 30% of patients had spontaneous resolution of the meconium plug without any treatment. Of those patients requiring treatment, contrast barium enema was used, with 97% success. Only 2 patients required surgical intervention owing to worsening distension and subsequent peritonitis. When we stratified the patients according to gestational age of >36 and <36 wk, contrast barium enemas were performed 2.2 ± 1.8 versus 8.6 ± 7.8 d after birth (P = 0.003), respectively, and the lower gestational age patients had a longer length of stay. Contrast barium enema was still successful in 94% of patients with a gestational age of <36 wk. Magnesium tocolysis was noted in 16% of the cases, and Hirschsprung's disease was only found in 3.2% of patients., Conclusions: Patients with MPS have excellent outcomes, independent of gestational age. Contrast barium enema remains the initial diagnostic and treatment of choice for patients with MPS. Also, although previous reports have shown a link between magnesium tocolysis and Hirschsprung's disease with MPS, our experience suggests otherwise., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Colectomy is the definitive treatment for ulcerative colitis (UC) to remove the inflammatory burden. Crohn's disease, however, can affect any portion of the bowel with a propensity to involve the terminal ileum. In some patients with fulminant colitis, distinction between the two is imperfect. Manifestations of Crohn's after colectomy can be devastating because the ileum is needed for restoration of continuity. There is currently little information in the pediatric literature addressing this concern. Therefore, we reviewed all of our patients who underwent colectomy for inflammatory bowel disease to evaluate the risk of subsequent Crohn's manifestations and to document the outcomes., Methods: A two-center retrospective review of children who underwent colectomy for IBD from January 2000 to July 2010 was performed. Demographic, diagnostic, management, and outcome variables were recorded., Results: We identified 70 patients who underwent colectomy for UC. The mean age at diagnosis was 12 y ± 7 y, and 59% were female. Clinical diagnosis prior to colectomy was UC in 90%, and indeterminate colitis in 10%. There was discordance between clinical and pathologic diagnosis in five patients, two patients were clinically diagnosed with UC but had an indeterminate biopsy, and three patients were clinically diagnosed as indeterminate colitis with a biopsy confirming UC. Indications for colectomy were refractory bleeding in 63%, failure of medical treatment in 28%, toxic megacolon in 6%, and perforation in 3%. A restorative pouch was created after colectomy in 46% using a two-stage approach while, 53% were managed with an initial colectomy and three-stage approach. In one patient, Crohn's was intraoperatively diagnosed from the operative colectomy specimen. This patient had a clinical diagnosis of UC with concordant biopsy prior to surgery. After total abdominal colectomy, 68 patients went on to ileal pouch anal anastomosis by either a two-stage or three-stage approach. In these patients, nine (13%) had a change in their diagnosis to Crohn's after reconstruction. Crohn's complications requiring an operation consisted of two patients with anastomotic dilations, four patients with fistulotomies, and one patient with perianal abscess drainage procedures., Conclusions: In the children studied, 13% had a diagnostic change to Crohn's disease, and 13% were diagnosed with Crohn's after ileal pouch-anal anastomosis (IPAA). In patients with IPAA and Crohn's, there were more operative interventions for perianal disease., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Tracheal ligation has been shown to accelerate fetal pulmonary growth in normal and hypoplastic lungs. Our aim was to study the effects of tracheal ligation on established molecular markers of growth and differentiation [mitogen-activated protein (MAP) kinase] and maturity [surfactant protein B (SPB) and fatty acid synthase (FAS)]., Materials and Methods: Tracheal ligation was performed on four 100-day-gestation fetal sheep, with four age-matched fetuses undergoing maternal laparotomy and hysterotomy as control. Lungs from surviving fetuses (n = 2 in each group) were harvested after 4 days and frozen in liquid nitrogen. Protein lysates were prepared, and MAP kinase enzymatic assays [extracellular signal regulated protein kinase (ERK)-1 and -2] and Western blots were performed. Total RNA was isolated, and a fetal sheep lung cDNA library was created. The sheep SPB and FAS genes were cloned and sequenced. Northern blots were performed with the new clones, normalizing to beta-actin., Results: Tracheal ligation lungs contained a larger volume of fluid (40 ml) compared with age-matched controls (8 ml). MAP kinase enzymatic ERK-1 activity was increased and SPB mRNA expression was reduced in fetal lungs after tracheal ligation. Neither ERK-2 enzymatic activities and FAS mRNA nor ERK protein levels were affected by tracheal ligation, by Western blot analysis., Conclusion: Tracheal ligation-induced fetal lung growth may be mediated in part via the MAP kinase pathway. Expression of SPB mRNA is attenuated by tracheal ligation, whereas FAS, one of the key enzymes that synthesizes the lipid portion of surfactant, is not affected., (Copyright 1999 Academic Press.)