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Nonoperative management of acute appendicitis is a safe and effective alternative to appendectomy, though rates of treatment failure and disease recurrence are significant. The purpose of this study was to determine whether COVID-19-positive children with acute appendicitis were more likely to undergo nonoperative management when compared to COVID-19-negative peers and to compare clinical outcomes and healthcare use for these groups.A retrospective cohort study of children18 years with acute appendicitis across 45 US Children's Hospitals during the first 12 months of the COVID-19 pandemic was performed. Operative management was defined as appendectomy or percutaneous drain placement, whereas nonoperative management was defined as admission with antibiotics alone. Multivariable hierarchical logistic regression using an exact matched cohort was used to determine the association between COVID-19 positivity and nonoperative management. The secondary outcomes included intensive care unit admission, mechanical ventilation, length of stay, nonoperative management failure rates, and hospital variation in nonoperative management.Of 17,481 children in the cohort, 581 (3.3%) were positive for COVID-19. The odds of nonoperative management was significantly higher in the COVID-19-positive group (adjusted odds ratio [95% confidence interval]: 13.4 [10.7-16.8], P.001). Patients positive for COVID-19 had increased odds of intensive care unit admission (adjusted odds ratio [95% confidence interval]: 3.78 [2.01-7.12], P.001) and longer length of stay (median 2 days vs 1 day, P.001). Hospital rates of nonoperative management ranged from 0% to 100% for COVID-19-positive patients and 0% to 42% for COVID-19-negative patients.Children with concurrent acute appendicitis and COVID-19 positivity are significantly more likely to undergo nonoperative management. Both groups experience infrequent nonoperative management failure rates and rare intensive care unit admissions. Marked hospital variability in nonoperative management practices was demonstrated.

More than twenty years ago, the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties began the conversion of graduate medical education from a structure- and process-based model to a competency-based framework. The educational outcomes assessment tool, known as the Milestones, was introduced in 2013 for seven specialties and by 2015 for the remaining specialties, including pediatric surgery. Designed to be an iterative process with improvements over time based on feedback and evidence-based literature, the Milestones started the evolution from 1.0 to 2.0 in 2016. The formation of Pediatric Surgery Milestones 2.0 began in 2019 and was finalized in 2021 for implementation in the 2022-2023 academic year. Milestones 2.0 are fewer in number and are stated in more straightforward language. It incorporated the harmonized milestones, subcompetencies for non-patient care and non-medical knowledge that are consistent across all medical and surgical specialties. There is a new Supplemental Guide that lists examples, references and links to other assessment tools and resources for each subcompetency. Milestones 2.0 represents a continuous process of feedback, literature review and revision with goals of improving patient care and maintaining public trust in graduate medical education's ability to self-regulate. LEVEL OF EVIDENCE: V.

We sought to determine the relationship between a patient's proximal familial social support, defined as the geographic proximity of family members, and healthcare utilization after complex cardiovascular and oncologic procedures.Social support mechanisms are increasingly identified as modifiable risk factors for healthcare utilization.We performed a retrospective cohort study of 60,895 patients undergoing complex cardiovascular procedures or oncologic procedures. We defined healthcare utilization outcomes as 30-day all-cause readmission unplanned readmission, nonindex hospital readmission, index hospital length of stay, and home discharge disposition. For each patient, we aggregated the number of first-degree relatives (FDR) living within 30 miles of the patient's home address at the time of the surgical procedure into the following categories: 0 to 1, 2 to 3, 4 to 5, 6+ FDRs. We developed hierarchical multivariable regression models to determine the relationship between the number of FDR living within 30 miles of the patient and the healthcare utilization outcomes.Compared with patients with 0 to 1 FDRs, patients with 6+ FDRs living in close proximity had significantly lower rates of all-cause readmission (12.1% vs 13.5%, P0.001), unplanned readmission (10.9% vs 12.0%, P =0.001), nonindex readmission (2.6% vs 3.2%, P =0.003); higher rates of home discharge (88.0% vs 85.3%, P0.001); and shorter length of stay (7.3 vs 7.5 days, P =0.02). After multivariable adjustment, a larger number of FDRs living within 30 miles of the patient was significantly associated with a lower likelihood of all-cause readmission ( P0.001 for trend), 30-day unplanned readmission ( P0.001), nonindex readmission ( P0.001); higher likelihood of home discharge ( P0.001); and shorter index length of stay ( P0.001).The geographic proximity of family members is significantly associated with decreased healthcare utilization after complex cardiovascular and oncologic surgical procedures.

The insurance status of pediatric trauma patients is associated with access to post-discharge resources, including inpatient rehabilitation. Our goal was to understand the impact of changes in insurance coverage on access to post-acute care resources for pediatric trauma patients.We utilized the National Trauma Data Bank from 2012 to 2016 for all pediatric trauma patients with a highest body region abbreviated injury score2. Our primary outcome was hospital discharge disposition location. We used multivariable regression to adjust for salient patient and trauma center characteristics. Additionally, we performed a sensitivity analysis including only high-volume hospitals to examine the relationship between the magnitude of facility level expansion in coverage and changes in patient disposition.We identified 195,649 pediatric trauma patients meeting inclusion criteria. From 2012 to 2016 the proportion of patients with Medicaid (35% versus 39%, P0.001) and private insurance (39% versus 45%, P0.001) increased. Increased discharges with home health (HH) (+0.6% adjusted risk difference 2012 to 2016, P0.001) and decreased discharges to inpatient rehabilitation and skilled nursing facilities (-0.6% adjusted risk difference 2012 to 2016, P = 0.01) were associated with changes in insurance coverage. After stratifying high volume facilities by magnitude of increase in Medicaid and private insurance, we found that, for all groups, discharge to inpatient rehabilitation and skilled nursing facilities decreased (P0.01).Expanded insurance coverage for children was paradoxically associated with decreased discharge to inpatient rehabilitation and skilled nursing facilities after severe traumatic injury. These findings suggest that additional barriers may drive limitations in access to pediatric post-discharge services.

This cohort study uses administrative health data to evaluate trends in pediatric firearm injuries before and during the COVID-19 pandemic.

Differential access to specialty surgical care can drive healthcare disparities, and interhospital transfer (IHT) is one mechanism through which access barriers can be realized for vulnerable populations. The association between race/ethnicity and IHT for patients presenting with complex emergency general surgery (EGS) disease is understudied.Using the 2019 Nationwide Emergency Department Sample, we identified patients aged ≥18 years with 1 of 13 complex EGS diseases based on International Classification of Diseases 10th Edition Diagnosis Codes. The primary outcome was IHT. A series of weighted logistic regression models were created to determine the association of race/ethnicity with the primary outcome while controlling for patient and hospital characteristics.Of 387,610 weighted patient encounters from 989 hospitals, 59,395 (15.3%) patients underwent IHT. Compared to Non-Hispanic White (NHW) patients, rates of IHT were significantly lower for Non-Hispanic Black (NHB) (15% vs. 17%, unadjusted odds ratio (uOR) [95% CI]: 0.58 [0.49 - 0.68], p.001), Hispanic/Latinx (HL) (9.0% vs. 17%, uOR [95% CI]: 0.48 [0.43 - 0.54], p.001), Asian/Pacific Islander (Asian/PI) (11% vs. 17%, uOR [95% CI]: 0.84 [0.78 - 0.91], p.001), and other race/ethnicity (12% vs 17%, uOR [95% CI]: 0.68 [0.57 - 0.81], p.001) patients. In multivariable models, the adjusted odds of IHT remained significantly lower for HL (aOR [95% CI]: 0.76 [0.72 - 0.83], p.001) and Asian/PI (aOR [95% CI]: 0.73 [0.62 - 0.86], p.001) patients, but not for NHB and other race/ethnicity patients (p.05).In a nationally representative sample of Emergency Departments across the United States, patients of minority race/ethnicity presenting with complex EGS disease were less likely to undergo IHT when compared to NHW patients. Disparities persisted for HL and Asian/PI patients when controlling for comorbid conditions, hospital and residential geography, neighborhood socioeconomic status, and insurance; these patients may face unique barriers in accessing surgical care.Level III, Prognostic/Epidemiological.

The objective of this study was to develop a portal natural language processing approach to aid in the identification of postoperative venous thromboembolism events from free-text clinical notes.We abstracted clinical notes from 25,494 operative events from 2 independent health care systems. A venous thromboembolism detected as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was used as the reference standard. A natural language processing engine, easy clinical information extractor-pulmonary embolism/deep vein thrombosis (EasyCIE-PEDVT), was trained to detect pulmonary embolism and deep vein thrombosis from clinical notes. International Classification of Diseases (ICD) discharge diagnosis codes for venous thromboembolism were used as baseline comparators. The classification performance of EasyCIE-PEDVT was compared with International Classification of Diseases codes using sensitivity, specificity, area under the receiver operating characteristic curve, using an internal and external validation cohort.To detect pulmonary embolism, EasyCIE-PEDVT had a sensitivity of 0.714 and 0.815 in internal and external validation, respectively. To detect deep vein thrombosis, EasyCIE-PEDVT had a sensitivity of 0.846 and 0.849 in internal and external validation, respectively. EasyCIE-PEDVT had significantly higher discrimination for deep vein thrombosis compared with International Classification of Diseases codes in internal validation (area under the receiver operating characteristic curve: 0.920 vs 0.761; P.001) and external validation (area under the receiver operating characteristic curve: 0.921 vs 0.794; P.001). There was no significant difference in the discrimination for pulmonary embolism between EasyCIE-PEDVT and ICD codes.Accurate surveillance of postoperative venous thromboembolism may be achieved using natural language processing on clinical notes in 2 independent health care systems. These findings suggest natural language processing may augment manual chart abstraction for large registries such as NSQIP.

Children with ulcerative colitis (UC) may undergo a staged approach for restorative proctocolectomy and ileal pouch anal anastomosis (IPAA). Previous studies in adults suggest a decreased morbidity with delayed pouch creation, but pediatric studies are limited. We compared outcomes for delayed versus early pouch construction in children.Patients with UC undergoing IPAA were selected from the National Surgical Quality Improvement Program Pediatric database from 2012 to 2018. Patients were categorized as early (2-stage) or delayed (3-stage) pouch construction based on Current Procedural Terminology codes. Our primary outcome was any adverse event. We used a multivariable logistic regression model to assess the relationship between timing of pouch creation and adverse events.We identified 371 children who underwent IPAA: 157 (42.3%) had early pouch creation and 214 (57.6%) had a delayed pouch. Those with an early pouch creation were more likely to have exposure to immunosuppressants (11% vs. 5%, p = 0.017) and steroids (30% vs. 10%, p 0.001) at the time of surgery. After controlling for patient characteristics, there were no significant differences in adverse events between the two groups.Children undergoing early pouch creation have increased exposure to steroids and immune suppressants; nevertheless, no differences in adverse events were identified.II.

Background The effect of the consolidation of neonatal pediatric surgical cases to limited surgeons within a hospital is unknown. We elected to model the distribution of complex neonatal procedures using an economic measure of market concentration, the Herfindahl-Hirschmann Index (HHI), and study its effect on outcomes of index pediatric surgical operations. Methods We used data from 49 US children's hospitals between 2007 and 2017 for the following procedures: congenital diaphragmatic hernia repair (CDH), esophageal atresia and tracheoesophageal fistula repair (EA/TEF), and pull-through for Hirschsprung disease (HD). Mixed effects logistic regression modeling was used to adjust for salient patient characteristics to determine the effect of HHI on in-hospital mortality, condition-specific one-year re-operation, and one-year unplanned readmissions. Results A total of 2270 infants were identified who underwent surgery for the three conditions of interest. On multivariable analysis, increasing HHI was not associated with differences in mortality or condition-specific re-operation within the first year. A decrease in the number of unplanned readmissions at highly concentrated centers was seen for HD (RR 0.8 CI (0.69–0.97), p = 0.02) and CDH (RR 0.4 CI (0.28–0.71), p Conclusions Pediatric surgical specialization did not affect mortality or condition-specific re-operation. However, it did decrease the number of unplanned readmissions following CDH repairs and pull-throughs for HD. Study design Retrospective Cohort Study. Level of Evidence Level II.

There is increasing need to avoid excess opioid prescribing after surgery. We prospectively assessed overprescription in our hospital system and used these data to design a quality improvement intervention to reduce overprescription.Beginning in January 2017, an e-mail-based survey to assess the quantity of opioids used postoperatively as well as patient-reported pain control was sent to all surgical patients in a 23-hospital system. In January 2018, as a quality improvement initiative, guidelines were given to surgeons based on patient consumption data. Prescription and consumption were then tracked prospectively. Wilcoxon signed-rank, analysis of variance, and Cuzick trend tests were used to assess for overprescription and changes over time in opioid prescribing and consumption.We included 2239 patients in our cohort. The amount prescribed (median [IQR]: 30 [24-45] versus 18 [12-30], P 0.001) and consumed (median [IQR]: 12 [7-20] versus 8 [3-15], P 0.001) each decreased between the first and last quarter studied. Academic hospitals prescribed fewer opioids than nonacademic hospitals (median [IQR]: 24[15-40] versus median [IQR]: 30 [20-45], P 0.001). There was no difference in the quantity of opioids consumed between patients treated at academic and nonacademic facilities (median [IQR]: 10[3-19] versus 10.5 [4-20], P = 0.08). Patients consumed a median of 42% of the opioids prescribed, and there was no significant trend in the percent consumed over time (P = 0.8).Patients used far fewer opioids than prescribed after common adult general surgery procedures. When surgeons were provided with patient consumption data, the number of opioids prescribed decreased significantly.

Significant racial and ethnic disparities exist for children presenting with acute appendicitis; however, it is unknown if disparities persist after initial management and hospital discharge.We performed a retrospective cohort study of children (aged18 y) who underwent treatment for acute appendicitis in 47 U.S. Children's Hospitals between 2017 and 2019. Primary outcomes were 30-d emergency department (ED) visits and 30-d inpatient readmission. Hierarchical multivariable logistic regression models were developed to determine the association of race and ethnicity on the primary outcomes. Inverse odds-weighted mediation analyses were used to estimate the degree to which complicated disease, insurance status, urbanicity, and residential socioeconomic status- mediated disparate outcomes.A total of 67,303 patients were included. Compared with Non-Hispanic White children, Non-Hispanic Black (NHB) (odds ratio [OR] 1.40, 95% confidence interval [CI] 1.23-1.59) and Hispanic/Latinx (HL) children (OR 1.55, 95% CI 1.44-1.67) had higher odds of ED visits. Only NHB children had higher odds of readmission (OR 1.43, 95% CI 1.30-1.57). On a multivariable analysis, NHB (adjusted OR 1.19, 95% CI 1.04-1.36) and HL (adjusted OR 1.19, 95% CI 1.09-1.31) children had higher odds of ED visits. Insurance, disease severity, socioeconomic status, and urbanicity mediated 61.6% (95% CI 29.7-100%) and 66.3% (95% CI 46.9-89.3%) of disparities for NHB and HL children, respectively.Children of racial and ethnic minorities are more likely to visit the ED after treatment for acute appendicitis, but HL patients did not have a corresponding increase in readmission. These differences were mediated mainly by insurance status and urban residence. A lack of appropriate postdischarge education and follow-up may drive disparities in healthcare utilization after pediatric appendicitis.

Objective: We sought to determine the association of gastrostomy placement on post NICU-discharge resource utilization in premature infants. Study Design: We performed a propensity-matched retrospective cohort study of NICU infants born under 32-weeks’ gestation in US Children’s Hospitals. Multivariable logistic regression and propensity score-matching were used to determine the association of gastrostomy placement on 90-day hospital readmissions and emergency department visits adjusting for salient patient characteristics. Result: A total of 12,621 premature infants were included of which 697 (5.5%) underwent gastrostomy placement. After propensity matching, infants who underwent gastrostomy placement have a higher rate of 90-day inpatient readmission (41.9% vs 26.3%, p

To identify cumulative 5-year healthcare costs and healthcare days in children with anorectal malformation (ARM) and to compare the cumulative 5-year healthcare costs and healthcare days in children with ARM with 3 control cohorts: healthy, premature, and congenital heart disease (CHD).We performed a retrospective case-control study using the Truven MarketScan database of commercial claims encounters between 2008 and 2017. The ARM, CHD, and premature cohorts were identified using a targeted list of International Classification of Diseases 9th or 10th Revision diagnosis and Current Procedural Terminology codes. The healthy cohort included patients without ARM, preterm birth, or CHD.We identified 664 children with ARM, 3356 children with heart disease, 63 190 children who were born preterm, and 2947 healthy patients. At 5 years, the total healthcare costs of children with ARM ($273K, 95% CI $168K-$378K) were similar to the premature cohort ($246K, 95% CI $237K-$255K) and lower than the CHD cohort ($466K, 95% CI $401K-$530K, P .001). Total healthcare days were similar in children with ARM (158 days, 95% CI 117-198) and prematurity (141 days, 95% CI 137-144) but lower than CHD (223 days, 95% CI 197-250, P = .02). In ARM, outpatient care (126 days, 95% CI 93-159) represented the largest contribution to total healthcare days.Children with ARM accumulate similar healthcare costs to children with prematurity and comparable healthcare days to children with CHD and prematurity in the first 5 years of life. Outpatient care represents the majority of healthcare days in children with ARM, identifying this as a target for quality improvement and demonstrating the long-term impact of this condition.

We performed a retrospective analysis of the changes in accuracy of International Classification of Diseases, Clinical Modification (ICD-CM) diagnosis codes for colectomy and hysterectomy surgical site infection surveillance. After the transition from ICD-CM ninth edition to tenth edition codes, there was no significant change in the accuracy of these codes for SSI surveillance.

Objectives We present the development and validation of a portable NLP approach for automated surveillance of SSIs. Summary of background data The surveillance of SSIs is labor-intensive limiting the generalizability and scalability of surgical quality surveillance programs. Methods We abstracted patient clinical text notes after surgical procedures from 2 independent healthcare systems using different electronic healthcare records. An SSI detected as part of the American College of Surgeons' National Surgical Quality Improvement Program was used as the reference standard. We developed a rules-based NLP system (Easy Clinical Information Extractor [CIE]-SSI) for operative event-level detection of SSIs using an training cohort (4574 operative events) from 1 healthcare system and then conducted internal validation on a blind cohort from the same healthcare system (1850 operative events) and external validation on a blind cohort from the second healthcare system (15,360 operative events). EasyCIE-SSI performance was measured using sensitivity, specificity, and area under the receiver-operating-curve (AUC). Results The prevalence of SSI was 4% and 5% in the internal and external validation corpora. In internal validation, EasyCIE-SSI had a sensitivity, specificity, AUC of 94%, 88%, 0.912 for the detection of SSI, respectively. In external validation, EasyCIE-SSI had sensitivity, specificity, AUC of 79%, 92%, 0.852 for the detection of SSI, respectively. The sensitivity of EasyCIE-SSI decreased in clean, skin/subcutaneous, and outpatient procedures in the external validation compared to internal validation. Conclusion Automated surveillance of SSIs can be achieved using NLP of clinical notes with high sensitivity and specificity.

Introduction The current understanding of Hirschsprung-associated enterocolitis (HAEC) is based mainly on single-center, retrospective studies. The aims of this study are to determine risk factors for postoperative HAEC using the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) database. Materials and Methods We performed a multicenter, retrospective, case–control study of children with Hirschsprung disease (HD) who had undergone a pull-through procedure and were evaluated at a PCPLC member site between February 2017 and March 2020. The cohort with a history of postoperative HAEC was compared with that without postoperative episodes of HAEC to determine relevant associations with postoperative HAEC. Results One-hundred forty of 299 (46.8%) patients enrolled had a history of postoperative HAEC. Patients with a rectosigmoid transition zone had a lower association with postoperative HAEC as compared with those with a more proximal transition zone (odds ratio [OR]: 0.46, 95% confidence interval [CI]: 0.26, 0.84, p Conclusion Patients with a rectosigmoid transition zone have less postoperative HAEC compared with patients with a more proximal transition zone. Multi-institutional collection of clinical information in patients with HD may allow for the identification of additional risk factors for HAEC and afford the opportunity to improve care.

Background Hirschsprung-associated enterocolitis (HAEC) is a serious potential complication after primary pull-through surgery for Hirschsprung's disease (HSCR). Administration of anal botulinum toxin (BT) injection may improve obstructive symptoms at the internal anal sphincter, leading to improved fecal passage. The timing of administration and effects on delay or prevention of HAEC are unknown. We hypothesized that BT administration increased the postoperative time to HAEC and aimed to investigate whether anal BT administration after primary pull-through surgery for HSCR is associated with increased time to inpatient HAEC admission development. Methods We performed a retrospective cohort study examining children with HSCR at US children's hospitals from 2008 to 2018 using the Pediatric Health Information System database with an associated primary pull-through operation performed before 60 d of age. The intervention assessed was the administration of BT concerning the timing of primary pull-through, and two groups were identified: PRO (received BT at or after primary pull-through, before HAEC) and NOT (never received BT, or received BT after HAEC). The primary outcome was time from pull-through to the first HAEC admission. The Cox proportional hazards model was developed to examine the BT administration effect on the primary outcome after controlling for patient-level covariates. Results We examined a total of 1439 children (67 in the PRO and 1372 in the NOT groups). A total of 308 (21.4%) developed at least one episode of HAEC, including 76 (5.3%) who had two or more episodes. Between 2008 and 2018, the frequency of BT administration has increased from three to 20 hospitals with a frequency of administration between 2.2% and 16.2%. Prophylactic BT (PRO) was not associated with increased time to HAEC event on adjusted analysis. Conclusions Among children with HSCR undergoing primary pull-through surgery, prophylactic BT administration did not demonstrate increased time to first HAEC event. A better-powered study with prophylactic BT is required to determine the effect on HAEC occurrence and timing. Level of Evidence Level II (retrospective cohort study).

BACKGROUND: The variability of parenteral nutrition (PN) utilization for pediatric inpatients is currently unknown. The purpose of this study is to determine the variability in PN utilization in U.S. children’s hospitals and the association of PN utilization with inpatient healthcare utilization. METHODS: We performed a retrospective cohort study of children who received PN during an inpatient encounter in U.S. children’s hospitals. Hospitals were divided into tertiles based on their rates of PN utilization into low (51.8/1,000 encounters) categories. Multivariable regression models were developed to assess the associations between hospital PN utilization and time to PN initiation, PN duration, and encounter length of stay after adjustment for salient patient characteristics. RESULTS: The cohort included 82,142 patients receiving PN, and rates of hospital PN utilization ranged from 5.9 to 76.7 encounters receiving PN per 1,000 inpatient encounters. After multivariable adjustment, patients treated at high utilization hospitals had a significantly shorter time to initiation of PN compared to low utilization hospitals (incident rate ratio [95% Confidence Interval]: 0.78 [0.69–0.89], p

Introduction To our knowledge, there are no studies to date that have compared patients with isolated anorectal malformation (ARM) to patients with ARM and an associated genitourinary (GU) malformation despite a possible etiological difference between these two entities. We examined the differences in maternal and prenatal exposures and comorbidities between patients with isolated ARM and patients with ARM and associated GU malformations. Materials and methods A retrospective cohort study of children with ARM, enrolled in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) between February 2017 and October 2019, was performed comparing those with isolated ARM to those with ARM and associated GU anomalies (GU +/- additional anomalies) as well as to those with ARM and a GU anomaly with no anomaly of any other system (GU-only). We compared the prevalence of prematurity, family history of colorectal disorders, as well as maternal and prenatal comorbidities and exposures between these two cohorts and the isolated ARM cohort. Results A total of 505 patients (117 with isolated ARM and 388 with ARM and associated GU anomalies) were enrolled. Of the 388 patients with ARM and associated GU anomalies, 48 had an ARM with a GU anomaly without an anomaly in any other system. There was an increased prevalence of premature births in the GU +/- additional anomalies cohort compared to the isolated ARM cohort (27 vs 14%, p=0.003). This difference was not seen in the GU-only cohort. There was no difference between the cohorts regarding prevalence of family history of ARM or maternal and prenatal comorbidities or exposures. Conclusions Patients with an ARM and an associated GU anomaly with or without other congenital anomalies are more likely to be born prematurely compared to patients with an isolated ARM. Parents of these children should be counseled on this increased risk.

Surgical Site Infection surveillance in healthcare systems is labor intensive and plagued by underreporting as current methodology relies heavily on manual chart review. The rapid adoption of electronic health records (EHRs) has the potential to allow the secondary use of EHR data for quality surveillance programs. This study aims to investigate the effectiveness of integrating natural language processing (NLP) outputs with structured EHR data to build machine learning models for SSI identification using real-world clinical data. We examined a set of models using structured data with and without NLP document-level, mention-level, and keyword features. The top-performing model was based on a Random Forest classifier enhanced with NLP document-level features achieving a 0.58 sensitivity, 0.97 specificity, 0.54 PPV, 0.98 NPV, and 0.52 F(0.5) score. We further interrogated the feature contributions, analyzed the errors, and discussed future directions.

Social Determinants of Health, including marital status, are becoming increasingly identified as key drivers of health care utilization. This paper describes a robust method to determine the marital status of patients using structured and unstructured electronic healthcare data from a single academic institution in the United States. We developed and validated a natural language processing pipeline (NLP) for the ascertainment of marital status from clinical notes and compared the performance against two baseline methods: a machine learning n-gram model, and structured data obtained from the electronic health record. Overall our NLP engine had excellent performance on both document-level (F1 0.97) and patient-level (F1 0.95) classification. The NLP Engine had superior performance compared with a baseline machine learning n-gram model. We also observed a good correlation between the marital status obtained from our NLP engine and the baseline structured electronic healthcare data (κ 0.6).

Purpose We sought to examine the short-term outcomes following single-stage repair of rectoperineal and rectovestibular fistulae in infants and identify risk factors for wound complication. Methods Patients with a rectoperineal or rectovestibular fistula treated with a single-stage repair beyond the neonatal period (>30days of age) at a pediatric colorectal center (2011–2016) were reviewed. Results 36 patients with a rectoperineal and 7 patients with a rectovestibular fistula were repaired using the Posterior Sagittal Anorectoplasty (PSARP) approach. Median follow-up was 31months. The median age and weight at the time of repair were 166days and 6.5kg. Four patients (11%) suffered a wound complication (3 rectoperineal, 1 rectovestibular). Two required a diverting colostomy to allow wound healing. Two patients suffered skin separation managed with local wound care. All 4 patients experienced satisfactory wound healing without anoplasty stricture. Two different patients developed a stricture of the neo-anus. Age and weight at time of repair, gender, and presence of a genitourinary anomaly were not associated with wound complications. Conclusion Delayed single-stage repair of rectoperineal and rectovestibular fistulae can be performed safely in infants beyond the newborn period. With attentive treatment, satisfactory healing can be anticipated if a wound complication is encountered. Level of Evidence Retrospective Comparative Study, Level III.

Background Machine-learning can elucidate complex relationships/provide insight to important variables for large datasets. This study aimed to develop an accurate model to predict neonatal surgical site infections (SSI) using different statistical methods. Methods The 2012–2015 National Surgical Quality Improvement Program-Pediatric for neonates was utilized for development and validations models. The primary outcome was any SSI. Models included different algorithms: full multiple logistic regression (LR), a priori clinical LR, random forest classification (RFC), and a hybrid model (combination of clinical knowledge and significant variables from RF) to maximize predictive power. Results 16,842 patients (median age 18 days, IQR 3–58) were included. 542 SSIs (4%) were identified. Agreement was observed for multiple covariates among significant variables between models. Area under the curve for each model was similar (full model 0.65, clinical model 0.67, RF 0.68, hybrid LR 0.67); however, the hybrid model utilized the fewest variables (18). Conclusions The hybrid model had similar predictability as other models with fewer and more clinically relevant variables. Machine-learning algorithms can identify important novel characteristics, which enhance clinical prediction models.

Secretory breast carcinoma (SBC) is a rare form of breast cancer found in both children and adults, and is the most common breast cancer in the pediatric population. Although SBC usually carries a favorable prognosis, there have been reported cases of axillary and distant metastases. Surgery is the primary mode of treatment, however, there exists variability within the literature surrounding the management of SBC. We report a case of an 8-year-old girl who presented with a firm, mobile, palpable breast mass. Ultrasonography was performed, followed by local excision, with surgical pathology concerning for SBC. The patient was definitively treated with mastectomy and sentinel lymph node (SLN) biopsy. She received no adjuvant therapies and 2 years later, remains disease free. Herein, we review the literature, curate data from 89 reported cases of pediatric and adult SBC, and address some of the controversy surrounding its treatment. From this review we conclude that patients with SBC should be reviewed at multidisciplinary treatment planning conference, undergo surgery with mastectomy or lumpectomy with SLN biopsy, and have long-term postoperative follow-up.

Background The optimal time to reinsert central venous catheters (tCVC) after a documented central line associated blood stream infection (CLABSI) is unclear. The goal of this study is to identify risk factors for children who develop persistent bacteremia after tCVC removal due to CLABSI. Methods We performed a retrospective cohort study from a tertiary children's hospital. Children who underwent removal of a tCVC due to CLABSI were included in our analysis. Our primary outcome was persistent bacteremia after tCVC removal defined by a persistently positive blood culture. Salient patient demographic and clinical factors were extracted from the medical record. Results A total of 140 patients met inclusion criteria and 27 (19%) had a persistent CLABSI after removal of the tCVC. There were no significant differences between the patients who cleared their bacteremia and those who develop persistent bacteremia. The median (IQR) time to positive blood culture after tCVC removal was 2.7 days (1.7– 4.0). Conclusions We did not identify any patient risk factors distinguishing between a child who will clear a CLABSI versus develop a persistent CLABSI after tCVC removal. Blood stream infection clearance was rapid after tCVC removal, supporting a brief line holiday prior to tCVC reinsertion. Level of Evidence Level III Retrospective Case-Control Study

BACKGROUND: Surgical complications have tremendous consequences and costs. Complication detection is important for quality improvement, but traditional manual chart review is burdensome. Automated mechanisms are needed to make this more efficient. To understand the generalizability of a machine learning algorithm between sites, automated surgical site infection (SSI) detection algorithms developed at one center were tested at another distinct center. STUDY DESIGN: NSQIP patients had electronic health record (EHR) data extracted at one center (University of Minnesota Medical Center, Site A) over a 4-year period for model development and internal validation, and at a second center (University of California San Francisco, Site B) over a subsequent 2-year period for external validation. Models for automated NSQIP SSI detection of superficial, organ space, and total SSI within 30 days postoperatively were validated using area under the curve (AUC) scores and corresponding 95% confidence intervals. RESULTS: For the 8,883 patients (Site A) and 1,473 patients (Site B), AUC scores were not statistically different for any outcome including superficial (external 0.804, internal [0.784, 0.874] AUC); organ/space (external 0.905, internal [0.867, 0.941] AUC); and total (external 0.855, internal [0.854, 0.908] AUC) SSI. False negative rates decreased with increasing case review volume and would be amenable to a strategy in which cases with low predicted probabilities of SSI could be excluded from chart review. CONCLUSIONS: Our findings demonstrated that SSI detection machine learning algorithms developed at 1 site were generalizable to another institution. SSI detection models are practically applicable to accelerate and focus chart review.

Purpose Awareness of equestrian related injury remains limited. Studies evaluating children after equestrian injury report under-utilization of safety equipment and rates of operative intervention as high as 33%. Methods We hypothesized that helmets are underutilized during equestrian activity and lack of use is associated with increased traumatic brain injury. We queried the trauma database of a level one pediatric trauma center for all cases of equestrian and rodeo related injury from 2005 to 2015. Analysis was conducted using SAS 9.4. Results Of 312 children identified, 142 were assessed for use of a helmet. Only 28 children (19.7%) had documented use of a helmet. Most injuries occurred while riding a horse (83%) or bull (13%) with traumatic brain injury being the most common injury (51%). Helmet use was associated with decreased ISS (7.1 vs. 11.3, p p =0.03), and ICU admission (10.7% vs. 29%, p =0.05). Multivariable analysis reveals lack of helmet use to be an independent predictor of TBI (OR 2.5, 95% CI 1.1–6.3). Conclusion Helmets are underutilized by children during equestrian related activity. Increased awareness of TBI and education encouraging helmet use may decrease morbidity associated with equestrian activities. Level of Evidence Retrospective comparative study, Level III.

BACKGROUND: The incidence of and risk factors for Hirschsprung’s-associated enterocolitis (HAEC) following pull-through have been limited to single institutions studies. We characterized the incidence of, risk factors for, and consequences of post-operative HAEC. METHODS: We identified children with Hirschsprung’s Disease (HD) at US Children’s Hospitals from 2007 to 2017 with and an associated pull-through operation at less than 1 year of age. HAEC readmissions were identified using ICD9/10 Diagnosis Codes and antibiotic administration. Hierarchical logistic regression models were developed for the risk factors for HAEC after pull-through and effects of recurrent HAEC on HD-related reoperations. RESULTS: We identified 2030 children with HD, and 138 (7%) who had two or more readmissions related to HAEC. The frequency of recurrent HAEC by hospital ranged from 0 to 33%. Pre-operative HAEC, history of central nervous system infection, and congenital neurologic anomalies were associated with increased risk of recurrent HAEC. Recurrent HAEC was associated with HD-specific re-operation (OR 5.2, CI 3.3–8.1, p < 0.001); however, it was not associated with risk of in-hospital mortality (OR 3.3, CI 0.88–12.1, p = 0.08). CONCLUSIONS: HAEC following pull-through occurs in a large proportion of infants with HD and predicts reoperation. Multicenter studies are needed to develop prediction models and treatment protocols for HAEC. LEVEL OF EVIDENCE: II TYPE OF STUDY: Retrospective cohort study.

Background/purpose The purpose of this study was to study the effect of trisomy 21 (T21) on enterocolitis rates and bowel function among children with Hirschsprung disease (HD). Methods A retrospective cohort study of patients with HD treated at our tertiary children's hospital (2000–2015) and a cohort of patients with HD treated in our pediatric colorectal center (CRC) (2011–2015) were performed. Results 26/207 (13%) patients with HD had T21. 70 (41%) with HD alone were diagnosed with enterocolitis episodes compared to 9 (38%) with HD+T21 ( p =0.71). 55/207 patients were managed in the CRC. 11/55 patients (20%) had HD+T21. 25 (58%) with HD had one or more enterocolitis episodes compared to 4 (36%) with HD+T21 ( p =0.20). Number of hospitalizations for enterocolitis was similar between all groups. Toilet training was assessed in 32 CRC patients (25 HD, 7 HD+T21). One child with HD+T21 was toilet trained by age 4years versus 12 with HD ( p =0.20). Laxative or enema therapy was required for constipation management in 57% HD versus 64% HD+T21. Conclusion Enterocolitis rates in children with HD+T21 did not differ from rates in children with HD alone. The majority of patients with CRC follow-up had constipation requiring laxative or enema therapy, which demonstrates the need for consistent postoperative follow-up. Level of Evidence: Retrospective Study – Level II.

Importance Conventional approaches for tracking postoperative adverse events requires manual medical record review, thus limiting the scalability of such efforts. Objective To determine if a surveillance system using computerized provider order entry (CPOE) events for selected medications as well as laboratory, microbiologic, and radiologic orders can decrease the manual medical record review burden for surveillance of postoperative complications. Design, Setting, and Participants This cohort study reviewed the medical records of 21 775 patients who underwent surgical procedures at a university-based tertiary referral center (University of Utah, Salt Lake City) from July 1, 2007, to August 31, 2017. Patients were included if their case was selected for review by a surgical clinical reviewer as part of the National Surgical Quality Improvement Program. Patients were excluded if they had incomplete follow-up data. Main Outcomes and Measures Thirty-day postoperative occurrences of superficial surgical site infection, deep surgical site infection, organ space surgical site infection, urinary tract infection, pneumonia, sepsis, septic shock, deep vein thrombosis requiring therapy, and pulmonary embolism, as defined by the National Surgical Quality Improvement Program. A logistic regression model was developed for each postoperative complication using CPOE features as predictors on a development set, and performance was measured on a holdout internal validation set. The models were internally validated using bootstrapping with 10 000 replications to determine the sensitivity, specificity, positive predictive value, and negative predictive value of CPOE-based surveillance system. Results The study included 21 775 patients who underwent surgical procedures. Among these patients, 11 855 (54.4%) were women and 9920 (45.6%) were men, with a mean (SD) age of 51.7 (16.8) years. Overall, the prevalence of postoperative complications was low, ranging from 0.2% (pulmonary embolism) to 2.6% (superficial surgical site infection). Use of CPOE events to detect patients who experienced at least 1 complication had a sensitivity of 74.8% (95% CI, 71.1%-78.4%), specificity of 86.8% (95% CI, 85.5%-88.3%), positive predictive value of 33.8% (95% CI, 31.2%-36.4%), negative predictive value of 97.5% (95% CI, 97.1%-97.8%), and area under the curve of 0.808 (95% CI, 0.791-0.824). The negative predictive value for individual complications ranged from 98.7% to 100%. Use of CPOE events to screen for adverse events was estimated to diminish the burden of manual medical record review by 55.4% to 90.3%. A CPOE-based surveillance system performed well for both inpatient and outpatient procedures. Conclusions and Relevance A CPOE-based surveillance of postoperative complications has high negative predictive value, which demonstrates that this approach can augment the currently used, resource-intensive manual medical record review process.

Key Points Question Can a natural language processing approach that uses text from clinical notes identify bleeding events among critically ill patients? Findings In this diagnostic study of a rules-based natural language processing model to identify bleeding events using clinical notes, the model was superior to a machine learning approach, with high sensitivity and negative predictive value. The extra trees machine learning model had high sensitivity but poor positive predictive value. Meaning Bleeding complications can be detected with a high-throughput natural language processing algorithm, an approach that can be used for quality improvement and prevention programs., This diagnostic study compares a rules-based natural language processing (NLP) model with a machine learning (ML) model to detect bleeding events among patients in an intensive care unit (ICU) using clinical notes., Importance To improve patient safety, health care systems need reliable methods to detect adverse events in large patient populations. Events are often described in clinical notes, rather than structured data, which make them difficult to identify on a large scale. Objective To develop and compare 2 natural language processing methods, a rules-based approach and a machine learning (ML) approach, for identifying bleeding events in clinical notes. Design, Setting, and Participants This diagnostic study used deidentified notes from the Medical Information Mart for Intensive Care, which spans 2001 to 2012. A training set of 990 notes and a test set of 660 notes were randomly selected. Physicians classified each note as present or absent for a clinically relevant bleeding event during the hospitalization. A bleeding dictionary was developed for the rules-based approach; bleeding mentions were then aggregated to arrive at a classification for each note. Three ML models (support vector machine, extra trees, and convolutional neural network) were developed and trained using the 990-note training set. Another instance of each ML model was also trained on a sample of 450 notes, with equal numbers of bleeding-present and bleeding-absent notes. The notes were represented using term frequency–inverse document frequency vectors and global vectors for word representation. Main Outcomes and Measures The main outcomes were accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for each model. Following training, the models were tested on the test set and sensitivities were compared using a McNemar test. Results The 990-note training set represented 769 patients (296 [38.5%] female; mean [SD] age, 67.42 [14.7] years). The 660-note test set represented 527 patients (211 [40.0%] female; mean [SD] age, 67.86 [14.7] years). Bleeding was present in 146 notes (22.1%). The extra trees down-sampled model and rules-based approaches were similarly sensitive (93.8% vs 91.1%; difference, 2.7%; 95% CI, −3.8% to 7.9%; P = .44). The positive predictive value for the extra trees model, however, was 48.6%. The rules-based model had the best performance overall, with 84.6% specificity, 62.7% positive predictive value, and 97.1% negative predictive value. Conclusions and Relevance Bleeding is a common complication in health care, and these results demonstrate an automated and scalable detection method. The rules-based natural language processing approach, compared with ML, had the best performance in identifying bleeding, with high sensitivity and negative predictive value.

Background There are various suture techniques used during laparoscopic gastrostomy to secure the stomach to the anterior abdominal wall. However, it remains unclear whether temporary fixation or subcutaneous absorbable sutures predispose pediatric patients to fewer postoperative complications. Our goal was to determine if a particular suture technique resulted in an increased risk for the development of postoperative complications. Materials and methods A retrospective cohort analysis was performed for patients less than 18 y of age who underwent laparoscopic gastrostomy at a tertiary Children's Hospital between 2012 and 2016. Children were grouped according to suture techniques for laparoscopic gastrostomy placement: temporary sutures or subcutaneous absorbable sutures. Postoperative outcomes at 30 d were defined as major complications (tube dislodgement, unplanned reoperation, readmission) and minor complications (stitch abscess, surgical site infection, emergency department visit). The chi squared test was used to determine if an association existed between the suture techniques and 30 d postoperative complications. Results We identified 682 pediatric patients who underwent laparoscopic gastrostomy. There were 301 (44%) patients with subcutaneous sutures placed and 381 (56%) with temporary sutures placed. The overall rate of major and minor complications was 8.3% and 22%, respectively. We observed a significant difference in the occurrence of major postoperative complications between the subcutaneous and temporary suture techniques (11% versus 6.3%, P = 0.029). There was no significant difference in the development of minor complications between subcutaneous and temporary suture techniques. Conclusions Children who receive subcutaneous sutures during laparoscopic gastrostomy are at an increased risk for developing a major postoperative complication.

Retained foreign bodies discovered after surgery are documented as Agency for Health Care Quality and Research Patient Safety Indicators. Our goal was to identify pediatric patient and procedure risk factors and outcomes associated with RFB based on AHRQ Definitions.We performed a retrospective case-control study of children with RFB using the PHIS database. Patients were defined as having RFB based on the AHRQ PSI definition. Controls were matched in a 5:1 ratio on age, procedure date, and hospital. Our primary outcome was the presence of RFB. Secondary outcomes included hospital length of stay and mortality.Patients with RFB often underwent emergent procedures, experienced one or more chronic conditions, and required ICU admission or mechanical ventilation. Musculoskeletal procedures contribute the largest numbers of RFB (30.4%), but interventional radiology procedures had higher odds of having RFB (AOR 7.88, p 0.0001). After multivariate adjustment, children with RFB required 4 more days of hospitalization (p .001), but there was no difference in mortality (p = .579).The implications of our study include identifying which administrative flags can be used to identify children at higher risks for RFB. Early identification of at-risk patients and prevention are key towards addressing the primary problem and corresponding sequela of RFB.Prognostic Study Level III.

Esophageal atresia (EA) without tracheoesophageal fistula is characterized typically by a long gap between the discontinuous upper and lower esophageal pouches. In these challenging patients, initial esophagoesophagostomy is often not possible due to excessive tension produced when approximating the two pouches. This tension poses significant risk for pouch retraction, anastomotic leak, mediastinitis, and subsequent esophageal stricture. Consequently, multiple strategies exist to induce pouch lengthening and to achieve full continuity of native esophageal tissue, which if not accomplished, requires interpositions of stomach, small bowel, or colon to establish deglutition. One strategy involves a two-staged approach: first, after a period of growth into early infancy, the two esophageal pouches are suture-approximated without anastomosis, and second, repeat surgery is performed to establish luminal continuity once tension between the pouches has resolved. Esophageal growth and continuity are thereby achieved. Here, we describe an innovative, staged treatment approach for long-gap EA in two premature babies who initially underwent suture-approximation of the esophageal pouches at 3 months of age, followed by catheter-based magnetic compression anastomosis 10 weeks later. In both babies, the magnetic procedure allowed preservation of the gained full esophageal length, established successful esophageal canalization, created a leak-free anastomosis, and prevented the need for additional thoracotomy to accomplish these goals.