Search

OBJECTIVE: Clinical trial designs that randomize patients to fixed treatment regimens may disrupt preexisting relationships between illness severity and level of therapy. The practice misalignments created by such designs may have unintended effects on trial results and safety. METHODS: To illustrate this problem, the Transfusion Requirements in Critical Care (TRICC) trial and the Acute Respiratory Distress Syndrome Network low tidal volume (ARMA) trial were analyzed. RESULTS: Publications before TRICC indicated that clinicians used higher transfusion thresholds in patients with ischemic heart disease compared with younger, healthier patients (p = .001). The trial, however, randomized patients (n = 838) to liberal (10 g/dL hemoglobin) or restrictive (7 g/dL) transfusion thresholds. Thirty-day mortality was different and opposite in the liberal compared with the restrictive arm depending on presence (21 vs. 26%) or absence (25 vs. 16%) of ischemic heart disease (p = .03). At baseline in ARMA, consistent with prior publications, physicians set ventilator volumes lower in patients with high airway pressures and poor compliance (8.4-10.6 mL/kg interquartile range) than patients with less severe abnormalities (9.6-12 mL/kg) (p = .0001). In the trial, however, patients (n = 861) were randomized to low (6 mL/kg) or high (12 mL/kg) tidal volumes. In patients with low compliance (<0.6 mL/kg), 28-day mortality was higher when tidal volumes were raised rather than lowered (42 vs. 29%), but this effect was reversed in patients with higher compliance (21 vs. 37%; p = .003). CONCLUSIONS: In TRICC and ARMA, randomization to fixed treatment regimens disrupted preexisting relationships between illness severity and therapy level. This created noncomparable subgroups in both study arms that received care different and opposite from titrated care, that is, practice misalignments. These subgroups reduced the interpretability and safety of each trial. Characterizing current practice, incorporating current practice controls, and using alternative trial designs to minimize practice misalignments should improve trial safety and interpretability. [ABSTRACT FROM AUTHOR]

Background: Nonoperative management (NOM) with antibiotics alone for pediatric uncomplicated appendicitis is accepted to be safe and effective. However, the relative cost-effectiveness of this approach compared with appendectomy remains unknown. We aimed to evaluate the cost-effectiveness of nonoperative vs operative management for pediatric uncomplicated acute appendicitis., Study Design: A trial-based real-world economic evaluation from the healthcare sector perspective was performed using data collected from a multi-institutional nonrandomized controlled trial investigating NOM vs surgery. The time horizon was 1 year, with costs in 2023 US dollars. Ratio of costs-to-charges-based data for the initial hospitalization, readmissions, and unplanned emergency department visits were extracted from the Pediatric Health Information System. Utility data were derived from patient-reported disability days and health-related quality-of-life scores. Multiple scenarios and 1-way deterministic and probabilistic sensitivity analyses accounted for parameter uncertainty. Willingness-to-pay threshold was set at $100,000 per quality-adjusted life year (QALY) or disability-adjusted life year. Primary outcome measures included total and incremental mean costs, QALY, disability-adjusted life year, and incremental cost-effectiveness ratios., Results: Of 1,068 participants, 370 (35%) selected NOM and 698 (65%) selected urgent laparoscopic appendectomy. Operative management cost an average of $9,791 per patient and yielded an average of 0.884 QALYs, whereas NOM cost an average of $8,044 per patient and yielded an average of 0.895 QALYs. NOM was both less costly and more effective in base case and scenario analyses using disability days and alternate methods of calculating uses., Conclusions: NOM is cost-effective compared with laparoscopic appendectomy for pediatric uncomplicated appendicitis for 1 year., (Copyright © 2025 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Early Kasai portoenterostomy (KPE) for infants with biliary atresia (BA) increases the chance of transplant-free survival (TFS). However, early timing of KPE is not consistently achieved in the United States. Clearance of jaundice at three months is predictive of TFS. Among a cohort of patients with BA, we investigated institutional variability in the initiation of hyperbilirubinemia evaluation and operative timing to identify factors associated with successful jaundice clearance., Methods: A multi-institutional, retrospective study was performed at eleven U.S. tertiary children's hospitals. Infants diagnosed with BA between 10/1/2015-10/1/2020 were identified. Age at initiation of diagnostic workup and age at KPE were collected. Adjusted multivariable logistic regression was used to determine factors associated with direct bilirubin normalization at three months following KPE., Results: In 161 infants, the median age at initiation of jaundice evaluation was 35 days (IQR 8-60). Among 148 patients who underwent KPE, median age at surgery was 53 days (IQR 37.3-67.5). Each 10-day increase in age at KPE was associated with a 18.8 % decrease in odds of normalizing bilirubin at three months (OR 0.81, 95 % CI 0.66-0.99), with infants who underwent KPE ≤50 days significantly more likely to normalize bilirubin (OR 2.6, CI 1.1-6.1) compared to KPE >50 days. There was significant variation among institutions in the time from initiation of workup to KPE (range 0-24.5 days, p = 0.02) and the odds of patients normalizing direct bilirubin at three months (range 0.04-0.89, p = 0.044)., Conclusion: Our results confirmed that increasing age at KPE decreases the odds of clearing bilirubin at three months post-KPE. We identified significant institutional variability in the time from workup to KPE that may have impacted the likelihood of successful biliary drainage., Level of Evidence: IV (Well-designed case-control or cohort study)., Competing Interests: Conflicts of interest Nothing to report., (Copyright © 2025 Elsevier Inc. All rights reserved.)

Objective: To investigate the heterogeneity of treatment effects (HTE) of laser epilation in preventing pilonidal disease recurrence through analysis of prespecified clinical factors., Background: Pilonidal disease is a common, painful disease affecting 1% of the population aged 15 to 30 years with postoperative recurrence rates as high as 30% to 40%., Methods: Single-institution randomized controlled trial from September 2017 to September 2022 with 1-year follow-up, including patients aged 11 to 21 years with pilonidal disease undergoing gluteal cleft laser epilation and standard care (improved hygiene and mechanical or chemical depilation) or standard care alone., Results: In total, 302 patients were enrolled with 151 randomized to each intervention. 1-year follow-up was available for 96 patients in the laser group and 134 in the standard care group. There were no significant differences in treatment effects based on sex, body mass index, previous disease, prior surgical excision, or annual household income (all P > 0.05). HTE was identified by race and ethnicity ( P = 0.005) and health insurance type ( P = 0.001). Recurrence among non-Hispanic white patients was 4% (3/75) with laser treatment and 31.6% (31/98) with standard care versus 38.9% (7/18) with laser treatment and 38.2% (13/34) with standard care among all other racial/ethnic groups. Recurrence rates among privately insured patients were 4.0% (3/75) with laser treatment and 33.3% (29/87) with standard care versus 36.8% (7/19) with laser treatment and 29.7% (11/37) with standard care in patients with public insurance., Conclusions: The effectiveness of laser epilation to reduce pilonidal disease recurrence rates may vary based on race and ethnicity and insurance type. Additional studies are warranted to investigate this potential HTE., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Study Objective: To assess the diagnostic performance of MRI to predict ovarian malignancy alone and compared with other diagnostic studies., Methods: A retrospective analysis was conducted of patients aged 2-21 years who underwent ovarian mass resection between 2009 and 2021 at 11 pediatric hospitals. Sociodemographic information, clinical and imaging findings, tumor markers, and operative and pathology details were collected. Diagnostic performance for detecting malignancy was assessed by calculating sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for MRI with other diagnostic modalities., Results: One thousand and fifty-three patients, with a median age of 14.6 years, underwent resection of an ovarian mass; 10% (110/1053) had malignant disease on pathology, and 13% (136/1053) underwent preoperative MRI. MRI sensitivity, specificity, PPV, and NPV were 60%, 94%, 60%, and 94%. Ultrasound sensitivity, specificity, PPV, and NPV were 31%, 99%, 73%, and 95%. Tumor marker sensitivity, specificity, PPV, and NPV were 90%, 46%, 22%, and 96%. MRI and ultrasound concordance was 88%, with sensitivity, specificity, PPV, and NPV of 33%, 99%, 75%, and 94%. MRI sensitivity in ultrasound-discordant cases was 100%. MRI and tumor marker concordance was 88% with sensitivity, specificity, PPV, and NPV of 100%, 86%, 64%, and 100%. MRI specificity in tumor marker-discordant cases was 100%., Conclusion: Diagnostic modalities used to assess ovarian neoplasms in pediatric patients typically agree. In cases of disagreement, MRI is more sensitive for malignancy than ultrasound and more specific than tumor markers. Selective use of MRI with preoperative ultrasound and tumor markers may be beneficial when the risk of malignancy is uncertain., Concise Abstract: This retrospective review of 1053 patients aged 2-21 years who underwent ovarian mass resection between 2009 and 2021 at 11 pediatric hospitals found that ultrasound, tumor markers, and MRI tend to agree on benign vs malignant, but in cases of disagreement, MRI is more sensitive for malignancy than ultrasound., (Copyright © 2023. Published by Elsevier Inc.)

Purpose: Long-term psychological effects may occur after childhood dog bite injuries. We performed a national survey to assess psychosocial interventions for children presenting with dog bite injuries to pediatric trauma centers., Methods: A 26-question, online survey was administered to Pediatric Trauma Program Managers in the United States ( n  = 83). The survey queried whether institutions provide directed psychosocial interventions to pediatric dog bite injury patients in the Emergency Department, inpatient, or outpatient settings and the types of interventions being used. Descriptive statistics were performed to demonstrate survey results., Results: In total, 28 American College of Surgeons or State-verified Pediatric Trauma Centers responded to the survey ( n  = 28/83, 34%). Of the respondents, 18 (64.3%) did not have any interventions in place to address the psychosocial effects of pediatric patients' dog bite injuries. Of the 10 (35.7%) institutions with interventions in place, the types of psychosocial resources offered included: automated order sets within the electronic medical record, specialized teams that assess the patient while hospitalized or outpatient, child psychology referrals initiated at discharge, pet therapy, and trauma resiliency programs., Conclusion: Most institutions surveyed did not have protocols or interventions in place to address psychosocial disturbances in children with dog bite injuries. We provide the example of our institution's practice, in which automatic psychology consults are placed for every child who is admitted with a dog bite injury. Performing caregiver education in the emergency department, providing caregivers with regional psychosocial resources, and communicating with a child's pediatrician may promote the necessary standardized psychological screening and/or follow up of these patients., Competing Interests: Conflict of interestAll authors have no conflicts of interest to declare. The authors have no commercial associations or sources of support that might pose a conflict of interest., (© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2024.)

Importance: Recurrence continues to be a significant challenge in the treatment and management of pilonidal disease., Objective: To compare the effectiveness of laser epilation (LE) as an adjunct to standard care vs standard care alone in preventing recurrence of pilonidal disease in adolescents and young adults., Design, Setting, and Participants: This was a single-institution, randomized clinical trial with 1-year follow-up conducted from September 2017 to September 2022. Patients aged 11 to 21 years with pilonidal disease were recruited from a single tertiary children's hospital., Intervention: LE and standard care (improved hygiene and mechanical or chemical depilation) or standard care alone., Main Outcomes and Measures: The primary outcome was the rate of recurrence of pilonidal disease at 1 year. Secondary outcomes assessed during the 1-year follow-up included disability days, health-related quality of life (HRQOL), health care satisfaction, disease-related attitudes and perceived stigma, and rates of procedures, surgical excisions, and postoperative complications., Results: A total of 302 participants (median [IQR] age, 17 [15-18] years; 157 male [56.1%]) with pilonidal disease were enrolled; 151 participants were randomly assigned to each intervention group. One-year follow-up was available for 96 patients (63.6%) in the LE group and 134 (88.7%) in the standard care group. The proportion of patients who experienced a recurrence within 1 year was significantly lower in the LE treatment arm than in the standard care arm (-23.2%; 95% CI, -33.2 to -13.1; P < .001). Over 1 year, there were no differences between groups in either patient or caregiver disability days, or patient- or caregiver-reported HRQOL, health care satisfaction, or perceived stigma at any time point. The LE group had significantly higher Child Attitude Toward Illness Scores (CATIS) at 6 months (median [IQR], 3.8 [3.4-4.2] vs 3.6 [3.2-4.1]; P = .01). There were no differences between groups in disease-related health care utilization, disease-related procedures, or postoperative complications., Conclusions and Relevance: LE as an adjunct to standard care significantly reduced 1-year recurrence rates of pilonidal disease compared with standard care alone. These results provide further evidence that LE is safe and well tolerated in patients with pilonidal disease. LE should be considered a standard treatment modality for patients with pilonidal disease and should be available as an initial treatment option or adjunct treatment modality for all eligible patients., Trial Registration: ClinicalTrials.gov Identifier: NCT03276065.

Background: The COVID-19 pandemic disrupted social, political, and economic life across the world, shining a light on the vulnerability of many communities. The objective of this study was to assess injury patterns before and after implementation of stay-at-home orders (SHOs) between White children and children of color and across varying levels of vulnerability based upon children's home residence., Methods: A multi-institutional retrospective study was conducted evaluating patients < 18 years with traumatic injuries. A "Control" cohort from an averaged March-September 2016-2019 time period was compared to patients injured after SHO initiation-September 2020 ("COVID" cohort). Interactions between race/ethnicity or social vulnerability index (SVI), a marker of neighborhood vulnerability and socioeconomic status, and the COVID-19 timeframe with regard to the outcomes of interest were assessed using likelihood ratio Chi-square tests. Differences in injury intent, type, and mechanism were then stratified and explored by race/ethnicity and SVI separately., Results: A total of 47,385 patients met study inclusion. Significant interactions existed between race/ethnicity and the COVID-19 SHO period for intent (p < 0.001) and mechanism of injury (p < 0.001). There was also significant interaction between SVI and the COVID-19 SHO period for mechanism of injury (p = 0.01). Children of color experienced a significant increase in intentional (COVID 16.4% vs. Control 13.7%, p = 0.03) and firearm (COVID 9.0% vs. Control 5.2%, p < 0.001) injuries, but no change was seen among White children. Children from the most vulnerable neighborhoods suffered an increase in firearm injuries (COVID 11.1% vs. Control 6.1%, p = 0.001) with children from the least vulnerable neighborhoods having no change. All-terrain vehicle (ATV) and bicycle crashes increased for children of color (COVID 2.0% vs. Control 1.1%, p = 0.04 for ATV; COVID 6.7% vs. Control 4.8%, p = 0.02 for bicycle) and White children (COVID 9.6% vs. Control 6.2%, p < 0.001 for ATV; COVID 8.8% vs. Control 5.8%, p < 0.001 for bicycle)., Conclusions: In contrast to White children and children from neighborhoods of lower vulnerability, children of color and children living in higher vulnerability neighborhoods experienced an increase in intentional and firearm-related injuries during the COVID-19 pandemic. Understanding inequities in trauma burden during times of stress is critical to directing resources and targeting intervention strategies., (© 2023. The Author(s).)

Background: Esophageal injury after caustic ingestion can vary in severity and may result in significant long-term morbidity due to stricture development. The optimal management remains unknown. We aim to determine the incidence of esophageal stricture due to caustic ingestion and quantify current procedural and operative management strategies., Methods: The Pediatric Health Information System (PHIS) was utilized to identify patients 0-18 years old who experienced caustic ingestion from January 2007-September 2015 and developed subsequent esophageal stricture until December 2021. Post-injury procedural and operative management was identified utilizing ICD-9/10 procedure codes for esophagogastroduodenoscopy (EGD), esophageal dilation, gastrostomy tube placement, fundoplication, tracheostomy, and major esophageal surgery., Results: 1,588 patients from 40 hospitals experienced caustic ingestion of which 56.6% were male, 32.5% non-Hispanic White, and the median age at time of injury was 2.2 years (IQR: 1.4,4.8). Median length of initial admission was 1.0 day (IQR: 1.0, 3.0). 171/1,588 (10.8%) developed esophageal stricture. Among those who developed stricture, 144 (84.2%) underwent at least 1 additional EGD, 138 (80.7%) underwent dilation, 70 (40.9%) underwent gastrostomy tube, 6 (3.5%) underwent fundoplication, 10 (5.8%) underwent tracheostomy, and 40 (23.4%) underwent major esophageal surgery. Patients underwent a median of 9 dilations (IQR 3, 20). Major surgery was performed at a median of 208 (IQR: 74, 480) days after caustic ingestion., Conclusion: Many patients with esophageal stricture after caustic ingestion will require multiple procedural interventions and potentially major surgery. These patients may benefit from early multi-disciplinary care coordination and the development of a best-practice treatment algorithm., Level of Evidence: III., Competing Interests: Conflicts of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Reports of pediatric injury patterns during the COVID-19 pandemic are conflicting and lack the granularity to explore differences across regions. We hypothesized there would be considerable variation in injury patterns across pediatric trauma centers in the United States., Materials and Methods: A multicenter, retrospective study evaluating patients <18 y old with traumatic injuries meeting National Trauma Data Bank criteria was performed. Patients injured after stay-at-home orders through September 2020 ("COVID" cohort) were compared to "Historical" controls from an averaged period of equivalent dates in 2016-2019. Differences in injury type, intent, and mechanism were explored at the site level., Results: 47,385 pediatric trauma patients were included. Overall trauma volume increased during the COVID cohort compared to the Historical (COVID 7068 patients versus Historical 5891 patients); however, some sites demonstrated a decrease in overall trauma of 25% while others had an increase of over 33%. Bicycle injuries increased at every site, with a range in percent change from 24% to 135% increase. Although the greatest net increase was due to blunt injuries, there was a greater relative increase in penetrating injuries at 7/9 sites, with a range in percent change from a 110% increase to a 69% decrease., Conclusions: There was considerable discrepancy in pediatric injury patterns at the individual site level, perhaps suggesting a variable impact of the specific sociopolitical climate and pandemic policies of each catchment area. Investigation of the unique response of the community during times of stress at pediatric trauma centers is warranted to be better prepared for future environmental stressors., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The management of pediatric appendicitis continues to advance with the development of evidence-based treatment algorithms and a recent shift toward patient-centered treatment approaches. Further research should focus on development of standardized institution-specific diagnostic algorithms to minimize rates of missed diagnosis and appendiceal perforation and refinement of evidence-based clinical treatment pathways that reduce complication rates and minimize health care resource utilization., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Importance: The management of pilonidal disease continues to be a challenge due to high rates of recurrence and treatment-associated morbidity., Observations: There is a heterogeneous repertoire of treatment modalities used in the management of pilonidal disease and wide practice variation among clinicians. Available treatment options vary considerably in their level of invasiveness, associated morbidity and disability, risks of complications, and effectiveness at preventing disease recurrence. Conservative nonoperative management strategies, including persistent improved hygiene, depilation, and lifestyle modification, focus on disease prevention and minimization of disease activity. Epilation techniques using both laser and intense pulse light therapy are also used as primary and adjunct treatment modalities. Other nonoperative treatment modalities include phenol and fibrin injection to promote closure of pilonidal sinuses. The traditional operative management strategy for pilonidal disease involves excision of affected tissue paired with a variety of closure types including primary midline closure, primary off-midline closure techniques (ie, Karydakis flap, Limberg flap, Bascom cleft lift), and healing by secondary intention. There has been a recent shift toward more minimally invasive operative approaches including sinusectomy (ie, trephination or Gips procedure) and endoscopic approaches. Overall, the current evidence supporting the different treatment options is limited by study quality with inconsistent characterization of disease severity and use of variable definitions and reporting of treatment-associated outcomes across studies., Conclusions and Relevance: Pilonidal disease is associated with significant physical and psychosocial morbidity. Optimal treatments will minimize disease and treatment-associated morbidity. There is a need for standardization of definitions used to characterize pilonidal disease and its outcomes to develop evidence-based treatment algorithms.

In recent years, studies have demonstrated non-operative management with antibiotics alone to be a safe and effective treatment option for children with uncomplicated acute appendicitis. Shared decision-making is critical in the treatment of uncomplicated appendicitis due to the markedly different risks and benefits associated with surgery and non-operative management. In this report, we discuss the importance of shared decision-making in surgery using a case of uncomplicated appendicitis as an example. We present both the patient-family and provider perspectives on evaluating and deciding between operative and non-operative management and discuss the value of shared decision-making in the unique setting of an acute pathologic process with surgical and medical treatment options.

Objective: In this study, we explored which postoperative opioid prescribing practices were associated with persistent opioid use among adolescents and young adults., Background: Approximately 5% of adolescents and young adults develop postoperative new persistent opioid use. The impact of physician prescribing practices on persistent use among young patients is unknown., Methods: We identified opioid-naïve patients aged 13 to 21 who underwent 1 of 13 procedures (2008-2016) and filled a perioperative opioid prescription using commercial insurance claims (Optum Deidentified Clinformatics Data Mart Database). Persistent use was defined as ≥ 1 opioid prescription fill 91 to 180 days after surgery. High-risk opioid prescribing included overlapping opioid prescriptions, co-prescribed benzodiazepines, high daily prescribed dosage, long-acting formulations, and multiple prescribers. Logistic regression modeled persistent use as a function of exposure to high-risk prescribing, adjusted for patient demographics, procedure, and comorbidities., Results: High-risk opioid prescribing practices increased from 34.9% to 43.5% over the study period; the largest increase was in co-prescribed benzodiazepines (24.1%-33.4%). High-risk opioid prescribing was associated with persistent use (aOR 1.235 [1.12,1.36]). Receipt of prescriptions from multiple opioid prescribers was individually associated with persistent use (aOR 1.288 [1.16,1.44]). The majority of opioid prescriptions to patients with persistent use beyond the postoperative period were from nonsurgical prescribers (79.6%)., Conclusions: High-risk opioid prescribing practices, particularly receiving prescriptions from multiple prescribers across specialties, were associated with a significant increase in adolescent and young adult patients' risk of persistent opioid use. Prescription drug monitoring programs may help identify young patients at risk of persistent opioid use., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Dog bite injuries cause over 100 000 paediatric emergency department visits annually. Our objective was to analyse associations between regional dog ownership laws and incidence of paediatric dog bites., Methods: This observational study used an online search to locate local dog-related policies within Ohio cities. Data collected by Ohio Partners For Kids from 2011 through 2020 regarding claims for paediatric dog bite injuries were used to compare areas with and without located policies and the incidence of injury., Results: Our cohort consisted of 6175 paediatric patients with dog bite injury encounters. A majority were white (79.1%), male (55.0%), 0-5 years old (39.2%) and did not require hospital admission (98.1%). Seventy-nine of 303 cities (26.1%) had city-specific policies related to dogs. Overall, the presence of dog-related policies was associated with lower incidence of dog bite injury claims (p = 0.01). Specifically, metropolitan areas and the Central Ohio region had a significantly lower incidence when dog-related policies were present (324.85 per 100 000 children per year when present vs 398.56 when absent; p<0.05; 304.87 per 100 000 children per year when present vs 411.43 when absent; p<0.05)., Conclusions: The presence of city-specific dog-related policies is associated with lower incidence of paediatric dog bite injury claims, suggesting that local policy impacts this important public health issue. There are limited dog-related policies addressing dog bite prevention, with inconsistencies in breadth and depth. Creating consistent, practical requirements among policies with vigorous enforcement could ameliorate public health concerns from paediatric dog bite injuries., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Study Objective: Describe the current practice patterns and diagnostic accuracy of frozen section (FS) pathology for children and adolescents with ovarian masses DESIGN: Prospective cohort study from 2018 to 2021 SETTING: Eleven children's hospitals PARTICIPANTS: Females age 6-21 years undergoing surgical management of an ovarian mass INTERVENTIONS: Obtaining intraoperative FS pathology MAIN OUTCOME MEASURE: Diagnostic accuracy of FS pathology RESULTS: Of 691 patients who underwent surgical management of an ovarian mass, FS was performed in 27 (3.9%), of which 9 (33.3%) had a final malignant pathology. Among FS patients, 12 of 27 (44.4%) underwent ovary-sparing surgery, and 15 of 27 (55.5%) underwent oophorectomy with or without other procedures. FS results were disparate from final pathology in 7 of 27 (25.9%) cases. FS had a sensitivity of 44.4% and specificity of 94.4% for identifying malignancy, with a c-statistic of 0.69. Malignant diagnoses missed on FS included serous borderline tumor (n = 1), mucinous borderline tumor (n = 2), mucinous carcinoma (n = 1), and immature teratoma (n = 1). FS did not guide intervention in 10 of 27 (37.0%) patients: 9 with benign FS underwent oophorectomy, and 1 with malignant FS did not undergo oophorectomy. Of the 9 patients who underwent oophorectomy with benign FS, 5 (55.6%) had benign and 4 (44.4%) had malignant final pathology., Conclusions: FSs are infrequently utilized for pediatric and adolescent ovarian masses and could be inaccurate for predicting malignancy and guiding operative decision-making. We recommend continued assessment and refinement of guidance before any standardization of use of FS to assist with intraoperative decision-making for surgical resection and staging in children and adolescents with ovarian masses., (Copyright © 2022. Published by Elsevier Inc.)

Nonoperative management (NOM) of uncomplicated appendicitis is a safe and effective treatment alternative to surgery that may be preferred by some families. Surgery and NOM differ significantly in their associated risks and benefits. Choosing a treatment for acute appendicitis requires patients and their caregivers to make timely, informed decisions that allow for incorporation of personal perspectives, values, and preferences. This article will address the concept of shared decision-making and establish its role in patient-centered care. It will demonstrate the effectiveness of shared decision-making in a high acuity surgical setting for children and highlight how the choice for management of acute appendicitis may be impacted by patients' and families' individualized circumstances and values., (Copyright © 2022 Elsevier Inc. All rights reserved.)

During the COVID-19 pandemic, children were out of school due to Stay-at-Home Orders. The objective of this study was to investigate how the COVID-19 pandemic may have impacted the incidence of burn injuries in children. Eight Level I Pediatric Trauma Centers participated in a retrospective study evaluating children <18 years old with traumatic injuries defined by the National Trauma Data Bank. Patients with burn injuries were identified by ICD-10 codes. Historical controls from March to September 2019 ("Control" cohort) were compared to patients injured after the start of the COVID-19 pandemic from March to September 2020 ("COVID" cohort). A total of 12,549 pediatric trauma patients were included, of which 916 patients had burn injuries. Burn injuries increased after the start of the pandemic (COVID 522/6711 [7.8%] vs Control 394/5838 [6.7%], P = .03). There were no significant differences in age, race, insurance status, burn severity, injury severity score, intent or location of injury, and occurrence on a weekday or weekend between cohorts. There was an increase in flame burns (COVID 140/522 [26.8%] vs Control 75/394 [19.0%], P = .01) and a decrease in contact burns (COVID 118/522 [22.6%] vs Control 112/394 [28.4%], P = .05). More patients were transferred from an outside institution (COVID 315/522 patients [60.3%] vs Control 208/394 patients [52.8%], P = .02), and intensive care unit length of stay increased (COVID median 3.5 days [interquartile range 2.0-11.0] vs Control median 3.0 days [interquartile range 1.0-4.0], P = .05). Pediatric burn injuries increased after the start of the COVID-19 pandemic despite Stay-at-Home Orders intended to optimize health and increase public safety., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Previous work has shown that the Affordable Care Act (ACA) Medicaid expansion decreased the uninsured rate and improved some trauma outcomes among young adult trauma patients, but no studies have investigated the impact of ACA Medicaid expansion on secondary overtriage, namely the unnecessary transfer of non-severely injured patients to tertiary trauma centers., Methods: Statewide hospital inpatient and emergency department discharge data from two Medicaid expansion and one non-expansion state were used to compare changes in insurance coverage and secondary overtriage among trauma patients aged 19-44 y transferred into a level I or II trauma center before (2011-2013) to after (2014-quarter 3, 2015) Medicaid expansion. Difference-in-difference (DD) analyses were used to compare changes overall, by race/ethnicity, and by ZIP code-level median income quartiles., Results: Medicaid expansion was associated with a decrease in the proportion of patients uninsured (DD: -4.3 percentage points; 95% confidence interval (CI): -7.4 to -1.2), an increase in the proportion of patients insured by Medicaid (DD: 8.2; 95% CI: 5.0 to 11.3), but no difference in the proportion of patients who experienced secondary overtriage (DD: -1.5; 95% CI: -4.8 to 1.8). There were no differences by race/ethnicity or community income level in the association of Medicaid expansion with secondary overtriage., Conclusions: In the first 2 y after ACA Medicaid expansion, insurance coverage increased but secondary overtriage rates were unchanged among young adult trauma patients transferred to level I or II trauma centers., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Adolescent females with developmental delays (DDs) experience unique physical and emotional challenges related to menstruation. Providers often recommend hormonal medication for menstrual management. The objective of our study was to describe the utilization and safety of the levonorgestrel-releasing intrauterine system (LNG-IUS) in adolescents with DDs., Methods: We utilized the Pediatric Health Information System to identify females aged 10-25 with DDs who underwent an LNG-IUS insertion between 2011 and 2020. Using a gynecologic procedure and diagnosis codes, we assessed indications for and complications of LNG-IUS use. We also evaluated early LNG-IUS removal., Results: One thousand five hundred and sixty female patients with DDs underwent LNG-IUS insertion. LNG-IUS insertion under anesthesia was most commonly performed in patients with autism and Down syndrome, and unspecified menstrual issues were documented for 40% of the cohort. Perforation was observed in 11 patients (1%), and mechanical complications (malpositioned IUS or lost threads) were observed in 23 patients (1%)., Discussion: This is the largest analysis of LNG-IUS use in patients with DDs to our knowledge and shows the utilization of LNG-IUS in patients with DDs. We provide descriptive information that providers can use to accurately advise their patients with DDs on the risks and benefits of LNG-IUS use for menstrual management., (Copyright © 2022. Published by Elsevier Inc.)

Introduction: With the expected surge of adult patients with COVID-19, the Children's Hospital Association recommended a tiered approach to divert children to pediatric centers. Our objective was understanding changes in interfacility transfer to Pediatric Trauma Centers (PTCs) during the first 6 mo of the pandemic., Methods: Children aged < 18 y injured between January 1, 2016 and September 30, 2020, who met National Trauma Databank inclusion criteria from 9 PTCs were included. An interrupted time-series analysis was used to estimate an expected number of transferred patients compared to observed volume. The "COVID" cohort was compared to a historical cohort (historical average [HA]), using an average across 2016-2019. Site-based differences in transfer volume, demographics, injury characteristics, and hospital-based outcomes were compared between cohorts., Results: Twenty seven thousand thirty one/47,382 injured patients (57.05%) were transferred to a participating PTC during the study period. Of the COVID cohort, 65.4% (4620/7067) were transferred, compared to 55.7% (3281/5888) of the HA (P < 0.001). There was a decrease in 15-y-old to 17-y-old patients (10.43% COVID versus 12.64% HA, P = 0.003). More patients in the COVID cohort had injury severity scores ≤ 15 (93.25% COVID versus 87.63% HA, P < 0.001). More patients were discharged home after transfer (31.80% COVID versus 21.83% HA, P < 0.001)., Conclusions: Transferred trauma patients to Level I PTC increased during the COVID-19 pandemic. The proportion of transferred patients discharged from emergency departments increased. Pediatric trauma transfers may be a surrogate for referring emergency department capacity and resources and a measure of pediatric trauma triage capability., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The impact of the COVID-19 pandemic on pediatric injury, particularly relative to a community's vulnerability, is unknown. The objective of this study was to describe the change in pediatric injury during the first 6 months of the COVID-19 pandemic compared with prior years, focusing on intentional injury relative to the social vulnerability index (SVI)., Methods: All patients younger than 18 years meeting inclusion criteria for the National Trauma Data Bank between January 1, 2016, and September 30, 2020, at nine Level I pediatric trauma centers were included. The COVID cohort (children injured in the first 6 months of the pandemic) was compared with an averaged historical cohort (corresponding dates, 2016-2019). Demographic and injury characteristics and hospital-based outcomes were compared. Multivariable logistic regression was used to estimate the adjusted odds of intentional injury associated with SVI, moderated by exposure to the pandemic. Interrupted time series analysis with autoregressive integrated moving average modeling was used to predict expected injury patterns. Volume trends and observed versus expected rates of injury were analyzed., Results: There were 47,385 patients that met inclusion criteria, with 8,991 treated in 2020 and 38,394 treated in 2016 to 2019. The COVID cohort included 7,068 patients and the averaged historical cohort included 5,891 patients (SD, 472), indicating a 20% increase in pediatric injury ( p = 0.031). Penetrating injuries increased (722 [10.2%] COVID vs. 421 [8.0%] historical; p < 0.001), specifically firearm injuries (163 [2.3%] COVID vs. 105 [1.8%] historical; p = 0.043). Bicycle collisions (505 [26.3%] COVID vs. 261 [18.2%] historical; p < 0.001) and collisions on other land transportation (e.g., all-terrain vehicles) (525 [27.3%] COVID vs. 280 [19.5%] historical; p < 0.001) also increased. Overall, SVI was associated with intentional injury (odds ratio, 7.9; 95% confidence interval, 6.5-9.8), a relationship which increased during the pandemic., Conclusion: Pediatric injury increased during the pandemic across multiple sites and states. The relationship between increased vulnerability and intentional injury increased during the pandemic., Level of Evidence: Prognostic and Epidemiological; Level III., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background/purpose: Controversy persists regarding the ideal surgical approach for repair of esophageal atresia with tracheoesophageal fistula (EA/TEF). We examined complications and outcomes of infants undergoing thoracoscopy and thoracotomy for repair of Type C EA/TEF using propensity score-based overlap weights to minimize the effects of selection bias., Methods: Secondary analysis of two databases from multicenter retrospective and prospective studies examining outcomes of infants with proximal EA and distal TEF who underwent repair at 11 institutions was performed based on surgical approach. Regression analysis using propensity score-based overlap weights was utilized to evaluate outcomes of patients undergoing thoracotomy or thoracoscopy for Type C EA/TEF repair., Results: Of 504 patients included, 448 (89%) underwent thoracotomy and 56 (11%) thoracoscopy. Patients undergoing thoracoscopy were more likely to be full term (37.9 vs. 36.3 weeks estimated gestational age, p < 0.001), have a higher weight at operative repair (2.9 vs. 2.6 kg, p < 0.001), and less likely to have congenital heart disease (16% vs. 39%, p < 0.001). Postoperative stricture rate did not differ by approach, 29 (52%) thoracoscopy and 198 (44%) thoracotomy (p = 0.42). Similarly, there was no significant difference in time from surgery to stricture formation (p > 0.26). Regression analysis using propensity score-based overlap weighting found no significant difference in the odds of vocal cord paresis or paralysis (OR 1.087 p = 0.885), odds of anastomotic leak (OR 1.683 p = 0.123), the hazard of time to anastomotic stricture (HR 1.204 p = 0.378), or the number of dilations (IRR 1.182 p = 0.519) between thoracoscopy and thoracotomy., Conclusion: Infants undergoing thoracoscopic repair of Type C EA/TEF are more commonly full term, with higher weight at repair, and without congenital heart disease as compared to infants repaired via thoracotomy. Utilizing propensity score-based overlap weighting to minimize the effects of selection bias, we found no significant difference in complications based on surgical approach. However, our study may be underpowered to detect such outcome differences owing to the small number of infants undergoing thoracoscopic repair., Level of Evidence: Level III., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The prevalence and natural history of patent processus vaginalis (PPV) are unknown. An interim analysis was performed of a multi-institutional, prospective, observational study in neonates undergoing laparoscopic pyloromyotomy during which bilateral inguinal canals were evaluated., Methods: Infants under 4 months undergoing laparoscopic pyloromyotomy were enrolled at 8 children's hospitals. The presence of a PPV was evaluated and measurements recorded. Patients with a PPV are undergoing annual phone follow-up to 18 years of age. Interim analysis was performed., Results: In a cohort of 610 patient, 80 did not have a PPV examined, 4 had consent issues and were excluded, leaving 526 patients. Of these, 433 (82%) were male, median age 1.2 months (IQR 0.9, 1.6), median weight 3.89 kg (IQR 3.4, 4.46), and EGA 39 weeks (IQR 37, 40). There were 283 PPVs, 132 bilateral (47%), 116 right (41%), and 35 left (12%). Patients with a PPV were significantly younger (1.1 months (IQR 0.9, 1.5) vs 1.3 months (IQR 0.9, 1.7), p=0.02), weighed less (3.76kg (IQR 3.35, 4.26) vs 3.9kg (IQR 3.4, 4.5) p=0.03) and had a significantly lower EGA at birth (38 weeks (IQR 37, 40) vs 39 weeks (IQR 38, 40) p=0.003). Of 246 eligible infants, 208 (85%) responded to at least one annual follow-up. Two patients had an inguinal hernia repair for a symptomatic hernia, 49- and 51-days post pyloromyotomy. One had an orchiopexy and incidental inguinal hernia repair 120 days post pyloromyotomy; for a total of 3 (1.2%) hernia repairs. No additional hernias were identified in 116 patients with the PPV patients who have been followed for > 1 year., Conclusions: The presence of a PPV at the time of pyloromyotomy is common but the need for hernia repair is rare within the first year of life. Continued long-term longitudinal follow-up of this cohort is needed., Level of Evidence: II., Competing Interests: Declarations of Competing Interest The authors report no conflicts of interest., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: This study compared perioperative outcomes among infants undergoing repair of congenital anomalies using minimally invasive (MIS) versus open surgical approaches., Methods: The ACS NSQIP Pediatric (2013-2018) was queried for patients undergoing repair of any of the following 9 congenital anomalies: congenital lung lesion (LL), mediastinal mass (MM), congenital malrotation (CM), anorectal malformation (ARM), Hirschsprung disease (HD), congenital diaphragmatic hernia (CDH), tracheoesophageal fistula (TEF), hepatobiliary anomalies (HB), and intestinal atresia (IA). Inverse probability of treatment weights (IPTW) derived from propensity scores were utilized to estimate risk-adjusted association between surgical approach and 30-day outcomes., Results: 12,871 patients undergoing congenital anomaly repair were included (10,343 open; 2528 MIS). After IPTW, MIS was associated with longer operative time (difference; 95% CI) (16 min; 9-23) and anesthesia time (13 min; 6-21), but less postoperative ventilation days (-1.0 days; -1.4- -0.6) and shorter postoperative length of stay (-1.4 days; -2.4- -0.3). MIS repairs had decreased risk of any surgical complication (risk difference: -6.6%; -9.2- -4.0), including hematologic complications (-7.3%; -8.9- -5.8). There was no significant difference in risk of complication when hematologic complications were excluded (RD -2.3% [-4.7%, 0.1%]). There were no significant differences in the risk of unplanned reoperation (0.4%; -1.5-2.2) or unplanned readmission (0.2%; -1.2-1.5)., Conclusions: MIS repair of congenital anomalies is associated with improved perioperative outcomes when compared to open. Additional studies are needed to compare long-term functional and disease-specific outcomes., Mini-Abstract: In this propensity-weighted multi-institutional analysis of nine congenital anomalies, minimally invasive surgical repair was associated with improved 30-day outcomes when compared to open surgical repair., Level of Evidence: III., Competing Interests: Declaration of Competing Interest All authors declare they have no conflicts of interest or financial disclosures, including financial, consultant, institutional and other relationships that might lead to bias or a conflict of interest. The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP provide the source of the data for this study and are not responsible for the statistical validity of the data analyses or conclusions drawn by the authors., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: We evaluate the incidence, outcomes, and management of peri‑umbilical hernias after sutured or sutureless gastroschisis closure., Methods: A retrospective, longitudinal follow-up of neonates with gastroschisis who underwent closure at 11 children's hospitals from 2013 to 2016 was performed. Patient encounters were reviewed through 2019 to identify the presence of a peri‑umbilical hernia, time to spontaneous closure or repair, and associated complications., Results: Of 397 patients, 375 had follow-up data. Sutured closure was performed in 305 (81.3%). A total of 310 (82.7%) infants had uncomplicated gastroschisis. Peri-umbilical hernia incidence after gastroschisis closure was 22.7% overall within a median follow-up of 2.5 years [IQR 1.3,3.9], and higher in those with uncomplicated gastroschisis who underwent primary vs. silo assisted closure (53.0% vs. 17.2%, p< 0.001). At follow-up, 50.0% of sutureless closures had a persistent hernia, while 16.4% of sutured closures had a postoperative hernia of the fascial defect (50.0% vs. 16.4%, p< 0.001). Spontaneous closure was observed in 38.8% of patients within a median of 17 months [9,26] and most frequently observed in those who underwent a sutureless primary closure (52.2%). Twenty-seven patients (31.8%) underwent operative repair within a median of 13 months [7,23.5]. Rate and interval of spontaneous closure or repair were similar between the sutured and sutureless closure groups, with no difference between those who underwent primary vs. silo assisted closure., Conclusion: Peri-umbilical hernias after sutured or sutureless gastroschisis closure may be safely observed similar to congenital umbilical hernias as spontaneous closure occurs, with minimal complications and no additional risk with either closure approach., Levels of Evidence: Level II., Competing Interests: Declarations of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Disparities in surgical management have been documented across a range of disease processes. The objective of this study was to investigate sociodemographic disparities in young females undergoing excision of a breast mass., Methods: A retrospective study of females aged 10-21 y who underwent surgery for a breast lesion across eleven pediatric hospitals from 2011 to 2016 was performed. Differences in patient characteristics, workup, management, and pathology by race/ethnicity, insurance status, median neighborhood income, and urbanicity were evaluated with bivariate and multivariable regression analyses., Results: A total of 454 females were included, with a median age of 16 y interquartile range (IQR: 3). 44% of patients were nonHispanic (NH) Black, 40% were NH White, and 7% were Hispanic. 50% of patients had private insurance, 39% had public insurance, and 9% had other/unknown insurance status. Median neighborhood income was $49,974, and 88% of patients resided in a metropolitan area. NH Whites have 4.5 times the odds of undergoing preoperative fine needle aspiration or core needle biopsy compared to NH Blacks (CI: 2.0, 10.0). No differences in time to surgery from the initial imaging study, size of the lesion, or pathology were observed on multivariable analysis., Conclusions: We found no significant differences by race/ethnicity, insurance status, household income, or urbanicity in the time to surgery after the initial imaging study. The only significant disparity noted on multivariable analysis was NH White patients were more likely to undergo preoperative biopsy than were NH Black patients; however, the utility of biopsy in pediatric breast masses is not well established., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to assess current clinical outcomes in children with prenatally diagnosed congenital lung malformations (CLMs) and to identify prenatal characteristics associated with adverse outcomes., Summary Background Data: Despite a wide spectrum of clinical disease, the identification of fetal CLM subgroups at increased risk for hydrops and respiratory compromise at delivery has not been well defined., Methods: A retrospective cohort study was conducted using an operative database of prenatally diagnosed CLMs managed at 11 children's hospitals from 2009 to 2016. Statistical analyses were performed using nonparametric bivariate or multivariable logistic regression., Results: Three hundred forty-four children were analyzed. Fifteen (5.5%) fetuses were managed with maternal steroids in the setting of hydrops, and prenatal surgical intervention was uncommon (1.7%). Seventy-five (21.8%) had respiratory symptoms at birth, and 34 (10.0%) required neonatal lung resection. Congenital pulmonary airway malformation volume ratio (CVR) measurements were recorded in 169 (49.1%) cases and were significantly associated with perinatal outcome, including hydrops, respiratory distress at birth, need for supplemental oxygen, neonatal ventilator use, and neonatal resection ( P < 0.001). An initial CVR ≤1.4 was significantly correlated with a reduced risk for hydrops [area under the curve (AUC), 0.93; 95% confidence interval (CI), 0.87-1.00]. A maximum CVR <0.9 (AUC, 0.72; 95% CI, 0.67-0.85) was associated with a low risk for respiratory symptoms at birth., Conclusions: In this large, multi-institutional study, an initial CVR ≤ 1.4 identifies fetuses at very low risk for hydrops, and a maximum CVR < 0.9 is associated with asymptomatic disease at birth. These findings represent an opportunity for standardization and quality improvement for prenatal counseling and delivery planning., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The objective of this study was to determine the rates at which gynecologic history and related exams are performed among adolescent females presenting with abdominal pain and whether the rates differ between patients seeking care at a pediatric compared with a general emergency department (ED)., Methods: We conducted a retrospective cohort study of female patients aged 12-21 years who presented to the ED for a chief complaint of abdominal pain at either a single academic children's ED or a single general academic ED during 2016. We examined differences in the rates of gynecologic history and related exams between institutions, before and after adjustment with inverse probability weights., Results: A total of 837 females met the inclusion criteria for this study, and 627 patients were included in the adjusted analyses. Outcomes more commonly performed at the pediatric institution included documentation of contraception (28% at the general ED vs 43% at the pediatric ED, P < .001), sexually transmitted infection testing (32% at the general ED vs 42% at the pediatric ED, P = .04), and radiologic imaging (46% at the general ED vs 70% at the pediatric ED, P < .001). Outcomes that were more commonly performed at the general ED were pelvic exam (26% at the general ED vs 10% at the pediatric ED, P < .001) and complete blood count draw (67% at the general ED vs 39% at the pediatric ED, P < .001). No differences were observed between institutions in the documentation of menarche or sexual activity, the performance of a pregnancy test or CT scan, or the rate of subsequent ED/urgent care visits in the following year., Conclusion: The rates at which gynecologic history and pelvic examination were performed in adolescent females presenting for abdominal pain at both a general ED and a pediatric ED were low and inconsistent. Providers should have a low threshold for testing for sexually transmitted infections and pregnancy. Pelvic examination and diagnostic lab testing should be performed when indicated in the setting of a clinically appropriate history. These efforts would ensure adequate evaluation of adolescent women and reduce unnecessary health resource utilization., Competing Interests: Declaration of Competing Interest There are no conflicts of interest to disclose., (Copyright © 2022. Published by Elsevier Inc.)

Introduction: Telemedicine use within pediatric surgery fields has been growing, but research on the utility of remote evaluation in the perioperative period remains scarce. The objective of this study was to examine the utility of perioperative telemedicine care for the pediatric patient by evaluating the outcomes following completion of an outpatient appointment with a surgical provider., Materials and Methods: We performed a retrospective chart review of all patients who completed a telemedicine appointment with a provider across nine pediatric surgery divisions, without a limitation based on patient-specific characteristics or telemedicine platform. We examined the result of the initial telemedicine appointment and the outcome of any surgical procedure that was performed as a result., Results: A total of 803 patients were evaluated by telemedicine during the study period. Of the 164 encounters (20.2%) that were followed by a surgery, nearly 70% were performed using a video. There was no discordance in the preoperative and postoperative diagnoses for more than 98% of patients. Nearly 25% of operations were followed by at least a 1-night hospital stay and 6.7% of patients developed a postoperative complication., Conclusions: Telemedicine is a safe tool for evaluating pediatric patients in the preoperative and postoperative phases of care and offers potential value for families seeking an alternative to the traditional in-person appointment. Ongoing support will require permanent legislative changes aimed at ensuring comparable compensation and the development of strategies to adapt the outpatient healthcare model to better accommodate the evolving requirements of remotely evaluating and treating pediatric patients., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Study Objective: To assess the preoperative imaging impression and surgeon diagnostic accuracy for pediatric ovarian mature cystic teratomas (MCTs) DESIGN: Retrospective review SETTING: Eleven pediatric hospitals PARTICIPANTS: Patients ages 2 to 21 who underwent surgical management of an ovarian neoplasm or adnexal torsion with an associated ovarian lesion INTERVENTION: None MAIN OUTCOME MEASURES: Preoperative imaging impression, surgeon diagnosis, tumor markers, and pathology RESULTS: Our cohort included 946 females. Final pathology identified 422 (45%) MCTs, 405 (43%) other benign pathologies, and 119 (12%) malignancies. Preoperative imaging impression for MCTs had a 70% sensitivity, 92% specificity, 88% positive predictive value (PPV), and 79% negative predictive value (NPV). For the preoperative surgeon diagnosis, sensitivity was 59%, specificity 96%, PPV 92%, and NPV 74%. Some measures of diagnostic accuracy were affected by the presence of torsion, size of the lesion on imaging, imaging modality, and surgeon specialty. Of the 352 masses preoperatively thought to be MCTs, 14 were malignancies (4%). Eleven patients with inaccurately diagnosed malignancies had tumor markers evaluated and 82% had at least 1 elevated tumor marker, compared with 49% of those with MCTs., Conclusions: Diagnostic accuracy for the preoperative imaging impression and surgeon diagnosis is lower than expected for pediatric ovarian MCTs. For all ovarian neoplasms, preoperative risk assessment including a panel of tumor markers and a multidisciplinary review is recommended. This process could minimize the risk of misdiagnosis and improve operative planning to maximize the use of ovarian-sparing surgery for benign lesions and allow for appropriate resection and staging for lesions suspected to be malignant., Competing Interests: Declaration of Competing Interest S. Paige Hertweck performs research for AbbVie on topics unrelated to ovarian neoplasms., (Copyright © 2022. Published by Elsevier Inc.)

Background: This study assessed inter-hospital variability in operative-vs-nonoperative management of pediatric adhesive small bowel obstruction (ASBO)., Methods: A multi-institutional retrospective study was performed examining patients 1-21 years-of-age presenting with ASBO from 2010 to 2019 utilizing the Pediatric Health Information System. Multivariable mixed-effects logistic regression was performed assessing inter-hospital variability in operative-vs-nonoperative management of ASBO., Results: Among 6410 pediatric ASBO admissions identified at 46 hospitals, 3,239 (50.5%) underwent surgery during that admission. The hospital-specific rate of surgery ranged from 35.3% (95%CI: 28.5-42.6%) to 74.7% (66.3-81.6%) in the unadjusted model (p < 0.001), and from 35.1% (26.3-45.1%) to 73.9% (66.7-79.9%) in the adjusted model (p < 0.001). Factors associated with operative management for ASBO included admission to a surgical service (OR 2.8 [95%CI: 2.4-3.2], p < 0.001), congenital intestinal and/or rotational anomaly (OR 2.5 [2.1-3.1], p < 0.001), diagnostic workup including advanced abdominal imaging (OR 1.7 [1.5-1.9], p < 0.001), non-emergent admission status (OR 1.5 [1.3-1.8], p < 0.001), and increasing number of complex chronic comorbidities (OR 1.3 [1.2-1.4], p < 0.001). Factors associated with nonoperative management for ASBO included increased hospital-specific annual ASBO volume (OR 0.98 [95%CI: 0.97-0.99], p = 0.002), older age (OR 0.97 [0.96-0.98], p < 0.001), public insurance (OR 0.87 [0.78-0.96], p = 0.008), and presence of coinciding non-intestinal congenital anomalies, neurologic/neuromuscular disease, and/or medical technology dependence (OR 0.57 [95%CI: 0.47-0.68], p < 0.001)., Conclusions: Rates of surgical intervention for ASBO vary significantly across tertiary children's hospitals in the United States. The variability was independent of patient and hospital characteristics and is likely due to practice variation., Level of Evidence: III., Competing Interests: Declaration of Competing Interest All authors declare they have no conflicts of interest or financial disclosures, including financial, consultant, institutional and other relationships that might lead to bias or a conflict of interest., (Copyright © 2021. Published by Elsevier Inc.)

Background: Firearm sales in the United States (U.S.) markedly increased during the COVID-19 pandemic. Our objective was to determine if firearm injuries in children were associated with stay-at-home orders (SHO) during the COVID-19 pandemic. We hypothesized there would be an increase in pediatric firearm injuries during SHO., Methods: This was a multi institutional, retrospective study of institutional trauma registries. Patients <18 years with traumatic injuries meeting National Trauma Data Bank (NTDB) criteria were included. A "COVID" cohort, defined as time from initiation of state SHO through September 30, 2020 was compared to "Historical" controls from an averaged period of corresponding dates in 2016-2019. An interrupted time series analysis (ITSA) was utilized to evaluate the association of the U.S. declaration of a national state of emergency with pediatric firearm injuries., Results: Nine Level I pediatric trauma centers were included, contributing 48,111 pediatric trauma patients, of which 1,090 patients (2.3%) suffered firearm injuries. There was a significant increase in the proportion of firearm injuries in the COVID cohort (COVID 3.04% vs. Historical 1.83%; p < 0.001). There was an increased cumulative burden of firearm injuries in 2020 compared to a historical average. ITSA showed an 87% increase in the observed rate of firearm injuries above expected after the declaration of a nationwide emergency (p < 0.001)., Conclusion: The proportion of firearm injuries affecting children increased during the COVID-19 pandemic. The pandemic was associated with an increase in pediatric firearm injuries above expected rates based on historical patterns., Competing Interests: Declaration of Competing Interest The authors have no financial disclosures. The study had no source of funding., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: It is unclear how Stay-at-Home Orders (SHO) of the COVID-19 pandemic impacted the welfare of children and rates of non-accidental trauma (NAT). We hypothesized that NAT would initially decrease during the SHO as children did not have access to mandatory reporters, and then increase as physicians' offices and schools reopened., Methods: A multicenter study evaluating patients <18 years with ICD-10 Diagnosis and/or External Cause of Injury codes meeting criteria for NAT. "Historical" controls from an averaged period of March-September 2016-2019 were compared to patients injured March-September 2020, after the implementation of SHO ("COVID" cohort). An interrupted time series analysis was utilized to evaluate the effects of SHO implementation., Results: Nine Level I pediatric trauma centers contributed 2064 patients meeting NAT criteria. During initial SHO, NAT rates dropped below what was expected based on historical trends; however, thereafter the rate increased above the expected. The COVID cohort experienced a significant increase in the proportion of NAT patients age ≥5 years, minority children, and least resourced as determined by social vulnerability index (SVI)., Conclusions: The COVID-19 pandemic affected the presentation of children with NAT to the hospital. In times of public health crisis, maintaining systems of protection for children remain essential., Level of Evidence: III., (Copyright © 2022. Published by Elsevier Inc.)

Importance: The ability of computed tomography (CT) to distinguish between benign congenital lung malformations and malignant cystic pleuropulmonary blastomas (PPBs) is unclear., Objective: To assess whether chest CT can detect malignant tumors among postnatally detected lung lesions in children., Design, Setting, and Participants: This retrospective multicenter case-control study used a consortium database of 521 pathologically confirmed primary lung lesions from January 1, 2009, through December 31, 2015, to assess diagnostic accuracy. Preoperative CT scans of children with cystic PPB (cases) were selected and age-matched with CT scans from patients with postnatally detected congenital lung malformations (controls). Statistical analysis was performed from January 18 to September 6, 2020. Preoperative CT scans were interpreted independently by 9 experienced pediatric radiologists in a blinded fashion and analyzed from January 24, 2019, to September 6, 2020., Main Outcomes and Measures: Accuracy, sensitivity, and specificity of CT in correctly identifying children with malignant tumors., Results: Among 477 CT scans identified (282 boys [59%]; median age at CT, 3.6 months [IQR, 1.2-7.2 months]; median age at resection, 6.9 months [IQR, 4.2-12.8 months]), 40 cases were extensively reviewed; 9 cases (23%) had pathologically confirmed cystic PPB. The median age at CT was 7.3 months (IQR, 2.9-22.4 months), and median age at resection was 8.7 months (IQR, 5.0-24.4 months). The sensitivity of CT for detecting PPB was 58%, and the specificity was 83%. High suspicion for malignancy correlated with PPB pathology (odds ratio, 13.5; 95% CI, 2.7-67.3; P = .002). There was poor interrater reliability (κ = 0.36 [range, 0.06-0.64]; P < .001) and no significant difference in specific imaging characteristics between PPB and benign cystic lesions. The overall accuracy rate for distinguishing benign vs malignant lesions was 81%., Conclusions and Relevance: This study suggests that chest CT, the current criterion standard imaging modality to assess the lung parenchyma, may not accurately and reliably distinguish PPB from benign congenital lung malformations in children. In any cystic lung lesion without a prenatal diagnosis, operative management to confirm pathologic diagnosis is warranted.

Introduction: Anastomotic stricture is the most common complication after esophageal atresia (EA) repair. We sought to determine if postoperative acid suppression is associated with reduced stricture formation., Methods: A prospective, multi-institutional cohort study of infants undergoing primary EA repair from 2016 to 2020 was performed. Landmark analysis and multivariate Cox regression were used to explore if initial duration of acid suppression was associated with stricture formation at hospital discharge (DC), 3-, 6-, and 9-months postoperatively., Results: Of 156 patients, 79 (51%) developed strictures and 60 (76%) strictures occurred within three months following repair. Acid suppression was used in 141 patients (90%). Landmark analysis showed acid suppression was not associated with reduction in initial stricture formation at DC, 3-, 6- and 9-months, respectively (p = 0.19-0.95). Multivariate regression demonstrated use of a transanastomotic tube was significantly associated with stricture formation at DC (Hazard Ratio (HR) = 2.21 (95% CI 1.24-3.95, p<0.01) and 3-months (HR 5.31, 95% CI 1.65-17.16, p<0.01). There was no association between acid suppression duration and stricture formation., Conclusion: No association between the duration of postoperative acid suppression and anastomotic stricture was observed. Transanastomotic tube use increased the risk of anastomotic strictures at hospital discharge and 3 months after repair., Competing Interests: Declarations of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: With increased surgeon comfort using laparoscopy, we hypothesized resection of pediatric ovarian dermoids using laparoscopy would yield a shorter length of stay and no increase in morbidity or recurrence compared to laparotomy., Methods: A retrospective review was performed amongst eleven pediatric hospitals. Patients aged 2 to 21 who underwent resection of an ovarian dermoid from 2010 to 2020 were included. Patient characteristics, operative details, and outcomes by approach were evaluated using Chi-squared and Wilcoxon-Mann tests., Results: 466 patients were included, with a median age of 14.4 and median follow-up of 4.0 months. 279 patients underwent laparoscopy (60%), 139 laparotomy (30%), and 48 laparoscopy converted to laparotomy (10%). There were no differences in rates of tumor spillage by approach (p = 0.15). 65% underwent ovarian-sparing surgery and 35% underwent oophorectomy. Length of stay was significantly shorter amongst patients who underwent laparoscopy (1 day versus 2 days for laparotomy and converted, p<0.0001). There were no differences in rates of suspected recurrence or reoperation (p = 0.19 and p = 0.57, respectively)., Conclusion: Patients who underwent laparoscopy experienced no differences in the rates of tumor spillage, recurrence, or reoperation and had a shorter length of stay compared to laparotomy. Laparoscopy is an acceptable approach for resection of pediatric ovarian dermoids., (Copyright © 2022. Published by Elsevier Inc.)

Importance: The factors associated with the failure of nonoperative management of appendicitis and the differences in patient-reported outcomes between successful and unsuccessful nonoperative management remain unknown., Objectives: To investigate factors associated with the failure of nonoperative management of appendicitis and compare patient-reported outcomes between patients whose treatment succeeded and those whose treatment failed., Design, Setting, and Participants: This study was a planned subgroup secondary analysis conducted in 10 children's hospitals that included 370 children aged 7 to 17 years with uncomplicated appendicitis enrolled in a prospective, nonrandomized clinical trial between May 1, 2015, and October 31, 2018, with 1-year follow-up comparing nonoperative management with antibiotics vs surgery for uncomplicated appendicitis. Statistical analysis was performed from November 1, 2019, to February 12, 2022., Interventions: Nonoperative management with antibiotics vs surgery., Main Outcomes and Measures: Failure of nonoperative management and patient-reported outcomes. The relative risk (RR) of failure based on sociodemographic and clinical characteristics was calculated. Patient-reported outcomes were compared based on the success or failure of nonoperative management., Results: Of 370 patients (34.6% of 1068 total patients; 229 boys [61.9%]; median age, 12.3 years [IQR, 10.0-14.6 years]) enrolled in the nonoperative group, treatment failure occurred for 125 patients (33.8%) at 1 year, with 53 patients (14.3%) undergoing appendectomy during initial hospitalization and 72 patients (19.5%) experiencing delayed treatment failure after hospital discharge. Higher patient-reported pain at presentation was associated with increased risk of in-hospital treatment failure (RR, 2.1 [95% CI, 1.0-4.4]) but not delayed treatment failure (RR, 1.3 [95% CI, 0.7-2.3]) or overall treatment failure at 1 year (RR, 1.5 [95% CI, 1.0-2.2]). Pain duration greater than 24 hours was associated with decreased risk of delayed treatment failure (RR, 0.3 [95% CI, 0.1-1.0]) but not in-hospital treatment failure (RR, 1.2 [95% CI, 0.5-2.7]) or treatment failure at 1 year (RR, 0.7 [95% CI, 0.4-1.2]). There was no increased risk of treatment failure associated with age, white blood cell count, sex, race, ethnicity, primary language, insurance status, transfer status, symptoms at presentation, or imaging results. Health care satisfaction at 30 days and patient-reported, health-related quality of life at 30 days and 1 year were not different. Satisfaction with the decision was higher with successful nonoperative management at 30 days (28.0 vs 27.0; difference, 1.0 [95% CI, 0.01-2.0]) and 1 year (28.1 vs 27.0; difference, 1.1 [95% CI, 0.2-2.0])., Conclusions and Relevance: This analysis suggests that a higher pain level at presentation was associated with a higher risk of initial failure of nonoperative management and that a longer duration of pain was associated with lower risk of delayed treatment failure. Although satisfaction was high in both groups, satisfaction with the treatment decision was higher among patients with successful nonoperative management at 1 year., Trial Registration: ClinicalTrials.gov Identifier: NCT02271932.

Introduction: Dog bites are one of the leading causes of non-fatal emergency room visits in children. These injuries not only cause physical harm but can lead to long-term psychological stress. This study evaluated the current literature related to pediatric dog bite injuries to identify research gaps which should be prioritized to improve a major public health concern., Methods: We performed a keyword search of PubMed, Scopus, and OVID Medline databases (January 1980- March 2020) for all published studies focused on dog bite injuries in the pediatric population (≤18 years of age) using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses., Results: Out of 1859 abstracts screened, 43 studies involving 86 880 patients were included. Twenty-nine studies were retrospective chart reviews characterizing the epidemiology of dog bites and their associated treatment outcomes; six were prospective cohort studies; two were cross-sectional studies; and six were experimental studies. Synthesized results demonstrate that children <9 years of age suffer the greatest burden of injuries, with children <6 years of age at higher risk of more severe injuries involving the head, neck, and face., Conclusion: Studies analyzing the prevention or psychosocial consequences of dog bites injuries are needed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Infants with newborn congenital anomalies are increasingly undergoing minimally invasive surgical (MIS) repair. Currently available data on outcomes are limited. This study provides national estimates for length of stay and 30-day complications following MIS for congenital anomalies., Methods: Using the ACS-NSQIP Pediatric (2013-2018), a retrospective analysis of MIS for congenital anomalies was performed. MIS repairs for the following diagnoses were included: pyloric stenosis (PS), congenital lung lesion (LL), mediastinal mass (MM), congenital malrotation (CM), anorectal malformation (ARM), Hirschsprung's disease (HD), congenital diaphragmatic hernia (CDH), tracheoesophageal fistula (TEF), biliary atresia/choledochal cyst (HB), and intestinal atresia (IA). Postoperative LOS (pLOS) and complication rates were examined using multivariable analysis for risk factors after categorizing surgeries by complexity of care related to congenital anomaly: Simple (PS), Complex Group 1 (LL, MM, CM, and ARM), and Complex Group 2 (HD, CDH, TEF, HB, and IA)., Results: Across 10 anomalies, 8,326 repairs were performed using an MIS approach. Procedure-specific median postoperative LOS (75th-percentile, 90th-percentile) for PS was 1 day (1, 3); LL was 3 (4, 7); MM was 2 (3, 5); CM was 4 (7, 14); ARM was 3 (5, 8); HD was 5 (8, 12); CDH was 8 (18, 31); HB was 5 (8, 12); TEF was 20 (31, 53); and IA was 17 (25, 40). The overall surgical complication rates (95% CI) were: PS, 5.1% (4.7%-5.6%); LL, 14.2% (12.3-16.4); MM, 8.4% (6.4-11.0); CM, 14.6% (11.9-17.9); ARM, 12.0% (7.1-19.5); HD, 22.1% (19.5-25.0); CDH, 21.1% (17.1-25.6); HB, 20.6% (13.7-29.7); TEF, 36% (27.5-45.5); and IA, 28.6% (19.3-40.1). Risk factors for increased pLOS and complications varied by procedure category and included patient-level and admission characteristics., Conclusion: This study provides national benchmarks and risk factors for expected postoperative LOS and 30-day complications following MIS for congenital anomalies., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)