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Importance: Extreme weather has major implications for state and national health care systems; however, statistics examining weather-related injuries and fatalities are limited. Objective: To examine the frequency and regional distribution of major disaster events (MDEs) in the US. Design, Setting, and Participants: This ecologic cross-sectional study of MDEs occurring between January 1, 2006, and December 31, 2021, evaluated US data on all injuries and fatalities included in the National Oceanic and Atmospheric Administration National Centers for Environmental Information Storm Events Database. The data analysis was performed between February 22, 2023, and April 1, 2024. Exposures: Major disaster events defined as an environmental event that caused either at least 50 injuries or at least 10 deaths. Main Outcomes and Measures: All MDEs were evaluated using descriptive statistics for event type, property damage, and rural or urban classification according to the National Centers for Health Statistics Urban-Rural Classification Scheme for Counties. The location of events according to Administration for Strategic Preparedness and Response (ASPR) region and hospital bed capacity of ASPR regions were also examined. Results: Between 2006 and 2021, 11 159 storm events caused 42 254 injuries and 9760 deaths. Major disaster events accounted for 209 weather events (1.9%) but caused 19 463 weather-associated injuries (46.1%) and 2189 weather-associated deaths (22.4%). The majority of MDEs were caused by extreme heat (86 [41.1%]) and tornadoes (67 [32.1%]). While a larger proportion of MDEs occurred in urban areas (151 [75.1%]) vs rural areas (50 [24.9%]), rural MDEs caused a median of 9 (IQR, 2-16) deaths per event vs 4 (IQR, 0-14) deaths per event in urban areas. The majority of MDEs occurred in either ASPR region 4 (51 [24.5%]) or region 9 (45 [21.6%]). Certain event types, such as fires, wind, and hurricanes or storms, were geographically concentrated, while extreme heat and floods affected regions across the US equally. Urban counties had disproportionately greater hospital bed capacity than rural counties relative to population and MDE distributions. Conclusions and Relevance: The findings of this ecologic study indicate that while MDEs accounted for a small proportion of all weather events, they were associated with a disproportionate number of injuries and fatalities. Integrating these data into county, state, and regional hazard vulnerability analyses is crucial to ensuring preparedness and mitigating climate risk.

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Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

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Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging, is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

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Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

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Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

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Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

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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.

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ABSTRACT: Pediatric trauma system development is essential to public health infrastructure and pediatric health systems. Currently, trauma systems are managed at the state level, with significant variation in consideration of pediatric needs. A recently developed Pediatric Trauma System Assessment Score (PTSAS) demonstrated that states with lower PTSAS have increased pediatric mortality from trauma. Critical gaps are identified within 6 PTSAS domains: Legislation & Funding, Access to Care, Injury Prevention and Recognition, Disaster, Quality Improvement & Trauma Registry, and Pediatric Readiness. For each gap, a recommendation is provided regarding the necessary steps to address these challenges. Existing national organizations, including governmental, professional, and advocacy, highlight the potential partnerships that could be fostered to support efforts to address existing gaps. The organizations created under the U.S. Administration are described to highlight the ongoing efforts to support the development of pediatric emergency health systems.It is no longer sufficient to describe the disparities in pediatric trauma outcomes without taking action to ensure the health system is equipped to manage injured children. By capitalizing on organizations that intersect with trauma and emergency systems to address known gaps, we can reduce the impact of injury on all children across the United States.

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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.

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Mass casualty events particularly those requiring multiple simultaneous operating rooms are of increasing concern. Existing literature predominantly focuses on mass casualty care in the emergency department. Hospital disaster plans should include a component focused on preparing for multiple simultaneous operations. When developing this plan, representatives from all segments of the perioperative team should be included. The plan needs to address activation, communication, physical space, staffing, equipment, blood and medications, disposition offloading, special populations, and rehearsal.

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Importance: There is variability in practice and imaging usage to diagnose cervical spine injury (CSI) following blunt trauma in pediatric patients. Objective: To develop a prediction model to guide imaging usage and to identify trends in imaging and to evaluate the PEDSPINE model. Design, Setting, and Participants: This cohort study included pediatric patients (<3 years years) following blunt trauma between January 2007 and July 2017. Of 22 centers in PEDSPINE, 15 centers, comprising level 1 and 2 stand-alone pediatric hospitals, level 1 and 2 pediatric hospitals within an adult hospital, and level 1 adult hospitals, were included. Patients who died prior to obtaining cervical spine imaging were excluded. Descriptive analysis was performed to describe the population, use of imaging, and injury patterns. PEDSPINE model validation was performed. A new algorithm was derived using clinical criteria and formulation of a multiclass classification problem. Analysis took place from January to October 2022. Exposure: Blunt trauma. Main Outcomes and Measures: Primary outcome was CSI. The primary and secondary objectives were predetermined. Results: The current study, PEDSPINE II, included 9389 patients, of which 128 (1.36%) had CSI, twice the rate in PEDSPINE (0.66%). The mean (SD) age was 1.3 (0.9) years; and 70 patients (54.7%) were male. Overall, 7113 children (80%) underwent cervical spine imaging, compared with 7882 (63%) in PEDSPINE. Several candidate models were fitted for the multiclass classification problem. After comparative analysis, the multinomial regression model was chosen with one-vs-rest area under the curve (AUC) of 0.903 (95% CI, 0.836-0.943) and was able to discriminate between bony and ligamentous injury. PEDSPINE and PEDSPINE II models' ability to identify CSI were compared. In predicting the presence of any injury, PEDSPINE II obtained a one-vs-rest AUC of 0.885 (95% CI, 0.804-0.934), outperforming the PEDSPINE score (AUC, 0.845; 95% CI, 0.769-0.915). Conclusion and Relevance: This study found wide clinical variability in the evaluation of pediatric trauma patients with increased use of cervical spine imaging. This has implications of increased cost, increased radiation exposure, and a potential for overdiagnosis. This prediction tool could help to decrease the use of imaging, aid in clinical decision-making, and decrease hospital resource use and cost.

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Importance: Emergency department (ED) pediatric readiness is associated with improved survival among children. However, the association between geographic access to high-readiness EDs in US trauma centers and mortality is unclear. Objective: To evaluate the association between the proximity of injury location to receiving trauma centers, including the level of ED pediatric readiness, and mortality among injured children. Design, Setting, and Participants: This retrospective cohort study used a standardized risk-adjustment model to evaluate the association between trauma center proximity, ED pediatric readiness, and in-hospital survival. There were 765 trauma centers (level I-V, adult and pediatric) that contributed data to the National Trauma Data Bank (January 1, 2012, through December 31, 2017) and completed the 2013 National Pediatric Readiness Assessment (conducted from January 1 through August 31, 2013). The study comprised children aged younger than 18 years who were transported by ground to the included trauma centers. Data analysis was performed between January 1 and March 31, 2022. Exposures: Trauma center proximity within 30 minutes by ground transport and ED pediatric readiness, as measured by weighted pediatric readiness score (wPRS; range, 0-100; quartiles 1 [low readiness] to 4 [high readiness]). Main Outcomes and Measures: In-hospital mortality. We used a patient-level mixed-effects logistic regression model to evaluate the association of transport time, proximity, and ED pediatric readiness on mortality. Results: This study included 212 689 injured children seen at 765 trauma centers. The median patient age was 10 (IQR, 4-15) years, 136 538 (64.2%) were male, and 127 885 (60.1%) were White. A total of 4156 children (2.0%) died during their hospital stay. The median wPRS at these hospitals was 79.1 (IQR, 62.9-92.7). A total of 105 871 children (49.8%) were transported to trauma centers with high-readiness EDs (wPRS quartile 4) and another 36 330 children (33.7%) were injured within 30 minutes of a quartile 4 ED. After adjustment for confounders, proximity, and transport time, high ED pediatric readiness was associated with lower mortality (highest-readiness vs lowest-readiness EDs by wPRS quartiles: adjusted odds ratio, 0.65 [95% CI, 0.47-0.89]). The survival benefit of high-readiness EDs persisted for transport times up to 45 minutes. The findings suggest that matching children to trauma centers with high-readiness EDs within 30 minutes of the injury location may have potentially saved 468 lives (95% CI, 460-476 lives), but increasing all trauma centers to high ED pediatric readiness may have potentially saved 1655 lives (95% CI, 1647-1664 lives). Conclusions and Relevance: These findings suggest that trauma centers with high ED pediatric readiness had lower mortality after considering transport time and proximity. Improving ED pediatric readiness among all trauma centers, rather than selective transport to trauma centers with high ED readiness, had the largest association with pediatric survival. Thus, increased pediatric readiness at all US trauma centers may substantially improve patient outcomes after trauma.

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ABSTRACT: Injury is the leading cause of death in children older than 1 year, and children make up 22% of the population. Pediatric readiness (PR) of the nation's emergency departments and state trauma and emergency medical services (EMS) systems is conceptually important and vital to mitigate mortality and morbidity in this population. The extension of PR to the trauma community has become a focused area for training, staffing, education, and equipment at all levels of trauma center designation, and there is evidence that a higher level of emergency department PR is independently associated with long-term survival among injured children. Although less well studied, there is an associated need for EMS PR, which is relevant to the injured child who needs assessment, treatment, triage, and transport to a trauma center. We outline a blueprint along with recommendations for incorporating PR into trauma system development in this opinion from the EMS Committee of the American College of Surgeons Committee on Trauma. These recommendations are particularly pertinent in the rural and underserved areas of the United States but are directed toward all levels of professionals who care for an injured child along the trauma continuum of care.

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The Children's Surgery Verification Program of the American College of Surgeons began in 2016 based on the standards created by the Task Force for Children's Surgery. This program seeks to improve the surgical care of children by assuring the appropriate resources and robust performance improvement programs at participating centers. Three levels of centers with defined scopes of practice and matching resources are defined. Since its inception more than 50 center have been verified. A specialty hospital program was launched in 2019. The standards for all hospitals were revised in 2021 based on lessons learned. In this article the leaders of the program discuss the development, areas of greatest impact and future directions of the program.

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With the prevailing focus on increasing value in healthcare, understanding the different components of the value equation is of primary importance. Michael E. Porter's writings on the value agenda and the use of integrated practice units (IPUs) have provided easy correlation to adult disease entities with large populations sharing common pathways and providers in the diagnosis and care of these patients. In pediatric surgery, with smaller populations and larger numbers of rare or unique conditions and anatomic challenges, utilizing the concept of an IPU is more challenging. The literature has generally shown the improvements in quality of care through participation in various programs through the American College of Surgeons (ACS) such as trauma verification, or the National Surgical Quality Improvement Project (NSQIP), but that participation alone does not guarantee better outcomes. Use of these programs in conjunction with participation in quality collaboratives have tended to show favorable returns on investment for these programs. We seek to demonstrate how the Children's Surgery Verification (CSV) program provides pediatric surgeons an effective vehicle with which to engage the value agenda, evaluating and improving care over the care continuum in order to improve the function of children's hospitals as larger integrated units.

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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.

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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.

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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.

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