Doernbecher Children's Hospital

Introduction Flavored tobacco restrictions provide an opportunity to reduce tobacco product initiation. However, this policy raises concerns about the decrease in cessation of combustible tobacco due to decreased transition to e-cigarettes. Methods We developed a Markov model using transition rates between inhaled tobacco product use states derived from the Population Assessment of Tobacco and Health (PATH) study to assess how a flavored tobacco restriction may impact current users and those at risk of starting tobacco products. This quasi-experimental cohort study assesses the potential impact of flavored restrictions on primary and secondary prevention strategies, providing a cohort and population assessment of flavored tobacco restrictions. Results The model predicts that for every million adolescents at risk of starting tobacco, a restrictive flavor policy will have 121,000 fewer people ever using tobacco, with a decrease in every use state. After 10 years of policy for every million people over 21 years old, the model predicts 25,200 fewer tobacco product users and 19,200 fewer combustible tobacco users. Discussion We demonstrated that a flavored tobacco restriction would see a short-term increase in combustible use from a substitution effect, before seeing a long-term downward trend in all tobacco product use is largely driven by a reduction in initiation among the youth cohort. Current users would see little to no long-term change in combustible use rates compared to a permissive flavor policy. Conclusion These findings support a restrictive flavor policy by showing that current combustible users face minimal to no harm, with significant improvements in tobacco use rates across the population leading to improved community health.

Despite the growing use of unsedated transnasal endoscopy (uTNE) in pediatrics, no validated tool exists to assess competence in performing uTNE, hindering effective training and consistent, high-quality performance. Video-based assessment offers a scalable and reliable method for assessing and enhancing procedural skills. Using Delphi methodology, we aimed to identify key competencies and establish content validity evidence for the TransNasal Endoscopy Skills Assessment Tool (TNE-SAT), a video-based tool designed to assess clinician competence in performing uTNE. North American pediatric uTNE experts iteratively rated potential assessment items, on a 5-point scale, based on their importance as indicators of endoscopist competence in performing uTNE. After each voting round, items scoring ≤3/5 were eliminated, and the remaining items were re-sent to the panel for further rating until consensus was reached, defined as ≥80% of panelists rating all remaining items ≥4. Items meeting this threshold were included in the final TNE-SAT tool. Twenty-seven experts from 19 sites across North America participated. One hundred thirty items were generated through literature review, task deconstruction, and Delphi panelist input. Three rounds of surveys were completed before consensus was achieved, with response rates ranging from 85% to 9. Seven items reached consensus for inclusion in the final TNE-SAT. This North American Delphi study identified core competencies required for effective uTNE performance and informed the development of the TNE-SAT, a structured, video-based tool to assess clinician competence. The TNE-SAT offers a promising tool to guide training and support quality improvement in pediatric uTNE.

Minimally invasive repair of pectus excavatum (MIRPE) is among the most painful elective procedures in pediatric patients and is frequently managed with both inpatient and outpatient opioids. However, opioid prescribing practices vary, and evidence-based discharge guidelines are lacking. This study aimed to evaluate outpatient opioid prescribing patterns following MIRPE across multiple institutions. A multicenter retrospective review was performed of patients (<21 years) who underwent MIRPE from 2022 to 2023 across 10 hospitals in the Western Pediatric Surgery Research Consortium. Demographic, operative, inpatient, and outpatient opioid data were collected. All opioid doses were converted to oral morphine equivalents (OME) using standardized conversion factors. Associations between inpatient opioid use and discharge prescriptions were assessed with linear regression. Among 532 patients (85.9 % male; median age 15.5 years [IQR 14.5-17.1]; median Haller index 4.5 [3.8-5.7]), 91 % received intercostal nerve cryoablation. Median hospital length of stay was 1 day [1-2]. Patients were discharged with a median of 10 opioid doses [8-16.5], equivalent to 75 OME [45-120] or 1.32 OME/kg [0.85-2.12]. Discharge prescriptions varied substantially by institution, ranging from 0 [0-10] to 20 [10-20] doses. Discharge OME correlated with inpatient opioid use (β = 0.35, 95%CI 0.26-0.44) and length of stay (β = 20.9, 95%CI 13.4-28.3). Outpatient opioid prescriptions following MIRPE varied widely across hospitals and were positively associated with inpatient opioid use and hospital stay. These findings underscore the need for standardized discharge analgesia guidelines to reduce variability and minimize excess opioid prescribing in pediatric surgical care.

Pleural drains are used routinely after thoracic surgery in children despite evidence that drainage is not always necessary. The purpose of this study was to assess the necessity of intraoperative drain placement after resectional lung surgery in children, provide a contemporary characterization of the use of pleural drains, and evaluate the utility of intraoperative air leak testing. A multi-institutional prospective cohort study was performed at 10 free-standing children's hospitals in the United States from 2023 to 2024. Patients ≤18 years old who underwent open or thoracoscopic wedge resection or lobectomy were included. Patients undergoing operation for spontaneous pneumothorax or trauma, those on extra-corporeal life support, those undergoing bi-lobectomy or pneumonectomy, and those undergoing reoperation in the affected hemithorax were excluded. Operative parameters, intra-operative air leak, length of post-operative drain placement, and number of post-operative chest x-rays were evaluated using bivariate comparisons. Among 229 patients (58% male, median age 12.3 years [IQR 5-16]), 113 (49%) underwent wedge resection and the remaining 116 (51%) underwent lobectomy. 201 patients (87.8%) had a pleural drain vs 28 (12.2%) without. Air leak testing was performed for 198 children: among those with a negative leak test (168, 73.4%), 144 (85.7%) had a pleural drain placed. Of the 90 children undergoing wedge resection with air leak test results available, 78 (87%) had a negative leak test and 57 (73%) of those patients still received pleural drainage. None of the 28 cases initially without pleural drainage required post-operative insertion of a pleural drain. Children with pleural drainage had significantly more post-operative chest x-rays compared to those without (median 5 vs 2, p < 0.001), and a significantly longer post-operative length of stay (median 3 vs 1 days, p < 0.001). Pleural drain placement after lung resection in pediatric patients is routine but may not be necessary. Patients with pleural drain incur significantly higher postoperative radiation exposure compared to those without. Randomized control trials of pleural drainage after resectional lung surgery are needed to examine further if the routine use of pleural drainage is necessary. III.

The erosion of pediatric care capability in community hospitals has heavily impacted rural communities, leading to more transfers to larger regional children's hospitals. The 2022 triple-demic of influenza, respiratory syncytial virus, and COVID-19 worsened these issues, increasing denials and delaying care. This study analyzed interfacility transfer requests, transfer denials, and consultation requests for pediatric services at a large academic regional children's hospital, focusing on the impact of patient surges on transfer denials and the use of telephone and telemedicine consultations to support denials. This retrospective study reviewed incoming calls from July 2019 to December 2023 to the UC Davis Children's Hospital transfer center from non-children's hospital emergency departments. Data on transfer requests to the pediatric intensive care unit, neonatal intensive care unit, and pediatric ward were analyzed, focusing on transfer denials due to limited bed space and staffing. Over the 42-month study period, transfer requests to the pediatric intensive care unit, neonatal intensive care unit, and pediatric ward averaged 279 per month, with 211 accepted and 38 denied per month. Telephone consultations averaged 27 per month, while telemedicine consultations averaged 3.3 per month. In November 2022, during the triple-demic, transfer requests spiked to 640 per month, with denials due to bed/staffing shortages rising to 375 (58.6% of requests). Despite these surges, the number of accepted transfers remained stable. The data highlight the challenges faced by a large regional children's hospital in managing transfer requests during surges, particularly exacerbated by the triple-demic in late 2022. As pediatric units close nationwide, telephone and telemedicine consultations offer valuable support for managing transfers that cannot be accommodated.

Intra-atrial baffles of pulmonary and systemic venous flows are relatively rarely used but are important surgical procedures for late-presenting d-transposition of the great arteries (D-TGA) or heterotaxy with anomalous venous connections. Atrial baffle surgery is employed less frequently today due to the advent of the arterial switch procedure. Two children presented with mirror-image venous connections in polysplenic heterotaxy and underwent intra-atrial baffle biventricular repairs. Both cases had ipsilateral pulmonary venous connections, interrupted inferior vena cava with azygous continuation, and concordant ventriculo-arterial connections. Furthermore, a single superior vena cava receiving the azygous and hepatic veins connected to the atrium contralateral to the sub-pulmonary right ventricle was present in both cases. Volumetric cardiac imaging using computed tomography and magnetic resonance imaging allowed for the creation of three-dimensional (3D) model reconstructions for pre-operative surgical planning and postoperative assessment of the atrial baffle pathways. The 3D model reconstructions presented here provide improved visualization and understanding of complex surgical atrial baffles.

On-demand support is necessary to mitigate distress and attrition in healthcare staff. Healthcare chaplains' scope includes such support. This pilot studied the acceptability, feasibility, and effectiveness of a Code Lavender protocol utilizing chaplain support and stress-relief items. A post-hoc analysis examined the protocol's cost-effectiveness. The results indicated the protocol's acceptability, effectiveness, feasibility, and cost-effectiveness. Healthcare worker distress can be mitigated with this simple, on-demand support utilizing the specialized skills and training of healthcare chaplains.

The pediatric subspecialty workforce is challenged by shortages and geographic maldistribution of subspecialists. We invited leaders in pediatrics to discuss how the field's vitality and survival can be secured. These leaders presented their own opinions and not the opinion of the society or organization that they are presenting. Early exposure of future trainees to pediatrics and advocacy for improved reimbursement structures, loan repayment, and funded programs for physician scientists will enhance the recruitment and retention of pediatric subspecialists to guarantee advancement of knowledge and the appropriate care of children with chronic and complex diseases.