COVID-19 Publications

Fetal Risk Stratification and Outcomes in Children with Prenatally Diagnosed Lung Malformations: Results from a Multi-Institutional Research Collaborative.

Kunisaki SM, Saito JM, Fallat ME, St Peter SD, Lal DR, Karmakar M, Deans KJ, Gadepalli SK, Hirschl RB, Minneci PC, Helmrath MA; Midwest Pediatric Surgery Consortium. Fetal Risk Stratification and Outcome in Children with Prenatally Diagnosed Lung Malformations: Results from a Multi-Institutional Research Collaborative. Ann Surg. 2020 Nov 17. Ann Surg. 2020 Nov 17. doi: 10.1097/SLA.0000000000004566. Online ahead of print. PMID: 33214447

Abstract
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.
Cite
Kunisaki SM, Saito JM, Fallat ME, St Peter SD, Lal DR, Karmakar M, Deans KJ, Gadepalli SK, Hirschl RB, Minneci PC, Helmrath MA; Midwest Pediatric Surgery Consortium. Fetal Risk Stratification and Outcome in Children with Prenatally Diagnosed Lung Malformations: Results from a Multi-Institutional Research Collaborative. Ann Surg. 2020 Nov 17. Ann Surg. 2020 Nov 17. doi: 10.1097/SLA.0000000000004566. Online ahead of print. PMID: 33214447

Relationship Between the COVID-19 Pandemic and Structural Inequalities Within the Pediatric Trauma Population

Georgeades C, Collings AT, Farazi M, Bergner C, Fallat ME, Minneci PC, Speck KE, Van Arendonk KJ, Deans KJ, Falcone RA Jr, Foley DS, Fraser JD, Gadepalli SK, Keller MS, Kotagal M, Landman MP, Leys CM, Markel TA, Rubalcava NS, St Peter SD, Sato TT, Flynn-O'Brien KT; Midwest Pediatric Surgery Consortium (MWPSC). Relationship between the COVID-19 pandemic and structural inequalities within the pediatric trauma population. Inj Epidemiol. 2023 Nov 28;10(Suppl 1):62. doi: 10.1186/s40621-023-00475-0. PMID: 38017506; PMCID: PMC10683076.

Abstract
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.
Cite
Georgeades C, Collings AT, Farazi M, Bergner C, Fallat ME, Minneci PC, Speck KE, Van Arendonk KJ, Deans KJ, Falcone RA Jr, Foley DS, Fraser JD, Gadepalli SK, Keller MS, Kotagal M, Landman MP, Leys CM, Markel TA, Rubalcava NS, St Peter SD, Sato TT, Flynn-O'Brien KT; Midwest Pediatric Surgery Consortium (MWPSC). Relationship between the COVID-19 pandemic and structural inequalities within the pediatric trauma population. Inj Epidemiol. 2023 Nov 28;10(Suppl 1):62. doi: 10.1186/s40621-023-00475-0. PMID: 38017506; PMCID: PMC10683076.

A Multi-institutional Study Evaluating Pediatric Burn Injuries During the COVID-19 Pandemic

Georgeades CM, Collings AT, Farazi M, Fallat ME, Minneci PC, Sato TT, Speck KE, Van Arendonk K, Deans KJ, Falcone RA, Foley DS, Fraser J, Gadepalli S, Keller MS, Kotagal M, Landman MP, Leys CM, Markel TA, Rubalcava N, St Peter SD, Flynn-O'Brien KT. A Multi-institutional Study Evaluating Pediatric Burn Injuries During the COVID-19 Pandemic. J Burn Care Res. 2023 Mar 2;44(2):399-407. doi: 10.1093/jbcr/irac118. PMID: 35985296; PMCID: PMC9452075.

Abstract
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.
Cite
Georgeades CM, Collings AT, Farazi M, Fallat ME, Minneci PC, Sato TT, Speck KE, Van Arendonk K, Deans KJ, Falcone RA, Foley DS, Fraser J, Gadepalli S, Keller MS, Kotagal M, Landman MP, Leys CM, Markel TA, Rubalcava N, St Peter SD, Flynn-O'Brien KT. A Multi-institutional Study Evaluating Pediatric Burn Injuries During the COVID-19 Pandemic. J Burn Care Res. 2023 Mar 2;44(2):399-407. doi: 10.1093/jbcr/irac118. PMID: 35985296; PMCID: PMC9452075.

The COVID-19 Pandemic and Associated Rise in Pediatric Firearm Injuries: A Multi-institutional Study

Collings AT, Farazi M, Van Arendonk KJ, Fallat ME, Minneci PC, Sato TT, Speck KE, Deans KJ, Falcone RA Jr, Foley DS, Fraser JD, Gadepalli SK, Keller MS, Kotagal M, Landman MP, Leys CM, Markel TA, Rubalcava N, St Peter SD, Flynn-O'Brien KT; Midwest Pediatric Surgery Consortium. The COVID-19 pandemic and associated rise in pediatric firearm injuries: A multi-institutional study. J Pediatr Surg. 2022 Apr 12:S0022-3468(22)00267-6. doi: 10.1016/j.jpedsurg.2022.03.034. Epub ahead of print. PMID: 35501165; PMCID: PMC9001175.

Abstract
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.
Cite
Collings AT, Farazi M, Van Arendonk KJ, Fallat ME, Minneci PC, Sato TT, Speck KE, Deans KJ, Falcone RA Jr, Foley DS, Fraser JD, Gadepalli SK, Keller MS, Kotagal M, Landman MP, Leys CM, Markel TA, Rubalcava N, St Peter SD, Flynn-O'Brien KT; Midwest Pediatric Surgery Consortium. The COVID-19 pandemic and associated rise in pediatric firearm injuries: A multi-institutional study. J Pediatr Surg. 2022 Apr 12:S0022-3468(22)00267-6. doi: 10.1016/j.jpedsurg.2022.03.034. Epub ahead of print. PMID: 35501165; PMCID: PMC9001175.

Impact of "Stay-at-Home" Orders on Non-accidental Trauma: A Multi-institutional Study

Collings AT, Farazi M, Van Arendonk K, Fallat ME, Minneci PC, Sato TT, Speck KE, Deans KJ, Falcone RA, Foley DS, Fraser JD, Keller MS, Kotagal M, Landman MP, Leys CM, Markel T, Rubalcava N, St Peter SD, Flynn-O'Brien KT; Midwest Pediatric Surgery Consortium. Impact of "Stay-at-Home" orders on non-accidental trauma: A multi-institutional study. J Pediatr Surg. 2022 Feb 14:S0022-3468(22)00130-0. doi: 10.1016/j.jpedsurg.2022.01.056. Epub ahead of print. PMID: 35292165; PMCID: PMC8842346.

Abstract
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.
Cite
Collings AT, Farazi M, Van Arendonk K, Fallat ME, Minneci PC, Sato TT, Speck KE, Deans KJ, Falcone RA, Foley DS, Fraser JD, Keller MS, Kotagal M, Landman MP, Leys CM, Markel T, Rubalcava N, St Peter SD, Flynn-O'Brien KT; Midwest Pediatric Surgery Consortium. Impact of "Stay-at-Home" orders on non-accidental trauma: A multi-institutional study. J Pediatr Surg. 2022 Feb 14:S0022-3468(22)00130-0. doi: 10.1016/j.jpedsurg.2022.01.056. Epub ahead of print. PMID: 35292165; PMCID: PMC8842346.

Evaluating the Regional Differences in Pediatric Injury Patterns During the COVID-19 Pandemic

Collings AT, Farazi M, Van Arendonk KJ, Fallat ME, Minneci PC, Sato TT, Speck KE, Gadepalli S, Deans KJ, Falcone RA Jr, Foley DS, Fraser JD, Keller MS, Kotagal M, Landman MP, Leys CM, Markel T, Rubalcava N, St Peter SD, Flynn-O'Brien KT; Midwest Pediatric Surgery Consortium. Evaluating the Regional Differences in Pediatric Injury Patterns During the COVID-19 Pandemic. J Surg Res. 2023 Mar 23;289:61-68. doi: 10.1016/j.jss.2023.03.003. Epub ahead of print. PMID: 37086597; PMCID: PMC10033255.

Abstract
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.
Cite
Collings AT, Farazi M, Van Arendonk KJ, Fallat ME, Minneci PC, Sato TT, Speck KE, Gadepalli S, Deans KJ, Falcone RA Jr, Foley DS, Fraser JD, Keller MS, Kotagal M, Landman MP, Leys CM, Markel T, Rubalcava N, St Peter SD, Flynn-O'Brien KT; Midwest Pediatric Surgery Consortium. Evaluating the Regional Differences in Pediatric Injury Patterns During the COVID-19 Pandemic. J Surg Res. 2023 Mar 23;289:61-68. doi: 10.1016/j.jss.2023.03.003. Epub ahead of print. PMID: 37086597; PMCID: PMC10033255.

Pediatric Injury Transfer Patterns During the COVID-19 Pandemic: An Interrupted Time Series Analysis

Flynn-O'Brien KT, Collings AT, Farazi M, Fallat ME, Minneci PC, Speck KE, Van Arendonk K, Deans KJ, Falcone RA Jr, Foley DS, Fraser JD, Gadepalli S, Keller MS, Kotagal M, Landman MP, Leys CM, Markel TA, Rubalcava N, St Peter SD, Sato TT; Midwest Pediatric Surgery Consortium. Pediatric Injury Transfer Patterns During the COVID-19 Pandemic: An Interrupted time Series Analysis. J Surg Res. 2022 Aug 30;281:130-142. doi: 10.1016/j.jss.2022.08.029. Epub ahead of print. PMID: 36155270; PMCID: PMC9424522.

Abstract
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.
Cite
Flynn-O'Brien KT, Collings AT, Farazi M, Fallat ME, Minneci PC, Speck KE, Van Arendonk K, Deans KJ, Falcone RA Jr, Foley DS, Fraser JD, Gadepalli S, Keller MS, Kotagal M, Landman MP, Leys CM, Markel TA, Rubalcava N, St Peter SD, Sato TT; Midwest Pediatric Surgery Consortium. Pediatric Injury Transfer Patterns During the COVID-19 Pandemic: An Interrupted time Series Analysis. J Surg Res. 2022 Aug 30;281:130-142. doi: 10.1016/j.jss.2022.08.029. Epub ahead of print. PMID: 36155270; PMCID: PMC9424522.

Pediatric Injury Trends and Relationships with Social Vulnerability During the COVID-19 Pandemic: A Multi-institutional Analysis

Flynn-O'Brien KT, Collings AT, Farazi M, Fallat ME, Minneci PC, Speck KE, Van Arendonk K, Deans KJ, Falcone RA Jr, Foley DS, Fraser JD, Gadepalli S, Keller MS, Kotagal M, Landman MP, Leys CM, Markel TA, Rubalcava N, St Peter SD, Sato TT; Midwest Pediatric Surgery Consortium. Pediatric injury trends and relationships with social vulnerability during the COVID-19 pandemic: a multi-institutional analysis. J Trauma Acute Care Surg. 2022 May 20. doi: 10.1097/TA.0000000000003687. Epub ahead of print. PMID: 35995783.

Abstract
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.
Cite
Flynn-O'Brien KT, Collings AT, Farazi M, Fallat ME, Minneci PC, Speck KE, Van Arendonk K, Deans KJ, Falcone RA Jr, Foley DS, Fraser JD, Gadepalli S, Keller MS, Kotagal M, Landman MP, Leys CM, Markel TA, Rubalcava N, St Peter SD, Sato TT; Midwest Pediatric Surgery Consortium. Pediatric injury trends and relationships with social vulnerability during the COVID-19 pandemic: a multi-institutional analysis. J Trauma Acute Care Surg. 2022 May 20. doi: 10.1097/TA.0000000000003687. Epub ahead of print. PMID: 35995783.