This descriptive study reports caregiver experiences with GnRH agonist implants among a cohort of youth followed in a pediatric hospital-based gender clinic. We administered a survey to 36 of 55 eligible caregivers ascertaining demographics and satisfaction, with a medical record review of any surgical complications. The overwhelming majority (97.1%) reported satisfaction with the procedure and would undergo the implant procedure again (94.4%). The most frequent challenges noted were about affordability (39.8%) and insurance denials (39.8%). Implantable GnRH agonist can be used successfully in pediatric patients with gender dysphoria. Future policy should seek to address concerns regarding insurance approval and reimbursement.

<p><strong>OBJECTIVES: </strong>To characterize patterns of surgery among pediatric patients during terminal hospitalizations in children's hospitals.</p>

<p><strong>METHODS: </strong>We reviewed patients ≤20 years of age who died among 4 424 886 hospitalizations from January 2013-December 2019 within 49 US children's hospitals in the Pediatric Health Information System database. Surgical procedures, identified by International Classification of Diseases procedure codes, were classified by type and purpose. Descriptive statistics characterized procedures, and hypothesis testing determined if undergoing surgery varied by patient age, race and ethnicity, or the presence of chronic complex conditions (CCCs).</p>

<p><strong>RESULTS: </strong>Among 33 693 terminal hospitalizations, the majority (n = 30 440, 90.3%) of children were admitted for nontraumatic causes. Of these children, 15 142 (49.7%) underwent surgery during the hospitalization, with the percentage declining over time (P &lt; .001). When surgical procedures were classified according to likely purpose, the most common were to insert or address hardware or catheters (31%), explore or aid in diagnosis (14%), attempt to rescue patient from mortality (13%), or obtain a biopsy (13%). Specific CCC types were associated with undergoing surgery. Surgery during terminal hospitalization was less likely among Hispanic children (47.8%; P &lt; .001), increasingly less likely as patient age increased, and more so for Black, Asian American, and Hispanic patients compared with white patients (P &lt; .001).</p>

<p><strong>CONCLUSIONS: </strong>Nearly half of children undergo surgery during their terminal hospitalization, and accordingly, pediatric surgical care is an important aspect of end-of-life care in hospital settings. Differences observed across race and ethnicity categories of patients may reflect different preferences for and access to nonhospital-based palliative, hospice, and end-of-life care.</p>

<p>In US trauma centers, firearms are the second leading cause of trauma-related death in pediatric patients. In children (&lt;18 years), firearms are associated with one of the highest case fatality rates (16.7%) of all injury mechanisms. According to the Gun Violence Archive, in 2019 alone, 3774 children experienced gun violence, including 985 killed and 2789 injured. The US Centers for Disease Control and Prevention reports multiple-victim school homicide rates have increased significantly between 2009 and 2018, following 15 years of decline. Considering the overall burden of gun violence, mass shootings are responsible for a relatively small number of deaths and injuries. However, these events also expose other residents, notably children, in the nearby communities to violence. This study examines the location of mass shootings relative to schools and places frequented by children, highlighting the potential risk of exposure to violence in our communities.</p>

<p>According to federal statistics, mass shootings have tripled in the United States in the past decade. These mass-casualty events can easily overwhelm the resources of local hospitals. As the number of persons injured increases, even a well-prepared center can be pushed beyond capacity. While trauma systems have been established throughout the United States to prioritize getting the right patient to the right place at the right time, travel distance, traffic, casualty volume, and injury severity often result in transport of patients to a hospital that is not a trauma center (TC). It is hypothesized that the nearest available hospitals to mass shooting events will commonly be non–trauma center (NTC) hospitals, where such patient loads are more likely to overwhelm capacity and advanced care options may be limited. This study evaluates the location of recent mass shooting events relative to nearest hospitals and TCs.</p>

<p><strong>OBJECTIVES: </strong>More childhood deaths are attributed to trauma than all other causes combined. Our objectives were to provide the first national description of the proportion of injured children treated at pediatric trauma centers (TCs), and to provide clarity to the presumed benefit of pediatric TC verification by comparing injury mortality across hospital types.</p>

<p><strong>METHODS: </strong>We performed a population-based cohort study using the 2006 Healthcare Cost and Utilization Project Kids Inpatient Database combined with national TC inventories. We included pediatric discharges (≤16 y) with the International Classification of Diseases, Ninth Revision code(s) for injury. Descriptive analyses were performed evaluating proportions of injured children cared for by TC level. Multivariable logistic regression models were used to estimate differences in in-hospital mortality by TC type (among level-1 TCs only). Analyses were survey-weighted using Healthcare Cost and Utilization Project sampling weights.</p>

<p><strong>RESULTS: </strong>Of 153,380 injured children, 22.3% were admitted to pediatric TCs, 45.2% to general TCs, and 32.6% to non-TCs. Overall mortality was 0.9%. Among level-1 TCs, raw mortality was 1.0% pediatric TC, 1.4% dual TC, and 2.1% general TC. In adjusted analyses, treatment at level-1 pediatric TCs was associated with a significant mortality decrease compared to level-1 general TCs (adjusted odds ratio, 0.6; 95% confidence intervals, 0.4-0.9).</p>

<p><strong>CONCLUSIONS: </strong>Our results provide the first national evidence that treatment at verified pediatric TCs may improve outcomes, supporting a survival benefit with pediatric trauma verification. Given lack of similar survival advantage found for level-1 dual TCs (both general/pediatric verified), we highlight the need for further investigation to understand factors responsible for the survival advantage at pediatric-only TCs, refine pediatric accreditation guidelines, and disseminate best practices.</p>

<p><strong>BACKGROUND: </strong>Unintentional injuries are one of the leading causes of death in the United States. Many of these injuries are preventable, and unintentional firearm injuries, in particular, may be responsive to prevention efforts. We investigated the relationship between unintentional firearm death and urbanicity among adults.</p>

<p><strong>METHODS: </strong>This study was a retrospective analysis of national death certificate data. Unintentional adult firearm deaths in the United States from 1999 to 2006 were identified using the Multiple Cause of Death Data files from the National Center for Health Statistics. Decedents were assigned to a county of death and classified along an urban-rural continuum defined by population density and proximity to metropolitan areas. Total unintentional firearm death rates by county were analyzed in adjusted analyses using negative binomial regression.</p>

<p><strong>RESULTS: </strong>A total of 4,595 unintentional firearm injury deaths of adults occurred in the United States during the study period (a mean of 574.4 per year). Adjusted rates of unintentional firearm death showed increases from urban to rural counties. Americans in the most rural counties were significantly more likely to die of unintentional firearm deaths than those in the most urban counties (relative rate, 2.16; 95% confidence interval, 1.44-3.21, p = 0.002).</p>

<p><strong>CONCLUSION: </strong>Rates of unintentional firearm death are significantly higher in rural counties than in urban counties. Prevention strategies should be tailored to account for both geographic location and manner of firearm injury.</p>

<p><strong>LEVEL OF EVIDENCE: </strong>Epidemiologic study, level III.</p>

<p><strong>STUDY OBJECTIVES: </strong>Many US cities have experienced population reductions, often blamed on crime and interpersonal injury. Yet the overall injury risk in urban areas compared with suburban and rural areas has not been fully described. We begin to investigate this evidence gap by looking specifically at injury-related mortality risk, determining the risk of all injury death across the rural-urban continuum.</p>

<p><strong>METHODS: </strong>A cross-sectional time-series analysis of US injury deaths from 1999 to 2006 in counties classified according to the rural-urban continuum was conducted. Negative binomial generalized estimating equations and tests for trend were completed. Total injury deaths were the primary comparator, whereas differences by mechanism and age were also explored.</p>

<p><strong>RESULTS: </strong>A total of 1,295,919 injury deaths in 3,141 US counties were analyzed. Injury mortality increased with increasing rurality. Urban counties demonstrated the lowest death rates, significantly less than rural counties (mean difference=24.0 per 100,000; 95% confidence interval 16.4 to 31.6 per 100,000). After adjustment, the risk of injury death was 1.22 times higher in the most rural counties compared with the most urban (95% confidence interval 1.07 to 1.39).</p>

<p><strong>CONCLUSION: </strong>Using total injury death rate as an overall safety metric, US urban counties were safer than their rural counterparts, and injury death risk increased steadily as counties became more rural. Greater emphasis on elevated injury-related mortality risk outside of large cities, attention to locality-specific injury prevention priorities, and an increased focus on matching emergency care needs to emergency care resources are in order.</p>

<p><strong>OBJECTIVES: </strong>To compare the presentation of young children with abdominal trauma caused by high-velocity accidental (HVA), low-velocity accidental (LVA), and inflicted injury, and to test the hypothesis that a delay in care is highly predictive of an inflicted injury.</p>

<p><strong>METHODS: </strong>We performed a retrospective chart review at an urban Level I pediatric trauma center between 1991 and 2001 of children younger than 6 years who were admitted with abdominal injuries and an Abbreviated Injury Scale (AIS) score &gt; or = 2. Charts were abstracted for demographic information, history of presentation, mechanism of injury, and diagnoses. Accidental injuries were defined as high velocity (motor vehicle crash or a fall from &gt; 10 feet) or low velocity (household trauma, bicycle crash, or a fall from &lt; 10 feet). Inflicted trauma was defined as a constellation of unexplained injuries, confessions by a perpetrator, or disclosure by the victim.</p>

<p><strong>RESULTS: </strong>Of the 121 children in the study, 77 (64%) had HVA injuries, 31 (26%) had LVA injuries, and 13 (11%) had inflicted injuries. Solid organ injuries (e.g., liver, spleen, and kidney) were most common in all groups, and abused children were significantly more likely to have suffered a hollow viscus injury (p = 0.03). Abused children were also significantly more likely to have suffered injuries with an AIS score &gt;3 and combined hollow viscus and solid organ injuries than the HVA group or the LVA group (p &lt; 0.001). Presentation for medical care occurred within 12 hours for 100% of the HVA group but only 65% of the LVA group, and 46% of the abuse group (p &lt; 0.001). Presentation to care at greater than 12 hours was neither specific nor highly predictive of abuse, as some children with LVA injuries presented for care late despite developing symptoms shortly after their injury occurred (specificity, 65% [95% confidence interval, 45-81%]; positive predictive value, 39% [95% confidence interval, 17-64%]).</p>

<p><strong>CONCLUSION: </strong>Young children with inflicted abdominal injuries are more likely to have more severe injuries, multiple injuries, and a delay in seeking care than young children with accidental abdominal trauma. However, delay in seeking care is not specific for inflicted injury and occurs in some children with LVA abdominal trauma.</p>