Connect with us


Pediatric scoring scale helps surgeons decide whether to operate during COVID-19 delays

Pediatric scoring scale helps surgeons decide whether to operate during COVID-19 delays



As understanding grows about how COVID-19 impacts children, surgeons present findings on a new pediatric specific-tool to prioritize operations in a new Journal of the American College of Surgeons article


Credit: American College of Surgeons

CHICAGO (May 27, 2020): As health care providers observe Coronavirus Disease 2019 (COVID-19) affecting children differently than adults, pediatric surgeons in Chicago have modified an evaluation tool for use in pediatric patients that allows surgeons in every pediatric specialty to prioritize nonemergency (“elective”) operations during all phases of the pandemic. The new pediatric-specific scoring system is presented in an “article in press” on the Journal of the American College of Surgeons (JACS) website ahead of print.

Called the Pediatric Medically Necessary Time-Sensitive, or pMeNTS, scoring system, the new index score created by researchers at The University of Chicago (UChicago) Medicine adapts the adult MeNTS approach. That original surgical prioritization approach was published on April 9 in a scientific article on the JACS website amid COVID-19-related resource constraints and nationwide recommendations to postpone elective operations.1

Pediatric surgeons at UChicago Medicine found that the adult MeNTS scoring system needed revisions for optimal use in pediatric surgery, according to Mark B. Slidell, MD, MPH, FACS, the lead investigator and associate professor of surgery at UChicago Medicine.

“It was very important to create a pediatric-specific system that recognizes there are big differences between adults and children,” Dr. Slidell said.

Need for revised scoring system

Among the differences is that many children testing positive for COVID-19 appear asymptomatic (have no symptoms).2 Also, recent reports noted a new serious complication of COVID-19 in some infected children, including those who were unaware they had the virus: an inflammatory syndrome that can lead to severe involvement of multiple organs.2

Dr. Slidell’s coauthor, Grace Z. Mak, MD, FACS, UChicago Medicine associate professor of pediatrics and surgery, said users of the pMeNTS scoring worksheet can adapt it to include new COVID-19 developments.

“Part of what we took into account is that asymptomatic COVID-positive patients in the pediatric population could very well have a worse outcome, and multisystem organ failure is a good example,” Dr. Mak said.

As the pandemic changes the concept of elective operations, pMeNTS focuses on an operation’s medical necessity and time-sensitivity–the effect of treatment delay on the patient’s disease. Plus, it assesses COVID-19 factors such as infection risk for the patient and providers as well as projected use of hospital resources, including protective gear, beds, blood products, and staffing. The tool, which Dr. Slidell emphasizes is not a risk calculator, systematically evaluates factors related to the procedure, the patient’s disease, and the patient’s individual risks. Users rate each factor on a five-point scale and total the scores. A lower overall pMeNTS score indicates a more favorable surgical risk, less risk to personnel, and less resource utilization, and can be used to determine a higher priority for the procedure.

The hospital’s surgical department leaders review the assigned scores for each surgical case and can shift the scoring cutoff each day for high-priority operations depending on available resources, Dr. Mak stated.

Unlike the adult scoring system, pMeNTS accounts for chronic diseases of childhood and birth defects such as prematurity or congenital heart and lung diseases that may raise susceptibility to more severe COVID-19 infection. It omits chronic illnesses of adulthood that are rare in children such as coronary artery disease and chronic obstructive pulmonary disease.

Another key change was pediatric age brackets reflecting the impact of age on a procedure. For instance, Dr. Mak said a hernia repair is a more difficult operation in a premature infant than a 14-year-old patient. In the adult MeNTS system, both patients would have the same score, but pMeNTS accounts for the child’s age and assigns the infant a higher number, she explained.

Testing the system

The investigators tested pMeNTS in 101 pediatric patients scheduled for operations at UChicago Comer Children’s Hospital from March 23 to April 19. In the article, they reported the system to be “a safe, equitable, transparent, and ethical strategy to prioritize children’s surgical procedures.”

During that month, they analyzed a sample of 53 deferred cases and 48 cases that were allowed to proceed as scheduled. Procedures they deemed time-sensitive included cancer biopsies and operations needed for discharge from the intensive care unit (ICU), thus freeing ICU beds, Dr. Mak said.

The researchers also compared scores of a sample of 21 patients using both the pediatric and adult scoring systems. Most children, they found, had higher scores with the adult MeNTS. Dr. Slidell said pMeNTS successfully captured the various factors that are unique to children.

Strengths of the pMeNTS tool, according to Dr. Slidell, include the flexibility to adapt to changes in the health care system now and during recovery from the pandemic. Because the tool received input from many different specialists, he said it works well across various pediatric surgical subspecialties.

The transparency of the pMeNTS tool has reduced surgeons’ moral dilemmas in the difficult decision-making process of which sick children can proceed with their scheduled operations, Dr. Slidell noted.
He said, “This is one of the most important questions to ask any time we are scheduling a procedure during a time like this: ‘Am I making the best decision with the information I have for the patient, for the hospital, for the workers in the hospital, and for the community at large?'”


Study coauthors are Jessica J. Kandel, MD, FACS; Vivek Prachand, MD, FACS; Fuad M. Baroody, MD; Mohan S. Gundeti, MD; Russell R. Reid, MD; Peter Angelos, MD, FACS; and Jeffrey B. Matthews, MD, FACS, all from the UChicago Medicine Department of Surgery.

The authors report no relevant disclosures related to the scope of this work.

“FACS” designates that a surgeon is a Fellow of the American College of Surgeons.

Citation: Pediatric modification of the Medically Necessary, Time-Sensitive scoring system for operating room procedure prioritization during the COVID-19 pandemic. Journal of the American College of Surgeons. DOI:

1 Prachand VN, Milner R, Angelos P, et al. Medically necessary, time-sensitive procedures: scoring system to ethically and efficiently manage resource scarcity and provider risk during the COVID-19 pandemic. Journal of the American College of Surgeons. 2020. DOI: https:/

2 Centers for Disease Control and Prevention. Information for pediatric healthcare providers. Updated May 15, 2020. Accessed May 19, 2020.

About the American College of Surgeons

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 82,000 members and is the largest organization of surgeons in the world. For more information, visit

Media Contact
Sally Garneski

Related Journal Article

Read More

Continue Reading


Defense Stocks Fall As Paralyzed House With No Speaker Puts US Ukraine Aid At Risk

Defense Stocks Fall As Paralyzed House With No Speaker Puts US Ukraine Aid At Risk

On Tuesday evening, Kevin McCarthy, a Republican, was voted…



Defense Stocks Fall As Paralyzed House With No Speaker Puts US Ukraine Aid At Risk

On Tuesday evening, Kevin McCarthy, a Republican, was voted out (216-to-210 vote) as the Speaker of the US House of Representatives. Hardline Republicans were angered by McCarthy's willingness to fund Ukraine's war while arguing that the money could have been better spent to protect the southern border and restore law and order in imploding major US cities. The historic ouster of the speaker has weighed on defense stocks as traders anticipate challenges for the new speaker in securing further funding for Ukraine.

"The conservative revolt that ousted McCarthy has left the chamber in a state of paralysis until a new speaker is found. That raises the chances of a US government shutdown next month and a delay in further Ukraine assistance," Bloomberg said. 

In a note to clients, Goldman's Alec Phillips said: 

All other things equal, the leadership change raises the odds of a government shutdown in November, though with several weeks left until the deadline, many outcomes are possible. With many policy disputes remaining and a $120bn difference between the parties on the preferred spending level for FY2024, it is difficult to see how Congress can pass the 12 necessary full-year spending bills before funding expires Nov. 17. The next speaker is likely to be under even more pressure to avoid passing another temporary extension—or additional funding for Ukraine—than former Speaker McCarthy had been.

On Wednesday morning, European defense stocks, such as Rheinmetall, Saab, BAE Systems, and Leonardo, slid in the cash market. Bloomberg said this was because of the oustering of McCarthy. 

German arms manufacturer Rheinmetall dropped as much as 4.8%. 

Swedish aerospace and defense company Saab fell 3%. 

British multinational arms, security, and aerospace company BAE Systems slid 3.5%

And Italian defense contractor Leonardo was down 2%. 

In the US, uncertainty over funding will likely weigh on defense stocks. The S&P 500 Aerospace & Defense Index has been running into resistance for much of this year. 

Washington's endless stream of taxpayer funds to Ukraine has benefited the military-industrial complex. Now, it appears that the pipeline of easy money is in question due to the ouster of McCarthy. 

Tyler Durden Wed, 10/04/2023 - 08:50

Read More

Continue Reading


Something “Big & Stupid” Is Coming…

Something "Big & Stupid" Is Coming…

Authored by James Rickards via,

With debt levels reaching all-time highs in…



Something "Big & Stupid" Is Coming...

Authored by James Rickards via,

With debt levels reaching all-time highs in major developed and developing economies, and with debt-to-GDP ratios also in record territory (not including contingent liabilities such as Social Security, health care and other entitlements, which make matters worse), it seems time to consider just how nations will deal with this problem.

The debt crisis may not be imminent, but it is unavoidable. When it happens, it may present the greatest financial disaster of all time. It’s never too soon for investors to consider the fallout.

When you issue debt in a currency you print, there’s no need for default in the sense of non-payment.

You can just have the central bank buy the debt (by printing money). This is the situation today in the U.S., Japan, the U.K. and the European Monetary Union (the countries that use the euro). They all have huge debt burdens, but they all have central banks that can simply buy the debt by printing money to avoid default.

Non-Payment Is Not the Issue

There are many bad consequences to printing money and storing up debt on central bank balance sheets, but non-payment of debt is not one of them. This is the mantra of the Modern Monetary Theorists (MMT) and their thought leader Stephanie Kelton.

In my view, MMT is garbage as economic policy, but the no-default tenet is valid. George Soros says the same thing.

That said, we are well past the point where the debt can be managed with real growth. That threshold is about a 90% debt-to-GDP ratio. A 60% debt-to-GDP ratio is even more comfortable and can be managed.

Unfortunately, the major reserve currency economies are all well past the 90% ratio as are those of many smaller countries. The U.S. ratio is 134%, an all-time high. The U.K. ratio is 102%. France is 111%. Spain is 112%. Italy is 145%.

China reports a figure of 77% but this is highly misleading because it ignores provincial debt for which Beijing is ultimately responsible. China’s actual figure is over 200% when provisional debt is included.

The champion debtor is Japan at 261%. The only major economy with a halfway respectable ratio is Germany at 67%. It’s Germany’s misfortune that they are probably responsible for the rest of Europe through the ECB Target2 system.

All these countries are headed for default. But we must consider the different ways to conduct a default.

There are three basic ways to default: non-payment, inflation and debt restructuring. You can take non-payment off the table for the reason mentioned above — you can always just print the money.

The same goes for restructuring. Inflation is clearly the best way to default. You pay back the money in nominal terms, but it’s worth very little in real terms. The creditor loses and the debtor countries win.

Nice and Easy Does It

The key to inflating away the real value of debt is to go slowly. It’s like stealing money from your mother’s purse. If she has $50 and you take $40, she’ll notice. If you take one dollar, she won’t notice. But a dollar stolen every day adds up over time.

This is what the U.S. did from 1945–1980. At the end of World War II, the U.S. debt-to-GDP ratio was 120% (about where it is now). By 1980, the ratio was 30%, which is entirely manageable.

Of course, nominal debt and GDP soared, but nominal GDP went up faster than nominal debt, so the ratio fell. If you can keep inflation around 3% and interest rates around 2% and exert fiscal discipline (which we did under Eisenhower, Kennedy, Nixon and Ford), the nominal GDP will grow faster than nominal debt (due to the Fed capping rates).

If you improve the ratio by, say, 2% per year and keep it up for 35 years (1945–1980), you can cut the ratio by 70%. That’s what we did.

The key was to do it slowly (like stealing from your mom’s purse). Almost no one noticed the decline in the real value of money until we got to the blow-off stage (1978–1981). But by then it was mission accomplished.

So there are two ways to deal with excessive debt: fiscal discipline and inflation. From 1945–1980, the U.S. did just that. If you run inflation at 3% and interest rates are 2%, you melt the real value of debt. If you exert fiscal discipline relative to GDP, you decrease the nominal debt-to-GDP ratio.

We did both.

The reason the debt-to-GDP ratio is back up to 134% is that Bush45, Obama, Trump and Biden ignored the formula. Since 2000, fiscal policy has been reckless so the formula doesn’t work. The problem isn’t really “money printing” (most of the money the Fed prints just comes back to the Fed as excess reserves, so it doesn’t do anything in the real economy).

The problem is that nominal debt is going up faster than nominal GDP, so the debt-to-GDP ratio goes up. This dynamic will be made much worse by the huge increase in interest rates over the past 18 months.

You can’t borrow your way out of a debt crisis. We have also been unable to generate much inflation. Inflation ran below 2% for almost all of the 2009–2019 recovery.

Japan Writ Large

Looking at the global picture, it’s important to understand that Japan is just a bigger version of the U.S. They don’t have fiscal discipline and they can’t get inflation to save their lives. The only way out for Japan is hyperinflation, which will come but not yet.

Japan can probably keep the debt game going for a while. The crash will come when the currency collapses. When I started in banking, USD/JPY was 400. Those were the days!

A debt crisis is on the way. Something big and stupid (in the words of the brilliant analyst Stephanie Pomboy) is coming from policymakers to address the issue. But the solution won’t be a policy and it won’t be a plan. A crisis will just happen almost overnight and seem to come from nowhere.

But it will come.

Tyler Durden Wed, 10/04/2023 - 09:45

Read More

Continue Reading


UK Has Run Out Of Vital Weapons To Give Ukraine

UK Has Run Out Of Vital Weapons To Give Ukraine

The hits just keep coming: a senior British military source has told The Telegraph that…



UK Has Run Out Of Vital Weapons To Give Ukraine

The hits just keep coming: a senior British military source has told The Telegraph that the UK has depleted available military equipment to give to Ukraine. Unlike the US or Poland at this point, it's not a question of funding or political will, but the British military has simply run out of vital arms and ammo to give, apparently.

"We’ve given away just about as much as we can afford," the official told the paper, explaining that all along the UK had encouraged other allies to keep arming Kiev.

Getty Images

"We will continue to source equipment to provide for Ukraine, but what they need now is things like air defense assets and artillery ammunition, and we’ve run dry on all that," the official added.

The shortage was revealed after controversial remarks given by recent Defence Secretary Ben Wallace

The comments come after Ben Wallace revealed that he asked Rishi Sunak to spend £2.3 billion more on support for Ukraine before he resigned as defence secretary last month.

Mr Wallace warned that the UK had been overtaken by Germany as the biggest European military donor to Ukraine as he called for the 50 per cent increase on funding that the UK has committed so far.

And now the public spat is yet another setback for the pro-Ukraine war cause, as The Telegraph underscores in saying, "The Western alliance has suffered a series of blows in recent days, with support for Ukraine dropped from a US stop-gap budget bill, election success for a pro-Russian party in Slovakia and rows between Poland and Kyiv over grain supplies."

These trends suggest NATO support and unity is fracturing, given also the most powerful country in the world is in a severe political fight, with the fate of future billions for Ukraine on the line. Biden still tried to 'assure' allies in phone calls on Tuesday.

And now the UK's resolve could be fracturing too. Prime Minister Rishi Sunak's reaction was that he would not waver:

Last night a senior military source told The Telegraph that the onus should not be on the UK to provide the “billions” Mr Wallace has called for.

“Giving billions more doesn’t mean giving billions of British kit,” they said, adding that the UK had a role to play in “encouraging other nations to give more money and weapons”.

...On Monday Mr Sunak was forced to insist that the UK’s commitment to Ukraine would not “waver” in the light of Mr Wallace’s comments.

The last months have seen Ukraine undertake a series of high-risk major operations against Russian-controlled Crimea, including significant strikes on the naval port of Sevastopol - including docked ships, submarines, and even the headquarters of Russia's Black Sea Fleet.

The latter strike reportedly used UK-made Storm Shadow cruise missiles. They are effective, and yet such an advanced UK-made missile is clearly in short supply, not to mention very expensive, at over $3 million per unit.

Tyler Durden Wed, 10/04/2023 - 09:30

Read More

Continue Reading