Views of American Pediatric Surgeons on Diversity, Equity, and Inclusion.

INTRODUCTION: Diversity, Equity, and Inclusion (DEI) are concepts common in surgery. However, these can be difficult to define, and what constitutes DEI can be vague. Closing this knowledge gap, particularly within pediatric surgery, would be helpful to understand the views and needs of current surgeons. METHODS: 1558 APSA members were sent an anonymous survey, of which 423 (27%) responded. Respondents were asked about their demographics, views on what constitutes diversity as well as questions on how DEI is handled within APSA and definitions of common DEI terms. RESULTS: Of 11 possible diversity measures, members agreed that a median of 9 (IQR 7-11) counted towards diversity. The most common being race and ethnicity (98%), gender (96%), sexual orientation (93%), religion (92%), age (91%), and disability (90%). On a 5-point Likert scale, the median response was 4 or greater on questions regarding how APSA handles issues related to DEI. However, members who identify as black were less likely to score in favor of APSA, and members identifying as women were more likely to rank higher importance of DEI initiatives. We also captured subjective responses on DEI terminology. CONCLUSION: Respondents had broad definitions of diversity. There is support for further DEI initiatives and how APSA handles DEI, however this perception differs based on identities. There is significant variability in beliefs and views regarding DEI definitions and understanding this is helpful for the organization moving forward. LEVEL OF EVIDENCE: IV. TYPE OF STUDY: Original Research.

APSA Members experience bias and discrimination in training and practice.

INTRODUCTION: Bias and discrimination remain pervasive in the medical field and increase the risk of burnout, mental health disorders, and medical errors. The experiences of APSA members with bias and discrimination are unknown, therefore the APSA committee on Diversity, Equity and Inclusion conducted a survey to characterize the prevalence of bias and discrimination. METHODS: 1558 APSA members were sent an anonymous survey, of which 423 (27%) responded. Respondents were asked about their demographics, knowledge of implicit bias, and experience of bias and discrimination within their primary workplace, APSA, and APSA committees. Data were analyzed using Fisher's Exact test, Kruskal-Wallis test, and multivariable logistic regression as appropriate with significance defined as p<0.05. RESULTS: Discrimination was reported across all levels of practice, academic appointments, race, ethnicity, and gender identities. On multivariable analysis, surgical trainees (OR 3.6) as well as Asian American and Pacific Islander (OR 4.8), Black (OR 5.2), Hispanic (OR 8.2) and women (OR 8.7) surgeons were more likely to experience bias and discrimination in the workplace. Community practice surgeons were more likely to experience discrimination within APSA committees (OR 3.6). Members identifying as Asian (OR 0.4), or women (OR 0.6) were less likely to express comfort reporting instances of bias and discrimination. CONCLUSION: Workplace discrimination exists across all training levels, academic appointments, and racial and gender identities. Trainees and racial- and gender-minority surgeons report disproportionately high prevalence of bias and discrimination. Improving reporting mechanisms and implicit bias training are possible initiatives in addressing these findings.

Diversity and demographics of APSA members: Understanding our identity.

INTRODUCTION: There are existing healthcare disparities in pediatric surgery today. Identity and racial incongruity between patients and providers contribute to systemic healthcare inequities and negatively impacts health outcomes of minoritized populations. Understanding the current demographics of the American Pediatric Surgical Association and therefore the cognitive diversity represented will help inform how best to strategically build the organization to optimize disparity solutions and improve patient care. METHODS: 1558 APSA members were sent an anonymous electronic survey. Comparative data was collected from the US Census Bureau and the Association of American Medical Colleges. Results were analyzed using standard statistical tests. RESULTS: Of 423 respondents (response rate 27%), the race and ethnicity composition were 68% non Hispanic White, 12% Asian American and Pacific Islander, 6% Hispanic, 5% multiracial, and 4% Black/African American. Respondents were 35% women, 63% men, and 1% transgender, androgyne, or uncertain. Distribution of sexual identity was 97% heterosexual and 3% LGBTQIA. Religious identity was 50% Christian, 22% Agnostic/Atheist, 11% Jewish, 3% Hindu, and 2% Muslim. 32% of respondents were first-generation Americans. Twenty-four different primary languages were spoken, and 46% of respondents were conversational in a second language. These findings differ in meaningful ways from the overall American population and from the population of matriculants in American medical schools. CONCLUSION: There are substantial differences in the racial, gender, and sexual identity composition of APSA members compared with the overall population in the United States. To achieve excellence in patient care and innovate solutions to existing disparities, representation, particularly in leadership is essential. TYPE OF STUDY: Survey; original research. LEVEL OF EVIDENCE: Level IV.

Cecal perforation secondary to fungal necrotizing enterocolitis in a premature neonate.

INTRODUCTION: Necrotizing enterocolitis (NEC) remains one of the most critical gastrointestinal comorbidities associated with neonatal prematurity and low birth weight. Despite extensive research and innovations for successful management, NEC remains the leading cause of morbidity and mortality in premature infants. NEC is commonly appreciated at the level of the small bowel, but in rare instances, it is experienced at the colon. While colonic perforation is rare, cecal perforation, specifically, is seldom reported. CASE REPORT: We report the successful surgical intervention of a preterm African-American infant born at 24-weeks' gestation found to have a cecal perforation due to fungal necrotizing enterocolitis. DISCUSSION: Perforation is a major cause of morbidity in necrotizing enterocolitis, and even with extensive research in the management of necrotizing enterocolitis, mortality rates have remained unchanged; the treatment option with the most advantageous outcomes is still uncertain. CONCLUSION: To our knowledge, there are few reported cases of cecal perforation due to NEC. The pathologic report of our colonic specimen demonstrated mucosal invasion with Candida Albicans. This case report is noteworthy due to the unusual location of bowel perforation, fungal sepsis, and successful surgical outcome that is not commonly seen in neonates with intestinal candidiasis. Cecal perforation is rare in necrotizing enterocolitis but should not rule out the pathology.

Wearable Activity Tracking Device Use in an Adolescent Weight Management Clinic: A Randomized Controlled Pilot Trial.

Background: The use of physical activity tracker devices has increased within the general population. However, there is limited medical literature studying the efficacy of such devices in adolescents with obesity. In this study, we explored the feasibility of using wearable activity tracking devices as an adjunct intervention on adolescents with obesity. Methods: Randomized controlled pilot trial evaluated the feasibility (attrition ≤50%) of an activity tracking intervention (ATI) and its effects on weight loss in adolescents with obesity enrolled in an adolescent weight management clinic (AWMC). Outcomes included feasibility (attrition rate) and absolute change in BMI. Differences between groups at 6, 12, and 18 weeks were examined. Results: Forty-eight participants were enrolled in the study. Eighteen subjects were randomly assigned to the ATI group and 30 to control. The average age was 14.5 years. Overall, the majority of participants were Hispanic (56%). Sexes were equally distributed. The average baseline BMI was 37.5 kg/m2. At the study conclusion, the overall attrition rate was 52.1%, 44.4% in the ATI group versus 56.6% in the control group, with a differential attrition of 12.2%. The ATI and control groups each showed an absolute decrease in BMI of -0.25 and -2.77, respectively, with no significant differences between the groups. Conclusion: The attrition rate in our study was >50%. Participation in the AWMC by the ATI and control groups resulted in maintenance of BMI and body weight for the study duration. However, the use of an activity tracking device was not associated with greater weight loss. This trial is registered with NCT03004378.

Education of pediatric surgery residents over time: Examining 15 years of case logs.

BACKGROUND/PURPOSE: Surgical indications and techniques have changed over the last 15 years. The number of Pediatric Surgery training programs has also increased. We sought to examine the effect of these changes on resident education by examining case log data. METHODS: Accreditation Council for Graduate Medical Education (ACGME) case logs for graduating Pediatric Surgery residents were examined from 2004 to 2018. Using the summary statistics provided, linear regression analysis was conducted on each case log code and category. RESULTS: In 2004, there were 24 Pediatric Surgery training programs and 24 Pediatric Surgery residents graduating with an average of 979.8 total cases logged. In 2018, there were 36 programs with 38 residents graduating with an average of 1260.2 total cases logged. Total case volume of graduating residents significantly increased over the last 15 years (p < 0.001). Significant increases were demonstrated in skin/soft tissue/musculoskeletal (p < 0.01), abdominal (p < 0.001), hernia repair (p < 0.001), genitourinary (p < 0.01), and endoscopy (p < 0.001). No significant changes were seen in the head and neck, thoracic, cardiovascular, liver/biliary, and non-operative trauma categories. No categories significantly decreased over the time period. No significant changes were seen in the number of multiple index congenital cases, including tracheoesophageal fistula/esophageal atresia repair, omphalocele, gastroschisis, choledochal cyst excision, perineal procedure for imperforate anus, and major hepatic resections for tumors. Pertinent increases in specific procedures include diaphragmatic hernia repair (p < 0.01), ECMO cannulation/decannulation(p < 0.05), thyroidectomy (p < 0.001), parathyroidectomy (p < 0.001), biliary atresia (p < 0.001), and circumcision (p < 0.001) as well as most laparoscopic abdominal procedures. Specific procedure codes with significant decreases include tracheostomy (p < 0.05), minimally invasive decortication/pleurectomy/blebectomy (p < 0.001), laparoscopic splenectomy (p < 0.001), as well as most open abdominal procedures. CONCLUSION: Despite increasing numbers of Pediatric Surgery residents and training programs, the number of cases performed by each graduating resident has increased. This increase is primarily fueled by increase in abdominal, skin/soft tissue/musculoskeletal, hernia repair, genitourinary, and endoscopic cases. LEVEL OF EVIDENCE: Level II.

Complete gastroesophageal junction avulsion after near drowning: A case report and review of literature.

INTRODUCTION: Gastroesophageal (GE) junction injuries are rare in the pediatric population. A complete GE junction separation in a child secondary to trauma has not reported in the literature yet. PRESENTATION OF CASE: A 14-year-old boy presented with a complete GE junction avulsion after a near-drowning experience. He underwent immediate damage control surgery and delayed gastric pull-up esophageal reconstruction in 3-months. At the most recent clinic visit 5 months from the reconstruction, he can tolerate a regular diet without difficulty and is gaining weight and recovering well. CONCLUSION: Complete GE junction injuries and avulsions are rare with limited data to guide management. These injuries are associated with mortality rates from 25% to 33%, therefore, high index of suspicion, prompt recognition and careful surgical planning is needed for favorable outcomes.

One Size Does Not Fit All: Sociodemographic Factors Affecting Weight Loss in Adolescents.

Successful lifestyle changes for weight reduction are heavily dependent on recognizing the importance of societal and cultural factors. Patients 13-19 years of age with a BMI ≥95th percentile are eligible for our multidisciplinary adolescent weight loss clinic. A behavioral questionnaire was administered at the initial visit. Patients were seen every 4-6 weeks. Bivariate analysis was used to identify sociodemographic factors associated with differences in weight loss. Overall, receiving reduced cost meals was associated with a lower likelihood of losing weight (kg) (p < 0.01). When stratified by race, White adolescents were more likely to lose weight if caretakers reported having enough money to buy healthy food (p < 0.05); in contrast, Black adolescents were less likely to lose weight (p < 0.05). However, Black patients were more likely to lose weight if they reported eating fruits and vegetables (p < 0.05). Female adolescents were more likely to lose weight if they felt unhappy about their appearance (p < 0.05). Interestingly, male adolescents were less likely to lose weight if they felt unhappy about their appearance (p < 0.05). Social and cultural norms influence weight loss in adolescents in unique and differing ways. Culturally competent individualized interventions could increase weight loss in diverse groups of adolescents with obesity.

Pediatric firearm injuries: Racial disparities and predictors of healthcare outcomes.

BACKGROUND/PURPOSE: The U.S. has an alarming rate of firearm injuries. Racial disparities among victims and predictors of outcomes are not well established. Our objective was to assess costs, length of stay (LOS), and inpatient mortality among nonfatal and fatal pediatric firearm injuries that required hospitalization. METHODS: Pediatric (≤18 years of age) hospitalizations with a firearm injury discharge diagnosis were identified from the national Kids' Inpatient Databases (KID) for 2006 through 2012. Firearm injury intent, weapon type, and hospitalization rates by racial groups were examined. Inpatient mortality, costs, and length of stay were examined using regression models. RESULTS: Of 15,211 hospitalizations, the majority of injuries were due to assault (60%) and the intentions of firearm injury differed by race (p < 0.001). The median cost per hospitalization was $10,159 (interquartile range: $5071 to $20,565), totaling more than a quarter of a billion dollars. On regression analysis, Black (OR: 0.41; CI: 0.30-0.55) and Hispanic (OR: 0.47; CI: 0.34-0.66) patients were less likely to die than White patients. CONCLUSION: Pediatric firearm injury circumstances and survival vary by race with Whites being more likely to experience unintentional injury and suicide, while Blacks and Hispanics are more likely to experience inflicted injury. LEVEL OF EVIDENCE: Level II. TYPE OF STUDY: Clinical Research Study.

Adolescent Bariatric Surgery: Effects of Socioeconomic, Demographic, and Hospital Characteristics on Cost, Length of Stay, and Type of Procedure Performed.

BACKGROUND: Despite the efficacy of bariatric surgery in adolescents and the increasing rates of adolescent obesity, the use of bariatric surgery remains low. Treatment cost and length of stay (LOS) could be influencing the utilization of bariatric surgery. METHODS: We used the Kids' Inpatient Database (KID) from 2006, 2009, and 2012. Adolescents with a primary diagnosis of obesity who underwent bariatric surgery were included. Multinomial logistic and linear regression modeling was used to determine the association of the predictor variables with type of procedure and treatment cost and LOS, respectively. RESULTS: We identified 1799 adolescents who underwent bariatric surgery. The majority of the subjects were female (77%) and White (60%). The most commonly performed procedure was Roux-en-Y gastric bypass (56%). Race, region, hospital teaching status, and hospital ownership affected the type of procedure performed. Self-pay patients were less likely to undergo Roux-en-Y gastric bypass (RYGB) than sleeve gastrectomy (SG) when compared to patients with private insurance. Teaching hospitals were less likely to perform RYGB or AGB than SG when compared to non-teaching hospitals. Treatment cost was significantly affected by income, teaching hospital status, hospital size, and surgery type. LOS was affected by income quartile, region, and surgery type. CONCLUSION: Socioeconomic and demographic factors as well as hospital characteristics affect not only the LOS and treatment cost, but also the type of bariatric surgery performed in adolescents. Identifying and understanding the factors influencing procedure choice, treatment cost, and LOS can improve care and healthcare resource utilization.

Personality Testing May Identify Applicants Who Will Become Successful in General Surgery Residency.

BACKGROUND: Identification of successful general surgical residents remains a challenging endeavor for program directors with a national attrition of approximately 20% per year. The Big 5 personality traits and the Grit Scale have been extensively studied in many industries, and certain traits are associated with professional or academic success. However, their utility in surgery resident selection is unknown. METHODS: We performed a retrospective review of all categorical surgery residents (n = 34) at the University of Texas Medical Branch from 2015 to 2017. Current residents were classified into low performing (n = 12) or non-low performing (n = 22) based on residency performance and standardized test scores. Groups were assessed for differences in both conventional metrics used for selection and Big 5 and grit scores using bivariate analysis and Pearson's correlation coefficient. Personality testing was administered to recent resident applicants (n = 81). Applicants were ranked using conventional application information. We then examined the applicants' personalities and their rank position with personality characteristics of non-low-performing residents to determine if there was any correlation. RESULTS: The Big 5 personality test identified significantly higher extroversion, conscientiousness, and emotional stability scores in those residents classified as non-low performers. There was no significant difference in conventional metrics or in grit scores between non-low performers and low performers. Our final rank does not correlate well with personality traits of non-low performers. CONCLUSIONS: The Big 5 test may prove to be a useful adjunct to the traditional residency application in identifying applicants who may become successful in general surgery residency.

Sociodemographic determinants of non-accidental traumatic injuries in children.

BACKGROUND: Traumatic injuries account for 18% of child abuse cases and 1680 children die from abuse annually. We set out to determine the impact of sociodemographic characteristics on resource utilization and outcomes in nonaccidental trauma (NAT). METHODS: We used the Kid's Inpatient Database to identify children with two main subgroups of child abuse diagnoses: NAT and other forms of child abuse. Income was represented by quartiles. Statistical analysis included descriptive statistics and regression analyses. RESULTS: We identified 5617 children requiring hospital admission due to NAT. Medicaid insurance payer status was associated with higher rates of traumatic injuries than private insurance. Black race, male sex, and high-income-quartile were independent factors associated with increased cost. We identified an increased risk of mortality in younger children and those with self-pay/uninsured status. CONCLUSION: NAT represents a prevalent cause of childhood mortality. This study identifies sociodemographic factors associated with increased occurrence, higher resource utilization, and increased mortality in NAT.

Race, Income and Insurance Status Affect Neonatal Sepsis Mortality and Healthcare Resource Utilization.

BACKGROUND: Socioeconomic disparities negatively impact neonatal health. The influence of sociodemographic disparities on neonatal sepsis is understudied. We examined the association of insurance payer status, income, race and gender on neonatal sepsis mortality and healthcare resource utilization. METHODS: We used the Kid's Inpatient Database, a nationwide population-based survey from 2006, 2009 and 2012. Neonates diagnosed with sepsis were included in the study. Multivariable logistic regression (mortality) and multivariable linear regression (length of stay and total hospital costs) were constructed to determine the association of patient and hospital characteristics. RESULTS: Our study cohort included a weighted sample of 160,677 septic neonates. Several sociodemographic disparities significantly increased mortality. Self-pay patients had increased mortality (odds ratio 3.26 [95% confidence interval: 2.60-4.08]), decreased length of stay (-2.49 ± 0.31 days, P < 0.0001) and total cost (-$5015.50 ± 783.15, P < 0.0001) compared with privately insured neonates. Additionally, low household income increased odds of death compared with the most affluent households (odds ratio 1.19 [95% confidence interval: 1.05-1.35]). Moreover, Black neonates had significantly decreased length of stay (-0.86 ± 0.25, P = 0.0005) compared with White neonates. CONCLUSIONS: This study identified specific socioeconomic disparities that increased odds of death and increased healthcare resource utilization. Moreover, this study provides specific societal targets to address to reduce neonatal sepsis mortality in the United States.

Hospital admission unnecessary for successful uncomplicated radiographic reduction of pediatric intussusception.

PURPOSE: After radiologic reduction, patients with ileocolic intussusception are often admitted. We hypothesize that discharge of stable patients after 4 h of emergency department (ED) observation does not result in an increase of adverse outcomes. METHODS: We retrospectively reviewed pediatric patients with ileocolic intussusception between 2011 and 2016, managed with either 24-h inpatient or 4-h ED observation. Outcomes included length of stay, adverse outcomes, and total hospital charges. RESULTS: Fifty-one patients were managed with ED observation and 79 with inpatient observation. Recurrence rates, time to recurrence, and adverse outcomes were similar in both protocols. Total recurrence rates for ED observation was 15% versus 14% for inpatient observation. ED observation reduced time in the hospital by 26.8 h (4.9 versus 31.7 h). CONCLUSION: Discharging patients following uncomplicated hydrostatic reduction of ileocolic intussusception after a 4-h observation period does not result in an increase in adverse outcomes.

Health Disparities in Adolescent Bariatric Surgery: Nationwide Outcomes and Utilization.

PURPOSE: Bariatric surgery represents an appropriate treatment for adolescent severe obesity, but its utilization remains low in this patient population. We studied the impact of race and sex on preoperative characteristics, outcomes, and utilization of adolescent bariatric surgery. METHODS: Retrospective analysis (2007-2014) of adolescent bariatric surgery using the Bariatric Outcomes Longitudinal Database, a national database that collects bariatric surgical care data. We assessed the relationships between baseline characteristics and outcomes (weight loss and remission of obesity-related conditions [ORCs]). Using the National Health and Nutrition Examination Survey and U.S. census data, we calculated the ratio of severe obesity and bariatric procedures among races and determined the ratio of ratios to assess for disparities. RESULTS: About 1,539 adolescents underwent bariatric surgery. Males had higher preoperative body mass index (BMI; 51.8 ± 10.5 vs. 47.1 ± 8.7, p < .001) and higher rates of obstructive sleep apnea and dyslipidemia. Blacks had higher preoperative BMI (52.4 ± 10.6 vs. 47.3 ± 8.3; 48.7 ± 8.8; 48.2 ± 12.1 kg/m2; whites, Hispanics, and others, respectively p < .001) and higher rates of hypertension, obstructive sleep apnea, and asthma. Weight loss and ORCs remission rates did not differ between sexes or races after accounting for the rate of severe obesity in each racial group. White adolescents underwent bariatric surgery at a higher proportion than blacks and Hispanics (2.5 and 2.3 times higher, respectively). CONCLUSIONS: Preoperative characteristics vary according to race and sex. Race and sex do not impact 12-month weight loss or ORC's remission rates. Minority adolescents undergo bariatric surgery at lower-than-expected rates.