Characterizing Inequities in Pediatric Appendicitis Delayed Diagnosis and Perforation.

Objective: We sought to characterize the impact of a child's sociodemographic characteristics on their odds of delayed diagnosis and perforation in pediatric appendicitis. Study design: We performed a single-center, retrospective cohort study of all pediatric appendicitis admissions between 2016 and 2021. Using a multivariable model, we evaluated for associations between delayed diagnosis and perforation and a child's sociodemographic characteristics, including their age, sex, race and ethnicity, insurance status, and their home census-tract Material Community Deprivation Index value. Results: The study included 3248 patients. The median age was 12.1 years (IQR 9.5-14.9 years). Most patients were male (60.3%), identified as non-Hispanic White (78.0%), and had private insurance (55.4%). The delayed diagnosis and perforation rates were 6.4% and 25.1%, respectively. Delayed diagnosis cases had a greater perforation rate (56% compared with 21.5%, P < .001). On adjusted analysis, older age decreased the odds (OR 0.91, CI 0.87-0.94) of delayed diagnosis, whereas female sex (OR 1.50, CI 1.13-2.00) and socioeconomic disadvantage (OR 1.56 for quartile 4 vs quartile 1, CI 1.00-2.43) increased the odds. Furthermore, older age (OR 0.91, CI 0.89-0.93) decreased the odds of perforation, whereas non-Hispanic Black (OR 1.72, CI 1.3-2.29) or Hispanic (OR 1.60, CI 1.24-2.08) compared with non-Hispanic White identification and socioeconomic disadvantage (OR 1.43 Q4 vs Q1, CI 1.12-1.83) increased the odds. Conclusions: Our reported delayed diagnosis rate is greater than recent literature, highlighting the need to consider visits that occur across different health care settings. We further identify sociodemographic factors, including socioeconomic status, that impact a child's risk of delayed diagnosis and perforation.

Potential causes of delays in paediatric perforated appendicitis: A prospective interview study.

AIM: Delays in care may be a driver of inequities in perforated appendicitis rates. The goal of this study was to explore potential causes of delay in care for children with perforated appendicitis. METHODS: We conducted an interview study of caregivers of children admitted with perforated appendicitis to a children's hospital between December 2022 and March 2023. Semi-structured interviews based on an iteratively revised interview guide were conducted in-person during the child's admission. All interviews were transcribed, coded and underwent a process of thematic analysis. RESULTS: We reached thematic saturation after 12 interviews. The median age for children was 13.5 years, 50% were male, 83% of caregivers self-identified as White, and one interview required an interpreter. Through thematic analysis, four major themes for potential causes of delay emerged. The first theme of symptom recognition includes delays related to recognising the symptoms, their severity and the need for medical evaluation. The second theme - accessing care - describes delays that occur after a decision was made to seek care until the child was evaluated. The third theme includes delays that occur in making the diagnosis after evaluation. The last theme captures potential delays in definitive treatment after a diagnosis of appendicitis is made. CONCLUSION: We identify four major themes from the patient and family perspective, each with multiple sub-themes, for potential delays in definitive care for children with perforated appendicitis. Additional research is needed to further characterise these potential delays and quantify their role in contributing to inequities in perforation rates.

Future Surgical Leaders: Resident Perception Of Longitudinal Leadership And Non-Technical Skills Curriculum.

OBJECTIVE: A paucity of formal leadership training programs exists for residents, and outcomes of those are limited in reporting. Based on a robust needs assessment, our program created a longitudinal cohort curriculum, Future Surgical Leaders, for residents and fellows of all levels to provide training in nontechnical skills. Our objective was to evaluate surgical resident short-term outcomes and satisfaction with the Future Surgical Leaders (FSL) curriculum. DESIGN: Participants were sent a brief survey after each session of the curriculum from October 2020 to February 2022. The data was compiled after seventeen months of delivery. Likert Scale responses and text comments were analyzed with a 2-sample t-test and 2-way analysis of variance. SETTING: Academic tertiary institution. PARTICIPANTS: General surgery residents. RESULTS: Survey response rate from 54 sessions among all postgraduate year levels was 73%. Overall, 96% of residents/fellows either "agreed" or "strongly agreed" that the topics of the FSL curriculum were important to learn during surgical training. Only 24% of learners knew "a lot" or "a great deal" about the topics prior to the session which rose to 73% afterwards (p < 0.01). Each postgraduate year class showed statistically significant increase in knowledge. About 80% of learners wanted to investigate these topics further. Open comment questions identified themes requesting delivery of specific sessions earlier in residency training and positive overall attitudes toward the FSL curriculum. CONCLUSIONS: FSL is a satisfactory means of teaching leadership skills to surgical residents. Residents recognize the need to develop leadership skills prior to entering practice and want to learn more. The FSL curriculum may be considered for application at other surgical training programs.

Opioid Use, Disposition, and Parent Satisfaction Following Common Pediatric Surgical Procedures.

INTRODUCTION: There is wide variability in prescribing practices among providers, even for patients undergoing the same operations. Our study aims to analyze the variation in opioid prescription practices using a patient-centered approach to establish more appropriate prescribing guidelines for health care providers. METHODS: We conducted phone surveys 30 days after surgery to assess patient-reported opioid use. Over a two-year collection period, we identified patients that had undergone common outpatient pediatric surgery procedures in our 4-surgeon group. Included in the survey tool was the narcotic prescribed (if any), the amount used, and patient/family rating of pain control. RESULTS: We collected data for 189 separate procedures (88 umbilical hernias, 30 laparoscopic inguinal hernias, 2 open inguinal hernias, 41 appendectomies, 15 laparoscopic cholecystectomies, and 13 pectus bar removals). Patient age ranged from less than 1 month to 246 months. 83.5% of patients had a narcotic prescribed. The average number of doses used was 4, ranging from 0 (11.3%) to 30 (1.5%). 72.6% of families surveyed felt pain control was appropriate. However, 19.6% did feel they received too much pain medication. 10.6% reported completing their entire prescription; however, only 13.6% of families with excess narcotics reported proper disposal. CONCLUSIONS: Despite heightened awareness of the opioid epidemic, there is still a poor understanding of appropriate pain control regimens in the pediatric surgical population. We demonstrate that most patients are discharged home with excess opioids and that many families save the leftover pills/liquid. Further research and education are encouraged to limit the use of opioids in standard pediatric surgical procedures.

General surgery applicant perspectives: Two years of virtual interview experiences and supplemental application impressions.

BACKGROUND: We sought to evaluate the unique benefits and challenges the virtual recruitment and interviewing platform had on general surgery residency applicants. METHODS: Applicants who interviewed for a categorical position at our institution during the 2021 and 2022 Match season were contacted to participate in the anonymous online survey focused on applicant behavior related to the virtual interview format. Data were analyzed using chi-square and paired t-tests. RESULTS: A response rate of 56.7 â€‹% (n â€‹= â€‹135) was achieved. Applicants accepted a median of 17 (IQR 13-20) interviews in 2021 and 15 (IQR 11-19) interviews in 2022. More than half (54 â€‹%) of applicants indicated they applied to more programs, and 53 â€‹% accepted more interviews, because of the virtual format. The greatest advantages of the virtual interviews as cited by applicants were saving money (96.3 â€‹%), saving time (49.6 â€‹%), and avoiding travel risks (43.7 â€‹%). The top limitations of virtual interviews were less exposure to current residents and faculty (61.5 â€‹%), to the city or location of the program (58.5 â€‹%), and difficultly comparing programs (57.8 â€‹%). The 2022 Match cycle included use of the supplemental application; however, 85 â€‹% of applicants did not feel that the supplemental improved their overall application. Some applicants (20 â€‹%) who "signaled" programs did not receive an interview offer from any of the programs they signaled. CONCLUSION: The transition to virtual interviews saved applicants time and money but limited their exposure. Future efforts to maintain virtual interviews will need to be balanced against the intangible benefit of human interaction and observing a program's culture.

The Importance of General Surgery Residency Program's Online Presence Varies Among Applicant Groups.

INTRODUCTION: The COVID-19 pandemic necessitated an exclusively virtual 2021 residency application cycle. We hypothesized that residency programs' online presence would have increased utility and influence for applicants. METHODS: Substantial surgery residency website modifications were undertaken in the summer of 2020. Page views were gathered by our institution's information technology office for comparison across years and programs. An anonymous, voluntary, online survey was sent to all interviewed applicants for our 2021 general surgery program match. Five-point Likert-scale questions evaluated applicants' perspective on the online experience. RESULTS: Our residency website received 10,650 page views in 2019 and 12,688 in 2020 (P = 0.14). Page views increased with a greater margin compared to a different specialty residency program's (P < 0.01). From 108 interviewees, 75 completed the survey (69.4%). Respondents indicated our website was satisfactory or very satisfactory compared to other programs (83.9%), and none found it unsatisfactory. Applicants overall stated our institution's online presence impacted their decision to interview (51.6%). Programs' online presence impacted the decision to interview for nonWhite applicants (68%) but significantly less for white applicants (31%, P < 0.03). We observed a trend that those with fewer than this cohort's median interviews (17 or less) put more weight on online presence (65%), compared to those with 18 or greater interviews (35%). CONCLUSIONS: Applicants utilized program websites more during the 2021 virtual application cycle; our data show most applicants depend on institutions' websites to supplement their decision-making; however, there are subgroup differences in the influence online presence has on applicant decisions. Efforts to enhance residency webpages and online resources for candidates may positively influence prospective surgical trainees, and especially those underrepresented in medicine, to decide to interview.

Clinical Characteristics and Treatment Patterns of Open Hand Fractures in the Pediatric Population.

BACKGROUND: Open hand fractures are one of the most common injuries in the pediatric population. These injuries are at higher risk of infection, especially in cases of frank contamination. Several studies on adult hand fractures are available in the literature; however, pediatric open hand fractures have yet to be extensively studied. This study aimed to define pediatric open hand fracture's demographics, clinical characteristics, and treatment patterns. METHODS: Using the Protected Health Information database, pediatric patients (<18 y old) with the diagnosis of open hand fracture from June 2016 to June 2018 were extracted. Demographic, treatment, and follow-up data were collected. Clinical outcomes included readmission and postoperative infection rates. RESULTS: There were a total of 4516 patients who met the inclusion criteria; the median age was 7 years (interquartile range: 3 to 11); 60% males; 60% white. Displaced fractures occurred in 74% of patients, with the right hand (52%) and middle finger (27%) predominance. The most common mechanism of injury was a crushing injury in-between objects (56%). Associated nerve injury occurred in 78 patients (4%) and vascular injury in 43 patients (2%). Open reduction and internal fixation were performed in 30% of patients. Cephalosporins were the most commonly prescribed antibiotics (73%), followed by aminopenicillins (7%). Nine patients had complications related to surgical intervention (0.2%), and postoperative infection occurred in 44 patients (1%). CONCLUSIONS: Pediatric open hand fractures most often occur during childhood and more frequently in males. These fractures tend to be more distal and displaced; reduction and fixation are required in one-third of the cases. Despite the absence of treatment guidelines and variability, this injury exhibits low complication rates. LEVEL OF EVIDENCE: Level III, retrospective study.

Impact of the Coronavirus (COVID-19) Pandemic on the Care of Pediatric Acute Appendicitis.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency in children. With the rise of the Coronavirus-19 pandemic, quarantine measures have been enforced to limit the viral transmission of this disease. The purpose of this study was to identify differences in the clinical presentation and outcomes of pediatric acute appendicitis during the Coronavirus-19 pandemic. METHODS: A single-institution retrospective assessment of all pediatric patients (<18 years old) with acute appendicitis from December 2019 to June 2020 was performed at a tertiary care children's hospital. Patients were divided into two groups: (1) the Pre-COVID group presented on or before March 15, 2020, and (2) the COVID group presented after March 15, 2020. Demographic, preoperative, and clinical outcomes data were analyzed. RESULTS: 45 patients were included with a median age of 13 years [IQR 9.9 - 16.2] and 35 males (78%). 28 patients were in the Pre-COVID group (62%) and 17 in the COVID group (38%). There were no differences in demographics or use of diagnostic imaging. The COVID group did have a significantly delayed presentation from symptom onset (36 vs 24 hours, P < .05), higher Pediatric Appendicitis Scores (8 vs 6, P = .003), and longer hospital stays (2.2 vs 1.3 days, P = .04). There were no significant differences for rates of re-admission, re-operation, surgical site infection, perforation, or abscess formation. CONCLUSION: During the Coronavirus-19 pandemic, the incidence of pediatric acute appendicitis was approximately 40% lower. These children presented in a delayed fashion with longer hospital stays. No differences were noted for postoperative complications.

Ovary-Sparing Surgery for Ovarian Teratoma in an Infant with Nonbilious Vomiting.

Ovarian teratoma is the most common ovarian tumor in children with an overall incidence of 2.6 cases per 100,000 girls per year. Diagnosis and management are challenging due to its nonspecific presentation, malignancy determination, and need to conserve fertility. A previously healthy 5-month-old female infant presented with fever, abdominal distension, and nonbilious emesis, and an 8.2 × 6.8 × 6.1-centimeter pelvic mass originating from the left adnexa was found on imaging. Due to concern for malignancy and torsion, exploratory laparotomy and ovarian-sparing surgery (OSS) with resection of the mass were performed. Histology showed a grade 1 teratoma. This case illustrates a challenging diagnosis and its symptom overlap with other etiologies in infants. The keys to diagnosing and managing this entity are including ovarian pathology in the differential diagnosis and performing OSS whenever possible. Furthermore, ultrasound follow-up is needed to monitor for ipsilateral and contralateral ovarian tumors later in life.

Vascular and Neurological Injury in Children With Posterior Traumatic Knee Dislocation.

Posterior knee dislocations (PKD) in children are uncommon but may be associated with vascular injury. The purpose of this study is to characterize the frequency of vascular injury in PKD as well as define patient characteristic, procedures, types of treating hospitals, and clinical outcomes. This study utilized the National Trauma Data Set (NTDS) from the American College of Surgeons on years 2015 and 2016. All demographic and clinical data on pediatric patients (≤18 years) with the ICD codes for PKD were obtained. 44 PKD were identified. The median age was 17 years [IQR 15,18], 70% male; 49% white. The mean body mass index was 29.6 [IQR 23-38]. We found that vascular injury was present in 16 patients (36%); 14 (30%) underwent repair (eight with saphenous vein graft) and fasciotomies in eight patients. Nerve injury was present in five patients (11%). Lower extremity amputation was performed in three patients (7%).

Management of pediatric appendicitis during the COVID-19 pandemic: A nationwide multicenter cohort study.

BACKGROUND: The COVID-19 pandemic has impacted timely access to care for children, including patients with appendicitis. This study aimed to evaluate the effect of the COVID-19 pandemic on management of appendicitis and patient outcomes. METHODS: A multicenter retrospective study was performed including 19 children's hospitals from April 2019-October 2020 of children (age≤18 years) diagnosed with appendicitis. Groups were defined by each hospital's city/state stay-at-home orders (SAHO), designating patients as Pre-COVID (Pre-SAHO) or COVID (Post-SAHO). Demographic, treatment, and outcome data were obtained, and univariate and multivariable analysis was performed. RESULTS: Of 6,014 patients, 2,413 (40.1%) presented during the COVID-19 pandemic. More patients were managed non-operatively during the COVID-19 pandemic compared to before the pandemic (147 (6.1%) vs 144 (4.0%), p < 0.001). Despite this change, there was no difference in the proportion of complicated appendicitis between groups (1,247 (34.6%) vs 849 (35.2%), p = 0.12). COVID era non-operative patients received fewer additional procedures, including interventional radiology (IR) drain placements, compared to pre-COVID non-operative patients (29 (19.7%) vs 69 (47.9%), p < 0.001). On adjusted analysis, factors associated with increased odds of receiving non-operative management included: increasing duration of symptoms (OR=1.01, 95% CI: 1.01-1.012), African American race (OR=2.4, 95% CI: 1.3-4.6), and testing positive for COVID-19 (OR=10.8, 95% CI: 5.4-21.6). CONCLUSION: Non-operative management of appendicitis increased during the COVID-19 pandemic. Additionally, fewer COVID era cases required IR procedures. These changes in the management of pediatric appendicitis during the COVID pandemic demonstrates the potential for future utilization of non-operative management.

The effect of socioeconomic factors on patient outcomes in cardiac surgery.

OBJECTIVES: Healthcare delivery is heterogenous; the reasons for this are numerous and complex. Patient-specific factors including geography, income, insurance status, age, and gender have been shown to bias surgical outcomes. Utilizing a prospectively collected all-payer database, we aim to evaluate the influence of socioeconomic factors on mortality and length of stay (LOS) after common cardiac surgical procedures. METHODS: We utilized the National Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality for the year 2019. We included patients undergoing coronary artery bypass grafting (CABG), aortic valve replacement (AVR), transcatheter aortic valve replacement (TAVR), and combined AVR/CABG using the 10th revision of the International Classification of Diseases procedure codes. AVR and CABG were combined into a separate cohort as this was felt to represent a different pathology than isolated valvular or coronary arterial disease. Baseline demographics were summarized. Multivariable regression was performed within each procedure group to model the odds of in-hospital mortality and hospital LOS with age, sex, insurance, zip-code median household income, and location as predictors. RESULTS: Baseline patient characteristics including gender, income, geography, and payer status were similar between CABG, AVR, and AVR/CABG. TAVR patients had a higher proportion of female sex and Medicare as the primary payer, with an overall greater age. Multivariable Cox proportional hazards regression found that higher income was strongly associated with decreased LOS following AVR and CABG, and moderately associated in TAVR and AVR/CABG. Private insurance was associated with a decreased LOS in patients undergoing CABG, AVR, TAVR, and AVR/CABG. Female sex and increased age were associated with increased odds of mortality in TAVR, CABG, and AVR/CABG. Private insurance was associated with a decreased odds of mortality in patients undergoing AVR. CONCLUSIONS: These findings reveal significant disparities in patient outcomes after routine cardiac operations that are associated with socioeconomic status. Patients who did not have private insurance or had lower incomes were found to be at risk for increased LOS. Women were at a higher risk of mortality for several operations, a finding which has been previously described elsewhere. Private insurance conveyed a decreased odds of mortality in patients undergoing AVR. This data set serves to highlight differences in healthcare outcomes based on a variety of socioeconomic, geographic, and other inherent factors. Additional research is needed to identify the mechanisms behind these disparities with the goal of providing equitable care to all patients.

Warning Labels and High-Powered Magnet Exposures.

BACKGROUND AND OBJECTIVES: High-powered magnets are among the most dangerous childhood foreign bodies. Consumer advocates and physicians have called for these products to be effectively banned, but manufacturers assert warning labels would sufficiently mitigate risk. METHODS: Subjects from Injuries, Morbidity, and Parental Attitudes Concerning Tiny High-powered Magnets (IMPACT of Magnets), a retrospective, multicenter study of children with high-powered magnet exposures (ie, ingestion or bodily insertion), were contacted. Consenting participants responded to a standardized questionnaire regarding the presence and utility of warning labels, magnet product manufacturer, and attitudes around risk. RESULTS: Of 596 patients in the IMPACT study, 173 parents and 1 adult patient were reached and consented to participate. The median age was 7.5 years. Subjects reported not knowing if a warning label was present in 60 (53.6%) cases, whereas 25 (22.3%) stated warnings were absent. Warnings were present in 28 (24.1%) cases but only 13 (46.4%) reported reading them. A manufacturer was identified by families in 28 (16.1%) exposures; 25 of these were domestic and 27 had warnings. Subjects reported knowing magnets were dangerous in 58% of the cases, although 44.3% believed they were children's toys and only 6.9% knew high-powered magnets were previously removed from the United States market. CONCLUSIONS: Over 90% of subjects from the IMPACT study didn't know if warning labels were present or failed to read them if they were, whereas almost half believed high-powered magnets were children's toys. Warning labels on high-powered magnet products are, therefore, unlikely to prevent injuries in children.

High-Powered Magnet Exposures in Children: A Multi-Center Cohort Study.

BACKGROUND AND OBJECTIVES: High-powered magnets were effectively removed from the US market by the Consumer Product Safety Commission (CPSC) in 2012 but returned in 2016 after federal court decisions. The United States Court of Appeals for the 10th Circuit cited imprecise data among other reasons as justification for overturning CPSC protections. Since then, incidence of high-powered magnet exposure has increased markedly, but outcome data are limited. In this study, we aim to describe the epidemiology and outcomes in children seeking medical care for high-powered magnets after reintroduction to market. METHODS: This is a multicenter, retrospective cohort study of patients aged 0 to 21 years with a confirmed high-powered magnet exposure (ie, ingestion or insertion) at 25 children's hospitals in the United States between 2017 and 2019. RESULTS: Of 596 patients with high-powered magnet exposures identified, 362 (60.7%) were male and 566 (95%) were <14 years of age. Nearly all sought care for magnet ingestion (n = 574, 96.3%), whereas 17 patients (2.9%) presented for management of nasal or aural magnet foreign bodies, 4 (0.7%) for magnets in their genitourinary tract, and 1 patient (0.2%) had magnets in their respiratory tract. A total of 57 children (9.6%) had a life-threatening morbidity; 276 (46.3%) required an endoscopy, surgery, or both; and 332 (55.7%) required hospitalization. There was no reported mortality. CONCLUSIONS: Despite being intended for use by those >14 years of age, high-powered magnets frequently cause morbidity and lead to high need for invasive intervention and hospitalization in children of all ages.

General surgery applicants report the impact of virtual interviews on their rank list and match.

Purpose: The transition to an all-virtual application cycle for General Surgery Match 2021 significantly altered interview day and the interactions of applicants with residency programs. We sought to evaluate the impact of a virtual match cycle on applicants' rank list and Match results. Methods: We surveyed applicants who were offered an interview for a categorical general surgery residency position at our institution during the 2021 match season. Voluntary anonymous surveys were sent after the rank list deadline and again after the Match. Results: Out of 108 interviewees, 43 completed the survey (40%). Median age was 26, and 61% of respondents were male and 82% white, which skewed from our diverse interview pool. They completed a median of 17 interviews. 69% felt they had sufficient exposure to make their rank list, and this group reached statistically significant higher confidence in their decisions when compared with those who endorsed not having enough exposure to the residency programs (58% vs 42%, p = 0.02). Applicants cited the most influential interview day factors to be their interview with faculty and the virtual social with residents. Least important was their ability to assess the hospital facility. Among seven different program factors, comradery between faculty and residents (31%) and perceived happiness of the residents (18.6%) were most often selected most influential. Only 56% reported ranking all programs at which they interviewed. After submitting their rank list, 59% of applicants stated they had not visited the city of their top ranked program; however, post-match surveys revealed only 44% matched to a program in a city unknown to them. 57% of applicants stated they reached out to their top choice program with additional questions, but only 47% matched at one of those institutions. Conclusions: Even in the constraints of the virtual interviews, most applicants felt they had sufficient exposure to programs to make their rank list. Applicants were willing to highly rank cities they had never visited and to reach out to programs but were ultimately less successful matching at those programs. Understanding what factors and communications most impact applicants and programs may lead to a more successful Match. Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-022-00071-8.

Nighttime Calls, Pages, and Interruptions to the On-Call Surgery Resident.

BACKGROUND: Communication is a keystone to good medical practice. At night, as physician numbers decrease, frequent, nonurgent interruptions have shown to disrupt patient care and impact resident/physician wellness. Potentially, interruptions can lead to an increase in medical errors. The frequency and activities interrupted during night calls have not been fully described. METHODS: For a period of 44 days (August through September), all calls and pages received during the 12-hour night call session were documented. Calls were analyzed by caller, urgency, need for intervention, and resident interrupted by the communication. RESULTS: A total of 494 communications were identified with a mean of 10 calls per shift (IQR 7-14). Communications lasted a mean of 2.7 +/- 2.9 minutes. Direct calls occurred in 78% and pages in 22% of the cases. From the non-ED calls (n = 335), most of them came from nursing staff (85%), followed by other specialties (12%). Five percent of the calls were directed to the wrong service. Communications occurred during charting (41%), patient assessment (33%), interrupted resident's sleep (12%), or during a surgical procedure (6%). Communication required no action in 47% of the cases. A physician order was needed in 41%, while bedside clinical assessment was required in 12% of the calls. CONCLUSIONS: Communications are common at night, but most did not require clinical assessment. A large portion of communications interrupted direct patient care. An opportunity exists to eliminate nonproductive communications and improve the quality of medical education.