'Undoing a knot': a qualitative study of massed 1-week Cognitive Processing Therapy.

Introduction: Intensive or massed Cognitive Processing Therapy (CPT) for posttraumatic stress disorder (PTSD) has been found to result in significant PTSD symptom reductions. However, few studies to date have used qualitative approaches to systematically evaluate client reflections about massed treatment approaches for PTSD. To address this gap, the present study aimed to improve our understanding of trauma survivors' reflections following the completion of 1-week CPT.Method: We conducted semi-structured interviews with seven trauma survivors within 3-months of the completion of 1-week CPT. We used the scissor-and-sort technique to identify themes and subthemes in the qualitative data.Results: Using the scissor-and-sort technique, we generated five main themes and associated subthemes from the data. The main themes were: (a) tangible skills, (b) feasibility, (c) therapeutic process, (d) symptom presentation, and (e) treatment expectations.Conclusion: Collectively, our results suggested that 1-week CPT was feasible and led to changes in PTSD symptoms and improved cognitive and affective coping skills.

Scant research has examined client reflections about massed treatment approaches for PTSD.Among participants who completed a semi-structured interview about their experiences with 1-week CPT for PTSD, we generated five themes: (a) tangible skills, (b) feasibility, (c) therapeutic process, (d) symptom presentation, and (e) treatment expectations.Collectively, our results suggested that 1-week CPT was feasible and led to changes in PTSD symptoms and improved cognitive and affective coping skills.

Thoracoscopy versus thoracotomy for esophageal atresia and tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium.

BACKGROUND/PURPOSE: Controversy persists regarding the ideal surgical approach for repair of esophageal atresia with tracheoesophageal fistula (EA/TEF). We examined complications and outcomes of infants undergoing thoracoscopy and thoracotomy for repair of Type C EA/TEF using propensity score-based overlap weights to minimize the effects of selection bias. METHODS: Secondary analysis of two databases from multicenter retrospective and prospective studies examining outcomes of infants with proximal EA and distal TEF who underwent repair at 11 institutions was performed based on surgical approach. Regression analysis using propensity score-based overlap weights was utilized to evaluate outcomes of patients undergoing thoracotomy or thoracoscopy for Type C EA/TEF repair. RESULTS: Of 504 patients included, 448 (89%) underwent thoracotomy and 56 (11%) thoracoscopy. Patients undergoing thoracoscopy were more likely to be full term (37.9 vs. 36.3 weeks estimated gestational age, p < 0.001), have a higher weight at operative repair (2.9 vs. 2.6 kg, p < 0.001), and less likely to have congenital heart disease (16% vs. 39%, p < 0.001). Postoperative stricture rate did not differ by approach, 29 (52%) thoracoscopy and 198 (44%) thoracotomy (p = 0.42). Similarly, there was no significant difference in time from surgery to stricture formation (p > 0.26). Regression analysis using propensity score-based overlap weighting found no significant difference in the odds of vocal cord paresis or paralysis (OR 1.087 p = 0.885), odds of anastomotic leak (OR 1.683 p = 0.123), the hazard of time to anastomotic stricture (HR 1.204 p = 0.378), or the number of dilations (IRR 1.182 p = 0.519) between thoracoscopy and thoracotomy. CONCLUSION: Infants undergoing thoracoscopic repair of Type C EA/TEF are more commonly full term, with higher weight at repair, and without congenital heart disease as compared to infants repaired via thoracotomy. Utilizing propensity score-based overlap weighting to minimize the effects of selection bias, we found no significant difference in complications based on surgical approach. However, our study may be underpowered to detect such outcome differences owing to the small number of infants undergoing thoracoscopic repair. LEVEL OF EVIDENCE: Level III.

The utilization of telehealth during the COVID-19 pandemic: An American Pediatric Surgical Association survey.

BACKGROUND: Limited in-person visits during the COVID-19 pandemic, with liberal reimbursement policies, resulted in increased use of video conferencing (hereby described as telehealth) for patient care. To better understand the impact on pediatric surgeons and their patients, we surveyed members of the American Pediatric Surgical Association (APSA) regarding telehealth use prior to and during the pandemic. METHODS: An iteratively developed survey was sent to all active, non-trainee surgeons within APSA during March 2021. RESULTS: Of 247 responses (23% response rate), 154 (62%) began using telehealth during the pandemic. In addition to the 101 (60.5%) respondents who felt telehealth had a positive impact on their clinical practice, 161 (74.2%) felt that it had a positive impact on their patients' satisfaction. The most common barriers to telehealth use prior to COVID-19 were availability of technology (39.3%), patient access to technology (36.0%), and lack of reimbursement (32.0%). These barriers became less substantial during the pandemic. Most respondents (95.3%) indicated they would continue using telehealth post-pandemic if it remains appropriately reimbursed. CONCLUSIONS: The majority of pediatric surgeons implemented telehealth during the COVID-19 pandemic and endorsed a positive effect on their clinical practice as well as on patient satisfaction. An overwhelming majority would continue using this technology if reimbursement policies remain favorable.

Acid suppression duration does not alter anastomotic stricture rates after esophageal atresia with distal tracheoesophageal fistula repair: A prospective multi-institutional cohort study.

INTRODUCTION: Anastomotic stricture is the most common complication after esophageal atresia (EA) repair. We sought to determine if postoperative acid suppression is associated with reduced stricture formation. METHODS: A prospective, multi-institutional cohort study of infants undergoing primary EA repair from 2016 to 2020 was performed. Landmark analysis and multivariate Cox regression were used to explore if initial duration of acid suppression was associated with stricture formation at hospital discharge (DC), 3-, 6-, and 9-months postoperatively. RESULTS: Of 156 patients, 79 (51%) developed strictures and 60 (76%) strictures occurred within three months following repair. Acid suppression was used in 141 patients (90%). Landmark analysis showed acid suppression was not associated with reduction in initial stricture formation at DC, 3-, 6- and 9-months, respectively (p = 0.19-0.95). Multivariate regression demonstrated use of a transanastomotic tube was significantly associated with stricture formation at DC (Hazard Ratio (HR) = 2.21 (95% CI 1.24-3.95, p<0.01) and 3-months (HR 5.31, 95% CI 1.65-17.16, p<0.01). There was no association between acid suppression duration and stricture formation. CONCLUSION: No association between the duration of postoperative acid suppression and anastomotic stricture was observed. Transanastomotic tube use increased the risk of anastomotic strictures at hospital discharge and 3 months after repair.

Clinical outcomes following implementation of a management bundle for esophageal atresia with distal tracheoesophageal fistula.

BACKGROUND/PURPOSE: This study evaluated compliance with a multi-institutional quality improvement management protocol for Type-C esophageal atresia with distal tracheoesophageal fistula (EA/TEF). METHODS: Compliance and outcomes before and after implementation of a perioperative protocol bundle for infants undergoing Type-C EA/TEF repair were compared across 11 children's hospitals from 1/2016-1/2019. Bundle components included elimination of prosthetic material between tracheal and esophageal suture lines during repair, not leaving a transanastomotic tube at the conclusion of repair (NO-TUBE), obtaining an esophagram by postoperative-day-5, and discontinuing prophylactic antibiotics 24 h postoperatively. RESULTS: One-hundred seventy patients were included, 40% pre-protocol and 60% post-protocol. Bundle compliance increased 2.5-fold pre- to post-protocol from 17.6% to 44.1% (p < 0.001). After stratifying by institutional compliance with all bundle components, 43.5% of patients were treated at low-compliance centers (<20%), 43% at medium-compliance centers (20-80%), and 13.5% at high-compliance centers (>80%). Rates of esophageal leak, anastomotic stricture, and time to full feeds did not differ between pre- and post-protocol cohorts, though there was an inverse correlation between NO-TUBE compliance and stricture rate over time (ρ = -0.75, p = 0.029). CONCLUSIONS: Compliance with our multi-institutional management protocol increased 2.5-fold over the study period without compromising safety or time to feeds and does not support the use of transanastomotic tubes. LEVEL OF EVIDENCE: Level II. TYPE OF STUDY: Treatment Study.

Subspecialization in pediatric surgery: Results of a survey to the American Pediatric Surgical Association.

BACKGROUND: Current practice patterns and opinions regarding subspecialization within pediatric surgery are not well known. We aimed to characterize the prevalence of and attitudes surrounding subspecialization within pediatric surgery. METHODS: An anonymous survey regarding subspecialization was distributed to all nonresident members of the American Pediatric Surgical Association. RESULTS: Of 1118 surveys, we received 458 responses (41%). A majority of respondents labeled themselves 'general pediatric surgeons' (63%), while 34% considered themselves general surgeons with a specific clinical focus, and 3% reported practicing solely within a specific niche. Subspecialists commonly serve as consultants for relevant cases (52%). Common niches included oncology (10%) and anorectal malformations (9%). Subspecialists felt to be necessary included transplant (79%) and fetal (78%) surgeons. Opinions about subspecialization were variable: 41% felt subspecialization improves patient care while 39% believe it is detrimental to surgeon well-roundedness. Only 10% felt subspecialists should practice solely within their subspecialty. Practicing at an academic hospital or fellowship program correlated with subspecialization, while length of time in practice did not. CONCLUSION: While pediatric surgeons report that subspecialization may benefit patient care, concerns exist regarding the unfavorable effect it may have on the individual surgeon. A better understanding of how subspecialization affects quality and outcomes would help clarify its utility. TYPE OF STUDY: Review article. LEVEL OF EVIDENCE: Level V.