Improving Accuracy of Administrative Data for Perforated Appendicitis Classification.

INTRODUCTION: Reliance on International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes may misclassify perforated appendicitis with resultant research, fiscal, and public health implications. We aimed to improve the accuracy of administrative data for perforated appendicitis classification relying on ICD-10-CM codes from 2015 to 2018. METHODS: We conducted a retrospective study of randomly sampled patients aged ≤18 years diagnosed with acute appendicitis from eight children's hospitals. Patients were identified using the Pediatric Health Information System, and true perforation status was determined by medical record review. We developed two algorithms by leveraging Pediatric Health Information System data elements and data mining (DM) approaches. The two developed algorithm performance was compared against algorithms that exclusively relied on ICD-10-CM codes using area under the curve and other measures. RESULTS: Of 1051 clinically validated encounters that were included, 383 (36.4%) patients were identified to have perforated appendicitis. The two algorithms developed using DM approaches primarily leveraged ICD-10-CM codes and length of stay. DM-developed algorithms had a significantly higher accuracy than algorithms relying exclusively on ICD-10-CM (P value < 0.01): sensitivity and specificity for DM-developed algorithms were 0.86-0.88 and 0.95-0.97, respectively, which were overall higher than algorithms that relied on only ICD-10-CM. CONCLUSIONS: This study provides an algorithm that can improve the accuracy of perforated appendicitis classification using commonly available elements in administrative data. We recommend that this algorithm is used in future appendicitis classification to ensure valid reporting, hospital-level benchmarking, and fiscal or public health assessments.

Coaching Program to Address Burnout, Well-Being, and Professional Development in Pediatric Surgery Trainees: A Randomized Controlled Trial.

OBJECTIVE: To assess impact of participation in a positive psychology coaching program on trainee burnout and well-being. BACKGROUND: Coaching using principles of positive psychology can improve well-being and reduce physician burnout. We hypothesized that participation in a coaching program would improve pediatric surgery trainee well-being. METHODS: With IRB approval, a coaching program was implemented during the COVID-19 pandemic (9/2020-7/2021) in the American Pediatric Surgical Association. Volunteer pediatric surgery trainees (n=43) were randomized to receive either one-on-one quarterly virtual coaching (n=22) from a pediatric surgeon trained in coaching skills or wellness reading materials (n=21). Participants completed pre- and post-study surveys containing validated measures including PERMA (positive emotion, engagement, relationships, meaning, accomplishment), professional fulfillment, burnout, self-valuation, gratitude, coping skills, and workplace experiences. Results were analyzed using Wilcoxon rank sum test, Kruskal-Wallis test, or chi-square test. RESULTS: Forty trainees (93%) completed both the baseline and year-end surveys and were included in the analysis. Twenty-five (64%) were female, mean age 35.7 (SD 2.3), 65% first-year fellows. Coached trainees showed an improved change in PERMA (P=0.034), burnout (P=0.024), and gratitude (P=0.03) scores from pre- to post-coaching compared to non-coached trainees. Coping skills also improved. More coaching sessions was associated with higher self-valuation scores (P=0.042), and more opportunities to reflect was associated with improved burnout and self-valuation. CONCLUSIONS: Despite the stress and challenges of medicine during COVID-19, a virtual positive psychology coaching program provided benefit in well-being and burnout to pediatric surgery trainees. Coaching should be integrated into existing wellness programs to support acquisition of coping skills that help trainees cope with the stressors they will face during their careers.

Effect of Early vs Late Inguinal Hernia Repair on Serious Adverse Event Rates in Preterm Infants: A Randomized Clinical Trial.

Importance: Inguinal hernia repair in preterm infants is common and is associated with considerable morbidity. Whether the inguinal hernia should be repaired prior to or after discharge from the neonatal intensive care unit is controversial. Objective: To evaluate the safety of early vs late surgical repair for preterm infants with an inguinal hernia. Design, Setting, and Participants: A multicenter randomized clinical trial including preterm infants with inguinal hernia diagnosed during initial hospitalization was conducted between September 2013 and April 2021 at 39 US hospitals. Follow-up was completed on January 3, 2023. Interventions: In the early repair strategy, infants underwent inguinal hernia repair before neonatal intensive care unit discharge. In the late repair strategy, hernia repair was planned after discharge from the neonatal intensive care unit and when the infants were older than 55 weeks' postmenstrual age. Main Outcomes and Measures: The primary outcome was occurrence of any prespecified serious adverse event during the 10-month observation period (determined by a blinded adjudication committee). The secondary outcomes included the total number of days in the hospital during the 10-month observation period. Results: Among the 338 randomized infants (172 in the early repair group and 166 in the late repair group), 320 underwent operative repair (86% were male; 2% were Asian, 30% were Black, 16% were Hispanic, 59% were White, and race and ethnicity were unknown in 9% and 4%, respectively; the mean gestational age at birth was 26.6 weeks [SD, 2.8 weeks]; the mean postnatal age at enrollment was 12 weeks [SD, 5 weeks]). Among 308 infants (91%) with complete data (159 in the early repair group and 149 in the late repair group), 44 (28%) in the early repair group vs 27 (18%) in the late repair group had at least 1 serious adverse event (risk difference, -7.9% [95% credible interval, -16.9% to 0%]; 97% bayesian posterior probability of benefit with late repair). The median number of days in the hospital during the 10-month observation period was 19.0 days (IQR, 9.8 to 35.0 days) in the early repair group vs 16.0 days (IQR, 7.0 to 38.0 days) in the late repair group (82% posterior probability of benefit with late repair). In the prespecified subgroup analyses, the probability that late repair reduced the number of infants with at least 1 serious adverse event was higher in infants with a gestational age younger than 28 weeks and in those with bronchopulmonary dysplasia (99% probability of benefit in each subgroup). Conclusions and Relevance: Among preterm infants with inguinal hernia, the late repair strategy resulted in fewer infants having at least 1 serious adverse event. These findings support delaying inguinal hernia repair until after initial discharge from the neonatal intensive care unit. Trial Registration: ClinicalTrials.gov Identifier: NCT01678638.

ChatGPT: What Every Pediatric Surgeon Should Know About Its Potential Uses and Pitfalls.

ChatGPT - currently the most popular generative artificial intelligence system - has been revolutionizing the world and healthcare since its release in November 2022. ChatGPT is a conversational chatbot that uses machine learning algorithms to enhance its replies based on user interactions and is a part of a broader effort to develop natural language processing that can assist people in their daily lives by understanding and responding to human language in a useful and engaging way. Thus far, many potential applications within healthcare have been described, despite its relatively recent release. This manuscript offers the pediatric surgical community a primer on this new technology and discusses some initial observations about its potential uses and pitfalls. Moreover, it introduces the perspectives of medical journals and surgical societies regarding the use of this artificial intelligence chatbot. As ChatGPT and other large language models continue to evolve, it is the responsibility of the pediatric surgery community to stay abreast of these changes and play an active role in safely incorporating them into our field for the benefit of our patients. LEVEL OF EVIDENCE: V.

PeRiOperative Glucose PRAgMatic (PROGRAM) trial protocol and statistical analysis plan for comparing automated intraoperative reminders to standardise insulin administration in surgical patients at high risk of hyperglycaemia.

INTRODUCTION: Studies finding perioperative hyperglycaemia is associated with adverse patient outcomes in surgical procedures spurred the development of blood glucose guidelines at many institutions. In this trial, we will assess the implementation of a clinical decision support tool that is integrated into the intraoperative portion of our electronic health record and provides real-time best practice recommendations for intraoperative insulin dosing in surgical patients at high risk for hyperglycaemia. METHODS AND DESIGN: We will assess this intervention using a sequential and repeated cross-over design at the institutional level with periods of time for wash-out, control and study intervention. The unit of analysis will be the surgical case. The primary outcome will be the frequency of hyperglycaemia (>180 mg/dL (10 mmol/L)) at first postoperative anaesthesia care unit measurement. There are several prespecified secondary analyses focused on perioperative glycaemic control. DISCUSSION: This protocol and statistical analysis plan describes the methodology, primary and secondary analyses. The PeRiOperative Glucose PRAgMatic (PROGRAM) trial was approved by the Vanderbilt University Institutional Review Board (IRB), Vanderbilt University Medical Center, Nashville, Tennessee, USA (IRB, 220991). The study results will be disseminated via publication in a peer-reviewed journal and presented at national scientific conferences. The results of PROGRAM trial will inform best practice for perioperative standardised insulin administration in surgical patients at high risk of hyperglycaemia. TRIAL REGISTRATION NUMBER: NCT05426096.

Postoperative Respiratory Complications in SARS-CoV-2 Positive Pediatric Patients Across 20 United States Hospitals: A Cohort Study.

INTRODUCTION: Data examining rates of postoperative complications among SARS-CoV-2 positive children are limited. The purpose of this study was to evaluate the impact of symptomatic and asymptomatic SARS-CoV-2 positive status on postoperative respiratory outcomes for children. METHODS: This retrospective cohort study included SARS-CoV-2 positive pediatric patients across 20 hospitals who underwent general anesthesia from March to October 2020. The primary outcome was frequency of postoperative respiratory complications, including: high-flow nasal cannula/non invasive ventilation, reintubation, pneumonia, Extracorporeal Membrane Oxygenation (ECMO), and 30-day respiratory-related readmissions or emergency department (ED) visits. Univariate analyses were used to evaluate associations between patient and procedure characteristics and stratified analyses by symptoms were performed examining incidence of complications. RESULTS: Of 266 SARS-CoV-2 positive patients, 163 (61.7%) were male, and the median age was 10 years (interquartile range 4-14). The majority of procedures were emergent or urgent (n = 214, 80.5%). The most common procedures were appendectomies (n = 78, 29.3%) and fracture repairs (n = 40,15.0%). 13 patients (4.9%) had preoperative symptoms including cough or dyspnea. 26 patients (9.8%) had postoperative respiratory complications, including 15 requiring high-flow oxygen, 8 with pneumonia, 4 requiring non invasive ventilation, 3 respiratory ED visits, and 2 respiratory readmissions. Respiratory complications were more common among symptomatic patients than asymptomatic patients (30.8% vs. 8.7%, p = 0.01). Higher ASA class and comorbidities were also associated with postoperative respiratory complications. CONCLUSIONS: Postoperative respiratory complications are less common in asymptomatic versus symptomatic SARS-COV-2 positive children. Relaxation of COVID-19-related restrictions for time-sensitive, non urgent procedures in selected asymptomatic patients may be reasonably considered. Additionally, further research is needed to evaluate the costs and benefits of routine testing for asymptomatic patients. LEVEL OF EVIDENCE: Iii, Respiratory complications.

The First Two Years of the Association of Pediatric Surgery Training Program Directors (APSTPD) Transition to Fellowship Course: Lessons Learned and Future Directions.

OBJECTIVE: The first transition to fellowship course for incoming pediatric surgery fellows was held in the US in 2018 and the second in 2019. The course aimed to facilitate a successful transition in to fellowship by introduction of the professional, patient care, and technical aspects unique to pediatric surgery training. The purpose of this study was to evaluate the feasibility and effectiveness of the first two years of this course in the US and discuss subsequent evolution of this endeavor. DESIGN: This is a descriptive and qualitative analysis of two years' experience with the Association of Pediatric Surgery Training Program Directors' (APSTPD) Transition to Fellowship course. Course development and curriculum, including clinical knowledge, soft skills, and hands-on skills labs, are presented. Participating incoming fellows completed multiple choice, boards-style pre- and post-tests. Scores were compared to determine if knowledge was effectively transferred. Participants also completed post-course evaluations and subsequent 3- or 12-month surveys inquiring on the lasting impact of the course on their transition into fellowship. Standard univariate statistics were used to present results. SETTING: The first APSTPD Transition to Fellowship course was held at the Johns Hopkins Hospital in Baltimore, Maryland in 2018, and the second course was held at the Oregon Health and Science University in Portland, Oregon in 2019. PARTICIPANTS: All fellows entering ACGME-certified Pediatric Surgery fellowships in the United States were invited to participate. Twenty fellows accepted and attended in 2018, and fourteen fellows participated in 2019. RESULTS: There were 34 incoming pediatric surgery fellow participants over 2 years. Faculty represented more than 10 institutions each year. Pre- and post-test scores were similar between years, with a significant improvement of scores after completion of the course (67±10% vs 79±8%, p < 0.001). Feedback from participants was overwhelmingly positive, with skills labs being attendees' favorite component. When asked about usefulness of individual course sessions, more attendees found clinical sessions more useful than soft skills (93% vs 73%, p = 0.011). Almost all (90%) of participants reported the course met its stated purpose and would recommend the course to future fellows. This was further reflected on 3 and 12 month follow up surveys wherein 85% stated they found the course helpful during the first few months of fellowship and 90% would still recommend it. CONCLUSIONS: A transition to fellowship course in the US for incoming pediatric surgery fellows is logistically feasible, effective in transfer of knowledge, and highly regarded among attendees. Feedback from each course has been used to improve the subsequent courses, ensuring that it remains a valuable addition to pediatric surgical training in the US.

Sledding while towed behind motorized vehicles associates with more severe and lethal injuries☆.

INTRODUCTION: Our institution has recently experienced an increase in sledding-related injuries, particularly when towed behind motorized vehicles. The purpose of this study was to characterize injury severity and clinical outcomes between pediatric patients who sustain injuries owing to motorized sledding accidents to aid in injury prevention messaging. METHODS: This retrospective study queried all patients who presented with a sledding-related injury to a single ACS-verified Level 1 Pediatric Trauma Center located in the Southeastern United States between 01/2015 and 01/2022. Demographics, injury details, and clinical outcomes were compared between two groups: patients towed behind a motorized vehicle (MOTOR) and those who were not (GRAVITY). RESULTS: Of the 67 patients included in our analysis, 15 (22%) were in the MOTOR group. Patients in the MOTOR group presented with significantly higher injury severity (ISS) and lower Glasgow coma scale (GCS) scores. Additionally, patients in this MOTOR group more often received a blood transfusion and intubation, had longer intensive care and overall hospital lengths of stay, and incurred higher hospital costs. In a multivariate analysis, the use of a motorized vehicle to sled was independently associated with increased ISS (OR: 9.7, 95% CI 1.9-17.5; p = 0.02). Two deaths occurred after sledding while being towed behind a motorized vehicle. CONCLUSION: Children experiencing sledding accidents while being towed by motorized vehicles sustain significantly more severe injuries and require more intensive treatments that together lead to increased hospital costs. These findings provide the framework for community educational initiatives and injury prevention measures to mitigate risk among children engaged in sledding. LEVEL OF EVIDENCE: IV retrospective cohort study.

Characteristics and predictors of intensive care unit admission in pediatric blunt abdominal trauma.

BACKGROUND: Pediatric trauma patients sustaining blunt abdominal trauma (BAT) with intra-abdominal injury (IAI) are frequently admitted to the intensive care unit (ICU). This study was performed to identify predictors for ICU admission following BAT. METHODS: Prospective study of children (< 16 years) who presented to 14 Level-One Pediatric Trauma Centers following BAT over a 1-year period. Patients were categorized as ICU or non-ICU patients. Data collected included vitals, physical exam findings, laboratory results, imaging, and traumatic injuries. A multivariable hierarchical logistic regression model was used to identify predictors of ICU admission. Predictive ability of the model was assessed via tenfold cross-validated area under the receiver operating characteristic curves (cvAUC). RESULTS: Included were 2,182 children with 21% (n = 463) admitted to the ICU. On univariate analysis, ICU patients were associated with abnormal age-adjusted shock index, increased injury severity scores (ISS), lower Glasgow coma scores (GCS), traumatic brain injury (TBI), and severe solid organ injury (SOI). With multivariable logistic regression, factors associated with ICU admission were severe trauma (ISS > 15), anemia (hematocrit < 30), severe TBI (GCS < 8), cervical spine injury, skull fracture, and severe solid organ injury. The cvAUC for the multivariable model was 0.91 (95% CI 0.88-0.92). CONCLUSION: Severe solid organ injury and traumatic brain injury, in association with multisystem trauma, appear to drive ICU admission in pediatric patients with BAT. These results may inform the design of a trauma bay prediction rule to assist in optimizing ICU resource utilization after BAT. STUDY DESIGN: Prognosis study.

Inclusion and representation in the pediatric surgery workforce: Strategies to mitigate bias in the fellowship application process.

Diverse perspectives are critical components of effective teams in every industry. Underrepresentation of minorities in medicine leads to worse outcomes for minority patients, and efforts to increase diversity in the health care workforce are critical. Presently, about 70% of the pediatric surgery workforce is white, and pediatric surgeons at large do not reflect the racial or ethnic diversity of the populations they serve. Pediatric surgery fellowship training programs are the gateway to the field, and fellow selection processes should be optimized to support diversity and inclusion. The Association of Pediatric Surgery Training Program Directors (APSTPD) Diversity Equity and Inclusion subcommittee compiled best practices for bias mitigation during fellow selection, drawing from published literature and personal experiences in our own programs. A list of concrete recommendations was compiled, which can be implemented in every phase from applicant screening to rank list creation. We present these as a position statement that has been endorsed by the executive committee of the APSTPD. Pediatric surgery fellowship programs can utilize this focused review of best practices to mitigate bias and support diverse applicants.

Pilot Study of Sham Feeding in Postoperative Neonates.

OBJECTIVE: Sham feeding may enhance development of oral skills in neonates after bowel surgery and decrease stress levels in mothers. In this pilot study, we test the feasibility of sham feeding, identify safety hazards, and assess maternal satisfaction. STUDY DESIGN: A convenience sample of 15 postoperative neonates was enrolled. Sham feeding with unfortified human milk was offered following a strict advancement protocol beginning with 5 mL once daily and increasing up to 30 mL, three times daily. Continuous gastric suction was used during sham feeding. Each mother completed a satisfaction survey. Sham-fed gastroschisis patients were compared with a historic cohort. RESULTS: All 15 patients were able to sham feed. A total of 312 sham feeds were offered with a median of 23 sham events per patient. Four minor complications occurred during sham feeding. No differences were noted between 11 sham-fed gastroschisis patients and 81 historic controls. The mothers reported a decrease in stress after sham feeding using a 5-point score (3.8 ± 1.4 vs. 1.5 ± 0.7, p < 0.005) and 100% satisfaction with sham feeding. CONCLUSION: Sham feeding is feasible for neonates after bowel surgery and is highly rated by mothers. KEY POINTS: · Sham-feeding human milk to neonates after bowel surgery is feasible and safe.. · A novel postoperative sham feeding protocol is described.. · Mothers of sham-fed infants report it reduces stress compared with not feeding..

Pediatric Snakebites: Comparing Patients in Two Geographic Locations in the United States.

BACKGROUND: Management of children with snakebites may vary based on subjective criteria, geographic, and climatic factors. We reviewed the incidence and management of snakebite injuries in children at two tertiary referral centers in separate geographic and climatic location to assess differences in management and outcomes of these patients. METHODS: After institutional review board approval, a retrospective chart review was performed for patients ≤18 years with snakebite injuries at emergency departments (ED) of two American College of Surgeons verified trauma centers (2006-2013). One center is in southeast US and experiences a sub-tropical climate whereas the other is in southwest US and experiences a semi-arid climate. Demographic and clinical parameters were extracted. RESULTS: A total of 108 patients (59% male), median age of 9 y (1 y-17 y), were included. Snake type was identified by bystanders in 55.5% cases; copperhead was the most common (37%) subtype. Approximately 30% of patients received antivenom. One quarter of all patients were discharged from the ED. Two patients received surgical intervention in the first 48 hours after presentation. Compared to patients who sustained a snakebite in semi-tropical regions, patients in semi-arid areas had shorter bite-to-ED time, presented directly to the referral center, were more frequently bitten by a rattlesnake, had longer lengths of hospital stay, required antivenom more frequently and at higher doses, and were more frequently admitted to the ICU. No differences were seen in gender, age at presentation, severity of wound, location of bite, abnormalities in coagulation profile or rate of admission to hospital amongst the two sites. CONCLUSIONS: Patients sustaining snakebites in semi-arid climates were more commonly exposed to dangerous snake types, resulting in higher antivenom requirement, as well as longer hospital stays and need for intensive monitoring. Although no fatalities were reported in our study, our data supports early transfer of snakebite victims to higher levels of care, especially in semi-arid or high-risk areas.

Determining the impact of body mass index on ultrasound accuracy for diagnosing appendicitis: Is it less useful in obese children?

BACKGROUND: Ultrasonography (US) is the preferred imaging for suspected pediatric appendicitis. We hypothesize that children with elevated Body-Mass-Index-for-age percentile (BMIP) may be more likely to have an inaccurate or equivocal (IE) US. METHODS: After IRB approval, a four-year review was performed on pediatric patients evaluated for appendicitis by US. The CDC BMIP Calculator was used. IE subgroups were analyzed together for comparison against the accurate group. RESULTS: 1059 patients were included: median age 11.3 years (IQR: 8.2, 14.6), 506 (47.8%) males. Median BMIP was 65.9 (IQR: 33.9, 89.6). US accurately diagnosed 857 (80.9%), incorrectly diagnosed 76 (7.2%), 126 (11.9%) were equivocal. Overall sensitivity was 0.85, specificity 0.96, PPV 0.93 and NPV 0.91. Obese children (BMIP ≥95%), had higher odds of IE US (OR: 1.86, 95% CI: 1.28, 2.70; p = 0.001). When analyzed by sex, risk increased in obese males (OR: 2.55, 95% CI:1.53, 4.24; p = 0.0003) but normalized in obese females (OR: 1.30, 95% CI:0.74, 2.28; p = 0.35). CONCLUSIONS: An elevated BMIP may increase difficulty in visualizing the appendix, resulting in inaccurate or equivocal findings. This risk is seen specifically in obese males. If US findings do not correlate with clinical assessment in obese children with abdominal pain, further evaluation may be warranted.

Poisson Probability of Failing to Meet Minimum Case Volumes in Pediatric Surgery Fellowships.

INTRODUCTION: With the expansion of pediatric surgery fellowships from 2008 to 2018, there is concern for the dilution of training experience, especially for rare index cases. The Accreditation Council for Graduate Medical Education (ACGME) established required minimum case numbers by case type, but this is a program requirement rather than an individual trainee requirement. The American Board of Surgery (ABS) is considering instituting minimum case requirements across 5 broad categories for individuals to be board-eligible in pediatric surgery. METHODS: The ACGME National Data Report summary case logs were obtained for graduating fellows in pediatric surgery from 2008 to 2018. Median case volumes were compared to minimum ACGME case numbers and proposed ABS individual requirements. Using Poisson distributions, probabilities of individual fellows failing to meet minimum case numbers were calculated. RESULTS: The average annual probability that a median program would fail to meet minimum ACGME case numbers in at least 1 category was estimated at 16.6%. Using the proposed ABS system, the probability of failure was estimated at 44.1%. No temporal trend was found in the annual probability of failure in either the ACGME or the proposed ABS system. CONCLUSIONS: There is significant risk of a fellow failing to meet case minimums in the ACGME system and the proposed ABS system. This probability is increased for the half of programs below median. If the ABS institutes case minimums as a requirement for certification in pediatric surgery, the current training paradigm may be impacted at some programs.

Opioid Prescribing and Use After Pediatric Umbilical Hernia Repair.

BACKGROUND: Opioid overuse is a concern in adult and pediatric populations. Physician education may improve appropriate opioid prescribing and patient instruction for use. Prescribing and use of opioids for pain control after pediatric umbilical hernia (UH) repair before and after surgeon education was evaluated. This is a substudy of a multi-institutional study assessing prescribing practice before and after surgeon education. This study further assessed patient prescription filling patterns and parent report of pain control. METHODS: A retrospective study was performed evaluating children who underwent UH 6 months before and after an educational presentation on opioid use. Prescriptions, prescription fills, patient medication use, and pain control effectiveness were assessed. Adverse events were collected. RESULTS: There were 78 subjects in the pre-education and 99 in the post-education group. Opioid prescribed changed from 98.7% to 61.6% (P < .0001), and nonopioid prescriptions increased following education (P = .0063). The number of opioid prescriptions filled decreased (P = .0296). There were limited data on opioid doses used and quality of pain control, but the post-education group showed good pain control. There was no difference in adverse events. DISCUSSION: Surgeon education on the current opioid epidemic and strategies for opioid stewardship improves opioid prescribing and use without adversely impacting pain control or clinical outcome.

The use of computed tomography versus clinical acumen in diagnosing appendicitis in children: A two-institution international study.

BACKGROUND: Appendicitis in children can be diagnosed utilizing clinical and laboratory findings, with the assistance of ultrasound (US) and/or computed tomography (CT). However, repeated exposure to ionizing radiation increases the lifetime risk of cancer. We compared the work-up of suspected appendicitis between a children's hospital in the United States (USA) and one in Spain to identify differences in imaging use and associated outcomes. METHODS: A two-institution retrospective review was performed for surgical consultations of suspected appendicitis from 2015-2017. We compared imaging use, the utilization of overnight observation, and diagnostic accuracy rates between the two centers. RESULTS: A total of 1,952 children were evaluated. Among the 1,288 in the USA center, 754(58.5%) underwent CT during their evaluation. The most common imaging modality was US only (39.9%), then CT only (39.3%), CT+US (19.3%), and no imaging (i.e. only clinical acumen) (1.6%). In Spain, only 19 (2.9%) of 664 children underwent CT compared to the USA (p < 0.0001). Only clinical acumen was the most common modality employed (48.6%), followed by US only (48.5%), US+CT (2.4%), and CT only (0.5%). In the USA, 16.8% were observed overnight, 2.3% of whom received no imaging. In Spain, 33.4% were observed overnight, 32.4% of whom had no imaging (p < 0.0001). The accuracy rates for diagnosing appendicitis in the USA and Spain centers were 94.7% and 95.1%, respectively. CONCLUSION: Use of clinical acumen and/or US have similar clinical outcomes and similar accuracy rates compared to heavy reliance on CT imaging for diagnosing appendicitis, with associated decrease in radiation exposure. The disparate diagnostic approach of the two centers may reflect that physical examination is a dying art in North America. LEVEL OF EVIDENCE: III.

Opioid Prescribing and Use After Pediatric Umbilical Hernia Repair.

BACKGROUND: Opioid overuse is a concern in adult and pediatric populations. Physician education may improve appropriate opioid prescribing and patient instruction for use. Prescribing and use of opioid for pain control after pediatric umbilical hernia repair (UH) before and after surgeon education was evaluated. This is a substudy of a multi-institutional study assessing prescribing practice before and after surgeon education. This study further assessed patient prescription filling pattern and parent report of pain control. METHODS: A retrospective study was performed evaluating children who underwent UH 6 months before and after an educational presentation on opioid use. Prescriptions, prescription fills, patient medication use, and pain control effectiveness were assessed. Adverse events were collected. RESULTS: There were 78 subjects in the pre- and 99 in the posteducation group. Opioid prescribed changed from 98.7% to 61.6% (P < .0001), and nonopioid prescriptions increased following education (P = .0063). The number of opioid prescriptions filled decreased (P = .0296). There were limited data on opioid doses used and quality of pain control, but the posteducation group showed good pain control. There was no difference in adverse events. DISCUSSION: Surgeon education on current opioid epidemic and strategies for opioid stewardship improves opioid prescribing and use without adversely impacting pain control or clinical outcome.

Surgical job negotiations: How current literature and expert opinion can inform your strategies.

BACKGROUND: Negotiation is an essential professional skill. Surgeons negotiating new roles must consider: 1) career level (e.g., new graduate, mid-career or leadership), 2) practice environment (e.g., academic, private practice), 3) organization (e.g., academic, university-affiliated, specialized center), and 4) work-life needs (e.g., geography, joint recruitment). METHODS: A review of the literature related to surgical job negotiation was conducted. Expert opinion was also sought. RESULTS: Current data and experience suggest that negotiation must be tailored to practice type, surgeon experience/skill set and should always occur with the advice of legal counsel. Understanding principled negotiation and engaging in preparation and practice will also improve negotiation skills. CONCLUSIONS: Our findings shed light on common blind spots among surgeons negotiating new professional roles and provide guidance on optimizing job negotiation skills.