Development of a Standardized Algorithm for Management of Newly Diagnosed Anorectal Malformations.

Neonates with a new diagnosis of anorectal malformation (ARM) present a unique challenge to the clinical team. ARM is strongly associated with additional midline malformations, such as those observed in the VACTERL sequence, including vertebral, cardiac, and renal malformations. Timely assessment is necessary to identify anomalies requiring intervention and to prevent undue stress and delayed treatment. We utilized a multidisciplinary team to develop an algorithm guiding the midline workup of patients newly diagnosed with ARM. Patients were included if born in or transferred to our neonatal intensive care unit (NICU), or if seen in clinic within one month of life. Complete imaging was defined as an echocardiogram, renal ultrasound, and spinal magnetic resonance imaging or ultrasound within the first month of life. We compared three periods: prior to implementation (2010-2014), adoption period (2015), and delayed implementation (2022); p ≤ 0.05 was considered significant. Rates of complete imaging significantly improved from pre-implementation to delayed implementation (65.2% vs. 50.0% vs. 97.0%, p = 0.0003); the most growth was observed in spinal imaging (71.0% vs. 90.0% vs. 100.0%, p = 0.001). While there were no differences in the rates of identified anomalies, there were fewer missed diagnoses with the algorithm (10.0% vs. 47.6%, p = 0.05). We demonstrate that the implementation of a standardized algorithm can significantly increase appropriate screening for anomalies associated with a new diagnosis of ARM and can decrease delayed diagnosis. Further qualitative studies will help to refine and optimize the algorithm moving forward.

Barriers to Family Building Among Physicians and Medical Students.

Importance: Physicians and medical students who desire to build families face significant barriers due to the structure and culture of medicine. Objective: To understand the barriers and facilitators to family building for all people in medicine-not only individuals who can become pregnant-through an open-ended, qualitative analysis of survey responses. Design, Setting, and Participants: This qualitative study used a survey conducted in April and May 2021 with a broad sample of physicians and medical students. Participants were recruited through social media, targeting physician and medical student communities. Physicians (residents, fellows, and physicians in independent practice) and medical students of all gender identities and sexual orientations were included. Informed by a postpositivist approach, coding reliability thematic analysis was performed on 3 open-ended survey questions on family-building experiences (what they would do differently, what advice they have for others, and anything else they wished to share). Main Outcomes and Measures: Identified themes were mapped to the social-ecological model, a model used in public health to examine how a spectrum of factors is associated with health outcomes. Results: A total of 2025 people (1860 [92%] women; 299 [15%] Asian, 151 [8%] Black, and 1303 [64%] White; 1730 [85%] heterosexual; and 1200 [59%] physicians who had completed training) responded to at least 1 of 3 open-ended questions. Themes mapped to social-ecological model levels included: (1) cultural, eg, medical training being at odds with family building; (2) organizational, eg, lack of institutional support for the range of family-building routes; (3) interpersonal, eg, impact of social support on family building; and (4) individual, eg, socioeconomic status and other individual factors that facilitate or inhibit family building. Recommendations to improve family-building experiences include implementing family-building curricula at medical schools, providing adequate parental leave for all physicians and medical students who become parents, and providing insurance coverage for all family-building routes. Conclusions and Relevance: In this qualitative study of physicians and medical students, self-reported barriers to family building were identified at each level of the social-ecological model. Addressing these barriers is critical to creating a more equitable family-building environment for physicians and medical students.

Parental Health Mindset Is Related to Preoperative Perceptions of Chest Wall Anomalies.

INTRODUCTION: Mindsets of health have been linked to different outcomes for patients with both surgical and medical conditions. A "growth" mindset, in which health is defined as malleable and subject to improvement, is associated with improved attitudes and outcomes when compared to a "fixed" mindset, in which health is defined as unchangeable. In pediatric surgery, parental growth mindsets of health have been correlated with better postoperative outcomes, including lower scores of anxiety and pain perceptions, for children. This was particularly notable in a study of postoperative outcomes for patients with pectus excavatum. In our current study, we extend our investigations to explore how health mindsets are associated with perceptions of chest wall anomalies before correction is undertaken. METHODS: Seventy-six patients (71 males, mean age 14 y, and 43 excavatum) and 18 parents were surveyed during a routine chest wall clinic visit. Demographic and clinical information as well as the Health Mindset Scale and Pectus Excavatum Evaluation Questionnaire were administered and collected pretreatment. RESULTS: Parental mindsets of health were significantly correlated with parent assessments of their children's chest pain, physical activity, and concerns about the life-time effect of the condition. A parental growth mindset was linked to lower scores of chest pain, higher ratings of activity, and lower overall level of concern. Furthermore, parental health mindsets also significantly correlated with children's own perceptions of their chest pain, physical activity, shortness of breath, and fatigue. Growth mindset also was linked to more positive ratings. CONCLUSIONS: Parental growth mindset was associated with more positive assessments of children's symptoms and limitations due to pectus deformities than fixed mindsets. Health mindset has been linked to patient perceptions of, and outcomes for, diabetes, renal disease, allergies, scoliosis, and obesity. Further study into parental and patient mindset correlation may help elucidate factors for bracing compliance, and perhaps to better prepare children and parents for corrective surgical procedures.

Adolescent Vaping-Associated Trauma in the Western United States.

INTRODUCTION: Electronic cigarettes (e-cigarettes) are handheld, battery-powered vaporizing devices. It is estimated that more than 25% of youth have used these devices recreationally. While vaping-associated lung injury is an increasingly recognized risk, little is known about the risk of traumatic injuries associated with e-cigarette malfunction. METHODS: A multi-institutional retrospective study was performed by querying the electronic health records at nine children's hospitals. Patients who sustained traumatic injuries while vaping from January 2016 through December 2019 were identified. Patient demographics, injury characteristics, and the details of trauma management were reviewed. RESULTS: 15 children sustained traumatic injuries due to e-cigarette explosion. The median age was 17 y (range 13-18). The median injury severity score was 2 (range 1-5). Three patients reported that their injury coincided with their first vaping experience. Ten patients required hospital admission, three of whom required intensive care unit admission. Admitted patients had a median length of stay of 3 d (range 1-6). The injuries sustained were: facial burns (6), loss of multiple teeth (5), thigh and groin burns (5), hand burns (4), ocular burns (4), a radial nerve injury, a facial laceration, and a mandible fracture. Six children required operative intervention, one of whom required multiple operations for a severe hand injury. CONCLUSIONS: In addition to vaping-associated lung injury, vaping-associated traumatic injuries are an emerging and worrisome injury pattern sustained by adolescents in the United States. This report highlights another means by which e-cigarettes pose an increasing risk to a vulnerable youth population.

Premature twin neonates with a Coronavirus-19 positive mother present with an unusual pattern of intestinal ischemia.

COVID-19 infection during pregnancy is associated with premature rupture of membranes, preterm delivery, and low birth weight. It has also been associated with hypercoagulability and vasculitis in certain patients. This article reports two premature twins born from a COVID-19 mother who presented with an unusual pattern of ileal ischemia and perforation within 24 hours of each other. We suggest that maternal infection with the novel coronavirus might lead to this atypical distribution of intestinal pathology.

A problem at any age: a case report of congenital malrotation with bowel ischemia in an 84-year-old.

BACKGROUND: Malrotation with bowel ischemia is classically thought of as a disease of infants. However, the true prevalence of malrotation in both the pediatric and adult population is unknown due to the unclear number of asymptomatic patients. CASE PRESENTATION: A previously healthy 84-year-old man with no prior abdominal surgeries presented with an acute abdomen and was found on CT to have small bowel located in the right hemiabdomen and an abnormal SMA-SMV relationship suggestive of intestinal malrotation, as well as pneumatosis intestinalis. He underwent an exploratory laparotomy, where he was found to have a paraduodenal space which did not contain any bowel but was the likely source of an internal hernia. His duodenojejunal flexure was located to the right of the spinal column, the cecum in the left lower quadrant, a thick congenital band at the proximal jejunum, and multiple Ladd's bands at the level of the duodenum. The bowel appeared viable and a Ladd's procedure was performed. The patient had an uneventful post-operative course. CONCLUSIONS: There is a lack of guidelines regarding screening for and management of asymptomatic malrotation in older children and adults. However, the traditional thinking is that asymptomatic malrotation diagnosed after two years of age poses minimal risk. This case illustrates the potential risk of an internal hernia in the setting of malrotation at any time during one's lifetime.

The Influence of Health Mindset on Perceptions of Illness and Behaviors Among Adolescents.

BACKGROUND: Health mindsets can be viewed on a continuum of malleability from fixed (health cannot be altered) to growth (health can be affected by behavior). We propose that mindsets may influence the health perceptions of healthy adolescents as well as the health behaviors of adolescents with a chronic illness. METHODS: In Study 1, we surveyed healthy adolescents about their health mindsets and their judgments of illness in response to vignettes of fictional others. In Study 2, we measured the health mindsets and health behaviors of adolescents with type 1 diabetes RESULTS: In Study 1, healthy adolescents with a fixed health mindset were more likely to rate fictional others as being less healthy, less likely to recover, and more vulnerable to additional diseases. In Study 2, a growth mindset was associated with a greater frequency of glucose monitoring among younger, but not older, adolescents with type 1 diabetes. Further, growth mindset was associated with lower HbA1c levels for younger adolescents. CONCLUSIONS: Health mindsets may shape views of the implications of illness or injury for overall health and, in adolescents with a chronic condition, may interact with age to influence health behaviors and outcomes.

A cross-sectional analysis of compassion fatigue, burnout, and compassion satisfaction in pediatric surgeons in the U.S.

BACKGROUND/PURPOSE: To determine the prevalence of compassion fatigue (CF), burnout (BO), and compassion satisfaction (CS) and identify potential predictors of these phenomena in pediatric surgeons. METHODS: The Compassion Fatigue and Satisfaction Self-Test and a survey of personal/professional characteristics were distributed electronically to American Pediatric Surgical Association members. Linear regression models for CF, BO, and CS as a function of potential risk factors were constructed. RESULTS: The analyzeable study response rate was 25.7%. The prevalence of CF, BO, and CS was 22%, 24% and 22, respectively, which were similar to prevalences previously identified in pediatric subspecialists. Higher CF scores were significantly associated with: higher BO scores; solo practice; compensation; ≥5 operating days/week; current distress about a 'clinical situation'; mental health-care for work-related distress; and history of childhood surgery. Lower CF scores were significantly associated with 'talking with a life partner' about work-related distress. Higher BO scores were significantly associated with: higher CF scores; current distress about 'coworkers'; and 'keeping lawsuits confidential'. Lower BO scores were significantly associated with higher CS scores. CONCLUSIONS: CF, BO, and CS are distinct but highly related entities. Pediatric surgeons experience these phenomena at similar rates to other pediatric subspecialists. Establishing local channels for physician peer support may be particularly impactful.

Supporting recovery after adverse events: An essential component of surgeon well-being.

BACKGROUND: Failure to recover after a medical error is a major contributor to burnout. The degree to which pediatric surgeons experience errors and the barriers and facilitators to successful recovery are largely unknown. METHODS: We conducted a survey of American Pediatric Surgical Association (APSA) members to measure frequency of personal experience with medical errors resulting in significant patient harm, describe coping mechanisms, and explore surgeon satisfaction with institutional support in the wake of an error. RESULTS: We found that 80% of respondents have personally experienced a medical error resulting in significant patient harm or death, and that only about one-quarter were satisfied with the support provided by their institution. Only 11% of surgeons would prefer not to be contacted after an adverse event, and most would want to be contacted by their partners. Barriers to providing and receiving support included lack of knowledge, "shame and blame" culture, and lack of trust in the institution as an ally. CONCLUSIONS: Pediatric surgeons routinely experience intense and stressful clinical scenarios and face challenging paths to recovery after adverse events. Institutions and national societies can play a critical role in creating infrastructure to help surgeons recover, in order to prevent burnout and promote well-being.

Health mindsets as a predictor of physical activity and body mass index in American Indian college students.

American Indians are at increased risk for cardiovascular disease in adulthood, and levels of physical activity and body mass index associate with cardiovascular disease risk. Recent research indicates that one's mindset may play a role in determining health behaviors and outcomes. In a sample of 105 American Indian college students, greater growth health mindset associated with lower body mass index. Bootstrapping analyses revealed a significant indirect effect of health mindset on body mass index through levels of physical activity. These findings suggest that interventions aiming to promote growth health mindsets may be successful in reducing risk for cardiovascular disease in American Indian college students.

The relationship between health mindsets and health protective behaviors: An exploratory investigation in a convenience sample of American Indian adults during the COVID-19 pandemic.

The Novel-coronavirus disease-2019 (COVID-2019) outbreak was declared a national emergency on March 13, 2020. To reduce the spread of the virus, Americans were asked to physically distance and to increase disinfecting behaviors such as hand washing. Previous research indicates that one's mindset about health, or the degree to which they view health as fixed or modifiable, influences health behaviors. Current data indicates that American Indians (AIs) are at greater risk for COVID-19. As such, it is important to understand whether mindsets about health may affect behaviors which could prevent spread of the virus in AIs. In this exploratory investigation, a convenience sample of two hundred AI adults completed a questionnaire one month prior to the declaration of the COVID-19 pandemic as a national emergency. They provided demographic information and completed a measure of health mindsets. The second wave of data was collected approximately one month later, where we collected a measure of physical distancing behavior and a measure of disinfecting behaviors. In AI adults, health mindset predicted frequency of physical distancing behaviors and disinfecting behaviors, with individuals who viewed health as less fixed engaging in more physical distancing and disinfecting behaviors, while individuals who viewed health as more fixed reported less physical distancing and less disinfecting behaviors. In AIs, growth health mindsets predicted physical distancing and disinfecting behaviors, both of which are important in reducing the spread of COVID-19. Interventions which are designed to promote growth mindsets of health may promote health-protective behaviors in the context of the COVID-19 pandemic.

Fluoroscopic-assisted laparoscopic retrieval of retained glucose sensor wire from the omentum.

We describe a case in which retained wires from a continuous glucose monitor were removed from the abdominal wall and peritoneum of a 6-year-old boy. We highlight a concern for continuous glucose monitor use in children and discuss surgical techniques used to retrieve tiny, mobile objects from complex body cavities.

Social Belonging as a Predictor of Surgical Resident Well-being and Attrition.

OBJECTIVE: In light of the predicted shortage of surgeons, attrition from surgical residency is a significant problem. Prior data have shown that those who are happier are more productive, and those who are less well have higher rates of absenteeism. This study sought to identify the role of social belonging and its relationship to well-being and risk of attrition. DESIGN: Surgical residents were invited to participate in an online survey containing measures of social belonging (a 10-item scale adapted from previous studies), well-being (the Dupuy Psychological General Well-Being Scale, Beck Depression Inventory Short Form, and Maslach Burnout Inventory), and risk of attrition (indicated by frequency of thoughts of leaving the program). SETTING: We surveyed residents at 2 tertiary care centers, Stanford Health Care (2010, 2011, and 2015) and Washington University in St. Louis (2017). PARTICIPANTS: Categorical general surgery residents, designated preliminary residents going into 7 surgical subspecialties, and nondesignated preliminary residents were included. RESULTS: One hundred sixty-nine residents responded to the survey for a response rate of 66%. Belonging was positively correlated with general psychological well-being (r = 0.56, p < 0.0001) and negatively correlated with depression (r = -0.57, p < 0.0001), emotional exhaustion (r = -0.58, p < 0.0001), and depersonalization (r = -0.36, p < 0.0001). Further, belonging was negatively correlated with frequency of thoughts of leaving residency (r = -0.45, p < 0.0001). In regression analysis controlling for demographic variables, belonging was a significant positive predictor of psychological well-being (B = 0.95, t = 8.18, p < 0.0001) and a significant negative predictor of thoughts of leaving (B = -1.04, t = -5.44, p < 0.0001). CONCLUSIONS: Social belonging has a significant positive correlation with well-being and negative correlation with thoughts of leaving surgical training. Lack of social belonging appears to be a significant predictor of risk of attrition in surgical residency. Efforts to enhance social belonging may protect against resident attrition.

Do health beliefs affect pain perception after pectus excavatum repair?

PURPOSE: The pain experience is highly variable among patients. Psychological mindsets, in which individuals view a particular characteristic as either fixed or changeable, have been demonstrated to influence people's actions and perceptions in a variety of settings including school, sports, and interpersonal. The purpose of this study was to determine if health mindsets influence the pain scores and immediate outcomes of post-operative surgical patients. METHODS: As part of a multi-institutional, prospective, randomized clinical trial involving patients undergoing a minimally invasive pectus excavatum repair of pectus excavatum, patients were surveyed to determine whether they had a fixed or growth health mindset. Their post-operative pain was followed prospectively and scored on a Visual Analog Scale and outcomes were measured according to time to oral pain medication use. RESULTS: Fifty patients completed the Health Beliefs survey, 17 had a fixed mindset (8 epidural, 9 PCA) and 33 had a growth mindset (17 epidural, 16 PCA). Patients with a growth mindset had lower post-operative pain scores than patients with a fixed mindset although pain medication use was not different. CONCLUSION: This is the first usage of health mindsets as a means to characterize the perception of pain in the post-operative period. Mindset appears to make a difference in how patients perceive and report their pain. Interventions to improve a patient's mindset could be effective in the future to improve pain control and patient satisfaction.

2016 CAPS ethics session/Ein debate: 1. Regionalization of pediatric surgical care 2. Ethical introduction of surgical innovation 3. Addressing stress in a surgical practice: resiliency, well-being, and burnout.

The following is the conference proceeding of the Second Ein Debate from the 48th Annual Meeting of the Canadian Association of Paediatric Surgeons held in Vancouver, BC, from September 22 to 24, 2016. The three main topics for debate, as prepared by the members of the CAPS Ethics Committee, are: 1. Regionalization of care: pros and cons, 2. Innovation in clinical care: ethical considerations, and 3. Surgeon well-being: caring for the caregiver. The authors of this paper, as participants in the debate, were assigned their positions at random. Therefore, the opinions they express within this summary might not reflect their own viewpoints. In the first discussion, arguments for and against the regionalization of pediatric surgical care are discussed, primarily in the context of a case of BA. In the pro argument, the evidence and lessons learned from different European countries are explored as well as different models to provide the best BA care outside of large teaching centers. In the counterargument, the author explains how regionalization of care could be detrimental for the patient, the family, the regional center, and for the health care system in general. In the debate on surgical innovation the authors define surgical innovation. They review the pertinent ethical principles, explore a model for its implementation, and the role of the institution at which the innovation is proposed. In the third section, surgeon well-being is examined, and recent literature on surgeon resiliency and burnout both at the attending and resident level is reviewed.

Regional block via continuous caudal infusion as sole anesthetic for inguinal hernia repair in conscious neonates.

PURPOSE: The use of general anesthesia in young children has come under increasing scrutiny due to its potential long-term neurotoxic effects. Meanwhile, regional anesthesia for surgical procedures in neonates has many advantages, including preservation of respiratory status and faster return to feeding. We describe the successful use of 3% 2-chloroprocaine administered via continuous caudal infusion as the sole anesthetic agent during elective surgical procedures in infants. METHODS: A retrospective chart review of all patients who underwent elective surgical procedures under continuous caudal regional anesthetic at a single institution was performed. Thirty patients (27 males, three females) were identified: 28 patients underwent inguinal hernia repairs. Caudal anesthesia was established via continuous infusion of 3% 2-chloroprocaine through an indwelling catheter. RESULTS: Successful analgesia by regional block alone was achieved in all patients for the duration of each surgical procedure without need for rescue anesthesia. Mean operative time was 49 min. Patients were able to return to feeding immediately after surgery and were ready for discharge home within that day. CONCLUSION: Continuous caudal infusion of chloroprocaine is a safe and effective way to maintain adequate analgesia for elective surgeries in infants. This successful regional approach obviates the use of general anesthetic which reduces post-operative recovery time and avoids concerns for neurotoxicity.

Prevalence and predictors of depression among general surgery residents.

BACKGROUND: Recent resident suicides have highlighted the need to address depression among medical trainees. This study sought to identify the prevalence and predictors of depression among surgical residents. METHODS: Surgical residents at a single institution were surveyed. Depression and personal traits were assessed using validated measures; participant demographics were also obtained. RESULTS: 73 residents completed the survey (response rate 63%). 36% met criteria for at least mild depression, of which 20% met criteria for moderate to severe depression. In multivariate linear regression analyses controlling for demographic factors, trait emotional intelligence alone was a significant inverse predictor of depression (ß = -0.60, p < 0.001). CONCLUSIONS: Depression is prevalent among general surgery residents. Identifying protective factors and at-risk populations may allow for effective initiatives to be developed to address depression, and optimize the mental health of trainees.

A Values Affirmation Intervention to Improve Female Residents' Surgical Performance.

BACKGROUND: Female residents in surgical training may face stereotype threat. The awareness of negative stereotypes about surgical ability based on gender may heighten stress and thus reduce performance. OBJECTIVE: The main objective of this study was to assess the effectiveness of a brief stress-reducing writing exercise, known as a values affirmation, to mitigate the negative effects of stereotype threat on the performance of female surgical residents. METHODS: This is a randomized, controlled trial in which 167 residents were invited to participate. A total of 45 resident volunteers, including 18 women, were randomized to the affirmation condition or the no-affirmation condition. We administered a values affirmation intervention and measured clinical evaluations data both prior to and 6 months after the intervention. RESULTS: Women benefited from the affirmation. Women who had participated in the affirmation exercise earned higher clinical evaluation scores than those in the control condition (B = 0.34, P < .05). For men, performance did not differ by affirmation condition (B = -0.20, P = .35). CONCLUSIONS: Our findings suggest a benefit of values affirmation for women in surgical training, as measured by performance on clinical evaluations. This suggests that a brief psychological intervention may improve on-the-job performance for women in surgery, an underrepresented group.

Gender disparities in scholarly productivity of US academic surgeons.

BACKGROUND: Female surgeons have faced significant challenges to promotion over the past decades, with attrition rates supporting a lack of improvement in women's position in academia. We examine gender disparities in research productivity, as measured by the number of citations, publications, and h-indices, across six decades. MATERIALS AND METHODS: The online profiles of full-time faculty members of surgery departments of three academic centers were reviewed. Faculty members were grouped into six cohorts by decade, based on year of graduation from medical school. Differences between men and women across cohorts as well as by academic rank were examined. RESULTS: The profiles of 978 surgeons (234 women and 744 men) were reviewed. The number of female faculty members in the institutions increased significantly over time, reaching the current percentage of 35.3%. Significant differences in number of articles published were noted at the assistant and full but not at the associate, professor level. Women at these ranks had fewer publications than men. Gender differences were also found in all age cohorts except among the most recent who graduated in the 2000s. The impact of publications, as measured by h-index and number of citations, was not consistently significantly different between the genders at any age or rank. CONCLUSIONS: We identified a consistent gender disparity in the number of publications for female faculty members across a 60-year span. Although the youngest cohort, those who graduated in the 2000s, appeared to avoid the gender divide, our data indicate that overall women still struggle with productivity in the academic arena.