Actions speak louder than words; pediatricians, gynecologists, nurses, and other mothers' perspectives on the human papillomavirus vaccine: an Istanbul multicenter study.

Introduction: Gynecologists and pediatricians have an essential duty to prevent cervical cancer. In this study, we compared the compliance of gynecologists (n = 22) and pediatricians (n = 49) with nurse/midwife (n = 66) and non-medical moms (n = 120) with regards to cervical cancer precautions. Methods: A questionnaire was used to gather data on their demographics, personal vaccination and screening practices, children's immunization status, and awareness of cervical cancer prevention. Results: The findings demonstrated that gynecologists and pediatricians were better than others at understanding the risk factors and prevention of cervical cancer. It was noted that compared to other groups, physician mothers and their offspring had higher vaccination rates (n = 13, 18.3%; n = 10, 29.4%, respectively). Medical professionals typically provided thorough and accurate answers to informational questions. More frequent Pap smear tests were performed by gynecologists. It was noted that mothers who worked as pediatricians and nurses/midwives neglected their own screening needs. Discussion: This questionnaire survey sought to ascertain Istanbul's health professionals' present opinions regarding HPV vaccination. Healthcare professionals should be the first to receive information on HPV vaccination and cervical cancer incidence reduction. The public could then readily use them as an example.

Chinese and Belgian pediatricians' perspectives toward pediatric palliative care: an online survey.

BACKGROUND: As pediatricians play a vital role in pediatric palliative care (PPC), understanding their perspectives toward PPC is important. PPC is established for a long time in Belgium, but has a shorter tradition in China, although it is growing in the last decade. Sampling and comparing the perspectives of these pediatricians could be insightful for both countries. Therefore, we sampled and compared perspectives of pediatricians in China and Belgium toward PPC, and explored factors influencing their perspectives. METHODS: We conducted a cross-sectional online survey using the validated Pediatric Palliative Care Attitude Scale (PPCAS). Over a five-month period, we recruited pediatricians practicing in China (C) and Flanders (F), Belgium. Convenience sampling and snowballing were used. We analyzed data with descriptive statistics, and evaluated group differences with univariate, multivariate and correlation tests. RESULTS: 440 complete surveys were analyzed (F: 115; C: 325). Pediatricians in both regions had limited PPC experience (F: 2.92 ± 0.94; C: 2.76 ± 0.92). Compared to Flemish pediatricians, Chinese pediatricians perceived receiving less unit support (F: 3.42 ± 0.86; C: 2.80 ± 0.89); perceived PPC less important (F: 4.70 ± 0.79; C: 4.18 ± 0.94); and faced more personal obstacles while practicing PPC (F: 3.50 ± 0.76; C: 2.25 ± 0.58). Also, select socio-demographic characteristics (e.g., experiences caring for children with life-threatening condition and providing PPC) influenced pediatricians' perspectives. Correlational analyses revealed that pediatricians' PPC experiences significantly correlated with perceived unit support (ρF = 0.454; ρC=0.661). CONCLUSIONS: Chinese pediatricians faced more barriers in practicing PPC. Expanding PPC experiences can influence pediatricians' perspectives positively, which may be beneficial for the child and their family.

Making it "EASI" for pediatricians to determine when toddler tantrums are "more than the terrible twos": Proof-of-concept for primary care screening with the Multidimensional Assessment Profiles-Early Assessment Screener for Irritability (MAPS-EASI).

BACKGROUND: Up to 20% of youth have impairing mental health problems as early as age 3. Early identification and intervention of mental health risks in pediatric primary care could mitigate this crisis via prevention prior to disease onset. The purpose of this study was to establish the feasibility and acceptability of implementing a brief transdiagnostic screening instrument in pediatric primary care for irritability and corollary impairment. METHOD: Five pediatric clinicians in a Midwest clinic implemented the Multidimensional Assessment Profiles-Early Assessment Screener of Irritability (MAPS-EASI) for toddlers (24-30 months) and their families. MAPS-EASI (psychometrically derived from the well-validated MAPS-Scales) includes six items (scored 0-5) about symptoms (e.g., tantrums, grumpy mood), context, and frequency and two items (scored 0-3) assessed impairment. Positive screens (MAPS-EASI ≥ 5 plus impairment ≥ 2) were referred to an evidence-based parenting intervention. We assessed reach and outcomes of MAPS-EASI screening. Follow-up interviews with clinicians assessed perspectives on irritability screening and MAPS-EASI implementation. RESULTS: Of 201 eligible families, 100 (49.8%) completed the screener for a 24- or 30-month well-child visit. Mean MAPS-EASI scores were 5.8 (SD = 3.2), mean impairment scores were 0.9 (SD = 0.9), and 24 (24.0%) screened positive. Clinicians indicated that irritability screening for toddlers was aligned with their prevention-oriented, developmentally based practice. MAPS-EASI had face validity and increased clinician decision-making confidence. Finally, clinicians identified barriers and facilitators to large-scale implementation. CONCLUSIONS: MAPS-EASI proved to be feasible and acceptable in pediatric primary care. Further tailoring will be needed as the MAPS-EASI processes are scaled out to new contexts and populations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

[Differences in Billing Patterns Between GPs and Pediatricians Using Early Diagnostics in Children and Adolescents as an Example: Analysis of Nationwide Data from Statutory Health Insurance Physicians]. / Kompensation von Leistungen zwischen Hausärzten und Kinder- und Jugendmedizinern am Beispiel der Früherkennungsuntersuchungen bei Kindern und Jugendlichen ­ Analyse von bundesweiten KBV-Daten.

BACKGROUND: Despite a 13.1% increase in the number of pediatricians between 2011 - 2020, the capacity of pediatric care has largely stagnated. This is due to increasing flexibility in working hours and a declining willingness of doctors to establish practices. In addition, there is an imbalance in the distribution of pediatric medical care capacities. While metropolitan areas are often characterized by oversupply, there is an increasing shortage of pediatricians, especially in rural areas. As a result, general practitioners in rural areas are increasingly taking over part of pediatric care. We quantify this compensation effect using the example of examinations of general health and normal child development (U1-U9). METHODS: Basis of the analysis was the Doctors' Fee Scale within the Statutory Health Insurance Scheme (Einheitlicher Bewertungsmaßstab, EBM) from 2015 (4th quarter). Nationwide data from the National Association of Statutory Health Insurance Physicians (KBV) for general practitioners and pediatricians from 2015 was evaluated. In the first step, the EBM was used to determine the potential overlap of services between the two groups of doctors. The actual compensation between the groups was quantified using general health and normal child development as an example. RESULTS: In section 1.7.1 (early detection of diseases in children) of the EBM, there is a list of 16 options for services that can be billed (fee schedule positions, GOP) by general practitioners and pediatricians. This particularly includes child examinations U1 to U9. The analysis of the national data of the KBV for the early detection of diseases in children showed significant differences between rural and urban regions in the billing procedure. Nationwide, general practitioners billed 6.6% of the services in the area of early detection of diseases in children in 2015. In rural regions this share was 23% compared to 3.6% in urban regions. The analysis of the nationwide data showed that the proportion of services billed by general practitioners was higher in rural regions than in urban regions. CONCLUSION: The EBM allows billing of services by both general practitioners and pediatricians, especially in the area of general GOP across all medical groups. The national billing data of the KBV shows that general practitioners in rural regions bill more services from the corresponding sections than in urban regions.

Covid-19 en trabajadores de la Salud: Experiencia en la Residencia de Pediatría de un hospital de La Plata, Argentina / Covid-19 in health workers: Experience in the Pediatric Residence of a hospital in La Plata, Argentina

Introducción: Los trabajadores de la salud (TS) poseen la mayor exposición laboral al contagio SARS-CoV-2. Los residentes forman parte fundamental de los servicios de salud por lo que no se encuentran exentos del impacto físico, psíquico, social y económico negativo producido por la pandemia por COVID-19. Objetivo: : Describir el impacto epidemiológico de la enfermedad profesional por COVID-19 en médicos residentes de pediatría. Material y métodos: Estudio descriptivo de corte transversal en médicos residentes de pediatría del H.I.A.E.P "Sor María Ludovica". El período comprendido en el estudio fue del 01/10/2020 al 30/09/2021. Se evaluaron los siguientes datos: género, edad, antecedentes personales, vacunación, cuadro clínico, métodos diagnósticos, aislamientos epidemiológicos, evolución y licencias tramitadas. Los datos fueron registrados por la jefatura de residentes. Resultados: 143 casos sospechosos de COVID-19, de ellos 30 resultaron confirmados de COVID-19. La edad media de los enfermos fue de 31 años (26-46 años) de los cuales 14 (47%) no estaban vacunados contra SARS COV-2, 11 (36%) estaban completamente inmunizados y 5 (17%) tenían calendario incompleto. 2 casos (6,6%) reportaron comorbilidad previa. Se realizaron pruebas de laboratorio en 130 de los 143 casos. 13 casos se descartaron por criterio clínico. La tasa de positividad fue 23,1%. 26 casos fueron confirmados por laboratorio y 4 casos mediante criterio clínico epidemiológico. Todos los casos fueron leves y evolucionaron favorablemente. Fueron gestionadas 326 licencias relacionadas a la pandemia por COVID-19 que significaron la pérdida de 2.830 días laborales. Conclusión: En el presente estudio se evidenció una alta tasa de incidencia de COVID-19 en residentes de pediatría en un año: 23,1%

Introduction: Health workers (HCWs) have the highest occupational exposure to SARS-CoV-2 contagion. Residents are a fundamental part of health services, so they are not exempt from the negative physical, psychological, social and economic impact caused by the COVID-19 pandemic. Objectives: To describe the epidemiological impact of the occupational disease by COVID-19 in resident pediatricians. Material and methods: Descriptive cross-sectional study in pediatric residents of the H.I.A.E.P "Sor María Ludovica". The period covered by the study was from 10/01/2020 to 09/30/2021. The following data were evaluated: gender, age, personal history, vaccination, clinical picture, diagnostic methods, epidemiological isolates, evolution and licenses processed. The data was recorded by the head of residents. Results: 143 suspected cases of COVID-19, of which 30 were confirmed to be COVID-19. The mean age of the patients was 31 years (26-46 years), of which 14 (47%) were not vaccinated against SARS COV.-2, 11 (36%) were fully immunized and 5 (17%) had an incomplete schedule. 2 cases (6.6%) reported previous comorbidity. Laboratory tests were performed in 130 of the 143 cases. 13 cases were ruled out based on clinical criteria. The positivity rate was 23.1%. 26 cases were confirmed by laboratory and 4 cases by clinical epidemiological criteria. All cases were mild and evolved favorably. 326 licenses related to the COVID-19 pandemic were managed, which meant the loss of 2,830 working days. Conclusion: In the present study, a high rate of incidence of COVID-19 was evidenced in pediatric residents in one year: 23.1%

Provider and Practice Characteristics and Perceived Barriers Associated With Different Levels of Adolescent SBIRT Implementation Among a National Sample of US Pediatricians.

Pediatrician Screening, Brief Intervention, and Referral to Treatment (SBIRT) practices vary widely, though little is known about the correlates of SBIRT implementation. Using data from a national sample of US pediatricians who treat adolescents (n = 250), we characterized self-reported utilization rates of SBIRT among US pediatricians and identified provider- and practice-level characteristics and barriers associated with SBIRT utilization. All participants completed an electronic survey querying the demographics, practice patterns, and perceived barriers related to SBIRT practices. Our results showed that 88% of respondents reported screening for substance use annually, but only 26% used structured/validated screening instruments. Furthermore, 40% of respondents provided evidence-based brief interventions, and only 11% implemented all core SBIRT practices. Common barriers (eg, confidentiality and insufficient time) and unique provider- and setting-specific barriers to implementation were identified. These findings indicate that although most pediatricians deliver some SBIRT components in their practice, few implement the full SBIRT model, and barriers persist.

Use of rituximab in paediatric nephrology.

Rituximab is a chimeric monoclonal antibody capable of depleting B cell populations by targeting the CD20 antigen expressed on the cell surface. Its use in oncology, initially in B cell lymphoma and post-transplant lymphoproliferative disorders, predates its current utility in various fields of medicine wherein it has become one of the safest and most effective antibody-based therapies. It was subsequently found to be effective for rheumatological conditions such as rheumatoid arthritis and antineutrophil cytoplasmic antibody-associated vasculitis. Over the past decade, rituximab has generated a lot of interest in nephrology and has become an emerging or accepted therapy for multiple renal conditions, including systemic lupus erythematosus, lupus nephritis, vasculitis, nephrotic syndrome and in different scenarios before and after kidney transplantation. This review outlines its current use in paediatric nephrology practice, focusing on the knowledge required for general paediatricians who may be caring for children prescribed this medication and reviewing them on a shared care basis.

Effect of Training Pediatric Clinicians in Human Papillomavirus Communication Strategies on Human Papillomavirus Vaccination Rates: A Cluster Randomized Clinical Trial.

Importance: Missed opportunities for human papillomavirus (HPV) vaccination during pediatric health care visits are common. Objectives: To evaluate the effect of online communication training for clinicians on missed opportunities for HPV vaccination rates overall and at well-child care (WCC) visits and visits for acute or chronic illness (hereafter referred to as acute or chronic visits) and on adolescent HPV vaccination rates. Design, Setting, and Participants: From December 26, 2018, to July 30, 2019, a longitudinal cluster randomized clinical trial allocated practices to communication training vs standard of care in staggered 6-month periods. A total of 48 primary care pediatric practices in 19 states were recruited from the American Academy of Pediatrics Pediatric Research in Office Settings network. Participants were clinicians in intervention practices. Outcomes were evaluated for all 11- to 17-year-old adolescents attending 24 intervention practices (188 clinicians) and 24 control practices (177 clinicians). Analyses were as randomized and performed on an intent-to-treat basis, accounting for clustering by practice. Interventions: Three sequential online educational modules were developed to help participating clinicians communicate with parents about the HPV vaccine. Weekly text messages were sent to participating clinicians to reinforce learning. Statisticians were blinded to group assignment. Main Outcomes and Measures: Main outcomes were missed opportunities for HPV vaccination overall and for HPV vaccine initiation and subsequent doses at WCC and acute or chronic visits (visit-level outcome). Secondary outcomes were HPV vaccination rates (person-level outcome). Outcomes were compared during the intervention vs baseline. Results: Altogether, 122 of 188 clinicians in intervention practices participated; of these, 120, 119, and 116 clinicians completed training modules 1, 2, and 3, respectively. During the intervention period, 29 206 adolescents (14 664 girls [50.2%]; mean [SD] age, 14.2 [2.0] years) made 15 888 WCC and 28 123 acute or chronic visits to intervention practices; 33 914 adolescents (17 069 girls [50.3%]; mean [SD] age, 14.2 [2.0] years) made 17 910 WCC and 35 281 acute or chronic visits to control practices. Intervention practices reduced missed opportunities overall by 2.4 percentage points (-2.4%; 95% CI, -3.5% to -1.2%) more than controls. Intervention practices reduced missed opportunities for vaccine initiation during WCC visits by 6.8 percentage points (-6.8%; 95% CI, -9.7% to -3.9%) more than controls. The intervention had no effect on missed opportunities for subsequent doses of the HPV vaccine or at acute or chronic visits. Adolescents in intervention practices had a 3.4-percentage point (95% CI, 0.6%-6.2%) greater improvement in HPV vaccine initiation compared with adolescents in control practices. Conclusions and Relevance: This scalable, online communication training increased HPV vaccination, particularly HPV vaccine initiation at WCC visits. Results support dissemination of this intervention. Trial Registration: ClinicalTrials.gov Identifier: NCT03599557.

CME suggestions for pediatricians, allergists, and dermatologists, directed by an online survey on urticaria knowledge.

BACKGROUND: The Mexican Guidelines for the diagnosis and treatment of urticaria have been published. Just before their launch, physicians' knowledge was explored relating to key issues of the guidelines. OBJECTIVE: The aim of this study was to investigate the opinion of medical specialists concerning urticaria management. METHODS: A SurveyMonkey® survey was sent out to board-certified physicians of three medical specialties treating urticaria. Replies were analyzed per specialty against the evidence-based recommendations. RESULTS: Sixty-five allergists (ALLERG), 24 dermatologists (DERM), and 120 pediatricians (PED) sent their replies. As for diagnosis: ALERG 42% and PED 76% believe cutaneous mastocytosis, urticarial vasculitis, and hereditary angioedema are forms of urticaria, versus DERM 29% (P < 0.005). Most of the specialties find that the clinical history and physical examination are enough to diagnose acute urticaria, except DERM 45% (P < 0.01). DERM 45% believe laboratory-tests are necessary, as opposed to <15% ALLERG-PED (P < 0.005). However, PED 69% did not know that the most frequent cause of acute urticaria in children is infections, versus ALLERG-DERM 30% (P < 0.005). Many erroneously do laboratory testing in physical urticaria and ALLERG 51%, DERM 59%, and PED 37% do extensive laboratory testing in chronic spontaneous urticaria (CSU); many more PED 59% take Immunoglobulin G (IgG) against foods (P < 0.005). More than half of non-allergists do not know about autologous serum testing nor autoimmunity (P < 0.05). As for treatment, there were a few major gaps: when CSU was controlled, >75% prescribed antihistamines pro re nata, and >85% gave first-generation antiH1 for insomnia. Finally, >40% of DERM did not know that cyclosporine A, omalizumab, or other immunosuppressants could be used in recalcitrant cases. CONCLUSION: Specialty-specific continuous medical education might enhance urticaria management.

Variations in the management of adolescent adnexal torsion at a single institution and the creation of a unified care pathway.

PURPOSE: Adnexal torsion is a gynecologic emergency, requiring intervention for tissue preservation. At our institution, torsion is managed by pediatric surgeons or gynecologists. We evaluated differences between specialties to streamline evaluation for children with gynecological emergencies, develop a clinical pathway, and prevent care delays. METHODS: A retrospective review of adolescents undergoing intervention for adnexal torsion from 2004-2018 was performed. Differences in time to intervention, operation duration, the procedure performed, and length of stay (LOS) between the specialties were analyzed. RESULTS: Eighty-six patients underwent 94 operations for presumed adnexal torsion with 87 positive cases. Pediatric surgeons performed 60 operations and 34 cases were performed by gynecologists. Preservation of fertility was the goal in both cohorts and the rate of oophoropexy, cystectomy, and oophorectomy were similar between the cohorts (p = 0.14, p = 1.0, p = 0.39, respectively). There was no difference in intra-operative time (p = 0.69). LOS was shorter in the gynecology cohort (median 1 day [1-2] vs. 2 days [2-3], p > 0.001). CONCLUSIONS: Adnexal torsion is a time-sensitive diagnosis requiring prompt intervention for ovarian or fallopian tube preservation. A multidisciplinary institutional care pathway should be developed and implemented.

[The physician's suicide: study of an Italian sample]. / Il suicidio del medico: studio di un campione italiano.

OBJECTIVE: The main objective of the present study is to examine a number of suicides among Italian doctors. We further compared data from our sample with those of suicide in the general population and in the literature, in order to detect any differences that can provide preventive recommendations. METHODS: This is a retrospective study of 60 suicides committed by doctors from 2009 to 2019, in Italy. RESULTS: The sample was constituted mainly by men (77%, 46 cases) aged between 50 and 69 years (70%, n=42). Most of the suicides took place in Northern Italy (50%, n=30). Among known medical specialization, 26% (n=14) concerned general practitioners, the remaining 74% (n=39) were specialized doctors, with a prevalence of anesthetists (9%, n=5), haematologists (8 %, n=4), pediatricians (6%, n=3), psychiatrists (6%, n=3) and oncologists (6%, n=3). Regarding the suicide method, the most used was precipitation (30%, n=16), followed by poisoning/overdose (24%, n=13), firearm (19%, n=10), suffocation/hanging (19%, n=10) and self-induced injuries (8%, n=4)). The most frequent place of suicide is in 35 cases was at home (59%), followed by the hospital (18%; n=11), or others (23%; n=14). When possible, any reported risk factors and predisposing conditions for suicide were studied, and divided into five categories: depression/psychiatric pathology (28%, n=16); other organic disease (8%, n=5); work-related problems (stress, burn-out, mobbing, work-related judicial problems) (20%, n=12); judicial problems unrelated to the medical profession (8%, n=5); family and relationship problems (12%, n=7). CONCLUSIONS: The risk factors for suicide in our sample of doctors overlap with data from literature for doctors in western countries. Clinical recommendations and prevention strategies for suicide risk are therefore similar.

Differences in perspectives of pediatricians on advance care planning: a cross-sectional survey.

BACKGROUND: The increase in the number of pediatric patients with complex health conditions necessitates the application of advance care planning for children. Earlier, withdrawal of life-sustaining treatment was taboo in the medical society in South Korea due to the history of such practice being punishable by law, and physicians tended to pursue aggressive treatment. With changes in public opinion on end-of-life care, the Korean government enacted a new law that protect human dignity by respecting patients' self-determination and facilitating advance care planning. However, little is known about current state of advance care planning for pediatric patients. The study aimed to assess perceptions regarding advance care planning among South Korean pediatricians and clarify any differences in perception among pediatric subspecialties. METHODS: This study was an observational cross-sectional survey that used a web-based self-report questionnaire. Participants comprised of pediatricians currently caring for children with life-limiting conditions in 2018. RESULTS: Of the 96 respondents, 89 were included in the analysis. In a hypothetical patient scenario, more hemato-oncologists and intensivists than neonatologists and neurologists preferred to provide comfort care than aggressive treatment. While 72.2% of hemato-oncologists reported that they usually or always discuss advance care plans with parents during treatment, more than half of other pediatricians reported that they seldom do so. Furthermore, 65% of respondents said that they never discuss advance care planning with adolescent patients. Moreover, there were no notable differences among subspecialties. The most prevalent answers to factors impeding advance care planning were lack of systemic support after performing advance care planning (82.0%) and uncertain legal responsibilities (70.8%). CONCLUSIONS: The pediatricians differed in their experiences and attitudes toward advance care planning based on their subspecialty. Consequently, institutional support and education should be provided to physicians so that they can include children and families in discussions on prognosis.

Conocimiento sobre cuidados paliativos pediátricos de los pediatras de atención primaria del Principado de Asturias, España / Knowledge of primary care pediatricians about pediatric palliative care in the Principality of Asturias, Spain

Resumen Introducción: Es importante conocer y evaluar la experiencia y el conocimiento de los pediatras de atención primaria del Principado de Asturias (España) sobre los cuidados paliativos pediátricos. Métodos: Se llevó a cabo un estudio descriptivo y transversal mediante un cuestionario dirigido a los pediatras de atención primaria del Principado de Asturias entre mayo y junio de 2018. Resultados: El 77% de los participantes no poseía formación previa y el 100% consideró que sus conocimientos en cuanto al tema no eran adecuados, a pesar de que el 37% había atendido en alguna ocasión a pacientes subsidiarios de este tipo de cuidados. Casi la totalidad de los encuestados (97%) consideraron necesaria la creación de una unidad de cuidados paliativos pediátricos. Conclusiones: El conocimiento del pediatra de atención primaria del Principado de Asturias con respecto a los cuidados paliativos pediátricos es muy escaso en una región en la que no se dispone de una unidad pediátrica exclusiva. Sería interesante aprovechar la gran disposición de este grupo de profesionales para mejorar su formación, además de incorporar la materia en facultades y en la formación del médico interno residente.

Abstract Background: To know and assess the experience and knowledge among primary care pediatricians about pediatric palliative care in the Principality of Asturias (Spain). Methods: A descriptive and cross-sectional analysis was conducted using a survey among primary care pediatricians in the Principality of Asturias between May and June 2018. Results: The majority of participants (77%) did not receive previous training, and 100% considered that their knowledge on the subject was insufficient, although 37% had occasionally attended to palliative care patients. Almost all participants (97%) considered that a pediatric palliative care unit is necessary. Conclusions: The knowledge of primary care pediatricians about pediatric palliative care is deficient in the Principality of Asturias, a region where no exclusive pediatric unit exists. It would be interesting to seize the opportunity to improve the training of these pediatricians, given their great willingness, and to incorporating the subject into colleges and medical intern formation as well.

Knowledge of primary care pediatricians about pediatric palliative care in the Principality of Asturias, Spain.

Background: To know and assess the experience and knowledge among primary care pediatricians about pediatric palliative care in the Principality of Asturias (Spain). Methods: A descriptive and cross-sectional analysis was conducted using a survey among primary care pediatricians in the Principality of Asturias between May and June 2018. Results: The majority of participants (77%) did not receive previous training, and 100% considered that their knowledge on the subject was insufficient, although 37% had occasionally attended to palliative care patients. Almost all participants (97%) considered that a pediatric palliative care unit is necessary. Conclusions: The knowledge of primary care pediatricians about pediatric palliative care is deficient in the Principality of Asturias, a region where no exclusive pediatric unit exists. It would be interesting to seize the opportunity to improve the training of these pediatricians, given their great willingness, and to incorporating the subject into colleges and medical intern formation as well.

Introducción: Es importante conocer y evaluar la experiencia y el conocimiento de los pediatras de atención primaria del Principado de Asturias (España) sobre los cuidados paliativos pediátricos. Métodos: Se llevó a cabo un estudio descriptivo y transversal mediante un cuestionario dirigido a los pediatras de atención primaria del Principado de Asturias entre mayo y junio de 2018. Resultados: El 77% de los participantes no poseía formación previa y el 100% consideró que sus conocimientos en cuanto al tema no eran adecuados, a pesar de que el 37% había atendido en alguna ocasión a pacientes subsidiarios de este tipo de cuidados. Casi la totalidad de los encuestados (97%) consideraron necesaria la creación de una unidad de cuidados paliativos pediátricos. Conclusiones: El conocimiento del pediatra de atención primaria del Principado de Asturias con respecto a los cuidados paliativos pediátricos es muy escaso en una región en la que no se dispone de una unidad pediátrica exclusiva. Sería interesante aprovechar la gran disposición de este grupo de profesionales para mejorar su formación, además de incorporar la materia en facultades y en la formación del médico interno residente.

Significant practice variability exists in the prevention of venous thromboembolism in injured children: results from a joint survey of the Pediatric Trauma Society and the Trauma Center Association of America.

BACKGROUND/PURPOSE: The purpose of this study was to characterize current practices to prevent venous thromboembolism (VTE) in children and measure adherence to recent joint consensus guidelines from the Pediatric Trauma Society and Eastern Association for the Surgery of Trauma (PTS/EAST). METHODS: An 18-question survey was sent to the membership of PTS and the Trauma Center Association of American. Responses were compared with Chi-square test. RESULTS: One hundred twenty-nine members completed the survey. Most respondents were from academic (84.5%), Level 1 pediatric (62.0%) trauma centers. Criteria for VTE prophylaxis varied between hospitals with freestanding pediatric trauma centers significantly more likely to stratify children by risk factors than adult trauma centers (p = 0.020). While awareness of PTS/EAST guidelines (58.7% overall) was not statistically different between hospital types (44% freestanding adult, 52% freestanding pediatric, 71% combined adult pediatric, p = 0.131), self-reported adherence to these guidelines was uniformly low at 37.2% for all respondents. Lastly, in three clinical scenarios, respondents chose VTE screening and prophylaxis plans in accordance with a prospective application of PTS/EAST guidelines 55.0% correctly. CONCLUSION: Currently no consensus regarding the prevention of VTE in pediatric trauma exists. Prospective application of PTS/EAST guidelines has been limited, likely due to poor quality of evidence and a reliance on post-injury metrics. Results of this survey suggest that further investigation is needed to more clearly define the risk of VTE in children, evaluate, and prospectively validate alternative scoring systems for VTE prevention in injured children. LEVEL OF EVIDENCE: N/A-Survey.

Practice Patterns and Outcomes of Pediatric Thyroid Surgery: An NSQIP Analysis.

BACKGROUND: Pediatric thyroid cancer rates are rising. The aim of this study was to determine the state of current practice and outcomes for pediatric thyroidectomies using the pediatric National Surgical Quality Improvement Program (NSQIP-P) with specific attention to differences based on surgeon type/specialty. METHODS: All cases of pediatric thyroidectomies and neck dissections within the NSQIP-P database were identified from 2015 to 2017. Patient, disease, and treatment-related factors affecting 30-day outcomes were analyzed using univariate and multivariate analyses. RESULTS: A total of 1300 cases were identified. Mean age at time of surgery was 14.0 (SD 3.5) years. The majority of patients were female (78%) and Caucasian (72%). Pediatric general surgeons performed the largest proportion of cases (42%) followed by pediatric otolaryngologists (33%). Malignancies were present in 29% of cases. The overall rate of complications was 3.0%. On multivariate analysis, non-pediatric surgeons were more likely to operate on Caucasian children, malignant pathology, and perform modified radical neck dissections. Pediatric surgeons were more likely to have longer operative times, have specialized in otolaryngology, and operate on sicker children (ASA>2). There were no differences in length of stay or overall complications rates. CONCLUSIONS: This study shows that pediatric surgeons currently perform the majority of thyroid surgeries in children. While unable to assess surgeon volume, our data show that thyroid surgery is being safely performed at NSQIP-affiliated hospitals by both non-pediatric and pediatric surgeons. Further studies are needed to determine if there are differences in specific procedure-related complications and long-term outcomes between surgeon types.

Contemporary practice and perceptions surrounding the management of asymptomatic umbilical hernias in children: A survey of the American Pediatric Surgical Association.

PURPOSE: To explore variation in perceptions regarding the natural history of asymptomatic umbilical hernias, and to characterize the influence of clinical and nonclinical factors on decision-making surrounding timing of repair. METHODS: This was a survey of the American Pediatric Surgical Association. Branching logic and Likert scale questions were used to explore perceptions surrounding natural history (risk of complications and likelihood of spontaneous closure), preferred age for repair, and influence of anatomic, caregiver, sociodemographic, and biological factors on operative timing. RESULTS: 44% of members completed the survey (371/846). The most common age respondents would consider elective repair was 3 years (37%), although the majority preferred to wait until 4 or 5 years (54%). Most respondents estimated a <1% risk of complications for unrepaired defects, and much greater variability was found in the perceived likelihood of spontaneous closure over time. Decision-making surrounding operative timing was most influenced by anatomic factors (larger defects, proboscoid changes, and interval growth) and parental anxiety surrounding need for emergency surgery, cosmesis, and stigma of parental neglect. CONCLUSION: Practice and perceptions surrounding management of asymptomatic umbilical hernias vary widely. More robust epidemiological data are needed to define the likelihood of spontaneous closure in the context of age and physical exam findings. Collaborative efforts between surgeons and referring providers are also needed to optimize management of caregiver anxiety and expectations surrounding need for surgical referral and repair. LEVEL OF EVIDENCE: Level V (expert opinion).

Trends in Pediatricians' Developmental Screening: 2002-2016.

BACKGROUND: Current guidelines from the American Academy of Pediatrics recommend screening children for developmental problems by using a standardized screening tool and referring at-risk patients to early intervention (EI) or subspecialists. Adoption of guidelines has been gradual, with research showing many children still not being screened and referred. METHODS: We analyzed American Academy of Pediatrics Periodic Survey data from 2002 (response rate = 58%; N = 562), 2009 (response rate = 57%; N = 532), and 2016 (response rate = 47%, N = 469). Surveys included items on pediatricians' knowledge, attitudes, and practices regarding screening and referring children for developmental problems. We used descriptive statistics and a multivariable logistic regression model to examine trends in screening and referral practices and attitudes. RESULTS: Pediatricians' reported use of developmental screening tools increased from 21% in 2002 to 63% in 2016 (P < .001). In 2016, on average pediatricians reported referring 59% of their at-risk patients to EI, up from 41% in 2002 (P < .001), and pediatricians in 2016 were more likely than in 2002 to report being "very likely" to refer a patient with global developmental delay, milestone loss, language delay, sensory impairment, motor delays, and family concern to EI. CONCLUSIONS: Pediatricians' reported use of a standardized developmental screening tool has tripled from 2002 to 2016, and more pediatricians are self-reporting making referrals for children with concerns in developmental screening. To sustain this progress, additional efforts are needed to enhance referral systems, improve EI programs, and provide better tracking of child outcomes.

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.

Umbilical access in laparoscopic surgery in infants less than 3 months of age: A survey of the American Pediatric Surgical Association.

PURPOSE: Laparoscopy is commonplace in pediatric surgery. Abdominal access via the umbilicus may present a unique challenge in neonates and young infants predisposing them to complications. We hypothesized that these complications may occur more than described in the literature. METHODS: Members of the American Pediatric Surgical Association (APSA) were anonymously surveyed in February of 2018 via REDCap™ regarding technique of umbilical access in infants less than 3 months of age and complications experienced during umbilical access. Approval was obtained from the IRB and the APSA Outcomes and Evidence-based Practice Committee. RESULTS: The response rate was 31.3% (329/1050). 62.3% of respondents performed 21 or greater neonatal laparoscopic procedures annually. 34 of 322 respondents reported a direct complication from umbilical access for laparoscopy in this age group (10.6%). Surgeons described 37 specific cases with complications related to umbilical access, with laparoscopic pyloromyotomy making up 47.2% (17/36). CO2 embolism was the most common complication; 15.4% of surgeons reported not knowing about the possibility of CO2 embolism. 41% of surgeons confirm intraabdominal placement of the umbilical trocar prior to insufflation. There was no association between any complication and where the umbilical trocar was placed (above/below/through umbilicus) or placement technique in patients with no umbilical cord stump. There may be an association between complication and where the umbilicus is entered in patients with an umbilical cord stump still in place (p = 0.013). CONCLUSIONS: Umbilical access for laparoscopy in neonates and infants less than 3 months of age can present a unique challenge and result in significant complications. All techniques and methods had complications. Surgeons should be aware of these risks and be prepared to manage them emergently if they arise. LEVEL OF EVIDENCE: V, expert opinion.