A Randomized Crossover Trial Evaluating the Impact of Cultural Dexterity Training on Surgical Residents' Knowledge, Cross-Cultural Care, Skills, and Beliefs: The Provider Awareness and Cultural Dexterity Training for Surgeons (PACTS) Trial.

OBJECTIVES: This trial examines the impact of the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum on surgical residents' knowledge, cross-cultural care, skills, and beliefs. BACKGROUND: Cross-cultural training of providers may reduce health care outcome disparities, but its effectiveness in surgical trainees is unknown. METHODS: PACTS focuses on developing skills needed for building trust, working with patients with limited English proficiency, optimizing informed consent, and managing pain. The PACTS trial was a randomized crossover trial of 8 academic general surgery programs in the United States: The Early group ("Early") received PACTS between periods 1 and 2, while the Delayed group ("Delayed") received PACTS between periods 2 and 3. Residents were assessed preintervention and postintervention on Knowledge, Cross-Cultural Care, Self-Assessed Skills, and Beliefs. χ 2 and Fisher exact tests were conducted to evaluate within-intervention and between-intervention group differences. RESULTS: Of 406 residents enrolled, 315 were exposed to the complete PACTS curriculum. Early residents' Cross-Cultural Care (79.6%-88.2%, P <0.0001), Self-Assessed Skills (74.5%--85.0%, P <0.0001), and Beliefs (89.6%-92.4%, P =0.0028) improved after PACTS; knowledge scores (71.3%-74.3%, P =0.0661) were unchanged. Delayed resident scores pre-PACTS to post-PACTS showed minimal improvements in all domains. When comparing the 2 groups in period 2, Early residents had modest improvement in all 4 assessment areas, with a statistically significant increase in Beliefs (92.4% vs 89.9%, P =0.0199). CONCLUSIONS: The PACTS curriculum is a comprehensive tool that improved surgical residents' knowledge, preparedness, skills, and beliefs, which will help with caring for diverse patient populations.

Intraventricular Hemorrhage and Patent Ductus Arteriosus Ligation Association with Infant Mortality.

BACKGROUND: Practice patterns for the management of patent ductus arteriosus (PDA) in premature infants are changing with advances in medical management. We sought to determine the increased mortality for premature infants who had a PDA ligation with a co-existing diagnosis of intraventricular hemorrhage (IVH). METHODS: Premature neonates (<1 y old with known gestational week ≤36 wk) with a diagnosis of IVH were identified within the Kids' Inpatient Database (KID) for the years 2006, 2009, and 2012. Diagnoses and procedures were analyzed by ICD-9 codes and stratified by a diagnosis of PDA and procedure of ligation. Case weighting was used to make national estimations. Multivariable logistic regression was performed to adjust for confounders. RESULTS: We identified 7567 hospitalizations for premature neonates undergoing PDA ligation. The population was predominately male (51.6%), non-Hispanic white (41.1%), were from the lowest income quartile (33.1%), had a gestational week of 25-26 wk (34.0%), and a birthweight between 500 and 749 g (37.3%). There was an increased mortality (10.7% versus 6.3%, P < 0.01) and an increased length of stay (88.2 d versus 74.4 d, P < 0.01) in those with any diagnosis of IVH compared with those without. Adjusted multivariable logistic regression demonstrated that high-grade IVH (III or IV) was associated with a significantly increased risk of mortality in those undergoing PDA ligation (aOR 2.59, P < 0.01). Specifically, grade III and IV were associated with an increased odds of in-hospital mortality (aOR 1.99 and 3.16, respectively, P < 0.01). CONCLUSIONS: Attitudes regarding the need for surgical intervention for PDA have shifted in recent years. This study highlights that premature neonates with grade III or IV IVH are at significantly increased risk of mortality if undergoing PDA ligation during the same hospitalization. LEVEL OF EVIDENCE: III.

Young lives cut short: The relationship between firearms and pediatric suicide.

BACKGROUND: To describe the demographic characteristics and burden of pediatric suicides by firearm in the United States using a large all-payer pediatric inpatient care database. METHODS: Children and young adults (<21 years old) were identified with an International Classification of Diseases, Ninth Revision diagnosis of suicide and self-inflicted injury with a firearm (SIF) in the Kids' Inpatient Database for the study years of 2006, 2009, and 2012. National estimates were obtained using case weighting. Multivariable logistic regression was performed to examine the association between SIF and risk factors while adjusting for various sociodemographic characteristics using separate models incorporating mental health diagnoses. RESULTS: There were a total of 613 hospitalizations for SIF during the years under study. Almost four hospitalizations per week occurred, and in-hospital mortality was 39.1%. The mean age of the study population was 17.3 years, and this population was predominantly male (87.5%), white (62.4%), resided in an urban area (43.8%), lived in the south (51.3%), and within the lowest income quartile (33.8%). Mental health (38.3%) and mood disorders (28.3%) were common. Males had a markedly increased likelihood of hospitalization for SIF (adjusted odds ratio [aOR], 7.56; 95% confidence interval [CI], 5.54-10.30). Children and adolescents from rural environments and those in the south were more likely to have a hospitalization for SIF than respective comparison groups. Using separate regression models, a diagnosis of any mental health disorder increased the likelihood of hospitalization for a SIF (aOR, 11.9: 95% CI, 9.51-14.9), mood disorders (aOR, 17.2; 95% CI, 13.3-22.3), and depression (aOR, 21.3; 95% CI, 16.1-28.3). CONCLUSION: Pediatric hospitalizations for SIF are a common occurrence with high associated mortality. The prevalence of mental health disorders and their impact on this population highlight the need for early identification and intervention for individuals at risk. LEVEL OF EVIDENCE: Epidemiological, level III.