Employment search, initial employment experience, and career preferences of recent pediatric surgical fellowship graduates: An APSA survey, part of the right child/right surgeon initiative.

BACKGROUND: APSA's Right Child/Right Surgeon Initiative addresses issues concerning patient access to appropriate pediatric surgical care and workforce distribution. The APSA Workforce Committee sought to understand the experiences and motivations of recent graduates of Pediatric Surgery Training Programs entering the workforce. METHODS: Using APSA membership databases, we identified members who completed fellowship training from 2010 to 2019. An online survey was created using Survey Monkey, and invitations to participate were sent via email. RESULTS: 144 of 447 invited participants responded (32% response rate). 91% of respondents participated in dedicated research prior to fellowship, but only 64% perform research during their employment. 23% completed an additional clinical fellowship, but only 54% currently practice within the second field. When asked to identify the top three factors used to choose a position, the most common responses were "location or geography" (71%), "available mentorship" (53%), and "compensation and benefits" (37%). Describing their first position, 77% reported working in an academic institution, 78% reported working in a metropolitan/urban area, and 55% reported working in a free-standing children's hospital. 94% participate in General Surgery resident education, and 49% are faculty within a Pediatric Surgery fellowship. Overall, 92% of respondents were able to find the type of employment position that they had wanted. CONCLUSION: In our survey the overwhelming majority of young pediatric surgeons found the type of job they desired. Most report beginning their practice in more populated, urban areas within academic institutions. Geographic location and work environment played heavily into their employment decisions. These preferences could contribute to continued disparity in access to pediatric surgeons between urban and rural America and to dilution of experience for urban surgeons. Possible solutions include alternative incentive programs for employment in less populated areas or new training models for general surgeons in rural areas to train in fundamentals of Pediatric Surgery.

Road Traffic Accidents and Disparities in Child Mortality.

BACKGROUND AND OBJECTIVES: Road traffic accidents are a leading cause of child deaths in the United States. Although this has been examined at the national and state levels, there is more value in acquiring information at the county level to guide local policies. We aimed to estimate county-specific child mortality from road traffic accidents in the United States. METHODS: We queried the Fatality Analysis Reporting System database, 2010-2017, for road traffic accidents that resulted in a death within 30 days of the auto crash. We included all children <15 years old who were fatally injured. We estimated county-specific age- and sex-standardized mortality. We evaluated the impact of the availability of trauma centers and urban-rural classification of counties on mortality. RESULTS: We included 9271 child deaths. Among those, 45% died at the scene. The median age was 7 years. The overall mortality was 1.87 deaths per 100 000 children. County-specific mortality ranged between 0.25 and 21.91 deaths per 100 000 children. The availability of a trauma center in a county was associated with decreased mortality (adult trauma center [odds ratio (OR): 0.59; 95% credibility interval (CI), 0.52-0.66]; pediatric trauma center [OR: 0.56; 95% CI, 0.46-0.67]). Less urbanized counties were associated with higher mortality, compared with large central metropolitan counties (noncore counties [OR: 2.33; 95% CI, 1.85-2.91]). CONCLUSIONS: There are marked differences in child mortality from road traffic accidents among US counties. Our findings can guide targeted public health interventions in high-risk counties with excessive child mortality and limited access to trauma care.

The impact of ethnic population dynamics on neonatal ECMO outcomes: a single urban institutional study.

INTRODUCTION: Neonatal extracorporeal membrane oxygenation ECMO has been clinically used for the last 25 y. It has been an effective tool for both cardiac and non cardiac conditions. The impact of ethno-demographic changes on ECMO outcomes however remains unknown. We evaluated a single institution's experience with non cardiac neonatal ECMO over a 28-y period. METHODS: A retrospective review of all neonates undergoing noncardiac ECMO between the y 1984 and 2011 was conducted and stratified into year groups I, II, III (≤1990, 1991-2000, and ≥2001). Demographic, clinical, and outcome data were collected. The patient specifics, ECMO type, ECMO length, blood use, complications, and outcomes were analyzed. Univariate, bivariate, and multivariate analyses were then performed. RESULTS: Data was available for 827 patients. The number of African-American and Hispanic patients increased over the last 27 y (27.5% versus 45.0% and 3.3% versus 21.5%, year group I versus year group III, respectively). The proportion of congenital diaphragmatic hernia (CDH) patients by ethnicity also increased for African-Americans and Hispanics between the two year groups (22.0% to 33.0% and 4.9% to 33.0%, respectively). Similar pattern was noted for non-CDH diagnoses. Low birth weight, low APGAR scores, CDH, primary pulmonary hypertension, central nervous system hemorrhage, and ECMO were independent predictors of mortality. Ethnicity, in itself however, was not associated with mortality on adjusted analysis. CONCLUSION: More African-Americans and Hispanics have required ECMO over the years with a concurrent decrease in the number of Caucasians. While ethnicity was not an independent predictor of mortality, it appears to be a surrogate for fatal but sometime preventable diagnoses among minorities. Further investigations are needed to better delineate the reason behind this disparity.

Revisiting childhood obesity: persistent underutilization of surgical intervention?

Over the last two decades, the prevalence of obesity in children ages 6 to 11 years has almost tripled, and more than tripled in teenagers. The purpose of this study is to define the characteristics of hospitalized obese children and utilization of bariatric surgery. Analysis of the 1998 to 2007 Healthcare Cost and Utilization Project Nationwide Inpatient Sample was conducted with years 2000, 2003, and 2006 substituted with the Kids' Inpatient Database dataset. Records with diagnosis of obesity were included in the analysis with major comorbidities defined as the presence of hypertension, obstructive sleep apnea, diabetes mellitus, or coronary artery disease. National estimates over a 10-year period were calculated using sampling weights. Approximately 223,700 children met the inclusion criteria, of which 20 per cent were morbidly obese, with an overall 20 per cent incidence of major comorbidity. Comorbidities were found to be significantly higher among Asian/Pacific Islander (28.3%), African-American (27.2%), and Hispanic (19.1%; P < 0.001) compared with white (15.6%) children. Only 2 per cent of morbidly obese children with major comorbidity underwent a bariatric procedure. Obesity remains a growing childhood epidemic with a disproportionate ethnic burden of comorbidities. Bariatric surgery remains a viable option and a structured guideline in children may provide equitable access across different ethnic and socioeconomic groups.

Primary vs delayed surgery for spontaneous pneumothorax in children: which is better?

BACKGROUND: Controversy exists regarding the timing of surgery for spontaneous pneumothorax (SP), which can be performed either after the first development of pneumothorax or after a recurrent spontaneous pneumothorax has occurred. Treatment after recurrence is often adopted because of the purported low recurrence of SP treated nonoperatively and the historical morbidity of open surgery. However, the effectiveness of VATS (to video-assisted bullectomy and pleurodesis) has raised the possibility of performing primary VATS (PV) in all patients. The authors therefore hypothesized that PV is safe and effective for SP and sought to perform a cost-benefit analysis of PV vs secondary VATS (SV). METHODS: After institutional review board approval, consecutive patients with SP (1991-2003) and no comorbidities were retrospectively divided into PV vs SV. Demographics, recurrent pneumothorax after VATS, length of stay, and costs were compared by Student's t test/chi2. The predicted incremental cost of PV was (cost of PV) - [cost of nonoperative treatment x (1 - recurrence rate)] + cost of SV x recurrence rate. Data are means +/- SEM. RESULTS: There were 54 spontaneous pneumothoraces in 43 patients (11 bilateral), of whom 3 were excluded because of open thoracotomy. Of 51 pneumothoraces, nonoperative treatment was attempted in 37, of whom 20 recurred and thus required SV. Primary VATS was performed in 14. Both groups had similar age, sex, weight, height, admission heart rate, and room air oxygen saturation. Total treatment length of stay was significantly shorter for PV vs SV (7.1 +/- 0.96 vs 10.5 +/- 1.2, P = .04). However, morbidity from recurrent pneumothorax after VATS occurred more frequently after PV than SV (4/14 vs 0/20 P < .05). Based on the observed recurrence rate of 54%, performing PV on all patients with SP would increase cost by $4010 per patient and require a recurrence rate of 72% or more to financially justify this approach. CONCLUSIONS: Contrary to the hypothesis, the increased morbidity and cost do not justify a strategy of PV blebectomy/pleurodesis in children with SP. Instead, secondary treatment is recommended.