Objective Personality Determination: A Useful Addition to the Traditional Process of Pediatric Surgical Fellow Selection.

BACKGROUND: Selection of pediatric surgical trainees is a multifaceted process heavily influenced by in-person interviews to determine personality makeup and institutional compatibility. We present our experience in utilizing a validated personality inventory in the selection of our candidates. METHODS: All applicants selected for an in-person interview for the 2020 Pediatric Surgery Match were offered the Big Five Inventory (BFI) questionnaire. An initial rank order list (ROL) was formulated employing application information and in-person interview score. A reformulated ROL was created after incorporating BFI data. Correlation of specific personality characteristics vs position on the ROL was assessed for both the initial ROL and the reformulated ROL. RESULTS: Thirty-four applicants were interviewed and 24 (70.6%) were ranked. Linear regression analysis identified a lower neuroticism score directly related to a higher position on the initial ROL {R = .4626, P = .023}. The reformulated ROL identified a higher conscientiousness score {R = .5331; P = .007} and a lower neuroticism score {R = -.4383; P = .032} correlated with ascending the final ROL. CONCLUSIONS: The self-administered BFI adds objectivity to personality determination gleamed from the standard face-to-face interview. Conscientiousness and neuroticism had a significant impact on the final ROL position. Adding objective personality data appears to provide additional aid in this difficult process.

Perioperative Tissue Oximetry-driven Fluid Resuscitation Improves Flap Perfusion in Autologous Free Tissue Breast Reconstruction.

Introduction: The use of tissue oximetry for monitoring following free tissue transfer has become a common practice to facilitate early detection of poor flap perfusion. We hypothesized that T stat readings may guide fluid administration in the postoperative period and improve perfusion in patients undergoing autologous breast reconstruction. Methods: Patients undergoing free flap breast reconstruction from 2015 to 2018 were reviewed. Mean percutaneous oximetry readings of the first four postoperative days were recorded. The mean change at 24 hours from the original reading was calculated (∆TO). The study population was divided in two groups based on whether administration of intravenous fluids (IVFs) was increased/maintained (group 1) or decreased (group 2) after postoperative day 1. Results: A total of 120 patients were identified. The mean age was 53, and mean BMI was 33. Overall, patients for whom fluid administration was decreased experienced an increase in their tissue perfusion, while patient who received a bolus or maintained the same rate of IVF experienced a decrease. Patients who had a negative ∆TO experienced a statistically significant difference between groups 1 and 2 at 24 and 72 hours (-4 versus +3 and -11 versus +13, respectively). For patients with a positive ∆TO, although decreasing fluids resulted in higher readings, it did not reach statistical significance at 24 or 72 hours (0 versus +2 and +4 versus +6, respectively). Conclusions: In patients undergoing free tissue breast reconstruction, tissue oximetry readings may be used as a novel guide for postoperative fluid management.

Palmar Venous Malformation: A Case Report of a Rare Occurrence and a Treatment Algorithm.

Palmar venous malformations are not well described in the surgical literature and are a therapeutic challenge due to the intricate anatomy of the hand. We present the case of a 19-year-old right-handed female patient from Mexico who was referred to us with a right palmar lesion present since birth, previously diagnosed as a venous malformation. The patient reported that she had undergone sclerotherapy 10 years before in addition to a prior aborted attempt at excision. Venous palmar malformations are rare occurrences. Although an individualized approach is important, the development of an algorithm may assist in the standardization of the treatment of this pathology to preserve the hand's functional status.

Full versus Baby Dose Aspirin for Antithrombotic Prophylaxis in Free Tissue Transfer: Does Size Matter?

The postoperative prophylactic use of aspirin is a common practice among plastic surgeons after free tissue transfer. The use of baby aspirin (81 mg) has become more popular due to previously published literature in other fields. We hypothesized that a full dose daily aspirin is nonsuperior to a baby dose daily aspirin in preventing arterial thrombosis in free tissue transfer. Methods: All patients undergoing free tissue transfer of the extremities from 2008 to 2020 were retrospectively reviewed. They were divided into two groups based on the postoperative dose of aspirin administered (full versus baby dose). The decision to administer full or baby dose was based on the surgeon's preference. Primary outcome was revision of the arterial anastomosis. Secondary outcomes included flap complications. Results: A total of 183 patients were identified. Out of those, 78 patients received full dose aspirin postoperatively, whereas 105 received a baby dose of aspirin. Patients who received baby aspirin did not have a higher incidence of returning to the operating room for revision of their arterial anastomosis [7.6% versus 7.7%; adjusted odds ratio, 0.93 (95% confidence interval, 0.28-3.11); adjusted P, 0.906]. No differences were found between the two groups in complete and partial flap loss, wound dehiscence, or infection. None of the patients experienced any aspirin-related gastrointestinal complications. Conclusions: In patients undergoing free tissue transfer, thrombosis of the arterial anastomosis is rare. Administration of a full dose of aspirin postoperatively was not superior to a baby dose of aspirin in preventing arterial-related complications.

Craniocervical Dissociation in Pediatric Patients: Pearls and Pitfalls of Diagnosis and Management.

AIMS: The aims of this study were to document the injury pattern in pediatric traumatic craniocervical dissociation (CCD) and identify features of survivors. METHODS: Pediatric traumatic CCDs, diagnosed between January 2004 and July 2016, were reviewed. Survivors and nonsurvivors were compared. Categorical and continuous variables were analyzed with Fisher exact and t tests, respectively. RESULTS: Twenty-seven children were identified; 10 died (37%). The median age was 60 months (ranges, 6-109 months [survivors], 2-98 months [nonsurvivors]). For survivors, the median follow-up was 13.4 months (range, 1-109 months). The median time to mortality was 1.5 days (range, 1-7 days). The injury modality was motor vehicle collision in 18 (67%), pedestrian struck in 8 (30%), and 1 shaken infant (3%). For nonsurvivors, CCD was equally diagnosed by plain radiograph and head/cervical spine computed tomography scan. For survivors, CCD was diagnosed by computed tomography in 7 (41%), magnetic resonance imaging in 10 (59%), and none by radiograph. Seven diagnosed by magnetic resonance imaging (41%) had nondiagnostic initial imaging but persistent neck pain. Magnetic resonance imaging was obtained and was diagnostic of CCD in all 7 (P < 0.01). Survivors required significantly less cardiopulmonary resuscitation (P < 0.01), had lower Injury Severity Scores (P < 0.01), higher Glasgow Coma Scale scores (P < 0.01), and shorter transport times (P < 0.01). Significantly more involved in motor vehicle collisions survived (P = 0.04). Nine (53%) had no disability at follow-up evaluation. CONCLUSIONS: In pediatric CCD, high-velocity mechanism, cardiac arrest, high Injury Severity Score, and low Glasgow Coma Scale score are associated with mortality. If CCD is correctly managed in the absence of cardiac arrest or traumatic brain or spinal cord injury, children may survive intact.

Safe phlebotomy reduction in stable pediatric liver and spleen injuries.

PURPOSE: Pediatric blunt solid organ injury management based on hemodynamic monitoring rather than grade may safely reduce resource expenditure and improve outcomes. Previously we have reported a retrospectively validated management algorithm for pediatric liver and spleen injuries which monitors hemodynamics without use of routine phlebotomy. We hypothesize that stable blunt pediatric isolated splenic/liver injuries can be managed safely using a protocol reliant on vital signs and not repeat hemoglobin levels. METHODS: A prospective multi-institutional study was performed at three pediatric trauma centers. All pediatric patients from 07/2016-12/2017 diagnosed with liver or splenic injuries were identified. If appropriate for the protocol, only a baseline hemoglobin was obtained unless hemodynamic instability as defined in an age-appropriate fashion was determined by treating physician discretion. Descriptive statistics were conducted. RESULTS: One hundred four patients were identified of which 38 were excluded from the protocol. There was a significant difference in abnormal shock index, pediatric age-adjusted (SIPA) values, hematocrit, and percentage of patients with hemoglobin less than 10 between the excluded and included patients. Of the 66 patients managed on the protocol, four patients had to be removed, two each on day one and day two. Of those four patients, only one required intervention. There were no mortalities. CONCLUSION: A phlebotomy limiting protocol may be a safe option for stable pediatric splenic and liver injuries cared for in a pediatric trauma center with the resources for rapid intervention should the need arise. The differences in groups highlight the importance of utilizing this protocol in the correct patient population. Reduced phlebotomy offers the potential for reduced resource expenditure without any evidence of increased morbidity or mortality. LEVEL OF EVIDENCE: Level IV.

Intestinal Function after Early versus Late Appendectomy in Children with Perforated Appendicitis.

The aim was to prospectively document the impact of early versus late appendectomy on intestinal function in pediatric perforated appendicitis. After Institutional Review Board approval, between September 2016 and August 2017, complete data were prospectively collected for children undergoing planned appendectomy for perforated appendicitis. One hundred children with pathologist-confirmed transmural perforations were included. The median time to operation after pain onset was three days. Operation on day 1 or 2 (early) was compared with that on day 3 or after (late) (range, 3-9 days). Emesis, nasogastric tubes, and time to tolerate diet evaluated intestinal function. Categorical and continuous variables were analyzed by chi-square and t tests. Of the 100, there were 45 in the early and 55 in the late group, with 22/55(40%) operated on day 3. Children with early appendectomy were significantly younger, 7.8 (3.5) versus 9.5 (3.8) years (P = 0.02). Pre-appendectomy, more than 80 per cent of each group had emesis (P = 0.84), but the late group had a 10-fold increase in nasogastric tube use (P = 0.02). The early group tolerated regular diet significantly faster, 2.5 (2.1) versus 4.4 (4.1) days (P = 0.01), and had a significantly shorter hospital stay, 3.5 (2.2) versus 5.6 (4.3) days (P = 0.01). When pain onset to appendectomy is less than three days, the time to return of intestinal function is significantly reduced.

Young children with perforated appendicitis benefit from prompt appendectomy.

BACKGROUND/PURPOSE: To identify factors associated with nonoperative treatment failure in pediatric perforated appendicitis compared to immediate appendectomy. METHODS: After IRB approval, between September 2016 and August 2017, prospective data were recorded for children (age: 1-18 years) with completed appendectomies and pathologist-confirmed perforations. Children were treated according to clinician-designated preference. Nonoperative treatment was considered failed if a nonresolving obstruction developed or any return of symptoms before the planned interval. The median time from pain onset to treatment initiation was 3 days (range: 1-14). Presentation on days 1 or 2 (early) was compared to day 3 or after(late). The nonoperatives were compared to appendectomies stratified by presentation time. Variables were compared by chi-square, Fisher exact or t-tests. Logistic regression evaluated for independence. RESULTS: Of 201 suspected perforations, 176 were included, 101 (57%) immediate appendectomies and 75 (43%) nonoperatives. Of 75, 24 (32%) failed; 6 (25%) in hospital, 18 (75%) after discharge. In 51 (68%), nonoperative treatment succeeded. Significantly younger children failed nonoperative treatment (p = 0.03). Failure was independently associated with treatment initiation within 2.75 days from pain onset (OR: 0.07, 95% CI: 0.57-0.98) (p = 0.010) and lower WBC at presentation (OR: 0.03, 95% CI: 0.81-0.98) (p = 0.014). When compared to immediate appendectomy, nonoperatives had more morbidity. CONCLUSION: Younger children fail nonoperative treatment, perforate rapidly and have a significantly lower WBC, but benefit from immediate appendectomy. LEVEL OF EVIDENCE: Treatment Study Level II.

Personality traits within a pediatric surgery fellowship applicant pool.

BACKGROUND: The Big Five framework examines five factors that represent a description of human personality. These factors correlate with success measures and job satisfaction. The Big Five Inventory is a 44-item instrument designed to measure the Big Five framework. Our aim was to document the distribution of Big Five personality traits among Pediatric Surgery fellowship applicants, compare with community norms, surgical residents, between genders, and correlate to the fellowship match results. MATERIALS AND METHODS: Forty Pediatric Surgery fellowship applicants at a university hospital completed the Big Five Inventory during the interview process. It was analyzed and compared with general surgery residents' results and community norms. The data were compared regarding gender and match results. Continuous variables were compared by unpaired t-tests and Mann-Whitney tests. A P value <0.05 was considered significant. RESULTS: The 40 applicants were equally divided between male and female. When compared with general surgery residents and community norms, applicants of both genders scored higher on agreeableness (P < 0.01), conscientiousness (P < 0.01), and emotional stability (P < 0.01). Applicants scored higher on openness when compared with surgical residents (P < 0.01). Male applicants scored higher on emotional stability than females (P = 0.026). Matched applicants scored higher for conscientiousness than unmatched applicants (P = 0.016). CONCLUSIONS: Pediatric Surgery fellowship applicants expressed higher levels of desirable professional traits compared with general surgery residents and community norms. Male applicants demonstrated higher emotional stability than females. Conscientiousness was higher in matching applicants. This first reported experience with personality testing in Pediatric Surgery fellow selection demonstrated potential utility in applicant matching.

Cervical spine injuries in young children: pattern and outcomes in accidental versus inflicted trauma.

BACKGROUND: The aim of the study was to compare the cervical spine (c-spine) pattern of injury and outcomes in children below 3 y with a head injury from confirmed inflicted versus accidental trauma. METHODS: After Institutional Review Board approval, data were prospectively collected between July 2011 and January 2016. Inclusion criteria were age below 3 y, a loss of consciousness, and any one of the following initial head computed tomography (CT) findings (subdural hematoma, intraventricular, intraparenchymal, subarachnoid hemorrhage, or cerebral edema). A protocol of brain and neck magnetic resonance imaging and magnetic resonance angiography was instituted. Brain and neck imaging results, clinical variables, and outcomes were recorded. Data were compared by t-test for continuous and Fisher exact test for categorical variables. RESULTS: 73 children were identified, 52 (71%) with inflicted and 21 (29%) with accidental trauma. The median age was 11 mo; (range: 1-35 mo). Ten (14%) had c-spine injuries, 7/52 (13%) inflicted, and 3/21 (14%) accidental. The mechanism was shaking for all inflicted and motor vehicle accident or pedestrian struck for accidental c-spine injuries. The inflicted group were significantly younger (P = 0.03), had higher Injury Severity Scores (P = 0.02), subdural hematomas (P = 0.03), fractures (P = 0.03), retinal hemorrhages (P = 0.02), brain infarcts (P = 0.01), and required cardiopulmonary resuscitation (P = 0.01). Seven with inflicted trauma died from brain injury (9.5%), one had atlanto-occipital dissociation. Six mortalities (86%) had no c-spine injury. Six with inflicted c-spine injuries survived with neurologic impairment, whereas three with accidental survived without disability, including one atlanto-occipital dissociation. CONCLUSIONS: Compared to accidental trauma, young children with inflicted c-spine injuries have more multisystem trauma, long-term disability from brain injury, and an injury pattern consistent with shaking.

Laparoscopic skills assessment: an additional modality for pediatric surgery fellowship selection.

AIM: The Pediatric Surgery fellow selection is a multi-layered process which has not included assessment of surgical dexterity. MATERIALS AND METHODS: Data was collected prospectively as part of the 2016 Pediatric Surgery Match interview process. Applicants completed a questionnaire to document laparoscopic experience and fine motor skills activities. Actual laparoscopic skills were assessed using a simulator. Time to complete an intracorporeal knot was tabulated. An initial rank list was formulated based only on the ERAS application and interview scores. The rank list was re-formulated following the laparoscopic assessment. Un-paired T-test and regression were utilized to analyze the data. RESULTS: Forty applicants were interviewed with 18 matched (45%). The mean knot tying time was 201.31s for matched and 202.35s for unmatched applicants. Playing a musical instrument correlated with faster knot tying (p=0.03). No correlation was identified between knot tying time and either video game experience (p=0.4) or passing the FLS exam (p=0.78). Laparoscopic skills assessment lead to significant reordering of rank list (p=0.01). CONCLUSIONS: Laparoscopic skills performance significantly impacted ranking. Playing a musical instrument correlated with faster knot tying. No correlation was identified between laparoscopic performance and passing the FLS exam or other activities traditionally believed to improve technical ability. TYPE OF STUDY: Prospective study. LEVEL OF EVIDENCE: Level II.