Utility of White Light Scanning as an Alternative to Computed Tomography to Evaluate Severity of Pectus Excavatum Deformity.

BACKGROUND: Pectus excavatum (PE) severity and surgical candidacy are determined by computed tomography (CT)-delineated Haller Index (HI) and Correction Index (CI). White light scanning (WLS) has been proposed as a non-ionizing alternative. The purpose of this retrospective study is to create models to determine PE severity using WLS as a non-ionizing alternative to CT. METHODS: Between November 2015 and February 2023, CT and WLS were performed for children ≤18 years undergoing evaluation at a high-volume, chest-wall deformity clinic. Separate quadratic discriminate analysis models were developed to predict CT HI ≥ 3.25 and CT CI ≥ 28% indicating surgical candidacy. Two bootstrap forest models were trained on WLS measurements and patient demographics to predict CT HI and CT CI values then compared to actual index values by intraclass correlation coefficient (ICC). RESULTS: In total, 242 patients were enrolled (86.4% male, mean [SD] age 15.2 [1.3] years). Quadratic discriminate analysis models predicted CT HI ≥ 3.25 with specificity = 91.7%, PPV = 97.7% (AUC = 0.91), and CT CI ≥ 28% with specificity = 92.3%, PPV = 93.5% (AUC = 0.84). Bootstrap forest model predicted CT HI with training dataset ICC (95% CI) = 0.91 (0.88-0.93, R2 = 0.85) and test dataset ICC (95% CI) = 0.86 (0.71-0.94, R2 = 0.77). For CT CI, training dataset ICC (95% CI) = 0.91 (0.81-0.93, R2 = 0.86) and test dataset ICC (95% CI) = 0.75 (0.50-0.88, R2 = 0.63). CONCLUSIONS: Using noninvasive and nonionizing WLS imaging, we can predict PE severity at surgical threshold with high specificity obviating the need for CT. Furthermore, we can predict actual CT HI and CI with moderate-excellent reliability. We anticipate this point-of-care tool to obviate the need for most cross-sectional imaging during surgical evaluation of PE. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Study of Diagnostic Test.

Cultural competency and ethical behavior for collaboration in limited-resource settings: Guidelines from the Society of University Surgeons Academic Global Surgery Committee and the Association for Academic Global Surgery.

BACKGROUND: There are an increasing number of global surgery activities worldwide. With such tremendous growth, there is a potential risk for untoward interactions between high-income country members and low-middle income country members, leading to programmatic failure, poor results, and/or low impact. METHODS: Key concepts for cultural competency and ethical behavior were generated by the Academic Global Surgery Committee of the Society for University Surgeons in collaboration with the Association for Academic Global Surgery. Both societies ensured active participation from high-income countries and low-middle income countries. RESULTS: The guidelines provide a framework for cultural competency and ethical behavior for high-income country members when collaborating with low-middle income country partners by offering recommendations for: (1) preparation for work with low-middle income countries; (2) process standardization; (3) working with the local community; (4) limits of practice; (5) patient autonomy and consent; (6) trainees; (7) potential pitfalls; and (8) gray areas. CONCLUSION: The article provides an actionable framework to address potential cultural competency and ethical behavior issues in high-income country - low-middle income country global surgery collaborations.

Feasibility of Leveraging Consumer Wearable Devices with Data Platform Integration for Patient Vital Monitoring in Low-Resource Settings.

Manual monitoring of vital signs, which often fails to capture the onset of deterioration, is the main monitoring modality in most Ghanaian hospitals due to the high cost and inadequate supply of patient bedside monitors. Consumer wearable devices (CWDs) are emerging, relatively low-cost technologies for continuous monitoring of physiological status; however, their validity has not been established in low-resource clinical settings. We aimed to (1) investigate the validity of the heart rate (HR) and oxygen saturation (SpO2) data from two widely used CWDs, the Fitbit Versa 2 and Xiaomi Mi Smart Band 6, against gold standard bedside monitors in one Ghanaian hospital and (2) develop a web application to capture and display CWD data in a clinician-friendly way. A healthy volunteer simultaneously wore both CWDs and blood pressure cuffs to measure HR and SpO2. To test for concordance, we conducted the Bland-Altman and mean absolute percentage error analyses. We also developed a web application that retrieves and displays CWD data in near real time as text and graphical trends. Compared to gold standards (patient monitor and manual), the Fitbit Versa 2 had 96.87% and 96.67% measurement accuracies for HR, and the Xiaomi Mi Smart Band 6 had 94.24% and 93.21% measurement accuracies for HR. The Xiaomi Mi Smart Band 6 had 98.79% measurement accuracy for SpO2. The strong concordance between CWD and gold standards supports the potential implementation of these devices as a novel method of vital sign monitoring to replace manual monitoring, thus saving costs and improving patient outcomes. Further studies are needed for confirmation.

Chest Wall Dermatitis Patterns Following Thoracoscopic Intercostal Nerve Cryoablation for Surgical Correction of Pectus Excavatum.

BACKGROUND: Intercostal nerve cryoablation (INC) has been shown to reduce postoperative pain and length of stay following surgical correction of pectus excavatum (SCOPE). Some patients have developed chest wall dermatological symptoms after INC that can be mistaken for metal allergy or infection. The purpose of this study is to report the symptoms, severity, incidence, and treatment of post-cryoablation dermatitis. METHODS: A retrospective single institution review was performed for patients who underwent SCOPE with and without INC between June 2016 and March 2023 to assess for incidence of postoperative dermatological findings. Characteristics associated with these findings were evaluated. RESULTS: During study period, 383 patients underwent SCOPE, 165 (43.1%) without INC and 218 (56.9%) with. Twenty-three (10.6%) patients who received INC developed exanthems characteristic of post-cryoablation dermatitis with two distinct phenotypes identified. No patients who underwent SCOPE without INC developed similar manifestations. Early dermatitis, characterized by a painless, erythematous, and blanching rash across the anterior thorax, was observed in 16 patients, presenting on median postoperative day 6.0 [IQR 6.0-8.5], with median time to resolution of 23.0 [IQR 12-71.0] days after symptom onset. Late dermatitis, characterized by hyperpigmentation spanning the anterior thorax, was observed in 7 patients, presenting on median postoperative day 129.0 [IQR 84.5-240.0], with median time to resolution of 114.0 [IQR 48.0-314.3] days. CONCLUSION: This is the first report of dermatological manifestations following SCOPE with INC, a phenomenon of unknown etiology and no known long-term sequela. In our experience, it is self-resolving and lacks systemic symptoms suggesting observation alone is sufficient for resolution. LEVEL OF EVIDENCE: IV.

Step cadence as a novel objective postoperative recovery metric in children who undergo laparoscopic appendectomy.

BACKGROUND: Daily step counts from consumer wearable devices have been used to objectively assess postsurgical recovery in children. However, step cadence, defined as steps taken per minute, may be a more specific measure of physiologic status. The purpose of this study is to define objective normative physical activity recovery trajectories after laparoscopic appendectomy using this novel metric. We hypothesized that patients would have a progressive increase in peak cadence until reaching a plateau representing baseline status, and this would occur earlier for simple compared with complicated appendicitis. METHODS: Children aged 3 to 18 years were enrolled after laparoscopic appendectomy for simple or complicated appendicitis between March 2019 and December 2022 at a tertiary children's hospital. Participants wore a Fitbit for 21 postoperative days. The peak 1-minute cadence and peak 30-minute cadence were determined each postoperative day. Piecewise linear regression was conducted to generate normative peak step cadence recovery trajectories for simple and complicated appendicitis. RESULTS: A total of 147 children met criteria (53.7% complicated appendicitis). Patients with simple appendicitis reached plateau postoperative day 10 at a mean peak 1-minute cadence of 111 steps/minute and a mean peak 30-minute cadence of 77 steps/minute. The complicated appendicitis recovery trajectory reached a plateau postoperative day 13 at a mean peak 1-minute cadence of 106 steps/minute and postoperative day 15 at a mean peak 30-minute cadence of 75 steps/minute. CONCLUSION: Using step cadence, we defined procedure-specific normative peak cadence recovery trajectories after laparoscopic appendectomy. This can empower clinicians to set data-driven expectations for recovery after surgery and establish the groundwork for consumer wearable devices as a post-discharge remote monitoring tool.

Intercostal Nerve Cryoablation Reduces Opioid Use and Length of Stay Without Increasing Adverse Events: A Retrospective Cohort Study of 5442 Patients Undergoing Surgical Correction of Pectus Excavatum.

OBJECTIVE: To examine differences in opioid use, length of stay, and adverse events after minimally invasive correction of pectus excavatum (MIRPE) with and without intercostal nerve cryoablation. BACKGROUND: Small studies show that intraoperative intercostal nerve cryoablation provides effective analgesia with no large-scale evaluations of this technique. METHODS: The pediatric health information system database was used to perform a retrospective cohort study comparing patients undergoing MIRPE at children's hospitals before and after the initiation of cryoablation. The association of cryoablation use with inpatient opioid use was determined using quantile regression with robust standard errors. Difference in risk-adjusted length of stay between the cohorts was estimated using negative binomial regression. Odds of adverse events between the two cohorts were compared using logistic regression with a generalized estimating equation. RESULTS: A total of 5442 patients underwent MIRPE at 44 children's hospitals between 2016 and 2022 with 1592 patients treated after cryoablation was introduced at their hospital. Cryoablation use was associated with a median decrease of 80.8 (95% CI: 68.6-93.0) total oral morphine equivalents as well as a decrease in estimated median length of stay from 3.5 [3.2-3.9] days to 2.5 [2.2-2.9] days ( P value: 0.016). Cryoablation use was not significantly associated with an increase in any studied adverse events. CONCLUSIONS: Introduction of cryoablation for perioperative analgesia was associated with decreased inpatient opioid use and length of stay in a large sample with no change in adverse events. This novel modality for perioperative analgesia offers a promising alternative to traditional pain management in thoracic surgery.

Disparities in Telemedicine Use Among Children Seen in Surgical Clinics During the COVID-19 Pandemic: Experience of One Tertiary Care Freestanding Children's Hospital.

Background: Telemedicine use dramatically increased during the COVID-19 pandemic. However, the effects of telemedicine on pre-existing disparities in pediatric surgical access have not been well described. We describe our center's early experience with telemedicine and disparities in patients' access to outpatient surgical care. Methods: A retrospective study of outpatient visits within all surgical divisions from May to December 2020 was conducted. We assessed the rates of scheduled telemedicine visits during that period, as well as the rate of completing a visit after it has been scheduled. Descriptive and logistic regression analyses were used to test for associations between these rates and patient characteristics. Results: Over the study period, 109,601 visits were scheduled. Telemedicine accounted for 6.1% of all visits with lower cancellation rates than in-person visits (26.9% vs. 34.7%). More scheduled telemedicine encounters were observed for older patients, White, English speakers, those with private insurance, and those living in rural areas. Lower odds of telemedicine visit completion were observed among patients with public insurance (odds ratio [OR] 0.7, 95% confidence interval [CI] 0.64-0.77), Spanish language preference (OR 0.84, 95% CI 0.72-0.97), and those living in rural areas (OR 0.73, 95% CI 0.64-0.84). In contrast, higher odds of telemedicine visit completion were associated with a higher Social Deprivation Index score (OR 1.41, 95% CI 1.27-1.58). Telemedicine visit completion was also associated with increasing community-level income and distance from the hospital. Conclusions: Telemedicine use for outpatient surgical care was generally low during the peak of the pandemic, and certain populations were less likely to utilize it. These findings call for further action to bridge gaps in telemedicine use.

Using Consumer Wearable Devices to Profile Postoperative Complications After Pediatric Appendectomy.

INTRODUCTION: Markers of postoperative recovery in pediatric patients are difficult for parents to evaluate after hospital discharge, who use subjective proxies to assess recovery and the onset of complications. Consumer-grade wearable devices (e.g., Fitbit) generate objective recovery data in near real time and thus may provide an opportunity to remotely monitor postoperative patients and identify complications beyond the initial hospitalization. The aim of this study was to use daily step counts from a Fitbit to compare recovery in patients with complications to those without complications after undergoing appendectomy for complicated appendicitis. METHODS: Children ages 3-17 years old undergoing laparoscopic appendectomy for complicated appendicitis were recruited. Patients wore a Fitbit device for 21 d after operation. After collection, patient data were included in the analysis if minimum wear-time criteria were achieved. Postoperative complications were identified through chart review, and step count trajectories for patients recovering with and without complications were compared. Additionally, to account for the patients experiencing a complication on different postoperative days, median daily step count for pre- and post-complication were analyzed. RESULTS: Eighty-six patients with complicated appendicitis were enrolled in the study, and fourteen children developed a postoperative complication. Three patients were excluded because they did not meet the minimum wear time requirements. Complications were divided into abscesses (n = 7, 64%), surgical site infections (n = 2, 18%), and other, which included small bowel obstruction and Clostridioides difficile infection (n = 2, 18%). Patients presented with a complication on mean postoperative day 8, while deviation from the normative recovery trajectory was evident 4 d prior. When compared to children with normative recovery, the patients with surgical complications experienced a slower increase in step count postoperatively, but the recovery trajectory was specific to each complication type. When corrected for day of presentation with complication, step count remained low prior to the discovery of the complication and increased after treatment resembling the normative recovery trajectory. CONCLUSIONS: This study profiled variations from the normative recovery trajectory in patients with complication after appendectomy for complicated appendicitis, with distinct trajectory patterns by complication type. Our findings have potentially profound clinical implications for monitoring pediatric patients postoperatively, particularly in the outpatient setting, thus providing objective data for potentially earlier identification of complications after hospital discharge.

Using Wearable Devices to Profile Demographic-Specific Recovery After Pediatric Appendectomy.

INTRODUCTION: Counseling patients and parents about the postoperative recovery expectations for physical activity after pediatric appendectomy varies significantly and is not specific to patients' demographic characteristics. Consumer wearable devices (CWD) can be used to objectively assess patients' normative postoperative recovery of physical activity. This study aimed to develop demographic-specific normative physical activity recovery trajectories using CWD in pediatric patients undergoing appendectomy. METHODS: Children ages 3-18 y old undergoing laparoscopic appendectomy for acute appendicitis were recruited. Patients wore a Fitbit device for 21 d postoperatively and daily step counts were measured. Patients with postoperative complications were excluded. Segmented regression models were fitted and time-to-plateau was estimated for patients with simple and complicated appendicitis separately for each age group, sex, race/ethnicity, and body mass index category. RESULTS: Among 147 eligible patients; 76 (51.7%) were female, 86 (58.5%) were in the younger group, and 79 (53.7%) had complicated appendicitis. Patients 3-11 y old demonstrated a faster trajectory to a physical activity plateau compared to those 12-18 in both simple (postoperative day [POD] 9 versus POD 17) and complicated appendicitis (POD 17 versus POD 21). Males and females had a similar postoperative recovery trajectory in simple and complicated appendicitis. There was no clear pattern differentiating trajectories based on race/ethnicity. Overweight/obese patients demonstrated a slower recovery trajectory in simple appendicitis. CONCLUSIONS: This study demonstrates that factors other than the disease itself, such as age, may affect recovery, suggesting the need for more tailored discharge instructions. CWDs can improve our understanding of recovery and allow for better data-driven counseling perioperatively.

Evaluating Skeletal Maturity at Time of Surgical Correction of Pectus Excavatum Based on Medial Clavicle Epiphyseal Ossification.

BACKGROUND: Surgical correction of pectus excavatum (SCOPE) is dependent upon chest wall pliability with optimal timing prior to complete skeletal maturation. Measures of skeletal maturity are not readily available for operative planning; therefore, surgeons use age as proxy despite patient-specific rates of skeletal maturation. We aimed to determine whether preoperative skeletal maturity is associated with postoperative pain as surrogate for chest wall pliability. METHODS: Children ≤18 years who underwent SCOPE from 2020 to 2022 were retrospectively identified. Preoperative CT within 3 months of procedure was reviewed by 2 radiologists and 1 surgeon. Skeletal maturity was determined by Schmeling-Kellinghaus classification which stages secondary epiphyseal ossification of the medial clavicle. Inter-rater reliability was evaluated. Schmeling-Kellinghaus stage and postoperative pain were compared. RESULTS: Of twenty-eight records reviewed, 57% were Schmeling-Kellinghaus stage 1. High inter-rater reliability was identified (inter-radiologist: kappa = .95, P < .001, all raters: kappa = .78, P < .001). Median age at operation was 15.5 years (interquartile range: 14.8-16.0) and increased with skeletal maturity (P < .001). When comparing stage 1 (n = 16) to >1 (n = 12), stage 1 had lower maximum pain scores (P < .001), total morphine equivalents (P < .001), and benzodiazepine use (P < .001) after surgery. CONCLUSIONS: The Schmeling-Kellinghaus classification system is a valid proxy of skeletal maturity that can be applied with high inter-rater reliability. SCOPE during stage 1 was found to have less postoperative pain and narcotic use than more mature stages. This is proof of concept that skeletal maturity should be considered when determining optimal timing of surgical correction. Future research will evaluate the impact of skeletal maturity on postoperative outcomes.

Consumer Wearables Define a Normative Recovery Trajectory Following the Modified Nuss Procedure.

INTRODUCTION: The modified Nuss procedure is an elective procedure associated with a lengthy recovery, uncontrolled pain, and risk of infrequent, yet life-threatening complications. The absence of objective measures of normative postoperative recovery creates uncertainty about the postdischarge period, which remains highly dependent on the patients' and their caregivers' expectations and management of recovery. We aimed to describe an objective-normative, physical activity recovery trajectory after the modified Nuss procedure, using step counts from the Fitbit. METHODS: This observational study enrolled children ≤18 y with pectus excavatum who underwent the modified Nuss procedure from 2021 to 2022. The Fitbit was worn for 21 postoperative days. Postdischarge outcomes and health-care utilization were evaluated. For patients without postoperative complications, piecewise linear regression analysis was conducted to generate a normative recovery trajectory model of daily step counts. RESULTS: Of 80 patients enrolled, 66 (86%) met eligibility criteria (mean age, 15.1 ± 1.3 y; 89.4% male, 62.1% non-Hispanic White). The mean number of telephone and electronic message encounters regarding concerns with the patient's recovery within 30 d postoperatively was 2.1 (standard deviation = 2.7). Ten patients (15.2%) returned to the emergency department (ED) within the 30-d postoperative period. Seven patients (10.6%) presented to the ED one time, and three patients (4.5%) presented to the ED twice. Thirty-day readmission rate was four patients (6.0%). Piecewise regression model showed that patients without complications steadily increased their daily step count on each postoperative day and plateaued on day 18. CONCLUSIONS: We have developed a normative recovery trajectory following the modified Nuss procedure using step count data collected by a consumer wearable device. This offers the potential to inform preoperative patient expectations and reduce avoidable health-care utilization through informed preoperative counseling, thus laying the ground work for the use of consumer wearable devices as a postdischarge remote monitoring tool.

Applying machine learning to consumer wearable data for the early detection of complications after pediatric appendectomy.

When children are discharged from the hospital after surgery, their caregivers often rely on subjective assessments (e.g., appetite, fatigue) to monitor postoperative recovery as objective assessment tools are scarce at home. Such imprecise and one-dimensional evaluations can result in unwarranted emergency department visits or delayed care. To address this gap in postoperative monitoring, we evaluated the ability of a consumer-grade wearable device, Fitbit, which records multimodal data about daily physical activity, heart rate, and sleep, in detecting abnormal recovery early in children recovering after appendectomy. One hundred and sixty-two children, ages 3-17 years old, who underwent an appendectomy (86 complicated and 76 simple cases of appendicitis) wore a Fitbit device on their wrist for 21 days postoperatively. Abnormal recovery events (i.e., abnormal symptoms or confirmed postoperative complications) that arose during this period were gathered from medical records and patient reports. Fitbit-derived measures, as well as demographic and clinical characteristics, were used to train machine learning models to retrospectively detect abnormal recovery in the two days leading up to the event for patients with complicated and simple appendicitis. A balanced random forest classifier accurately detected 83% of these abnormal recovery days in complicated appendicitis and 70% of abnormal recovery days in simple appendicitis prior to the true report of a symptom/complication. These results support the development of machine learning algorithms to predict onset of abnormal symptoms and complications in children undergoing surgery, and the use of consumer wearables as monitoring tools for early detection of postoperative events.

Measuring the Efficacy of Thymectomy for Pediatric Myasthenia Gravis Across Tertiary Children's Hospitals.

BACKGROUND: Thymectomy is a treatment for pediatric myasthenia gravis, but the efficacy over time is unknown. Multi-institutional data are also lacking. Therefore, the objective of this study was to determine the efficacy of thymectomy for pediatric myasthenia gravis using medication burden and health care utilization as proxies for disease severity. METHODS: This was a cross-sectional study of the Pediatric Health Information System database among children who underwent thymectomy at one of 49 children's hospitals from 2004 to 2022. Differences in annual median number of doses of myasthenia-related medications, admissions, and health care costs in the year before thymectomy to three years after were compared. A comparison cohort that did not undergo thymectomy was utilized. Medians were compared using the Wilcoxon signed-rank test. Generalized linear regression estimated the effect of surgical approach on outcomes. RESULTS: A total of451 patients (238 patients who underwent thymectomy and 213 nonthymectomy patients) were identified. Following thymectomy, the decrease in annual median total number of myasthenia-related doses was 12.0 (interquartile range: 6 to 31) (P < 0.001). The decrease in number of annual admissions was 2.0 (1 to 4) (P < 0.001), which represented a cost difference of $5292 ($3533 to $8681) (P < 0.001). No differences were observed in the control cohort. In a generalized linear regression model, surgical approach was not associated with the efficacy of thymectomy (P = 0.55). CONCLUSIONS: Thymectomy is an effective treatment for pediatric myasthenia gravis, evidenced by the decreased medication burden and health care utilization after surgery. Surgical approach did not influence the success of surgery. Thymectomy should be considered earlier in the treatment algorithm.

A Novel Pediatric Surgery Division Incentive Program Engaging Faculty, Advanced Practice Providers and Staff Around a Single Financial Growth Target.

BACKGROUND: Productivity-based financial incentive programs for faculty are common. We implemented a novel Division wide clinical productivity incentive sharing professional fee collections across faculty, nurses, and staff with half of bonuses reserved to be given out proportionally to achievement of the annual growth target. METHODS: A novel bonus plan was formulated to incentivize collection of professional fees to achieve a 15% annual growth target. The 15% was divided equally between the clinical provider, the responsible provider's center(s) of excellence, and all Division members. 50% of the bonus pool was paid out monthly and the remaining 50% was held for an end of the year payout proportional to achievement of the Divisional professional fee collection annual growth target. PRINCIPAL FINDINGS: During the initial year of the program, overall Division collections and charges grew 30% and 17%, respectively. Average monthly bonuses paid through the new incentive program for faculty, advanced practice providers, and staff were $1,700, $700, and $200, respectively. The program cost $525,000 in additional bonuses over the previous year while the Division saw an increase of 2 million dollars in collections over the previous year. CONCLUSION: A clinical productivity incentive program based upon professional fee collections distributed across faculty, nurses, and staff was feasible and successful in its first year. Collections increased by a significantly higher percentage than charges, we believe collections incentive including support staff will be most useful in practices with lower rates of charge collection. Further study is needed to measure the effects of different components of the program. LEVEL OF EVIDENCE: Level IV. STUDY TYPE: Cost Effectiveness Study.

Clinicians' perspectives on wearable sensor technology as an alternative bedside monitoring tool in two West African countries.

OBJECTIVE: Healthcare facilities in low- and middle-income countries (LMICs), especially in Africa, suffer from a lack of continuous bedside monitoring capability, adversely affecting timely detection of hemodynamic deterioration and the opportunity for life-saving intervention. Wearable device technologies can overcome many of the challenges of conventional bedside monitors and could be viable alternatives. We assessed clinicians' perspectives on the use of a novel experimental wearable device ("biosensor") to improve bedside monitoring of pediatric patients in two West African LMICs. METHODS: Focus groups were conducted in 3 hospitals (2 in Ghana and 1 in Liberia), in both urban and rural settings and of variable size, to elucidate clinicians' attitudes about the biosensor and to identify potential implementation needs. The focus group sessions were coded using a constant comparative method. Deductive thematic analysis was applied to pair themes with Consolidated Framework for Implementation Research (CFIR) contextual factors and domains. RESULTS: Four focus groups were conducted in October 2019, and included 9 physicians, 20 nurses, and 20 community health workers. Fifty-two codes in four thematic areas were linked to 3 CFIR contextual factors and 9 domains. Key themes were durability and cost of the biosensor, hospital setting, and staffing concerns, which were related to the "Inner Setting" and "Characteristics of the Intervention" CFIR contextual factors. Participants, who recognized the limitations of current vital sign monitoring systems, further identified 21 clinical settings in which a biosensor could potentially be useful and expressed willingness to implement the biosensor. CONCLUSION: Clinicians who provide care to pediatric patients in two West African LMICs suggested multiple uses of a novel experimental wearable biosensor and expressed willingness to use it for continuous bedside vital sign monitoring. They identified device design (e.g., durability, cost), hospital setting (rural vs urban), and staffing as important factors to consider during further development and implementation.

Postoperative Antibiotics for Complicated Appendicitis in Children: Piperacillin/Tazobactam Versus Ceftriaxone with Metronidazole.

INTRODUCTION: Recent studies are discordant regarding postoperative use of piperacillin/tazobactam (PT) versus ceftriaxone/metronidazole (CM) for pediatric complicated appendicitis. Some argue that the broader spectrum PT decreases intraabdominal abscess formation; however, antibiotic stewardship, and once-a-day dosing favor CM. We aim to compare outcomes of postoperative antibiotic utilization using a large administrative database. METHODS: We queried the Pediatric Health Information System for patients 2-18 years old who underwent laparoscopic appendectomy for complicated appendicitis between 2016 and 2021. Patients were grouped into PT, CM, or other using the first postoperative day antibiotics. Adverse events and antibiotic use trends were evaluated. RESULTS: We included 29,015 children from 45 hospitals. CM was used in 51.9% and 31.3% received PT. Wide variation was seen among hospitals with PT use decreasing over the years. Overall rate of abscess was 9.2%. On multivariable regression, PT was associated with higher risk for abscess formation (RR 1.35, 99% CI 1.04-1.75) and readmission (RR 1.38, 99% CI 1.13-1.68) compared to the CM group. However, following adjustment for hospitals with high CM prevalence, these associations were no longer significant. CONCLUSION: Postoperative use of PT for complicated appendicitis is associated with higher rates of readmissions and intraabdominal abscess when compared to CM. However, this effect is mitigated when adjusting for common practice patterns. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Retrospective Comparative Study.

A Call to Expand the Scope of Digital Phenotyping.

Digital phenotyping refers to near-real-time data collection from personal digital devices, particularly smartphones, to better quantify the human phenotype. Methodology using smartphones is often considered the gold standard by many for passive data collection within the field of digital phenotyping, which limits its applications mainly to adults or adolescents who use smartphones. However, other technologies, such as wearable devices, have evolved considerably in recent years to provide similar or better quality passive physiologic data of clinical relevance, thus expanding the potential of digital phenotyping applications to other patient populations. In this perspective, we argue for the continued expansion of digital phenotyping to include other potential gold standards in addition to smartphones and provide examples of currently excluded technologies and populations who may uniquely benefit from this technology.

Surgical neonates in a low-resource setting: Baseline nutrition and outcome assessment.

INTRODUCTION: Congenital anomalies necessitating prolonged fasting have a high mortality in low-income settings, partially due to malnutrition and electrolyte disturbances in the absence of parenteral nutrition (PN). Interventions to address these problems require an accurate baseline quantification of the morbidity and mortality of this population. This prospective study aimed to determine peri-operative morbidity, fluid and electrolyte disturbance, growth, and mortality in neonates with gastroschisis (GS), intestinal atresia (IA), and esophageal atresia (EA) in Uganda. METHODS: Standardized patient care of 45 neonates treated in Uganda from Oct 2021 to March 2022 with protocolized fluid and nutrition, vital signs, and routine laboratory measurements. Patient demographics, admission and hospital characteristics are described with mean ± SD. Characteristics of survivors and non-survivors were compared with Fischer's exact tests, logrank tests, and CoX Ph model. RESULTS: Twenty-eight (62.2%) patients had GS, 4 (8.9%) EA, and 13 (28.9%) IA. Thirty-six percent (16/44) of patients survived to discharge (26% GS, 50% EA, 54% IA) with an average length of stay of 17.3 days ( ± 2.2) (survivors) and 9 days ( ± 1.7) (non-survivors). Average weight was 2.21 kg ( ± 0.62) at presentation, with no significant weight change during the study. Abnormal serum sodium in 64%, phosphate 36.5%, and magnesium 20.8% of measurements. Mortality did not correlate with diagnosis (p = 0.47), electrolyte derangement, or weight change. CONCLUSION: Mortality of neonates born with GS, EA, and IA is high in Uganda. Malnutrition and fluid/electrolyte derangements are common and may affect mortality. This study provides a comparison group for studying interventions to improve outcomes for these populations. TYPE OF STUDY: Prospective cohort. LEVEL OF EVIDENCE: Level 3.

Association between appendiceal stump closure method and post-operative bowel obstruction after laparoscopic appendectomy.

BACKGROUND: Laparoscopic appendectomy is one of the most common urgent pediatric surgical operations. Endoscopic surgical staplers and pre-tied endoloop ligatures are both routinely used for closure of the appendiceal stump in children. Practice patterns vary for a number of reasons, including cost, size, and ease of use. While stapling is standard for some pediatric surgeons, others believe that staples can act as a nidus for small bowel obstruction (SBO). However, studies comparing closure methods have been conflicting in their results and limited in size. Therefore, we aim to determine if there is an association between appendiceal stump closure method and SBO using a national comparative pediatric database. METHODS: We queried the Pediatric Health Information System (PHIS) for patients ages 3-18 years who underwent laparoscopic appendectomy for appendicitis between 1/1/2016 - 12/31/2020. We included hospitals that had greater than 50 patients with billing data and excluded patients with inflammatory bowel disease and simultaneous abdominal operations. We used billing data for the patient's appendectomy to determine if a stapler or a suture ligature was used during the case. Our primary outcome of interest was post-operative SBO or reoperation for lysis of adhesion or intestinal surgery within the first 30 post-operative days. Multivariable regression analyses were used to estimate the association between stump closure method and post-operative SBO or reoperation in addition to cost while adjusting for patient demographics and appendiceal perforation. RESULTS: In total, 49,191 patients from 37 hospitals were included, of which, 29,733 (60.44%) were male, 21,403 (43.51%) were non-Hispanic white, and 18,291 (37.18%) had a diagnosis of complicated appendicitis. The median [IQR] age of the cohort was 11 [8-14] years. A surgical stapler was used during laparoscopic appendectomy in 35,788 (72.75%) patients, and early SBO or reoperation occurred in 653 (1.33%) patients. In adjusted analysis controlling for demographics and complicated appendicitis there was no statistically significant difference in the odds of SBO or reoperation between the two groups. (OR 1.17; 99% CI 0.86 - 1.6). Complicated appendicitis was the factor most associated with post-operative SBO or reoperation (OR 4.4; 99% CI 3.01 - 6.44). Median cumulative cost was slightly higher on unadjusted analysis in the stapler group ($10,329.3 vs $9,569.2). However, there was no significant difference on adjusted analysis. CONCLUSION: SBO or reoperation following laparoscopic appendectomy for appendicitis is uncommon. Complicated appendicitis is the most predictive factor of this outcome. Adjusting for available patient, disease, and hospital characteristics, use of a surgical stapler does not appear to be meaningfully associated with the development of acute SBO or reoperation. Surgeon preference remains the mainstay for safe appendiceal stump closure method. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Retrospective Comparative Study.