Hospitalization Patterns for Inpatient Pediatric Surgery and Procedures in California: 2000-2016.

BACKGROUND: We report hospitalization patterns from 2000 to 2016 for young children (ages 0-5 years old) in California who underwent 1 of the 20 most common inpatient procedures that required general anesthesia and evaluate the estimated probability of treatment at a tertiary care children's hospital (CH) by year. METHODS: We hypothesized that children ≤5 years old increasingly undergo care at tertiary care CHs for common inpatient surgeries or other procedures that require general anesthesia. Data from the California Office of Statewide Health Planning and Development dataset were used to determine procedure, patient age, year of procedure, and hospital name. Hospitals were designated as either tertiary care CHs, children's units within general hospitals (CUGHs), or general hospitals (GHs) based on the California Children's Services Provider List. A tertiary care CH was defined using the California Children's Services definition as a referral hospital that provides comprehensive, multidisciplinary, regionalized pediatric care to children from birth up to 21 years of age with a full range of medical and surgical care for severely ill children. We report the unadjusted percentage of patients treated at each hospital type and, after controlling for patient covariates and comorbidities, the estimated probability of undergoing care at a tertiary care CH from 2000 to 2016. RESULTS: There were 172,318 treatment episodes from 2000 to 2016. The estimated probability of undergoing care at a tertiary care CH increased from 63.4% (95% confidence interval [CI], 62.4%-64.4%) in 2000 to 78.3% (95% CI, 77.3%-79.4%) in 2016. CONCLUSIONS: Children ≤5 years old undergoing common inpatient procedures that require general anesthesia increasingly receive care at tertiary care CHs in California.

The Pediatric Anesthesiology Workforce: Projecting Supply and Trends 2015-2035.

BACKGROUND: A workforce analysis was conducted to predict whether the projected future supply of pediatric anesthesiologists is balanced with the requirements of the inpatient pediatric population. The specific aims of our analysis were to (1) project the number of pediatric anesthesiologists in the future workforce; (2) project pediatric anesthesiologist-to-pediatric population ratios (0-17 years); (3) project the mean number of inpatient pediatric procedures per pediatric anesthesiologist; and (4) evaluate the effect of alternative projections of individual variables on the model projections through 2035. METHODS: The future number of pediatric anesthesiologists is determined by the current supply, additions to the workforce, and departures from the workforce. We previously compiled a database of US pediatric anesthesiologists in the base year of 2015. The historical linear growth rate for pediatric anesthesiology fellowship positions was determined using the Accreditation Council for Graduate Medical Education Data Resource Books from 2002 to 2016. The future number of pediatric anesthesiologists in the workforce was projected given growth of pediatric anesthesiology fellowship positions at the historical linear growth rate, modeling that 75% of graduating fellows remain in the pediatric anesthesiology workforce, and anesthesiologists retire at the current mean retirement age of 64 years old. The baseline model projections were accompanied by age- and gender-adjusted anesthesiologist supply, and sensitivity analyses of potential variations in fellowship position growth, retirement, pediatric population, inpatient surgery, and market share to evaluate the effect of each model variable on the baseline model. The projected ratio of pediatric anesthesiologists to pediatric population was determined using the 2012 US Census pediatric population projections. The projected number of inpatient pediatric procedures per pediatric anesthesiologist was determined using the Kids' Inpatient Database historical data to project the future number of inpatient procedures (including out of operating room procedures). RESULTS: In 2015, there were 5.4 pediatric anesthesiologists per 100,000 pediatric population and a mean (±standard deviation [SD]) of 262 ±8 inpatient procedures per pediatric anesthesiologist. If historical trends continue, there will be an estimated 7.4 pediatric anesthesiologists per 100,000 pediatric population and a mean (±SD) 193 ±6 inpatient procedures per pediatric anesthesiologist in 2035. If pediatric anesthesiology fellowship positions plateau at 2015 levels, there will be an estimated 5.7 pediatric anesthesiologists per 100,000 pediatric population and a mean (±SD) 248 ±7 inpatient procedures per pediatric anesthesiologist in 2035. CONCLUSIONS: If historical trends continue, the growth in pediatric anesthesiologist supply may exceed the growth in both the pediatric population and inpatient procedures in the 20-year period from 2015 to 2035.

Guidelines and checklists for short-term missions in global pediatric surgery: Recommendations from the American Academy of Pediatrics Delivery of Surgical Care Global Health Subcommittee, American Pediatric Surgical Association Global Pediatric Surgery Committee, Society for Pediatric Anesthesia Committee on International Education and Service, and American Pediatric Surgical Nurses Association, Inc. Global Health Special Interest Group.

Pediatric surgeons, anesthesia providers, and nurses from North America and other high-income countries are increasingly engaged in resource-limited areas, with short-term missions as the most common form of involvement. However, consensus recommendations currently do not exist for short-term missions in pediatric general surgery and associated perioperative care. The American Academy of Pediatrics (AAP) Delivery of Surgical Care Subcommittee and American Pediatric Surgical Association (APSA) Global Pediatric Surgery Committee, with the American Pediatric Surgical Nurses Association, Inc. (APSNA) Global Health Special Interest Group, and the Society for Pediatric Anesthesia (SPA) Committee on International Education and Service generated consensus recommendations for short-term missions based on extensive experience with short-term missions. Three distinct, but related areas were identified: (i) Broad goals of surgical partnerships between high-income countries and low- and middle-income countries. A previous set of guidelines published by the Global Paediatric Surgery Network Collaborative (GPSN) was endorsed by all groups; (ii) Guidelines for the conduct of short-term missions were developed, including planning, in-country perioperative patient care, post-trip follow-up, and sustainability; and (iii) travel and safety considerations critical to short-term mission success were enumerated. A diverse group of stakeholders developed these guidelines for short-term missions in low- and middle-income countries. These guidelines may be a useful tool to ensure safe, responsible, and ethical short-term missions given increasing engagement of high-income country providers in this work.

The Geographic Distribution of Pediatric Anesthesiologists Relative to the US Pediatric Population.

BACKGROUND: The geographic relationship between pediatric anesthesiologists and the pediatric population has potentially important clinical and policy implications. In the current study, we describe the geographic distribution of pediatric anesthesiologists relative to the US pediatric population (0-17 years) and a subset of the pediatric population (0-4 years). METHODS: The percentage of the US pediatric population that lives within different driving distances to the nearest pediatric anesthesiologist (0 to 25 miles, >25 to 50 miles, >50 to 100 miles, >100 to 250 miles, and >250 miles) was determined by creating concentric driving distance service areas surrounding pediatric anesthesiologist practice locations. US Census block groups were used to determine the sum pediatric population in each anesthesiologist driving distance service area. The pediatric anesthesiologist-to-pediatric population ratio was then determined for each of the 306 hospital referral regions (HRRs) in the United States and compared with ratios of other physician groups to the pediatric population. All geographic mapping and analysis was performed using ArcGIS Desktop 10.2.2 mapping software (Redlands, CA). RESULTS: A majority of the pediatric population (71.4%) lives within a 25-mile drive of a pediatric anesthesiologist; however, 10.2 million US children (0-17 years) live greater than 50 miles from the nearest pediatric anesthesiologist. More than 2.7 million children ages 0 to 4 years live greater than 50 miles from the nearest identified pediatric anesthesiologist. The median ratio of pediatric anesthesiologists to 100,000 pediatric population at the HRR level was 2.25 (interquartile range, 0-5.46). Pediatric anesthesiologist geographic distribution relative to the pediatric population by HRR is lower and less uniform than for all anesthesiologists, neonatologists, and pediatricians. CONCLUSIONS: A substantial proportion of the US pediatric population lives greater than 50 miles from the nearest pediatric anesthesiologist, and pediatric anesthesiologist-to-pediatric population ratios by HRR vary widely across the United States. These findings are important given that the new guidelines from the American College of Surgeons Children's Surgery Verification™ Quality Improvement Program state that pediatric anesthesiologists must care for a subset of pediatric patients. Because of the geographic distribution of pediatric anesthesiologists relative to the pediatric population, access to care by a pediatric anesthesiologist may not be feasible for all children, particularly for those with limited resources or in emergent situations.

The Current Landscape of US Pediatric Anesthesiologists: Demographic Characteristics and Geographic Distribution.

BACKGROUND: There is no comprehensive database of pediatric anesthesiologists, their demographic characteristics, or geographic location in the United States. METHODS: We endeavored to create a comprehensive database of pediatric anesthesiologists by merging individuals identified as US pediatric anesthesiologists by the American Board of Anesthesiology, National Provider Identifier registry, Healthgrades.com database, and the Society for Pediatric Anesthesia membership list as of November 5, 2015. Professorial rank was accessed via the Association of American Medical Colleges and other online sources. Descriptive statistics characterized pediatric anesthesiologists' demographics. Pediatric anesthesiologists' locations at the city and state level were geocoded and mapped with the use of ArcGIS Desktop 10.1 mapping software (Redlands, CA). RESULTS: We identified 4048 pediatric anesthesiologists in the United States, which is approximately 8.8% of the physician anesthesiology workforce (n = 46,000). The median age of pediatric anesthesiologists was 49 years (interquartile range, 40-57 years), and the majority (56.4%) were men. Approximately two-thirds of identified pediatric anesthesiologists were subspecialty board certified in pediatric anesthesiology, and 33% of pediatric anesthesiologists had an identified academic affiliation. There is substantial heterogeneity in the geographic distribution of pediatric anesthesiologists by state and US Census Division with urban clustering. CONCLUSIONS: This description of pediatric anesthesiologists' demographic characteristics and geographic distribution fills an important gap in our understanding of pediatric anesthesia systems of care.

Radiation-guided breast sentinel lymph node biopsies - is a handling delay for radiation protection necessary?

AIMS: Radiation-guided sentinel lymph node (SLN) biopsy is a well-established procedure in many countries. However, histopathology protocols in different centres specify widely differing sample handling delays of between 0 and 72 h. Introducing a delay reduces the radiation exposure of pathologists, but has a detrimental effect on the quality and validity of histology. This study aims to show that a sample handling delay is not justified by the radiation doses to pathologists handling samples received directly from surgery. METHODS AND RESULTS: Radiation doses to the body and hands of pathologists handling samples delivered directly from theatres were measured using personal dose meters. These measurements were supplemented by dose assessments undertaken using dose-rate measurements at 1 cm and 30 cm from Tc-99m sources to simulate the processing of samples. The study has shown that radiation doses arising from a zero delay in sample handling represent a negligible radiation risk to pathologists and are well within relevant limits specified in the Ionising Radiations Regulations 1999. CONCLUSIONS: This study supports adoption of a zero-delay SLN histopathology protocol. Centres must, however, complete a risk assessment that accounts for local practice and adopt simple precautions to keep doses to pathologists as low as reasonably achievable.

Practice Characteristics of Board-certified Pediatric Anesthesiologists in the US: A Nationwide Survey.

Introduction We conducted a survey to describe the practice characteristics of anesthesiologists who have passed the American Board of Anesthesiology (ABA) Pediatric Anesthesiology Certification Examination. Methods In July 2017, a list of anesthesiologists who had taken the ABA Pediatric Anesthesiology Certification Examination (hereafter referred to as "pediatric anesthesiologists") was obtained from the American Board of Anesthesiologists (theaba.org). Email contact information for these individuals was collected from departmental rosters, email distribution lists, hospital or anesthesia group profiles, manuscript author contact information, website source code, and other publicly available online sources. The survey was designed using Qualtrics (Qualtrics, Provo, Utah; Seattle, Washington), a web-based tool, to ascertain residency/fellowship training history and current practice characteristics that includes: years in practice, clinical work hours per week, primary hospital setting, practice type, supervision model, estimated percentage of cases by patient age group, and percentage of respondents who cared for any patient undergoing a fellowship-level index cases within the previous year. The invitation to complete the survey included a financial incentive - the chance to win one of twenty $50 Amazon gift cards. Results There were 3,492 anesthesiologists who had taken the Pediatric Anesthesiology Certification Examination since 2013. Surveys were sent to those whom an email address was identified (2,681) and 962 complete survey responses were received (35.9%, 962/2,681). Over 80% (785) of respondents completed a pediatric anesthesiology fellowship. Of these, 485 respondents (50.4%) work in academic practice, 212 (22.0%) in private practice, 233 (24.2%) in private practice and have academic affiliations, and 32 (3.3%) as locum tenens or in other practice settings. The majority of respondents (64.3%) in academic practice work in freestanding children's hospitals. Pediatric anesthesiologists in academic practice and private practice with academic affiliations reported caring for a greater number of younger children and doing a wider variety of index cases than respondents in private practice. Conclusion The extent to which pediatric anesthesiologists care for pediatric patients - particularly young children and those undergoing complex cases - varies. The variability in practice characteristics is likely a result of differences in hospital type, anesthesia practice type, geographic location, and other factors.

Guidelines and checklists for short-term missions in global pediatric surgery: Recommendations from the American Academy of Pediatrics Delivery of Surgical Care Global Health Subcommittee, American Pediatric Surgical Association Global Pediatric Surgery Committee, Society for Pediatric Anesthesia Committee on International Education and Service, and American Pediatric Surgical Nurses Association, Inc. Global Health Special Interest Group.

INTRODUCTION: Pediatric surgeons, anesthesia providers, and nurses from North America and other high-income countries (HICs) are increasingly engaged in resource-limited areas, with short-term missions (STMs) as the most common form of involvement. However, consensus recommendations currently do not exist for STMs in pediatric general surgery and associated perioperative care. METHODS: The American Academy of Pediatrics (AAP) Delivery of Surgical Care Subcommittee and American Pediatric Surgical Association (APSA) Global Pediatric Surgery Committee, with the American Pediatric Surgical Nurses Association, Inc. (APSNA) Global Health Special Interest Group, and the Society for Pediatric Anesthesia (SPA) Committee on International Education and Service generated consensus recommendations for STMs based on extensive experience with STMs. RESULTS: Three distinct, but related areas were identified: 1) Broad goals of surgical partnerships between HICs- and low and middle-income countries (LMICs). A previous set of guidelines published by the Global Paediatric Surgery Network Collaborative (GPSN), was endorsed by all groups; 2) Guidelines for the conduct of STMs were developed, including planning, in-country perioperative patient care, post-trip follow-up, and sustainability; 3) travel and safety considerations critical to STM success were enumerated. CONCLUSION: A diverse group of stakeholders developed these guidelines for STMs in LMICs. These guidelines may be a useful tool to ensure safe, responsible, and ethical STMs given increasing engagement of HIC providers in this work. LEVEL OF EVIDENCE: 5.

Salmonella in Swine at Slaughter: Incidence and Serovar Distribution at Different Seasons.

Throughout a 1-year period samples were obtained from 874 hogs at slaughter at one local, state-inspected slaughter plant. Caecal contents were the source of the samples. A total of 118 salmonellae was isolated yielding 16 different serovars. Major serovars were derby (57%), alachua (11%), agona (8%), and newport (5%). The average number of hogs sampled per trip was 17. The maximum number of serovars obtained at any one sampling day was 3. The maximum number of Salmonella -positive samples in any one day was 11 of 17 samples (64.7%). Total numbers of Salmonella isolates did not vary with season; however, during the hot, dry summer and fall seasons, 10 and 11 different serovars were isolated, respectively, compared to 3 and 1 serovars for the cooler, wetter winter and spring seasons, respectively.