Is the changing landscape of fellowship recruitment during COVID-19 here to stay?

BACKGROUND

The 2020 Pediatric Surgery (PS) fellowship selection process was heavily impacted by the COVID-19 pandemic. A review of lessons learned can help determine best practices for the future. The purpose of the study was to analyze the virtual interview experience and assess opportunities to improve the post-pandemic fellowship recruitment process.

STUDY DESIGN

Using a 28-question survey of Program Directors (PDs) of PS fellowships as well as a 44-question survey of applicants to PS fellowships in the US and Canada, we gathered information on the recruitment process during the COVID-19 pandemic (2020). Dichotomous, multiple choice and open-ended questions about the changes in process, platforms used, format, comparison to on-site interviews and overall satisfaction were used for objective and subjective feedback.

RESULTS

A 95% participation rate was recorded for the PD survey. 24 out of 55 programs (44%) changed their on-site interviews to virtual format due to the pandemic. Most PDs described their overall impression of virtual interviews as satisfactory (66%, 16/24) and did not have an impact on the applicant's success in the match (35/54; 65%). About 50% of PDs preferred to have on-site interviews with virtual screening in the future. While the participation rate from applicants was much less (26 of 70), responses confirmed our survey results. Majority preferred on-site interviews (17/26), 6 of which preferred virtual screening followed by on-site interviews.

CONCLUSION

Components of virtual screening and interviews were found to have benefits financially and from both time and stress perspectives, and thus might survive past the pandemic. LEVELS OF EVIDENCE LEVEL IV: .

Success in pediatric surgery: An updated survey of Program Directors 2020

BACKGROUND

One of the most competitive surgical sub-specialty fellowships remains Pediatric Surgery (PS), which requires candidates to develop a strong and research-oriented curriculum vitae. Although some objective factors of matriculation are known, factors for the interview selection and ranking per the program directors (PDs) have not been reviewed in over a decade.

METHODS

A web-based survey of US and Canadian PS program directors (PDs) (n = 58) was used to evaluate a comprehensive list of factors in the selection criteria for PS fellowships. A mix of dichotomous, ranking, five-point Likert scale, and open-ended questions evaluated applicant characteristics, ABSITE scores, research productivity, interview day, and rank order criteria.

RESULTS

Fifty-five programs responded to the survey for a 95% participation rate. PDs desired an average of two years in dedicated research and weighted first authorship and total number of publications heavily. Only 38% of programs used an ABSITE score cutoff for offering interviews; however, the majority agreed that an overall upward trend was important. Quality letters of recommendation, especially from known colleagues, carried weight when deciding to offer interviews. Interview performance, being a team player, observed interpersonal interactions, perceived operative skills and patient care, and leadership were some of the notable factors when finalizing rank lists.

CONCLUSIONS

A multitude of factors define a successful matriculant, including quality of letters of recommendation, quality and quantity of publications, supportive phone calls, observed interactions, interview performance, perceptions of being team player with leadership skills as well as perceptions of good operative skills and patient care.

LEVEL OF EVIDENCE

Type II.

TYPE OF STUDY

Prognostic (retrospective).

Factors Associated With Functional Impairment After Pediatric Injury

Importance

Short- and long-term functional impairment after pediatric injury may be more sensitive for measuring quality of care compared with mortality alone. The characteristics of injured children and adolescents who are at the highest risk for functional impairment are unknown.

Objective

To evaluate categories of injuries associated with higher prevalence of impaired functional status at hospital discharge among children and adolescents and to estimate the number of those with injuries in these categories who received treatment at pediatric trauma centers.

Design, Setting, and Participants

This prospective cohort study (Assessment of Functional Outcomes and Health-Related Quality of Life After Pediatric Trauma) included children and adolescents younger than 15 years who were hospitalized with at least 1 serious injury at 1 of 7 level 1 pediatric trauma centers from March 2018 to February 2020.

Exposure

At least 1 serious injury (Abbreviated Injury Scale score, ≥3 [scores range from 1 to 6, with higher scores indicating more severe injury]) classified into 9 categories based on the body region injured and the presence of a severe traumatic brain injury (Glasgow Coma Scale score <9 or Glasgow Coma Scale motor score <5).

Main Outcomes and Measures

New domain morbidity defined as a 2 points or more change in any of 6 domains (mental status, sensory, communication, motor function, feeding, and respiratory) measured using the Functional Status Scale (FSS) (scores range from 1 [normal] to 5 [very severe dysfunction] for each domain) in each injury category at hospital discharge. The estimated prevalence of impairment associated with each injury category was assessed in the population of seriously injured children and adolescents treated at participating sites.

Results

This study included a sample of 427 injured children and adolescents (271 [63.5%] male; median age, 7.2 years [interquartile range, 2.5-11.7 years]), 74 (17.3%) of whom had new FSS domain morbidity at discharge. The proportion of new FSS domain morbidity was highest among those with multiple injured body regions and severe head injury (20 of 24 [83.3%]) and lowest among those with an isolated head injury of mild or moderate severity (1 of 84 [1.2%]). After adjusting for oversampling of specific injuries in the study sample, 749 of 5195 seriously injured children and adolescents (14.4%) were estimated to have functional impairment at hospital discharge. Children and adolescents with extremity injuries (302 of 749 [40.3%]) and those with severe traumatic brain injuries (258 of 749 [34.4%]) comprised the largest proportions of those estimated to have impairment at discharge.

Conclusions and Relevance

In this cohort study, most injured children and adolescents returned to baseline functional status by hospital discharge. These findings suggest that functional status assessments can be limited to cohorts of injured children and adolescents at the highest risk for impairment.

Comparison of diagnostic imaging modalities for the evaluation of pancreatic duct injury in children: a multi-institutional analysis from the Pancreatic Trauma Study Group

PURPOSE

Determining the integrity of the pancreatic duct is important in high-grade pancreatic trauma to guide decision making for operative vs non-operative management. Computed tomography (CT) is generally an inadequate study for this purpose, and magnetic resonance cholangiopancreatography (MRCP) is sometimes obtained to gain additional information regarding the duct. The purpose of this multi-institutional study was to directly compare the results from CT and MRCP for evaluating pancreatic duct disruption in children with these rare injuries.

METHODS

Retrospective study of data obtained from eleven pediatric trauma centers from 2010 to 2015. Children up to age 18 with suspected blunt pancreatic duct injury who had both CT and MRCP within 1 week of injury were included. Imaging findings of both studies were directly compared and analyzed using descriptive statistics, Chi square, Wilcoxon rank-sum, and McNemar's tests.

RESULTS

Data were collected for 21 patients (mean age 7.8 years). The duct was visualized more often on MRCP than CT (48 vs 5%, p < 0.05). Duct disruption was confirmed more often on MRCP than CT (24 vs 0%), suspected based on secondary findings equally (38 vs 38%), and more often indeterminate on CT (62 vs 38%). Overall, MRCP was not superior to CT for determining duct integrity (62 vs 38%, p = 0.28).

CONCLUSIONS

In children with blunt pancreatic injury, MRCP is more useful than CT for identifying the pancreatic duct but may not be superior for confirmation of duct integrity. Endoscopic retrograde cholangiogram (ERCP) may be necessary to confirm duct disruption when considering pancreatic resection.

LEVEL OF EVIDENCE

III.

The utility of ERCP in pediatric pancreatic trauma

BACKGROUND/PURPOSE

Endoscopic retrograde cholangiopancreatography (ERCP) is an adjunct for pediatric pancreatic injury management, but its use and utility in pediatric patients are unclear. We set out to evaluate the use of ERCP and its effects on outcomes.

METHODS

A retrospective review was performed for children who had pancreatic injuries at 22 pediatric trauma centers between 2010 and 2015. ERCP details and outcomes were collected. Analysis was performed using descriptive statistics and Wilcoxon rank-sum tests.

RESULTS

ERCP was used at 14/22 centers for 26 patients. Indications were duct evaluation, duct leak control, pseudocyst, fistula, and stricture. ERCP altered management or improved outcomes in 13/26 (50%), most commonly in patients with ERCP for duct evaluation, stricture, and fistula. In patients managed nonoperatively, those with early endoscopic intervention (within one week of injury) with stent or sphincterotomy (n=9) had similar time to regular diet [median (IQR)]: [10 (7-211) vs 7 (4-12) days; p=0.55], similar hospital days: [12 (8-20) vs 11 (6-19) days, p=0.63], and similar time on parenteral nutrition: [17 (10-40) vs 10 (6-18) days; p=0.19] compared to patients who were only observed.

CONCLUSIONS

In children with blunt pancreatic injury, ERCP can be useful to diagnose duct injury and for management of late complications such as stricture and fistula. However, early endoscopic intervention for pancreatic duct disruption may not improve outcome or expedite recovery. Further study is needed.

STUDY TYPE

Retrospective Study; Treatment Study.

LEVEL OF EVIDENCE

III.

Evaluation of Clinical Metrology Instrument in Dogs with Osteoarthritis

Background

In veterinary clinical pain studies, there is a paucity of data on test‐retest variability in Clinical Metrology Instruments (CMIs), and it is unknown whether CMIs should be administered using independent (respondents not permitted to see previous answers) or dependent (respondents shown previous answers) interviewing.

Objectives

To compare baseline variability in CMIs designed to assess pain in dogs with osteoarthritis, and compare CMI scores using independent (InD) and dependent interviewing (DI) for the Canine Brief Pain Inventory (CBPI) and the Client‐Specific Outcome Measures (CSOM).

Animals

Fifty‐one client‐owned dogs with radiographic evidence of osteoarthritis and associated pain.

Methods

Clinical Metrology Instruments data were collected during 2 randomized, double‐masked, placebo‐controlled, proof of principle pilot studies with parallel treatment groups. Enrolled dogs received either placebo or antinerve growth factor antibody (NV‐01).

Results

Agreement between baseline CMI scores was good (CBPI Pain P = .29, CBPI Interference P = .32, CSOM P = .036, LOAD P = .67, HCPI P = .27), being best for the LOAD (ICC = 0.89). CMI responses collected during independent and dependent interviewing were not statistically different (CBPI Pain P = .33, CBPI Interference P = .28, CSOM P = .42) and showed good agreement. Additionally, dependent interviewing resulted in increased treatment effect sizes.

Conclusions and Clinical Importance

There is little difference between independent and dependent interviewing, however, dependent interviewing resulted in increased treatment effect sizes. By using dependent interviewing, investigators could increase clinical trial power through minimal change to study design. Further research is warranted to investigate the use of dependent interviewing.

Evolving Mechanisms of Injury and Management of Pediatric Blunt Renal Trauma--20 Years of Experience

OBJECTIVE

To review 20 years of a prospectively maintained trauma database to identify changing trends in mechanisms of renal injury, demographics, and management outcomes.

MATERIALS AND METHODS

Following the approval from the institutional review board, a prospectively maintained trauma database was reviewed for renal trauma patient demographics, management, and mechanisms of injury. Data were reviewed first for the entire cohort and then incrementally to identify mechanisms of injury associated with increasing frequency or grade of injury.

RESULTS

A total of 228 graded renal injuries were identified from 1993 to 2013. The majority of renal injuries occurred in males (77.2%) >6 years of age (85.1%). Low grade (I-III) injuries were more common (70.6%). The most frequent mechanisms of injury identified were falls, recreational motor vehicle (RMV) accidents, bike accidents, motor vehicle collisions, and sports accidents, in descending order of frequency. RMV-related injuries have become frequent with time despite recommendations against use in the pediatric age population. Surgical intervention was rarely necessary. Over the 20 year study period, 5 nephrectomies (1.4%) were required, whereas 10 endoscopic interventions or percutaneous drainage procedures were needed (2.4%).

CONCLUSION

The majority of blunt pediatric renal injuries are low grade and can be managed nonoperatively. Nephrectomy is rarely required but is indicated for hemodynamic instability refractory to resuscitation. Pediatric blunt renal trauma secondary to RMV use is increasing despite recommendations against their use in the pediatric population.

An analysis of proctoscopy vs computed tomography scanning in the diagnosis of rectal injuries in children: which is better?

BACKGROUND

Current dogma suggests that the diagnosis of rectal injury can be made after physical examination and proctoscopy (PR). However, anecdotal evidence suggests that these modalities lack specificity when applied to children and that computed tomography (CT) scanning may be superior. A direct comparison between CT scanning and PR has not been performed. We therefore sought to compare CT with PR in the diagnosis of rectal injury by analyzing our large institutional experience.

METHODS

To assess institutional outcome, the charts of all children younger than 18 years admitted to our level I trauma center (1999-2004) were prospectively collected and retrospectively assessed. Demographics, diagnostic accuracy (PR vs CT), and outcome (length of stay, days in the intensive care unit [ICU], Injury Severity Score, and missed injury) were assessed.

RESULTS

There were 24 injuries (63% boys, 71% blunt, 100% survival), and diagnostic modality included the following: PR, 37.5%; CT, 37.5%; laparotomy alone, 8%. Length of stay (PR 5.7 +/- 6.2 vs CT 13.7 +/- 22.2, NS) were similar between groups. Of the missed rectal injuries, 66% of patients undergoing PR had missed injuries that were ultimately detected by CT whereas 33% of the patients undergoing CT scan had a missed injury.

CONCLUSION

CT is at least as accurate as PR in diagnosing pediatric rectal injury. Consideration of early scanning as opposed to PR may improve diagnosis and outcome in these patients.

Intraoperative handling and wound healing: controlled clinical trial comparing coated VICRYL plus antibacterial suture (coated polyglactin 910 suture with triclosan) with coated VICRYL suture (coated polyglactin 910 suture)

BACKGROUND

Coated polyglactin 910 suture with triclosan was developed recently in order to imbue the parent suture, coated polyglactin 910, with antibacterial activity against the most common organisms that cause surgical site infections (SSI). Because such alterations could alter the physical properties of the suture, this study sought to compare the intraoperative handling and wound healing characteristics of coated polyglactin 910 suture with triclosan and traditional coated polyglactin 910 suture in pediatric patients undergoing various general surgical procedures.

METHODS

This was a prospective, randomized, controlled, open-label, comparative, single-center study. Pediatric patients (age 1-18 years) undergoing various surgical procedures were randomized in a 2:1 ratio to treatment with either coated polyglactin 910 suture with triclosan or coated polyglactin 910 suture. The primary endpoint was the surgeon's assessment of the overall intraoperative handling of coated polyglactin 910 suture with triclosan and traditional coated polyglactin 910 suture without triclosan. The secondary endpoints included specific intraoperative suture handling measures and wound healing assessments. The suture handling measures were (1) ease of passage through tissue; (2) first-throw knot holding; (3) knot tie-down smoothness; (4) knot security; (5) surgical handling; (6) surgical hand; (7) memory; and (8) suture fraying. Assessment of wound healing included the following: Healing progress, infection, edema, erythema, skin temperature, seroma, suture sinus, and pain. Adverse events were recorded.

RESULTS

Scores for intraoperative handling were favorable and not significantly different for both sutures, although coated polyglactin 910 suture with triclosan received more "excellent" scores (71% vs. 59%). Wound healing characteristics were comparable for both sutures except for pain on postoperative day 1. Significantly fewer patients treated with polyglactin 910 suture with triclosan reported pain on day 1 than patients who received the other suture (68% vs. 89%, p = 0.01). The overall incidence of adverse events was 18%; none was devicerelated.

CONCLUSIONS

Coated polyglactin 910 suture with triclosan performed as well or better than traditional coated polyglactin 910 suture in pediatric patients undergoing general surgical procedures. The incidence of postoperative pain was significantly less in patients treated with coated polyglactin 910 suture with triclosan than the traditional suture. We speculate that polyglactin 910 suture with triclosan, by inhibiting bacterial colonization of the suture, reduced pain that can be an indicator of "subclinical" infection. Coated polyglactin 910 suture with triclosan may be a useful alternative in patients at increased risk of developing SSI.

A spontaneous intramural hematoma of the bowel presenting as obstruction in a child receiving low-molecular-weight heparin

Low-molecular-weight heparin (LMWH) is a safe and effective alternative to unfractionated heparin and coumadin in the treatment and prophylaxis of thrombosis in children. When compared with these more established anticoagulants, it is easier to achieve therapeutic levels and the incidence of hemorrhagic complications is equivalent or lower. In children there is less published experience than in adults, but the low frequency of significant bleeding appears to be similar. The authors describe a child on therapeutic doses of LMWH for a deep vein thrombosis who spontaneously developed an intramural hemorrhage in his small bowel, leading to infarction and a partial bowel resection.

Effect of age on cervical spine injuries in children after motor vehicle collisions: effectiveness of restraint devices

PURPOSE

Despite the devastating consequences of cervical spine (C-spine) injury in children after motor vehicle collisions (MVC), the factors leading to the injury and the appropriateness of protective restraints remain undefined. The authors hypothesized that age-related anatomic factors contribute to inadequate restraints and therefore increase injury severity after MVC.

METHODS

Data on children (<18 years, 1997 to 2002) admitted to a level 1 pediatric trauma center were prospectively collected and retrospectively reviewed. Those with C-spine injuries caused by MVC were extracted and divided into 2 groups: young (0 to 8 years) and old (9 to 18 years). Statistical comparison was by Student's t test or Z-test, with P less than.05 accepted as significant.

RESULTS

Of 5,117 trauma admissions, 94 had C-spine injuries with a mean age of 11 +/- 5 years, 66% of which were boys. Among 1,124 patients who had sustained MVC there were 27 C-spine injuries (2.4% incidence), of which, 12 were less than 8 and 15 were older than 8 years. Restraint devices were utilized at least as frequently in younger children (young, 58% v. old, 43%; not significant). However, younger children had an increased incidence of permanent cord deficit (young, 57% v. old, 13%; P <.05) and closed head injury (young, 50% v. old, 7%; P <.05) even while wearing restraint devices, suggesting that restraint devices are inadequate or improperly used in younger patients. This is supported by the increased injury severity scores of the younger group (young, 37.7 +/- 8.5 v. old, 16.5 +/- 4.6; P <.05).

CONCLUSIONS

Younger children suffer more sever cervical spine injuries after motor vehicle collisions than their older counterparts, in part because of the inadequacy of currently existing restraint devices. Design modifications to current restraints, including the use of head straps, might improve outcome after MVC in younger patients.

Early functional outcome in children with pelvic fractures

BACKGROUND/PURPOSE

Although the mortality, morbidity, and spectrum of associated injuries in children with pelvic fractures have been extensively studied, little is known about the functional outcomes in these patients. The authors examined retrospectively functional independence measurement (FIM) at discharge in children with pelvic fractures to determine how it should influence their management protocol.

METHODS

The authors reviewed the records of all patients who sustained pelvic fractures between 1993 and 1998 in the trauma registry of a level I pediatric trauma center. Patients were stratified according to demographics, type of pelvic fracture, functional independence measurement, and discharge disposition. Fractures graded 1, 2, or 3 were defined as stable, whereas grade 4 fractures were deemed unstable.

RESULTS

A total of 88 children sustained pelvic fractures. Seventy-four percent had stable fractures, whereas 26% sustained unstable fractures. There was no difference in age or sex between the groups; boys were more commonly injured than girls. Motor vehicle-related crashes accounted for most injuries. The mean injury severity score (ISS) for patients with a stable fracture was 17 +/- 14 and 20 +/- 13 for unstable fractures. There was no difference in overall hospitalization nor intensive care unit stay between the unstable and stable fracture patients. Eighty percent of the patients with unstable and 52% of the patients with stable pelvic fractures were dependent based on locomotion, and similar proportions were seen for the transfer category.

CONCLUSIONS

Short-term function appears to be significantly impaired in a high percentage of children with stable and unstable pelvic fractures. Therefore, aggressive rehabilitation should be instituted early in all children with pelvic fractures to achieve optimal functional outcome.

The cognitive-affective crossfire: when self-consistency confronts self-enhancement

Self-consistency theory assumes that people want others to treat them in a predictable manner. Self-enhancement theory contends that people want others to treat them in a positive manner. We attempted to help reconcile the two theories by testing the hypothesis that people's cognitive responses conform to self-consistency theory and their affective responses conform to self-enhancement theory. We presented individuals who possessed either positive or negative self-concepts with either favorable or unfavorable social feedback. We then measured cognitive reactions to the feedback (e.g., perceived self-descriptiveness) and affective reactions to the feedback (e.g., mood states). Cognitive responses were primarily driven by the consistency of the feedback and affective responses were controlled by how enhancing it was. We propose that conceptualizing cognition an affect as partially independent mental systems helps resolve some long-standing paradoxes regarding people's responses to self-relevant social feedback.

The cognitive–affective crossfire: When self-consistency confronts self-enhancement

Self-consistency theory assumes that people want others to treat them in a predictable manner. Self-enhancement theory contends that people want others to treat them in a positive manner. We attempted to help reconcile the two theories by testing the hypothesis that people's cognitive responses conform to self-consistency theory and their affective responses conform to self-enhancement theory. We presented individuals who possessed either positive or negative self-concepts with either favorable or unfavorable social feedback. We then measured cognitive reactions to the feedback (e.g., perceived self-descriptiveness) and affective reactions to the feedback (e.g., mood states). Cognitive responses were primarily driven by the consistency of the feedback and affective responses were controlled by how enhancing it was. We propose that conceptualizing cognition an affect as partially independent mental systems helps resolve some long-standing paradoxes regarding people's responses to self-relevant social feedback.