Surgical video review improves performance, but video capture, editing, sharing, and platform usability challenges hinder implementation. Evaluating platform usability by end-users is vital for effective adoption. In this study, we utilized a standardized measurement scale, the System Usability Scale (SUS), to measure the usability of an existing local network video capture (LNVC) platform within a surgical department. The existing LNVC system consists of intraoperative camera capture with an attached hard drive for data retention. The SUS survey was administered to surgical residents and faculty at a surgical department. The SUS was distributed via an online survey tool, and the SUS was calculated for distinct user groups. The median usability score for the entire cohort was low (Score:43, SUS average score: 68, 10thpercentile score:40). The median score was worst among routine video users (Score: 36). For the first time, we demonstrate that LNVC has among the lowest usability scores in a single surgery department.

The Child Opportunity Index (COI) is a measure of neighborhood conditions associated with healthy child development. Inguinal hernia repair (IHR) is a common pediatric procedure. We sought to evaluate the association between COI and complicated inguinal hernia (IH), incarcerated or strangulated IH, among children with employer-based insurance coverage. We performed a retrospective cohort study of children who underwent IHR in the IBM Watson Health MarketScan® Research Database from 2015 to 2019. Claims data were merged with the COI at the metropolitan statistical area (MSA) level. We performed a multivariate regression analysis to determine the association between COI and complicated IH. A total of 12,084 eligible pediatric patients were identified, of which 3.7

Background: There is a lack of consensus on the optimal antibiotic regimen for pediatric appendicitis, and conflicting data exist regarding the need for extended-spectrum use in this population. We implemented an antibiotic stewardship program with a standard, preferred antibiotic regimen for both uncomplicated and complicated appendicitis and hypothesized that clinical outcomes would be equivalent. Methods: This is a single-institution, retrospective study of pediatric patients (≤18 y) who underwent appendectomy for acute appendicitis between October 2015 and May 2022. We used institutional data from our stewardship program supplemented by manual chart review. Patients were assigned to pre- and post-pathway cohorts on the basis of appendectomy date. Patients were further stratified on the basis of whether they met criteria for complicated appendicitis on the basis of intra-operative findings. Results: There were 752 patients that were included: 346 (46.0%) in the pre-pathway cohort and 406 (54.0%) in the post-pathway cohort. The pre-pathway cohort had a higher rate of complicated appendicitis (40.2 vs. 25.6%). However, pre- and post-pathway cohorts had similar rates of post-operative infections, readmissions, and reoperations. When separated by complicated operative findings, patients with uncomplicated appendicitis had a shorter length of stay post-pathway implementation (p < 0.001). After controlling for complicated operative findings and pertinent covariates, the preferred antibiotic regimen was independently associated with decreased odds of post-operative organ space surgical site infections (SSI) (adjusted odds ratio 0.22, 95% CI: 0.05-0.99). Discussion: Antibiotic stewardship to increase the use of a standardized, preferred antibiotic regimen did not result in worse clinical outcomes. The preferred regimen was significantly associated with a decreased rate of organ space SSI, even when controlling for complicated operative findings. The mechanism of this finding requires additional study.

BACKGROUND:Cytochrome-P450 eicosanoids from arachidonic acid, including vasodilator epoxyeicosatrienoic acids (EETs) and the vasoconstrictor 20-HETE, are important in regulating blood pressure, vascular tone, and cardiac and renal function. This study examined plasma 20-HETE and EETs in relation to blood pressure and vascular stiffness in a cohort of 1054 community-dwelling young adults from the Raine Study at 27 years. METHODS:Plasma 20-HETE, EETs, and their hydroxylated products were measured by liquid chromatography-tandem mass spectrometry. Pulse wave velocity and aortic distensibility were measured to assess vascular stiffness. Sex differences were assessed using univariate analysis. Multiple regression models assessed the relationship between 20-HETE and systolic blood pressure (SBP) and measures of vascular stiffness. RESULTS:The regression model for SBP showed a positive relationship with plasma 20-HETE (β, 0.092; P<0.0001), after adjusting for sex (P<0.0001), body mass index (P<0.0001), (ln)triglycerides (P<0.0001), and (ln)Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) (P=0.015), and accounted for 29% of the variance in SBP. 20-HETE was positively related to pulse wave velocity (β, 0.059; P=0.021); after adjusting for sex (P<0.0001), SBP (P<0.0001), (ln)triglycerides (P=0.014), (ln)HOMA-IR (P=0.0001), (ln)high-sensitivity C-reactive protein (P=0.005), and age (P=0.002), the model accounted for 34% of the variance in pulse wave velocity. 20-HETE was inversely associated with aortic distensibility (β, -0.051; P=0.029), independent of sex (P<0.0001), SBP (P<0.0001), and (ln)HOMA-IR (P<0.0001); the model accounted for 25% of the variance in aortic distensibility. Plasma EETs were not significant predictors of SBP or vascular stiffness. CONCLUSIONS:In young adults, 20-HETE may play a fundamental role in regulating blood pressure and vascular stiffness independent of numerous cardiometabolic risk factors and cytochrome 450-derived EETs. REGISTRATION:URL: https://www.anzctr.org.au; Unique identifier: CTRN12617001599369.

Introduction The impact of diverting ileostomy in adults with ulcerative colitis (UC) undergoing ileal pouch-anal anastomosis (IPAA) is unclear. This study uses a novel approach with population-level data to identify patients with diverting ileostomy at the time of IPAA and determine the impact of diverting ileostomy on postoperative outcomes.Methods Using the International Business Machines (IBM) MarketScan (R) database, adults (18-64 years old) with a diagnosis of UC who underwent IPAA between 2000 and 2019 were examined. Patients were assigned to the diverting ileostomy (DI) cohort or no-DI cohort based on the presence of an ostomy closure code in the 1-year following their IPAA. Rates of ileostomy formation and readmissions were quantified and outcomes between cohorts compared.Results There were 540 patients in the no-DI and 2494 in the DI cohort. There were regional differences in the rate of ostomy creation, but the overall rate of ostomy creation remained stable across years. Patients with no-DI vs DI had a longer index length of stay (LOS) (7 vs 6 days, P = .001). Adverse postoperative outcomes did not differ between cohorts. Diversion did not independently affect the likelihood of a 30-day readmission, and since 2000, readmission rates have declined for all IPAA patients.Discussion This is the first study to capture population-level data on the effect of diversion at the time of IPAA for adult UC patients. This study demonstrates that the rate of fecal diversion at the time of IPAA has remained stable over time, but readmission rates have declined.

ABSTRACTBackgroundPrevious studies have reported volatile organic compounds (VOCs) in the breath as biomarkers of breast cancer. These biomarkers may be derived from cancer-associated fibroblasts, in which oxidative stress degrades polyunsaturated fatty acids to volatile alkanes and methylated alkane derivatives that are excreted in the breath. We evaluated a rapid point-of-care test for breath VOC biomarkers as predictors of breast cancer and abnormal mammograms.MethodsWe studied 593 women aged ≥ 18 yr referred to three sites for mammography for a symptomatic breast-related concern (e.g. breast mass, nipple discharge). A rapid point-of-care breath testing system collected and concentrated alveolar breath VOCs on a sorbent trap and analyzed them with gas chromatography and surface acoustic wave detection in < 6 min. Breath VOC chromatograms were randomly assigned to a training set or to a validation set. Monte Carlo analysis identified significant breath VOC biomarkers of breast cancer and abnormal mammograms in the training set, and these biomarkers were incorporated into a multivariate algorithm to predict disease in the validation set.ResultsPrediction of breast cancer: 50 women had biopsy-proven breast cancer (invasive cancer 41, ductal non-invasive cancer 9) Unsplit data set: Breath VOCs identified breast cancer with 83% accuracy (area under curve of receiver operating characteristic), 82% sensitivity and 77.1% specificity. Split data sets: Training set breath VOCs identified breast cancer with 80.3% accuracy, 84% sensitivity and 74.3% specificity. Corresponding values in the validation set were 68%% accuracy, 72.4% sensitivity and 61.5% specificity.Prediction of BIRADS 4 and 5 mammograms (versus BIRADS 1, 2 and 3): Unsplit data set: Breath VOCs identified abnormal mammograms with 76.2% accuracy. Split data sets: Breath VOCs identified abnormal mammograms with 74.2% accuracy, 73.3% sensitivity and 60% specificity. Corresponding values in the validation set were 60.5% accuracy, 64.2% sensitivity and 51% specificity.ConclusionsA rapid point-of-care test for breath VOC biomarkers accurately predicted risk of breast cancer and abnormal mammograms in women with breast-related symptoms.

IntroductionParental health literacy and neighborhood socioeconomic disadvantage are associated with adverse health outcomes and increased health-care resource utilization in children. We sought to evaluate the association between community-level health literacy and neighborhood socioeconomic disadvantage and their relationships with outcomes of pediatric patients undergoing gastrostomy tube (GT) placement.MethodsPediatric patients who underwent GT placement from 2000 to 2019 were identified using the IBM MarketScan Research database. Claims data were merged with the health literacy index (HLI) and area deprivation index (ADI), measures of community-level health literacy and neighborhood socioeconomic disadvantage, respectively. We used multivariate logistic regression to estimate factors associated with postoperative 30- and 90-day ED visits (EVs) and 30-day readmissions.ResultsA total of 4374 pediatric patients underwent GT placement. In this cohort, 6.1% and 11.4% had 30-day and 90-day EV; and 30-day readmissions in 19.75%. HLI was lower in those with 30-(244.6 ± 6.1 versus 245.4 ± 6.1; P = 0.0482) and 90-(244.5 ± 5.8 versus 245.5 ± 6.1; P = 0.001) day EV, and 30-day readmission (244.5 ± 5.56 versus 245.4 ± 6.1; P = 0.001) related to GT. ADI was lower in those with 90-day EV (55.1 ± 13.1 versus 55.9 ± 14.6; P = 0.0244). HLI was associated with decreased odds of 30- (adjusted odds ratio: 0.968; 95% confidence interval: 0.941-0.997) and 90-day (adjusted odds ratio: 0.975; 95% confidence interval: 0.954-0.998) EV following GT placement. ADI was also significantly associated with 30 and 90-day EV following GT placement.ConclusionsIn pediatric patients undergoing GT placement, higher ecologically-measured health literacy and neighborhood socioeconomic disadvantage are associated with decreased health-care resource utilization, as evidenced by decreased ED visits. Future studies should focus on the role of individual parental health literacy in outcomes of pediatric surgical patients.

OBJECTIVETo define the current state of peer-reviewed literature demonstrating the usability, acceptability, and implementation of artificial intelligence (AI) and machine learning (ML) techniques in surgical coaching and training.DESIGNWe conducted a literature search with defined inclusion and exclusion criteria. We searched five scholarly databases: MEDLINE via PubMed, Embase via Elsevier, Scopus via Elsevier, Cochrane Central Register of Controlled Trials, and the Healthcare Administration Database via ProQuest. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines.RESULTSOnly 4 articles met the inclusion criteria and used standardized methods for performance evaluation with expert observation. We found no literature examining the impact on performance, user acceptance, or implementation of AI/ML techniques used for surgical coaching and training. We highlight the need for qualitative and quantitative research demonstrating these techniques' effectiveness before broad implementation.CONCLUSION AND RELEVANCEWe emphasize the need for research to specifically evaluate performance, impact, user acceptance, and implementation of AI/ML techniques. Incorporating these facets of research when developing AI/ML techniques for surgical training is crucial to ensure emerging technology meets user needs without increasing cognitive burden or frustrating users.

The physiology of pediatric trauma patients leads to lower deep venous thrombosis (DVT) and venous thromboembolism (VTE) event rates than adults.1 This makes developing guidelines and tracking the effectiveness of chemical VTE prophylaxis (cVTE) challenging.

The use of enhanced recovery protocols (ERP) in surgery delivers standardized, repeatable, and measurable care that improves clinical outcomes for patients. These pathways address the surgical care episode, from preoperative surgical readiness, during the surgical admission, until after discharge. Standardized pathways have been well-studied in adults, and emerging data in children show promise. However, data reporting has been targeted toward specific study populations and may be a barrier to broader pathway implementation. In this review, we discuss implementation of pediatric ERPs, examine outcome studies and published inclusion and exclusion criteria, and describe strategies for broader implementation of pediatric ERPs.

Background Inadequate inflammation resolution may contribute to persistent low-grade inflammation that accompanies many chronic conditions. Resolution of inflammation is an active process driven by Specialized Pro-resolving Mediators (SPM) that derive from long chain n-3 and n-6 fatty acids. This study examined plasma SPM in relation to sex differences, lifestyle and a broad range cardiovascular disease (CVD) risk factors in 978, 27-year olds from the Australian Raine Study. Methods Plasma SPM pathway intermediates (18-HEPE, 17-HDHA and 14-HDHA), and SPM (E- and D-series resolvins, PD1, MaR1) and LTB 4 were measured by liquid chromatography-tandem mass spectrometry (LCMSMS). Pearson correlations and multiple regression analyses assessed relationships between SPM and CVD risk factors. Unpaired t-tests or ANOVA assessed the effect of sex, smoking, unhealthy alcohol consumption and obesity on SPM. Results Women had higher 17-HDHA ( p = 0.01) and lower RvE1 ( p < 0.0001) and RvD1 ( p = 0.05) levels compared with men. In univariate analysis, obesity associated with lower RvE1 ( p = 0.002), whereas smoking ( p < 0.001) and higher alcohol consumption ( p < 0.001) associated with increased RvE1. In multiple regression analysis, plasma RvE1 was negatively associated with a range of measures of adiposity including BMI, waist circumference, waist-to-height ratio, abdominal subcutaneous fat volume, and skinfold thicknesses in both men and women. Conclusion This population study suggests that a deficiency in plasma RvE1 may occur in response to increasing adiposity. This observation could be relevant to ongoing inflammation that associates with CVD and other chronic diseases.

Background:A breath test for volatile organic compounds has identified biomarkers associated with breast cancer. We evaluated the potential clinical and economic benefits of a breath test to detect women at low risk for breast cancer by comparing its negative predictive value (NPV) to the NPV of screening mammography. Methods:Sensitivity and specificity values for screening mammography were obtained from the Food & Drug Administration Mammography Quality Standards Act; Amendments to Part 900 Regulations Docket No. FDA-2013-N-0134. The high values were sensitivity = 79.0%, specificity = 88.9% and the low values were sensitivity = 66.0%, specificity = 88.9%. In two previous studies of 771 women undergoing mammography, breath testing identified breast cancer with sensitivity=84% and specificity = 68.6% in 178 asymptomatic women, and sensitivity=82% and specificity = 77% in 593 who were symptomatic. These values were projected to a hypothetical screening population of 100,000 asymptomatic women with average breast cancer prevalence of 450/100,000, in order to estimate the NPV and PPV (positive predictive value) for breath testing and screening mammography respectively. Results:Breath test in asymptomatic women: NPV = 99.895% and PPV = 1.19%; in symptomatic women: NPV = 99.895% and PPV = 1.59%. For screening mammography, NPV = 99.83% and PPV = 2.82% (low values), increasing to NPV= 99.89% and PPV = 3.12% (high values). A negative breath test identified 68.3% of the screening population as having low risk of breast cancer, with NPV similar to mammography. Based on Medicare reimbursement rates, elimination of mammography in women with a negative breath test could reduce the annual cost of breast cancer screening by 38.9. Conclusions:In a hypothetical screening population, a negative breath test ruled out breast cancer with the same accuracy as a negative mammogram. A screening breath test could potentially eliminate the need for two thirds of all mammograms and reduce the costs of screening without increasing the risk of false-negative findings. If applied in clinical practice, this approach could potentially reduce the costs and burdens of breast cancer screening services, and benefit women by lessening the discomfort, anxiety, radiation exposure, and costs associated with mammography.

Introduction: Pediatric burns are associated with socioeconomic disadvantage and lead to significant morbidity. The Child Opportunity Index (COI ) is a well -validated measure of neighborhood characteristics associated with healthy child development. We sought to evaluate the relationship between COI and outcomes of burn injuries in children. Methods: We performed a single -institution retrospective review of pediatric (< 16 years ) burn admissions between 2015 and 2019. Based on United States residential zip codes, patients were stratified into national COI quintiles. We performed a multivariate Poisson regression analysis to determine the association between COI and increased length of stay. Results: 2095 pediatric burn admissions occurred over the study period. Most children admitted were from very low (n = 644, 33.2 % ) and low (n = 566, 29.2 % ) COI neighborhoods. The proportion of non -Hispanic Black patients was significantly higher in neighborhoods with very low (44.5 % ) compared to others (low:28.8 % vs. moderate:11.9 % vs. high:10.5 % vs. very high:4.3 % ) (p < 0.01 ). Hospital length of stay was significantly longer in patients from very low COI neighborhoods (3.6 +/- 4.1 vs. 3.2 +/- 4.9 vs. 3.3 +/- 4.8 vs. 2.8 +/- 3.5 vs. 3.2 +/- 8.1 ) (p = 0.02 ). On multivariate regression analysis, living in very high COI neighborhoods was associated with significantly decreased hospital length of stay (IRR: 0.51; 95 % CI: 0.45-0.56 ). Conclusion: Children from neighborhoods with significant socioeconomic disadvantage, as measured by the Child Opportunity Index, had a significantly higher incidence of burn injuries resulting in hospital admissions and longer hospital length of stay. Public health interventions focused on neighborhood-level drivers of childhood development are needed to decrease the incidence and reduce hospital costs in pediatric burns. Type of study: Retrospective study Level of evidence: Level III (c) 2024 Elsevier Ltd and ISBI. All rights reserved.

BACKGROUND:Virtual Reality (VR) is used as an effective tool for distraction and as an adjunct for pain management. This study was conducted to compare VR to standard iPad use after surgery and examine its effect on pain score and opioid consumption.METHODS:This was a randomized controlled study, with stratification by surgery type, age group (7-12yo, 13-18yo) and gender. Pain and anxiety were assessed with validated scales (STAI, FACES, VAS, FLACC) and outcomes were compared between each group.RESULTS:50 of the 106 enrolled patients used the VR device. After adjusting for age, gender, and STAI, patients had a decreased FLACC score while using the VR device compared to the iPad group (odds ratio 2.95, P = .021). The younger patients were found to have lower FLACC scores while using the VR device (odds ratio 1.15, p=0.044); this finding was most significant when patients used the VR device for 20-30 minutes (odds ratio 1.67, P = .0003). Additionally, after adjusting for treatment group, gender, and STAI, the younger patients had higher odds of withdrawal or exclusion from the study (odds ratio 1.18, P = .021). No significant difference in opioid consumption between the groups was found.DISCUSSION:Virtual reality was well tolerated and more effective in decreasing pain during the immediate postoperative period than iPad use. Despite a slightly higher withdrawal rate, younger patients benefited more from the intervention.

BACKGROUND:Central venous line (CVL) placement in children is often necessary for treatment and may be complicated by central line-associated bloodstream infection (CLABSI). We hypothesize that line type and clinical and demographic factors at line placement impact CLABSI rates. METHODS:This is a single-institution case-control study of pediatric patients (≤18 years old) admitted between January 1, 2015, and December 31, 2019. Case patients had a documented CLABSI. Control patients had a CVL placed during the study period and were matched by sex and age in a 2:1 ratio. Bivariate and multivariate logistic regression analysis was performed. RESULTS:We identified 78 patients with a CLABSI and 140 patients without a CLABSI. After controlling for pertinent covariates, patients undergoing tunneled or non-tunneled CVL had higher odds of CLABSI than those undergoing PICC (OR 2.51, CI 1.12-5.64 and OR 3.88, CI 1.06-14.20 respectively), and patients undergoing port placement had decreased odds of CLABSI compared to PICC (OR .05, CI 0.01-.51). There were lower odds of CLABSI when lines were placed for intravenous medications compared to those placed for solid tumor malignancy (OR .15, CI .03-.79). Race and age were not statistically significant risk factors. DISCUSSION:Central lines placed for medication administration compared to solid tumors, PICC compared to tunneled and non-tunneled central lines, and ports compared to PICC were associated with lower odds of CLABSI. Future improvement efforts should focus on PICC and port placement in appropriate patients to decrease CLABSI rates.

Background: Deep surgical site infections (dSSI) following total knee arthroplasty (TKA) are associated with morbidity and poor outcomes. Although numerous patient and non-patient factors have been correlated with dSSI development, the temporal and seasonal variability of dSSI is unclear. The purpose of this study was to investigate the monthly and seasonal variability of dSSI rates following TKA.Methods: The dSSI database at a single large, urban, academic medical center was reviewed for TKAs performed between January 2009 and August 2018. The monthly and seasonal variability of dSSI was evaluated using a Poisson regression. Additionally, the change in dSSI rate was calculated over the entire study period.Results: We reviewed 15,230 consecutive TKAs. The av-erage dSSI rate following TKA was 1.11% (SD: 0.91). The rate of dSSI decreased over the study period (r = 0.94, 95% CI: 0.85-1.05) but did not reach statistical significance. With summer as the reference season, there were no significant differences in the dSSI rate in fall, winter, or spring. With July as the reference season, there were no differences in the dSSI rate in any other months of the year.Conclusion: Although non-significant, this analysis found a decreasing rate of dSSI after TKA over a nearly 10-year period. Interestingly, there was no difference in the dSSI rate following TKA in July as compared to other months or in summer as compared to other seasons. This conflicts with previous reports that have found an increased incidence of dSSI and other complications in July when the graduate medical education calendar begins.

Background: Both general surgeons (GS) and pediatric surgeons (PS) perform a high volume of appendectomies in pediatric patients, but there is a paucity of data on these outcomes based on surgeon training. We performed a systematic review and meta-analysis to compare postoperative outcomes and perioperative resource utilization for pediatric appendectomies.Methods: We searched PubMed to identify articles examining the association between surgeon specialization and outcomes for pediatric patients undergoing appendectomies. Study selection, data extraction, risk of bias assessment, and quality assessment were performed by one reviewer, with another reviewer to resolve discrepancies.Results: We identified 4799 articles, with 98.4% (4724/2799) concordance after initial review. Following resolution of discrepancies, 16 studies met inclusion criteria. Of the studies that reported each outcome, GS and PS demonstrated similar rates of readmission within 30 days (pooled RR 1.61 95% CI 0.66, 2.55) wound infections (pooled RR 1.07, 95% CI .55, 1.60), use of laparoscopic surgery (pooled RR 1.87, 95% CI .21, 3.53), postoperative complications (pooled RR 1.40, 95% CI .83, 1.97), use of preoperative imaging (pooled RR .98,95% CI .90, 1.05), and intra-abdominal abscesses (pooled RR .80, 95% CI .03, 1.58). Patients treated by GS did have a significantly higher risk of negative appendectomies (pooled RR 1.47, 95% CI 1.10, 1.84) when compared to PS.Discussion: This is the first meta-analysis to compare outcomes for pediatric appendectomies performed by GS compared to PS. Patient outcomes and resource utilization were similar among PS and GS, except for negative appendectomies were significantly more likely with GS.