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Recurrent primary spontaneous pneumothorax (PSP) is often managed with a wedge resection (or blebectomy) and either pleurectomy or pleurodesis. There is a conflicting data regarding which approach is superior to reduce recurrence. Our objective is to evaluate the long-term recurrence rates following pleurectomy versus mechanical pleurodesis for recurrent PSP.The PearlDiver Mariner Patient Claims Database was queried for patients aged 10-25 who were presented with PSP and underwent either pleurectomy or mechanical pleurodesis between 2010 and 2020. The primary outcome was recurrence and secondary outcomes included 30-day opioid prescriptions, pain diagnoses, and reimbursement. Kaplan-Meier analysis and Cox proportional hazards regression models were used with adjustment for age and sex.Of 18,955 patients presenting with PSP, 5.1% (n = 968) were managed operatively with either pleurectomy (18.3%, n = 177) or mechanical pleurodesis (81.7%, n = 791). There was no difference in the rate of recurrence between pleurectomy and mechanical pleurodesis (5-year risk of recurrence: 25.8% versus 26.5%, adjusted hazard ratio (HR) = 1.12 [95% confidence interval (CI): 0.79, 1.58]). Furthermore, there was no difference in rate of outpatient opioid prescription (49.2% versus 52.8%, P = 0.58) or pain diagnoses (22.0% versus 22.8%, P = 0.46) between pleurectomy and mechanical pleurodesis, respectively. The median reimbursement was higher following pleurectomy as compared to mechanical pleurodesis ($14,040 versus $5,811, P = 0.02).There is no significant difference in recurrence based on type of procedure performed for recurrent primary spontaneous pneumothorax. However, reimbursement is higher following pleurectomy. Given the similar outcomes but higher cost, we recommend mechanical pleurodesis over pleurectomy for recurrent PSP.

This cross-sectional study characterizes the use of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Z codes for social determinants of health among surgical vs nonsurgical practitioners at 3 academic hospitals.

Introduction : General surgery residents often feel unprepared to perform pediatric surgery procedures since case volume and experience may be low. Previously, we successfully implemented a simulation-based training (SBT) module for placement of a silastic silo for gastroschisis. Therefore, we designed a single institution pilot study to assess whether SBT for placement of a percutaneous peritoneal drain for perforated necrotizing enterocolitis (NEC) was feasible and lead to skill acquisition and increased confidence. Methods : Our newly created NEC module within our pediatric surgery SBT curriculum for general surgery residents was used. Residents completed two simulation sessions three months apart with confidence testing before and after each session. Skill acquisition and performance were assessed using a standardized case scenario and procedure checklist. Changes in residents’ confidence and performance were determined using Wilcoxon Signed-Rank Tests. Results : Nine post-graduate-year three general surgery residents completed this curriculum. Following completion, residents reported improved confidence completing each step of the procedure initially (p = 0.005) and at 3 months (p = 0.008) with improved technical scores (p = 0.011). The number of residents deemed proficient significantly improved (p = 0.031). Conclusion : Implementation of SBT module for perforated NEC was feasible and improved residents’ confidence and proficiency completing the procedure.

Introduction The disruption score is a new bibliometric tool that has recently been utilized to identify studies that are innovative and shift paradigms. We sought to identify and characterize the top 100 most disruptive publications in pediatric surgery. Methods The 100 most disruptive and cited publications in 17 pediatric surgery journals were identified from a validated dataset and linked with the iCite NIH tool. The top 100 most disruptive publications were reviewed to determine study design, clinical focus, and perceived contribution. Results The publications included in the top 100 list were more disruptive than 99.5% of the entire PubMed universe. Journal of Pediatric Surgery (n = 45) had the most articles included. There was a weak correlation between citation count and disruption score (r = 0.27). Retrospective cohort studies (38%), contributions in clinical outcomes (39%), technical/technological innovations (31%), clinical focus in trauma (18%), and disorders of the gastrointestinal tract (18%) were the most represented. The disruption score identified a unique subset of literature that has created new paradigms with long lasting influence and may be further applied as another tool to measure scientific impact. This wide array of literature highlights both technical and technological innovations as well as key moments in the history of pediatric surgery. Level of evidence V

Total thyroidectomy for benign disease is becoming more common among children. The purpose of this study was to evaluate 30-day outcomes in children undergoing total thyroidectomy and determine if the short-term outcomes are different in those with a malignant versus benign indication for surgery.This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-Pediatric) to identify all children who underwent total thyroidectomy from 2015 to 2019. Fisher's exact test was used to compare postoperative outcomes between benign and malignant indications for thyroidectomy.Among 1595 total thyroidectomy patients, 1091 (68.4%) had a benign indication and 504 (31.6%) had a malignant indication. There were 1234 (77.4%) females, and the median age was 14.9 y (interquartile range [IQR] 12.5, 16.6). Average length of stay (LOS) was similar between cohorts (1.7 d for benign and 1.9 d for malignant, P = 0.30). Parathyroid auto-transplantation was performed in 71 (6.5%) patients in the benign cohort and 43 (8.6%) in the malignant cohort (P = 0.15). The most common complications were readmissions (23 [2.1%] benign and 15 [3.0%] malignant, P = 0.29) and reoperations (7 [0.6%] benign and 5 [1.0%] malignant, P = 0.54). Complication profiles were similar between benign and malignant cohorts (2.8% and 4.6%, respectively [P = 0.10]).Children undergoing total thyroidectomy for benign and malignant indications have low rates of 30-d postoperative complications, suggesting that total thyroidectomy is a safe option for children with benign disease. Evaluation of long-term outcomes is needed.

Alignment between pediatric patients and caregiver perspectives on patient-reported outcome (PRO) data is contingent upon context. We aimed to assess agreement between patient and caregiver responses to a series of perioperative domains.Agreement between pediatric patients and caregiver responses to preoperative and postoperative surveys about surgery preparedness, perioperative expectations, PRO Measurement Information System (PROMIS) measures for overall health and pain, and reaching milestones gathered as part of an ongoing clinical trial for children undergoing gastrointestinal surgery, was evaluated. Gwet's AC and Spearman's correlation coefficients were calculated, as appropriate, to assess agreement.Of 209 enrolled patients, 65 (31.1%) dyads completed all three surveys and were included. For the domains of education, expectations, and comprehension, patients and caregivers had good agreement with Gwet ACPediatric patient and caregiver agreement on perioperative survey items ranged from moderate to strong. Caregivers' responses may be acceptable when some patient-level responses are not available.

Reported recurrence rates after laparoscopic versus open inguinal hernia repair have been limited to high volume centers with short follow-up. We sought to compare national rates of recurrence after laparoscopic versus open bilateral inguinal hernia repair.Children under five who underwent bilateral inguinal hernia repair between 2010 and 2020 were identified using the PearlDiver Mariner database. Time to recurrence was compared using Kaplan Meier analysis and Cox proportional hazards regression models.Hernia recurrence requiring reoperation occurred in 182 (2.2%) of 8,367 children. Rate of recurrence was higher following laparoscopic repair compared to open (1-year: 2.8% vs. 1.5%; 3-year: 3.7% vs. 2.0%; p 0.01). This difference remained after adjustment for demographic and operative characteristics (adjusted hazard ratio [aHR]: 2.00 [95% confidence interval [CI]: 1.31, 3.05]).Risk of recurrence was higher after laparoscopic compared to open repair of bilateral inguinal hernia repair in a national cohort of children under age five.

Neonatal circumcision is a common pediatric procedure performed in both the inpatient and outpatient setting. We aimed to determine if procedure location affected 30-day post-procedure healthcare utilization rates, inpatient length of stay (LOS), and amount charged.We performed a retrospective cohort study comparing 30-day postoperative healthcare utilization (emergency department (ED) visits, office visits, readmissions) of full-term infants who underwent an outpatient versus inpatient (same admission as birth) circumcision from 2015 to 2020. Statistical analyses included Chi-square tests, multivariable adjusted logistic regression models when appropriate.3137 infants were included, 1426 (45.5%) had an outpatient circumcision, 1711 (54.5%) an inpatient. Outpatient had similar overall healthcare utilization rates as inpatients (5.7% vs. 5.6%, p = 0.933). The number of ED visits (1.5% vs 0.8%, p = 0.055), office visits (4.5% vs. 5.1%, p = 0.437), and readmissions (0.2% vs. 0.0%, p = 0.058) were not significantly different. Infants with inpatient circumcisions had longer LOS after adjusting for age, ethnicity and delivery type (Cesarean versus vaginal) with an incident rate ratio of 1.97 (95% confidence interval 1.84-2.11, p0.001). Outpatient circumcision resulted in average charges of $372 more than inpatient.Outpatient circumcision has a minimal effect on healthcare utilization rates but lead to a shorter hospital stay following birth and increased charge.Retrospective LEVEL OF EVIDENCE: III.

Limited in-person visits during the COVID-19 pandemic, with liberal reimbursement policies, resulted in increased use of video conferencing (hereby described as telehealth) for patient care. To better understand the impact on pediatric surgeons and their patients, we surveyed members of the American Pediatric Surgical Association (APSA) regarding telehealth use prior to and during the pandemic.An iteratively developed survey was sent to all active, non-trainee surgeons within APSA during March 2021.Of 247 responses (23% response rate), 154 (62%) began using telehealth during the pandemic. In addition to the 101 (60.5%) respondents who felt telehealth had a positive impact on their clinical practice, 161 (74.2%) felt that it had a positive impact on their patients' satisfaction. The most common barriers to telehealth use prior to COVID-19 were availability of technology (39.3%), patient access to technology (36.0%), and lack of reimbursement (32.0%). These barriers became less substantial during the pandemic. Most respondents (95.3%) indicated they would continue using telehealth post-pandemic if it remains appropriately reimbursed.The majority of pediatric surgeons implemented telehealth during the COVID-19 pandemic and endorsed a positive effect on their clinical practice as well as on patient satisfaction. An overwhelming majority would continue using this technology if reimbursement policies remain favorable.

Despite evidence supporting short course outpatient antibiotic treatment following appendectomy for perforated appendicitis, evidence of real-world implementation and consensus for antibiotic choice is lacking. We therefore aimed to compare outpatient antibiotic treatment regimens in a national cohort.We identified children who underwent surgery for perforated appendicitis between 2010 and 2018 using the PearlDiver database and compared 45-day disease-specific readmission between children who received shortened (5-8 days) versus prolonged (10-14 day) total antibiotic courses (inpatient intravenous and/or oral) completed with outpatient Amoxicillin/Clavulanate versus Ciprofloxacin/Metronidazole, and compared antibiotic type (5-14 days) to each other.4916 children were identified, 2001 (90.0%) treated with Amoxicillin/Clavulanate (5-14 days), 381 (19.0%) with shortened (5-8 days), 1464 (73.2%) with prolonged (10-14 days) courses. 222 (10.0%) were treated with Ciprofloxacin/Metronidazole, 44 (19.8%) with shortened, 174 (78.4%) with prolonged courses. Freedom from readmission was not different between prolonged and shortened course whether they received Amoxicillin/Clavulanate (adjusted hazard ratio [AHR] 1.54, 95%CI 0.95-2.5) or Ciprofloxacin/Metronidazole (AHR 3.49, 95%CI 0.45-27.3). Antibiotic type did not affect readmission rate (Amoxicillin/Clavulanate versus Ciprofloxacin/Metronidazole, AHR 1.21, 95%CI 0.71-2.05).Prolonged antibiotic regimens are routinely prescribed despite evidence suggesting shorter courses and antibiotic choice are not associated with greater treatment failure. As it is better tolerated, we recommend a shortened course of Amoxicillin/Clavulanate for oral management of perforated appendicitis.Retrospective.Level III.

Mesenteric cysts are benign congenital cysts typically discovered incidentally during abdominal explorations for other reasons. When feasible, they should be excised to prevent recurrence, bowel obstruction or volvulus, and resulting complications. We present a unique case of an infant, diagnosed prenatally by ultrasound with possible bowel obstruction, found to have micro and macro chylous mesenteric cysts. Although initially asymptomatic with normal abdominal x-ray and discharged on day of life 2, the parents were taught how to recognize symptoms of bowel obstruction. He presented at 1 month with obstructive symptoms, was confirmed to have large mesenteric cystic structures on ultrasound, and was immediately taken to the operating room. Due to the extensive number of cysts and intimate involvement of the largest cyst with the superior mesenteric artery, he was treated with partial excision and observation since resection may have resulted in short gut syndrome. Given a prenatal ultrasound suggestive of mesenteric cysts, we recommend abdominal imaging at birth with close follow-up until the appropriate time for elective resection. When disease is extensive precluding full enucleation and resection, we advocate for enucleation in combination with unroofing of as many cysts as possible followed by postoperative surveillance ultrasounds and family counseling.

To assess surgical outcomes of patients with cerebral palsy (CP) and if they differ from patients without CP.The NSQIP-Pediatric database from 2012 to 2019 was used to compare differences in presenting characteristics and outcomes between patients with and without CP. Chi-square tests and multivariable logistic regression analysis were used to determine significance.119,712 patients, 433 (0.4%) with CP, 119,279 (99.6%) without, were identified. Patients with CP had more postoperative complications (19.4% vs. 6.9%, p 0.001) with an OR of 3.2, (95%CI 2.5-4.1, p 0.001) on univariable analysis. They underwent fewer laparoscopic procedures (79.1% vs. 90.8%, p 0.001), had more readmissions (10.2% vs. 3.8%, p 0.001), reoperations (5.1% vs. 1.2%, p 0.001), and longer length of stays (LOS) (median 3 versus 1 day, p 0.001). On multivariable analysis, having CP did not increase the odds of postoperative morbidity (OR 0.99, 95% CI 0.7-1.3), but higher ASA class, congenital lung malformation, gastrointestinal disease, coagulopathy, preoperative inotropic support, oxygen use, nutritional support, and steroid use significantly increase the odds of morbidity, all of which were more common in patients with CP.Patients with CP have more postoperative complications, open procedures, and longer LOS. Patient complexity may account for these differences and risk-directed perioperative planning may improve outcomes.Level IV.

Introduction General surgery residents often feel unprepared for rotations on pediatric surgical services as case volume and experience performing pediatric procedures may be inadequate for high acuity, low volume procedures. We designed a single institution pilot study to assess whether simulation-based training (SBT) for placement of a silastic silo for gastroschisis was feasible and lead to skill acquisition, retention and increased resident confidence. Methods We used our newly created gastroschisis module within our pediatric surgery SBT curriculum for general surgery residents. Residents completed two simulation sessions three months apart, completed confidence testing before and after each session, and were assessed using a standardized case scenario and procedure checklist. Wilcoxon Signed-Rank Tests evaluated changes in residents’ confidence and performance. Results Ten post-graduate-year three general surgery residents completed this curriculum. Residents reported improved confidence completing each step of the procedure initially (p = 0.008) and at 3 months (p = 0.005). They had improved technical scores across all steps of the procedure (p = 0.005). The number of residents deemed proficient significantly improved (p = 0.008). Conclusion We demonstrated the feasibility of assessing the technical skills of general surgery residents performing a simulated placement of a silastic silo for gastroschisis. Residents’ confidence and proficiency improved over the three-month period. Study Type Prospective Level of Evidence Level II

Intussusception is the most common cause of bowel obstruction in infants four to ten months old and is commonly idiopathic or attributed to lymphoid hyperplasia. Our patient was a 7-month-old male who presented with two weeks of intermittent abdominal pain associated with crying, fist clenching and grimacing. Ultrasound demonstrated an ileocolic intussusception in the right abdomen. Symptoms resolved after contrast enemas, and he was discharged home. He re-presented similarly the next day and was found to be COVID-19 positive. Computed tomography scan demonstrated a left upper quadrant ileal-ileal intussusception. His symptoms spontaneously resolved, and he was discharged home. This suggests that COVID-19 may be a cause of intussusception in infants, and infants presenting with intussusception should be screened for this virus. Additionally, recurrence may happen days later at different intestinal locations. Caregiver education upon discharge is key to monitor for recurrence and need to return.

Smoking is associated with an increased risk of spontaneous pneumothorax. Typically linked to tobacco smoking and cannabis use, to date there have been no reports of spontaneous pneumothorax associated with electronic cigarette use or “vaping.” Rates of vaping are rapidly rising amongst adolescents. We present two male patients age 15 and 16 who had a spontaneous pneumothorax after vaping and were initially treated with tube thoracostomy placement. Both patients had recurrences requiring surgical intervention and have been recurrence-free since. This is the first known report of vaping and its association with spontaneous pneumothorax. A comprehensive smoking history that includes vaping is important in patients presenting with suspected pneumothoraces as it can lead to earlier cessation interventions, help prevent recurrence, and raise suspicion for pneumothorax in patients presenting without severe symptoms. As more studies demonstrate vaping-associated lung injury, we advocate for stricter standards of quality control for electronic cigarettes and encourage legislators to do the same. Keywords: Spontaneous pneumothorax, Vaping, Electronic cigarettes, Smoking

Mosquitoes in the Culex pipiens complex (Diptera: Culicidae), especially Cx. pipiens and Culex quinquefasciatus, have successfully exploited the rapid growth of the human population and globalization to their advantage by successfully utilizing man-made habitats, particularly for oviposition. Culex spp. lay over 100 eggs together in a raft. Each egg in the raft produces an apical droplet containing an oviposition attractant, erythro-6-acetoxy-5-hexadecanolide, commonly referred to as Mosquito Oviposition Pheromone (MOP). Here we present a detailed gas chromatography–mass spectrometry (GC–MS) analysis of the apical droplets from six populations that revealed MOP as the most abundant constituent. Subjecting MOP and the remaining 17 most abundant chemical constituents of the droplets from these populations to a Principal Component Analysis (PCA) resolved the populations into two distinct clusters that contained two populations each of Cx. quinquefasciatus and Culex pipiens molestus. The two Culex pipiens pipiens, however, did not resolve into a single cluster, with the Shasta population sorting closer to Cx. quinquefasciatus. Comparing the PCA scores with the genetic evidence from adult females using available molecular markers that have earlier shown to sort various Culex forms, we found that the molecular data support the PCA clustering pattern. Behavioral investigation of the droplet-induced attraction tested in gravid Cx. quinquefasciatus elicited various degrees of oviposition to the droplets from each population. Overall, droplets from all six populations induced higher attraction compared to controls. A detailed time-course analysis of droplet composition in Cx. quinquefasciatus from 6 to 54 h post egg-laying identified MOP again as the main constituent. Finally, our electrophysiological investigation identified MOP as the only biologically active constituent from of the droplets eliciting responses from female antennae. These studies will aid in global efforts to understand the vector biology and evolution that can be exploited to develop novel vector management strategies.

The development of sex-specific traits, including the female-specific ability to bite humans and vector disease, is critical for vector mosquito reproduction and pathogen transmission. Doublesex (Dsx), a terminal transcription factor in the sex determination pathway, is known to regulate sex-specific gene expression during development of the dengue fever vector mosquito Aedes aegypti. Here, the effects of developmental siRNA-mediated dsx silencing were assessed in adult females. Targeting of dsx during A. aegypti development resulted in decreased female wing size, a correlate for body size, which is typically larger in females. siRNA-mediated targeting of dsx also resulted in decreased length of the adult female proboscis. Although dsx silencing did not impact female membrane blood feeding or mating behavior in the laboratory, decreased fecundity and fertility correlated with decreased ovary length, ovariole length, and ovariole number in dsx knockdown females. Dsx silencing also resulted in disruption of olfactory system development, as evidenced by reduced length of the female antenna and maxillary palp and the sensilla present on these structures, as well as disrupted odorant receptor expression. Female lifespan, a critical component of the ability of A. aegypti to transmit pathogens, was also significantly reduced in adult females following developmental targeting of dsx. The results of this investigation demonstrate that silencing of dsx during A. aegypti development disrupts multiple sex-specific morphological, physiological, and behavioral traits of adult females, a number of which are directly or indirectly linked to mosquito reproduction and pathogen transmission. Moreover, the olfactory phenotypes observed connect Dsx to development of the olfactory system, suggesting that A. aegypti will be an excellent system in which to further assess the developmental genetics of sex-specific chemosensation., Author Summary Only adult female mosquitoes, which require blood meals for reproduction, bite humans and spread diseases. The genes that regulate development of sex-specific traits may therefore represent novel targets for mosquito control. Here, we examine the effects of silencing the sex-determination gene doublesex (dsx) during development of the human disease vector mosquito Aedes aegypti. Targeting of dsx resulted in decreased length of the female wing and proboscis, ovary and reproductive defects, and disruption of olfactory system development. Female lifespan, a critical aspect of mosquito pathogen transmission, was also significantly reduced in adult females following developmental targeting of dsx. The results of this investigation demonstrate that silencing of dsx during A. aegypti development disrupts multiple sex-specific morphological, physiological, and behavioral traits of adult females, a number of which are directly or indirectly linked to mosquito reproduction and pathogen transmission. The results obtained also connect Dsx to development of the mosquito olfactory system, suggesting that A. aegypti will be an excellent system in which to further assess the developmental genetics of sex-specific chemosensation.