From
StayCurrentMD
Update Course Rewind: 2022 Top Ten Key Takeaways
With Dr. Todd Ponsky · hosted by Dr. M. Tom Bash
Chapter 8 of 10 · Evidence & Research
Addressing bias
Implicit and Explicit Bias in Medicine
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Infants with gastroschisis often require prolonged hospitalization for surgical repair and initiation and advancement of feeds.
Based on recently updated protocols from Cincinnati Children's Hospital and Children's Mercy Kansas City, feeds can be started immediately after sutureless abdominal closure for uncomplicated gastroschisis, beginning with 10-20 mL/kg/day and advancing by 20 mL/kg/day if tolerated.
Immediate feeding after gastroschisis closure has been shown to be associated with shorter length of stay and faster attainment of goal feeds.
For babies with uncomplicated gastroschisis tolerating feeds for a few days, it is okay to continue the feeding protocol even after one bout of emesis.
High resolution esophageal manometry, esophagography, and endoscopy can help determine the diagnosis of congenital esophageal stenosis.
Serial dilations may be used to manage congenital esophageal stenosis if there is no cartilage component suspected in the stenotic area.
Surgical resection for congenital esophageal stenosis can be reserved for patients where serial dilation is unsuccessful or there is concern for a cartilaginous component.
Initial conservative management should be considered for patients with congenital esophageal stenosis, especially if a cartilaginous component is not suspected.
Management of intussusception after enema reduction varies in practice, with historically recommended inpatient observation lacking evidence-based guidelines.
A systematic review and meta-analysis found that overall recurrence rates and recurrences within 24 and 48 hours were similar between inpatient and outpatient management groups after intussusception enema reduction.
There was no significant difference in the rate of return to the emergency department between inpatient and outpatient management after intussusception reduction, and both groups had similar rates of requiring operative intervention.
Outpatient management of intussusception after air enema reduction results in shorter hospital stay with no difference in rate of ED returns, recurrence, need for operation, or mortality.
There is no compelling evidence in pediatric or adult literature to support mechanical bowel preparation reducing surgical site infections in colorectal surgery.
Recent adult studies have shown no benefit from mechanical bowel preparation in reducing surgical site infections, with some studies showing an increase in wound infections.
Adult studies suggest a possible benefit of oral and IV antibiotics to reduce surgical site infections in colorectal surgery.
Recent retrospective studies have not shown the importance of oral antibiotics for pediatric colorectal operations.
Case-appropriate preoperative IV antibiotics may reduce surgical site infection incidence in colorectal surgery.
Firearms are now the leading cause of death in all children and adolescents in the United States, overtaking motor vehicle crashes in 2019.
There are controversies about whether pediatric surgeons should be involved in firearm violence prevention efforts and advocacy across the country.
As pediatric surgeons, we need to advocate for protecting children's health and well-being, no matter what the topic is.
Pediatric surgeons can play key roles for patients affected by firearms, including direct patient care and advocacy.
Unwitnessed foreign body aspiration can be challenging to manage, and many items are not radiopaque so cannot be seen on plain x-ray.
The gold standard for airway evaluation has been rigid or flexible bronchoscopy, but there are risks of negative bronchoscopy with subsequent airway compromise.
CT bronchoscopy has been proposed as an adjunct in cases of children without obvious respiratory distress.
Low-dose non-contrast CT of the chest has high sensitivity and specificity for identification of airway foreign bodies.
CT can avoid the cost and resources of taking a child to the operating room for a non-therapeutic bronchoscopy procedure.
The largest study looking at initial laparotomy versus peritoneal drainage for necrotizing enterocolitis was conducted at 20 US centers and examined combined death or neurodevelopmental impairment at corrected age 18-22 months.
Death or neurodevelopmental impairment occurred in 69% of patients with preoperative diagnosis of NEC who underwent initial laparotomy versus 85% of those who underwent initial peritoneal drainage.
The prospective randomized cohort study from the National Institute of Child Health and Human Development showed no difference in overall survival but did show improved long-term neurodevelopmental outcomes with initial laparotomy for NEC.
For infants with necrotizing enterocolitis, initial laparotomy may be associated with less neurodevelopmental impairment and improved outcomes for extremely low birth weight babies.
Racism and sexism that manifest as microaggressions are commonly experienced by members of minority groups.
Individuals from minoritized groups are often left weighing the potential benefits and risks of addressing microaggression comments.
Placing the burden to interrupt bias on marginalized colleagues is unjust, and microaggressions can harm trainees' performance and sense of belonging.
Bystanders can and should make an effort to become upstanders, which means bystanders who respond with action to interrupt microaggressions.
Blunt head trauma represents the majority of pediatric trauma admissions, but there is very little evidence on how to best manage isolated skull fractures.
A 10-year retrospective review of isolated traumatic skull fractures with normal neurologic exam findings showed that 77% of patients were admitted for observation, but none needed neurosurgical intervention or additional imaging during the index admission.
Pediatric isolated skull fractures are low risk conditions with a low likelihood of complications, and these patients can be discharged safely from the emergency department without inpatient observation.
The IMPACT trial was a multi-institutional prospective randomized trial comparing piperacillin-tazobactam monotherapy versus ceftriaxone-metronidazole combination therapy for perforated appendicitis in children, with 30-day post-operative intra-abdominal abscess rate as the primary outcome.
Patients taking piperacillin-tazobactam had lower incidence of intra-abdominal abscesses, lower usage of CT scans, and fewer ED revisits compared to combination therapy.
Piperacillin-tazobactam monotherapy did not have an increase in antibiotic usage or increase in antibiotic-related complications compared to combination therapy.
Monotherapy with piperacillin-tazobactam has been shown to be associated with decreased incidence of intra-abdominal abscesses after surgery for patients with perforated appendicitis.