Pathways to the therapist paragon: a decolonial grounded theory.

Introduction: While many professional associations within clinical and counseling psychology have made an aspirational call for clinician awareness of social position, there is a lack of research into how socially-conferred privilege impacts psychotherapy. Specifically of interest is the differences in race and gender within the therapeutic dyad, in which there is a BIPOC (Black, Indigenous, and Persons of Color)/white or male/female-identified dynamic. Method: The authors utilized a Grounded Theory approach to analyze qualitative interviews with practicing psychologists to construct a process model regarding how socially-conferred privileged identity domains impact the therapeutic relationship and the participants' professionalization process. Results: The analysis identified the core conceptual theme of the Therapist Paragon, representing an idealized version of what a perfect therapist should be. This replicated the foundational figures of our field - primarily older, white men. The process model consisted of two distinct pathways toward the Therapist Paragon, one for BIPOC psychologists and one for white psychologists. The female BIPOC pathway consisted of imposter syndrome, persistent feelings of inadequacy, and tendencies to over-credential their professional identity to seek credibility in the eyes of clients and colleagues. The white pathway consisted of down-playing whiteness and attempting to initially modify behavior toward client cultural norms. Discussion: The results point to a distinct professionalization and practice process for BIPOC psychologists compared to white counterparts. This dynamic may have implications beyond increasing support for BIPOC clinicians specifically, but instead indicate a lack of acknowledgement of the psychological impact of socially-conferred privilege in the psychotherapy enterprise overall. Recommendations are offered for revisions to training models, continuing education, and supervision/consultation.

Profiling alveolar macrophage responses to inhaled compounds using in vitro high content image analysis.

One of the main hurdles in the development of new inhaled medicines is the frequent observation of foamy macrophage (FM) responses in non-clinical studies in experimental animals, which raises safety concerns and hinders progress into clinical trials. We have investigated the potential of a novel multi-parameter high content image analysis (HCIA) assay as an in vitro safety screening tool to predict drug induced FM. Rat (NR8383) and human U937-derived alveolar macrophages were exposed in vitro to a panel of model compounds with different biological activity, including inhaled bronchodilators, inhaled corticosteroids (ICS), phospholipidosis inducers and proapoptotic agents. An HCIA was utilized to produce drug-induced cell response profiles based on individual cell health, morphology and lipid content parameters. The profiles of both rat and human macrophage cell lines differentiated between cell responses to marketed inhaled drugs and compounds known to induce phospholipidosis and apoptosis. Hierarchical clustering of the aggregated data allowed identification of distinct cell profiles in response to exposure to phospholipidosis and apoptosis inducers. Additionally, in NR8383 cell responses formed two distinct clusters, associated with increased vacuolation with or without lipid accumulation. U937 cells presented a similar trend but appeared less sensitive to drug exposure and presented a narrower range of responses. These results indicate that our multi-parameter HCIA assay is suitable to generate characteristic drug-induced macrophage response profiles, thus enabling differentiation of foamy macrophage phenotypes associated with phospholipidosis and apoptosis. This approach shows great potential as pre-clinical in vitro screening tool for safety assessment of candidate inhaled medicines.

Threshold Microsecond Pulsed Electric Field Exposures for Change in Spinach Quality.

Pulsed electric fields (PEFs) are often used to pretreat foods to enhance subsequent processes, such as drying, where maintaining food product quality is important for consumer satisfaction. This study aims to establish a threshold PEF exposure to determine the doses at which electroporation is viable for use on spinach leaves, wherein integrity is maintained postexposure. Three numbers of consecutive pulses (1, 5, 50) and two pulse durations (10 and 100 µs) have been examined herein at a constant pulse repetition of 10 Hz and 1.4 kV/cm field strength. The data indicate that pore formation in itself is not a cause for loss of spinach leaf food quality, i.e., significant changes in color and water content. Rather, cell death, or the rupture of the cell membrane from a high-intensity treatment, is necessary to significantly alter the exterior integrity of the plant tissue. PEF exposures thus can be used on leafy greens up until the point of inactivation before consumers would see any alterations, making reversible electroporation a viable treatment for consumer-intended products. These results open up future opportunities to use emerging technologies based on PEF exposures and provide useful information in setting parameters to avoid food quality diminishment.

Spanish-Speaking Patients Have Limited Access Scheduling Outpatient Orthopaedic Appointments Compared With English-Speaking Patients Across the United States.

Purpose: To evaluate whether Spanish-speaking patients can obtain appointments to outpatient orthopaedic surgery clinics across the United States at a similar rate as English-speaking patients and to examine the language interpretation services available at those clinics. Methods: Orthopaedic offices nationwide were called by a bilingual investigator to request an appointment with a pre-established script. The investigators called in English asking for an appointment for an English-speaking patient (English-English), called in English requesting an appointment for a Spanish-speaking patient (English-Spanish), and called in Spanish asking for an appointment for a Spanish-speaking patient (Spanish-Spanish) in a random order. During each call whether an appointment was given, the number of days to the offered appointment, the mechanism of interpretation available in clinic, and whether the patient's citizenship or insurance information was requested was collected. Results: A total of 78 clinics included in the analysis. There was a statistically significant decrease in access to scheduling an orthopaedic appointment in the Spanish-Spanish group (26.3%) compared with English-English (61.3%) or English-Spanish (58.8%) groups (P < .001). There was no significant difference in access to appointment between rural and urban areas. Patients in the Spanish-Spanish group who made an appointment were offered in-person interpretation 55% of the time. There was no statistically significant difference in time from call to offered appointment or the request for citizenship status between the 3 groups. Conclusions: This study detected a considerable disparity regarding access to orthopaedic clinics nationwide in the individuals who called to establish an appointment in Spanish. Patients in the Spanish-Spanish group were able to make an appointment less often but had in-person interpreters available for interpretation services. Clinical Relevance: With a large Spanish-speaking population in the United States, it is important to understand how lack of proficiency with the English language may affect access to orthopaedic care. This study uncovers variables associated with difficulties scheduling appointments for Spanish-speaking patients.

Factors contributing to the utilization of robotic colorectal surgery: a systematic review and meta-analysis.

BACKGROUND: Some studies have suggested disparities in access to robotic colorectal surgery, however, it is unclear which factors are most meaningful in the determination of approach relative to laparoscopic or open surgery. This study aimed to identify the most influential factors contributing to robotic colorectal surgery utilization. METHODS: We conducted a systematic review and random-effects meta-analysis of published studies that compared the utilization of robotic colorectal surgery versus laparoscopic or open surgery. Eligible studies were identified through PubMed, EMBASE, CINAHL, Cochrane CENTRAL, PsycINFO, and ProQuest Dissertations in September 2021. RESULTS: Twenty-nine studies were included in the analysis. Patients were less likely to undergo robotic versus laparoscopic surgery if they were female (OR = 0.91, 0.84-0.98), older (OR = 1.61, 1.38-1.88), had Medicare (OR = 0.84, 0.71-0.99), or had comorbidities (OR = 0.83, 0.77-0.91). Non-academic hospitals had lower odds of conducting robotic versus laparoscopic surgery (OR = 0.73, 0.62-0.86). Additional disparities were observed when comparing robotic with open surgery for patients who were Black (OR = 0.78, 0.71-0.86), had lower income (OR = 0.67, 0.62-0.74), had Medicaid (OR = 0.58, 0.43-0.80), or were uninsured (OR = 0.29, 0.21-0.39). CONCLUSION: When determining who undergoes robotic surgery, consideration of factors such as age and comorbid conditions may be clinically justified, while other factors seem less justifiable. Black patients and the underinsured were less likely to undergo robotic surgery. This study identifies nonclinical disparities in access to robotics that should be addressed to provide more equitable access to innovations in colorectal surgery.

An appraisal of technical variant grafts compared to whole liver grafts in pediatric liver transplant recipients: Multicenter analysis from the SPLIT registry.

BACKGROUND: Shortages of liver allografts for children awaiting transplantation have led to high LT waitlist mortality. Prior studies have shown that usage of TVG can reduce waiting time and waitlist mortality, but their use is not universal. We sought to compare patient and graft survival between WLG and TVG and to identify potential associated risk factors in a contemporary pediatric LT cohort. METHODS: We performed a retrospective analysis of patient survival, graft survival, and biliary and vascular complications for LT recipients <18 years old entered into the Society of Pediatric Liver Transplantation prospective multicenter database. RESULTS: Of 1839 LT recipients, 1029 received a WLG and 810 received a TVG from either a LD or a DD. There was no difference in patient survival or graft survival by graft type. Three-year patient survival and graft survival were 96%, 93%, and 96%, and 95%, 89%, and 92% for TVG-LD, TVG-DD, and WLG, respectively. Biliary complications were more frequent in TVG. Hepatic artery thrombosis was more frequent in WLG. Multivariate analysis revealed primary diagnosis was the only significant predictor of patient survival. Predictors for graft survival included time-dependent development of biliary and vascular complications. CONCLUSIONS: There were no significant differences in patient and graft survival based on graft types in this North American multi-center pediatric cohort. Widespread routine use of TVG should be strongly encouraged to decrease mortality on the waitlist for pediatric LT candidates.

Predictors of survival following liver transplantation for pediatric hepatoblastoma and hepatocellular carcinoma: Experience from the Society of Pediatric Liver Transplantation (SPLIT).

Management of unresectable pediatric hepatoblastoma (HB) and hepatocellular carcinoma (HCC) remains challenging. The Society of Pediatric Liver Transplantation (SPLIT) database was used to study survival predictors in pediatric liver transplantation (LT) for HB and HCC. Event-free survival (EFS), associated risk factors, and postoperative complications were studied in children requiring LT for HB/HCC at 16 SPLIT centers. Three-year EFS was 81% for HB (n = 157) and 62% for HCC (n = 18) transplants. Of HB transplants, 6.9% were PRETEXT II and 15.3% were POST-TEXT I/II. Tumor extent did not impact survival (p = NS). Salvage (n = 13) and primary HB transplants had similar 3-year EFS (62% versus 78%, p = NS). Among HCC transplants, 3-year EFS was poorer in older patients (38% in ≥8-year-olds vs 86% <8-year-olds) and those with larger tumors (48% for those beyond versus 83% within Milan criteria, p = NS). Risk of infection (HR 1.5, 95% CI 1.1-2.2, p = .02) and renal injury (HR 2.4, 95% CI 1.7-3.3, p < .001) were higher in malignant versus nonmalignant LT. Survival is favorable for pediatric HB and HCC LT, including outcomes after salvage transplant. Unexpected numbers of LTs occurred in PRE/POST-TEXT I/II tumors. Judicious patient selection is critical to distinguish tumors that are potentially resectable; simultaneously, we must advocate for patients with unresectable malignancies to receive organs.

Employment search, initial employment experience, and career preferences of recent pediatric surgical fellowship graduates: An APSA survey, part of the right child/right surgeon initiative.

BACKGROUND: APSA's Right Child/Right Surgeon Initiative addresses issues concerning patient access to appropriate pediatric surgical care and workforce distribution. The APSA Workforce Committee sought to understand the experiences and motivations of recent graduates of Pediatric Surgery Training Programs entering the workforce. METHODS: Using APSA membership databases, we identified members who completed fellowship training from 2010 to 2019. An online survey was created using Survey Monkey, and invitations to participate were sent via email. RESULTS: 144 of 447 invited participants responded (32% response rate). 91% of respondents participated in dedicated research prior to fellowship, but only 64% perform research during their employment. 23% completed an additional clinical fellowship, but only 54% currently practice within the second field. When asked to identify the top three factors used to choose a position, the most common responses were "location or geography" (71%), "available mentorship" (53%), and "compensation and benefits" (37%). Describing their first position, 77% reported working in an academic institution, 78% reported working in a metropolitan/urban area, and 55% reported working in a free-standing children's hospital. 94% participate in General Surgery resident education, and 49% are faculty within a Pediatric Surgery fellowship. Overall, 92% of respondents were able to find the type of employment position that they had wanted. CONCLUSION: In our survey the overwhelming majority of young pediatric surgeons found the type of job they desired. Most report beginning their practice in more populated, urban areas within academic institutions. Geographic location and work environment played heavily into their employment decisions. These preferences could contribute to continued disparity in access to pediatric surgeons between urban and rural America and to dilution of experience for urban surgeons. Possible solutions include alternative incentive programs for employment in less populated areas or new training models for general surgeons in rural areas to train in fundamentals of Pediatric Surgery.

Ibalizumab-uiyk as a bridge therapy for a patient with drug-resistant HIV-1 infection receiving chemotherapy: A case report.

WHAT IS KNOWN AND OBJECTIVE: Treatment for diffuse large B-cell lymphoma (DLBCL) in persons with AIDS consists of chemotherapy alongside antiretroviral therapy (ART). To determine optimal HIV treatment, drug-drug interactions, toxic effects and ART resistance must be considered. CASE DESCRIPTION: A 40-year-old man with drug-resistant HIV and DLBCL initiating chemotherapy which had drug interactions with his ART. During chemotherapy, darunavir/cobicistat was held and ibalizumab-uiyk was started to ensure he was on three active HIV medications. WHAT IS NEW AND CONCLUSION: Ibalizumab-uiyk has no known drug-drug interactions and may be used as bridge therapy for patients with drug-resistant HIV undergoing chemotherapy.

Non-invasive forced oscillometry to quantify respiratory mechanics in term neonates.

BACKGROUND: To determine normative data by forced oscillation technique (FOT) in non-sedated normal term neonates and test the hypothesis that infants with transient tachypnea of the newborn (TTN) have higher resistance (R) and lower reactance (X) on day 1. METHODS: Healthy term infants (n = 138) and infants with TTN (n = 17) were evaluated on postnatal days 1 through 3 (NCT03346343). FOT was measured with a mask using a TremoFlo C-100 Airwave System™. R, X, and area under the reactance curve (AX) were measured at prime frequencies 7-41 Hz for 8 s. RESULTS: In all, 86% of control infants had adequate measurements (coherence >0.8, CV < 0.25) on day 1. Infants with TTN had higher resistance at 13 Hz (TTN 32.5 cm H2O·s/L [95% CI 25.5-39.4]; controls 23.8 cm H2O·s/L [95% CI 22.2 to 25.3], P = 0.007) and lower reactance from 17 to 37 Hz (TTN -35.1 to -10.5; controls -26.3 to -6.1, P < 0.05). In healthy controls, lung mechanics were unchanged from days 1 to 3. In TTN, lung mechanics normalized on days 2 and 3. CONCLUSIONS: FOT is feasible in neonates and distinguishes normal control infants from those with TTN on postnatal day 1. Oscillometry offers a non-invasive, longitudinal technique to assess lung mechanics in newborns.

Necrotizing enterocolitis totalis: High mortality in the absence of an aggressive surgical approach.

BACKGROUND: Necrotizing enterocolitis is the leading case of gastrointestinal-related morbidity in premature infants. Necrotizing enterocolitis totalis is an aggressive form of necrotizing enterocolitis, which has traditionally been managed with comfort care. Recent advances in management of short bowel syndrome have resulted in some reported long-term survival. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, studies that reported outcomes in children with necrotizing enterocolitis totalis were identified. The definition of necrotizing enterocolitis totalis was captured along with length of follow-up, patient demographics, and outcomes. RESULTS: A total of 766 articles were screened, of which 166 were selected for full article review. Of these, 32 articles included data on 414 patients with necrotizing enterocolitis totalis. In the majority of studies (52%), necrotizing enterocolitis totalis was not defined. Aggressive surgical therapy (defined as bowel resection or fecal diversion) was undertaken in 32 patients (7.7%), with a mortality rate of 68.8%. In contrast, nonaggressive surgical therapy was undertaken in 382 patients (92.3%), and the mortality in these patients was 95%. Long-term outcomes for necrotizing enterocolitis totalis survivors, such as length of time on parenteral nutrition, progression to liver and/or small bowel transplant, and quality of life, were not reported. CONCLUSION: We found that there is no accepted definition of necrotizing enterocolitis totalis. Aggressive surgical therapy is rarely pursued, which likely drives the overall high mortality rate. This study underscores the importance of standardizing the definition of necrotizing enterocolitis totalis and capturing short and long-term outcomes prospectively. With more aggressive surgical therapy, more infants are likely to survive this abdominal catastrophe, which was once thought to be uniformly fatal.

Risk factors for early onset peritonitis: the SCOPE collaborative.

BACKGROUND: Peritoneal dialysis (PD) is the preferred chronic dialysis modality amongst pediatric patients. Peritonitis is a devastating complication of PD. Adult data demonstrates early onset peritonitis (EP) is associated with higher rates of subsequent peritonitis and technique failure. Limited data exists regarding EP in the pediatric population, here defined as peritonitis occurring within 60 days of catheter insertion. METHODS: PD catheter insertion practices and EP episodes were examined from the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative database. RESULTS: There were 98 episodes of EP amongst 1106 PD catheters inserted. Multivariable analysis demonstrated a significant association between early use of the PD catheter and EP (P = 0.001). Age less than 1 year at the time of catheter insertion (P < 0.001), first catheter placed (P < 0.001) for the patient, use of a plastic adapter (P = 0.003), placement of sutures at the exit site (ES) (P = 0.032), and dressing change prior to 7 days post-operatively (P < 0.001) were all significantly associated with early PD catheter use. Concurrent placement of a hemodialysis catheter was associated with a decreased risk for early PD catheter use (P = 0.010). CONCLUSIONS: In this large cohort of pediatric PD recipients, 8.4% of PD catheters were associated with the development of EP. The finding of an association between early use of the PD catheter and EP represents a potentially modifiable risk factor to reduce infection rates within this patient population.

Extracorporeal Membrane Oxygenation in a Pediatric Patient with Hepatopulmonary Syndrome and Interrupted Inferior Vena Cava After Living Related Liver Donation.

Extracorporeal membrane oxygenation (ECMO) is used for cardiopulmonary dysfunction. Hepatopulmonary syndrome (HPS) occurs in the setting of liver failure and may cause hypoxemia. Previous reports have described the use of ECMO for HPS after liver transplant. Our patient is a 19-month-old female with biliary atresia, an interrupted inferior vena cava, and HPS on 8 liters per minute of high-flow oxygen. Following liver transplantation, her postoperative course was complicated by severe hypoxemia requiring ECMO. Due to her interrupted inferior vena cava, our standard bi-caval cannula could not be used. Hence, a 16-French double lumen venovenous right internal jugular to right atrial cannula was used to provide extracorporeal life support. She was decannulated after 17 days, remained intubated for 2 days, and weaned to room air over the next 3 weeks. This is the third pediatric liver transplant patient supported with ECMO identified in the literature, and the youngest and smallest of those reported. This approach to cannulation is unique because of the use of a double lumen venovenous cannula for HPS in a child, selected due to complex anatomy. Posttransplant ECMO may provide pediatric patients with HPS and posttransplant hypoxemia a period of support for their pulmonary remodeling and recovery from HPS.

Morphometric Characterization of Rat and Human Alveolar Macrophage Cell Models and their Response to Amiodarone using High Content Image Analysis.

PURPOSE: Progress to the clinic may be delayed or prevented when vacuolated or "foamy" alveolar macrophages are observed during non-clinical inhalation toxicology assessment. The first step in developing methods to study this response in vitro is to characterize macrophage cell lines and their response to drug exposures. METHODS: Human (U937) and rat (NR8383) cell lines and primary rat alveolar macrophages obtained by bronchoalveolar lavage were characterized using high content fluorescence imaging analysis quantification of cell viability, morphometry, and phospholipid and neutral lipid accumulation. RESULTS: Cell health, morphology and lipid content were comparable (p < 0.05) for both cell lines and the primary macrophages in terms of vacuole number, size and lipid content. Responses to amiodarone, a known inducer of phospholipidosis, required analysis of shifts in cell population profiles (the proportion of cells with elevated vacuolation or lipid content) rather than average population data which was insensitive to the changes observed. CONCLUSIONS: A high content image analysis assay was developed and used to provide detailed morphological characterization of rat and human alveolar-like macrophages and their response to a phospholipidosis-inducing agent. This provides a basis for development of assays to predict or understand macrophage vacuolation following inhaled drug exposure.

Effect of genetic deletion or pharmacological antagonism of tumor necrosis factor alpha on colitis-associated carcinogenesis in mice.

BACKGROUND: Intestinal inflammation in inflammatory bowel diseases is driven by abnormal levels of proinflammatory cytokines, where tumor necrosis factor (TNF)-α seems to be particularly important. Chronic inflammatory signaling in the colon increases the risk of colorectal cancer, so we sought to evaluate the role of TNF-α in a mouse model of this condition. METHODS: TNF mice were treated with azoxymethane/dextran sulfate sodium to induce inflammation and tumorigenesis. Etanercept was used to produce pharmacological ablation of TNF-α in wild-type mice. Subsequent activation of procarcinogenic transcription factor NF-κB and relevant proinflammatory cytokines of the TNF superfamily were measured through immunohistochemistry and quantitative polymerase chain reaction methods. RESULTS: Results showed that the severity of colitis, as assessed by mortality, histological scoring, and cytokine expression levels, was similar or slightly higher in mice lacking TNF-α than in control mice. Activation levels of NF-κB were not influenced by the presence of TNF-α. We also observed upregulated expression of TNF family member TNF-ß, TNF receptors 1 and 2 and a variety of other proinflammatory factors in colitis-associated tumors of TNF mice, compared with levels in tumors of control mice. Neither genetic ablation of TNF-α nor pharmacological inhibition of the TNF family using etanercept reduced tumor number. CONCLUSIONS: Our results reveal a redundant role for TNF-α in a mouse model of colitis-associated tumorigenesis, indicating a high degree of redundancy in proinflammatory cytokine networks in this model.

Congenital spigelian hernia and ipsilateral cryptorchidism: raising awareness among urologists.

Spigelian hernias (SHs) are rare in the pediatric population. Although pediatric general surgeons often treat this defect, the increased association between a congenital SH and an ipsilateral undescended testis suggests that urologists may be the first provider encountering this entity. Knowledge of this condition is therefore important. We report one such case of a male infant referred to urology for an undescended testicle. Further investigation revealed the testicle to be within a congenital SH sac. Herein, we additionally review the literature concerning SHs associated with ipsilateral undescended testicles.

The use of intraabdominal tissue expanders as a primary strategy for closure of giant omphaloceles.

BACKGROUND: Giant omphaloceles present a unique challenge to pediatric surgeons because of the difficulty in obtaining timely, tension-free closure of tissues over the defect. Reports of the use of tissue expanders in the subcutaneous space, intramuscular space, or intraabdominal cavity have illustrated the usefulness of this technique to provide biologic closure of abdominal wall defects. However, these reports have focused on use of tissue expanders as a second-line treatment after other options, such as silastic silos or attempted primary closure, have failed. METHODS: We report 2 cases in which intraabdominal tissue expanders were used as a primary strategy to obtain closure of giant omphalocele defects. CASE REPORTS: The first patient was a baby boy born at 36 weeks by date who was prenatally diagnosed with a giant omphalocele. An intraabdominal tissue expander was placed at 2 weeks of age. The tissue expander was removed and his abdomen was primarily closed at 8 weeks of age. The second patient was born at 25 weeks gestation as part of a twin gestation with severe intrauterine growth retardation (600 g birth weight). Bedside reduction was not attempted because of severe pulmonary hypertension and significant loss of abdominal domain because of herniated liver and bowel. At 8 months of age, she underwent laparoscopically assisted placement of an intraabdominal tissue expander. At 9 months of age, the tissue expander was removed, all abdominal viscera were reduced, and the defect was closed using only an 8 x 8-cm piece of AlloDerm (LifeCell, Branchburg, NJ). Both children are currently at home and doing well. CONCLUSIONS: We believe that early use of intraabdominal tissue expanders provides a more expedient method of obtaining closure of the defect in giant omphaloceles.

Dual localization technique for thoracoscopic resection of lung lesions in children.

BACKGROUND: Thoracoscopic wedge resection has gained widespread acceptance as a method of resecting pulmonary metastases in pediatric cancer patients. This is most successful for lesions on the pleural surface that can be identified without palpation. Deeper lesions can be marked by preoperative computed tomography (CT)-guided techniques, but neither needle localization nor dye injection alone is foolproof. In this paper, we present our experience with a dual localization technique. METHODS: Under CT guidance, a 20-G needle is advanced to within 1 cm of the lesion and 0.1 mL of methylene blue: Low osmolar contrast (4:1 ratio) is injected. A Kopans breast biopsy hook wire is then introduced through the needle and its tip placed within the lesion. Its tail is cut flush with the chest wall. The patient is transferred to the operating room, and a wedge resection around the hook wire is performed thoracoscopically. RESULTS: Six deep pulmonary metastatic lesions were preoperatively localized in 4 pediatric patients (ages, 6-17).Median localization time was 30 minutes. All lesions were successfully marked and identified at operation.Margin-free resection of the lesion was successful in all cases. CONCLUSIONS: Thoracoscopic resection of metastatic pulmonary lesions in children, using preoperative localization with both wire localization and methylene blue/contrast injection, is safe and effective. This method allows the successful localization of lesions, even in the event of either dislodgement of the wire or over infusion of the methylene blue dye.