Fluid management of the critically Ill child.

PURPOSE OF REVIEW: This review summarizes current literature pertaining to fluid management for critically ill children. It includes an overview on crystalloid fluid used throughout the critical illness course, management of fluid output and complications with fluid overload. RECENT FINDINGS: Observational paediatric studies and adult randomized trials show mixed results regarding risk of mortality and kidney injury with 0.9% saline and crystalloid fluid. A recent adult randomized trial suggests that a fluid restrictive strategy may be well tolerated in critically ill adults with septic shock, but further randomized trials are needed in paediatrics. Fluid overload has been associated with increased morbidity and mortality. Trials exploring ways to decrease fluid accumulation must be done in paediatrics. SUMMARY: Additional high-quality studies are needed to precisely define the type, timing and rate of intravenous fluid critically ill children should receive throughout their clinical illness course.

Applying a validated scoring rubric to pre-clerkship medical students' standardized patient notes: a pilot study.

BACKGROUND: With the elimination in 2021 of the United States Medical Licensing Examination Step 2 Clinical Skills test, it is incumbent upon U.S. medical schools to develop local validated assessments of clinical reasoning. While much attention has been paid to summative exams for graduating students, formative exams for pre-clerkship students have not been well studied. METHODS: We applied the University of Illinois at Chicago College of Medicine (UIC-COM) Patient Note (PN) Scoring Rubric to templated PNs written by 103 pre-clerkship students for two cases in an objective structured clinical examination (OSCE) at the Yale School of Medicine. The rubric consists of four section scores (Documentation, Differential Diagnosis, Justification, and Workup, each scored 1 to 4) and a composite score (scaled 23 to 100). We calculated item discrimination for each section score and Cronbach's alpha for each case. We surveyed students about their experience writing the templated PN. RESULTS: Mean Documentation, Differential Diagnosis, Justification, Workup, and composite scores for case A were 2.16, 1.80, 1.65, 2.29, and 47.67, respectively. For case B, the scores were 2.13, 1.21, 1.60, 1.67, and 40.54, respectively. Item discrimination ranged from 0.41 to 0.80. Cronbach's alpha for cases A and B was 0.48 and 0.25, respectively. A majority of the students felt that the exercise was useful and appropriate to their level of training. CONCLUSIONS: Despite performing poorly, pre-clerkship students found the note-writing task beneficial. Reliability of the scoring rubric was suboptimal, and modifications are needed to make this exercise a suitable measure of clinical reasoning.

Optimizing preclinical learning with retrieval practice: A call to action.

This Personal View is about our experience with preclinical education as medical students. We discuss the problem with current medical education in light of an ever-growing body of medical knowledge and increasing student disengagement with preclinical lectures. We briefly review the concept of retrieval practice as an effective, evidence-based learning strategy that helped us retain knowledge for longer periods and propose that medical educators should adopt this strategy to best prepare medical students to navigate the vastly expanding scope of modern medicine.

Outcomes of paediatric cardiac patients after 30 minutes of cardiopulmonary resuscitation prior to extracorporeal support.

OBJECTIVES: To characterise the mortality and neurological outcomes of paediatric cardiac patients requiring cardiopulmonary resuscitation for more than 30 minutes prior to extracorporeal membrane oxygenation cannulation and to identify risk factors associated with adverse outcomes in this population. MATERIALS AND METHODS: Observational retrospective cohort study in paediatric cardiac patients undergoing cardiopulmonary resuscitation for greater than 30 minutes prior to cannulation in a tertiary children's hospital, from July 2000 to July 2013. RESULTS: Seventy-three paediatric cardiac patients requiring cardiopulmonary resuscitation for more than 30 minutes prior to cannulation were included in the study. Survival to hospital discharge was 43.8%, with 75% of survivors having either normal neurologic function or only mild disability. Multivariable logistic regression analysis demonstrated that increased use of calcium during resuscitation (odds ratio 14.5, p 0.01), cardiopulmonary resuscitation duration >50 minutes (odds ratio 4.12, p 0.03), >6 interruptions of chest compressions during cannulation (odds ratio 6.40, p 0.03), the need for continuous renal replacement therapy (odds ratio 11.1, p 0.001), and abnormal pupillary response during extracorporeal membrane oxygenation (odds ratio 33.9, p 0.006) were independent predictors for hospital mortality. CONCLUSION: Survival after cardiopulmonary resuscitation for more than 30 minutes prior to extracorporeal membrane oxygenation cannulation in our paediatric cardiac cohort was 43.8%. Factors associated with mortality included calcium use during resuscitation, longer cardiopulmonary resuscitation, increased chest compression pauses during cannulation, the use of continuous renal replacement therapy, and abnormal pupils during extracorporeal membrane oxygenation support. A prospective assessment of these factors in paediatric cardiac patients may be beneficial in improving outcomes.

Beneficial effect of recombinant rC1rC2 collagenases on human islet function: Efficacy of low-dose enzymes on pancreas digestion and yield.

A high number of human islets can be isolated by using modern purified tissue dissociation enzymes; however, this requires the use of >20 Wunsch units (WU)/g of pancreas for digestion. Attempts to reduce this dose have resulted in pancreas underdigestion and poor islet recovery but improved islet function. In this study, we achieved a high number of functional islets using a low dose of recombinant collagenase enzyme mixture (RCEM-1200 WU rC2 and 10 million collagen-degrading activity [CDA] U of rC1 containing about 209 mg of collagenase to digest a 100-g pancreas). The collagenase dose used in these isolations is about 42% of the natural collagenase enzyme mixture (NCEM) dose commonly used to digest a 100-g pancreas. Low-dose RCEM was efficient in digesting entire pancreases to obtain higher yield (5535 ± 830 and 2582 ± 925 islet equivalent/g, P < .05) and less undigested tissue (16.7 ± 5% and 37.8 ± 3%, P < .05) compared with low-dose NCEM (12WU/g). Additionally, low-dose RCEM islets retained better morphology (confirmed with scanning electron microscopy) and higher in vitro basal insulin release (2391 ± 1342 and 1778 ± 978 µU/mL; P < .05) compared with standard-dose NCEM. Nude mouse bioassay demonstrated better islet function for low-dose RCEM (area under the curve [AUC] 24 968) compared with low-dose (AUC-38 225) or standard-dose NCEM (AUC-38 685), P < .05. This is the first report indicating that islet function can be improved by using low-dose rC1rC2 (RCEM).

Test-enhanced learning in health professions education: A systematic review: BEME Guide No. 48.

BACKGROUND: Cognitive psychology studies demonstrate that subjects who attempt to recall information show better learning, retention, and transfer than subjects who spend the same time studying the same material (test-enhanced learning, TEL). We systematically reviewed TEL interventions in health professions education. METHODS: We searched 13 databases, 14 medical education journals, and reference lists. Inclusion criteria included controlled studies of TEL that compared TEL to studying the same material or to a different TEL strategy. Two raters screened articles for inclusion, abstracted information, determined quality scores, and calculated the standardized mean difference (SMD) for the learning outcomes. RESULTS: Inter-rater agreement was excellent for all comparisons. The 19 included studies reported 41 outcomes with data sufficient to determine a SMD. TEL interventions included short answer questions, multiple choice questions, simulation, and standardized patients. Five of six immediate learning outcomes (SMD 0.09-0.44), 21 of 23 retention outcomes (SMD 0.12-2.5), and all seven transfer outcomes (SMD 0.33-1.1) favored TEL over studying. CONCLUSIONS: TEL demonstrates robust effects across health professions, learners, TEL formats, and learning outcomes. The effectiveness of TEL extends beyond knowledge assessed by examinations to clinical applications. Educators should include TEL in health professions curricula to enhance recall, retention, and transfer.

Defining leadership competencies for pediatric critical care fellows: Results of a national needs assessment.

INTRODUCTION: Physicians in training, including those in Pediatric Critical Care Medicine, must develop clinical leadership skills in preparation to lead multidisciplinary teams during their careers. This study seeks to identify multidisciplinary perceptions of leadership skills important for Pediatric Critical Care Medicine fellows to attain prior to fellowship completion. METHODS: We performed a multi-institutional survey of Pediatric Critical Care Medicine attendings, fellows, and nurses. Subjects were asked to rate importance of 59 leadership skills, behaviors, and attitudes for Pediatric Critical Care practitioners and to identify whether these skills should be achieved before completing fellowship. Skills with the highest ratings by respondents were deemed essential. RESULTS: Five hundred and eighteen subjects completed the survey. Of 59 items, only one item ("displays honesty and integrity") was considered essential by all respondents. When analyzed by discipline, nurses identified 21 behaviors essential, fellows 3, and attendings 1 (p < 0.05). Nurses differed (p < 0.05) from attendings in their opinion of importance in 64% (38/59) of skills. CONCLUSIONS: Despite significant variability among Pediatric Critical Care attendings, fellows, and nurses in identifying which clinical leadership competencies are important for graduating Pediatric Critical Care fellows, they place the highest importance on skills in self-management and self-awareness. Leadership skills identified as most important may guide the development of interventions to improve trainee education and interprofessional care.

Transforming primary care training--patient-centered medical home entrustable professional activities for internal medicine residents.

INTRODUCTION: The U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice. AIM: We address two key questions regarding the training of internal medicine residents for practice in PCMHs. First, what are the educational implications of practice transformations to primary care home models? Second, what must we do differently to prepare internal medicine residents for their futures in PCMHs? PROGRAM DESCRIPTION: The 2011 Society of General Internal Medicine (SGIM) PCMH Education Summit established seven work groups to address the following topics: resident workplace competencies, teamwork, continuity of care, assessment, faculty development, 'medical home builder' tools, and policy. The output from the competency work group was foundational for the work of other groups. The work group considered several educational frameworks, including developmental milestones, competencies, and entrustable professional activities (EPAs). RESULTS: The competency work group defined 25 internal medicine resident PCMH EPAs. The 2011 National Committee for Quality Assurance (NCQA) PCMH standards served as an organizing framework for EPAs. DISCUSSION: The list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.

Adrenocortical function in the postoperative pediatric cardiac surgical patient.

PURPOSE OF REVIEW: Corticosteroids are frequently used in the postoperative care of children with congenital heart disease. This review describes the function of the adrenocortical axis in this population and the effects of corticosteroids on cardiovascular function. In addition, it examines the diagnosis of adrenal insufficiency in this population and provides an overview of recent studies on the use of steroids in treating hemodynamic instability in these children. RECENT FINDINGS: Corticosteroids improve hemodynamic parameters in children with shock following congenital heart surgery. This improvement may be due to treatment of adrenal insufficiency or from direct cardiovascular effects of corticosteroids. The diagnosis of adrenal insufficiency in this population is challenging as low cortisol levels do not consistently correlate with adverse outcomes. SUMMARY: Because of the lack of evidence delineating what the normal adrenocortical function is in this population, cortisol levels alone are not sufficient to justify treating with steroids in this population. Corticosteroids are beneficial in improving hemodynamics in children with shock after congenital heart surgery, but the adverse effects of the therapy in this context are not fully known. Prospective trials are necessary to clarify which patients may benefit from steroid therapy and to examine long-term effects of steroids.

Screening, brief intervention, and referral to treatment (SBIRT) for alcohol and other drug use among adolescents: evaluation of a pediatric residency curriculum.

The objective of this study was to evaluate the integration of a screening, brief intervention, and referral to treatment (SBIRT) curriculum for alcohol and other drug use into a pediatric residency program. Pediatric and medicine/pediatric residents in an adolescent medicine rotation located in an urban teaching hospital participated in the study. Main outcome measures were pre- and post-training knowledge scores, performance of the Brief Negotiation Interview (BNI), training satisfaction, and adoption of the BNI into clinical practice. Thirty-four residents were trained. Significant pre- to post-training improvements were seen in knowledge scores (P < .001) and performance as measured by the BNI Adherence Scale (P < .001). Residents reported high satisfaction immediately post-training and at 30 days on a 1-5 Likert scale: mean 1.41 to 1.59 (1 = very satisfied) (P = 0.23). Over a 9-month period, 53% of residents documented performing at least 1 BNI, of which 2/3 reported ≥2 BNIs in a subsequent clinical setting. The results show that integrating a SBIRT curriculum into a pediatric residency program increases residents' knowledge and skills.

Developing and implementing a multispecialty graduate medical education curriculum on Screening, Brief Intervention, and Referral to Treatment (SBIRT).

The authors sought to evaluate the feasibility and acceptability of initiating a Screening, Brief Intervention, and Referral to Treatment (SBIRT) for alcohol and other drug use curriculum across multiple residency programs. SBIRT project faculty in the internal medicine (traditional, primary care internal medicine, medicine/pediatrics), psychiatry, obstetrics and gynecology, emergency medicine, and pediatrics programs were trained in performing and teaching SBIRT. The SBIRT project faculty trained the residents in their respective disciplines, accommodating discipline-specific implementation issues and developed a SBIRT training Web site. Post-training, residents were observed performing SBIRT with a standardized patient. Measurements included number of residents trained, performance of SBIRT in clinical practice, and training satisfaction. One hundred and ninety-nine residents were trained in SBIRT: 98 internal medicine, 35 psychiatry, 18 obstetrics and gynecology, 21 emergency medicine, and 27 pediatrics residents. To date, 338 self-reported SBIRT clinical encounters have occurred. Of the 196 satisfaction surveys completed, the mean satisfaction score for the training was 1.60 (1 = very satisfied to 5 = very dissatisfied). Standardized patient sessions with SBIRT project faculty supervision were the most positive aspect of the training and length of training was a noted weakness. Implementation of a graduate medical education SBIRT curriculum in a multispecialty format is feasible and acceptable. Future efforts focusing on evaluation of resident SBIRT performance and sustainability of SBIRT are needed.

Diagnosis and treatment of tracheal basal cell carcinoma in a Maine coon and long-term outcome.

A 6 yr old castrated male Maine coon presented with a 2 wk history of progressive dyspnea. Thoracic radiographs revealed a 2 cm diameter intratracheal mass at the level of the fourth rib. The tracheal mass was marginally excised via a combination of resection and anastomosis. Infiltrative basal cell carcinoma (BCC) with nodular osseous metaplasia was diagnosed. The thoracic trachea was then irradiated postoperatively for definitive treatment. The cat remained asymptomatic following surgical excision and radiation therapy for 32 mo when this report was written. The purpose of this report is to describe the treatment and long-term outcome of a Maine coon diagnosed with, and treated for, tracheal BCC.

Entrustment Decision Making in the Core Entrustable Professional Activities: Results of a Multi-Institutional Study.

PURPOSE: In 2014, the Association of American Medical Colleges defined 13 Core Entrustable Professional Activities (EPAs) that all graduating students should be ready to do with indirect supervision upon entering residency and commissioned a 10-school, 5-year pilot to test implementing the Core EPAs framework. In 2019, pilot schools convened trained entrustment groups (TEGs) to review assessment data and render theoretical summative entrustment decisions for class of 2019 graduates. Results were examined to determine the extent to which entrustment decisions could be made and the nature of these decisions. METHOD: For each EPA considered (4-13 per student), TEGs recorded an entrustment determination (ready, progressing but not yet ready, evidence against student progressing, could not make a decision); confidence in that determination (none, low, moderate, high); and the number of workplace-based assessments (WBAs) considered (0->15) per determination. These individual student-level data were de-identified and merged into a multischool database; chi-square analysis tested the significance of associations between variables. RESULTS: The 2,415 EPA-specific determinations (for 349 students by 4 participating schools) resulted in a decision of ready (n = 997/2,415; 41.3%), progressing but not yet ready (n = 558/2,415; 23.1%), or evidence against student progression (n = 175/2,415; 7.2%). No decision could be made for the remaining 28.4% (685/2,415), generally for lack of data. Entrustment determinations' distribution varied across EPAs (chi-square P < .001) and, for 10/13 EPAs, WBA availability was associated with making (vs not making) entrustment decisions (each chi-square P < .05). CONCLUSIONS: TEGs were able to make many decisions about readiness for indirect supervision; yet less than half of determinations resulted in a decision of readiness to perform this EPA with indirect supervision. More work is needed at the 10 schools to enable authentic summative entrustment in the Core EPAs framework.

Benefits and Limitations of Virtual Recruitment: Perspectives From Subspeciality Directors.

BACKGROUND AND OBJECTIVES: Because of the coronavirus disease 2019 pandemic and recommendations from a range of leaders and organizations, the pediatrics subspecialty 2020 recruitment season was entirely virtual. Minimal data exist on the effect of this change to guide future strategies. The aim of this study was to understand the effects of virtual recruitment on pediatric subspecialty programs as perceived by program leaders. METHODS: This concurrent, triangulation, mixed-methods study used a survey that was developed through an iterative (3 cycles), consensus-building, modified Delphi process and sent to all pediatric subspecialty program directors (PSPDs) between April and May 2021. Descriptive statistics and thematic analysis were used, and a conceptual framework was developed. RESULTS: Forty-two percent (352 of 840) of PSPDs responded from 16 of the 17 pediatric (94%) subspecialties; 60% felt the virtual interview process was beneficial to their training program. A majority of respondents (72%) reported cost savings were a benefit; additional benefits included greater efficiency of time, more applicants per day, greater faculty involvement, and perceived less time away from residency for applicants. PSPDs reported a more diverse applicant pool. Without an in-person component, PSPDs worried about programs and applicants missing informative, in-person interactions and applicants missing hospital tours and visiting the city. A model based upon theory of change was developed to aid program considerations for future application cycles. CONCLUSIONS: PSPDs identified several benefits to virtual recruitment, including ease of accommodating increased applicants with a diverse applicant pool and enhanced faculty involvement. Identified limitations included reduced interaction between the applicant and the larger institution/city.

Electrical activity of the diaphragm during extubation readiness testing in critically ill children.

OBJECTIVES: To investigate the electrical activity of the diaphragm during extubation readiness testing. DESIGN: Prospective observational trial. SETTING: A 29-bed medical-surgical pediatric intensive care unit. PATIENTS: Mechanically ventilated children between 1 month and 18 yrs of age. INTERVENTIONS: Twenty patients underwent a standardized extubation readiness test using a minimal pressure support ventilation strategy. A size-appropriate multiple-array esophageal electrode (electrical diaphragmatic activity catheter), which doubled as a feeding tube, was inserted. The electrical diaphragmatic activity, ventilatory parameters, and spirometry measurements were recorded with the Servo-i ventilator (Maquet, Solna, Sweden). Measurements were obtained before the extubation readiness test and 1 hr into the extubation readiness test. MEASUREMENTS AND MAIN RESULTS: During extubation readiness testing, the ratio of tidal volume to delta electrical diaphragmatic activity was significantly lower in those patients who passed the extubation readiness test compared to those who failed the extubation readiness test (extubation readiness test, pass: 24.8 ± 20.9 mL/µV vs. extubation readiness test, fail: 67.2 ± 27 mL/µV, respectively; p = .02). Delta electrical diaphragmatic activity correlated significantly with neuromuscular drive assessed by airway opening pressure at 0.1 secs (before extubation readiness test: r = .591, p < .001; during extubation readiness test: r = .682, p < .001). Eight out of 20 patients had ventilator dys-synchrony identified with electrical diaphragmatic activity during extubation readiness testing. CONCLUSIONS: Patients who generate higher diaphragmatic activity in relation to tidal volume may have better preserved diaphragmatic function and a better chance of passing the extubation readiness test as opposed to patients who generate lower diaphragmatic activity in relation to tidal volume, indicating diaphragmatic weakness. Electrical activity of the diaphragm also may be a useful adjunct to assess neuromuscular drive in ventilated children.

Electrocardiographic guidance for the placement of gastric feeding tubes: a pediatric case series.

BACKGROUND: The placement of nasal or oral gastric tubes is one of the most frequently performed procedures in critically ill children; tube malposition, particularly in the trachea, is an important complication. Neurally adjusted ventilatory assist (NAVA) ventilation (available only on the Servo-i ventilator, Maquet Critical Care, Solna, Sweden) requires a proprietary-design catheter (Maquet Critical Care, Solna, Sweden) with embedded electrodes that detect the electrical activity of the diaphragm (EA(di)). The EA(di) catheter has the potential benefit of confirming proper positioning of a gastric catheter, based on and the EA(di) waveforms. METHODS: In a case series study, our multidisciplinary team used EA(di) guidance for immediate, real-time confirmation of proper nasal or oral gastric tube placement in 20 mechanically ventilated pediatric patients who underwent 23 oral or nasal gastric tube placements. The catheters were placed with our standard practice, with the addition of a team member monitoring the EA(di) waveforms. As the tube passes down the esophagus and posterior to the heart, a characteristic EA(di) pattern is identified and the position of the atrial signal confirms correct placement of the gastric tube. If the EA(di) waveforms indicate incorrect placement, the tube is repositioned until the proper EA(di) waveform pattern is obtained. Then proper tube placement is reconfirmed via auscultation over the stomach while air is injected into the catheter, checking the pH of fluid suctioned from the catheter (gastric pH indicates correct positioning), and/or radiograph. RESULTS: The group's median age was 3 years (range 4 d to 16 y). All 20 patients had successful gastric catheter placement. The EA(di) catheter provided characteristic patterns for correctly placed tubes, tubes malpositioned above or below the gastroesophageal junction, and curled tubes. Proper catheter position was confirmed via radiograph and/or gastric pH in all 20 patients. CONCLUSIONS: EA(di) guidance helps confirm proper gastric catheter position, is equivalent to our standard practice for confirming gastric catheter placement, and may reduce the need for radiographs and improve patient safety by avoiding catheter malpositions.

Surgical versus non-surgical treatment of feline small intestinal adenocarcinoma and the influence of metastasis on long-term survival in 18 cats (2000-2007).

This study retrospectively evaluated long-term outcomes of 18 cats diagnosed with small intestinal adenocarcinoma, based on surgical versus non-surgical treatment and the presence or absence of metastasis at the time of surgery. Ten cats had surgery and histopathologic confirmation of adenocarcinoma and 8 cats did not have surgery but had cytologic diagnosis of adenocarcinoma. Median survival of cats with adenocarcinoma that underwent surgical excision was 365 days and 22 days for those with suspected adenocarcinoma that did not undergo surgery (P = 0.019). Median survival of cats was 843 days for those without evidence of metastatic disease at the time of surgery and 358 days for those that had (P = 0.25). In conclusion, surgical excision is beneficial in the treatment of small intestinal adenocarcinoma in the cat, including those patients with metastasis, and may result in a significantly longer survival time compared with patients which do not have their mass surgically excised.

Association between primary care physicians' evidence-based medicine knowledge and quality of care.

OBJECTIVE: Ample research has examined physicians' evidence-based medicine (EBM) knowledge and skills; however, previous research has not linked EBM knowledge to objective measures of process of care. DESIGN: A cross-sectional study of quality of care measures extracted from electronic medical records and EBM knowledge assessed via a validated questionnaire. SETTING: One region of the largest Health Maintenance Organization in Israel. PARTICIPANTS: Seventy-four physicians and their 8334 diabetic patients, 7092 coronary heart disease patients and 17 132 hypertensive patients. MAIN OUTCOME MEASURES: Outcome measures were four diabetes quality of care indicators (LDL tests, microalbumin tests, hemoglobin A1C tests, eye examination referrals), and two drug prescription indicators (statin prescription for coronary heart disease patients, and thiazide prescription for hypertensive patients). Independent variables were total EBM knowledge and its components: critical appraisal and information retrieval. RESULTS: Total EBM knowledge was independently and significantly associated with LDL testing (b = 0.13; P = 0.036), microalbumin testing (b = 0.33; P = 0.001), hemoglobin A1C testing (b = 0.17; P = 0.036), eye examination referrals (b = 0.16; P = 0.021) and statin prescriptions (b = 0.18; P = 0.025). Critical appraisal was independently associated with microalbumin tests (b = 0.46; P = 0.002) and eye examination referrals (b = 0.20; P = 0.048). Information retrieval was only independently associated with hemoglobin A1C testing (b = 0.43; P = 0.004). Thiazide prescription was not associated with EBM knowledge scores. CONCLUSIONS: Physicians' higher total EBM knowledge primarily correlates with better quality of care; however, correlations were modest and explained only a small portion in the variance of clinical performance. Results indicate that there might be a need to focus on teaching all the components of EBM rather than EBM microskills.

Surgical treatment of an elbow hygroma utilizing microvascular free muscle transfer in a newfoundland.

Microvascular free muscle transfer utilizing the rectus abdominis muscle, in combination with a mesh skin graft and transarticular external fixator, were used following the surgical excision of an elbow hygroma in a Newfoundland dog. Postoperatively, the dog did well with minimal complications and has yet to have a recurrence 10 months following surgery. This report describes the utility and successful use of the rectus abdominis free tissue transfer in the surgical correction of a difficult elbow hygroma in the dog.