Evaluating the Women's Empowerment and Leadership Initiative: Supporting mentorship, career satisfaction, and well-being among pediatric anesthesiologists.

The Society for Pediatric Anesthesia launched the Women's Empowerment and Leadership Initiative (WELI) in 2018 to empower highly productive women pediatric anesthesiologists to achieve equity, promotion, and leadership. WELI is focused on six career development domains: promotion and leadership, networking, conceptualization and completion of projects, mentoring, career satisfaction, and sense of well-being. We sought feedback about whether WELI supported members' career development by surveys emailed in November 2020 (baseline), May 2021 (6 months), and January 2022 (14 months). Program feedback was quantitatively evaluated by the Likert scale questions and qualitatively evaluated by extracting themes from free-text question responses. The response rates were 60.5% (92 of 152) for the baseline, 51% (82 of 161) for the 6-month, and 52% (96 of 185) for the 14-month surveys. Five main themes were identified from the free-text responses in the 6- and 14-month surveys. Members reported that WELI helped them create meaningful connections through networking, obtain new career opportunities, find tools and projects that supported their career advancement and promotion, build the confidence to try new things beyond their comfort zone, and achieve better work-life integration. Frustration with the inability to connect in-person during the coronavirus-19 pandemic was highlighted. Advisors further stated that WELI helped them improve their mentorship skills and gave them insight into early career faculty issues. Relative to the baseline survey, protégés reported greater contributions from WELI at 6 months in helping them clarify their priorities, increase their sense of achievement, and get promoted. These benefits persisted through 14 months. Advisors reported a steady increase in forming new meaningful relationships and finding new collaborators through WELI over time. All the members reported that their self-rated mentoring abilities improved at 6 months with sustained improvement at 14 months. Thus, programs such as WELI can assist women anesthesiologists and foster gender equity in career development, promotion, and leadership.

Pediatric ECMO: unfavorable outcomes are associated with inflammation and endothelial activation.

BACKGROUND: Inflammatory and endothelial activation responses during extracorporeal membrane oxygenation (ECMO) support in children are poorly understood. In this study, we aimed to determine if circulating inflammatory, endothelial activation, and fibrinolytic markers are associated with mortality and with neurologic outcomes in children on ECMO. METHODS: We conducted a secondary analysis of a two-center prospective observational study of 99 neonatal and pediatric ECMO patients. Inflammatory (interferon gamma [IFNγ], interleukin-6 [IL-6], IL-1ß, tumor necrosis factor alpha [TNFα]), endothelial activation (E-selectin, P-selectin, intercellular adhesion molecule-3 [ICAM-3], thrombomodulin [TM]), and fibrinolytic markers (tissue plasminogen activator [tPA], plasminogen activator inhibitor-1 [PAI-1]) were measured in plasma on days 1, 2, 3, 5, 7, and every third day thereafter during the ECMO course. RESULTS: All ECMO day 1 inflammatory biomarkers were significantly elevated in children with abnormal vs. normal neuroimaging. ECMO day 1 and peak levels of IL-6 and PAI-1 were significantly elevated in children who died compared to those who survived to hospital discharge. Tested biomarkers showed no significant association with long-term neurobehavioral outcomes measured using the Vineland Adaptive Behavioral Scales, Second Edition. CONCLUSIONS: High levels of circulating inflammatory, endothelial activation, and fibrinolytic markers are associated with mortality and abnormal neuroimaging in children on ECMO. IMPACT: The inflammatory, endothelial activation, and fibrinolytic profile of children on ECMO differs by primary indication for extracorporeal support. Proinflammatory biomarkers on ECMO day 1 are associated with abnormal neurologic imaging in children on ECMO in univariable but not multivariable models. In multivariable models, a pronounced proinflammatory and prothrombotic biomarker profile on ECMO day 1 and longitudinally was significantly associated with mortality. Further studies are needed to identify inflammatory, endothelial, and fibrinolytic profiles associated with increased risk for neurologic injury and mortality through potential mediation of bleeding and thrombosis.

Pediatric Safety Restraint Use in Motor Vehicle Crashes at a Level I Safety-Net Trauma Center.

BACKGROUND: Adherence to child passenger safety recommendations is essential to prevent death and injury in children involved in motor vehicle crashes. Parents may not undertake the proper safety measures, which can lead to increase injury. METHODS: A safety net, level I trauma center's database was used to identify admitted children (age<15 y/o) involved in motor vehicle crashes over a 2-y period to investigate safety restraint device use and compliance with state recommendations. Variables evaluated were crash characteristics, presence and method of passenger restraint, demographics, Glasgow Coma Scale, and Injury Severity Score. Excluded were patients where restraint characteristics could not be identified and those discharged from the trauma center. RESULTS: Eighty patients met inclusion criteria. Thirty-two (40%) children were unrestrained. Safety restraint device was noted in 48 (60%) children with 13 (27.1%) patients improperly restrained. The most common method of improper restraint (6, 46.2%) was traveling in the front seat before the age state law recommends. With respect to proper, improper, and no restraint, age (7.31 ± 14.26, 5.76 ± 3.24, P = 0.36), female sex (17, 8, 13, P = 0.32), low-income status (14, 5, 24, P = 0.28), and race (P = 0.08) did not differ between the groups. The unrestrained children had statistically lower initial Glasgow Coma Scale and higher Injury Severity Score and were more often involved in high-risk mechanism of Injury motor vehicle crashes. CONCLUSIONS: Despite recommendations and regulations regarding child passenger safety measures, there are a significant number of children that remain suboptimally restrained who are admitted to a safety-net trauma center. Further research is needed to understand the barriers to increase the compliance with recommendations along with targeted educational campaigns in low-compliance populations.

Empowering Women as Leaders in Pediatric Anesthesiology: Methodology, Lessons, and Early Outcomes of a National Initiative.

Research has shown that women have leadership ability equal to or better than that of their male counterparts, yet proportionally fewer women than men achieve leadership positions and promotion in medicine. The Women's Empowerment and Leadership Initiative (WELI) was founded within the Society for Pediatric Anesthesia (SPA) in 2018 as a multidimensional program to help address the significant career development, leadership, and promotion gender gap between men and women in anesthesiology. Herein, we describe WELI's development and implementation with an early assessment of effectiveness at 2 years. Members received an anonymous, voluntary survey by e-mail to assess whether they believed WELI was beneficial in several broad domains: career development, networking, project implementation and completion, goal setting, mentorship, well-being, and promotion and leadership. The response rate was 60.5% (92 of 152). The majority ranked several aspects of WELI to be very or extremely valuable, including the protégé-advisor dyads, workshops, nomination to join WELI, and virtual facilitated networking. For most members, WELI helped to improve optimism about their professional future. Most also reported that WELI somewhat or absolutely contributed to project improvement or completion, finding new collaborators, and obtaining invitations to be visiting speakers. Among those who applied for promotion or leadership positions, 51% found WELI to be somewhat or absolutely valuable to their application process, and 42% found the same in applying for leadership positions. Qualitative analysis of free-text survey responses identified 5 main themes: (1) feelings of empowerment and confidence, (2) acquisition of new skills in mentoring, coaching, career development, and project implementation, (3) clarification and focus on goal setting, (4) creating meaningful connections through networking, and (5) challenges from coronavirus disease 2019 (COVID-19) and the inability to sustain the advisor-protégé connection. We conclude that after 2 years, the WELI program has successfully supported career development for the majority of protégés and advisors. Continued assessment of whether WELI can meaningfully contribute to attainment of promotion and leadership positions will require study across a longer period. WELI could serve as a programmatic example to support women's career development in other subspecialties.

Coaching for the pediatric anesthesiologist: Becoming our best selves.

Anesthesiologists must balance demanding clinical workloads with career development goals. Leadership, conflict management, and other skills can improve medical outcomes, reduce stress at work, and increase career satisfaction. However, Medicine in general and Anesthesiology in particular have not traditionally emphasized physician growth in these areas. Coaching utilizes concepts from psychology, adult learning, and adult development theory to support an individual in personal and professional growth through inquiry, reflection, and shared discovery. This manuscript reviews the history and evidence basis for coaching, differentiates coaching from traditional mentorship, and presents some constructs of coaching and working with a coach. An example of a successful pilot program to disseminate coaching skills and support leadership growth among anesthesiologists, the Women's Empowerment and Leadership Initiative within the Society for Pediatric Anesthesia, is described.

Grow and Advance through Intentional Networking: A pilot program to foster connections within the Women's Empowerment and Leadership Initiative in the Society for Pediatric Anesthesia.

BACKGROUND: The Women's Empowerment and Leadership Initiative in the Society for Pediatric Anesthesia was established to support women's efforts to achieve promotion, leadership positions, and equity in pediatric anesthesiology through coaching, mentoring, sponsorship, and networking. Career advancement relies on the establishment of mentoring relationships within institutions and at regional and national levels. Prior to the SARS-CoV-2 (COVID-19) pandemic, networking was primarily conducted at large national meetings. AIMS: When national meetings were canceled by the COVID-19 pandemic, the Women's Empowerment and Leadership Initiative sought to reduce networking barriers by creating a pilot program called "Grow and Advance through Intentional Networking" (GAIN). MATERIALS & METHODS: Monthly 1-h virtual GAIN sessions were developed based on topics requested by the Women's Empowerment and Leadership Initiative members. Faculty facilitated psychologically safe small-group discussions to maximize engagement. RESULTS: We present an overview of our pilot GAIN program, which has been well received by the Women's Empowerment and Leadership Initiative members and met with continuous demand for more sessions. DISCUSSION: Professional networking is critical for career advancement and for developing and maintaining a sense of community and well-being. Early- and mid-career physicians depend on these relationships to facilitate academic productivity and promotion. CONCLUSION: Programs like the Women's Empowerment and Leadership Initiative GAIN are critical for advancing our specialty and supporting the well-being of pediatric anesthesiologists. GAIN addresses barriers to professional networking, including during the COVID-19 pandemic.

Using the ImPAACT program with preschoolers with Down syndrome: a hybrid service-delivery model.

Three parents of preschool-aged children with Down syndrome using mobile augmentative and alternative communication (AAC) technologies to communicate participated indirect, systematic communication-partner instruction. Intervention featured an adaptation of the ImPAACT Program (Improving Partner Applications of Augmentative Communication Techniques; Kent-Walsh, Binger, & Malani, 2010) that included six face-to-face and three telepractice sessions. Parents learned to use the evidence-based Read-Ask-Answer (RAA) instructional strategy (Kent-Walsh, Binger, & Hasham, 2010) during shared storybook reading with their children. A single-case, multiple-probe across participants design was used to assess parents' accurate implementation of the instructional strategy and children's multimodal communicative turns. All three parents increased their use of the RAA strategy and maintained strategy use over time, and all three children increased their frequency of communicative turns taken and maintained higher turn-taking rates. Results support the use of the ImPAACT Program with parents of children with complex communication needs, including the integration of hybrid learning as part of the instructional approach.

Applying Pediatric Brain Injury Guidelines at a Level I Adult/Pediatric Safety-Net Trauma Center.

BACKGROUND: Pediatric brain injuries are common, but current management of patients with mild traumatic intracranial hemorrhage (T-ICH) is suboptimal, often including unnecessary repeat head CT (RHCT) and neurosurgical consultation (NSC). Brain Injury Guidelines (BIG) have been developed to standardize the management of TBI, and recent work suggests they may be applied to children. The aim of this study was to apply BIG to a low-risk pediatric TBI population to further determine whether the framework can be safely applied to children in a way that reduces overutilization of RHCTs and NSC. METHODS: A retrospective chart review of a Level I Adult and Pediatric Trauma Center's pediatric registry over 4 y was performed. BIG was applied to these patients to evaluate the utility of RHCT and need for neurosurgical intervention (NSG-I) in those meeting BIG-1 criteria. Those with minor skull fracture (mSFx) who otherwise met BIG-1 criteria were also included. RESULTS: Twenty-eight patients with low-risk T-ICH met criteria for review. RHCT was performed in seven patients, with only two being prompted by clinical neurologic change/deterioration. NSC occurred in 21 of the cases. Ultimately, no patient identified by BIG-1 ± mSFx required NSG-I. CONCLUSIONS: Application of BIG criteria to children with mild T-ICH appears capable of reducing RHCT and NSC safely. Additionally, those with mSFx that otherwise fulfill BIG-1 criteria can be managed similarly by acute care surgeons. Further prospective studies should evaluate the application of BIG-1 in larger patient populations to support the generalizability of these findings.

Pediatric Cardiopulmonary Resuscitation Tasks and Hands-Off Time: A Descriptive Analysis Using Video Review.

OBJECTIVES: To characterize tasks performed during cardiopulmonary resuscitation in association with hands-off time, using video recordings of resuscitation events. DESIGN: Single-center, prospective, observational trial. SETTING: Twenty-six bed cardiac ICU in a quaternary care free standing pediatric academic hospital. PATIENTS: Patients admitted to the cardiac ICU with cardiopulmonary resuscitation events lasting greater than 2 minutes captured on video. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Videos of 17 cardiopulmonary resuscitation episodes comprising 264.5 minutes of cardiopulmonary resuscitation were reviewed: 11 classic cardiopulmonary resuscitation (87.5 min) and six extracorporeal cardiopulmonary resuscitations (177 min). A total of 209 tasks occurred in 178 discrete time periods including compressor change (36%), rhythm/pulse check (18%), surgical pause (18%), extracorporeal membrane oxygenation preparation/draping (9%), repositioning (7.5%), defibrillation (6%), backboard placement (3%), bagging (<1%), pacing (<1%), intubation (<1%). In 31 time periods, 62 tasks were clustered with 18 (58%) as compressor changes and pulse/rhythm check. In the 178 discrete time periods, 135 occurred with a pause in compressions for greater than or equal to 1 second; 43 tasks occurred without pause. After accounting for repeated measures from individual patients, providers were less likely to perform rhythm or pulse checks (p < 0.0001) or change compressors regularly (p = 0.02) during extracorporeal cardiopulmonary resuscitation as compared to classic cardiopulmonary resuscitation. The frequency of tasks occurring during cardiopulmonary resuscitation interruptions in the classic cardiopulmonary resuscitation group was constant over the resuscitation but variable in extracorporeal cardiopulmonary resuscitation, peaking during activities required for cannulation. CONCLUSIONS: On video review of cardiopulmonary resuscitation, we found that resuscitation guidelines were not strictly followed in either cardiopulmonary resuscitation or extracorporeal cardiopulmonary resuscitation patients, but adherence was worse in extracorporeal cardiopulmonary resuscitation. Clustering of resuscitation tasks occurred 23% of the time during chest compression pauses suggesting attempts at minimizing cardiopulmonary resuscitation interruptions. The frequency of cardiopulmonary resuscitation interruptions task events was relatively constant during classic cardiopulmonary resuscitation but variable in extracorporeal cardiopulmonary resuscitation. Characterization of resuscitation tasks by video review may inform better cardiopulmonary resuscitation orchestration and efficiency.

The Use of Bivalirudin in Pediatric Cardiac Surgery and in the Interventional Cardiology Suite.

Anticoagulation is an essential component for patients undergoing cardiopulmonary bypass or extracorporeal membrane oxygenation and for those with ventricular assist devices. However, thrombosis and bleeding are common complications. Heparin continues to be the agent of choice for most patients, likely owing to practitioners' comfort and experience and the ease with which the drug's effects can be reversed. However, especially in pediatric cardiac surgery, there is increasing interest in using bivalirudin as the primary anticoagulant. This drug circumvents certain problems with heparin administration, such as heparin resistance and heparin-induced thrombocytopenia, but it comes with additional challenges. In this manuscript, the authors review the literature on the emerging role of bivalirudin in pediatric cardiac surgery, including its use with cardiopulmonary bypass surgery, extracorporeal membrane oxygenation, ventricular assist devices, and interventional cardiology. Moreover, they provide an overview of bivalirudin's pharmacodynamics and monitoring methods.

Trends and Updates on Cardiopulmonary Bypass Setup in Pediatric Cardiac Surgery.

Perfusion strategies for cardiopulmonary bypass have direct consequences on pediatric cardiac surgery outcomes. However, inconsistent study results and a lack of uniform evidence-based guidelines for pediatric cardiopulmonary bypass management have led to considerable variability in perfusion practices among, and even within, institutions. Important aspects of cardiopulmonary bypass that can be optimized to improve clinical outcomes of pediatric patients undergoing cardiac surgery include extracorporeal circuit components, priming solutions, and additives. This review summarizes the current literature on circuit components and priming solution composition with an emphasis on crystalloid, colloid, and blood-based primes, as well as mannitol, bicarbonate, and calcium.

Anesthetic considerations for magnetic resonance imaging-guided right-heart catheterization in pediatric patients: A single institution experience.

Cardiac catheterization is an integral part of medical management for pediatric patients with congenital heart disease. Owing to age and lack of cooperation in children who need this procedure, general anesthesia is typically required. These patients have increased anesthesia risk secondary to cardiac pathology. Furthermore, multiple catheterization procedures result in exposure to harmful ionizing radiation. Magnetic resonance imaging-guided right-heart catheterization offers decreased radiation exposure and diagnostic imaging benefits over traditional fluoroscopy but potentially increases anesthetic complexity and risk. We describe our early experience with anesthetic techniques and challenges for pediatric magnetic resonance imaging-guided right-heart catheterization.

Comparison of Pediatric Cardiopulmonary Resuscitation Quality in Classic Cardiopulmonary Resuscitation and Extracorporeal Cardiopulmonary Resuscitation Events Using Video Review.

OBJECTIVES: To assess differences in cardiopulmonary resuscitation quality in classic cardiopulmonary resuscitation versus extracorporeal cardiopulmonary resuscitation events using video recordings of actual pediatric cardiac arrest events. DESIGN: Single-center, prospective, observational trial. SETTING: Tertiary-care pediatric teaching hospital, cardiac ICU. PATIENTS: All patients admitted to the pediatric cardiac ICU with cardiopulmonary resuscitation events lasting greater than 2 minutes captured on video. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Seventeen events comprising 264.5 minutes of cardiopulmonary resuscitation were included: 11 classic cardiopulmonary resuscitation events (87.5 min) and six extracorporeal cardiopulmonary resuscitation events (177 min). Events were divided into 30-second epochs, and cardiopulmonary resuscitation quality markers were assessed using video and telemetry data review of goal endpoints: end-tidal carbon dioxide greater than or equal to 15 mm Hg, diastolic blood pressure greater than or equal to 30 mm Hg, chest compression fraction greater than 80% per epoch, and chest compression rate between 100 and 120 chest compression per minute. Additionally, each chest compression pause (hands-off event) was recorded and timed. When compared with extracorporeal cardiopulmonary resuscitation, classic cardiopulmonary resuscitation epochs were more likely to have end-tidal carbon dioxide greater than or equal to 15 mm Hg (56% vs 6.2%; p = 0.01) and provide chest compression between 100 and 120 times per minute (112 vs 134 chest compression per minute; p < 0.001). No difference was found between classic cardiopulmonary resuscitation and extracorporeal cardiopulmonary resuscitation in compliance with diastolic blood pressure greater than or equal to 30 mm Hg (38% classic cardiopulmonary resuscitation vs 30% extracorporeal cardiopulmonary resuscitation). There were 135 hands-off events: 52 in classic cardiopulmonary resuscitation and 83 in extracorporeal cardiopulmonary resuscitation (p = 0.12). CONCLUSIONS: Classic cardiopulmonary resuscitation had superior adherence to end-tidal carbon dioxide goals and chest compression rate guidelines than extracorporeal cardiopulmonary resuscitation.

Neurologic Outcomes After Extracorporeal Membrane Oxygenation: A Systematic Review.

OBJECTIVES: The goal of this systematic review of the literature was to summarize neurologic outcomes following neonatal and pediatric extracorporeal membrane oxygenation. DATA SOURCES: We conducted electronic searches of PubMed, Scopus, Web of Science, CINAHL, Cochrane, and EMBASE. STUDY SELECTION: Inclusion criteria included publication dates 2000-2016, patient ages 0-18 years, and use of standardized measures to evaluate outcomes after extracorporeal membrane oxygenation. DATA EXTRACTION: We identified 3,497 unique citations; 60 full-text articles were included in the final review. DATA SYNTHESIS: Studies evaluated patients with congenital diaphragmatic hernia (7), cardiac disease (8), cardiac arrest (13), and mixed populations (32). Follow-up was conducted at hospital discharge in 10 studies (17%) and at a median of 26 months (interquartile range, 8-61 mo) after extracorporeal membrane oxygenation in 50 studies (83%). We found 55 outcome measures that assessed overall health and function (4), global cognitive ability (7), development (4), motor function (5), adaptive function (2), behavior/mood (6), hearing (2), quality of life (2), school achievement (5), speech and language (6), learning and memory (4), and attention and executive function (8). Overall, 10% to as many as 50% of children scored more than 2 SDS below the population mean on cognitive testing. Behavior problems were identified in 16-46% of children tested, and severe motor impairment was reported in 12% of children. Quality of life of former extracorporeal membrane oxygenation patients evaluated at school age or adolescence ranged from similar to healthy peers, to 31-53% having scores more than 1 SD below the population mean. CONCLUSIONS: This systematic review of the literature suggests that children who have undergone extracorporeal membrane oxygenation suffer from a wide range of disabilities. A meta-analysis was not feasible due to heterogeneity in pathologies, outcome measures, and age at follow-up, underscoring the importance of developing and employing a core set of outcomes measures in future extracorporeal membrane oxygenation studies.

Can Telemedicine Improve Adherence to Resuscitation Guidelines for Critically Ill Children at Community Hospitals? A Randomized Controlled Trial Using High-Fidelity Simulation.

OBJECTIVES: Children transferred from community hospitals lacking specialized pediatric care are more seriously ill than those presenting to pediatric centers. Pediatric consultation and adherence to management guidelines improve outcomes. The aims of the study were (1) to assess whether telemedicine consultation in critical situations is feasible and (2) to compare the impact of pediatric critical care medicine (PCCM) consultation via telemedicine versus telephone on community hospital adherence to resuscitation guidelines through a randomized controlled telemedicine trial. METHODS: In situ, high-fidelity simulation scenarios of critically ill children presenting to a community hospital and progressing to cardiopulmonary arrest were performed. Scenarios were randomized to PCCM consultation via telephone (control) or telemedicine (intervention). Primary outcome measure was proportion of teams who successfully defibrillated in 180 seconds or less from presentation of pulseless ventricular tachycardia. RESULTS: The following 30 scenarios were completed: 15 control and 15 intervention. Only 11 (37%) of 30 teams, defibrillated in 180 seconds or less from presentation of pulseless ventricular tachycardia; control: 6 (40%) of 15 versus intervention: 5 (33%) of 15, P = 0.7. Request for or use of backboard during cardiopulmonary resuscitation occurred in 24 (80%) of 30 scenarios; control: 9 (60%) of 15 versus intervention: 15 (100%) of 15, P = 0.006. Request for or use of stepstool during cardiopulmonary resuscitation occurred in 6 (20%) of 30 scenarios; control: 1 (7%) of 15 versus intervention: 5 (33%) of 15, P = 0.07. CONCLUSIONS: This study demonstrates the feasibility of using telemedicine to support acute management of children who present to community hospitals. Neither study arm adhered to current resuscitation guidelines and telemedicine consultation with PCCM experts was not associated with improvement. However, further research on optimizing telemedicine impact on the quality of pediatric care at community hospitals is warranted.

The development of writing skills in 4-year-old children with and without specific language impairment.

Research shows that many preschool children with specific language impairment (SLI) have difficulty acquiring literacy skills including phonological awareness, print concepts, and alphabet knowledge. Limited research suggests that preschool children with SLI also have difficulty with emergent writing tasks such as name writing and word writing. In typically developing children, research indicates that emergent writing skills are acquired in a developmental sequence: (1) linearity, (2) segmentation, (3) simple characters, (4) left-right orientation, (5) complex characters, (6) random letters, and (7) invented spelling. This study compared the emergent writing skills of 4-year-old children with SLI (n = 22) to their age- and gender-matched peers (n = 22). Results indicated that children with SLI demonstrate difficulty with a variety of writing tasks, including letter writing, name writing, word writing, and sentence writing when compared to their typically-developing peers. Children with SLI followed the same developmental sequence in acquiring writing skills as their typically-developing peers.

Joint attention interventions for children with autism spectrum disorder: a systematic review and meta-analysis.

BACKGROUND: A core social-communication deficit in children with autism spectrum disorder (ASD) is limited joint attention behaviours-important in the diagnosis of ASD and shown to be a powerful predictor of later language ability. Various interventions have been used to train joint attention skills in children with ASD. However, it is unclear which participant, intervention and interventionist factors yield more positive results. AIMS: The purpose of this systematic review and meta-analysis was to provide a quantitative assessment of the effectiveness of joint attention interventions aimed at improving joint attention abilities in children with ASD. METHODS & PROCEDURES: The researchers searched six databases for studies meeting the inclusion criteria at two levels: title/abstract and full-text stages. Two independent coders completed data extraction using a coding manual and form developed specifically for this research study. Meta-analysis procedures were used to determine the overall effects of several comparisons including treatment type, treatment administrator, intervention characteristics and follow-up. MAIN CONTRIBUTION: Fifteen randomized experimental studies met inclusion criteria. All comparisons resulted in statistically significant effects, though overlapping confidence intervals suggest that none of the comparisons were statistically different from each other. Specifically, treatment administrator, dosage and design (control or comparison, etc.) characteristics of the studies do not appear to produce significantly different effects. CONCLUSIONS & IMPLICATIONS: The results of this meta-analysis provide strong support for explicit joint attention interventions for young children with ASD; however, it remains unclear which children with ASD respond to which type of intervention.

Risk assessment and anesthetic management of patients with Williams syndrome: a comprehensive review.

Since the first description in 1961, several case reports have documented an increased incidence of anesthesia-related cardiac arrest in patients with Williams-Beuren syndrome, commonly known as Williams syndrome (WS). Widespread arteriopathy secondary to an elastin gene defect results in various cardiac defects, including supravalvar aortic stenosis (SVAS) and coronary artery anomalies, which can increase the risk of myocardial ischemia. Even though patients with WS are known to have increased risk of adverse events during anesthesia and sedation, they often undergo several procedures that require anesthesia during their lifetimes, and cases of perianesthetic cardiac arrest continue to be reported. To date, no prospective studies have been reported that quantify anesthetic risk in individual patients with WS. In this article, we review the clinical manifestations of WS, propose a consensus, expert-informed method to estimate anesthetic risk based on the current literature, and provide recommendations for periprocedural management of this patient population.

Acute Renal and Hepatic Failure in an Adolescent: An Unusual Presentation of Multiple Aortic Aneurysms.

Aortic dissection secondary to thoracoabdominal aortic aneurysms is very uncommon in children, and this life-threatening diagnosis requires a high clinical index of suspicion. Unlike adults, in whom atherosclerosis, inflammation, and advanced age are typically contributing factors, aortic dissection in children is usually due to nonatherosclerotic causes.Aortic aneurysms can be asymptomatic when small but, when significantly enlarged, can compromise organ function and dissect, resulting in high mortality rates. It is therefore critical that children with this uncommon condition be identified early when medical or surgical management can potentially improve outcome. We describe a 15-year-old patient with multiple aortic aneurysms with dissection whose presentation includes chronic anemia, acute-on-chronic renal failure with hyperkalemia, and liver injury.