Risk Stratification by Percent Liver Herniation in Congenital Diaphragmatic Hernia.

INTRODUCTION: Congenital diaphragmatic hernia is associated with pulmonary hypoplasia, pulmonary hypertension, and significant neonatal morbidity. Although intrathoracic liver herniation (LH) >20% is associated with adverse outcomes, the relationship between LH <20% and outcomes is poorly characterized. METHODS: A single-center retrospective cohort study was performed from 2011 to 2020 of 80 fetuses with left-sided congenital diaphragmatic hernia that were delivered and repaired at our institution. Perinatal, perioperative, and postoperative data were collected. We evaluated the association of %LH with outcomes as a stratified ordinal variable (0%-10% LH, 10%-19% LH, and >20% LH) and as a continuous variable. Data were analyzed by analysis of variance with Bonferroni post hoc analysis, chi-square analyses, and univariate logistic regression. RESULTS: Extracorporeal membrane oxygenation (ECMO) (P < 0.001), repair on ECMO (P = 0.002), repair with patch (P < 0.001), length of stay (P = 0.002), inhaled nitric oxide use (P < 0.001), and sildenafil use at discharge (P < 0.001), showed significant differences among LH groups. There were no differences among the groups concerning survival (at discharge, 6 mo, and 1 y) and tracheostomy. On further analysis there was no difference between 10% and 19% LH and ≥20% LH patients concerning ECMO (P = 0.55), repair on ECMO (P = 0.54), repair with patch (P = 1.00), length of stay (P = 1.00), and inhaled nitric oxide use (P = 0.33). Logistic regression analysis displayed a significant association with LH and ECMO, repair on ECMO, repair with patch, inhaled nitric oxide use, and sildenafil use. CONCLUSIONS: Our analysis displays no significant difference in perinatal management between patients with 10%-19% and ≥20% LH. These findings suggest that the historical cutoff of ≥20% LH may not be sufficient alone to guide perinatal counseling and decision-making.

Efficacy of quality improvement and patient safety workshops for students: a pilot study.

BACKGROUND: While the Association of American Medical Colleges encourages medical schools to incorporate quality improvement and patient safety (QI/PS) into their curriculum, medical students continue to have limited QI/PS exposure. To prepare medical students for careers that involve QI/PS, the Institute for Healthcare Improvement chapter at an allopathic medical school and school of allied health professions initiated self-directed learning by offering student-led workshops to equip learners with skills to improve the quality and safety of healthcare processes. METHODS: In this prospective cohort study, workshops were hosted for medical students between 2015 and 2018 on five QI/PS topics: Process Mapping, Root-Cause Analysis (RCA), Plan-Do-Study-Act (PDSA) Cycles, Evidence Based Medicine (EBM), and Patient Handoffs. Each workshop included a hands-on component to engage learners in practical applications of QI/PS skills in their careers. Change in knowledge, attitudes, and behaviors was assessed via pre- and post-surveys using 5-point Likert scales, and analyzed using either the McNemar test or non-parametric Wilcoxon signed-rank test. Surveys also gathered qualitative feedback regarding strengths, future areas for improvement, and reasons for attending the workshops. RESULTS: Data was collected from 88.5% of learners (n = 185/209); 19.5% of learners reported prior formal instruction in these topics. Statistically significant improvements in learners' confidence were observed for each workshop. Additionally, after attending workshops, learners felt comfortable teaching the learned QI/PS skill to colleagues (mean pre/post difference 1.96, p < 0.0001, n = 139) and were more likely to pursue QI/PS projects in their careers (mean pre/post difference 0.45, p < 0.0001, n = 139). Lastly, learners demonstrated a statistically significant increase in knowledge in four out of five skills workshop topics. CONCLUSION: Few medical students have formal instruction in QI/PS tools. This pilot study highlights advantages of incorporating an innovative, student-directed modified 'flipped classroom' methodology, with a focus on active experiential learning and minimal didactic instruction.

"Covering provider": an effort to streamline clinical communication chaos.

Objective: This report describes a root cause analysis of incorrect provider assignments and a standardized workflow developed to improve the clarity and accuracy of provider assignments. Materials and Methods: A multidisciplinary working group involving housestaff was assembled. Key drivers were identified using value stream mapping and fishbone analysis. A report was developed to allow for the analysis of correct provider assignments. A standardized workflow was created and piloted with a single service line. Pre- and post-pilot surveys were administered to nursing staff and participating housestaff on the unit. Results: Four key drivers were identified. A standardized workflow was created with an exclusive treatment team role in Epic held by a single provider at any given time, with a corresponding patient list column displaying provider information for each patient. Pre- and post-survey responses report decreased confusion, decreased provider identification errors, and increased user satisfaction among RNs and residents with sustained uptake over time. Conclusion: This work demonstrates structured root cause analysis, notably engaging housestaff, to develop a standardized workflow for an understudied and growing problem. The development of tools and strategies to address the widespread burdens resulting from clinical communication failures is needed.

Management of Pediatric Aortic Pseudoaneurysm Due to Penetrating Trauma.

Due to the increasing frequency of pediatric penetrating trauma, pediatric surgeons need to be prepared to evaluate and manage complex penetrating injuries. In this report, we discuss the endovascular management of a traumatic aortic pseudoaneurym and subsequent bullet retrieval following penetrating chest trauma in a child. The key to successful management included multidisciplinary decision making and use of an expandable covered stent generally used for management of aortic coarctation.

Management of Concurrent Pediatric Blunt Aortic and Traumatic Brain Injury.

This is the case of a pediatric blunt trauma patient who presented with a concurrent blunt traumatic aortic and severe brain injury. We describe successful simultaneous management of the aortic and brain injury with delayed endovascular repair of the aorta. This report details the importance of multidisciplinary discussion in definitive management of children with these concurrent injuries and the endovascular technical considerations in children.

Surgical Approach to Pediatric Ovarian Growing Teratoma Syndrome: A Case Report.

BACKGROUND: Growing teratoma syndrome is defined as conversion of a metastatic immature tumor to a mature tumor after adjuvant chemotherapy and remains an area of investigation because of its unclear pathogenesis. Because of its risk of malignant transformation, the primary treatment strategy for pediatric patients is surgical resection. CASE: In this report we present a case of a pediatric patient with recurrent growing teratoma syndrome who was treated with chemotherapy, debulking procedures, and cryoablation for the growing nodules throughout her abdominal cavity. The patient has had a good clinical outcome without recurrent malignant tumor. SUMMARY AND CONCLUSION: These masses do not always regress with chemotherapy and complete surgical excision or ablation should be attempted when possible.

Using a Teaching Intervention and Calibrated Peer Review™ Diagnostics to Improve Visual Communication Skills.

Rice University's bioengineering department incorporates written, oral, and visual communication instruction into its undergraduate curriculum to aid student learning and to prepare students to communicate their knowledge and discoveries precisely and persuasively. In a tissue culture lab course, we used a self- and peer-review tool called Calibrated Peer Review™ (CPR) to diagnose student learning gaps in visual communication skills on a poster assignment. We then designed an active learning intervention that required students to practice the visual communication skills that needed improvement and used CPR to measure the changes. After the intervention, we observed that students performed significantly better in their ability to develop high quality graphs and tables that represent experimental data. Based on these outcomes, we conclude that guided task practice, collaborative learning, and calibrated peer review can be used to improve engineering students' visual communication skills.

Dual-energy computed tomography imaging of atherosclerotic plaques in a mouse model using a liposomal-iodine nanoparticle contrast agent.

BACKGROUND: The accumulation of macrophages in inflamed atherosclerotic plaques has long been recognized. In an attempt to develop an imaging agent for detection of vulnerable plaques, we evaluated the feasibility of a liposomal-iodine nanoparticle contrast agent for computed tomography imaging of macrophage-rich atherosclerotic plaques in a mouse model. METHODS AND RESULTS: Liposomal-iodine formulations varying in particle size and polyethylene glycol coating were fabricated and shown to stably encapsulate the iodine compound. In vitro uptake studies using optical and computed tomography imaging in the RAW 264.7 macrophage cell line identified the formulation that promoted maximal uptake. Dual-energy computed tomography imaging using this formulation in apolipoprotein E-deficient (ApoE(-/-)) mice (n=8) and control C57BL/6 mice (n=6) followed by spectral decomposition of the dual-energy images enabled imaging of the liposomes localized in the plaque. Imaging cytometry confirmed the presence of liposomes in the plaque and their colocalization with a small fraction (≈2%) of the macrophages in the plaque. CONCLUSIONS: The results demonstrate the feasibility of imaging macrophage-rich atherosclerotic plaques using a liposomal-iodine nanoparticle contrast agent and dual-energy computed tomography.