The role of vascular surgeons in the management of pediatric bone tumors.

OBJECTIVES: The objective of this study was to review the outcomes of a multidisciplinary approach to the surgical management of pediatric bone tumors with blood vessel involvement over a 14- year period. METHODS: A retrospective review was conducted of all pediatric bone tumor resections performed with the assistance of vascular surgery at our institution between January 2006 and January 2021. Inclusion criteria for the study included the presence of a vascular surgeon at the operative resection and radiographic evidence of major blood vessel involvement. RESULTS: From 2006 to 2021, 117 patients underwent a bone tumor resection by a single orthopedic surgeon/vascular surgeon team. Sixty were malignant tumors, and 57 were benign. Of the 117 procedures, 5.1% (6/117) required reconstruction of an artery; five in malignant cases and one in benign. No venous reconstructions were undertaken in this study. Ligation of a major artery without reconstruction was performed in 8.8% (5/57) of malignant and 1.7% (1/60) of benign resections. Despite this vessel-sparing approach, microscopic margins were clear in all cases. Local recurrence occurred in a single patient in the malignant group at 61 months. CONCLUSIONS: The ideal management of pediatric bone tumors with major blood vessel involvement remains poorly defined. Our results demonstrate that even in the setting of radiographic evidence of vessel involvement, a multidisciplinary team of vascular and orthopedic surgeons can employ a vessel-sparing approach with minimal blood loss, excellent limb salvage, and minimal local recurrence.

Adapting Elements of Cleft Care Protocols in Low- and Middle-income Countries During and After COVID-19: A Process-driven Review With Recommendations.

A consortium of global cleft professionals, predominantly from low- and middle-income countries, identified adaptations to cleft care protocols during and after COVID-19 as a priority learning area of need.A multidisciplinary international working group met on a videoconferencing platform in a multi-staged process to make consensus recommendations for adaptations to cleft protocols within resource-constrained settings. Feedback was sought from a roundtable discussion forum and global organizations involved in comprehensive cleft care.Foundational principles were agreed to enable recommendations to be globally relevant and two areas of focus within the specified topic were identified. First the safety aspects of cleft surgery protocols were scrutinized and COVID-19 adaptations, specifically in the pre- and perioperative periods, were highlighted. Second, surgical procedures and cleft care services were prioritized according to their relationship to functional outcomes and time-sensitivity. The surgical procedures assigned the highest priority were emergent interventions for breathing and nutritional requirements and primary palatoplasty. The cleft care services assigned the highest priority were new-born assessments, pediatric support for children with syndromes, management of acute dental or auditory infections and speech pathology intervention.A collaborative, interdisciplinary and international working group delivered consensus recommendations to assist with the provision of cleft care in low- and middle-income countries. At a time of global cleft care delays due to COVID-19, a united approach amongst global cleft care providers will be advantageous to advocate for children born with cleft lip and palate in resource-constrained settings.

Smile Train: A Sustainable Approach to Global Cleft Care.

ABSTRACT: Smile Train, the largest global cleft nonprofit organization, employs a model of establishing partnerships with treatment centers and medical professionals in low- and middle-income countries (LMICs). Having a presence in over 90 countries throughout its history, the organization provides support for cleft lip and palate repair as well as comprehensive cleft care (CCC) for patients with clefts. With the goal of reducing disparities in access to quality surgical, anesthesia, and medical care, Smile Train strengthens partners with training, education, equipment, and patient support grants. Furthermore, safety and quality protocols have been put in place as guidelines for each partner center, and partnerships with other nongovernmental agencies were created to increase safety in the operating rooms. The founder of Smile Train desired to apply technology wherever possible to build sustainability within the treatment centers and surgeons supporting their own community. Smile Train's model, aimed at increased sustainability, is supplemented by technological advancements to assist in the safety and quality of cleft care services provided in LMIC treatment centers. Examples include centralized online data record keeping for every patient, virtual simulations and training, and mobile applications to enhance care. Recently, Smile Train's focus is expanding CCC with nutrition, oral health, speech, and nursing care programs to improve functional and psychosocial outcomes for patients following their procedure. Despite the challenges imposed by the COVID-19 pandemic, Smile Train continues to provide safe, efficacious, and CCC alongside their partners in LMICs further investing tremendous efforts towards the livelihood of children with clefts globally.

Unusual complication of late presentation deceleration aortic injury.

A 50-year-old patient presented with a stroke. An ascending aortic mass noted by computed tomography was attached to the aortic wall and was found to be thrombus at surgery. Pathologic examination revealed an intraluminal thrombus attached to a focal segment of intimal fragmentation. Sectioning of the aortic wall revealed what were findings consistent with what would be noted with a previously unrecognized traumatic ascending aortic deceleration injury. To our knowledge, this is the first case of a late presentation of deceleration aortic injury, presenting with a thrombus within the ascending aorta.

Screening pediatric surgical patients during the COVID-19 pandemic.

ABSTRACT: SARS-CoV-2 has profoundly affected the way healthcare is delivered and has created significant strain on medical facilities globally. As a result, hospitals have had to continuously adapt in order to provide optimal patient care while minimizing the risk of SARS-CoV-2 transmission, particularly in the surgical setting. Texas Children's Hospital developed a set of protocols for surgical screening and clearance of patients in the context of the COVID-19 pandemic. These screening protocols were designed to mitigate the risk of exposing patients and healthcare providers to SARS-CoV-2 and have evolved significantly as a result of the emerging changes in medicine, technology, and governmental regulations. In this article, we share the reasoning behind the development, implementation, and successive modification of our institutional screening protocols.

Wound Healing and Wound Care in Neonates: Current Therapies and Novel Options.

GENERAL PURPOSE: To provide wound care information that considers the specific physiology of neonates. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Differentiate the use of hydrocolloids, hydrogels, foam dressings, and barrier creams in the neonatal population.2. Identify issues related to the use of solvents, alginates, collagen dressings, and negative-pressure wound therapy in neonates. ABSTRACT: OBJECTIVETo discuss what is known about the wound milieu in premature and full-term neonates, including the unique challenges pediatric clinicians face, the therapies that have proven effective, and the therapies contraindicated for use in neonatal wound healing to guide treatment that accounts for the specific physiological characteristics of this often overlooked population. DATA SOURCES: Data were collected on neonatal wound healing from a wide variety of sources, including PubMed, Google Scholar, journals, and textbooks. STUDY SELECTION: Selection criteria included publications focused on the differences and nuances of wound healing in neonates in comparison with all other age groups. DATA EXTRACTION: Data were extracted based on articles covering wound healing therapies with proven effectiveness in neonates. Terms for neonatal wound care were compiled, and then a comprehensive literature search was performed by the authors. DATA SYNTHESIS: Although many therapies are safe for treatment of older children and adolescents, most have not been explicitly tested for neonatal use. This article reviews therapies with proven effectiveness and/or specific concerns in the neonatal population. CONCLUSION: This review sheds light on the advantages and disadvantages of current standards of care regarding wound healing for neonates to direct researchers and clinicians toward developing treatments specifically for this delicate population.

To discuss what is known about the wound milieu in premature and full-term neonates, including the unique challenges pediatric clinicians face, the therapies that have proven effective, and the therapies contraindicated for use in neonatal wound healing to guide treatment that accounts for the specific physiological characteristics of this often overlooked population. Data were collected on neonatal wound healing from a wide variety of sources, including PubMed, Google Scholar, journals, and textbooks. Selection criteria included publications focused on the differences and nuances of wound healing in neonates in comparison with all other age groups. Data were extracted based on articles covering wound healing therapies with proven effectiveness in neonates. Terms for neonatal wound care were compiled, and then a comprehensive literature search was performed by the authors. Although many therapies are safe for treatment of older children and adolescents, most have not been explicitly tested for neonatal use. This article reviews therapies with proven effectiveness and/or specific concerns in the neonatal population. This review sheds light on the advantages and disadvantages of current standards of care regarding wound healing for neonates to direct researchers and clinicians toward developing treatments specifically for this delicate population.

An Unreported Complication After Fetoscopic Myelomeningocele Closure.

Myelomeningocele (MMC) is a type of open neural tube defect characterized by exposure of the spinal cord through a defect in the skin and posterior hindbrain herniation through the foramen magnum. Outcomes vary but common morbidities include paraplegia, hydrocephalus, neurogenic bladder, scoliosis, and tethered cord. Fetal surgery, although not a cure, has been shown to decrease the risk of associated morbidity.A study of a neonate born at 39 5/7 weeks gestation status-post in utero fetoscopic MMC repair at 24 weeks gestation was presented in this study along with a concise review of the literature. Fasciocutaneous advancement flaps were made in utero to facilitate a tension-free midline closure and were left to heal secondarily. The neonate underwent uncomplicated spontaneous vaginal delivery but was noted to have a right flank hernia through the relaxing incision in addition to delayed healing of the left relaxing incision. According to authors, iatrogenic flank hernia following fetoscopic MMC repair has not been previously reported in the literature. Both defects were repaired primarily in layers with undermining and retroperitoneal domain was reestablished with imbrication of the overlying muscle on the right side. The authors report their experience to contribute to the scarce literature describing postnatal complications arising from this novel procedure.

Facial Gunshot Wounds.

Craniomaxillofacial gunshot injuries, resulting from assault, suicide attempts, and accidental trauma, represent a major public health dilemma in the United States. Due to the extent of injury and resulting osseous and soft tissue loss, facial gunshot wounds pose a unique challenge to the reconstructive surgeon. Initial management should use advanced trauma life support principles with the goal of patient stabilization. Acute operative management should center around wound decontamination, debridement, and temporary closure. Historically, definitive surgical management focused on delayed reconstruction secondary to high rates of wound infections, necrosis, and ischemia. With improvements in imaging modalities, the advent of virtual surgical planning, and the popularization of microvascular free flaps, contemporary methods have shifted toward earlier more definitive reconstruction. Autologous free tissue transfer has resulted in a decrease in hospital stay and the number of overall surgeries. Importantly, due to the variability in injury pattern and complexity in reconstruction, a systematic approach toward intervention is needed to mitigate complications and optimize overall functional and aesthetic outcomes.