Effect of citizenship status on access to pediatric liver and kidney transplantation.

Transplantation of non-US citizen residents remains controversial. We evaluate national trends in transplant activity among pediatric noncitizen residents (PNCR). Pediatric liver and kidney transplant data were obtained from the Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients. Data on transplanted organs, region, waitlist additions, procedures, and citizenship status were analyzed from 2012-2022. Rates of PNCR transplantation activity were compared with population rates from the US Census Bureau. On average, 713 ± 47 pediatric liver and 1039 ± 51 kidney patients were added to the waitlist, with 544 ± 32 liver and 742 ± 33 kidney transplants performed annually. Of these, PNCR comprised 1.5% and 3.3% of liver and kidney waitlist additions and 1.5% and 2.9% of liver and kidney transplant procedures, respectively. There were no significant changes in waitlist or transplant activity nationwide over the study period. There was a significant geographic variation in the percentage of waitlist additions and transplants across the United Network for Organ Sharing regions among the PNCR for liver and kidney transplantation. This is the first study to evaluate national trends in transplantation activity among PNCRs. The significant regional variation in transplantation activity for PNCR may suggest multilevel structural and systemic barriers to transplant accessibility.

Metastatic pulmonary calcifications after pediatric liver transplantation.

BACKGROUND: Pulmonary calcification (PC) is a rare clinical entity observed following liver transplantation (LT). Most often identified in adults or in patients with concomitant renal failure, PC is rarely reported in children. While the clinical course of PC is largely benign, cases of progressive respiratory failure and death have been reported. Additionally, PC may mimic several other disease processes making diagnosis and management challenging. Currently, little is reported regarding the diagnosis, management, and long-term outcomes of children with PC following LT. METHODS: We performed a retrospective chart review of patients undergoing LT at our institution between 2006 and 2023. We identified two patients who developed PC following LT. Their diagnosis, clinical course, and long-term outcomes are reported. A literature review of the presentation, diagnosis, management, and outcomes of adult and pediatric patients with PC post-LT was also performed. CONCLUSIONS: Pulmonary calcifications are a rare but notable complication after pediatric liver transplantation. Our case series adds to the limited literature on this clinical entity in children but also highlights the fact that effective diagnosis and treatment may be safely accomplished without the use of lung biopsy.

Student-led curricular approaches in medical education: the educational effects of a virtual fundamentals of COVID-19 course.

BACKGROUND: As the field of education was adapting to virtual learning during the COVID-19 pandemic, a need quickly emerged for a course to prepare medical students for future clinical practice. This call to action was answered by creating an innovative Fundamentals of COVID-19 course at the Indiana University School of Medicine (IUSM). As a group of medical student leaders at IUSM, we developed this online course in order to support our fellow students and the community. METHODS: The study examined the educational effects of completing the Fundamentals of COVID-19 course. In order to examine these effects, the study asked enrolled students to complete both a pre- and post-course self-assessment survey. Students were asked an identical set of questions on each survey about their knowledge, skills, and abilities (KSA) regarding COVID-19. Composite scores were created for each KSA learning domain. Responses were provided using a five-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. RESULTS: Out of the 724 students enrolled, 645 students completed both the pre- and post-course assessment surveys. Findings show that there were both meaningful and statistically significant differences in students' responses to the pre- and post-course surveys. Results show 1.) a significant mean increase in the knowledge composite score of 1.01, 95% CI [0.95, 1.06], t(644) = 36.4, p < .001, d = 1.43; 2.) a significant mean increase in the skills composite score of .55, 95% CI [0.50, 0.60], t(644) = 20.70, p < .001, d = 0.81. and 3.) a significant mean increase of the abilities composite score of 1.02, 95% CI [.97, 1.07], t(644) = 36.56, p < .001, d = 1.44. CONCLUSIONS: These findings demonstrate that the student-developed, online Fundamentals of COVID-19 course resulted in notable and statistically significant educational effects. The increase in students' self-reported ratings, especially in the knowledge and abilities domains, indicate that meaningful learning occurred within the course. These findings have notable implications for medical student training during healthcare emergencies, such as a pandemic, as well as within modern clerkship environments. Overall, our findings provide evidence that student-led curricular design and virtual delivery of course content can be effective tools in undergraduate medical education.

Botulinum Toxin Enhanced Foker Process for Long Gap Esophageal Atresia.

BACKGROUND: The traction-induced esophageal growth (Foker) process for the treatment of long gap esophageal atresia (LGEA) relies on applying progressive tension to the esophagus to induce growth. Due to its anti-fibrotic and muscle-relaxing properties, we hypothesize that Botulinum Toxin A (BTX) can enhance traction-induced esophageal growth. METHODS: A retrospective two-center cohort study was conducted on children who underwent a BTX-enhanced Foker process for LGEA repair from 2021 to 2023. BTX (10 units/ml, 2 units/kg, per esophageal pouch) was applied at the time of traction initiation. Time on traction, complications, and anastomotic outcomes were compared against historical controls (Foker process without BTX) from 2014 to 2021. RESULTS: Twenty infants (LGEA type A:12, B:4, C:4; 35% reoperative; median [IQR] age 3 [2-5] months), underwent BTX-enhanced Foker process (thoracotomy with external traction: 9; minimally invasive [MIS] multi-staged internal traction: 11). Mean gap lengths were similar between BTX-enhanced external and external traction control patients (mean [SD], 50.6 mm [12.6] vs. 44.5 mm [11.9], p = 0.21). When compared to controls, the BTX-enhanced external traction process was significantly faster (mean [SD], 12.1 [1.6] days vs. 16.6 [13.2] without BTX, p = 0.04) despite similar preoperative gap lengths. There was no difference in time on traction for those undergoing a minimally invasive process. There were no significant differences in complications or anastomotic outcomes in either cohort. CONCLUSION: Botulinum toxin may play a role in accelerating the traction-induced esophageal growth process for LGEA repair. Minimizing time on traction can decrease sedation and paralysis burden while on external traction. Further studies are needed to elucidate the effects of BTX on the esophagus. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Retrospective, Two-center, Cohort study.

Effectiveness of intraoperative nerve monitoring in reducing rates of recurrent laryngeal nerve injury in aerodigestive and cardiovascular pediatric surgery.

OBJECTIVE: To investigate the effectiveness of intraoperative nerve monitoring at decreasing vocal fold movement impairment in children undergoing at-risk procedures. BACKGROUND: Children undergoing aerodigestive or cardiovascular procedures are at risk for recurrent laryngeal nerve injury, leading to vocal fold movement impairment. Although intraoperative nerve monitoring has been shown to decrease recurrent laryngeal nerve injury in adults, there is paucity of data in children. METHODS: This was a retrospective, single-center cohort study of children who underwent airway, esophageal, or great vessel surgery between 2018 and 2023. Vocal fold movement impairment was evaluated with pre- and postoperative awake flexible fiberoptic laryngoscopy. Vocal fold movement impairment rates and associated characteristics were compared between those with and without intraoperative nerve monitoring. RESULTS: Among 387 children undergoing 426 at-risk procedures, intraoperative nerve monitoring was used in 72.1% (n = 307) of procedures. Intraoperative nerve monitoring significantly reduced postoperative vocal fold movement impairment compared with those without (11.4% vs 20.2%, P = .019, 43.6% relative risk reduction, number needed to treat: 12). In children with a pre-existing vocal fold movement impairment (n = 79, 18.5%), intraoperative nerve monitoring provided enhanced protection (vocal fold movement impairment 7.8% with intraoperative nerve monitoring compared with 25% without, P = .046, 68.6% relative risk reduction, number needed to treat: 3). Bilateral vocal fold movement impairment was 14 times more likely without intraoperative nerve monitoring (1.8% overall, 0.3% with intraoperative nerve monitoring, 5.6% without; 95% confidence interval 1.6-123.2; P = .006). Increasing intraoperative nerve monitoring use correlated with decreasing vocal fold movement impairment rates year over year (P = .046). Multivariable logistic regression demonstrated intraoperative nerve monitoring to remain significantly associated with reduced risk of vocal fold movement impairment (odds ratio, 0.48; 95% confidence interval, 0.26-0.85; P = .013). CONCLUSION: Intraoperative nerve monitoring in children seems effective at decreasing recurrent laryngeal nerve injury and consequently vocal fold movement impairment. Intraoperative nerve monitoring should be considered in children undergoing cervicothoracic or cardiothoracic procedures, especially in those with preoperative vocal fold movement impairment.