Extracorporeal membrane oxygenation and paracorporeal lung assist devices as a bridge to pediatric lung transplantation.

BACKGROUND: "Bridging" is a term used to describe the implementation of various treatment modalities to improve waitlist survival while a patient awaits lung transplantation. ECMO and PLAD are technologies used to bridge patients to lung transplantation. ECMO and PLAD are cardiopulmonary support systems that help move blood forward while using an artificial membrane to remove CO2 from and add O2 to the blood. Recent studies showed that these technologies are increasingly effective in bridging patients to lung transplantation, especially with optimizing patient selection, implementing physical rehabilitation and ambulation goals, standardization of management decisions, and increasing staff experience, among other considerations. We review these technologies, their roles as bridges to pediatric lung transplantation, as well as indications, contraindications, complications, and mortality rates. CONCLUSION: Finally, we discuss the existing knowledge gaps and areas for future research to improve patient outcomes and understanding of lung assist devices.

The Outcomes of Surgically Treated Distal Tibia Salter-Harris Type III and IV Fractures.

Current literature suggests that distal tibia Salter-Harris Type III and IV fractures with > 2 mm of displacement should be treated surgically to minimize growth arrest. The objective of the current study is to determine, in Salter-Harris Type III and IV distal tibia fractures, if gap displacements < 2 mm post-surgery are associated with fracture union, if step-offs > 2 mm post-surgery are associated with osteoarthritis, and to determine how often growth disturbances are observed in surgically-treated patients. A retrospective case series review of fourteen patients with displaced distal tibia Salter-Harris Type III and IV fractures was performed. The patients were evaluated using Kärrholm's method of clinical evaluation. The current study demonstrated that surgical reduction to < 2 mm gap displacement results in fracture union in all cases, reduction to < 2 mm does not result in osteoarthritis in any cases, and only 8% of patients demonstrated a growth disturbance with surgical intervention. (Journal of Surgical Orthopaedic Advances 29(4):219-224, 2020).

Pediatric Respiratory Syncytial Virus Hospitalizations and Respiratory Support After the COVID-19 Pandemic.

Importance: After the COVID-19 pandemic, there was a surge of pediatric respiratory syncytial virus (RSV) infections, but national data on hospitalization and intensive care unit use and advanced respiratory support modalities have not been reported. Objective: To analyze demographics, respiratory support modes, and clinical outcomes of children with RSV infections at tertiary pediatric hospitals from 2017 to 2023. Design, Setting, and Participants: This cross-sectional study evaluated children from 48 freestanding US children's hospitals registered in the Pediatric Health Information System (PHIS) database. Patients 5 years or younger with RSV from July 1, 2017, to June 30, 2023, were included. Each season was defined from July 1 to June 30. Prepandemic RSV seasons included 2017 to 2018, 2018 to 2019, and 2019 to 2020. The postpandemic season was delineated as 2022 to 2023. Exposure: Hospital presentation with RSV infection. Main Outcomes and Measures: Data on emergency department presentations, hospital or intensive care unit admission and length of stay, demographics, respiratory support use, mortality, and cardiopulmonary resuscitation were analyzed. Postpandemic season data were compared with prepandemic seasonal averages. Results: A total of 288 816 children aged 5 years or younger (median [IQR] age, 8.9 [3.3-21.5] months; 159 348 [55.2%] male) presented to 48 US children's hospitals with RSV from July 1, 2017, to June 30, 2023. Respiratory syncytial virus hospital presentations increased from 39 698 before the COVID-19 pandemic to 94 347 after the pandemic (P < .001), with 86.7% more hospitalizations than before the pandemic (50 619 vs 27 114; P < .001). In 2022 to 2023, children were older (median [IQR] age, 11.3 [4.1-26.6] months vs 6.8 [2.6-16.8] months; P < .001) and had fewer comorbidities (17.6% vs 21.8% of hospitalized patients; P < .001) than during prepandemic seasons. Advanced respiratory support use increased 70.1% in 2022 to 2023 (9094 vs 5340; P < .001), and children requiring high-flow nasal cannula (HFNC) or noninvasive ventilation (NIV) were older than during prepandemic seasons (median [IQR] age for HFNC, 6.9 [2.7-16.0] months vs 4.6 [2.0-11.7] months; for NIV, 6.0 [2.1-16.5] months vs 4.3 [1.9-11.9] months). Comorbid conditions were less frequent after the pandemic across all respiratory support modalities (HFNC, 14.9% vs 19.1%, NIV, 22.0% vs 28.5%, invasive mechanical ventilation, 30.5% vs 38.0%; P < .001). Conclusions and Relevance: This cross-sectional study identified a postpandemic pediatric RSV surge that resulted in markedly increased hospital volumes and advanced respiratory support needs in older children with fewer comorbidities than prepandemic seasons. These clinical trends may inform novel vaccine allocation to reduce the overall burden during future RSV seasons.

Outcomes of surgical treatment of tracheobronchomalacia in children.

BACKGROUND: Tracheobronchomalacia (TBM) is characterized by excessive dynamic airway collapse. Severe TBM can be associated with substantial morbidity. Children with secondary TBM associated with esophageal atresia/tracheoesophageal fistula (EA/TEF) and vascular-related airway compression (VRAC) demonstrate clinical improvement following airway pexy surgery. It is unclear if children with severe primary TBM, without secondary etiologies (EA/TEF, vascular ring, intrinsic pulmonary pathology, or complex cardiac disease) demonstrate clinical improvement following airway pexy surgery. MATERIALS AND METHODS: The study cohort consisted of 73 children with severe primary TBM who underwent airway pexy surgery between 2013 and 2020 at Boston Children's Hospital. Pre- and postoperative symptoms as well as bronchoscopic findings were compared with Fisher exact test for categorical data and Student's t-test for continuous data. RESULTS: Statistically significant improvements in clinical symptoms were observed, including cough, noisy breathing, prolonged respiratory infections, pneumonias, exercise intolerance, cyanotic spells, brief resolved unexplained events (BRUE), and noninvasive positive pressure ventilation (NIPPV) dependence. No significant differences were seen regarding oxygen dependence, ventilator dependence, or respiratory distress requiring NIPPV. Comparison of pre- and postoperative dynamic bronchoscopy findings revealed statistically significant improvement in the percent of airway collapse in all anatomic locations except at the level of the upper trachea (usually not malacic). Despite some initial improvements, 21 (29%) patients remained symptomatic and underwent additional airway pexies with improvement in symptoms. CONCLUSION: Airway pexy surgery resulted in significant improvement in clinical symptoms and bronchoscopic findings for children with severe primary TBM; however, future prospective and long-term studies are needed to confirm this benefit.

Bridge Builders: A Qualitative Study of Fellows' Successful Supervision of Residents.

PURPOSE: Clinical fellows, those training to become subspecialists in a program certified by the Accreditation Council for Graduate Medical Education, supervise residents on inpatient subspecialty rotations. Unlike for supervising residents or for faculty, there is a paucity of literature describing fellows' supervision of residents. The aim of this study was to understand residents' and fellows' perception of successful supervision of residents by fellows on inpatient subspecialty rotations to inform the development of curricula to support fellows as supervisors. METHOD: Using grounded theory methodology, the authors held focus groups in May 2020 of pediatric residents and pediatric subspecialty fellows at Boston Children's Hospital, Boston, Massachusetts. Focus groups were conducted until thematic saturation was achieved. Deidentified transcripts were independently coded by 2 authors. The author team consolidated the codes into themes and developed an interpretive model for fellows' successful supervision of residents. Key results were confirmed via member checking. RESULTS: The authors conducted 4 resident focus groups, composed of 16 pediatric residents, and 4 fellow focus groups, composed of 13 pediatric subspecialty fellows. Participants perceived that fellows who provided successful resident supervision advanced residents' professional growth and supported residents' development along 5 "bridges": (1) generalist to subspecialist, (2) trainee to autonomous practitioner, (3) individual to member of the interprofessional team, (4) emerging physician to patient-facing care provider, and (5) newcomer to engaged clinical learner. Fellows can further residents' growth in these areas by demonstrating approachability, empathy, appreciation, and kindness. CONCLUSIONS: As newcomers on inpatient subspecialty rotations, residents engage in legitimate peripheral participation. Fellows who are successful supervisors move residents toward full participation in their profession via the bridge model. The fellow-resident dynamic carries advantages of near-peer learning. Fellows can harness their role, subspecialty knowledge, and familiarity with the training environment to enhance resident supervision.

The Reduction Maneuver for Pediatric Extension Type 3 Supracondylar Humerus Fractures.

Extension type supracondylar humerus fractures in children commonly displace in two directions: posteromedial and posterolateral. The traditional maneuver to reduce posteromedial displaced fractures utilizes pronation of the forearm, while the maneuver for posterolateral displaced fractures utilizes supination. Traditional teaching suggests that the periosteum is an aid to reduction. The purpose of this study is to take a second look at this periosteal hinge theory and reexamine the maneuver performed when reducing an extension type 3 supracondylar fracture. Sixty-nine consecutive displaced extension type 3 supracondylar fractures were studied. Intraoperative fluoroscopic radiographs were graded as posteromedial, posterolateral, or direct posterior displacement. All fractures were treated with closed reduction and percutaneous pinning. The best maneuver used to align the fracture during surgery was recorded in the operative note. The direction of displacement on radiographs was 32 (46.3%) posteromedial, 31 (45%) posterolateral, and six (8.7%) direct posterior. All of the 32 posteromedial displaced fractures were best aligned when pronation was utilized. All of the 31 posterolaterally displaced fractures were best aligned when supination was utilized. The six direct posteriorly displaced fractures obtained the best alignment in pronation. The current study reaffirms the classic teaching that the direction of displacement of the fracture indicates the site of the intact periosteum. The intact periosteal hinge can be used to obtain fracture reduction.

Positive and Negative Themes Depicted in Combat-Related Sports Films.

Participation in boxing, mixed martial arts, and wrestling is extremely popular among children and adolescents. The objective of this study was to determine themes depicted in a select number of combat-related films. Twenty films were independently viewed and analyzed by 4 reviewers. The average number of positive and negative themes was 34.4 and 18.1 mean events/hour for all included films, respectively. The most common positive themes were "positive interactions with family/friends/fans," "importance of mentorship," and "positive interactions with a coach/trainer" (4.23, 3.63, and 3.06 mean events/hour, respectively). The most common negative themes were "choosing to do the wrong thing," "negative interactions with family/friends/fans," and "poor sportsmanship" (2.70, 2.00, and 1.58 mean events/hour, respectively). In conclusion, the co-viewing of combat-related films among pediatric athletes and their coaches/trainers and/or parents in order to focus on "teachable moments" may encourage the acquisition and development of positive themes and the avoidance and de-emphasis of negative themes.

Utility of a long arm extension cast in management of pediatric fractures: A technique revisited.

A long arm cast with the elbow extended is a useful but often forgotten technique to manage some pediatric fractures. Specifically, proximal forearm fractures of both the radius and ulna, olecranon fractures, flexion-type supracondylar fractures and type II Monteggia fractures are well managed in this manner. Although some of these fractures are seen infrequently, timely diagnosis and treatment are essential to prevent complications. In this article, we present a review of the evaluation and management of these fractures in children, and a description of the technique used to apply a long arm cast in extension.

Surgical treatment of displaced pediatric lateral condyle fractures of the humerus by the posterior approach.

The surgical approach for open reduction and internal fixation of lateral condyle fractures in children is controversial. Some authors recommend the lateral approach to the elbow over the posterior approach because of theoretical concern for injury to the vascular supply of the distal humerus and potential avascular necrosis (AVN). The purpose of this retrospective case series study is to report the outcomes of open reduction and internal fixation of displaced lateral condyle fractures of the humerus by the posterior approach. Fifteen consecutive cases were reviewed and the posterior approach resulted in minimal postoperative loss of motion, no angular deformity, cosmetic scars, and no AVN. We support that AVN occurs because of stripping of soft tissues from the lateral condyle fragment and not the approach used. Stripping of soft tissues is not required when using the posterior approach because of excellent visualization of the fracture reduction.

Alagille Syndrome: A Case Report Highlighting Dysmorphic Facies, Chronic Illness, and Depression.

Alagille syndrome is a rare multisystem disorder affecting the liver, heart, vertebrae, eyes, and face. Alagille syndrome shares multiple phenotypic variants of other congenital or chronic childhood illnesses such as DiGeorge syndrome, Down syndrome, spina bifida, type 1 diabetes mellitus, and cystic fibrosis. All of these chronic illnesses have well-established links to psychiatric conditions. There are few community resources for Alagille patients, as it is an extremely rare condition. Despite the overlap with other chronic childhood illnesses, the psychiatric manifestations of Alagille syndrome have not been previously discussed in literature. The current study is a case report of a twelve-year-old female hospitalized in our pediatric psychiatric hospital for suicidal ideation with intent and plan. The patient had major depressive disorder, anxiety, other specified feeding and eating disorder, and attention-deficit/hyperactive disorder.

Surgical treatment for osteochondritis dessicans of the knee.

Osteochondritis dissecans (OCD) of the knee is a disease of the subchondral bone with secondary injury to the overlying articular cartilage. OCD lesions are generally categorized as juvenile-growth plates open-or adult-growth plates closed. This maturity-based classification scheme has a prognostic value in that many juvenile OCD lesions will heal with conservative care while most symptomatic adult OCD lesions need surgical intervention. OCD can result in pain, knee joint effusions, loose body formation, and arthritis. Short-term treatment goals include pain and symptom resolution while the long-term goal is to minimize arthritis. Surgical options include debridement, drilling, microfracture, reduction and fixation, autograft osteochondral transplantation, autologous chondrocyte implantation, and allograft osteochondreal transplantation.