Teamwork and mental workload in postsurgical pediatric patient handovers: Prospective effect evaluation of an improvement intervention for OR-PICU patient transitions.

Postsurgical handover of pediatric patients from operating rooms (OR) to pediatric intensive care units (PICU) is a critical step. This transition is susceptible to errors and inefficiencies particularly if poor multidisciplinary teamwork occurs. Despite wide adoption of standardized handover interventions, comprehensive investigations into joint effects for patient care and provider outcomes are scarce. We aimed to improve OR-PICU handovers quality and sought to evaluate the intervention with particular attention to patient care effects and provider outcomes. A prospective, before-after-study design with an interrupted-series and a multi-source, mixed-methods evaluation approach was established. Drawing upon a participative plan-do-study-act approach, a standardized, checklist-based handover process was designed and implemented. For effect assessments, we observed OR-PICU handovers on site (pre implementation: n = 31, post: n = 30), respectively, with standardized expert observation and provider self-report tools (n = 111, n = 110). Setting was a tertiary Pediatric University Hospital. Supplementary qualitative, semi-structured interviews were conducted, and a general inductive content analysis approach was used to identify key facilitators and barriers on implementation. Improvement efforts focused on stepwise implementation of (1) standardized handover process and (2) a checklist for multi-professional OR-PICU handover communication. We observed significant increases in team and patient setup (pre: 79.3%, post: 98.6%, p < .01), enhanced team engagement (pre: 50%, post: 81.7%, p < .01), and comprehensive information transfer by the anesthesia sub-team (pre: 78.6%, post: 87.3%, p < .01). Expert-rated teamwork outcomes were consistently higher, yet self-reported teamwork did not change over time. Provider perceived stress and disruptions did not change, mental workload tended to decrease over time (pre: M = 3.2, post: 2.9, p = .08). Comprehensiveness of post-operative patient information reported by PICU physician increased significantly: pre: 65.9%, post: 76.2%, p < .05. After implementation, providers acknowledged the importance of standardized handover practices and associated benefits for facilitation of information transfer and comprehensiveness. Among reported barriers were obstacles during implementation as well as insufficient consideration of professionals' individual workflow after surgery. CONCLUSION:  A multidisciplinary intervention for postsurgical pediatric patient handovers was associated with improved expert-rated teamwork and fewer omissions of key patient information over time. Inconsistent results were obtained for provider-rated mental workload and teamwork outcomes. The findings contribute to a better understanding concerning the interplay of teamwork and provider cognitions in the course of establishing safe patient transitions in pediatric care. WHAT IS KNOWN: • Transfer of critically ill children conveys significant challenges for interprofessional communication and teamwork. Prospective research into interventions for safe and efficient handover practices of OR PICU patient transitions is necessary. • Checklists are assumed to facilitate cognitive load among providers in acute clinical environments. WHAT IS NEW: • A standardized, checklist-based handover intervention was associated with improvements in team set-up and information transfer. Provider outcomes such as mental workload and stress did not change over time. • The combination of teamwork and provider assessments allows a more nuanced understanding of implementation barriers and sustainable effects in course of OR-PICU handover interventions.

Genetic Disruption of Cilia-Associated Signaling Pathways in Patients with VACTERL Association.

VACTERL association is a rare malformation complex consisting of vertebral defects, anorectal malformation, cardiovascular defects, tracheoesophageal fistulae with esophageal atresia, renal malformation, and limb anomalies. According to current knowledge, VACTERL is based on a multifactorial pathogenesis including genomic alterations. This study aimed to improve the understanding of the genetic mechanisms in the development of VACTERL by investigating the genetic background with a focus on signaling pathways and cilia function. The study was designed as genetic association study. For this, whole-exome sequencing with subsequent functional enrichment analyses was performed for 21 patients with VACTERL or a VACTERL-like phenotype. In addition, whole-exome sequencing was performed for three pairs of parents and Sanger-sequencing was performed for ten pairs of parents. Analysis of the WES-data revealed genetic alteration in the Shh- and Wnt-signaling pathways. Additional performed functional enrichment analysis identified an overrepresentation of the cilia, including 47 affected ciliary genes with clustering in the DNAH gene family and the IFT-complex. The examination of the parents showed that most of the genetic changes were inherited. In summary, this study indicates three genetically determined damage mechanisms for VACTERL with the potential to influence each other, namely Shh- and Wnt-signaling pathway disruption, structural cilia defects and disruption of the ciliary signal transduction.

SuSiPed: An initial step towards a universal, low-cost, 3D-printable platform for pediatric minimal-invasive surgery training.

BACKGROUND: Training platforms such as the Fundamentals of Laparoscopic Surgery have become an integral part of postgraduate adult general surgical education. So far, however, there is no such universal tool for pediatric minimal-invasive surgery (MIS). We therefore designed and validated a novel 3D printable pediatric MIS simulation program. METHODS: The SuSiPed (Surgical Simulation in Pediatrics) curriculum consists of 6 MIS training modules: camera guidance, shell transfer, figure cutting, cyst resection, single interrupted suturing, and slipknot suturing. All modules can be 3D printed, and thus manufactured in a low-cost, sustainable and reproducible fashion. Instructional videos for the participants for each module were created. For validation, a group of medical students and surgical residents were compared to a group of pediatric surgical specialists with experience in MIS. All participants performed the entire SuSiPed curriculum 3 times, measuring time to task completion and technical mistakes. The results of the last attempt were compared using Welch's T-test. RESULTS: There were 25 participants in the novice group and 5 in expert group. Times to task completion were lower in the expert group for all modules except camera guidance. Errors were significantly more frequent during slipknot suturing in the novice group, while there were no difference in the other modules. CONCLUSION: Our novel training platform showed good construct validity for 5 out of 6 modules, while scores of camera navigation was not associated with prior experience. The SuSiPed platform is useful for pediatric minimal-invasive surgery training and evaluation, even in low-resource countries where expensive simulators are not affordable. LEVEL OF EVIDENCE: Level III, Validation Study.

[Special diagnostics in pediatric urology-Ultrasound, VCUG, CT and MRI : Part 1: tips for the practice]. / Spezielle Diagnostik in der Kinderurologie ­ konventionelle und spezielle Sonographie, MCU, CT und MRT : Teil 1: Tipps für die Praxis.

The diagnostics and treatment of pediatric urology patients in the clinical routine can be extremely challenging. In comparison to adult patients, congenital diseases, more time consuming examinations and limited options in addition to the parents' expectations must be taken into account in the diagnostic work up. In this first of two parts we will delve into ultrasound diagnostics as the cornerstone in the diagnostic pathway of children with hydronephrosis ans take a closer look on contrast enhanced ultrasound (CEUS). Conventional voiding cystourethrography still plays a major role in the diagnostic pathway of vesicoureteric reflux and will be treated in this article. Computed tomography should only be considered in pediatric patients in rare cases, always taking radiation into critical account. Magnetic resonance imaging provides an excellent anatomical overview without exposing the child to unnecessary radiation. This article provides an overview on the diagnostic imaging studies in pediatric urology and brings tips for the diagnostic evaluation.

[Special diagnostics in pediatric urology-Nuclear medicine diagnostics, advanced diagnostics for bladder voiding disorders and imaging diagnostics in the operating room : Tips for the practice part 2]. / Spezielle Diagnostik in der Kinderurologie ­ Nuklearmedizinische Diagnostik, weiterführende Diagnostik bei Blasenentleerungsstörungen und bildgebende Diagnostik im OP : Teil 2: Tipps für die Praxis.

The diagnostics and treatment of pediatric urology patients in the clinical routine can be extremely challenging. In contrast to adult patients, the main concerns in the diagnostics of congenital diseases are time consuming examinations and limited options in addition to the expectations of the parents. The exact knowledge of the diagnostic possibilities in association with the correct interpretation of the indications is essential. Simple processes can be much more time consuming because of a lack of compliance, especially in very young children. Sonography is considered the standard for imaging in pediatric urology. Profound knowledge of the embryonal development and also physiological processes throughout childhood contribute to making the correct diagnosis. This article deals with the possibilities of nuclear medicine diagnostics, advanced diagnostics in bladder voiding disorders and finally imaging diagnostics in the pediatric urological operating room.

Using modified Tessier sequential extraction to specify potentially toxic metals at a former sewage farm.

The main objectives of this study were to evaluate the Cu, Zn, Pb, Cr and Ni mobility using modified Tessier sequential extraction procedure and to study the functional group changes affected by each extraction step using FTIR analysis in the soil of a former sewage farm sedimentation basin. Tessier extraction revealed element dependent fractionation of studied metals: Pb was mostly discovered in the residual fraction (77%) followed by Cr (53%), Cu (8%), and Zn (5%), while Ni was not extracted in this fraction. The organic matter-bound was the dominant species of Cu (77%). Zn and Ni exhibited the highest affinity for Fe/Mn oxides fraction (55% and 39%, respectively). The average recovery rate was 62-111%, whereas the lowest rate was obtained for Ni (62%) and the highest for Cu/Pb (110-111%). Results indicated elevated concentrations of studied elements, with the following order of mobility factor: Ni > Zn > Cu > PbCr. The preliminary interpretation of the sequential extraction FTIR spectral response revealed that DRIFT is applicable to interpret the sequential metal extraction and revealed three most profound changes correlated to the carbonate, Fe/Mn oxides, and OM fraction.

Genetic Evidence for Congenital Vascular Disorders in Patients with VACTERL Association.

INTRODUCTION: The VACTERL association is a rare malformation complex, showing at least three anomalies of the following organ systems: vertebra, anorectum, heart and vessels, trachea and esophagus, genitourinary tract, and limbs. In addition to a multifactorial event, congenital vascular disorders are also discussed as triggers for the VACTERL association. The aim of this study was to determine whether there is a genetic background for vascular disorders triggering VACTERL association. MATERIALS AND METHODS: We performed a functional analysis on whole exome sequencing data of 21 patients with VACTERL or VACTERL-like phenotype using the online analysis tool "Database for Annotation, Visualization and Integrated Discovery (DAVID) v6.8." The study was approved by the institutional ethics committee (approval no. 026-13). Written informed consent was obtained from all patients or their parents. RESULTS: We identified a total of 86 genetic variants (in 75 genes) classified as damaging (including probably damaging missense, nonsense, and frameshift variants), which are associated to cardiovascular development. Each investigated patient showed at least one damaging variant in genes associated to cardiovascular development. These variants were further reduced by significance in cardiovascular development to 39 genetic variants (in 33 genes). Of note, a pair of siblings, both presenting with cardiac and renal defects, had the same damaging variant in two different genes. CONCLUSION: Our results indicate a genetic background for congenital vascular disorders in patients with VACTERL association. In line with the literature, our data suggest that genetic mutation led to vascular diseases, which in turn may cause malformations similar to the VACTERL association.

Evaluation of a Pilot Project to Introduce Simulation-Based Team Training to Pediatric Surgery Trauma Room Care.

Introduction. Several studies in pediatric trauma care have demonstrated substantial deficits in both prehospital and emergency department management. Methods. In February 2015 the PAEDSIM collaborative conducted a one and a half day interdisciplinary, simulation based team-training course in a simulated pediatric emergency department. 14 physicians from the medical fields of pediatric surgery, pediatric intensive care and emergency medicine, and anesthesia participated, as well as four pediatric nurses. After a theoretical introduction and familiarization with the simulator, course attendees alternately participated in six simulation scenarios and debriefings. Each scenario incorporated elements of pediatric trauma management as well as Crew Resource Management (CRM) educational objectives. Participants completed anonymous pre- and postcourse questionnaires and rated the course itself as well as their own medical qualification and knowledge of CRM. Results. Participants found the course very realistic and selected scenarios highly relevant to their daily work. They reported a feeling of improved medical and nontechnical skills as well as no uncomfortable feeling during scenarios or debriefings. Conclusion. To our knowledge this pilot-project represents the first successful implementation of a simulation-based team-training course focused on pediatric trauma care in German-speaking countries with good acceptance.

Parents reported reduced symptoms and improved satisfaction after fundoplication and their perceptions were an important outcome measure.

AIM: Fundoplication is required for children with chronic recurrent gastro-oesophageal reflux disease (GERD). The aim of this study was to report parental perceptions of symptoms and overall satisfaction with the long-term course following fundoplication with special reference to patients with GERD risk factors. METHODS: We studied 34 patients, with a median age of 6.5 ± 4.9 years, who received fundoplication between 2001 and 2005. Clinical information and surgical complications were recorded. Parents were interviewed to evaluate post-operative symptoms, mode of nutrition and satisfaction. RESULTS: The median follow-up time was 7.3 years. Comorbidities were neurological impairment in 15 patients, other gastrointestinal disorders in seven patients and isolated GERD in 12 patients. The parents reported that fundoplication effectively treated initial reflux symptoms in 60% and improved symptoms in 37%. Vomiting and reflux-associated pain were treated most effectively. Pulmonary symptoms often remained unchanged in neurologically impaired children. Redo fundoplication was necessary in seven patients. Only two parents regretted consenting to surgery. CONCLUSION: A high percentage of parents reported improved gastrointestinal reflux-related symptoms and a high level of satisfaction following fundoplication. Parental perceptions of GERD symptoms should be an important outcome measure when assessing the efficacy of antireflux surgery in children in routine clinical follow-up.

Effects of Long-Term Rice Bran Extract Supplementation on Survival, Cognition and Brain Mitochondrial Function in Aged NMRI Mice.

Aging represents a major risk factor for the development of neurodegenerative diseases like Alzheimer's disease (AD). As mitochondrial dysfunction plays an important role in brain aging and occurs early in the development of AD, the prevention of mitochondrial dysfunction might help to slow brain aging and the development of neurodegenerative diseases. Rice bran extract (RBE) contains high concentrations of vitamin E congeners and γ-oryzanol. We have previously shown that RBE increased mitochondrial function and protected from mitochondrial dysfunction in vitro and in short-term in vivo feeding studies. To mimic the use of RBE as food additive, we have now investigated the effects of a long-term (6 months) feeding of RBE on survival, behavior and brain mitochondrial function in aged NMRI mice. RBE administration significantly increased survival and performance of aged NMRI mice in the passive avoidance and Y-maze test. Brain mitochondrial dysfunction found in aged mice was ameliorated after RBE administration. Furthermore, data from mRNA and protein expression studies revealed an up-regulation of mitochondrial proteins in RBE-fed mice, suggesting an increase in mitochondrial content which is mediated by a peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC1α)-dependent mechanism. Our findings suggest that a long-term treatment with a nutraceutical containing RBE could be useful for slowing down brain aging and thereby delaying or even preventing AD.

Self-administered procedural analgesia using nitrous oxide/oxygen (50:50) in the pediatric surgery emergency room: effectiveness and limitations.

INTRODUCTION: Minor surgical interventions in children are often at times challenging due to the lack of cooperation by the child. Procedural sedation and analgesia is often appropriate, but unpleasant or painful applications of medication add additional discomfort to the child. A mixture of nitrous oxide (N2O)/oxygen (O2) in a ratio of 50:50, functioning as an inhalational sedative analgesic, may be a viable alternative, in particular in an emergency care setting because such mixtures require no fasting period and are self-administered. Therefore, in this study we investigated the feasibility and the effectiveness of N2O/O2 (50:50) as a sedative analgesic when performing minor surgical procedures. PATIENTS AND METHODS: Procedural sedation and analgesia with an N2O/O2 (50:50) mixture applied during minor surgical procedures were prospectively evaluated over 2.5 years in a major pediatric hospital in Germany. Indications for sedation were either minor painful interventions, the injection of a local anesthetic, or a digital block in an emergency care setting. Diagnosis, type of surgery, inhalation time, complications, side effects, pain scores, and the child's behavioral reaction were assessed. RESULTS: A N2O/O2 (50:50) mixture was administered in 210 children, ages 2.7 to 16.5 years (mean 9.0 years). Three treatments were terminated because of lack of compliance, nausea, or dizziness. No other side effects were encountered. During the intervention, 80.5% of all patients were pain free, and 81.9% were relaxed and calm. A higher rate of insufficient pain control was observed when the indication was an injection of a digital block or a reposition of fractures and dislocations. CONCLUSIONS: The use of self-administered N2O/O2 (50:50) mixture for minor painful procedures in children is safe and adequate pain control can be achieved in most cases. The benefits of this approach for the child and its parents are its good acceptance and adequate pain control. The benefit for the health care provider is the lack of a fasting period before administration, good anxiolysis at minimum sedation, and a cooperative patient. Limitations are unsatisfying analgesia in some cases. Though not found in our study, potentially serious adverse events are a possibility and standard safety guidelines for minimal sedation should always be applied.

Screening for depression in adolescent paediatric patients: validity of the new Depression Screener for Teenagers (DesTeen).

BACKGROUND: Depression in adolescents is often hard to detect. In many cases paediatricians are the first point of contact. In order to increase recognition rates, screening instruments may be a helpful support for health care professionals. However, there is a lack of valid and economical screening instruments for primary care patients. Thus, the aim of the study was the development of the new Depression Screener for Teenagers (DesTeen) and its validation in a paediatric sample. METHOD: 326 patients between 13 and 16 years old completed the DesTeen and a diagnostic interview, serving as gold standard. Prevalence rate for any depressive disorder (minor depression, major depression and dysthymia) was 12.6%. Psychometric properties were calculated. For validity measures, the area under the receiver operating characteristic curves (AUC) for any depressive disorder and the diagnostic subgroups was computed. RESULTS: DesTeen showed a high reliability (Cronbach's α=.87) and a high validity (AUC=.91). For the diagnostic subgroups AUC values did not significantly differ from overall accuracy of any depressive disorder (major depression: AUC=.95, p=.179; dysthymia: AUC=.88, p=.605; minor depression: AUC=.87, p=.327). The optimal cut-off point for any depressive disorder according to the Youden-Index yielded a sensitivity of .90 and a specificity of .80. An abbreviated 5-item version of DesTeen showed no loss in validity (AUC=.90, p=.695). CONCLUSIONS: Overall, DesTeen can be regarded as a valid screening instrument for adolescent paediatric patients. For practical use, the 5-item version is even more promising. A replication of these results is essential.

Postoperative bladder and rectal function in children with sacrococcygeal teratoma.

BACKGROUND: In patients with sacrococcygeal teratoma, the location of the tumor and surgical intervention affects bladder and rectal function. However, there are no clear guidelines for postoperative assessment of bladder function, and the literature on this subject is scarce especially for children requiring multiple surgical interventions. The aim of this study is to evaluate postoperative bladder and rectal function in children with sacrococcygeal teratoma. METHODS: Retrospective analysis was performed of 25 patients (6 male, 19 female) with sacrococcygeal teratoma operated at our institution from 1998 to 2009. Functional assessment of the bladder and rectum was carried out by clinical follow-up, rectomanometry, and urodynamic studies. Data of 24 children were available for follow-up. RESULTS: Of the 24 children, twelve had bladder dysfunction (50%). Ten children (42%) required more than one surgical intervention. Of the 14 children operated on only once, three developed bladder dysfunction (21%), compared to nine of the 10 children who underwent multiple surgical interventions (90%). All four Altman stages were represented, and bladder dysfunction was found for all tumor types. All children with clinical bladder dysfunction showed abnormalities on urodynamic studies, with seven cases of neurogenic bladder. In contrast, no rectal dysfunction was found. CONCLUSIONS: Bladder dysfunction is a common risk of sacrococcygeal tumors. The risk increases particularly if multiple surgical interventions are needed in order to excise the tumor. Therefore, the need for meticulous and complete excision upon first intent is crucial in order to avoid bladder dysfunction.

Efficacy, tolerability and safety of propiverine hydrochloride in comparison to oxybutynin in children with urge incontinence due to overactive bladder: Results of a multicentre observational cohort study.

OBJECTIVE: To compare, in a retrospective observational cohort study, the efficacy, tolerability and safety of propiverine and oxybutynin in children with urge incontinence (UI) due to overactive bladder. PATIENTS AND METHODS: Medical records were scrutinized for children with UI. As a primary efficacy outcome variable the achievement of continence after treatment with variable doses of propiverine or oxybutynin was assessed. Weekly UI episodes and daily voiding frequency were evaluated as secondary efficacy outcomes. Tolerability was evaluated by the rate of adverse events, adverse drug reactions caused by antimuscarinics and premature treatment termination. RESULTS: At 16 study centres, 621 children aged 5-14 years with UI due to overactive bladder were enrolled. After anticholinergic treatment (437 propiverine, 184 oxybutynin) continence was achieved in 61.6% and 58.7% of the patients after 186 and 259 days, respectively. There were clinically relevant improvements in voiding frequency across treatment groups. Daily doses of propiverine were markedly below the recommendations (0.54 vs 0.8 mg/kg body weight), daily doses of oxybutynin were according to the recommendations (0.31 vs 0.2-0.4 mg/kg body weight) at treatment initiation. There was a significantly more favourable tolerability to propiverine than oxybutynin for the overall rate of adverse events (3.9% vs 16.3%, odds ratio 4.813), adverse drug reactions caused by propiverine or oxybutynin (2.8% vs 9.2%) and premature treatment termination due to adverse drug reactions (1.6% vs 4.4%). CONCLUSION: Propiverine and oxybutynin are effective in children with UI due to overactive bladder. Sufficient treatment periods of at least 2, preferably 3-4, months are the crucial factors for a successful treatment. The tolerability profile of propiverine is better than for oxybutynin.

The rabbit model serves as a valuable operative experience and helps to establish new techniques for abdominal and thoracic endosurgery.

Minimally invasive surgery in infants requires great experience and highly specialised skills. However, in most paediatric surgical departments, the number of patients requiring such surgery is usually small and the personal experience of the surgeon limited. An experimental setting with small animals could improve these training conditions if it adequately simulates the underlying situation and conveys beneficial surgical experiences. The authors implemented an endosurgical training model with New Zealand white rabbits. The mean body weight was 3.3 (range 2.9-3.5) kg. The abdominal cavity had a volume of about 580 ml and the thoracic cavity a volume of about 250 ml, comparable with those of a newborn baby. Several relevant techniques were established (gastrostomy, colostomy, gut biopsies, lung biopsies, and anastomosis of the oesophagus). Overall, the rabbit model served to refine technical skills and operative experience. In paediatric surgical departments with a specific focus on endosurgery in the abdominal and thoracic cavities, this training model could help to introduce new techniques and add valuable educational strategies.

[Effectiveness and safety of rectal analgesic sedation in ambulatory pediatric surgery]. / Effektivität und Sicherheit der rektalen Analgosedierung in der ambulanten Kinderchirurgie.

Purpose of the study was to evaluate efficacy and safety of conscious sedation in ambulatory pediatric surgery. During 50 settings 38 patients were administered 0.75 mg/kg Ketamine and 0.4 mg/kg Midazolam rectally prior to the diagnostic or therapeutic procedure. Effects on vital signs, anxiolysis and pain reduction were documented. Side effects and complications were assessed. Satisfaction of patients and their parents were evaluated separately. Conscious Sedation can been administered safely by the physician, even in the absence of anesthesiological colleagues, as long as the correct indication is taken account of and only well established analgetics in standardised doses are given. Furthermore the intervention needs to take place in a well-organised setting. Advantages of the procedure are a cooperative patient with stable vital signs with the patients themselves and their parents profiting from stress-reduction through amnesia and effective pain management.