Utility of Thermal Imaging in Predicting Superficial Infections in Transfemoral Osseointegrated Implants.

Background: Superficial infection is a common minor complication of transcutaneous implants that can be challenging to predict or diagnose. Although it remains unclear whether superficial infections progress to deep infections (which may require implant removal), predicting and treating any infection in these patients is important. Given that flap thinning during stage II surgery requires compromising vascularity for stability of the skin penetration aperture, we hypothesized that early skin temperature changes predict long-term superficial infection risk. Methods: We obtained standardized thermal imaging and recorded surface temperatures of the aperture and overlying flaps 2 weeks postoperatively for the first 34 patients (46 limbs) treated with the Osseointegrated Prosthesis for the Rehabilitation of Amputees transfemoral implant system. We used two-sided t tests to compare temperatures surrounding the aperture and adjacent soft tissues in patients with and without subsequent infection. Results: During median follow-up of 3 years, 14 limbs (30.4%) developed 23 superficial infections. At patients' initial 2-week visit, mean skin temperature surrounding the aperture was 36.3ºC in limbs that later developed superficial infections and 36.7ºC in uninfected limbs (P = 0.35). In four patients with bilateral implants who later developed superficial infection in one limb, average temperature was 1.5ºC colder in the infected limb (P = 0.12). Conclusions: Superficial infections remain a frequent complication of transfemoral osseointegration surgery. We did not find differences in early heat signatures between limbs subsequently complicated and those not complicated by superficial infection. Further research should explore more objective measures to predict, diagnose, and prevent infections after osseointegration surgery.

Pediatric Pulmonary Fellowship Program Size Effect on Recruitment and Workforce Distribution.

Background: Concerns about the pediatric pulmonology workforce suggest a need to improve fellowship recruitment. Program size is related to the financial health and recruitment success of pediatric subspecialty education programs, but there are few data on how program size impacts recruitment and workforce in pediatric pulmonology. Objective: Assess the impact of program size in pediatric pulmonology through examination of the distribution of applicants matching into pediatric pulmonology training programs over time and relationships to workforce distribution. Methods: Data from the National Residency Match Program from 2010 to 2022 were extracted from published documents. Positions offered, positioned filled, and match rates were calculated for each appointment year. Statewide statistics for the number of fellows matched were analyzed relative to the number of pediatric pulmonologists per capita using data from the American Board of Pediatrics. Results: From 2010 to 2018, the size and distribution of programs in pediatric pulmonology were stable, with most fellows (82.4%) matching into programs with one or two positions per cycle. Starting in 2019, programs offering three or more positions steadily increased in number and aggregate positions offered. This change was associated with an increase in total filled positions (38.9 ± 7.3 in 2010-2018 vs. 50.5 ± 8.7 in 2019-2022; P < 0.03) and an increased fraction who matched into larger programs (17.6% in 2010-2018 vs. 36.9% in 2019-2022; P < 0.001). Among states with fellowship programs, the number of fellows matched over the past 5 years correlated with the number of practicing pediatric pulmonologists per capita (r = 0.78; P < 0.001). Conclusion: The period 2019-2022 saw a marked shift of pediatric pulmonary trainees matching into a relatively small number of larger programs. This shift was associated with overall growth in the number of trainees but may have implications on geographical distribution of practicing pediatric pulmonologists.

A Comparison of Outcomes following Plate versus Pin Fixation of Metacarpal Shaft and Neck Fractures.

The aim of this study is to compare clinical and radiographic outcomes of open reduction and internal fixation versus closed reduction and percutaneous pinning of metacarpal fractures in relation to anatomic and surgical variables. Methods: Electronic medical records at two institutions were reviewed for patients who underwent surgical intervention for metacarpal fractures. Data were collected from those who underwent reduction and internal fixation with either plates or Kirschner wires (K-wires). Inclusion criteria included minimum postoperative follow-up of 60 days and age 18 years or older. Exclusion criteria included insufficient radiographic data, previously attempted closed reduction with immobilization, pathologic fracture mechanism, history of previous trauma or surgery to the affected bone, and fixation technique other than plate or K-wire. Results: We reviewed data for patients treated over a 22-year time period. Ultimately, 81 metacarpal shaft and neck fractures in 60 patients met inclusion criteria. Among all metacarpal fractures, complications were present in 39 (48.1%) cases. There were no significant associations between complication prevalence and hardware type. Revision surgery was required in 11 (13.6%) patients; there were no significant associations between revision procedures and hardware type. Postoperatively, all patients with imaging data had radiograph follow-up to assess union status. There was no significant association between time to union and hardware type. Conclusions: Outcomes showed no significant difference between plate and pin fixation for metacarpal shaft and neck fractures. These findings suggest that surgeons may have flexibility to decide on the type of operative intervention while considering patient-specific factors, such as the need for early mobilization.

Expectations versus reality: Understanding the accuracy of impressions made during virtual interviews of pediatric pulmonary fellowship programs.

RATIONALE: As a result of the SARS-CoV-2 pandemic, all pediatric pulmonary fellowship programs conducted virtual interviews for the first time in the Fall of 2020. This study aimed to understand the accuracy of virtual-interview derived-impressions of fellowship programs, as well as applicant preference for future fellowship interview cycles. METHODS: A group of pediatric pulmonary fellows and Program Directors designed a REDCap survey. The survey was distributed to all first-year pediatric pulmonary fellows who participated in the 2020-2021 virtual interview season. RESULTS: 23/52 (44%) of first-year pediatric pulmonary fellows completed the survey. 96% were able to form general impressions about fellowship programs during their virtual interviews. 96% reported that generally their fellowship experience matched their virtual-interview derived-impressions. 17 of the 19 factors applicants use to rank programs had no statistically significant change (p > 0.05) in impression from virtual interview to fellowship experience. The two factors with a statistically significant (p < 0.05) change in impression were patient care related-volume of "bread and butter" pediatric pulmonary patients and volume of tertiary care pediatric pulmonary patients. 87% prefer some form of in-person interview option in future application cycles. A tiered interview format in which applicants are first invited to a virtual interview day followed by an optional in-person second look day was the most popular preference for future interview cycles (48%). CONCLUSIONS: Virtual interviews may provide accurate representations of pediatric pulmonary fellowship programs and applicants prefer some type of in-person interview option in future application cycles.

A statement on the current status and future needs of the pediatric pulmonology workforce: Pipeline Workgroup.

There is growing concern that current trends in pediatric pulmonology will lead to a workforce shortage resulting in patients having difficulty accessing subspecialty care. As part of the Pediatric Pulmonology Division Directors Association and Pediatric Pulmonary Training Directors Association Workforce Summit, we examined factors affecting the recruitment of learners into pediatric pulmonary fellowship training (PPFT) programs. The goal of our workgroup was to describe these issues and develop a plan to increase the pipeline of learners who ultimately pursue PPFT. Specifically, we summarize factors that impact decisions to undertake PPFT, describe existing initiatives to enhance recruitment, and propose future strategies to increase early career learner interest.

Confidence of Faculty in Writing Letters of Recommendation for Pediatric Fellowship Applicants.

BACKGROUND: The assessment of pediatric residents applying to subspecialty fellowship programs relies on faculty letters of recommendation (LOR). However, it is unclear if pediatric faculty are confident that their LOR are effective. OBJECTIVE: This study aims to assess the confidence of pediatric faculty in writing an effective LOR for pediatric residents applying to subspecialty fellowship programs. METHODS: Survey development was conducted using evidence-based best practices. Surveys were distributed via email in 2021 to all full-time pediatric faculty members who taught pediatric residents in a large academic medical center. Categorical values were compared by chi-square test. RESULTS: Eighty-five out of 150 (57%) faculty members completed the survey. Forty-one percent of participants were very confident that their LOR provided adequate content to assess residents during the application process. Confidence was associated with higher academic rank (p=0.02), frequent contact with residents (p=0.01), and writing >2 LOR in the last five years (p=0.0002). Confident LOR writers were more likely to describe their own background, details about the resident's scholarly activity, and the resident's ability to work as part of a team. Thirty-five percent of respondents reported never considering gender bias when writing LOR, whereas 28% reported always considering gender bias. Eighty-seven percent of respondents reported an interest in receiving LOR writing guidelines. CONCLUSION: Half of the faculty respondents were not very confident in their ability to write an effective LOR for pediatric residents applying for a fellowship. Faculty development and standardized instructions on writing effective LOR may be helpful both at the institutional and national levels, including the importance of considering gender bias when writing LOR.

How and Why Trainees Choose a Career in Pediatric Pulmonology. A Qualitative Study.

Background: There is concern that inadequate recruitment of new subspecialty trainees to replace the aging physician population will lead to significant workforce issues in pediatric pulmonology. The factors leading trainees to pursue a fellowship in pediatric pulmonology are unclear. Objective: To gain a better understanding of the decision-making process surrounding the choice to pursue a pediatric pulmonary fellowship and to provide informed recommendations to increase recruitment of new trainees. Methods: Informed by the Social Cognitive Career Theory, eight focus groups were held with pediatric residents and fellows attending the 2019 American Thoracic Society International Conference. Questions focused on personal background, learning experiences, self-efficacy and outcome expectations, interests, and goals. Transcripts were analyzed by conventional content analysis. Results: Fifty-six residents and fellows representing 42 different institutions participated. Responses resulted in seven major themes: 1) attractive aspects of pediatric pulmonology draw trainees to the field, 2) exposure to the breadth and scope of the field is limited, 3) mentorship is key, 4) decisions surrounding fellowship selection occur early in the second year, 5) trainees want flexibility in length and structure of fellowship, 6) financial considerations are not the driving factor in decision-making, and 7) there are inherent aspects of pulmonology that trainees may not enjoy. Conclusion: A lack of broad exposure to pediatric pulmonology during residency results in false perceptions of the field and is a deterrent to recruitment. Improving faculty engagement, guaranteeing broad and early exposure to the field, and creating learning experiences aimed at raising self-efficacy may improve recruitment and ultimately improve the pediatric pulmonary workforce.

Creating Effective and Efficient Pediatric-Specific CME Content: More than Just Checking a Box.

States dictate the type of continuing medical education (CME) required for licensing; however, CME providers are not mandated to create content relevant to all specialties. This often forces pediatricians to engage in educational activities that are irrelevant to their practice. This is contrary to what constitutes effective CME. The goal was to develop pediatric content using adult learning theory that aligns with effective CME principles while simultaneously satisfying state licensure requirements. A targeted needs assessment of pediatric providers revealed that pediatric-specific CME activities satisfying the state's requirement for pain management and end-of-life issues were lacking. Webinars adhering to adult learning principles were created in consultation with content experts. Five hundred ninety-seven learners across 30 states successfully completed the webinars and received CME credit. To satisfy ongoing state licensing requirements, 44% of learners had completed similar activities in the past, but 72% of those learners participated in activities focused on adult medicine due to the lack of available pediatric modules. Until states and regulators allow for more flexibility in satisfying licensing requirements, it will be incumbent on those who create CME to develop educational activities that satisfy state requirements while aligning with the principles of effective CME. With strategic planning, this is possible and will hopefully empower physicians to engage in CME without resorting to "checking a box."

BRD4-NUT carcinoma of the mediastinum in a pediatric patient: multidetector computed tomography imaging findings.

Midline carcinoma with chromosomal rearrangement of the gene nuclear protein in testis (NUT) is termed NUT midline carcinoma (NMC), and is a rare and highly lethal neoplasm. The gene BRD4 is its most common translocation partner, forming a BRD4-NUT fusion oncogene. NMCs typically occur in the midline, most commonly in the head, neck, or mediastinum, as poorly differentiated carcinomas with variable degrees of squamous differentiation. This is a recently characterized tumor, and thus is still largely unfamiliar to radiologists. We report a 10-year-old boy with NMC involving the posterior mediastinum and invading the left pulmonary vein with an extension into the left atrium; these findings are presented with an emphasis on multidetector computed tomography imaging.