Pediatric and Adolescent Gynecologic Emergencies.

Pediatric gynecology encompasses a wide range of topics from the maternal estrogen impact on the neonate, to the unique pathophysiology of the lack of estrogen on prepubescent females, and the independence and sexual maturation that occurs with adolescence. This article will review the impact of normal hormonal variations in children, unique pathophysiology of certain conditions in the prepubescent period, as well as common injuries and infections of the genitourinary system in children.

Cognitive load during training for out-of-department emergency responses.

Background: Emergency medicine (EM) physicians sometimes respond to critical events outside the emergency department. To prepare for these complex cases-typically called "rapid responses" (RRs)-EM residents receive simulation-based training involving four practice tasks and three exam tasks during a 1-day session. Cognitive load (CL) theory describes how humans function with limited working memories to perform complex tasks. RRs are expected to generate high levels of CL, but the profile of CL across providers and RR cases is not well understood. In this study, we analyzed resident's CL during RR training. We hypothesized variations in CL across individual and case and that exam cases would cause higher CLs than practice cases. Methods: Residents anonymously self-reported CL levels after each case using the Paas scale, a single-item, 9-point scale from "very, very low CL" to "very, very high CL." To examine case-based differences in CL, data were rescaled by individual residents. "High CL" was defined as a score of 9/9. Results: Among 18 residents participating, CLs ranged from 4 to 9, with median of 7 and interquartile range of 7-8. While many cases showed bell curve-like distributions of CLs, one case-a bleeding tracheostomy-showed a rightward skew reflecting higher levels of CL. No significant difference was found in CL between practice and exam cases. There were 20 reports (16.5%) of "high" CL with variation across residents (0/7 [0%] to 5/6 [83.3%] cases) and across cases (1/18 [5.6%) to 8/18 [44.4%]). Conclusions: The CL that EM residents experienced did show considerable interpersonal and intercase variation, but there was no significant difference between practice and exam cases. These results highlight several questions about how to optimally design future training, including how best to balance low and high CL training cases and which cases may require further training.

Creation of a Porcine Kyphotic Model.

STUDY DESIGN: Large animal study. OBJECTIVE: Create a thoracic hyperkyphotic deformity in an immature porcine spine, so that future researchers may use this model to validate spinal instrumentation and other therapies used in the treatment of hyperkyphosis. SUMMARY OF BACKGROUND DATA: Although several scoliotic animal models have been developed, there have been no reports of a thoracic hyperkyphotic animal model creation in an immature animal. The present study was designed to produce a porcine hyperkyphotic model by the time the pig weighed 25 kg, which corresponds to the approximate weight of a child undergoing surgery for early-onset scoliosis (EOS). METHODS: Successful surgical procedures were performed in 6 consecutive 10-kg (male, 5-week-old) immature Yorkshire pigs. Procedure protocol consisted of 1) a left thoracotomy at T10-T11, 2) screw placement at T9 and T11, 3) partial vertebrectomy at T10, 4) posterior interspinous ligament transection, and 5) placement of wire loop around screws and tightening. Weekly x-ray imaging was performed preoperatively and postoperatively, documenting progressively increasing kyphosis as the pig grew. Necropsy was performed 5-6 weeks after surgery, with CT, slab section, and histologic analysis. RESULTS: Average T9-T11 kyphosis (measured by sagittal Cobb angle) was 6.1° ± 1.4° (mean ± SD) preoperatively, 30.5° ± 1.0° immediately postoperation, and significantly increased to 50.3° ± 7.2° (p < .0001) over 5-6 weeks in 6 consecutive pigs at time of necropsy. CONCLUSIONS: An animal model of relatively more rigid-appearing thoracic hyperkyphotic deformities in immature pigs has been created. Subsequent studies addressing management of early-onset kyphosis with spinal instrumentation are now possible. LEVEL OF EVIDENCE: Level V.