Recommendations for Medical Discharge Documentation and Academic Supports for University Students Recovering From Concussion.

OBJECTIVE: This study sought to (1) collate the experiences of university students with concussion history and academic stakeholders through interviews and (2) develop concussion management recommendations for institutions of higher learning using a multidisciplinary Delphi procedure. SETTING: Remote semistructured interviews and online surveys. PARTICIPANTS: The first aim of this study included undergraduate university students with concussion history who did not participate in varsity athletics ( n = 21; 57.1% female), as well as academic faculty/staff with experience assisting university students with their postconcussion academic needs ( n = 7; 71.4% female). The second aim enrolled 22 participants (54.5% female) to serve on the Delphi panel including 9 clinicians, 8 researchers, and 5 academic faculty/staff. DESIGN: An exploratory-sequential mixed-methods approach. MAIN MEASURES: Semistructured interviews were conducted to unveil barriers regarding the return-to-learn (RTL) process after concussion, with emergent themes serving as a general framework for the Delphi procedure. Panelists participated in 3 stages of a modified Delphi process beginning with a series of open-ended questions regarding postconcussion management in higher education. The second stage included anonymous ratings of the recommendations, followed by an opportunity to review and/or modify responses based on the group's consensus. RESULTS: The results from the semistructured interviews indicated students felt supported by their instructors; however, academic faculty/staff lacked information on appropriate academic supports and/or pathways to facilitate the RTL process. Of the original 67 statements, 39 achieved consensus (58.2%) upon cessation of the Delphi procedure across 3 main categories: recommendations for discharge documentation (21 statements), guidelines to facilitate a multidisciplinary RTL approach (10 statements), and processes to obtain academic supports for students who require them after concussion (8 statements). CONCLUSIONS: These findings serve as a basis for future policy in higher education to standardize RTL processes for students who may need academic supports following concussion.

Perforated Appendicitis During a Pandemic: The Downstream Effect of COVID-19 in Children.

INTRODUCTION: Coronavirus Disease-19 (COVID-19) was declared a pandemic in March 2020. States issued stay-at-home orders and hospitals cancelled non-emergent surgeries. During this time, we anecdotally noticed more admissions for perforated appendicitis. Therefore, we hypothesized that during the months following the COVID-19 pandemic declaration, more children were presenting with perforated appendicitis. MATERIALS AND METHODS: This is a retrospective cohort study reviewing pediatric patients admitted at a single institution with acute and/or perforated appendicitis between October 2019 to May 2020. Interval appendectomies were excluded. COVID-19 months were designated as March, April, and May 2020. Additional analysis of March, April, and May 2019 was performed for comparison purposes. Analyzed data included demographics, symptoms, white blood cell count, imaging findings, procedures performed, and perforation status. Statistical analysis was performed. RESULTS: During the study period, 285 patients were admitted with the diagnosis of acute appendicitis with 95 patients being perforated. We identified a significant increase in perforated appendicitis cases in the three COVID-19 months compared with the preceding five months (45.6% vs 26.4%; P <0.001). In addition, a similar significant increase was identified when comparing to the same months a year prior (P = 0.003). No significant difference in duration of pain was identified (P=0.926). CONCLUSION: The COVID-19 pandemic and its associated stay-at-home orders have had downstream effects on healthcare. Our review has demonstrated a significant increase in the number of children presenting with perforated appendicitis following these stay-at-home ordinances. These results demonstrate that further investigations into the issues surrounding access to healthcare, especially during this pandemic, are warranted.

Mindfulness in Athletes.

ABSTRACT: Interventions to promote athlete health and performance have traditionally been focused on the physical elements of injury and training. More recently, however, increasing attention has been placed on the mental aspects of athlete health, with emerging evidence suggesting that injury risk and athletic performance are significantly affected by athlete well-being. Mindfulness meditation has been shown to have significant benefits for a number of physical and mental health outcomes in various clinical populations, and recent research has explored how mindfulness may enhance athletic performance, improve athlete mental health, reduce injury risk, and perhaps even facilitate recovery from injury. As awareness of mindfulness as a noninvasive, low-risk, and accessible intervention increases in the Western society, use among athletes has increased as well. Health care providers should be aware of this evidence in order to guide athletes regarding the use of mindfulness as an intervention to potentially improve athlete health and performance.

Summit on Exercise Collapse Associated with Sickle Cell Trait: Finding the "Way Ahead".

ABSTRACT: Although largely benign, sickle cell trait (SCT) has been associated with exertion-related events, to include sudden death. In 2011, a summit on SCT introduced the term exercise collapse associated with SCT (ECAST). A series of ECAST deaths in military personnel in 2019 prompted reevaluation of current efforts and led to a second summit in October 2019 hosted by the Consortium for Health and Military Performance of the Uniformed Services University in Bethesda, MD. The goals were to (1) review current service policies on SCT screening, (2) develop draft procedural instructions for executing current policy on SCT within the Department of Defense, (3) develop draft clinical practice guidelines for management of ECAST, (4) establish a framework for education on SCT and ECAST, and (5) prepare a research agenda to address identified gaps.

Preventing catastrophic injury and death in collegiate athletes: interassociation recommendations endorsed by 13 medical and sports medicine organisations.

The following organisations endorsed this document: American Association of Neurological Surgeons, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine, College Athletic Trainers' Society, Collegiate Strength and Conditioning Coaches Association, Congress of Neurological Surgeons, Korey Stringer Institute, National Athletic Trainers' Association, National Strength and Conditioning Association, National Operating Committee for Standards on Athletic Equipment, Sports Neuropsychology Society. The following organisation has affirmed the value of this document: American Academy of Neurology. The Second Safety in College Football Summit resulted in interassociation consensus recommendations for three paramount safety issues in collegiate athletics: (1) independent medical care for collegiate athletes; (2) diagnosis and management of sport-related concussion; and (3) year-round football practice contact for collegiate athletes. This document, the fourth arising from the 2016 event, addresses the prevention of catastrophic injury, including traumatic and non-traumatic death, in collegiate athletes. The final recommendations in this document are the result of presentations and discussions on key items that occurred at the summit. After those presentations and discussions, endorsing organisation representatives agreed on 18 foundational statements that became the basis for this consensus paper that has been subsequently reviewed by relevant stakeholders and endorsing organisations. This is the final endorsed document for preventing catastrophic injury and death in collegiate athletes. This document is divided into the following components. (1) Background-this section provides an overview of catastrophic injury and death in collegiate athletes. (2) Interassociation recommendations: preventing catastrophic injury and death in collegiate athletes-this section provides the final recommendations of the medical organisations for preventing catastrophic injuries in collegiate athletes. (3) Interassociation recommendations: checklist-this section provides a checklist for each member school. The checklist statements stem from foundational statements voted on by representatives of medical organisations during the summit, and they serve as the primary vehicle for each member school to implement the prevention recommendations. (4) References-this section provides the relevant references for this document. (5) Appendices-this section lists the foundational statements, agenda, summit attendees and medical organisations that endorsed this document.

Pathogenetics of alveolar capillary dysplasia with misalignment of pulmonary veins.

Alveolar capillary dysplasia with misalignment of pulmonary veins (ACDMPV) is a lethal lung developmental disorder caused by heterozygous point mutations or genomic deletion copy-number variants (CNVs) of FOXF1 or its upstream enhancer involving fetal lung-expressed long noncoding RNA genes LINC01081 and LINC01082. Using custom-designed array comparative genomic hybridization, Sanger sequencing, whole exome sequencing (WES), and bioinformatic analyses, we studied 22 new unrelated families (20 postnatal and two prenatal) with clinically diagnosed ACDMPV. We describe novel deletion CNVs at the FOXF1 locus in 13 unrelated ACDMPV patients. Together with the previously reported cases, all 31 genomic deletions in 16q24.1, pathogenic for ACDMPV, for which parental origin was determined, arose de novo with 30 of them occurring on the maternally inherited chromosome 16, strongly implicating genomic imprinting of the FOXF1 locus in human lungs. Surprisingly, we have also identified four ACDMPV families with the pathogenic variants in the FOXF1 locus that arose on paternal chromosome 16. Interestingly, a combination of the severe cardiac defects, including hypoplastic left heart, and single umbilical artery were observed only in children with deletion CNVs involving FOXF1 and its upstream enhancer. Our data demonstrate that genomic imprinting at 16q24.1 plays an important role in variable ACDMPV manifestation likely through long-range regulation of FOXF1 expression, and may be also responsible for key phenotypic features of maternal uniparental disomy 16. Moreover, in one family, WES revealed a de novo missense variant in ESRP1, potentially implicating FGF signaling in the etiology of ACDMPV.

Outcome assessment of renal replacement therapy in neonates.

BACKGROUND: Recent advances in renal replacement therapy (RRT) have brought about a proliferation of dialysis in neonates (<30 d). This study aimed to assess morbidity and mortality after RRT initiation in this population. METHODS: Retrospective chart review of all patients between 2006 and 2014 requiring RRT initiated in the first 30 d of life was performed. RESULTS: A total of 49 patients were identified, of which 39 were boys and 10 were girls. Thirty-two patients (65%) had end-stage renal disease, 11 (22%) had errors of metabolism, and six (12%) required RRT for other pathologies. Median age and weight at RRT onset were 6 (4-14) d and 3.1 (2.7-4.0) kg, respectively. A total of 201 surgeries were performed. Excluding catheter revisions, 83 new hemodialysis (HD) and 28 new peritoneal dialysis lines were placed, with maximum of six HD and four peritoneal catheters placed in single patient. Catheter-associated morbidities occurred in 100% of patients. Most common complications for HD included circuit clotting (87%), bleeding (68%), and bacteremia (50%). Peritoneal dialysis complications included peritonitis (83%), malpositioned catheters (72%), and leaks (55%). Overall mortality was 65.3%, with 56% of all deaths occurring within first month of life and 94% occurring within first year. Among long-term survivors (median follow-up of 5.3 y), 44% were severely and 22% moderately developmentally delayed. CONCLUSIONS: Although RRT is becoming more technically feasible for neonates with renal and metabolic diseases, it remains associated with significant morbidity and mortality. Pediatric surgeons must be aware of the challenges, taking them into account when considering the care of these critically ill children.

Single-incision pediatric endosurgery (SIPES) splenectomy: what dictates the need for additional ports?

BACKGROUND: As proficiency with single-incision pediatric endosurgery (SIPES) increases, more challenging operations are being performed. While the ultimate goal is safe surgery, it may be beneficial to know what anatomical and technical factors contribute to the need for additional ports. This aspect of SIPES splenectomy has yet to be evaluated. The study objective was to identify these factors, potentially allowing surgeons to gauge appropriateness for single incision and to tailor techniques for optimal results. METHODS: This was an institutional review board-approved retrospective analysis of prospectively collected data (FWA00005960). SIPES splenectomies performed at a tertiary children's hospital since March of 2009 were included. Demographic and technical factors pertaining to each operation were available in our SIPES database. Fischer's exact and Wilcoxon rank sum tests were used to analyze categorical and continuous variables, respectively. RESULTS: Thirty-seven patients 18 years of age and younger underwent attempted SIPES splenectomy. Two operations were converted directly to open and were excluded from analysis. Of the remaining 35 operations, 15 (42.9 %) were completed with additional ports. Gender, age, body mass index, splenic weight, indication for operation and the presence of accessory spleens did not contribute to the need for added ports. The only factor to reach statistical significance was the number of channels present in the SIPES access device (p = 0.002). CONCLUSIONS: Completion of SIPES splenectomy was associated with the decision to utilize an access device with four channels. Anatomic variables did not appear to affect the ability to complete SIPES splenectomy.

Catastrophic Sports Injuries: Causation and Prevention.

➤ Catastrophic injuries in U.S. high school and college athletes are rare but devastating injuries.➤ Catastrophic sports injuries are classified as either traumatic, caused by direct contact during sports participation, or nontraumatic, associated with exertion while participating in a sport.➤ Football is associated with the greatest number of traumatic and nontraumatic catastrophic injuries for male athletes, whereas cheerleading has the highest number of traumatic catastrophic injuries and basketball has the highest number of nontraumatic catastrophic injuries for female athletes.➤ The incidence of traumatic catastrophic injuries for all sports has declined over the past 40 years, due to effective rule changes, especially in football, pole-vaulting, cheerleading, ice hockey, and rugby. Further research is necessary to reduce the incidence of structural brain injury in contact sports such as football.➤ The incidence of nontraumatic catastrophic injuries has increased over the last 40 years and requires additional research and preventive measures. Avoiding overexertion during training, confirming sickle cell trait status in high school athletes during the preparticipation physical examination, and developing cost-effective screening tools for cardiac abnormalities are critical next steps.

Preventing Exertional Heat Stroke in Football: Time for a Paradigm Shift.

CONTEXT: Among American sports, football has the highest incidence of exertional heat stroke (EHS), despite decades of prevention strategies. Based on recent reports, 100% of high school and college EHS football fatalities occur during conditioning sessions. Linemen are the at-risk population, constituting 97% of football EHS deaths. Linemen heat up faster and cool down slower than other players. EVIDENCE ACQUISITION: Case series were identified from organized, supervised football at the youth, high school, and collegiate levels and compiled in the National Registry of Catastrophic Sports Injuries. Sources for event occurrence were media reports and newspaper clippings, autopsy reports, certificates of death, school-sponsored investigations, and published medical literature. Articles were identified through PubMed with search terms "football," "exertional heat stroke," and "prevention." STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 5. RESULTS: Football EHS is tied to (1) high-intensity drills and conditioning that is not specific to individual player positions, (2) physical exertion as punishment; (3) failure to modify physical activity for high heat and humidity, (4) failure to recognize early signs and symptoms of EHS, and (5) death when cooling is delayed. CONCLUSION: To prevent football EHS, (1) all training and conditioning should be position specific; (2) physical activity should be modified per the heat load; (3) understand that some players have a "do-or-die" mentality that supersedes their personal safety; (4) never use physical exertion as punishment; (5) eliminate conditioning tests, serial sprints, and any reckless drills that are inappropriate for linemen; and (6) consider air-conditioned venues for linemen during hot practices. To prevent EHS, train linemen based on game demands. STRENGTH-OF-RECOMMENDATION TAXONOMY: n/a.

Sport-related Structural Brain Injury in High School and College American Football Athletes, 2002-2020: Effect of Lystedt Law.

BACKGROUND: A previous report revealed an average of 7.2 (0.67 per 100,000 participants) sport-related structural brain injuries (SRSBIs) with macroscopic lesions per year in high school (HS) and college football players. The Lystedt law and other rule changes have been implemented with intent to reduce the risk of brain injury in football. HYPOTHESIS: To update the profile of SRSBIs in HS and college football players and evaluate the efficacy of legislation intended to reduce brain injuries. STUDY DESIGN: Descriptive epidemiology study. LEVEL OF EVIDENCE: Level 4. METHODS: We retrospectively reviewed 18 academic years (July 2002 through June 2020) of SRSBIs catalogued by the National Registry of Catastrophic Sports Injuries. The incidence of SRSBIs was assessed at the HS level during the pre (July 2002 through June 2009), transitional (July 2009 through June 2014), and post (July 2014 through June 2020) universal adoption time periods of the Lystedt law. In addition, the incidence of SRSBIs during the second half of the study (2011-2012 through 2019-2020) was compared with the first half of the study (2002-2003 through 2010-2011). RESULTS: During the study period, there was a total of 228 SRSBIs (12.7 per year, 1.01 per 100,000 participants): 212 (93%, 11.8 per year, 1.00 per 100,000) in HS athletes and 16 (7%, 0.89 per year, 1.17 per 100,000) in college athletes. There were 52 fatalities (2.9 per year, 0.22 per 100,000 participants) with 46 (2.56 per year, 0.22 per 100,000) in HS athletes and 6 (0.33 per year, 0.43/100,000) in college athletes. There was no significant difference in risk of HS total SRSBIs or fatalities during the 3 Lystedt periods. The risk of combined SRSBI cases [relative risk (RR) = 1.22, P = 0.13] and fatalities (RR = 1.20, P = 0.52) was similar in the second half of the study compared with the first half of the study. CONCLUSION: Despite implementation of rule changes intended to reduce head injury, in particular the Lystedt law, the incidence of SRSBIs has remained unchanged. Further research is necessary to develop effective prevention programs for SRSBIs. CLINICAL RELEVANCE: SRSBIs remain a persistent problem in HS and college American football. The recent head injury rule changes have not been effective at reducing SRSBIs.

The First Two Years of the Association of Pediatric Surgery Training Program Directors (APSTPD) Transition to Fellowship Course: Lessons Learned and Future Directions.

OBJECTIVE: The first transition to fellowship course for incoming pediatric surgery fellows was held in the US in 2018 and the second in 2019. The course aimed to facilitate a successful transition in to fellowship by introduction of the professional, patient care, and technical aspects unique to pediatric surgery training. The purpose of this study was to evaluate the feasibility and effectiveness of the first two years of this course in the US and discuss subsequent evolution of this endeavor. DESIGN: This is a descriptive and qualitative analysis of two years' experience with the Association of Pediatric Surgery Training Program Directors' (APSTPD) Transition to Fellowship course. Course development and curriculum, including clinical knowledge, soft skills, and hands-on skills labs, are presented. Participating incoming fellows completed multiple choice, boards-style pre- and post-tests. Scores were compared to determine if knowledge was effectively transferred. Participants also completed post-course evaluations and subsequent 3- or 12-month surveys inquiring on the lasting impact of the course on their transition into fellowship. Standard univariate statistics were used to present results. SETTING: The first APSTPD Transition to Fellowship course was held at the Johns Hopkins Hospital in Baltimore, Maryland in 2018, and the second course was held at the Oregon Health and Science University in Portland, Oregon in 2019. PARTICIPANTS: All fellows entering ACGME-certified Pediatric Surgery fellowships in the United States were invited to participate. Twenty fellows accepted and attended in 2018, and fourteen fellows participated in 2019. RESULTS: There were 34 incoming pediatric surgery fellow participants over 2 years. Faculty represented more than 10 institutions each year. Pre- and post-test scores were similar between years, with a significant improvement of scores after completion of the course (67±10% vs 79±8%, p < 0.001). Feedback from participants was overwhelmingly positive, with skills labs being attendees' favorite component. When asked about usefulness of individual course sessions, more attendees found clinical sessions more useful than soft skills (93% vs 73%, p = 0.011). Almost all (90%) of participants reported the course met its stated purpose and would recommend the course to future fellows. This was further reflected on 3 and 12 month follow up surveys wherein 85% stated they found the course helpful during the first few months of fellowship and 90% would still recommend it. CONCLUSIONS: A transition to fellowship course in the US for incoming pediatric surgery fellows is logistically feasible, effective in transfer of knowledge, and highly regarded among attendees. Feedback from each course has been used to improve the subsequent courses, ensuring that it remains a valuable addition to pediatric surgical training in the US.

Achieving Consensus Through a Modified Delphi Technique to Create the Post-concussion Collegiate Return-to-Learn Protocol.

BACKGROUND: Sport-related concussions (SRCs) affect millions of adolescents and young adults annually in the USA; however, current SRC consensus statements provide limited guidance on academic support for students within higher education. OBJECTIVE: To generate consensus on appropriate academic recommendations for clinicians, students, and academic stakeholders to support university students during their recovery. METHODS: Panelists participated in three stages of a modified Delphi procedure: the first stage included a series of open-ended questions after reviewing a literature review on post-SRC return-to-learn (RTL) in higher education; the second stage asked panelists to anonymously rate the recommendations developed through the first Delphi stage using a 9-point scale; and the final stage offered panelists the opportunity to change their responses and/or provide feedback based on the group's overall ratings. RESULTS: Twenty-two panelists including clinicians, concussion researchers, and academic stakeholders (54.5% female) from 15 institutions and/or healthcare systems participated in a modified Delphi procedure. A total of 42 statements were developed after round one. Following the next two rounds, 27 statements achieved consensus amongst the panel resulting in the four-stage Post-Concussion Collegiate RTL Protocol. CONCLUSION: There are several unique challenges when assisting university students back to the classroom after SRC. Explicit guidelines on when to seek additional medical care (e.g., if they are experiencing worsening or persistent symptoms) and how to approach their instructor(s) regarding academic support may help the student self-advocate. Findings from the present study address barriers and provide a framework for universities to facilitate a multidisciplinary approach amongst medical and academic stakeholders.

The Junction Boys syndrome.

Strength and conditioning training for football has become year-round in virtually all levels of play, but none so much as contemporary NCAA DI football. Football players spend more off-season months and weeks in preparation for sport than is given to in-season practice, let alone play. A present peculiarity to NCAA Football Bowl Subdivision is conditioning and off-season football training is the sole setting for non-traumatic death in its participant players. Training regimens are too often built on tradition versus based on science and place players at-risk.

Who manages burn injuries in children? A program director survey evaluating burn training during pediatric surgery fellowship.

PURPOSE: Burn is one of the leading causes of injury and death in children. Currently, the Residency Review Committee does not require general surgery residents to rotate on a burn service. With many trainees no longer receiving burn training during residency, we sought to evaluate the exposure to burn management in pediatric surgery training programs. MATERIAL AND METHODS: An electronic survey was sent to program directors at accredited pediatric surgery training programs (56) during the 2020 academic year. Case log reviews were performed for 2005-2019. Descriptive statistical analysis was performed. RESULTS: Thirty-six program directors participated in the survey (64%), and 56% reported having an inpatient and outpatient component for burn management. Nearly 20% of program directors reported having no burn management at their institution. Fifty-four percent of responding programs had fellow participation in burn management. Over a fifteen-year period, case logs identified a median of 0-2 burn cases logged each year for graduating fellows. Logistically, 65% of burn centers relied on general pediatric surgeons for management. CONCLUSION: Pediatric surgery trainee involvement in burn management varies with many programs offering no designated burn training. Increasing exposure to pediatric burn management during training is needed to provide improved care for this patient population. LEVEL OF EVIDENCE: III, Retrospective Review.

Epidemiology of Exertional Rhabdomyolysis in the United States: Analysis of NEISS Database 2000 to 2019.

OBJECTIVE: There have been numerous case series of exertional rhabdomyolysis (ER) but no comprehensive studies investigating the incidence of ER in the civilian athletic population in the United States (US). METHODS: A retrospective review of patients with ER presenting to emergency departments in the US over a 20-year period between 2000 and 2019 was performed using the National Electronic Injury Surveillance System (NEISS) database. RESULTS: The national estimate of hospital visits in the US for ER during the 20-year period was 40,654 (0.66 per 100,000 population). There was a 10-fold increase in the incidence of ER from the first to the second decade. The odds of ER were 3.77 (95% CI 3.67-3.86, P < .0001) times higher for males (31,921, 78.5%, 1.06 per 100,000) than females (8,733, 21.5%, 0.28 per 100,000) and 3.82 (95% CI 3.71-3.93, P < .0001) higher in African Americans (33.6, 0.93 per 100,000) than white patients (53%, 0.24 per 100,000). American football (3,064, 7.5%) was responsible for 43.9% of the sports-induced ER cases. The majority (67.3%) of ER cases occurred between the ages of 16 and 35 years old. The majority of patients required hospitalization (26,550, 65.3%). CONCLUSIONS: The number of ER cases presenting to emergency departments in the US increased from 2000-2009 to 2010-2019. Young males and African Americans are at highest risk of ER. There was a high rate of hospitalization.

A Multicenter Phase II Trial of Ipilimumab and Nivolumab in Unresectable or Metastatic Metaplastic Breast Cancer: Cohort 36 of Dual Anti-CTLA-4 and Anti-PD-1 Blockade in Rare Tumors (DART, SWOG S1609).

PURPOSE: Metaplastic breast cancer (MpBC) is a rare aggressive subtype that responds poorly to cytotoxics. Median survival is approximately 8 months for metastatic disease. We report results for advanced MpBC treated with ipilimumab + nivolumab, a cohort of S1609 for rare cancers (DART: NCT02834013). PATIENTS AND METHODS: Prospective, open-label, multicenter phase II (two-stage) trial of ipilimumab (1 mg/kg i.v. every 6 weeks) plus nivolumab (240 mg i.v. every 2 weeks) for advanced MpBC. Primary endpoint was objective response rate (ORR). Secondary endpoints included progression-free survival (PFS), overall survival (OS), and toxicity. RESULTS: Overall, 17 evaluable patients enrolled. Median age was 60 years (26-85); median number of prior therapy lines was 2 (0-5). ORR was 18%; 3 of 17 patients achieved objective responses (1 complete, 2 partial responses; 2 spindle cell, 1 chondromyxoid histology), which are ongoing at 28+, 33+, and 34+ months, respectively. Median PFS and OS were 2 and 12 months, respectively. Altogether, 11 patients (65%) experienced adverse events (AE), including one grade 5 AE. Eight patients (47%) developed an immune-related AE (irAE), with adrenal insufficiency observed in all 3 responders. Responses occurred in tumors with low tumor mutational burden, low PD-L1, and absent tumor-infiltrating lymphocytes. CONCLUSIONS: The ipilimumab and nivolumab combination showed no new safety signals and met its primary endpoint with 18% ORR in advanced, chemotherapy-refractory MpBC. All responses are ongoing at >2 to almost 3 years later. The effect of ipilimumab and nivolumab was associated with exceptional responses in a subset of patients versus no activity. This combination warrants further investigation in MpBC, with special attention to understanding mechanism of action, and carefully designed to weigh against the significant risks of irAEs.

The diminishing experience in pediatric surgery for general surgery residents in the United States.

PURPOSE: The Accreditation Council for Graduate Medical Education (ACGME) regulates the general surgery residency curriculum. Case volume remains a priority as recent concerns surrounding a lack of proficiency for certain surgical cases have circulated. We hypothesize that there is a significant decrease in pediatric surgery case numbers during general surgery residency despite residents meeting the minimum case requirements. METHODS: We reviewed publicly available ACGME case reports for general surgery residency from 1999 to 2018. Cases are classified as Surgeon Chief or Surgeon Junior. Analyzed data included case classifications, number of residents, and number of residency programs. Simple linear regression analysis was performed. RESULTS: We identified a significant decrease in total number of logged pediatric surgery cases over the past 20 years (p<0.001). Nearly 60% of cases were logged under a single category - inguinal/umbilical hernia. From the past five years, pyloric stenosis was the only other category with an average of greater than two cases logged (range 2.1-2.8). CONCLUSION: We identified a significant decrease in total pediatric surgery case numbers during general surgery residency from 1999 to 2018. Though meeting set requirements, overall case variety was limited. With minimal number of cases required by the ACGME, graduating general surgery residents may lack proficiency in simple pediatric surgery cases.