Detection of Bronchiolitis Obliterans Syndrome Following Pediatric Hematopoietic Stem Cell Transplantation. An Official American Thoracic Society Clinical Practice Guideline.

BACKGROUND: Many children undergo allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for the treatment of malignant and non-malignant conditions. Unfortunately, pulmonary complications occur frequently post-HSCT, with bronchiolitis obliterans syndrome (BOS) being the most common non-infectious pulmonary complication. Current international guidelines contain conflicting recommendations regarding post-HSCT surveillance for BOS, and a recent National Institutes of Health workshop highlighted the need for a standardized approach to post-HSCT monitoring. As such, this guideline provides an evidence-based approach to detection of post-HSCT BOS in children. METHODS: A multinational, multidisciplinary panel of experts identified six questions regarding surveillance for, and evaluation of post-HSCT BOS in children. Systematic review of the literature was undertaken to answer each question. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of recommendations. RESULTS: The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Recommendations addressing the role of screening pulmonary function testing and diagnostic tests in children with suspected post-HSCT BOS were made. Following a Delphi process, new diagnostic criteria for pediatric post-HSCT BOS were also proposed. CONCLUSIONS: This document provides an evidence-based approach to detection of post-HSCT BOS in children, while also highlighting considerations for implementation of each recommendation. Further, the document describes important areas for future research.

Thoracoscopic thymectomy for juvenile myasthenia gravis.

PURPOSE: A randomized controlled trial of thymectomy in myasthenia gravis demonstrated improved clinical outcomes in adults, but data surrounding juvenile cases, especially those treated with minimally invasive approaches, are limited. Here, we review our experience with thoracoscopic thymectomy for juvenile myasthenia gravis (JMG) in the largest cohort to date. METHODS: All cases of thymectomy for JMG in a single tertiary referral center between 2007 and 2018 were reviewed (N = 50). Patients underwent left thoracoscopic approach with extended dissection and without use of monopolar energy. Demographics, diagnostic criteria, and clinical classification, as well as surgical data were collected. Clinical status and medications were reviewed in follow-up. RESULTS: The mean age at surgery was 10.5 ± 0.8 years. Ocular disease and generalized disease each comprised half of the cohort. No patients suffered complications or increased risk of morbidity or mortality with thymectomy. At any interval of follow-up through 3.5 years, 49.8% of patients were improved compared to their pre-operative presentation, and there was a significant trend towards decreased steroid use. CONCLUSION: Thoracoscopic thymectomy is a safe treatment for juvenile myasthenia gravis in pediatric patients over a wide range of ages, body masses, and symptoms. Our experience adds evidence that pediatric patients likely benefit from thymectomy with improved clinical status and reduced medications.

Automatically rating trainee skill at a pediatric laparoscopic suturing task.

BACKGROUND: Minimally invasive surgeons must acquire complex technical skills while minimizing patient risk, a challenge that is magnified in pediatric surgery. Trainees need realistic practice with frequent detailed feedback, but human grading is tedious and subjective. We aim to validate a novel motion-tracking system and algorithms that automatically evaluate trainee performance of a pediatric laparoscopic suturing task. METHODS: Subjects (n = 32) ranging from medical students to fellows performed two trials of intracorporeal suturing in a custom pediatric laparoscopic box trainer after watching a video of ideal performance. The motions of the tools and endoscope were recorded over time using a magnetic sensing system, and both tool grip angles were recorded using handle-mounted flex sensors. An expert rated the 63 trial videos on five domains from the Objective Structured Assessment of Technical Skill (OSATS), yielding summed scores from 5 to 20. Motion data from each trial were processed to calculate 280 features. We used regularized least squares regression to identify the most predictive features from different subsets of the motion data and then built six regression tree models that predict summed OSATS score. Model accuracy was evaluated via leave-one-subject-out cross-validation. RESULTS: The model that used all sensor data streams performed best, achieving 71% accuracy at predicting summed scores within 2 points, 89% accuracy within 4, and a correlation of 0.85 with human ratings. 59% of the rounded average OSATS score predictions were perfect, and 100% were within 1 point. This model employed 87 features, including none based on completion time, 77 from tool tip motion, 3 from tool tip visibility, and 7 from grip angle. CONCLUSIONS: Our novel hardware and software automatically rated previously unseen trials with summed OSATS scores that closely match human expert ratings. Such a system facilitates more feedback-intensive surgical training and may yield insights into the fundamental components of surgical skill.

Vessel sealing comparison: old school is still hip.

BACKGROUND: Ligation with either absorbable or non-absorbable sutures has been the traditional state of the art, but a proliferation of technology now offers a host of methods to close and divide vessels. Only limited data are available that objectively compare different vessel sealing methods. The objective of this study was to compare a broad variety of methods of surgical vessel closure in a reproducible, independent, standardized test-to-failure ex vivo pressure challenge. METHODS: Ten of the most common surgical sealing devices were represented in this study, including both mechanical and energy devices. Unfixed porcine carotid arteries were selected for testing. They were connected to a pump, and automated controlled infusion was initiated. Upon identification of a leak at the source of sealing, the maximum pressure in mmHg was logged. RESULTS: There were a total of 184 trials conducted using the 10 vessel sealing methods. The average burst pressure across all trials was 1100 mmHg with a range of 51.3-5171 mmHg. Suture-based methods displayed the highest average pressure until failure. Stapling methods showed the lowest burst pressures. All methods showed mean burst pressures above the "physiologically relevant" level of 250 mmHg. CONCLUSIONS: This study presents an independent, reproducible, ex vivo comparison of multiple methods of surgical arterial closure. In these laboratory conditions, tests to failure demonstrated widely varying sealing strength, highly dependent on method. All hemostatic modalities tested are capable of securing vessels safely and well above physiologic blood pressures, while suture-based methods were significantly stronger than other mechanical methods or modern energy devices.

Scheduled surgery admissions and occupancy at a children's hospital: variation we can control to improve efficiency and value in health care delivery.

OBJECTIVE: Describe variability in admission, discharge, and occupancy patterns for surgical patients at a large children's hospital and assess the relationship between scheduled admissions and occupancy. BACKGROUND: High hospital occupancy degrades quality of care and access, whereas low levels of occupancy use hospital resources inefficiently. Variability in scheduling patients for surgical procedures may affect occupancy and be amenable to alteration. METHODS: This is a retrospective administrative data analysis that took place at 1 urban, tertiary-care children's hospital. A total of 8552 surgical patients hospitalized from July 1, 2009, to June 30, 2010, were included in the analysis, and admission-discharge-transfer data for 1 fiscal year were abstracted for analysis of admission and occupancy patterns. RESULTS: Among 6257 surgical admissions for non-intensive care unit (ICU) patients, 49% were emergent and 51% were scheduled. Variation in admission volume by day of week was more than 3 times higher for scheduled admissions than for emergent admissions. For non-ICU surgical patients with length of stay 7 days or less (97%), Mondays and Tuesdays generated 42% of scheduled patient occupancy time. Thursdays and Fridays often had high occupancy of surgical patients (>90% of designated beds filled), whereas Saturdays, Sundays, and Mondays were often at low occupancy for those beds (<80% filled). Only 20% of all days in the year had designated non-ICU surgery beds with occupancy between 80% and 95%. CONCLUSIONS: Scheduled admissions contribute significantly to variability in occupancy. Predictable patterns of admissions lead to high occupancy on some days and unused capacity on others, with few days being at an optimal level of occupancy. These predictable patterns suggest opportunities to improve hospital operations with changes in scheduled admission patterns, which present a different problem than random demand.

Troubleshooting the pediatric gastrostomy.

Gastrostomy tubes benefit patients but also introduce hazards and costs. Most of these costs tend to be administratively invisible, but clinically expensive. Nurses, residents, emergency physicians, surgeons, and others routinely manage complaints about gastrostomy tubes or sites, and the time and effort costs are enormous. Despite widespread use of gastrostomy tubes and the large "cost of ownership," scant instruction guides practitioners on troubleshooting the panoply of tube-related problems. Instead, clinical folk-wisdom leaves staff disarmed, resorting to lore or maladaptive work-arounds that are futile or even harmful. But tubes and gastrostomies fail in predictable ways. This guide reviews commonly used gastrostomy tubes and how they are placed. Routine care of these tubes both in the immediate postoperative period and long-term is detailed. Then, specific gastrostomy tube complications and their principle-based countermeasures are described, organized by presenting complaint. Throughout, specific clinical pitfalls are called out along with their remedies. The aim is to demystify these devices and dispel myths that lead to error.

Postoperative surveillance and detection of postprandial hypoglycemia after fundoplasty in children.

OBJECTIVE: To evaluate the prevalence of postprandial hypoglycemia (PPH) after fundoplasty after the initiation of a universal postoperative glucose surveillance plan in the neonatal intensive care unit (NICU). STUDY DESIGN: This was a retrospective chart review of children (newborn to 18 years) who underwent fundoplasty at The Children's Hospital of Philadelphia during the 2-year-period after the launch of a surveillance protocol in the NICU and other units. The rate of screening, frequency of PPH (postprandial blood glucose <60 mg/dL [3.3 mmol/L] on 2 occasions), frequency of postprandial hyperglycemia preceding PPH, timing of PPH presentation, and related symptoms were evaluated. RESULTS: A total of 285 children were included (n = 64 in the NICU; n = 221 in other units). Of the children screened in all units, 24.0% showed evidence of PPH, compared with 1.3% of unscreened children. Hyperglycemia preceded PPH in 67.7% (21/31) of all screened children. Within the NICU, most children had PPH within 1 week, but only 53.3% exhibited symptoms of dumping syndrome. CONCLUSIONS: This study supports the use of universal postoperative blood glucose surveillance in identifying PPH in children after fundoplasty. Earlier identification of PPH would lead to earlier treatment and minimize the effects of unidentified hypoglycemic events.

Disrupting the Fellowship Match: COVID-19 and the Applicant Arms Race.

Resident and fellow selection carried out via "the Match" has historically relied upon in-person interviews to evaluate and rank candidates. However, the COVID-19 pandemic has required fellowship matches and the upcoming Main Residency Match® to become wholly virtual. The 2020 pediatric surgery match offers a unique case study in the benefits and shortcomings of a virtual process and begins a much-needed conversation regarding opportunities for innovation in candidate selection. For many candidates, the application cycle imposes considerable costs - financial, professional, and personal - which have only escalated over time. We draw on our experience from the most recent match cycle to discuss limitations of the traditional Match® and suggest potential solutions to improve the subspecialty interview process moving forward.

Coil-Localized Laparoscopic-Assisted Resection of Symptomatic Gastrointestinal Vascular Malformations in Children and Young Adults.

Gastrointestinal (GI) bleeding from pediatric vascular malformation is uncommon and difficult to diagnose and manage. The preferred treatment is surgical resection; however, it can be challenging to precisely localize the lesion, particularly if it is not serosal. Objectives: To describe a technique of intentional preoperative coil localization of symptomatic pediatric GI vascular malformations by pediatric interventional radiology to facilitate fluoroscopically assisted laparoscopic resection. Methods: We searched the electronic privacy information center and picture archive and communication system in our center and found 3 cases. The electronic privacy information center and picture archive and communication system databases were the sources for retrieval of demographic, medical, radiological, and procedural information in all 3 cases. Results: After many nondiagnostic investigations in all 3 patients, a GI vascular malformation as a cause of GI bleeding was diagnosed with computed tomography angiography/magnetic resonance angiography and catheter angiography. A preoperative 0.018-inch Hilal coil was placed as close as possible to the vascular malformation during super selective angiography. Laparoscopic surgery was performed within 24 hours of coil placement. In all cases, histology confirmed the resected bowel lesions to be vascular malformations. Conclusions: Intentional endovascular coil localization has the potential to increase the precision of lesion localization and may reduce laparoscopic operative time, when guided by the coil position.

Surgical Interventions During End-of-Life Hospitalizations in Children's Hospitals.

OBJECTIVES: To characterize patterns of surgery among pediatric patients during terminal hospitalizations in children's hospitals. METHODS: We reviewed patients ≤20 years of age who died among 4 424 886 hospitalizations from January 2013-December 2019 within 49 US children's hospitals in the Pediatric Health Information System database. Surgical procedures, identified by International Classification of Diseases procedure codes, were classified by type and purpose. Descriptive statistics characterized procedures, and hypothesis testing determined if undergoing surgery varied by patient age, race and ethnicity, or the presence of chronic complex conditions (CCCs). RESULTS: Among 33 693 terminal hospitalizations, the majority (n = 30 440, 90.3%) of children were admitted for nontraumatic causes. Of these children, 15 142 (49.7%) underwent surgery during the hospitalization, with the percentage declining over time (P < .001). When surgical procedures were classified according to likely purpose, the most common were to insert or address hardware or catheters (31%), explore or aid in diagnosis (14%), attempt to rescue patient from mortality (13%), or obtain a biopsy (13%). Specific CCC types were associated with undergoing surgery. Surgery during terminal hospitalization was less likely among Hispanic children (47.8%; P < .001), increasingly less likely as patient age increased, and more so for Black, Asian American, and Hispanic patients compared with white patients (P < .001). CONCLUSIONS: Nearly half of children undergo surgery during their terminal hospitalization, and accordingly, pediatric surgical care is an important aspect of end-of-life care in hospital settings. Differences observed across race and ethnicity categories of patients may reflect different preferences for and access to nonhospital-based palliative, hospice, and end-of-life care.

Incisions do not simply sum.

BACKGROUND: Critics of minimally invasive methods sometimes argue that the summed lengths of all trocar sites have a morbidity similar to that for an open incision of equal length. This argument assumes correctly that pain and scarring are proportional to the total tension normal to a linear incision. But the argument also assumes that total tension sums linearly with incision length. This report demonstrates why that premise is not valid. METHODS: Wounds of various sizes are compared using a simple mathematical model. The closing tension perpendicular to any linear incision is a function of the incision's length, varying symmetrically together with a maximum at the midpoint of length. If tension rises linearly across an incision, integration of the tension relationship demonstrates that the total wound tension actually is proportional to the square of the length. In this report, incisions of various lengths are modeled, and plausible alternative incision scenarios for various procedures (e.g., Nissen, appendectomy) are compared. RESULTS: Total tension rises nonlinearly with increasing wound length. Thus, total tension across multiple incisions is always less than the total tension for an incision of the same total length. For example, an open appendectomy creates 2.7-fold more wound tension than a laparoscopic appendectomy. Similarly, two 3-mm trocars create less total tension than a single 5-mm trocar. CONCLUSION: Conventional incisions are subject to more total tension than any combination of trocar incisions of equal total length. This inequality yields three clinically relevant corollaries. First, it supports the practice of using the smallest effective trocars (or even no-trocar methods) to minimize pain and scar. Second, addition of a trocar in difficult cases adds relatively little morbidity. Finally, using two small trocars is better than using a single larger trocar.

Pediatric firearm mortality in the United States, 2010 to 2016: A National Trauma Data Bank analysis.

BACKGROUND: Pediatric firearm injury is a leading cause of death for U.S. children. We sought to further characterize children who die from these injuries using a validated national database. METHODS: The National Trauma Data Bank 2010 to 2016 was queried for patients aged 0 to 19 years old. International Classification of Diseases external cause of injury codes were used to classify patients by intent. Differences between groups were analyzed using χ or Mann-Whitney U tests. Patterns over time were analyzed using nonparametric tests for trend. Multivariable logistic regression was used to investigate associations between the above factors and mortality. RESULTS: There were a total of 45,288 children with firearm injuries, 12.0% (n = 5,412) of whom died. Those who died were younger and more often white than survivors. Mortality was associated with increased injury severity, shock on presentation, and polytrauma (p < 0.001 for all). There was an increasing trend in the proportion of self-inflicted injuries over the study period (p < 0.001), and mortality from these self-inflicted injuries increased concordantly (35.3% in 2010 to 47.8% in 2016, p = 0.001). Location of severe injuries had significant different mortality rates, ranging from 51.3% of head injuries to 3.9% in the extremities. In the multivariable model, treatment at a pediatric trauma center was protective against mortality, with odds ratios of 2.10 (confidence interval, 1.64-2.68) and 1.80 (confidence interval, 1.39-2.32) for death at adult and dual-designated trauma centers, respectively. This finding was confirmed in age-stratified cohorts. CONCLUSION: Proportions of self-inflicted pediatric firearm injury in the National Trauma Data Bank increased from 2010 to 2016, as did mortality from self-inflicted injury. Because mortality is highest in this subpopulation, prevention and treatment efforts should be prioritized in this group of firearm-injured children. LEVEL OF EVIDENCE: Epidemiological study, level V.

Laparoscopic Management of Pediatric Abdominal Trauma: A National Trauma Data Bank Experience.

Purpose: To characterize injury patterns and institutional trends associated with the utilization of laparoscopy in the management of pediatric abdominal trauma. Methods: The National Trauma Data Bank (2010-2014) was queried for encounters involving patients ≤14 years who underwent an open or laparoscopic abdominal operation within 48 hours of emergency department arrival. Patient, injury, and hospital characteristics associated with each approach were identified. Multivariate logistic regression was used to evaluate the influence of patient and hospital characteristics on operative approach. Results: Laparoscopy comprised 7.8% (n = 355) of all abdominal trauma operations. Patients undergoing laparoscopy had lower injury severity scores and higher Glasgow Coma Scale scores on arrival compared with laparotomy subjects (P < .001). Laparoscopic patients also had a shorter length of hospital stay (5.0 versus 8.6 days, P < .001), but longer time to the operating room (9.2 versus 6.3 hours, P < .001) compared with their open counterparts. The proportion of cases managed laparoscopically increased from 6.2% in 2010 to 10.1% in 2014 (P = .013), with increase in utilization primarily driven by university hospitals (P = .026) and level I pediatric trauma centers (P = .043). Conversion to laparotomy was uncommon (18.6%), and mortality in the laparoscopic cohort was low (0.4%). Conclusions: Use of laparoscopy has increased in the pediatric abdominal trauma population, typically in a less injured cohort of patients. As familiarity with and availability of minimally invasive techniques increase, this trend will likely continue.

Life-saving interventions in pediatric trauma: A National Trauma Data Bank experience.

BACKGROUND: Emergent procedures are infrequent in pediatric trauma. We sought to determine the frequency and efficacy of life-saving interventions (LSI) performed for pediatric trauma patients within the first hour of care at a trauma center. METHODS: The National Trauma Data Bank (2010-2014) was queried for patients 19 years or younger who underwent LSIs within 1 hour of arrival to the emergency department. Life-saving interventions included emergency department thoracotomy (EDT) and emergent airway procedures (EAP). Multivariable logistic regression was used to evaluate the influence of patient and hospital characteristics on mortality. RESULTS: Of 725,284 recorded traumatic encounters, only 1,488 (0.2%) pediatric patients underwent at least one of the defined LSI during the 5-year study period (EDT, 1,323; EAP, 187). Most patients (85.6%) were 15 years or older. Mortality was high but varied by procedure type (EDT, 64.3%; EAP, 28.3%). Mortality for patients younger than 1 year undergoing EDT was 100%, decreasing to 62.6% in patients aged 15 years to 19 years. For EAP, mortality ranged from 66.7% for infants to 27.2% in 15-year-old to 19-year-old patients. Lower Glasgow Coma Scale score, higher Injury Severity Score, presence of shock, and a blunt mechanism of injury were independently associated with mortality in the EDT cohort. On average, trauma centers in this study performed approximately one LSI per year, with only 13.8% of cases occurring at a verified pediatric trauma center. CONCLUSION: Life-saving interventions in the pediatric trauma population are uncommon and outcomes variable. Novel solutions to keep proficient at such interventions should be sought, especially for younger children. Guidelines to improve identification of appropriate candidates for LSI are critical given their rare occurrence. LEVEL OF EVIDENCE: Retrospective cohort study, III.

Qualities and Methods of Highly Effective Surgical Educators: A Grounded Theory Model.

OBJECTIVE: To identify personal qualities and teaching methods of highly effective surgical educators using a novel research design. DESIGN: In this qualitative study, surgical residents were sent an electronic survey soliciting nominations for faculty perceived as highly effective surgical educators. In-depth, semistructured interviews were conducted with surgeons receiving the most nominations. Grounded theory methodology identified themes for analysis. SETTING: General, vascular, and plastic surgery residents and faculty at the University of Pennsylvania Health System. PARTICIPANTS: A total of 77 surgical residents were surveyed. Data saturation occurred after 12 semistructured interviews with attending surgeons, corresponding to the top 15% of faculty. RESULTS: Interviewees described both personal characteristics and specific teaching approaches that facilitated successful learning. These included providing exceptional surgical education as a mission, a strong influence from past mentors and role models, a love for the profession, and a low rate of self-professed burnout. Desirable teaching methods included promoting a culture of psychological safety (the perceived ability to take interpersonal risks within one's environment), progressive autonomy, accountability of trainees, and individualized teaching for the learner. Interviewees saw education as inseparable from clinical duties, and all surgeons believed providing exceptional patient care was the foundation of effective surgical teaching. The derived themes suggested that educators prefer "cognitive-based" approaches, focusing on learning processes rather than specific outcomes. CONCLUSIONS: This study identified characteristics and educational styles of highly effective educators in a cohort of academic surgeons. This framework may inform the development of educational programs for residents and faculty in effective teaching methods.

Pediatric Perioperative DNR Orders: A Case Series in a Children's Hospital.

CONTEXT: Do-not-resuscitate (DNR) orders are common among children receiving palliative care, who may nevertheless benefit from surgery and other procedures. Although anesthesia, surgery, and pediatric guidelines recommend systematic reconsideration of DNR orders in the perioperative period, data regarding how clinicians evaluate and manage DNR orders in the perioperative period are limited. OBJECTIVES: To evaluate perioperative management of DNR orders at a tertiary care children's hospital. METHODS: We reviewed electronic medical records for all children with DNR orders in place within 30 days of surgery at a tertiary care pediatric hospital from February 1, 2016, to August 1, 2017. Using standardized case report forms, we abstracted the following from physician notes: 1) patient/family wishes with respect to the DNR, 2) whether preoperative DNR orders were continued, modified, or suspended during the perioperative period, and 3) whether life-threatening events occurred in the perioperative period. Based on data from these reports, we created a process flow diagram regarding DNR order decision-making in the perioperative period. RESULTS: Twenty-three patients aged six days to 17 years had a DNR order in place within 30 days of 29 procedures. No documented systematic reconsideration took place for 41% of procedures. DNR orders were modified for two (7%) procedures and suspended for 15 (51%). Three children (13%) suffered life-threatening events. We identified four time points in the perioperative period where systematic reconsideration should be documented in the medical record, and identified recommended personnel involved and important discussion points at each time point. CONCLUSION: Opportunities exist to improve how DNR orders are managed during the perioperative period.