Scene-dependent, feedforward eye gaze metrics can differentiate technical skill levels of trainees in laparoscopic surgery.

INTRODUCTION: In laparoscopic surgery, looking in the target areas is an indicator of proficiency. However, gaze behaviors revealing feedforward control (i.e., looking ahead) and their importance have been under-investigated in surgery. This study aims to establish the sensitivity and relative importance of different scene-dependent gaze and motion metrics for estimating trainee proficiency levels in surgical skills. METHODS: Medical students performed the Fundamentals of Laparoscopic Surgery peg transfer task while recording their gaze on the monitor and tool activities inside the trainer box. Using computer vision and fixation algorithms, five scene-dependent gaze metrics and one tool speed metric were computed for 499 practice trials. Cluster analysis on the six metrics was used to group the trials into different clusters/proficiency levels, and ANOVAs were conducted to test differences between proficiency levels. A Random Forest model was trained to study metric importance at predicting proficiency levels. RESULTS: Three clusters were identified, corresponding to three proficiency levels. The correspondence between the clusters and proficiency levels was confirmed by differences between completion times (F2,488 = 38.94, p < .001). Further, ANOVAs revealed significant differences between the three levels for all six metrics. The Random Forest model predicted proficiency level with 99% out-of-bag accuracy and revealed that scene-dependent gaze metrics reflecting feedforward behaviors were more important for prediction than the ones reflecting feedback behaviors. CONCLUSION: Scene-dependent gaze metrics revealed skill levels of trainees more precisely than between experts and novices as suggested in the literature. Further, feedforward gaze metrics appeared to be more important than feedback ones at predicting proficiency.

Attending Surgeons Demonstrate Greater Correlations of Skill Assessment and Anticipation of Adverse Events Than Residents During Laparoscopic Cholecystectomy.

BACKGROUND: Surgical training includes the development of technical and nontechnical skills. While technical skills are more easily quantified, nontechnical skills such as situation awareness (SA) are more difficult to measure and quantify. This study investigated the relationships between different SA elements and expertise. METHODS: Twenty attending and resident surgeons rated their anticipation of an impending adverse event while watching 20 videos of laparoscopic cholecystectomies with and without adverse events. After watching each video, they assessed surgeon skills and self-assessed their anticipation ratings. All participants answered a general confidence questionnaire before and after the study. RESULTS: Videos with adverse events led to significantly higher anticipation of adverse events (P < 0.001), lower surgeon skill rating (P < 0.001), and higher self-assessment in their anticipation ratings (P < 0.001) across both participant groups. General confidence was significantly lower for residents than that for attending surgeons (P < 0.001). Compared with the residents, attendings exhibited stronger and more stable correlations between measurements of SA. When viewing videos with adverse events, attendings showed significantly higher correlation between anticipation of an impending adverse event and skill assessment of the surgeon (P = 0.005). CONCLUSIONS: This study investigated how different elements of SA and their relationships were influenced by experience. The results indicated that attendings had stronger and more stable correlations between SA elements than residents, demonstrating how measurement correlations could be meaningful and sensitive indicators of expertise and autonomy readiness.

Eye tracking in surgical education: gaze-based dynamic area of interest can discriminate adverse events and expertise.

BACKGROUND: Eye-gaze metrics derived from areas of interest (AOIs) have been suggested to be effective for surgical skill assessment. However, prior research is mostly based on static images and simulated tasks that may not translate to complex and dynamic surgical scenes. Therefore, eye-gaze metrics must advance to account for changes in the location of important information during a surgical procedure. METHODS: We developed a dynamic AOI generation technique based on eye gaze collected from an expert viewing surgery videos. This AOI updated as the gaze of the expert moved with changes in the surgical scene. This technique was evaluated through an experiment recruiting a total of 20 attendings and residents to view 10 videos associated with and another 10 without adverse events. RESULTS: Dwell time percentage (i.e., gaze duration) inside the AOI differentiated video type (U = 13508.5, p < 0.001) between videos with the presence (Mdn = 16.75) versus absence (Mdn = 19.95) of adverse events. This metric also differentiated participant group (U = 14029.5, p < 0.001) between attendings (Mdn = 15.45) and residents (Mdn = 19.80). This indicates that our dynamic AOIs reflecting the expert eye gaze was able to differentiate expertise, and the presence of unexpected adverse events. CONCLUSION: This dynamic AOI generation technique produced dynamic AOIs for deriving eye-gaze metrics that were sensitive to expertise level and event characteristics.

Do inflammatory markers portend heterotopic ossification and wound failure in combat wounds?

BACKGROUND: After a decade of war in Iraq and Afghanistan, we have observed an increase in combat-related injury survival and a paradoxical increase in injury severity, mainly because of the effects of blasts. These severe injuries have a devastating effect on each patient's immune system resulting in massive upregulation of the systemic inflammatory response. By examining inflammatory mediators, preliminary data suggest that it may be possible to correlate complications such as wound failure and heterotopic ossification (HO) with distinct systemic and local inflammatory profiles, but this is a relatively new topic. QUESTIONS/PURPOSES: We asked whether systemic or local markers of inflammation could be used as an objective means, independent of demographic and subjective factors, to estimate the likelihood of (1) HO and/or (2) wound failure (defined as wounds requiring surgical débridement after definitive closure, or wounds that were not closed or covered within 21 days of injury) in patients sustaining combat wounds. METHODS: Two hundred combat wounded active-duty service members who sustained high-energy extremity injuries were prospectively enrolled between 2008 and 2012. Of these 200 patients, 189 had adequate followups to determine the presence or absence of HO, and 191 had adequate followups to determine the presence or absence of wound failure. In addition to injury-specific and demographic data, we quantified 24 cytokines and chemokines during each débridement. Patients were followed clinically for 6 weeks, and radiographs were obtained 3 months after definitive wound closure. Associations were investigated between these markers and wound failure or HO, while controlling for known confounders. RESULTS: The presence of an amputation (p < 0.001; odds ratio [OR], 6.1; 95% CI. 1.63-27.2), Injury Severity Score (p = 0.002; OR, 33.2; 95% CI, 4.2-413), wound surface area (p = 0.001; OR, 1.01; 95% CI, 1.002-1.009), serum interleukin (IL)-3 (p = 0.002; OR, 2.41; 95% CI, 1.5-4.5), serum IL-12p70 (p = 0.01; OR, 0.49; 95% CI, 0.27-0.81), effluent IL-3 (p = 0.02; OR, 1.75; 95% CI, 1.2-2.9), and effluent IL-13 (p = 0.006; OR, 0.67; 95% CI, 0.50-0.87) were independently associated with HO formation. Injury Severity Score (p = 0.05; OR, 18; 95% CI, 5.1-87), wound surface area (p = 0.05; OR, 28.7; 95% CI, 1.5-1250), serum procalcitonin ([ProCT] (p = 0.03; OR, 1596; 95% CI, 5.1-1,758,613) and effluent IL-6 (p = 0.02; OR, 83; 95% CI, 2.5-5820) were independently associated with wound failure. CONCLUSIONS: We identified associations between patients' systemic and local inflammatory responses and wound-specific complications such as HO and wound failure. However, future efforts to model these data must account for their complex, time dependent, and nonlinear nature. LEVEL OF EVIDENCE: Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Prevalence and outcomes of high versus low ratio plasma to red blood cell resuscitation in a multi-institutional cohort of severely injured children.

BACKGROUND: The benefit of targeting high ratio fresh frozen plasma (FFP)/red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP/RBC transfusion and the association with outcomes in children presenting in shock. METHODS: A post hoc analysis of a 24-institution prospective observational study (April 2018 to September 2019) of injured children younger than 18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (≥1:2) ratio FFP/RBC. Nonparametric Kruskal-Wallis and χ 2 were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS: Of 135 children with median (interquartile range) age 10 (5-14) years and weight 40 (20-64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (low-38%, high-46%, p = 0.34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = 0.01); however, hospital mortality was similar (low-24%, high-20%, p = 0.65) as was the risk of extended ventilator, intensive care unit, and hospital days (all p > 0.05). CONCLUSION: Despite increased injury severity, patients who received a high ratio of FFP/RBC had comparable rates of mortality. These data suggest high ratio FFP/RBC resuscitation is not associated with worst outcomes in children who present in shock. Massive transfusion protocol activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Routine Repeat Imaging of Pediatric Blunt Solid Organ Injuries Is Not Necessary.

INTRODUCTION: Nonoperative management of hemodynamically stable patients with blunt splenic and/or hepatic injury has been widely accepted in the pediatric population. However, variability exists in the utilization and timing of repeat imaging to assess for delayed complications during index hospitalization. Recent level-IV evidence suggests that repeat imaging in children should be performed based on a patient's clinical status rather than on a routine basis. The aim of this study is to examine the rate of delayed complications and interventions in pediatric trauma patients with blunt splenic and/or hepatic injuries who undergo repeat imaging prompted either by a clinical change (CC) or non-clinical change (NCC). METHODS: A 9-year (2011-2019), retrospective, dual-institution study was performed of children (0-17 years) with blunt splenic and/or hepatic injuries. Patients were grouped based on reason for repeat imaging: CC or NCC. The rate of organ-specific delayed complications and interventions was examined by reason for scan. RESULTS: A total of 307 injuries were included in the study period (174 splenic, 113 hepatic, and 20 both). Of 194 splenic injuries, 30(15.5%) underwent repeat imaging (CC = 19; NCC = 11). Of 133 hepatic injuries, 27(20.3%) underwent repeat imaging (CC = 21; NCC = 6). There was no difference in the incidence of organ-specific delayed complications between the CC and NCC groups. Of the 4 patients with complications necessitating intervention, only one was identified based on NCC. CONCLUSIONS: Our data suggest routine repeat imaging is unnecessary in children with blunt splenic and/or hepatic injuries; therefore, practitioners may rely on a patient's clinical change.

Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis.

OBJECTIVE: This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI. METHODS: This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses. RESULTS: There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010). CONCLUSION: Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Employment search, initial employment experience, and career preferences of recent pediatric surgical fellowship graduates: An APSA survey, part of the right child/right surgeon initiative.

BACKGROUND: APSA's Right Child/Right Surgeon Initiative addresses issues concerning patient access to appropriate pediatric surgical care and workforce distribution. The APSA Workforce Committee sought to understand the experiences and motivations of recent graduates of Pediatric Surgery Training Programs entering the workforce. METHODS: Using APSA membership databases, we identified members who completed fellowship training from 2010 to 2019. An online survey was created using Survey Monkey, and invitations to participate were sent via email. RESULTS: 144 of 447 invited participants responded (32% response rate). 91% of respondents participated in dedicated research prior to fellowship, but only 64% perform research during their employment. 23% completed an additional clinical fellowship, but only 54% currently practice within the second field. When asked to identify the top three factors used to choose a position, the most common responses were "location or geography" (71%), "available mentorship" (53%), and "compensation and benefits" (37%). Describing their first position, 77% reported working in an academic institution, 78% reported working in a metropolitan/urban area, and 55% reported working in a free-standing children's hospital. 94% participate in General Surgery resident education, and 49% are faculty within a Pediatric Surgery fellowship. Overall, 92% of respondents were able to find the type of employment position that they had wanted. CONCLUSION: In our survey the overwhelming majority of young pediatric surgeons found the type of job they desired. Most report beginning their practice in more populated, urban areas within academic institutions. Geographic location and work environment played heavily into their employment decisions. These preferences could contribute to continued disparity in access to pediatric surgeons between urban and rural America and to dilution of experience for urban surgeons. Possible solutions include alternative incentive programs for employment in less populated areas or new training models for general surgeons in rural areas to train in fundamentals of Pediatric Surgery.

Renal aplasia in humans is associated with RET mutations.

In animal models, kidney formation is known to be controlled by the proteins RET, GDNF, and GFRA1; however, no human studies to date have shown an association between abnormal kidney development and mutation of these genes. We hypothesized that stillborn fetuses with congenital renal agenesis or severe dysplasia would possess mutations in RET, GDNF, or GFRA1. We assayed for mutations in these genes in 33 stillborn fetuses that had bilateral or unilateral renal agenesis (29 subjects) or severe congenital renal dysplasia (4 subjects). Mutations in RET were found in 7 of 19 fetuses with bilateral renal agenesis (37%) and 2 of 10 fetuses (20%) with unilateral agenesis. In two fetuses, there were two different RET mutations found, and a total of ten different sequence variations were identified. We also investigated whether these mutations affected RET activation; in each case, RET phosphorylation was either absent or constitutively activated. A GNDF mutation was identified in only one fetus with unilateral agenesis; this subject also had two RET mutations. No GFRA1 mutations were seen in any fetuses. These data suggest that in humans, mutations in RET and GDNF may contribute significantly to abnormal kidney development.

Timing and volume of crystalloid and blood products in pediatric trauma: An Eastern Association for the Surgery of Trauma multicenter prospective observational study.

BACKGROUND: The purpose of this study was to determine the relationship between timing and volume of crystalloid before blood products and mortality, hypothesizing that earlier transfusion and decreased crystalloid before transfusion would be associated with improved outcomes. METHODS: A multi-institutional prospective observational study of pediatric trauma patients younger than 18 years, transported from the scene of injury with elevated age-adjusted shock index on arrival, was performed from April 2018 to September 2019. Volume and timing of prehospital, emergency department, and initial admission resuscitation were assessed including calculation of 20 ± 10 mL/kg crystalloid boluses overall and before transfusion. Multivariable Cox proportional hazards and logistic regression models identified factors associated with mortality and extended intensive care, ventilator, and hospital days. RESULTS: In 712 children at 24 trauma centers, mean age was 7.6 years, median (interquartile range) Injury Severity Score was 9 (2-20), and in-hospital mortality was 5.3% (n = 38). There were 311 patients(43.7%) who received at least one crystalloid bolus and 149 (20.9%) who received blood including 65 (9.6%) with massive transfusion activation. Half (53.3%) of patients who received greater than one crystalloid bolus required transfusion. Patients who received blood first (n = 41) had shorter median time to transfusion (19.8 vs. 78.0 minutes, p = 0.005) and less total fluid volume (50.4 vs. 86.6 mL/kg, p = 0.033) than those who received crystalloid first despite similar Injury Severity Score (median, 22 vs. 27, p = 0.40). On multivariable analysis, there was no association with mortality (p = 0.51); however, each crystalloid bolus after the first was incrementally associated with increased odds of extended ventilator, intensive care unit, and hospital days (all p < 0.05). Longer time to transfusion was associated with extended ventilator duration (odds ratio, 1.11; p = 0.04). CONCLUSION: Resuscitation with greater than one crystalloid bolus was associated with increased need for transfusion and worse outcomes including extended duration of mechanical ventilation and hospitalization in this prospective study. These data support a crystalloid-sparing, early transfusion approach for resuscitation of injured children. LEVEL OF EVIDENCE: Therapeutic, level IV.

Improving the Intraoperative Educational Experience: Understanding the Role of Confidence in the Resident-Attending Relationship.

OBJECTIVE: With recent changes to graduate medical education, the balance between resident autonomy and need for supervision impacts the educational and training experience of residents. The objective of this study was to understand the relationship between the confidence of attendings and residents and their different perspectives of perceived educational experience and autonomy in the operating room (OR). We hypothesized that the attending's confidence in the resident would be an important factor in improving the educational experience and resident's autonomy in the OR. DESIGN: Self-reported confidence-rating and operative experience surveys were administered to teams of post-graduate year (PGY 1) through PGY 5 surgical residents and attendings in two temporal sets (Early: Sept-Dec 2015, n = 20; Late: Jan-Apr 2016, n = 22). A second "end-of-year" survey was distributed to residents (n = 9, 37.5% response) and attendings (n = 10, 35% response) asking questions regarding their educational experience and operative experience during the past year. SETTING: Large rural teaching hospital. PARTICIPANTS: Nineteen general surgery residents (PGY 1 - 5) and 14 general surgery attendings. RESULTS: Resident perception of confidence differs from junior to senior residents, and that there was discordance between resident's confidence and skill as perceived by attendings, particularly in senior residents. Results also showed that attending's confidence in residents was positively correlated with attending's perceived educational experience in the OR. Residents and attendings both indicated attending's confidence in residents as an important factor in increasing resident autonomy in the OR, thus the attending's confidence in residents could have a positive impact on resident autonomy and educational experience in the OR. CONCLUSIONS: We have demonstrated a relationship between self-confidence for residents and improved confidence from attendings in residents' capabilities. Based on these findings, we would propose identifying methods to expand resident's awareness of surgical situations and develop attending's confidence in residents.

Insurance status, mortality, and hospital use among pediatric trauma patients over three decades.

BACKGROUND: We investigated the association between lack of insurance and mortality, resource use, and medical comorbidities among pediatric trauma patients. METHODS: Our trauma database was queried for patients <18 years old from 1989 through 2013. Data collected included demographics, injury severity score (ISS), and insurance status. Dependent variables included major medical comorbidities, hospital and ICU lengths of stay (LOS), and mortality. Logistic regression and tests of equivalence were used to analyze the data. RESULTS: A total of 3120 patients were included. The mortality among patients with insurance was 3.6% compared to 8.4% among those without insurance (p=0.0001, OR =2.42, 95% CI=1.53-3.82). This relationship remained statistically significant with adjustment via multivariable logistic regression (p=0.0001, OR =2.83, 95% CI: 1.64-4.74). Hospital and ICU LOS were significantly greater among insured patients in severely and moderately injured samples, respectively. There was no correlation between insurance and medical comorbidities. The uninsured mortality rate was 12.9% from 1989 to 1997 compared to 3.9% in 2006-2013. CONCLUSION: Lack of insurance was associated with mortality but not preexisting comorbidity. This relationship persisted over time despite an overall decline in mortality. Additionally, lack of insurance was associated with decreased hospital stay and ICU utilization. LEVEL OF EVIDENCE: Treatment Study, Level III.

Thyroid and parathyroid disease in children.

Although diseases of the thyroid and parathyroid glands are relatively uncommon in children, the implications of missed diagnoses can be severe. This review describes the embryology, anatomy, and physiology of the thyroid and parathyroid glands, and focuses on significant benign and malignant pathologies of these glands.

Effects of age and size in the ears of gekkonomorph lizards: middle-ear morphology with evolutionary implications.

The function of the ear depends in part on its absolute size and internal proportions. Thus, in both young individuals and small species, the middle ear is expected to be allometrically enlarged despite its smaller absolute size. Here we aim to compare the ontogenetic allometry of relevant middle-ear structures as observed within gecko (gekkonomorph lizards) species, with the evolutionary allometry observed interspecifically. These observations also provide middle-ear data for future evaluation of variation in auditory sensitivity. The material comprised 84 museum specimens of geckos, representing nine species of three gekkonomorph subfamilies. The results of dissections and measurements show that different reports notwithstanding, the middle-ear ossicular chain is indeed structured as described for geckos by Werner and Wever. Some sexual dimorphism is indicated, but this requires further study. During postnatal ontogeny, the allometric growth in the ratio of the columellar footplate area to body length differed between the intraspecific and interspecific levels, hence species differences in the middle ear do not merely result from animal size. The ratio of the tympanic membrane area to the columellar footplate area increased during ontogeny. In this, geckos resemble birds and probably also mammals. Similarly, when the comparison was among adults representing different species, the ratio of the tympanic membrane area to the columellar footplate area increased with body size. In this, however, the geckos differed from birds and mammals, in which this ratio varied taxonomically, irrespective of body size. It would thus seem that middle-ear proportions have evolved among geckos to produce small interspecific differences, but among amniote tetrapods they have evolved according to different principles in the classes reptiles, birds, and mammals.

The impact of children's hospital designation on outcomes in children with malrotation.

BACKGROUND: The benefit of Ladd's procedure for malrotation at a Children's Hospital (CH) has not previously been established. Our aim was to characterize the potential variations in management and outcomes between CH and Non-Children's Hospitals (NCH) in the treatment of malrotation with Ladd's procedure. METHODS: There were 2827 children identified with malrotation and complete information from the Kids' Inpatient Database (2003, 2006, 2009). Outcomes were compared between CH and NCH and evaluated with logistic and linear regressions. Additional propensity score matching was used to balance covariates between CH and NCH. RESULTS: There were 2261 (80.0%) children with malrotation undergoing Ladd's procedures treated at CH; 566 (20.0%) were treated at NCH. In multivariate analysis, CH was associated with a 39% lower odds of resection (p=0.004), with no differences observed for mortality, morbidity and LOS. Comparison of a propensity score matched cohort confirmed these findings, as well as demonstrated no significant differences in associated costs. CONCLUSIONS: The majority of pediatric intestinal malrotation is managed at CH. While measured outcomes of mortality, morbidity, LOS, and costs were not different at NCH, CH was less likely to perform intestinal resection during Ladd's procedure.

Comparing 30-day outcomes between thoracoscopic and open approaches for resection of pediatric congenital lung malformations: Evidence from NSQIP.

BACKGROUND/PURPOSE: Thoracoscopic surgery has been increasingly utilized in treating pediatric congenital lung malformations (CLM). Comparative studies evaluating 30-day outcomes between thoracoscopic and open resection of CLM are lacking. METHODS: There were 258 patients identified in pediatric NSQIP with a CLM and pulmonary resection in 2012-2013. Comparisons of patient characteristics and outcomes between surgical approaches were made using standard univariate statistics. In addition, a propensity score match was performed to evaluate outcomes in similar patient cohorts. RESULTS: One-hundred twelve patients (43.4%) received thoracoscopic resections and 146 patients (56.6%) received open resections. Patients undergoing open resections were more likely to be less than 5 months of age and have a comorbidity/preoperative condition (47.3% vs. 25.0%, p<0.001). The extent of resection was a lobectomy in 84.8% of thoracoscopic and 92.5% of open resection patients. Median operative time was similar between both groups (thoracoscopic 172 vs. open 153.5 minutes). On univariate analysis, thoracoscopic resection was associated with decreased postoperative complications (9.8% vs. 25.3%, p=0.001) and LOS (3 vs. 4 days, p<0.001). However, after adjusting for similar patient and operative characteristics, no significant differences were encountered between techniques. CONCLUSIONS: Thoracoscopic and open resection provide comparable 30-day outcomes and safety in the management of congenital lung malformations.

Iodine -131 metaiodobenzylguanidine is an effective treatment for malignant pheochromocytoma and paraganglioma.

INTRODUCTION: Iodine 131-meta-iodobenzylguanidine ((131)I-MIBG) has been applied to the palliative treatment of metastatic pheochromocytoma in small studies. We report our institutional experience for the treatment of metastatic pheochromocytoma and paraganglioma. METHODS: We performed a retrospective review of 33 patients with metastatic pheochromocytoma (n=22) and paraganglioma (n=11) treated at our institution with (131)I-MIBG over a 10-year period. RESULTS: Patients received a mean dose of 388+/-131 mCi (131)I-MIBG. Median survival after treatment was 4.7 years. Most patients experienced a symptomatic response leading to an improved survival (4.7 years vs 1.8 years, P<.01). Patients with a measurable hormone response demonstrated an increased survival in comparison to those with no response (4.7 years vs 2.6 years, P=.01). Patients who received a high dose (>500 mCi) as their initial therapy also had improved survival (3.8 years vs 2.8 years, P=.02). CONCLUSION: These data support (131)I-MIBG treatment for select patients with metastatic pheochromocytoma. In our experience, prolonged survival was best predicted by symptomatic and hormone response to (131)I-MIBG treatment. An initial dose of 500 mCi may be optimal. The benefit of (131)I-MIBG treatment for metastatic pheochromocytoma must also be weighed against its side effects.

A cost and outcomes comparison of a novel integrated pediatric air and ground transportation system.

BACKGROUND: The purpose of this study is to compare air transportation of critically ill pediatric patients with a mixed air-ground transportation system by evaluating timeliness, safety, and cost. The setting was a tertiary care "hub" center with three outlying-referral "spoke" facilities. STUDY DESIGN: Our study included 96 children transported between June and December 1997, with 45% constituting surgical admissions and 55% medical admissions. Data collected at the outlying facilities, en route, and at our institution included vital signs, laboratory values, and Glasgow coma scores. We evaluated transport time, transport cost, Pediatric Risk of Mortality scores, and Pediatric Index of Mortality of the children during transportation using ANOVA statistical analysis. We also compared adverse events in transportation, total hospital length of stay, and mortality at 24 and 72 hours in both the air and ground transport groups to determine differences in predicted and observed mortality. RESULTS: A total of 96 children were transported (48% by ground and 52% by air) between June and December 1997. The time at the referring facility was significantly shorter in the ground group than in the air group (air, 55.4 minutes versus ground, 36.7 minutes, p < 0.01). Total transport time differed by only 27 minutes between groups. No difference was identified in morbidity or mortality between air and ground groups. Actual mortality was not significantly different from predicted mortality in either group. The cost of ground transportation was significantly lower (air, $4,236 versus ground, $1,566). When our system of a combined air and ground group transport system is compared with a hypothetical 100% air transport system, we saved an average of more than $240,000 annually. CONCLUSIONS: We have demonstrated that a "hub-and-spoke" ground transportation system supplements air transportation in a safe, timely, and cost-effective manner.

RET tyrosine kinase and medullary thyroid cells are unaffected by clinical doses of STI571.

BACKGROUND: Activating mutations in the RET receptor tyrosine kinase are responsible for the development of medullary thyroid cancer (MTC) in persons with Multiple Endocrine Neoplasia type 2. We hypothesized that STI571 (Gleevec) would inhibit RET kinase and be a useful agent in the treatment of MTC. MATERIALS AND METHODS: We determined the IC50 of STI571 for RET using an in vitro kinase assay and also examined the effects of STI571 on cellular proliferation and viability in TT cells, a human MTC cell line. RESULTS: The average in vitro IC50 of STI571 for RET is 37 microM +/- 4 microM. Additionally, TT cells incubated with 10 microM STI571 for up to 8 days showed no apparent reduction in cell proliferation or viability. Higher concentrations of STI571, from 25 to 100 microM, induced necrosis of TT cells. CONCLUSION: The concentrations of STI571 required to significantly inhibit RET and to inhibit TT cell proliferation are not clinically achievable. We conclude that STI571 is not likely to be an effective treatment for MTC.