A Case of Metastatic Melanoma Post Orthotopic Liver Transplantation.

With the rising prevalence of organ transplantation, clinicians must be aware of the many potential complications that may arise. One such complication is post-transplantation melanoma. Herein, we present a case of advanced metastatic melanoma following orthotopic liver transplantation (OLT).  This is a 54-year-old cirrhotic male who underwent OLT that was complicated by metastatic melanoma. Despite adherence to yearly screening guidelines and timely radiation and immunotherapy, the disease course was rapidly progressive and fatal. This case aims to highlight the risk of post-transplantation melanoma and the potential need for screening modifications to identify melanoma earlier in its development.  The association between organ transplantation and melanoma is well-reported, but the underlying risks and mechanisms remain incompletely understood. One potential risk factor is post-transplant immunosuppressive therapy, which may result in fatally aggressive melanoma. Understanding the potential mortality risks in transplant patients, modifications to peri-transplant screening guidelines, and immunosuppressive therapy may be lifesaving.

Safe Ground Transport of Pediatric Patients: A Qualitative Assessment of Best Practice Guidelines Implementation.

OBJECTIVE: The National Highway Traffic Safety Administration issued guidelines on the safe transport of pediatric patients to lessen the chance of injury during ambulance transport. However, adherence to these standards have been slow to take hold. The objective of this quality improvement study is to evaluate barriers and facilitators of safe transport at the individual, organizational, and societal levels and identify improvement opportunities in the safe transport of pediatric patients. METHODS: This study was designed using an implementation science framework. Six focus groups were held with EMS clinicians to assess knowledge, behaviors, barriers, and facilitators of safe pediatric transport. Four interviews were conducted with EMS leadership to characterize organizational safe transport practices and policies. Detailed notes were taken during focus groups; interviews were recorded and transcribed. Qualitative data were analyzed using a thematic content analysis approach where team members reviewed transcripts using an established framework and identified major and minor themes related to safe pediatric transport. RESULTS: Three focus groups were conducted in a hospital setting and three were conducted at EMS base stations. Interview participants included two paramedic leaders, an ambulance service chief executive officer, and an ambulance service clinical coordinator. Recurring themes included the belief that children were inherently difficult to transport, the sentiment that training in pediatric transport is lacking, and the acknowledgement that familiarity with pediatric transport guidelines is low. Additionally, a major theme was that situational practicality can take precedence over adherence to best practice recommendations. Participants reported the presence of organizational and external barriers that made it more difficult for EMS personnel to follow safety guidelines. This included equipment unavailability, lack of clear policies, low pediatric patient volume, manufacturer design preferences, and prevailing EMS culture/norms. CONCLUSION: EMS clinicians need hands-on training and knowledge reinforcement in safe pediatric ground ambulance transport. EMS agencies should ensure that their crews have proper equipment, training, and protocols in place. Regulators and manufacturers can be catalysts for the implementation of these recommendations. Substantial change at the individual, organizational, and societal levels are needed to improve the safety of pediatric patients being transported via ground ambulance.

Expanding access to difficult urinary catheter insertion services through a novel nurse practitioner-led team.

BACKGROUND: Within the United States health care system, one of the most common procedures performed daily is urinary catheterization. Oftentimes, the urinary catheter is placed by nursing personnel without any difficulty. Although the procedure is usually simple and routine, there are instances in which placement can be problematic. LOCAL PROBLEM: Urology is one of the smallest surgical subspecialties, with intermittent availability given active commitments in the operating room and clinic. This opened an opportunity for nurse practitioners (NPs) at an urban quaternary care hospital to further enhance their skill set in the care of these patients. METHODS: Fifteen Rapid Response Team NPs were selected based on specific criteria. Their roles expanded to include consults for difficult urinary catheter insertions. INTERVENTION: A 2-step training program was implemented for NPs to develop proficiency in inserting urinary catheters in patients with new or known urologic conditions. RESULTS: Of the 391 catheter consults made to the NP group, 73 (18.7%) of them required urology follow-up. CONCLUSION: This program can benefit patients by potentially reducing catheter-related complications and associated length of stay.

Sociodemographic Factors Associated with Do-Not-Resuscitate Order Utilization in the Surgical Intensive Care Unit: An Observational Study.

The use of a do-not-resuscitate (DNR) order is a powerful tool in outlining end-of-life care. This study explores sociodemographic factors associated with selection of a DNR order and assigning a healthcare proxy in the Surgical Intensive Care Unit (SICU). A retrospective chart review of 312 patients who expired in the SICU over a 7-year period was conducted. We analyzed the association of sociodemographic factors to selection of a DNR order and assignment of a healthcare proxy. Year of admission, age, religion, and proxy were independently associated with selection of DNR. In particular, the relative chance of a DNR selection in 2019 compared to 2012 was 3.538 (95% CL = 2.001-6.255, P < .01). There are significant sociodemographic factors that influence DNR utilization, highlighting the need to consider the social and religious backgrounds when engaging patients and their families in end-of-life care. Future studies will need to be conducted on whether these sociodemographic factors influence surviving patients as this study's findings can only be applied to those who have expired.

Clinical and radiographic predictors of the need for facial CT in pediatric blunt trauma: a multi-institutional study.

Background: Facial injuries are common in children with blunt trauma. Most are soft tissue lacerations and dental injuries readily apparent on clinical examination. Fractures requiring operative intervention are rare. Guidelines for utilization of maxillofacial CT in children are lacking. We hypothesized that head CT is a useful screening tool to identify children requiring dedicated facial CT. Methods: We conducted a multicenter retrospective review of children aged 18 years and under with blunt facial injury who underwent both CT of the face and head from 2014 through 2018 at five pediatric trauma centers. Penetrating injuries and animal bites were excluded. Imaging and physical examination findings as well as interventions for facial fracture were reviewed. Clinically significant fractures were those requiring an intervention during hospital stay or within 30 days of injury. Results: 322 children with facial fractures were identified. Head CT was able to identify a facial fracture in 89% (287 of 322) of children with facial fractures seen on dedicated facial CT. Minimally displaced nasal fractures, mandibular fractures, and dental injuries were the most common facial fractures not identified on head CT. Only 2% of the cohort (7 of 322) had facial injuries missed on head CT and required an intervention. All seven had mandibular or alveolar plate injuries with findings on physical examination suggestive of injury. Discussion: In pediatric blunt trauma, head CT is an excellent screening tool for facial fracture. In the absence of clinical evidence of a mandibular or dental injury, a normal head CT will usually exclude a clinically significant facial fracture. Level of evidence: III.

Characterizing physical trauma in children and youth with special health care needs.

BACKGROUND: Children and youth with special health care needs (CYSHCN) have or are at an increased risk for a chronic condition necessitating medical and related services beyond what children usually require. While evidence suggests that CYSHCN are at an increased risk of injury, little is known about this population within the trauma system. This study describes CYSHCN within the pediatric trauma system and examines patterns of injury risk (i.e., intent, place of injury, trauma type, and mechanism of injury) based on special health care need (SHCN) status. METHODS: For this cross-sectional study, we used data from the 2018 National Trauma Data Bank to identify pediatric encounters (1-18 years, N = 115,578) and compare demographics (sex, race/ethnicity, insurance status, and age) by CYSHCN status using χ 2 and t tests. Children and youth with special health care needs encounters were compared with non-SHCN encounters using multinomial logistic regression models, controlling for demographics. RESULTS: Overall, 16.7% pediatric encounters reported an SHCN. Children and youth with special health care needs encounters are older, and a higher proportion is publicly insured than non-SHCN encounters ( p < 0.001). Furthermore, CYSHCN encounters have a higher risk of assault (relative risk, 1.331) and self-inflicted (relative risk, 4.208) injuries relative to unintentional injury ( p < 0.001), as well as a higher relative risk of traumatic injury occurring in a private residence ( p < 0.01) than other locations such as school (relative risk, 0.894). Younger CYSHCN encounters have a higher risk of assault relative to unintentional injury when compared with non-SHCN encounters ( p < 0.01). Pediatric trauma encounters reporting mental health and alcohol/substance use disorder SHCN have a higher probability of self-inflicted and assault injuries than non-SHCN encounters ( p < 0.001). CONCLUSIONS: These findings suggest that CYSHCN have different traumatic injury patterns than their non-SHCN peers, particularly in terms of intentional and private residence injury, and deserve a special focus for traumatic injury prevention. LEVEL OF EVIDENCE: Prognostic/epidemiologic, level III.

Which Sport Is More Dangerous: Ice Hockey or Field Hockey? A Review of the Head and Neck Injuries Associated With the Two Sports.

PURPOSE: Ice hockey and field hockey are contact sports with the potential for injury, especially to the head and neck regions. The purpose of this study is to estimate and compare hospital admission (injury severity) between ice hockey and field hockey of those who presented to the emergency department with head and neck injuries. METHODS: The investigators designed and implemented a 20-year retrospective cohort study using the National Electronic Injury Surveillance System database. We included data related to ice hockey and field hockey injuries from January 2000 to December 2019 in this study. The primary predictor variable was sport played (ice hockey vs field hockey). Secondary predictor variables and covariates were derived from patient and injury characteristics. The primary outcome variable was hospital admission. Logistic regression was used to determine independent risk factors for the outcome variable. RESULTS: Our final sample was composed of 5,472 patients: 4,472 patients suffered head and neck injuries from ice hockey while the remaining 1,000 patients suffered head and neck injuries from field hockey. Players less than 18 years old were associated with 2.07-fold odds of admission (P < .01). Injury to the head (odds ratio [OR] = 14.339; 95% confidence interval [CI], 2.0 to 105.1; P < .01) and neck (OR = 89.260; 95% CI, 11.2 to 712.6; P < .01) were independently associated with an increased odds of admission. Relative to contusions/abrasions, players who suffered a concussion (OR = 141.637; 95% CI, 11.5 to 1,741.5; P < .01), fracture (OR = 155.434; 95% CI, 17.0 to 1,419.2; P < .01), internal organ injury (OR = 186.450; 95% CI, 15.5 to 2,236.8; P < .01), or hematoma (OR = 23.046; 95% CI, 1.2 to 442.5; P < .05) were all independently associated with an increased odds of admission. Ice hockey was not an independent risk factor for admission relative to field hockey. CONCLUSIONS: The findings of this study suggest that ice hockey was more associated with injuries to the head and neck as well as with concussions and internal organ injury compared to field hockey. However, ice hockey was not associated with increased risk of hospitalization relative to field hockey.

An analysis of American physician professional statements about gun violence against children.

BACKGROUND: We examine the content of physician professional association statements and assess the extent to which these statements kept gun violence-especially against children-on policymakers' agendas. METHODS: After constructing a list of U.S. physician professional associations, we located position statements by consulting association websites, conducting a PubMed search, and reviewing the citations of identified statements. Once unique statements were identified (N = 32), two reviewers independently coded content such as major events, pediatric focus, firearm type, and policy recommendations. RESULTS: Recent statements appear to be timed following mass casualty events such as the Sandy Hook and Parkland school shootings. Associations have increasingly adopted public health framing over time. Nine statements focused on the pediatric population, while an additional 13 made reference to the pediatric population. The most common recommendations include increased gun violence research or research funding (84%), freedom of physician counseling (75%), mandatory background checks (72%), and safe storage (72%). CONCLUSION: Based on this analysis, recent statement volume appears to be tied to current events rather than keeping daily gun violence against children continuously on the agenda. Mentions of "gun control" have receded over time and have been replaced by public health framing that places advocacy for firearm injury prevention in the physician's domain. LEVEL OF EVIDENCE: III/IV.

Initial Laparotomy Versus Peritoneal Drainage in Extremely Low Birthweight Infants With Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation: A Multicenter Randomized Clinical Trial.

OBJECTIVE: The aim of this study was to determine which initial surgical treatment results in the lowest rate of death or neurodevelopmental impairment (NDI) in premature infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP). SUMMARY BACKGROUND DATA: The impact of initial laparotomy versus peritoneal drainage for NEC or IP on the rate of death or NDI in extremely low birth weight infants is unknown. METHODS: We conducted the largest feasible randomized trial in 20 US centers, comparing initial laparotomy versus peritoneal drainage. The primary outcome was a composite of death or NDI at 18 to 22 months corrected age, analyzed using prespecified frequentist and Bayesian approaches. RESULTS: Of 992 eligible infants, 310 were randomized and 96% had primary outcome assessed. Death or NDI occurred in 69% of infants in the laparotomy group versus 70% with drainage [adjusted relative risk (aRR) 1.0; 95% confidence interval (CI): 0.87-1.14]. A preplanned analysis identified an interaction between preoperative diagnosis and treatment group (P = 0.03). With a preoperative diagnosis of NEC, death or NDI occurred in 69% after laparotomy versus 85% with drainage (aRR 0.81; 95% CI: 0.64-1.04). The Bayesian posterior probability that laparotomy was beneficial (risk difference <0) for a preoperative diagnosis of NEC was 97%. For preoperative diagnosis of IP, death or NDI occurred in 69% after laparotomy versus 63% with drainage (aRR, 1.11; 95% CI: 0.95-1.31); Bayesian probability of benefit with laparotomy = 18%. CONCLUSIONS: There was no overall difference in death or NDI rates at 18 to 22 months corrected age between initial laparotomy versus drainage. However, the preoperative diagnosis of NEC or IP modified the impact of initial treatment.

Dehydrated Human Amnion Chorion Membrane as Treatment for Pediatric Burns.

Objective: Pediatric burns are a major source of injury and in the absence of adequate care can lead to lifelong functional loss and disfigurement. While split thickness skin autografts are the current standard of care for deep partial and full-thickness burns, this approach is associated with considerable morbidity. For this reason, alternative skin substitutes such as allografts have gained interest. Approach: In the present study, we present a case series of 30 children with various types of burns treated with dehydrated human amnion chorion membrane (dHACM). Results: We show that treatment with dHACM is associated with an excellent rate of healing comparable to split thickness skin grafts with less rate of hypertrophic scar and contracture. Innovation: Treatment with dHACM is particularly attractive as it consists of many tissue regenerative factors, such as growth factors and immune modulators, thus it will reduce the risk of scaring. Conclusion: While dHACM is associated with an increased upfront cost, treating patients with small to moderate-sized burns with dHACM in their regional centers works to decrease downstream costs such as management of prolonged pain from donor-site morbidity, revisional surgeries from scar and contractures of split thickness grafts, and avoiding the cost of transfer to higher level centers of care. Our findings challenge the current standard of care, suggesting that dHACM provides an alternative to the current use of split thickness skin grafting and is a safe, feasible, and potentially superior substitute for the management of small to moderate total body surface area partial and full-thickness pediatric burns.

Opioid use in children's surgery: Awareness, current state, and advocacy.

In response to the ongoing opioid epidemic, many surgeons who care for children have reflected upon current practices and the history of our own prescribing. In this editorial review, we provide a brief summary of the origins of opioid use in medicine and surgery, we describe how the ongoing opioid epidemic specifically impacts children and adolescents, and we explore contemporary efforts underway to facilitate evidence-based opioid prescribing. Resources for pediatric surgeons including national guidelines related to safe opioid prescribing and web-based toolkits that may be used to implement change locally are highlighted. The goal of the present manuscript is to introduce opioid stewardship as a guiding principle in pediatric surgery. LEVEL OF EVIDENCE: LEVEL V (Expert opinion).

Improving the performance of the Revised Trauma Score using Shock Index, Peripheral Oxygen Saturation, and Temperature-a National Trauma Database study 2011 to 2015.

BACKGROUND: The Revised Trauma Score is the standard physiologic injury severity indicator used in trauma research and quality control. Shock index, peripheral oxygen saturation, and temperature have emerged as strong predictors for mortality and morbidity. We hypothesized that replacing systolic blood pressure and respiratory rate with age-adjusted shock index and peripheral oxygen saturation and adding temperature would generate a more accurate model, valid across all ages. METHODS: This is a retrospective database analysis using children and adults from the National Trauma Data Bank for years 2011 to 2015. Glasgow Coma Scale, systolic blood pressure, heart rate, respiratory rate, peripheral oxygen saturation, temperature, and shock index (calculated as heart rate/systolic blood pressure) were used as predictor variables, alone or in combination, in logistic models with survival as primary outcome. Bayesian information criterion and area under the receiver operator characteristic curve were used to compare models' performances. To adjust for age, models tested on the entire population (children and adults) used Z-scores derived on age-based homogenous intervals rather than the raw value. RESULTS: The analysis included 283,724 pediatric and 1,555,478 adult patients. Overall mortality was 0.7% and 2.7%, respectively. The Glasgow Coma Scale + shock index + peripheral oxygen saturation + temperature model outperformed the revised trauma score in both adults (Bayesian information criterion 296,345.94 vs 298,494.72; area under the receiver operator characteristic curve 0.831 vs 0.809, P < .001) and children (Bayesian information criterion 12,251.48 vs 12,283.48; area under the receiver operator characteristic curve 0.974 vs 0.968, P = .05) cohorts. On the merged (children and adults) cohort the Glasgow Coma Scale + Z-scores derived on age-based homogenous intervals + peripheral oxygen saturation + temperature model outperformed the Revised Trauma Score (Bayesian information criterion 313,814.78 vs 317,781.31; area under the receiver operator characteristic curve 0.852 vs 0.809, P < .001). CONCLUSIONS: Replacing systolic blood pressure and respiratory rate with shock index and peripheral oxygen saturation in the Revised Trauma Score model and adding temperature generated a more accurate model in both children and adults. Adjusting shock index for age rendered the model accurate across all ages. Calibration on population-derived nomograms of vital signs would further increase the model's accuracy and precision.

The adherence of adult trauma centers to American Pediatric Surgical Association guidelines on management of blunt splenic injuries.

BACKGROUND: Nonoperative management (NOM) is commonly utilized in hemodynamically stable children with blunt splenic injuries (BSI). Guidelines published by the American Pediatric Surgical Association over the past 15 years support this approach. We sought to determine the rates and outcomes of NOM in pediatric BSI and compare trends between pediatric (PTC), mixed (MTC) and adult trauma centers (ATC). METHODS: This was a retrospective database analysis of the NTDB data from 2011 to 2015 including pediatric patients with BSI, as described by ICD-9-CM Codes 865.00-865.09. Patients with head injuries with AIS > 2, multiple intraabdominal injuries, and transfers-out were excluded. According to ACS and/or state designation, trauma facilities were defined as PTC (level I/II pediatric only), MTC (level I/II adult and pediatric) and ATC (level I/II adult only). OM group was defined as presence of procedure codes reflecting exploratory laparotomy/laparoscopy and/or any splenic procedures. NOM group consisted of patients who were observed, transfused or had transarterial embolization (TAE). Variables analyzed were age, ISS, spleen AIS, amount and type of blood products transfused, and intensive care unit (ICU) and hospital (H) length of stay (LOS). RESULTS: 5323 children met the inclusion criteria. 11.4% received care at PTC (NOM, 97%), 40.7% at MTC (NOM, 89.9%) and 47.8% at ATC (NOM, 83.8%) (P < 0.001). In NOM group, PTC patients had the highest spleen AIS (3.46 ±â€¯0.95, P < 0.001). TAE was predominantly used at MTC and ATC (P = 0.001). MTC and ATC were more likely to transfuse than PTC (P = 0.002). MTC and ATC OM rates were lower in children aged ≤12 than in children aged >12 (P < 0.001). Splenectomy rate was 1.5% at PTC, 8.4% at MTC, and 14.4% at ATC (P < 0.001). In OM group, PTC patients had a higher ISS (P = 0.018) and spleen AIS (P = 0.048) than both MTC and ATC. The proportion of patients treated by NOM at ATC increased during the 5-year period studied (P = 0.015). Treatment at MTC or ATC increased the risk for OM by 3.89 and 5.36 times respectively (P < 0.001). CONCLUSIONS: PTCs still outperform ATCs in NOM success rates despite higher ISS and splenic injury grades. From 2011 to 2015, ATC OM rates dropped from 17% to 12.4% suggesting increased adoption of the APSA guidelines. Further educational initiatives may help augment this trend. LEVEL OF EVIDENCE: II TYPE OF STUDY: Retrospective.

Predictors and Outcomes of Laparoscopy in Pediatric Trauma Patients: A Retrospective Cohort Study.

Introduction: Laparoscopy has been shown to offer a safe alternative to laparotomy in hemodynamically stable pediatric trauma patients. Our purpose was to identify factors predictive of this approach and examine surgical outcomes. Methods: This is a retrospective cohort study using the ACS Pediatric Trauma Quality Improvement Program to examine pediatric patients who underwent exploration for blunt or penetrating abdominal trauma in 2014 and 2015. Patients with contraindications to laparoscopy were excluded. Multivariable modeling identified predictors of a laparoscopic approach. Secondary analysis assessed differences in outcomes and resource utilization between laparoscopy and laparotomy groups. Results: A total of 160 patients met inclusion criteria. Patients undergoing surgery in the northeastern (odds ratio [OR]: 2.25, 95% confidence interval [CI]: 1.26-4.03, P = .006) and western (OR: 2.03, 95% CI: 1.06-3.88, P = .032) U.S. regions had over two times greater odds of undergoing laparoscopy as those treated in the south. Patients injured by a firearm were significantly less likely to undergo laparoscopy than those suffering blunt injury (OR: 0.27, 95% CI: 0.13-0.55, P < .001). After adjustment, patients explored laparoscopically in comparison with those through laparotomy had decreased average length of stay (LOS) (mean difference [MD]: 2.55 days, 95% CI: 1.19-3.90, P < .001) and number of intensive care unit (ICU) days (MD: 1.13 days, 95% CI: 0.28-1.98, P = .01). Conclusion: Trauma laparoscopy may decrease LOS and ICU days in select pediatric patients requiring abdominal exploration; however, laparoscopy is not uniformly practiced in the United States. Targeted education and protocols for initial use of laparoscopy should be incorporated into hospitals treating this group to minimize morbidity and resource utilization.

Incidence of nonaccidental head trauma in infants: a call to revisit prevention strategies.

OBJECTIVE: Traumatic brain injury is a major sequela of nonaccidental trauma (NAT) that disproportionately affects young children and can have lasting sequelae. Considering the potentially devastating effects, many hospitals develop parent education programs to prevent NAT. Despite these efforts, NAT is still common in Western New York. The authors studied the incidence of NAT following the implementation of the Western New York Shaken Baby Syndrome Education Program in 1998. METHODS: The authors performed a retrospective chart review of children admitted to our pediatric hospital between 1999 and 2016 with ICD-9-CM and ICD-10-CM codes for types of child abuse and intracranial hemorrhage. Data were also provided by the Safe Babies New York program, which tracks NAT in Western New York. Children with a diagnosis of abuse at 0-24 months old were included in the study. Children who suffered a genuine accidental trauma or those with insufficient corroborating evidence to support the NAT diagnosis were excluded. RESULTS: A total of 107 children were included in the study. There was a statistically significant rise in both the incidence of NAT (p = 0.0086) and the incidence rate of NAT (p = 0.0235) during the study period. There was no significant difference in trendlines for annual NAT incidence between sexes (y-intercept p = 0.5270, slope p = 0.5263). When stratified by age and sex, each age group had a distinct and statistically significant incidence of NAT (y-intercept p = 0.0069, slope p = 0.0374). CONCLUSIONS: Despite educational interventions targeted at preventing NAT, there is a significant rise in the trend of newly reported cases of NAT, indicating a great need for better injury prevention programming.

Use of Magnets as a Minimally Invasive Approach for Anastomosis in Esophageal Atresia: Long-Term Outcomes.

Introduction: The majority of esophageal atresia (EA) patients undergo surgical repair soon after birth. However, factors due to patient characteristics, esophageal length, or surgical complications can limit the ability to obtain esophageal continuity. A number of techniques have been described to treat these patients with "long-gap" EA. Magnets are a nonsurgical alternative for esophageal anastomosis. The purpose of this study was to report long-term outcomes for the use of magnets in EA. Materials and Methods: Between July 2001 and December 2017, 13 patients underwent placement of a magnetic catheter-based system under fluoroscopic guidance at six institutions. Daily chest radiographs were obtained until there was union of the magnets. Magnets were then removed and replaced with an oro- or nasogastric tube. Complications and outcomes were recorded. The average length of follow-up was 9.3 years (range 1.42-17.75). Results: A total of 85% of the patients had type A, pure EA, and 15% had type C with previous fistula ligation. The average length of time to achieve anastomosis was 6.3 days (range 3-13). No anastomotic leaks occurred, and all of the patients had an expected esophageal stenosis that required dilation given the 10F coupling surface of the magnets (average 9.8, range 3-22). Six patients (46%) had retrievable esophageal stents, and two underwent surgery; yet all maintained their native esophagus without interposition. A total of 92% were on full oral feeds at the time of follow-up. Conclusion: The use of magnets for treatment of long-gap EA is safe and feasible and accomplished good long-term outcomes. The main complication was esophageal stricture, although all patients maintained their native esophagus. A prospective observational study is currently enrolling patients to evaluate the safety and benefit of a catheter-based magnetic device for EA.

Effects of a surfactant-based gel on acute and chronic paediatric wounds: a panel discussion and case series.

On 20 November 2018, following the International Society for Paediatric Wound Care conference, a closed panel meeting took place in which the use of a surfactant-based gel (PluroGel (PMM), Medline Industries, Illinois, US) in paediatric wound care was discussed. The authors shared their experiences, thoughts, experimental data and clinical results. The panel identified the need for a product that can gently cleanse paediatric wounds and remove devitalised tissue without causing discomfort or skin reactions, as well as potentially promote healing. In adults, PMM has been shown to assist healing by hydrating the wound, controlling exudate and debriding non-viable tissue. Islands of neo-epithelium have also been reported to appear rapidly in different parts of the wound bed. No adverse effects on these proliferating cells have been observed. In vitro data suggest that PMM can remove biofilm, as well as potentially promote healing through cell salvage. The panel, therefore, set out to discuss their experiences of using PMM in the paediatric patients and to establish a consensus on the indications for its use and application in this population. This article will describe the main outcomes of that discussion and present case studies from paediatric patients with a variety of wound types, who were treated with PMM by members of the panel.

Porcine bladder extracellular matrix in paediatric pilonidal wound care: healing and patient experience evaluation.

OBJECTIVE: Pilonidal disease (PD) with inflammation and abscess formation occurs frequently in adolescents. The management of pilonidal disease, time to wound healing, and patient satisfaction, however remains variable despite advances in wound care methods. Porcine bladder extracellular matrix (PBEM) facilitates site-specific tissue deposition/re-growth for the management of a variety of wounds. The aim was to describe the use and outcomes of PBEM in PD at a single centre. METHOD: A retrospective chart review of adolescent patients who underwent treatment of pilonidal disease with PBEM between 2012 and 2016 at a single institution, was undertaken. Patient demographics and clinical characteristics were collected and compared with historical controls and literature regarding traditional wound therapies. RESULTS: We reviewed 52 pilonidal disease wounds on 41 patients. Of these 36 were treated with PBEM. The average age was 16 years old at the time of operation with 39% male. Furthermore, 85% were being treated for recurrent pilonidal disease. Follow-up was available by chart review for 89% of patients with documented complete wound healing in 78% of patients treated with PBEM at an average of two months. Subjective reports included majority positive experience with PBEM dressing, minimal pain and overall high levels of patient satisfaction. There were three patients in which pilonidal disease recurred within two years of initial treatment and underwent repeat treatment with PBEM. There was one patient who transitioned to wet-to-dry saline dressings because of difficulty keeping the PBEM dressing intact. CONCLUSION: Advances in wound care technology include materials such as PBEM to promote site-specific tissue deposition. Follow-up phone calls and a prospective study to compare alternative wound care with porcine PBEM in the management of pilonidal disease is underway to better quantify time to wound healing and patient satisfaction.

Photobiomodulation Therapy for Wound Care: A Potent, Noninvasive, Photoceutical Approach.

GENERAL PURPOSE: To provide background and examine evidence for the therapeutic application of light energy treatments for wound healing. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After completing this continuing education activity, you should be better able to:1. Explain the basics of lasers, light-emitting diodes, and light-tissue interactions as they apply to photobiomodulation therapy.2. Summarize the results of the authors' literature review of the evidence regarding the therapeutic applications of photobiomodulation treatments for wound healing. ABSTRACT: To provide background and examine evidence for the therapeutic applications of light energy treatments for wound healing.A search was performed in PubMed for peer-reviewed scientific articles published in the last 5 years using the search terms "photobiomodulation therapy" and "low-level laser therapy," and these terms combined with "wound," using a "human species" filter. This search yielded 218 articles on photobiomodulation therapy or low-level laser therapy and wounds. Of these, only articles on in vivo wound care using light treatments were specifically included in this review (n = 11).The wound healing effects of low-dose laser treatments were first described over 50 years ago. Various doses ranging from 0.1 to 10 J/cm and wavelengths ranging from 405 to 1,000 nm appear to provide therapeutic benefits for a broad range of chronic wounds. A range of light energy sources from LEDs to lasers have been used and have specific advantages and limitations. There is a lack of consensus on standardized treatment parameters such as wavelengths, dose, and therapeutic outcomes in the reviewed studies, preventing direct comparison and clinical protocol recommendation. An expert opinion based on ongoing research studies and reported literature is offered.Noninvasive, economical, and multipurpose light devices are an attractive tool for wound management. However, there is an urgent need in the wound care community to develop optimal clinical protocols for use based on well-designed, rigorous clinical research studies.

Scaling Up Evidence-Based Public Health Training.

Evidence-based public health (EBPH) is the process of integrating science-based interventions with community preferences. Training in EBPH improves the knowledge and skills of public health practitioners. To reach a wider audience, we conducted scale-up efforts including a train-the-trainer version of the EBPH course to build states' capacity to train additional staff. In this essay, we describe formats for course delivery and local adaptations to content, and we review success factors and barriers for state-based replication of the EBPH training course. Findings were based on our experiences and interviews. EBPH training was delivered in varied blended formats as well as in person and in distance courses, each with advantages and disadvantages. Adaptations were made to meet the needs of learners. Success factors included having committed and competent coordinators and trainers, organizational incentives, leadership support, funding, internal and external collaborators, the infrastructure to support training, and models to learn from. Barriers reported included insufficient staff or trainer capacity; time constraints for organizers, trainers, and participants; and lack of sustained funding. We hope our experience and findings will be a guide for states that are committed to building and sustaining capacity through continued EBPH training. Our lessons may also apply more generally to other workforce development training efforts.