The impact of fatigue on the non-technical skills performance of critical care air ambulance clinicians.

BACKGROUND: The relationship between fatigue-related risk and impaired clinical performance is not entirely clear. Non-technical factors represent an important component of clinical performance and may be sensitive to the effects of fatigue. The hypothesis was that the sum score of overall non-technical performance is degraded by fatigue. METHODS: Nineteen physicians undertook two different simulated air ambulance missions, once when rested, and once when fatigued (randomised crossover design). Trained assessors blinded to participants' fatigue status performed detailed structured assessments based on expected behaviours in four non-technical skills domains: teamwork, situational awareness, task management, and decision making. Participants also provided self-ratings of their performance. The primary endpoint was the sum score of overall non-technical performance. RESULTS: The main finding, the overall non-technical skills performance rating of the clinicians, was better in rested than fatigued states (mean difference with 95% CI, 2.8 [2.2-3.4]). The findings remained consistent across individual non-technical skills domains; also when controlling for an order effect and examining the impact of a number of possible covariates. There was no difference in self-ratings of clinical performance between rested and fatigued states. CONCLUSION: Non-technical performance of critical care air transfer clinicians is degraded when they are fatigued. Fatigued clinicians may fail to recognise the degree to which their performance is compromised. These findings represent risk to clinical care quality and patient safety in the dynamic and isolated environment of air ambulance transfer.

Effect of short-term exercise training on insulin sensitivity in obese and lean mares.

Twelve untrained aged mares were used to determine whether 7 days of light exercise improved peripheral tissue insulin sensitivity. Mares were divided into obese-exercised (n = 3), obese-sedentary (n = 3), lean-exercised (n = 3) and lean-sedentary (n = 3) groups. The exercised groups were worked at a trot to a heart rate (HR) of not more than 140 beats/min for 30 min in a round pen. Each group was subjected to 3 euglycaemic hyperinsulinaemic clamps: prior to exercise (P), 24 h following the seventh exercise training session (E) and 9 days postexercise training (PE). Prior to exercise training, the mares in the obese group were confirmed insulin-resistant compared to the mares in the lean group. There was no change in bodyweight or body condition in the obese or lean groups throughout the study. Glucose infusion rate (GIR) was higher (P<0.05) on E compared to P days in the obese-exercised and lean-exercised groups. Insulin sensitivity returned to pre-exercise values by 9 days postexercise in the obese-exercised and lean-exercised groups. The results of this study suggest that improvement in insulin sensitivity occurs in obese mares without a long interval of exercise training and in the absence of a change in bodyweight.

Potential signals mediating the maintenance of reproductive activity during the non-breeding season of the mare.

The seasonal nature of reproductive activity in mares is widely accepted and considerable attention has focused on the mechanisms that lead to the initiation of the breeding season. In contrast, considerably less information is available about the termination of the breeding season. It is interesting to note that each winter a sub-population of mares continues to undergo oestrous cyclicity during the non-breeding season. Continuation of reproductive activity during the winter occurs most frequently in mares that maintain a non-pregnant condition in successive years. The maintenance of a non-pregnant condition in successive years leads to an increase in the percentage of total body fat and it has been proposed that the degree of adiposity may be a determinant of reproductive activity during the winter months. To investigate this hypothesis we have manipulated fat stores by either pharmacological treatments or feed restriction. The studies described in this review demonstrate that manipulation of body fat during the autumn months fails to modify the mechanisms that lead to anoestrus or the proportion of mares that continues to show oestrous cyclicity during the winter months. On the basis of these and related studies two hypotheses are presented that may serve as a template for future work. The first hypothesis proposes that one aspect of the long-term regulation of seasonal reproductive rhythms in mares, specifically anoestrus, may reflect recognition of the availability of metabolic fuels before perception of a change in photoperiod. Alternatively, energy availability may need to reach a critical value before a presumptive inhibitory daylength signal initiates termination of the breeding season. This review describes previous and current studies that have led to development of these proposals.

Recovery from deep-plane rhytidectomy following unilateral wound treatment with autologous platelet gel: a pilot study.

OBJECTIVE: To determine the effects of treatment with autologous platelet-rich plasma mixed with thrombin and calcium chloride to form an autologous platelet gel (APG) on postoperative recovery from deep-plane rhytidectomy. STUDY DESIGN: A prospective, randomized, controlled pilot study. SETTING: An accredited ambulatory facial plastic surgery center. PATIENTS: Healthy volunteer women (N = 8) undergoing rhytidectomy. INTERVENTION: Unilateral autologous platelet-rich plasma wound treatment during standard deep-plane rhytidectomy. MAIN OUTCOME MEASURES: Staged postoperative facial photographs were graded in a blinded fashion by 3 facial plastic surgeon reviewers for postoperative ecchymosis and edema. Each facial side treated with APG that demonstrated less edema or ecchymosis than the non-APG-treated side was designated a positive response; otherwise, the response was equal (no difference) or negative (untreated side had less edema or ecchymosis). RESULTS: Twenty-one positive and 21 equal responses were observed compared with 8 negative ones. Of 20 unanimous observations, 15 were positive, only 3 equal, and 1 negative. CONCLUSIONS: Treatment with APG may prevent or improve edema or ecchymosis after deep-plane rhytidectomy. This trend is more apparent for ecchymosis than for edema, and is chiefly demonstrable in the early phases of recovery. These observations are consistent with previous reports of cell tissue culture and wound response to concentrated platelet product.

The use of a bioactive skin substitute decreases length of stay for pediatric burn patients.

BACKGROUND: To optimize burn care for children, the authors introduced a protocol incorporating the use of a bioactive skin substitute, TransCyte (Advanced Tissue Sciences, La Jolla, CA). This study was designed to determine whether this management plan was safe, efficacious, and decreased hospital inpatient length of stay (LOS) compared with conventional burn management in children. METHODS: All pediatric burns greater than 7% total body surface area (TBSA) that occurred after October 1999 underwent wound closure with TransCyte (n = 20). These cases were compared with the previous 20 consecutive burn cases greater than 7% TBSA that received standard therapy. Standard therapy consisted of application of antimicrobial ointments and hydrodebridement. The following information was obtained: burn mechanism, age, size of burn, requirement of autograft, and LOS. Data were analyzed using the student's t test. RESULTS: Data for age, percent TBSA burn and LOS are reported as means +/- SEM. The children who received standard therapy were 2.99 +/- 0.7 years compared with those receiving TransCyte were 3.1 +/- 0.8 years. There was no difference between the treatment groups with regard to percent TBSA burn: standard therapy, 14.3 +/- 1.4% TBSA versus TransCyte, 12.7 +/- 1.3% TBSA. There was no difference in the type of burns in each group, the majority were liquid scald type, 70% in the standard therapy group versus 90% in the TransCyte group. Only 1 child in the TransCyte group required autografting (5%) compared with 7 children in the standard therapy group (35%). Children treated with TransCyte had a statistically 6 significant decreaed LOS compared with those receiving standard therapy, 5.9 +/- 0.9 days versus 13.8 +/- 2.2 days, respectively (P =.002). CONCLUSIONS: This is the first study using TransCyte in children. The authors found that this protocol of burn care was safe, effective, and significantly reduced the LOS. This new approach to pediatric burn care is effective and improves the quality of care for children with burns.

Bedside tracheostomy in the intensive care unit: a prospective randomized trial comparing open surgical tracheostomy with endoscopically guided percutaneous dilational tracheotomy.

OBJECTIVES: Objectives of the study were 1) to analyze the complication incidence and resource utilization of two methods of bedside tracheostomy and 2) to define selection criteria for bedside tracheostomy. STUDY DESIGN: Prospective randomized trial in the setting of a tertiary care center at a university hospital. METHODS: One hundred sixty-four consecutive intubated patients selected for elective tracheostomy were enrolled. One hundred patients met selection criteria for bedside tracheostomy and were randomly assigned to either open surgical tracheostomy (50) or endoscopically guided percutaneous dilational tracheotomy(50). The remaining 64 patients received open surgical tracheostomies in the operating room. Main outcome measures were 1) perioperative and postoperative complication incidence and 2) resource utilization. RESULTS: Patients meeting our selection criteria for bedside tracheostomy had a significantly reduced perioperative complication rate compared with those who failed to meet these criteria, and subsequently underwent tracheostomy placement in the operating room (5% vs. 20%, P less than or equal to.01). No statistically significant difference was found in the perioperative complication incidence between the two methods of bedside tracheostomy. However, percutaneous tracheostomy placement at the bedside resulted in a significant increase in postoperative complication incidence (16% vs. 2%, P <.05) and incurred an additional patient charge of $436 per bedside procedure. CONCLUSIONS: This investigation prospectively confirms the safety of bedside tracheostomy placement in properly selected patients. Complication incidence and resource utilization are defined for two methods of bedside tracheostomy. The results of this study confirm that open surgical tracheostomy represents the standard of care in bedside tracheostomy placement by providing a more secure airway at a markedly reduced patient charge. These findings will aid in the development of protocols and pathways for surgical airway management in critically ill patients to maximize cost-effective, high-quality care.

Quantification of the learning curve for percutaneous dilatational tracheotomy.

OBJECTIVES/HYPOTHESIS: Although numerous investigators have reported a bedside percutaneous dilatational tracheotomy (PDT) complication incidence similar to that of standard operative tracheostomy, others have proposed a "learning curve" for PDT resulting in increased complications early in individual or institutional experience with this procedure. The objective of this investigation is to characterize and quantify the proposed learning curve for PDT. STUDY DESIGN: Prospective analysis of complication incidence for the first 100 PDT procedures performed in a local community hospital Department of General Surgery. METHODS: Demographic data, patient disease variables, and patient anatomic features, as well as perioperative, postoperative, and late complications, were recorded prospectively. Patients were divided into sequential cohorts of 20 and were evaluated for complications at regular intervals. RESULTS: Perioperative and late complication incidence was significantly higher in the first 20 patients who underwent PDT. However, postoperative complication incidence did not significantly vary with operator or institutional experience. In addition, patients with suboptimal anatomy were found to have a significantly increased complication incidence, independent of operator and institutional experience. CONCLUSIONS: Percutaneous dilational tracheotomy has an identifiable learning curve that is most prominent in the first 20 patients treated. Early experience with PDT should be obtained under controlled circumstances, ideally the operating suite. Although most complications occur during acquisition of early experience with PDT, certain life-threatening complications such as tube dislodgment or inability to complete procedure may occur even after extensive experience is obtained. Bedside PDT has an acceptable complication incidence, but any surgeon employing this technique must be prepared to perform immediate standard open tracheotomy to minimize potentially lethal complications of this elective procedure.

Thoughts on the source of tissue on subsequent cell culture success.

This paper describes attempts to initiate equine adipocyte cultures from necropsy cases with varying intervals from time of death to isolation and culture. Equine adipocytes were isolated from 21 necropsy cases, regardless of the interval from time after death to establishment in primary ceiling cultures. However, while all cultures produced adipocytes, only 2 attempts to produce long-term equine adipocyte cultures from the subcutaneous rump fat depots were successful and not contaminated. Findings from these experiments indicate that it is possible to collect and culture equine adipocytes from necropsy cases with varying intervals of time of death to culturing provided that the issue of contamination is addressed. Viable cells were produced from tissue with an interval of 38.5 hours as well as 45 minutes. This result encourages the continuation of research using equine necropsy cases as a source of adipose tissue.

Paradoxical vocal cord dysfunction in juveniles.

OBJECTIVE: To evaluate demographic and videolaryngoscopic features in a large series of juveniles with paradoxical vocal cord dysfunction (PVCD). DESIGN: Case series data from videolaryngoscopic tapes retrospectively evaluated in a masked, controlled fashion, and demographic data collected via retrospective medical chart review. SETTING: A tertiary care otolaryngology and speech pathology referral center. PATIENTS: Twenty-two patients with PVCD aged 18 years and younger diagnosed as having PVCD at The Ohio State University Voice Institute, Columbus. MAIN OUTCOME MEASURES: Age, sex, social history, and medical history (demographic); epiglottic position, arytenoid and interarytenoid appearance, phase 0 stability, true vocal cord respiratory motion, degree of anteroposterior (AP) constriction, and false vocal cord adduction (videolaryngoscopic). RESULTS: Of 22 patients, 18 were girls, and 12 had significant social stressors, particularly organized sports. Nineteen patients had posterior laryngeal changes commonly found in gastroesophageal reflux disease. Twelve patients demonstrated abnormal true vocal cord adduction during quiet respiration. Seven patients demonstrated supraglottic anteroposterior constriction and false vocal cord approximation during phonation. CONCLUSIONS: Juvenile PVCD is more common in girls and is associatedwith social stresses. Anatomic laryngeal changes typically associated with gastroesophageal reflux disease are extremely common in these patients. Juveniles with PVCD frequently demonstrate abnormal true vocal cord adduction during quiet respiration. We recommend that initial evaluation of juvenile patients for possible PVCD be conducted via transnasal fiberoptic laryngoscopy while the patient is asymptomatic, and that strong consideration be given to empiric pharmacological treatment of gastroesophageal reflux disease in juveniles diagnosed as having PVCD.

Effect of short-term feed restriction and calorie source on hormonal and metabolic responses in geldings receiving a small meal.

The metabolic effects of short-term feed restriction and dietary calorie source were studied in horses receiving high-roughage or high-concentrate diets. Four Thoroughbred geldings were assigned to four treatment groups in a 4 x 4 Latin square experiment. The four treatments were 1) a nutritionally adequate high-roughage ration (70% roughage, 30% concentrate; AHR), 2) a nutritionally adequate high-concentrate ration (40% roughage, 60% concentrate; AHC), 3) 70% of the intake of the AHR diet (RHR), and 4) 70% of the intake of the AHC diet (RHC). Diets AHR and AHC were designed to meet the caloric need of horses undergoing moderately intense work. Blood samples were taken on the first 7 d of each period for analysis of serum T4 and T3 concentrations. On d 9 of each feeding period, each horse was fed 1.0 kg of oats as the morning meal. Jugular blood was sampled before and immediately after, as well as at 30 min after, completion of the meal and subsequently every hour for 7 h. Daily serum T4 and T3 concentrations were not affected by day, feeding level, or diet composition. Meal feeding produced an increase (P < 0.01) in T4 and T3 concentrations when horses were adapted to the AHR and AHC diets but not the RHR or RHC diets. Thyroxine concentrations were lowest (P < 0.05) when horses were adapted to the AHC diet. Glucose (P < 0.05), insulin (P < 0.01), and NEFA (P < 0.01) concentrations were higher in response to the meal when horses received RHR than for the other diets. These results indicate that nutrient restriction alters responses to meal feeding in horses and that this response may also be affected by the dietary roughage:concentrate ratio.

Primary laparoscopic-assisted endorectal colon pull-through for Hirschsprung's disease: a new gold standard.

OBJECTIVE: To describe the surgical technique and early clinical results after a one-stage laparoscopic-assisted endorectal colon pull-through for Hirschsprung's disease. SUMMARY BACKGROUND DATA: Recent trends in surgery for Hirschsprung's disease have been toward earlier repair and fewer surgical stages. A one-stage pull-through for Hirschsprung's disease avoids the additional anesthesia, surgery, and complications of a colostomy. A laparoscopic-assisted approach diminishes surgical trauma to the peritoneal cavity. METHODS: The technique uses four small abdominal ports. The transition zone is initially identified by seromuscular biopsies obtained laparoscopically. A colon pedicle preserving the marginal artery is fashioned endoscopically. The rectal mobilization is performed transanally using an endorectal sleeve technique. The anastomosis is performed transanally 1 cm above the dentate line. This report discusses the outcome of primary laparoscopic pull-through in 80 patients performed at six pediatric surgery centers over the past 5 years. RESULTS: The age at surgery ranged from 3 days to 96 months. The average length of the surgical procedure was 2.5 hours. Almost all of the patients passed stool and flatus within 24 hours of surgery. The average time for discharge after surgery was 3.7 days. All 80 patients are currently alive and well. Most of the children are too young to evaluate for fecal continence, but 18 of the older children have been reported to be continent. CONCLUSION: Laparoscopic-assisted colon pull-through appears to reduce perioperative complications and postoperative recovery time dramatically. The technique is quickly learned and has been performed in multiple centers with consistently good results.

The effect of dietary fibre on hydration status after dehydration with frusemide.

Three diets were fed to 6 horses in a 3 x 6 Latin rectangle experiment to determine if dietary fibre could improve hydration status in response to dehydration with frusemide. Frusemide was used to simulate dehydration from exercise-induced sweat loss. Diets contained similar dry matter (DM), energy, protein and electrolyte content, but differed in total dietary fibre (TDF) and/or soluble fibre (SDF). The 3 diets were: 1) HIGH-HIGH (high TDF, high SDF); 2) HIGH-LOW (high TDF, low SDF); and 3) LOW-LOW (low TDF, low SDF). In each 10 day period, water intake and faecal moisture content were assessed on Day 7. On Day 10, feed and water were withheld and horses were dehydrated with frusemide (1 mg/kg bwt, i.m.). Plasma volume (PV), plasma total protein (TP), packed cell volume (PCV) and plasma electrolyte concentrations were determined before and after frusemide administration. Water consumption was greater (P < 0.05) when horses received diets high in TDF. Faecal moisture content was greatest (P < 0.01) when horses received the HIGH-HIGH diet. The decline in PV and the rise in plasma TP concentration following frusemide administration were similar for all diets. When horses received the HIGH-HIGH diet, they had a greater (P < 0.05) bodyweight before dehydration and lost more (P < 0.05) bodyweight in response to frusemide. A greater loss of bodyweight in response to frusemide without a proportional loss of PV when horses received the HIGH-HIGH diet suggests that a diet high in SDF may provide the horse with a source of dispensable water in the hind gut during dehydration.

Preliminary evaluation of porcine zona pellucida (PZP) immunocontraception for behavioral effects in feral horses (Equus caballus).

Successful management of captive populations of wild animals requires effective control of reproduction. Contraception is one tool for controlling reproduction of animals in zoos; however, the options available to the animal manager are limited. Contraceptives vary in efficacy, reversibility, and side effects, and thus may not be suitable for widespread use. One consideration when selecting a contraceptive is its potential for side effects on behavior, especially given the fact that reproduction plays such a prominent role in the biology of any species. To date, there have been few evaluations of contraceptives for behavioral effects, and those that have been conducted have focused on hormone-based contraceptives. This study sought to evaluate a novel method of population control, immunocontraception, for behavioral effects in a population of feral horses. Porcine zona pellucida (PZP) immunocontraception prevents fertilization of ova and does not alter normal hormone secretion patterns. It therefore should leave the animal behaviorally intact in terms of reproductive behavior. The study examined the behavior of 43 sexually mature mares on Assateague Island during the 1997 breeding season and, with help from Earthwatch volunteers, collected observations over a 3-month period. The study found no significant differences between treated and untreated mares in general activity budget, aggression given or received, and spatial relationships relative to the stallion. These preliminary findings indicate that PZP contraception seems to have no acute behavioral effects on the behavior of individuals. The study findings also suggest that PZP could be a desirable and effective management tool for captive species in which social behavior plays an integral role in group dynamics. Analyses of group level effects and population level effects are continuing.

Review of percutaneous tracheostomy.

The purpose of this study is to assess the safety and efficacy of the four known methods of percutaneous tracheostomy. Perioperative, postoperative, and late complication rates were generated for each method after a complete literature review identified 1684 percutaneous tracheostomy patients reported in 40 series. Two methods, the Toye and the guide wire dilator forceps (GWDF) methods, have been the subject of few investigations. Two other methods have been extensively studied. A high perioperative complication rate was calculated for the Rapitrac method, whereas percutaneous dilational tracheostomy (PDT) has complication rates similar to those reported for standard operative tracheostomy. A retrospective review of 22 patients who underwent PDT at a local community hospital confirmed a "learning curve" for this technique that had been previously suggested. Review of the literature suggests that PDT can be safe and cost-effective for selected patients, but a learning curve for this technique exists that dictates caution, experience, and preparation on the part of any surgeon who wishes to add percutaneous tracheostomy to his or her repertoire.

Characteristics of the myocardial PM-FABP: effect of diabetes mellitus.

Properties of the myocardial PM-FABP were studied in normal and STZ-diabetic rats. The fluorescent fatty acids trans-parinaric and cis-parinaric acids were used as analogs of straight-chain (saturated) and kinked-chain (unsaturated) fatty acids respectively. Parinaric acid binding was sensitive to trypsin. Trans-parinaric acid binding was more sensitive to this protease than the binding of cis-parinaric acid. Based on the difference in sensitivity of parinaric acid binding we believe that there are two separate binding sites associated with myocardial PM-FABP; one for unsaturated fats and the other for saturated fats. Diabetes enhanced both cis- and trans-parinaric acid binding capacity in cardiomyocytes; cis-parinaric acid by 2 fold and trans-parinaric acid by 2.6 fold. In addition, there was a concomitant accumulation of free fatty acids and triglycerides in the hearts of the diabetic animals. There was a 2.2 fold increase for fatty acids and a 1.6 fold increase for trigylcerides. This association between myocardial fatty acid build-up and enhanced myocardial PM-FABP during diabetes suggest that this carrier protein might have contributed to lipid accumulation in the hearts of the diabetic rats.

The management of choledocholithiasis in children in the era of laparoscopic cholecystectomy.

Although laparoscopic cholecystectomy has become the procedure of choice for gallbladder removal in children, the treatment of children who have choledocholithiasis remains unclear. For adults who have suspected choledocholithiasis, preoperative endoscopic retrograde cholangiopancreatography (ERCP) is a well-described and effective approach, however, its use for common bile duct stones in children has not been defined. The authors reviewed the records of 131 consecutive children undergoing laparoscopic cholecystectomy on two surgical services to define the efficacy of ERCP followed by laparoscopic cholecystectomy in managing choledocholithiasis in children. Fourteen children were suspected of having common duct stones noted on preoperative ultrasound scan and laboratory data. At ERCP, six children had no stones visualized; eight had stones and underwent stone extraction and sphincter dilation or sphincterotomy. All 14 underwent laparoscopic cholecystectomy a mean of 3.8 days after ERCP. None of the 14 had evidence of retained stones. Only one of 117 children undergoing primary laparoscopic cholecystectomy had unsuspected common bile duct stones and was treated with laparoscopic common bile duct exploration and stone removal. A management plan incorporating ERCP followed by early laparoscopic cholecystectomy is a safe and effective strategy for children who have choledocholithiasis.

HIV Rev-dependent binding of SF2/ASF to the Rev response element: possible role in Rev-mediated inhibition of HIV RNA splicing.

Production of the structural and enzymatic proteins of type 1 human immunodeficiency virus (HIV-1) is controlled by the rev regulatory gene product. The 116-amino acid Rev protein acts by binding to the Rev response element (RRE), a complex RNA stem-loop structure located within the env gene of HIV. Rev exerts a series of posttranscriptional effects, including the inhibition of viral RNA splicing, the activation of nuclear export of incompletely spliced viral RNAs, and the enhancement of translation of RRE-containing RNAs. Our studies now demonstrate that at least one member of the SR family of splicing factors, SF2/ASF, specifically binds to a subregion of the RRE in vitro in a Rev-dependent manner. Furthermore, expression of high levels of SF2/ASF inhibits Rev function and impairs HIV replication in vivo. Both the in vitro binding of SF2/ASF to the Rev/RRE complex and the in vivo inhibition of Rev action by SF2/ASF are abrogated by mutation of the N-terminal RNA recognition motif but are not affected by mutation of the C-terminal arginine-serine-rich domain. These findings suggest that Rev inhibition of HIV splicing likely involves recruitment of the essential splicing factor SF2/ASF to the Rev/RRE complex. However, these inhibitory effects of Rev on viral RNA splicing are apparently overcome by augmenting the intracellular levels of SF2/ASF expression.

Optimizing outcomes in ventilator-dependent patients: challenging critical care practice.

This article examines the structure and process of a collaborative practice team established specifically to improve the quality and financial outcomes of ventilator-dependent patients in a tertiary care teaching hospital. A brief overview of descriptors regarding ventilator-dependent patients is synthesized from the literature and compared with the population at St. Luke's Episcopal Hospital in Houston, Tex. An analysis of statistically significant physiologic variances that have been found to increase mechanical ventilation time or length of stay is detailed. Focused quality initiatives are discussed. Specific criteria indicative of improved outcomes are presented along with recommendations for future improvements.

Video-assisted thoracic surgery (VATS) for children with pulmonary metastases from osteosarcoma.

BACKGROUND: Video-assisted thoracic surgery (VATS) may complement open thoracotomy in children with osteosarcoma requiring pulmonary metastasectomy. METHODS: The records of children with metastatic pulmonary osteosarcoma considered for initial VATS intervention (n = 9) were reviewed. RESULTS: Two children did not have VATS exploration: one child with multiple bilateral nodules and another child with a deep parenchymal nodule. VATS provided diagnostic biopsy material in all cases when used (n = 7). Two children had benign inflammatory lesions; four children had VATS-directed wedge resections of solitary malignant lesions; and one child had VATS biopsy of diffuse parenchymal and pleural pulmonary disease not amenable to resection. The mean operative time and hospital length of stay were 1.78 +/- 0.54 h and 3.5 +/- 1.8 days, respectively. There were two complications of VATS: bleeding in a child, requiring a transfusion, and a latent pneumothorax in a patient after removal of the chest tube. CONCLUSION: VATS is safe, serves as an excellent diagnostic modality, complements the open thoracotomy, and may enable the surgeon to avoid more extensive procedures in selected cases.