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Background: Although previous studies have reported good short-term results for superficial medial collateral ligament (sMCL) reconstruction, whether an augmented MCL repair is clinically equivalent remains unclear. Purpose/Hypothesis: The purpose of this study was to compare clinical outcomes between randomized groups that underwent sMCL augmentation repair and sMCL autograft reconstruction. The hypothesis was that there would be no significant differences in objective or subjective outcomes between groups. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients were prospectively enrolled between 2013 and 2019 from 3 centers. Grade III sMCL injuries were confirmed via stress radiography. Patients were randomized to anatomic sMCL reconstruction versus augmented repair with surgical treatment, determined after examination under anesthesia confirmed sMCL incompetence. Postoperative visits occurred at 6 weeks and 6 months for repeat evaluation, with repeat stress radiography at final follow-up. Patient-reported outcome measures were obtained pre- and postoperatively at 6 months, 1 year, and final follow-up. The primary outcome measure was side-to-side difference on valgus stress radiographs at a minimum follow-up of 1 year. The two 1-sided t test procedure was used to test clinical equivalence for side-to-side difference in valgus gapping, and the Mann-Whitney U test was used to compare postoperative patient-reported outcome measures between groups. Results: A total of 54 patients were prospectively enrolled into this study. Of these, 50 patients had 6-month stress radiograph data, while 40 had 1-year postoperative valgus stress radiograph data. The mean (SD) patient age was 38.0 years (14.2), and body mass index was 25.0 (3.6). Preoperative valgus stress radiographs demonstrated 3.74 mm (1.1 mm) of increased side-to-side gapping overall, while it was 4.10 mm (1.46 mm) in the MCL augmentation group and 3.42 mm (0.55 mm) in the MCL reconstruction group. Postoperative valgus stress radiographs at an average of 6 months were obtained in 50 patients after surgery, which showed 0.21 mm (0.81 mm) for the MCL augmentation group and 0.19 mm (0.67 mm) for the MCL reconstruction group ( P = .940). At final follow-up (minimum 1 year), median (interquartile range) Lysholm scores were significantly higher in the reconstruction group (90 [83-99]) as compared with the repair group (80 [67-92]) ( P = .031). Final International Knee Documentation Committee (IKDC) scores were also significantly higher for the reconstruction group (85 [68-89]) versus the repair group (72 [60-78] ( P = .039). Postoperative Tegner scores were not significantly different between the repair group (5 [3.5-6]) and the reconstruction group (5.5 [4-7]) ( P = .123). Patient satisfaction was also not significantly different between repair (7.5 [5.75-9.25]) and reconstruction groups (9.0 [7-10]) ( P = .184). Conclusion: This study found no difference in objective outcomes between an sMCL augmentation repair and a complete sMCL reconstruction at 1 year postoperatively, indicating equivalence between these procedures. Patient-reported clinical outcomes favored the reconstruction over a repair. In addition, this study demonstrated that anatomic-based treatment of MCL tears with an early knee motion program had a very low risk of graft attenuation and a low risk of arthrofibrosis.

Together, heart failure and arrhythmia represent the most important cardiovascular sources of morbidity and mortality among adults with congenital heart disease (ACHDs). Although traditionally conceptualized as operating within 2 distinct clinical silos, these scenarios frequently coexist within the same individual; consequently the mechanistic, therapeutic, and prognostic overlap between them demands increased recognition. In fact, given the near ubiquity of heart failure and arrhythmia among ACHDs, there is perhaps no other arena within cardiology where this critical intersection is more frequently observed. Optimal care for ACHDs therefore requires a heightened awareness of the relevant interactions as well as the pharmacologic and interventional resources that are increasingly available to the treating cardiologist. This review explores and highlights the overlap between these 2 fields to recommend a parallel, yet interactive, multidisciplinary approach to clinical management. Congenital heart disease categories are broken down into their archetypal subtypes to highlight subtleties of the pathophysiology, evaluation, and therapeutic approach.

The purpose of this review is to explore the historical and serendipitous events that led to the creation of modern-day pacemakers. In addition, this review will explore how contemporary conduction site-specific pacing has overcome some of the deleterious effects from historical chronic right ventricular apical pacing.Recently, there have been tremendous advances in not just the lead design but the tools required to promote more physiologic pacing. Although cardiac resynchronization pacing has been around for nearly 2 decades, this review also introduces and discusses the early results of His-bundle pacing and left bundle branch pacing and some of the potential applicability of this technology for our children.Pacemakers have evolved significantly in the last 30 years through collaborative partnerships between physicians and engineers. The future of cardiac pacing is bright compared to the field of electrotherapy 50 years ago. Future iterations of pacemakers must consider unusual anatomy and growing children. Pediatric patients contribute to a small percentage of the overall device volume, but the majority of these patients will have a pacemaker for life. We need to be proactive and consider what are the best short and long-term solutions for this cohort.

Purpose:Head and neck squamous cell carcinoma (HNSCC) is a frequently devastating cancer that affects more than a half million people annually worldwide. Although some cases arise from infection with human papillomavirus (HPV), HPV-negative HNSCC is more common, and associated with worse outcome. Advanced HPV-negative HNSCC may be treated with surgery, chemoradiation, targeted therapy, or immune checkpoint inhibition (ICI). There is considerable need for predictive biomarkers for these treatments. Defects in DNA repair capacity and loss of cell-cycle checkpoints sensitize tumors to cytotoxic therapies, and can contribute to phenotypes such as elevated tumor mutation burden (TMB), associated with response to ICI. Mutation of the tumor suppressors and checkpoint mediators TP53 and CDKN2A is common in HPV-negative HNSCC.Experimental Design:To gain insight into the relation of the interaction of TP53 and CDKN2A mutations with TMB in HNSCC, we have analyzed genomic data from 1,669 HPV-negative HNSCC tumors with multiple criteria proposed for assessing the damaging effect of TP53 mutations.Results:Data analysis established the TP53 and CDKN2A mutation profiles in specific anatomic subsites and suggested that specific categories of TP53 mutations are more likely to associate with CDKN2A mutation or high TMB based on tumor subsite. Intriguingly, the pattern of hotspot mutations in TP53 differed depending on the presence or absence of a cooccurring CDKN2A mutation.Conclusions:These data emphasize the role of tumor subsite in evaluation of mutational profiles in HNSCC, and link defects in TP53 and CDKN2A to elevated TMB levels in some tumor subgroups.

Background:The Pediatric and Congenital Electrophysiology Society (PACES) is a global organisation committed to the care of children and adults with CHD and arrhythmias.Objective:To evaluate the global needs and potential inequities as it relates to cardiac implantable electronic devices.Methods:ARROW (Assessment of Rhythm Resources arOund the World) is an online survey about cardiac implantable electronic devices, sent electronically to physicians within the field of Cardiology, Pediatric Cardiology, Electrophysiology and Pediatric Electrophysiology.Results:ARROW received 42 responders from 28 countries, 50% from low-/middle-income regions. The main differences between low-/middle- and high-income regions include availability of expertise on paediatric electrophysiology (50% versus 93%, p < 00.5) and possibility to perform invasive procedures (35% versus 93%, p < 0.005). Implant of devices in low-income areas relies significantly on patient’s resources (71%). The follow-up of the devices is on the hands of paediatric cardiologist/electrophysiologist in higher resources centres (93% versus 50%, p < 0.05).Conclusions:The ARROW survey represents an initial assessment of the geographical characteristics in the field of Pediatric Electrophysiology. The next step is to make this “state of the art” more extensive to other aspects of the expertise. The relevance of collecting this data before the World Congress of Pediatric Cardiology and Cardiac Surgery (WCPCCS) in 2023 in Washington DC was emphasised in order to share the resulting information with the international community and set a plan of action to assist the development of arrhythmia services for children within developing regions of the world.

Loss of expression or activity of the tumor suppressor PTEN acts similarly to an activating mutation in the oncogene PIK3CA in elevating intracellular levels of phosphatidylinositol (3,4,5)-trisphosphate (PIP3), inducing signaling by AKT and other pro-tumorigenic signaling proteins. Here, we analyze sequence data for 34,129 colorectal cancer (CRC) patients, capturing 3,434 PTEN mutations. We identify specific patterns of PTEN mutation associated with microsatellite stability/instability (MSS/MSI), tumor mutational burden (TMB), patient age, and tumor location. Within groups separated by MSS/MSI status, this identifies distinct profiles of nucleotide hotspots, and suggests differing profiles of protein-damaging effects of mutations. Moreover, discrete categories of PTEN mutations display non-identical patterns of co-occurrence with mutations in other genes important in CRC pathogenesis, including KRAS, APC, TP53, and PIK3CA. These data provide context for clinical targeting of proteins upstream and downstream of PTEN in distinct CRC cohorts.

To assess the most common presenting symptoms, clinical outcomes, and satisfaction after anatomic reconstruction of the proximal tibiofibular joint (PTFJ) with a free semitendinosus autograft.Consecutive patients with minimum 2-year follow-up after isolated anatomic PTFJ reconstruction were retrospectively reviewed. Patients were evaluated with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and Lysholm Knee Survey score along with a simple numeric patient satisfaction score (0-10, with 10 rated as perfect). Statistical analysis was performed with paired t tests, with P.05 considered significant.The study included 16 PTFJ reconstruction surgical procedures in 15 patients with isolated proximal tibiofibular instability verified by an examination under anesthesia (4 reconstructions in male patients vs 12 in female patients); the average age was 37.9 ± 14.6 years, with an average follow-up period of 43.2 months (range, 22-72 months). Of the 13 patients with complete follow-up, 11 (84.6%) were able to return to full desired activities and previous level of sport. Fourteen patients presented with concomitant common peroneal nerve pathology. Two patients had a subsequent complication. No patients needed an additional procedure. Significant (P.05) improvement occurred across all WOMAC domains and in the WOMAC total score, from 31.4 (±14.9) preoperatively to 15.2 (±15.5) postoperatively. Lysholm Knee Survey scores significantly (P.05) improved from 51.2 (±17.2) to 75.0 (±18.0). Patients' overall satisfaction was rated 7.6 (± 2.7) of 10.At an average follow-up of 43.2 months, anatomic PTFJ reconstruction for isolated PTFJ instability provided improvement in clinical outcomes, a return to activities, and a low risk of complications or need for additional procedures.PTFJ reconstruction with hamstring tendon graft is a promising surgical treatment that improves patient satisfaction when conservative treatment of PTFJ instability fails.Level IV, case series.

Background: Impaction fractures of the posterolateral tibial plateau commonly occur in the setting of anterior cruciate ligament (ACL) tears, with considerable variability found in fracture size and morphologic features. Purpose: The primary objective was to characterize different morphologic variants of posterolateral tibial plateau impaction fractures. The secondary objective was to investigate the association between these impaction fracture variants and concomitant meniscal and ligamentous injuries. Study Design: Cross-sectional study; Level of evidence 3. Methods: Patients treated for primary ACL tears and having magnetic resonance imaging available were included in this study, and magnetic resonance images were reviewed with denotation of displaced posterolateral tibial impaction fractures. A classification system was created based on morphologic variants of impaction fractures; associations were evaluated through use of independent chi-square testing. Results: There were 825 knees meeting the inclusion criteria, with displaced posterolateral tibial plateau impaction fractures present in 407 knees (49.3%). We observed 3 distinct morphologic variants of lateral tibial plateau impaction fractures: (I) posterior cortical buckle not involving the articular surface; (II) posterior impaction fracture involving the articular surface, with subtypes based on (A) tibial plateau depth bone loss 10%; and (III) displaced osteochondral fragment, with subtypes for (A) shear or (B) depressed fragment. Type IIIA impaction fractures were associated with an increased incidence of lateral meniscus posterior root tears (33.3% vs 12.4%; P = .009) and an increased incidence of lateral meniscal tears (83.3% vs 56.7%; P = .024) compared with all knees without type IIIA impaction fracture. An increased incidence of medial collateral ligament (MCL) tears was noted in patients with type IIIA impaction fractures compared with those who had no fracture or had another fracture type (61.1% vs 20.1%; P < .001). Type IIIB impaction fractures were associated with an increased incidence of lateral meniscal tears (80.0% vs 56.2%; P = .005). Conclusion: A high prevalence of displaced posterolateral tibial plateau impaction fractures occur in the setting of ACL tears, and they can be classified into distinct morphologic subtypes. Posterolateral tibial plateau impaction fractures with displaced depressed or shear fragments were both associated with an increased incidence of lateral meniscal tears, whereas impaction fractures with a shear fragment were associated with an increased incidence of lateral meniscus posterior root tears and MCL tears.

Meniscus root tears biomechanically disrupt normal joint loading and lead to joint overload with the possible development of spontaneous osteonecrosis of the knee and early-onset osteoarthritis. Proper identification and treatment of meniscal root tears has been proven to restore joint loading and improve patient outcomes.

PURPOSE OF REVIEW Review the current state of the art of arrhythmogenic right ventricular cardiomyopathy (ARVC) diagnosis and risk stratification in the pediatric population. RECENT FINDINGS ARVC is an inherited cardiomyopathy characterized by progressive myocyte loss and fibrofatty replacement of predominantly the right ventricle and high risk of ventricular arrhythmias and sudden cardiac death (SCD). ARVC is one of the leading causes of arrhythmic cardiac arrest in young people. Early diagnosis and accurate risk assessment are challenging, especially in children who often exhibit little to no phenotype, even if genotype positive. Multimodal imaging provides more detailed assessment of the right ventricle and has been shown in pediatric patients to identify earlier preclinical disease expression. Identification of patients with ARVC allows the clinician to intervene early with appropriate exercise restrictions, even if genotype positive only without phenotypic expression. Emphasis should be placed on stratifying the patient's risk of ventricular arrhythmias and SCD. SUMMARY ARVC is a challenging diagnosis to make in adolescents who often do not exhibit clinical symptoms. Newer multimodal imaging techniques and improvements in genetic testing and biomarkers should help improve early diagnosis. Exercise restriction for children with ARVC has been shown to reduce disease advancement and decreases the risk of a life-threatening event.

Background In a closed claims study, most patients experiencing cervical spinal cord injury had stable cervical spines. This raises two questions. First, in the presence of an intact (stable) cervical spine, are there tracheal intubation conditions in which cervical intervertebral motions exceed physiologically normal maximum values? Second, with an intact spine, are there tracheal intubation conditions in which potentially injurious cervical cord strains can occur? Methods This study utilized a computational model of the cervical spine and cord to predict intervertebral motions (rotation, translation) and cord strains (stretch, compression). Routine (Macintosh) intubation force conditions were defined by a specific application location (mid-C3 vertebral body), magnitude (48.8 N), and direction (70 degrees). A total of 48 intubation conditions were modeled: all combinations of 4 force locations (cephalad and caudad of routine), 4 magnitudes (50 to 200% of routine), and 3 directions (50, 70, and 90 degrees). Modeled maximum intervertebral motions were compared to motions reported in previous clinical studies of the range of voluntary cervical motion. Modeled peak cord strains were compared to potential strain injury thresholds. Results Modeled maximum intervertebral motions occurred with maximum force magnitude (97.6 N) and did not differ from physiologically normal maximum motion values. Peak tensile cord strains (stretch) did not exceed the potential injury threshold (0.14) in any of the 48 force conditions. Peak compressive strains exceeded the potential injury threshold (–0.20) in 3 of 48 conditions, all with maximum force magnitude applied in a nonroutine location. Conclusions With an intact cervical spine, even with application of twice the routine value of force magnitude, intervertebral motions during intubation did not exceed physiologically normal maximum values. However, under nonroutine high-force conditions, compressive strains exceeded potentially injurious values. In patients whose cords have less than normal tolerance to acute strain, compressive strains occurring with routine intubation forces may reach potentially injurious values. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

SARS-CoV-2, which causes the disease COVID-19, generally has a mild disease course in children. However, a severe post-infectious inflammatory process known as multisystem inflammatory syndrome in children has been observed in association with COVID-19. This inflammatory process is a result of an abnormal immune response with similar clinical features to Kawasaki disease. It is well established that multisystem inflammatory syndrome in children is associated with myocardial dysfunction, coronary artery dilation or aneurysms, and occasionally arrhythmias. The most common electrocardiographic abnormalities seen include premature atrial or ventricular ectopy, variable degrees of atrioventricular block, and QTc prolongation, and rarely, haemodynamically significant arrhythmias necessitating extracorporeal membrane oxygenation support. However, presentation with fever, hypotension, and relative bradycardia with a left axis idioventricular rhythm has not been previously reported. We present a case of a young adolescent with multisystem inflammatory syndrome in children with myocarditis and a profoundly inappropriate sinus node response to shock with complete resolution following intravenous immunoglobulin.

The objective of this study is to determine the prevalence of an abnormal electrocardiogram showing a prolonged QTc greater than 450 ms in infants with unilateral or bilateral sensorineural hearing loss. We conducted a prospective study of healthy term infants (≥37 weeks gestational age) who failed their newborn auditory brainstem response hearing screen, were seen by an audiologist and diagnosed as having sensorineural hearing loss during follow-up to 1 year of age. In infants with a diagnosis of hearing loss, we collected a detailed family history and performed an ECG between 2 and 6 months of age. We obtained follow-up for 1 year by calling the parent requesting the hearing and cardiac status of their child. Two of the 40 infants with sensorineural hearing loss (5%) had a QTc greater than 450 ms. Both had mild bilateral hearing loss and genetic testing did not identify a known mutation for long QT syndrome. The remaining 38 infants had QTc intervals of ≤ 450 ms. One patient diagnosed with bilateral severe sensorineural hearing loss had a normal ECG (QTc = 417 ms). Several months after the ECG was performed, the infant's mother contacted the study cardiologist after she learned that the infant's maternal grandmother was diagnosed with a cardiomyopathy and arrhythmias. Genetic testing was recommended even though the child was asymptomatic and was positive for a pathogenic mutation in the KCNQ1 gene. We speculate that molecular genetic testing in infants with hearing loss may become the standard of care rather than targeted electrocardiograms.Clinical Trial Registration NCT02082431 https://www.clinicaltrials.gov/ct2/show/NCT02692521?cond=NCT02692521rank=1 .

To minimize the risk of cervical spinal cord injury in patients who have cervical spine pathology, minimizing cervical spine motion during laryngoscopy and tracheal intubation is commonly recommended. However, clinicians may better aim to reduce cervical spinal cord strain during airway management of their patients. The aim of this study was to predict laryngoscope force characteristics (location, magnitude, and direction) that would minimize cervical spine motions and cord strains.We utilized a computational model of the adult human cervical spine and spinal cord to predict intervertebral motions (rotation [flexion/extension] and translation [subluxation]) and cord strains (stretch and compression) during laryngoscopy.Routine direct (Macintosh) laryngoscopy conditions were defined by a specific force application location (mid-C3 vertebral body), magnitude (48.8 N), and direction (70 degrees). Sixty laryngoscope force conditions were simulated using 4 force locations (cephalad and caudad of routine), 5 magnitudes (25-200% of routine), and 3 directions (50, 70, 90 degrees).Under all conditions, extension at Oc-C1 and C1-C2 were greater than in all other cervical segments. Decreasing force magnitude to values reported for indirect laryngoscopes (8-17 N) decreased cervical extension to ~50% of routine values. The cervical cord was most likely to experience potentially injurious compressive strain at C3, but force magnitudes ≤50% of routine (≤24.4 N) decreased strain in C3 and all other cord regions to non-injurious values. Changing laryngoscope force locations and directions had minor effects on motion and strain.The model predicts clinicians can most effectively minimize cervical spine motion and cord strain during laryngoscopy by decreasing laryngoscope force magnitude. Very low force magnitudes (5 N, ~10% of routine) are necessary to decrease overall cervical extension to50% of routine values. Force magnitudes ≤24.4 N (≤50% of routine) are predicted to help prevent potentially injurious compressive cord strain.

In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consenus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology, (ACC) and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate follow-up in pediatric patients.

Case A healthy 37-year-old man sustained a knee injury after performing a deep flexion maneuver while skiing and noted immediate knee pain and swelling. Because of persistent inability to fully extend his knee and persistent posterolateral knee pain, he was evaluated and noted to have an acute osteochondral defect of the posterolateral femoral condyle directly adjacent to his fabella. After a trial of nonoperative interventions, he elected to undergo an arthroscopic-assisted open excision of the fabella and a chondroplasty of the posterolateral femoral condyle defect. Conclusion A traumatic osteochondral defect secondary to a lateral fabella impaction is a rare pathology but must be evaluated in patients performing deep flexion maneuvers who have persistent knee pain and mechanical symptoms. When there is a focal defect with increased edema of both the fabella and posterolateral femoral condyle, an arthroscopic chondroplasty and fabella excision is a valid treatment to return the patient back to desired activities.

Background: Limited biomechanical data exist for dual small plate fixation of midshaft clavicle fractures, and no prior study has concurrently compared dual small plating to larger superior or anteroinferior single plate and screw constructs. Purpose: To biomechanically compare dual small orthogonal plating, superior plating, and anteroinferior plating of midshaft clavicle fractures by use of a cadaveric model. Study Design: Descriptive laboratory study. Methods: The study used 18 cadaveric clavicle specimens (9 pairs total), and 3 plating techniques were studied: anteroinferior, superior, and dual. The dual plating technique used smaller diameter plates and screws (1.6-mm thickness) than the other, single plate techniques (3.3-mm thickness). Each of the 9 clavicle pairs was randomly assigned a combination of 2 plating techniques, and randomization was used to determine which techniques were used for the right and left specimens. Clavicles were plated and then osteotomized to create an inferior butterfly fracture model, which was then fixed with a single interfragmentary screw. Clavicle specimens were then potted for mechanical testing. Initial bending, axial, and torsional stiffness of each construct was determined through use of a randomized nondestructive cyclic testing protocol followed by load to failure. Results: No significant differences were found in cyclical axial ( P = .667) or torsional ( P = .526) stiffness between plating groups. Anteroinferior plating demonstrated significantly higher cyclical bending stiffness than superior plating ( P = .005). No significant difference was found in bending stiffness between dual plating and either anteroinferior ( P = .129) or superior plating ( P = .067). No significant difference was noted in load to failure among plating methods ( P = .353). Conclusion: Dual plating with a smaller plate-screw construct is biomechanically similar to superior and anteroinferior single plate fixation that uses larger plate-screw constructs. No significant differences were found between dual plating and either superior or anteroinferior single plating in axial, bending, or torsional stiffness or in bending load to failure. Dual small plating is a viable option for fixing midshaft clavicle fractures and may be a useful low-profile technique that avoids a larger and more prominent plate-screw construct. Clinical Relevance: Plate prominence and hardware irritation are commonly reported complaints and reasons for revision surgery after plate fixation of midshaft clavicle fractures. Dual small plate fixation has been used to improve cosmetic acceptability, minimize hardware irritation, and decrease reoperation rate. Biomechanically, dual small plate fixation performed similarly to larger single plate fixation in this cadaveric model of butterfly fracture.

Background:Platelet-rich plasma (PRP) and bone marrow concentrate (BMC) are orthobiologic therapies with numerous growth factors and other bioactive molecules. Before the clinical utility of PRP and BMC is optimized as a combined therapy or monotherapy, an improved understanding of the components and respective concentrations is necessary.Purpose:To prospectively measure and compare anabolic, anti-inflammatory, and proinflammatory growth factors, cytokines, and chemokines in bone marrow aspirate (BMA), BMC, whole blood, leukocyte-poor PRP (LP-PRP), and leukocyte-rich PRP (LR-PRP) from samples collected and processed concurrently on the same day from patients presenting for elective knee surgery.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Patients presenting for elective knee surgery were prospectively enrolled over a 3-week period. Whole blood from peripheral venous draw and BMA from the posterior iliac crest were immediately processed via centrifugation and manual extraction methods to prepare LR-PRP, LP-PRP, and BMC samples, respectively. BMA, BMC, whole blood, LR-PRP, and LP-PRP samples were immediately assayed and analyzed to measure protein concentrations.Results:BMC had a significantly higher interleukin 1 receptor antagonist (IL-1Ra) concentration than all other preparations (all P < .0009). LR-PRP also had a significantly higher IL-1Ra concentration than LP-PRP ( P = .0006). There were no significant differences in IL-1Ra concentration based on age, sex, body mass index, or chronicity of injury in all preparations. LR-PRP had significantly higher concentrations of platelet-derived growth factor AA (PDGF-AA) and PDGF-AB/BB than all other preparations (all P < .0006). LR-PRP also had significantly higher concentrations of matrix metalloproteinase 1 (MMP-1) and soluble CD40 ligand than all other preparations (all P < .004). LP-PRP had significantly higher concentrations of MMPs, namely MMP-2, MMP-3, and MMP-12, than all other preparations (all P < .007).Conclusion:BMC is a clinically relevant source of anti-inflammatory biologic therapy that may be more effective in treating osteoarthritis and for use as an intra-articular biologic source for augmented healing in the postsurgical inflammatory and healing phases, owing to its significantly higher concentration of IL-1Ra as compared with LR-PRP and LP-PRP. Additionally, LR-PRP had a significantly higher concentration of IL-1Ra than LP-PRP. In cases where increased vascularity and healing are desired for pathological or injured tissues, including muscle and tendon, LR-PRP may be optimal given its higher overall concentrations of PDGF, TGF-β, EGF, VEGF, and soluble CD40 ligand.

Background: Recent biomechanical studies have identified sagittal plane posterior tibial slope as a potential risk factor for posterior cruciate ligament (PCL) injury because of its effects on the kinematics of the native and surgically treated knee. However, the literature lacks clinical correlation between primary PCL injuries and decreased posterior tibial slope. Purpose/Hypothesis: The purpose of this study was to retrospectively compare the amount of posterior tibial slope between patients with PCL injuries and age/sex-matched controls with intact PCLs. It was hypothesized that patients with PCL injuries would have a significantly decreased amount of posterior tibial slope when compared with patients without PCL injuries. Study Design: Case-control study; Level of evidence, 3. Methods: Patients who underwent primary PCL reconstruction without anterior cruciate ligament injury between 2010 and 2017 by a single surgeon were retrospectively analyzed. Measurements of posterior tibial slope were performed with lateral radiographs of PCL-injured knees and matched controls without clinical or magnetic resonance imaging evidence of ligamentous injury. Mean values of posterior tibial slope were compared between the groups. Inter- and intrarater agreement was assessed for the tibial slope measurement technique via a 2-way random effects model to calculate the intraclass correlation coefficient (ICC). Results: In sum, 104 patients with PCL tears met the inclusion criteria, and 104 controls were matched according to age and sex. There were no significant differences in age ( P = .166), sex ( P = .345), or body mass index ( P = .424) between the PCL-injured and control groups. Of the PCL tear cohort, 91 patients (87.5%) sustained a contact mechanism of injury, while 13 (12.5%) reported a noncontact mechanism of injury. The mean ± SD posterior tibial slopes were 5.7°± 2.1° (95% CI, 5.3°-6.1°) and 8.6°± 2.2° (95% CI, 8.1°-9.0°) for the PCL-injured and matched control groups, respectively ( P < .0001). Subgroup analysis of the PCL-injured knees according to mechanism of injury demonstrated significant differences in posterior tibial slope between noncontact (4.6°± 1.8°) and contact (6.2°± 2.2°) injuries for all patients with PCL tears ( P = .013) and among patients with isolated PCL tears ( P = .003). The tibial slope measurement technique was highly reliable, with an ICC of 0.852 for interrater reliability and an ICC of 0.872 for intrarater reliability. Conclusion: A decreased posterior tibial slope was associated with patients with PCL tears as compared with age- and sex-matched controls with intact PCLs. Decreased tibial slope appears to be a risk factor for primary PCL injury. However, further clinical research is needed to assess if decreased posterior tibial slope affects posterior knee stability and outcomes after PCL reconstruction.

BACKGROUND Implantable cardioverter defibrillator (ICD) lead failures occur at higher rates in pediatric and congenital heart disease (CHD) patients. OBJECTIVE To determine the rate and timing of Riata lead failure in pediatric and CHD patients. METHODS This was a retrospective, multicenter cohort study of pediatric patients and adults with CHD with implantation of a Riata or Riata ST lead between 2002 and 2009. The prevalence and timing of electrical failure and conductor coil externalization (CCE) were determined. RESULTS Fifty-eight patients and 63 leads from seven centers were included. Median (interquartile range [IQR]) age at implant was 14.4 (11.5-18.7) years and median follow-up was 8.7 (7.3-11.1) years. The underlying diagnosis was a primary arrhythmia disorder in 45%, cardiomyopathy in 31%, and CHD in 28% of patients. Electrical failure occurred in 43% and CCE in 16% of leads at median lead ages of 4.7 (3.4-7.5) and 4.3 (3.9-7.0) years, respectively. Median lead survival free from electrical failure or CCE was 7.9 (95% confidence interval, 5.8-10.0) years. Forty-one percent of leads were functional at the end of the follow-up period, and 33% were extracted with a complication rate of 5%. CONCLUSIONS The rate of Riata lead electrical failure was high in children and patients with CHD, while the rate of CCE was comparable with published data. Counseling on lead management should factor in the high rate of electrical failure with considerations for elective replacement.

PURPOSE To quantify and compare normative catabolic and anabolic factor concentrations in leukocyte-rich platelet-rich plasma (LR-PRP) at various time points, including baseline, 1 week after initiating naproxen use, and after a 1-week washout period. METHODS Asymptomatic healthy donors aged between 18 and 70 years were recruited (average age, 36.6 years; range, 25-64 years). Subjects were excluded from the study if they were actively taking any prescribed medications or nonsteroidal anti-inflammatory drugs (NSAIDs) or if they had any of the following at present or previously: blood or immunosuppression disorders, cancer, osteonecrosis, rheumatoid arthritis, avascular necrosis, NSAID intolerance, gastrointestinal or peptic ulcer disease, or kidney dysfunction. The anabolic factors vascular endothelial growth factor, fibroblast growth factor 2, platelet-derived growth factor AB (PDGF-AB), and platelet-derived growth factor AA (PDGF-AA) and the catabolic factors interleukin (IL) 1β, IL-6, IL-8, and tumor necrosis factor α in LR-PRP were measured. Peripheral blood was drawn at 3 time points: baseline, after 1 week of naproxen use, and after a 1-week washout period. RESULTS The angiogenic factors PDGF-AA (44% decrease in median) and PDGF-AB (47% decrease) significantly declined from baseline (P < .05) after 1 week of naproxen use. There was a significant recovery (P < .05) of PDGF-AA (94% increase) and PDGF-AB (153% increase) levels after the 1-week washout period, with a return to baseline levels. The catabolic factor IL-6 also had a significant decline from baseline (77% decrease in median, P < .05) after 1 week of naproxen use. After a 1-week washout period, the IL-6 level was similar to the baseline level (130% increase, P < .05). CONCLUSIONS Naproxen use diminished several biological factors in LR-PRP; however, a 1-week washout period was sufficient for the recovery of PDGF-AA, PDGF-AB, and IL-6 to return to baseline levels. Tumor necrosis factor α, IL-1β, IL-8, vascular endothelial growth factor, and fibroblast growth factor 2 did not show differences between the 3 time points of data collection. Discontinuing NSAIDs for a minimum of 1 week before LR-PRP treatment may improve certain biological factor levels. LEVEL OF EVIDENCE Level II, prospective comparative study.

Patients with tetralogy of Fallot are at risk for ventricular arrhythmias and sudden cardiac death. These abnormalities are associated with pulmonary regurgitation, right ventricular enlargement, and a substrate of discrete, slowly-conducting isthmuses. Although these arrhythmic events are rare, their prediction is challenging. This review will address contemporary risk assessment and prevention strategies. Numerous variables have been proposed to predict who would benefit from an implantable cardioverter-defibrillator. Current risk stratification models combine independently associated factors into risk scores. Cardiac magnetic resonance imaging, QRS fragmentation assessment, and electrophysiology testing in selected patients may refine some of these models. Interaction between right and left ventricular function is emerging as a critical factor in our understanding of disease progression and risk assessment. Multicenter studies evaluating risk factors and risk mitigating strategies such as pulmonary valve replacement, ablative strategies, and use of implantable cardiac-defibrillators are needed moving forward.

Purpose of review The COVID-19 pandemic has had unprecedented global effects, yet the rapid emergence of telehealth across the globe has allowed healthcare professionals to connect virtually with patients and families while following safe social distancing guidelines. Telehealth has been used relatively well in patients from remote regions with limited access to subspecialty healthcare providers. This article discusses novel ways of using telehealth during the current pandemic and measures that would need to be taken to sustain telehealth and teleconsultations. Recent findings Telehealth has expanded to outpatient pediatric cardiology clinics across the globe during the pandemic. Technological advancements in video conferencing and the abundance of readily available wearable devices have allowed cardiologists to establish a preliminary diagnosis and set forth a treatment plan. Additional support by insurance providers and relaxation of mandatory regulations by the government have allowed telehealth to succeed during the pandemic. Although many subdisciplines within pediatric cardiology can be easily adapted into a sustainable telehealth model, some unique patient interactions, such as fetal cardiology, exercise physiology, and echocardiograms cannot be done remotely. The field of telehealth medicine with HIPAA-compliant programs and both insurance and government support should remain in our armamentarium of available resources for all patients and families. Summary Although not unique to pediatric cardiology, telehealth has emerged as an avenue to perform an initial evaluation and even establish a care pathway for patients. It is well recognized that telehealth visits will not supplant all patient--physician interactions but is a very acceptable first step in the majority of cases and can often steer the patient to subsequently undergo more selective and streamlined care.

STUDY OBJECTIVE The purpose of the research was to both develop a vaginal hysterectomy model with surgically pertinent anatomic landmarks and assess its validity for simulation training. DESIGN A low-cost, reproducible vaginal hysterectomy model with relevant anatomic landmarks for key surgical steps. SETTING Nine academic and community-based obstetrics and gynecology residency programs. PARTICIPANTS One hundred sixty-nine obstetrics and gynecology residents. INTERVENTIONS A vaginal hysterectomy model with surgically pertinent anatomic landmarks was developed and tested for construct validity. MEASUREMENTS AND MAIN RESULTS Of the 184 available residents, 169 (91%) participated in this study and performed a vaginal hysterectomy procedure on the described model. The validated objective 7-item global rating scale (GRS) and the 13-item task-specific checklist (TSC) were used as tools to assess performance. The median TSC and GRS scores correlated with year of training, prior experience, and trainee confidence. In addition, the TSC scores also correlated with the GRS scores (p

Purpose of review The present article serves to review current risk assessment guidelines for sudden cardiac death (SCD) in patients with hypertrophic cardiomyopathy (HCM) and to discuss how these guidelines can be applied to patients with childhood HCM. New diagnostic techniques that could lead to more accurate risk assessment tools are also discussed. Recent findings Current guidelines for risk assessment in childhood HCM are extrapolated from adult guidelines and lack background research to validate their use. Continuous variables, such as wall thickness, are converted to binary variables, which is particularly concerning in pediatric patients' where weight gain and linear growth is likely to lead to more significant hemodynamic changes in shorter periods of time. Some studies have even shown that risk factors concerning in adults may actually be protective in pediatric patients. Additionally, large gaps still remain between genotype and phenotype expression in HCM. Summary A better understanding of the relationship between cause, phenotype, and outcomes is needed to truly be able to determine risk for SCD in childhood HCM. Larger studies, including newer technologies and quantitative models, similar to the European HCM Risk-SCD model, which allows for a quantitative risk diagnosis, are needed as well.

While the association with acute anterior cruciate ligament (ACL) tears has been established, other risk factors and associated pathologies which occur with a concomitant lateral meniscal posterior root tear (LMPRT) are not well defined. The purpose of this study was to compare the risk factors and concomitant pathologies between patients with LMPRT and patients without LMPRTs in the setting of a primary ACL tear.Patients with a LMPRT identified at the time of primary ACL reconstruction by a single surgeon were identified. These patients were matched by age and sex to patients undergoing primary ACL reconstruction who were not found to have lateral meniscus root tears (control group) in a 1:1 ratio. Lateral posterior tibial slope (PTS), medial PTS, lateral femoral condyle height and depth, lateral tibial plateau depth, and lateral tibial plateau subluxation were measured on MRI. Anteroposterior full-limb alignment radiographs were used to measure the medial proximal tibia angle (MPTA), the mechanical lateral distal femoral angle (mLDFA), and the mechanical weightbearing axis for the injured extremity.One-hundred three patients were included in both the LMPRT group and the matched control group. Patients with a LMPRT had a significantly steeper lateral PTS (9.1° vs. 7.0°, p = 0.001), a steeper medial PTS (7.0° vs. 6.0°, p = 0.03), and a greater lateral-to-medial slope asymmetry (2.0° vs. 1.0°, p = 0.001). There were no differences in lateral femoral condyle depth or height, lateral tibial plateau depth, lateral tibial plateau subluxation, MPTA, mLDFA, or mechanical weightbearing axis between groups. There was a significantly increased incidence of medial meniscus ramp lesions in patients with lateral meniscus posterior root tears compared with controls (34.0% vs. 15.5%, odds ratio: 2.8, p = 0.002). There were no associations with concomitant ligament injuries, medial meniscus root tears, or non-ramp tears based on case/control grouping.In conclusion, LMPRTs in the setting of primary ACL injuries were associated with significantly increased lateral and medial PTSs, and increased asymmetry between lateral and medial PTSs. In addition, clinicians should be aware of the increased incidence of concurrent medial meniscal ramp lesions in patients with LMPRTs. Knowledge of these associations helps guide clinical decision-making and counselling of patients in the setting of ACL tears with concomitant LMPRTs.IV.

Background: Impaction fractures of the posterolateral tibial plateau have been previously described to occur in association with anterior cruciate ligament (ACL) tears; however, the effect of these injuries on patient-reported outcomes (PROs) after ACL reconstruction (ACLR) is not well known. Purpose: (1) To assess the effect of posterolateral tibial plateau impaction fractures on preoperative clinical knee stability assessed by the Lachman and pivot-shift examinations and (2) to assess the effect of impaction fractures on PROs after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing ACLR for primary ACL tears with available magnetic resonance imaging (MRI) scans were included in this study. MRI scans were reviewed for the presence of posterolateral tibial plateau impaction fractures, which were classified according to the morphological variant. Associations with clinical laxity determined by an examination under anesthesia were assessed using binary logistic regression. Also, 2-year postoperative PROs (12-Item Short Form Health Survey [SF-12] Mental Component Scale and Physical Component Scale [PCS], Lysholm, Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Tegner scores) were modeled using multiple ordinal logistic regression to assess the effect of posterolateral tibial plateau impaction fracture classification while adjusting for other covariates. Pearson correlation coefficients (PCCs) were used to assess for correlations between postoperative PROs and the amount of tibial plateau bone loss present. Results: Displaced posterolateral tibial plateau impaction fractures were present in 407 (49.3%) of 825 total knees included in this study. Knees with type IIIB impaction fractures had an increased likelihood of having a high-grade pivot shift (odds ratio, 2.3; P = .047), with no other impaction fracture types showing a significant association. There were no significant associations between posterolateral tibial plateau impaction fracture type and a higher Lachman grade. Of the 599 eligible knees with 2-year follow-up, postoperative information was obtained for 419 (70.0%). Patients improved in all PROs at a mean of 3.0 years after ACLR ( P < .001). Multiple ordinal logistic regression demonstrated a posterolateral tibial plateau impaction fracture as an independent predictor of the postoperative Lysholm score, with higher grade impaction fractures showing decreased Lysholm scores. Pearson correlation testing demonstrated weak but statistically significant correlations between sagittal bone loss of posterolateral tibial plateau impaction fractures and SF-12 PCS (PCC = –0.156; P = .023), WOMAC total (PCC = 0.159; P = .02), Lysholm (PCC = –0.203; P = .003), and Tegner scores (PCC = –0.151; P = .032). Conclusion: When classified into distinct morphological subtypes, high-grade posterolateral tibial plateau impaction fractures were independently associated with decreased postoperative outcomes after ACLR when controlling for other demographic or clinical variables. Patients with large depression-type posterolateral tibial plateau impaction fractures (type IIIB) had an increased likelihood of having high-grade pivot-shift laxity on clinical examination under anesthesia.

Multifocal atrial tachycardia has certain electrocardiographic similarities to atrial fibrillation. The mechanism of atrial fibrillation is heterogenous but in some cases may arise from a single ectopic driver with fibrillatory conduction to the rest of the atria. This has led to the speculation that multifocal atrial tachycardia may have a similar mechanistic unifocal site that disperses through the atrium in a fibrillatory pattern. Ivabradine has been reported to be efficacious in an adult with paroxysmal atrial fibrillation as well as in children with junctional or ectopic atrial tachycardias. This is the first report of successfully using ivabradine, a novel anti-arrhythmic If blocking agent, to convert multifocal atrial tachycardia in a 5-month-old critically ill infant to a pattern indicating a single ectopic atrial focus. This allowed the patient’s single atrial focus to be ablated with return to sinus rhythm and decannulation from ventriculoarterial extracorporeal membrane oxygenation. This case suggests that multifocal atrial tachycardia may arise from a single automatic focus with downstream fibrillatory conduction to the atria.

Introduction We report a case of a fetus with complex congenital heart disease and supraventricular tachycardia in the setting of maternal high grade atrioventricular block at 26 weeks' gestation. Methods and results Electroanatomic mapping allowed successful implantation of a permanent pacemaker to provide adequate back-up pacing in the mother with zero radiation exposure, thus allowing safe delivery of transplacental anti-arrhythmic medications to reduce the fetal arrhythmia burden and optimize the fetal ventricular rate. Conclusion This is the first reported case of using electroanatomic mapping, with zero fluoroscopy use, for pacemaker lead placement and for a novel indication.

Guidelines for the implantation of cardiac implantable electronic devices (CIEDs) have evolved since publication of the initial ACC/AHA pacemaker guidelines in 1984 [ 1 ]. CIEDs have evolved to include novel forms of cardiac pacing, the development of implantable cardioverter defibrillators (ICDs) and the introduction of devices for long term monitoring of heart rhythm and other physiologic parameters. In view of the increasing complexity of both devices and patients, practice guidelines, by necessity, have become increasingly specific. In 2018, the ACC/AHA/HRS published Guidelines on the Evaluation and Management of Patients with Bradycardia and Cardiac Conduction Delay [ 2 ], which were specific recommendations for patients >18 years of age. This age-specific threshold was established in view of the differing indications for CIEDs in young patients as well as size-specific technology factors. Therefore, the following document was developed to update and further delineate indications for the use and management of CIEDs in pediatric patients, defined as ≤21 years of age, with recognition that there is often overlap in the care of patents between 18 and 21 years of age. This document is an abbreviated expert consensus statement (ECS) intended to focus primarily on the indications for CIEDs in the setting of specific disease/diagnostic categories. This document will also provide guidance regarding the management of lead systems and follow-up evaluation for pediatric patients with CIEDs. The recommendations are presented in an abbreviated modular format, with each section including the complete table of recommendations along with a brief synopsis of supportive text and select references to provide some context for the recommendations. This document is not intended to provide an exhaustive discussion of the basis for each of the recommendations, which are further addressed in the comprehensive PACES-CIED document [ 3 ], with further data easily accessible in electronic searches or textbooks.

To assess patient history, physical examination findings, magnetic resonance imaging (MRI) and 3-dimensional computed tomographic (3D CT) measurements of those with anterior cruciate ligament (ACL) graft failure compared with primary ACL tear patients to better discern risk factors for ACL graft failure.We performed a retrospective review comparing patients who underwent revision ACL reconstruction (ACLR) with a primary ACLR group with minimum 1-year follow-up. Preoperative history, examination, and imaging data were collected and compared. Measurements were made on MRI, plain radiographs, and 3D CT. Inclusion criteria were patients who underwent primary ACLR by a single surgeon at a single center with minimum 1-year follow-up or ACL graft failure with revision ACLR performed by the same surgeon.A total of 109 primary ACLR patients, mean age 33.7 years (range 15 to 71), enrolled between July 2016 and July 2018 and 90 revision ACLR patients, mean age 32.9 years (range 16 to 65), were included. The revision ACLR group had increased Beighton score (4 versus 0; P.001) and greater side-to-side differences in quadricep circumference (2 versus 0 cm; P.001) compared with the primary ACLR group. A family history of ACL tear was significantly more likely in the revision group (47.8% versus 16.5%; P.001). The revision group exhibited significantly increased lateral posterior tibial slope (7.9° versus 6.2°), anterolateral tibial subluxation (7.1 versus 4.9 mm), and anteromedial tibia subluxation (2.7 versus 0.5 mm; all P.005). In the revision group, femoral tunnel malposition occurred in 66.7% in the deep-shallow position and 33.3% in the high-low position. The rate of tibial tunnel malposition was 9.7% from medial to lateral and 54.2% from anterior to posterior. Fifty-six patients (77.8%) had tunnel malposition in ≥2 positions. Allograft tissue was used for the index ACLR in 28% in the revision group compared with 14.7% in the primary group.Beighton score, quadriceps circumference side-to-side difference, family history of ACL tear, lateral posterior tibial slope, anterolateral tibial subluxation, and anteromedial tibia subluxation were all significantly different between primary and revision ACLR groups. In addition, there was a high rate of tunnel malposition in the revision ACLR group.

To evaluate whether players with a history of an anterior cruciate ligament reconstruction (ACLR) before the National Football League (NFL) Combine played or started fewer games and/or participated in fewer eligible snaps compared with NFL Combine participants without a history of knee injury or surgery.We performed a retrospective review of all players who participated in the NFL Combine between 2009 and 2015 and who had a history of an ACLR. NFL Combine participants were included if they had a previous ACLR or combined anterior cruciate ligament (ACL) injury and nonoperatively managed medial collateral ligament injury. The number of games started, number of games played, draft number, overall draft pick, and snap percentage for each position were determined. The mean value of each outcome metric was compared between case and control players.We identified 110 players who had an ACL injury (n = 76) or a combined ACL and medial collateral ligament injury (n = 34). Players in the ACLR group had a significantly worse mean draft pick number (difference of 30.2, P = .002) and mean draft round (difference of 0.8, P = .019) versus controls. Compared with control players, players in the ACLR group started and played significantly fewer games in both season 1 (difference of 2.7 games started, P.001; difference of 2.7 games played, P.001) and season 2 (difference of 7.4 games started, P.001; difference of 3.0 games played, P = .003) and had a significantly lower snap percentage in both season 1 (difference of 23.1%, P.001) and season 2 (difference of 24.0%, P.001).Athletes at the NFL Combine who previously underwent an ACLR had significantly lower early-career NFL player metrics, including fewer games started, fewer games played, and a lower snap percentage, than uninjured controls. Defensive linemen, defensive backs, and linebackers were the 3 most affected positions. Players with a prior ACLR and combined meniscal-chondral pathology had significantly lower numbers of games started and games played in seasons 1 and 2 and a significantly lower season 2 snap percentage.Level III, case-control study.

Introduction CC-002 is a prospective cooperative group study conducted by NRG Oncology to evaluate whether a pre-operative GA-GYN score derived from a predictive model utilizing components of an abbreviated geriatric assessment (GA) is associated with major post-operative complications in elderly women with suspected ovarian, fallopian tube, primary peritoneal or advanced stage papillary serous uterine (GYN) carcinoma undergoing primary open cytoreductive surgery. Methods Patients 70 years or older with suspected advanced gynecologic cancers undergoing evaluation for surgery were eligible. A GA-GYN score was derived from a model utilizing the GA as a pre-operative tool. Patients were followed for six weeks post-operatively or until start of chemotherapy. Post-operative events were recorded either directly as binary occurrence (yes or no) using CTCAE version 4.0. Results There were 189 eligible patients, 117 patients with primary surgical intervention and 37 patients undergoing interval cytoreduction surgery. The association between higher GA-GYN score and major postoperative complications in patients undergoing primary surgery was not significant (p = 0.1341). In a subgroup analysis of patients with advanced staged malignant disease who underwent primary cytoreductive surgery, there was a trend towards an association with the GA-GYN score and post-operative complications. Conclusion The pre-operative GA-GYN score derived from a predictive model utilizing components of an abbreviated geriatric assessment was not predictive of major post-operative complications in elderly patients undergoing primary open cytoreductive surgery. However, there was an association between GA-GYN score and post-operative complications in a subgroup of patients with advanced staged malignant disease.

Objective Surgical site infections (SSI) are associated with increased morbidity, mortality, and healthcare costs. This study investigated whether implementation of an abdominal closure bundle reduces surgical site infection rates. We aimed to identify sub-populations that would benefit the most from this intervention. Methods We conducted a retrospective cohort study of all patients that underwent exploratory laparotomy by a Gynecologic Oncologist from January 1, 2011 to April 1, 2017. The abdominal closure bundle was implemented on May 6, 2014. SSI rates were assessed overall and within subgroups. Results 875 patients were included in the analysis. Overall, SSI rate was reduced, albeit not significantly, from 48/471 (10.2%) to 32/404 (7.9%) (p = 0.148) with implementation of the closing bundle. In patients that underwent a tumor debulking procedure, SSI was noted in 36/277 (13.0%) in the pre-bundle group and 14/208 (6.7%) in the post-bundle cohort (p = 0.017). In patients with malignant pathology, the pre-bundle cohort had an SSI rate of 38/282 (13.5%), which reduced to 18/215 (8.4%) in the post-bundle group (p = 0.049). In patients with FIGO stage III or IV disease, the SSI rate was reduced from 21/114 (18.4%) to 8/87 (8.4%) with implantation of the closure bundle (p = 0.028). In patients with intra-operative ascites, SSI rate decreased from 19/119 (15.9%) pre-bundle to 4/104 (3.8%) in the post-bundle group (p = 0.002). Conclusions Implementation of an abdominal closure bundle was not associated with a significant reduction in overall SSI rate. However, multiple subpopulations associated with advanced gynecologic cancer benefited from this intervention.

Purpose of review The purpose of this review is to explore the paradigm shift in healthcare delivery that will need to take place over the next few years away from an emphasis on supply-driven health care to better quality transparent-driven health care whose focus is on the consumer's best interest. Recent findings The current healthcare system is fragmented and costs continue to rise. The best way to contain costs is to improve quality to the consumer, the patient. Physicians and hospitals need to align in a team-based approach that allows physicians to understand current costs and how to strive toward a focus on healthcare outcomes. Pediatric cardiology is a unique discipline that cares for patients with complex congenital conditions that will span their lifetime and also involves not just cardiology but surgery, intensive care, anesthesia, nursing, and a host of inpatient and ambulatory services. Understanding what matters to the patient and his/her family and presenting quality outcomes in a transparent fashion will gradually allow a shift to take place away from physician visits, tests ordered, and procedures performed. This can only be achieved with physicians, given the appropriate tools to understand costs, value, and outcomes and models where the hospitals and physicians are aligned. Summary The transformation to a value-based healthcare system is beginning and pediatric cardiologists need to be educated, given the appropriate resources, receive appropriate feedback, and patients need to be part of the solution so that care providers can understand what matters most to them.

The 1st World Congress of Paediatric Cardiology was held in London, United Kingdom, in 1980, organised by Dr Jane Somerville and Prof. Fergus Macartney. The idea was that of Jane Somerville, who worked with enormous energy and enthusiasm to bring together paediatric cardiologists and surgeons from around the world. The 2nd World Congress of Paediatric Cardiology took place in New York in 1985, organised by Bill Rashkind, Mary Ellen Engle, and Eugene Doyle. The 3rd World Congress of Paediatric Cardiology was held in Bangkok, Thailand, in 1989, organised by Chompol Vongraprateep. Although cardiac surgeons were heavily involved in these early meetings, a separate World Congress of Paediatric Cardiac Surgery was held in Bergamo, Italy, in 1988, organised by Lucio Parenzan. Thereafter, it was recognised that surgeons and cardiologists working on the same problems and driven by a desire to help children would really rather meet together. A momentous decision was taken to initiate a Joint World Congress of Paediatric Cardiology and Cardiac Surgery. A steering committee was established with membership comprising the main organisers of the four separate previous Congresses and additional members were recruited in an effort to achieve numerical equality of cardiologists and surgeons and a broad geographical representation. The historic 1st “World Congress of Paediatric Cardiology and Cardiac Surgery” took place in Paris in June, 1993, organised by Jean Kachaner. The next was to be held in Japan, but the catastrophic Kobe earthquake in 1995 forced relocation to Hawaii in 1997. Then followed Toronto, Canada, 2001, organised by Bill Williams and Lee Benson; Buenos Aires, Argentina, 2005, organised by Horatio Capelli and Guillermo Kreutzer; Cairns, Australia, 2009, organised by Jim Wilkinson; Cape Town, South Africa, 2013, organised by Christopher Hugo-Hamman; and Barcelona, Spain, 2017, organised by Sertac Cicek. With stops in Europe (1993), Asia-Pacific (1997), North America (2001), South America (2005), Australia (2009), Africa (2013), and Europe again (2017), in 2021, The World Congress of Paediatric Cardiology and Cardiac Surgery will be held for the first time in the continental United States.1 The 8th World Congress of Paediatric Cardiology and Cardiac Surgery will be held in Washington DC, United States of America, 19–24 September, 2021, and will be organised by Jeffrey P. Jacobs and Gil Wernovsky. Mitchell I. Cohen served as the Scientific Program Co-Chair for the 2017 World Congress of Paediatric Cardiology and Cardiac Surgery, and he will again serve as the Scientific Program Co-Chair for the 2021 World Congress of Paediatric Cardiology and Cardiac Surgery along with Kathyrn Dodds RN, MSN, CRNP. Information about the upcoming 8th World Congress of Paediatric Cardiology and Cardiac Surgery can be found at www.WCPCCS2021.org

Objective To determine the mortality rate of patients treated with gastroschisis at a Jamaican pediatric hospital, and to identify factors that contribute significantly to mortality. Methods Eighty-five patients were treated with gastroschisis between November 1, 2006 and November 30, 2015. Of these, 80 records were recovered and reviewed retrospectively. Records were analyzed for maternal and patient characteristics, and details of the clinical course. Death during admission was the primary outcome measure. Results 63 of the 80 patients died during admission, giving a mortality rate of 78.8%. Sepsis was the main cause of death (82.4%). 27 patients (33.8%) had complicated gastroschisis (necrosis, perforation and/or atresia), all of whom died. Only preterm gestational age, complicated gastroschisis, and the lack of parenteral nutrition were found to be statistically associated with increased mortality. Conclusion Our mortality rate is higher than those quoted in high-income countries, and correlates to those found in low- to middle-income countries. Mortality in our cohort was significantly associated with prematurity, complicated gastroschisis, and the lack of parenteral nutrition. Efforts to improve outcome must focus on improving antenatal care, establishing transfer protocols, and optimizing nutrition for all patients with gastroschisis. Study type Prognostic/Retrospective Study Level of evidence Level II

AIMS: Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an ion channelopathy characterized by ventricular arrhythmia during exertion or stress. Mutations in RYR2-coded Ryanodine Receptor-2 (RyR2) and CASQ2-coded Calsequestrin-2 (CASQ2) genes underlie CPVT1 and CPVT2, respectively. However, prognostic markers are scarce. We sought to better characterize the phenotypic and genotypic spectrum of CPVT, and utilize molecular modelling to help account for clinical phenotypes. METHODS AND RESULTS: This is a Pediatric and Congenital Electrophysiology Society multicentre, retrospective cohort study of CPVT patients diagnosed at

Glenohumeral instability is a common pathology of the shoulder joint, especially among young athletes. Despite advancements in technology and the widespread use of diagnostic imaging, a careful history and physical examination still remain the cornerstone of diagnosing patients with shoulder instability. Due to the involvement of many static and dynamic stabilizers, proficient physical examination can be challenging. With a systematic approach to clinical evaluation, the clinician can recognize characteristic patterns of relevant signs and symptoms and make an accurate diagnosis.

We present a case of a large left ventricular capillary haemangioma incidentally discovered in a pre-adolescent patient.

Abrupt loss of ventricular preexcitation on noninvasive evaluation, or nonpersistent preexcitation, in Wolff-Parkinson-White syndrome (WPW) is thought to indicate a low risk of life-threatening events.The purpose of this study was to compare accessory pathway (AP) characteristics and occurrences of sudden cardiac arrest (SCA) and rapidly conducted preexcited atrial fibrillation (RC-AF) in patients with nonpersistent and persistent preexcitation.Patients 21 years or younger with WPW and invasive electrophysiology study (EPS) data, SCA, or RC-AF were identified from multicenter databases. Nonpersistent preexcitation was defined as absence/sudden loss of preexcitation on electrocardiogram, Holter monitoring, or exercise stress test. RC-AF was defined as clinical preexcited atrial fibrillation with shortest preexcited R-R interval (SPERRI) ≤ 250 ms. AP effective refractory period (APERP), SPERRI at EPS , and shortest preexcited paced cycle length (SPPCL) were collected. High-risk APs were defined as APERP, SPERRI, or SPPCL ≤ 250 ms.Of 1589 patients, 244 (15%) had nonpersistent preexcitation and 1345 (85%) had persistent preexcitation. There were no differences in sex (58% vs 60% male; P=.49) or age (13.3±3.6 years vs 13.1±3.9 years; P=.43) between groups. Although APERP (344±76 ms vs 312±61 ms; P.001) and SPPCL (394±123 ms vs 317±82 ms; P.001) were longer in nonpersistent vs persistent preexcitation, there was no difference in SPERRI at EPS (331±71 ms vs 316±73 ms; P=.15). Nonpersistent preexcitation was associated with fewer high-risk APs (13% vs 23%; P.001) than persistent preexcitation. Of 61 patients with SCA or RC-AF, 6 (10%) had nonpersistent preexcitation (3 SCA, 3 RC-AF).Nonpersistent preexcitation was associated with fewer high-risk APs, though it did not exclude the risk of SCA or RC-AF in children with WPW.

A primary pathological feature of polycystic kidney disease (PKD) is the hyperproliferation of epithelial cells in renal tubules, resulting in formation of fluid-filled cysts. The proliferative aspects of the two major forms of PKD—autosomal dominant PKD (ADPKD), which arises from mutations in the polycystins PKD1 and PKD2, and autosomal recessive PKD (ARPKD), which arises from mutations in PKHD1—has encouraged investigation into protein components of the core cell proliferative machinery as potential drivers of PKD pathogenesis. In this review, we examine the role of signaling by ERBB proteins and their effectors, with a primary focus on ADPKD. The ERBB family of receptor tyrosine kinases (EGFR/ERBB1, HER2/ERBB2, ERBB3, and ERBB4) are activated by extracellular ligands, inducing multiple pro-growth signaling cascades; among these, activation of signaling through the RAS GTPase, and the RAF, MEK1/2, and ERK1/2 kinases enhance cell proliferation and restrict apoptosis during renal tubuloepithelial cyst formation. Characteristics of PKD include overexpression and mislocalization of the ERBB receptors and ligands, leading to enhanced activation and increased activity of downstream signaling proteins. The altered regulation of ERBBs and their effectors in PKD is influenced by enhanced activity of SRC kinase, which is promoted by the loss of cytoplasmic Ca2+ and an increase in cAMP-dependent PKA kinase activity that stimulates CFTR, driving the secretory phenotype of ADPKD. We discuss the interplay between ERBB/SRC signaling, and polycystins and their depending signaling, with emphasis on thes changes that affect cell proliferation in cyst expansion, as well as the inflammation-associated fibrogenesis, which characterizes progressive disease. We summarize the current progress of preclinical and clinical trials directed at inhibiting this signaling axis, and discuss potential future strategies that may be productive for controlling PKD.

Background: Outcomes after sports-related multiple-ligament knee reconstructions are limited. Purpose: To evaluate outcomes after single-stage surgical treatment of sports-related multiple-ligament knee injuries and to compare outcomes after anterior cruciate ligament (ACL)–based and posterior cruciate ligament (PCL)–based multiple-ligament knee reconstructions. Study Design: Case series; Level of evidence, 4. Methods: Skeletally mature patients with at least 2 major knee ligaments torn during a sporting activity that required surgery with a minimum of 2 years’ follow-up were included. The Lysholm score, Tegner activity scale, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 12-Item Short Form Health Survey Physical Component Summary were collected preoperatively and at a minimum of 2 years’ follow-up. Clinical data, including range of motion and knee stability, were also recorded at final follow-up. Results: A total of 276 patients with multiple-ligament knee injuries incurred during sport participation from 2010 to 2016 were identified. Of the 276 patients, 194 (70.5%) had complete follow-up at a mean 3.5 years (range, 2-8 years). There was a significant improvement in all outcome scores as compared with the preoperative scores ( P < .001 for all scores). The median (first and third quartiles) Tegner activity score improved from 1 (0, 2) preoperatively to 6 (4, 7) postoperatively. Significant improvements were from 41 (22, 57) to 90 (78, 95) and 44 (24, 60) to 3 (1, 8) for median Lysholm and WOMAC scores, respectively. There was no significant difference in postoperative outcome scores between patients treated in the acute and chronic phases. Furthermore, there was no significant difference between PCL- and ACL-based multiple-ligament knee injuries. Eighteen (9.3%) patients developed arthrofibrosis requiring reintervention surgery. Conclusion: These results demonstrated that single-stage anatomic-based knee ligament reconstructions with immediate postoperative rehabilitation in the setting of sports-related multiligament injuries yielded significantly improved outcomes irrespective of the ligament injury pattern. In addition, there was no difference in outcomes between ACL- and PCL-based injuries in the setting of sports-related multiligament injuries.

This is the case of a 9-year-old girl who initially presents with episodes of syncope and potentially concerning family history. An extensive evaluation is unrevealing, and she appears to have simple benign autonomic dysfunction. Eventually, a rare and life-threatening disease is uncovered, and she receives appropriate treatment. The case report highlights the persistence and suspicion of the managing providers that ultimately allowed the diagnosis to be revealed as well as some of the key features of the underlying disease.

Background: Lateral posterior tibial slope (PTS) has been identified as a risk factor for primary anterior cruciate ligament (ACL) tears. Purpose/Hypothesis: The purpose was to prospectively determine if there was a difference in lateral PTS between male and female athletes sustaining contact ACL tears as compared with a group of sex-, age-, and activity-matched athletes who sustained noncontact ACL tears. It was hypothesized that there would be no difference in degree of lateral PTS between contact and noncontact mechanisms among patients sustaining primary ACL tears in sports. Study Design: Cohort study; Level of evidence, 3. Methods: Data from patients who underwent primary ACL reconstruction without posterior cruciate ligament injury between 2016 and 2018 by a single surgeon were prospectively analyzed. Measurements of lateral PTS were performed on magnetic resonance imaging. Mean values of lateral PTS were compared between the ACL tear groups. Additionally, a group of patients with intact knee ligaments were matched to patients with ACL tears to serve as controls. Results: A total of 245 patients had complete primary ACL tears during the inclusion period. Of these, 56 (23%) reported a contact mechanism of injury at the time of ACL tear, and 56 patients who sustained noncontact ACL tears were matched to the contact ACL tear group. There were no significant differences in sex ( P≥ .999), age ( P = .990), or body mass index ( P = .450) between the patient groups. The mean lateral PTS was 9.1°± 2.9° for the ACL contact and 9.9°± 3.0° for the ACL noncontact group ( P = .180). There was a significant difference in mean lateral PTS between the ACL tear groups (noncontact and contact: 9.5°± 3.0°) and matched control group (5.6°± 1.9°, P = .0001). Conclusion: The lateral PTS was significantly increased among patients with contact and noncontact ACL tears as compared with controls. However, there were no differences in lateral PTS between patients who sustained contact and noncontact ACL tears. Lateral PTS measured on magnetic resonance imaging does not appear to be predictive of the mechanism of injury type among patients who sustain a contact or noncontact primary ACL tear.

The posterolateral corner (PLC) of the knee was regarded as the "dark side" of the knee because of limited understanding of its anatomy and biomechanics and because of poor outcomes after injuries to PLC structures. These injuries rarely occur in isolation, with 28% reported as isolated PLC injuries. Nonoperative treatment of these injuries has led to persistent instability, development of early osteoarthritis, and poor outcomes. Several techniques for reconstruction of the PLC have been described, and all are reported to improve outcomes. Biomechanically validated anatomic reconstructions are preferred because they restore native knee kinematics and improve clinical outcomes without over-constraining the knee.

Background: Recent clinical studies identified sagittal plane posterior tibial slope as a risk factor for increased postoperative laxity after single-bundle posterior cruciate ligament reconstruction (PCLR). Purpose/Hypothesis: To retrospectively compare the degree of posterior tibial slope and its effect on posterior tibial translation (PTT) after double-bundle (DB) PCLR. Our null hypothesis was that preoperative tibial slope would not be associated with graft laxity. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent DB PCLR between 2010 and 2017 by a single surgeon were retrospectively analyzed. Measurements of posterior tibial slope were performed on lateral radiographs, and PTT was measured with pre- and postoperative kneeling stress radiographs. Simple and multiple linear regression was performed to estimate the unadjusted and adjusted effect of tibial slope on postoperative graft laxity, respectively. Results: A total of 103 patients with posterior cruciate ligament tears and subsequent reconstructions were included. There was a significant reduction of the mean ± SD side-to-side difference in PTT between stress radiographs (preoperative, 10.6 ± 2.7 mm; postoperative, 1.5 ± 2.6 mm; mean difference, 9.1 mm; 95% CI, 8.4-9.8; P < .001). Linear regression analysis revealed no significant correlation between preoperative posterior tibial slope and the amount of side-to-side difference in PTT on postoperative stress radiographs obtained at a mean 18.5 months ( R = −0.115, P = .249). Combined ligament injury (beta = −1.01; 95% CI, −2.00 to −0.01; P = .047) was a significant independent predictor of decreased postoperative side-to-side difference in PTT. Conclusion: Graft laxity, determined by PTT in posterior kneeling stress radiographs, was not influenced by decreased posterior tibial slope after DB PCLRs. The observed results in the current study support the use of DB PCLR. Future studies should be conducted to compare the effect of tibial slope after SB PCLR and DB PCLR at long-term follow-up.