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Purpose: We evaluated the impact of a virtual Pediatric Surgery Bootcamp curriculum on resource utilization, learner engagement, knowledge retention, and stakeholder satisfaction. Methods: A virtual curriculum was developed around Pediatric Surgery Milestones. GlobalCastMD delivered pre-recorded and live content over a single 10-h day with a concluding social hour. Metrics of learner engagement, faculty interaction, knowledge retention, and satisfaction were collected and analyzed during and after the course. Results: Of 56 PS residencies, 31 registered (55.4%; 8/8 Canadian and 23/48 US; p = 0.006), including 42 learners overall. The virtual BC budget was $15,500 (USD), 54% of the anticipated in-person course. Pre- and post-tests were administered, revealing significant knowledge improvement (48.6% [286/589] vs 66.9% [89/133] p < 0.0002). Learner surveys (n = 14) suggested the virtual BC facilitated fellowship transition (85%) and strengthened peer-group camaraderie (69%), but in-person events were still favored (77%). Program Directors (PD) were surveyed, and respondents (n = 22) also favored in-person events (61%). PDs not registering their learners (n = 7) perceived insufficient value-added and concern for excessive participants. Conclusions: The virtual bootcamp format reduced overall expenses, interfered less with schedules, achieved more inclusive reach, and facilitated content archiving. Despite these advantages, learners and program directors still favored in-person education. Level of evidence: III. [ABSTRACT FROM AUTHOR]

CONTEXT: Despite frequency of gastrostomy placement procedures in children, there remains considerable variability in preoperative work-up and procedural technique of gastrostomy placement and a paucity of literature regarding patient-centric outcomes. OBJECTIVES: This review summarizes existing literature and provides consensus-driven guidelines for patients throughout the enteral access decision-making process. DATA SOURCES: PubMed, Google Scholar, Medline, and Scopus. STUDY SELECTION: Included studies were identified through a combination of the search terms "gastrostomy," "g-tube," and "tube feeding" in children. DATA EXTRACTION: Relevant data, level of evidence, and risk of bias were extracted from included articles to guide formulation of consensus summaries of the evidence. Meta-analysis was conducted when data afforded a quantitative analysis. EVIDENCE REVIEW: Four themes were explored: preoperative nasogastric feeding tube trials, decision-making surrounding enteral access, the role of preoperative imaging, and gastrostomy insertion techniques. Guidelines were generated after evidence review with multidisciplinary stakeholder involvement adhering to GRADE methodology. RESULTS: Nearly 900 publications were reviewed, with 58 influencing final recommendations. In total, 17 recommendations are provided, including: (1) tTrial of home nasogastric feeding is safe and should be strongly considered before gastrostomy placement, especially for patients who are likely to learn to eat by mouth; (2) rRoutine contrast studies are not indicated before gastrostomy placement; and (3) lLaparoscopic placement is associated with the best safety profile. LIMITATIONS: Recommendations were generated almost exclusively from observational studies and expert opinion, with few studies describing direct comparisons between GT placement and prolonged nasogastric feeding tube trial. CONCLUSIONS: Additional patient- and family-centric evidence is needed to understand critical aspects of decision-making surrounding surgically placed enteral access devices for children. [ABSTRACT FROM AUTHOR]

Background: A popular paradigm to support surgical education for low- and middle-income countries (LMICs) is partnering with high-income country (HIC) surgeons. These relationships may, however, be asymmetric and fail to optimally address the most pressing curricular needs. We explored the effectiveness of our LMIC-HIC educational partnership. Methods: Through a partnership between a HIC (Canada) and a LMIC (Uganda), three candidate surgeons were commissioned for a custom designed 1-year training experience at our HIC accredited pediatric surgical training centre as part of their overall formal education. The training curriculum was developed in collaboration with the LMIC pediatric surgeon and utilized competency-based medical education principles. A Likert and short-answer survey tool was administered to these trainees upon completion of their training. Results: All prescribed milestones as well as specialty certification by examination of the College of Surgeons of East, Central and Southern Africa was achieved by participating fellows, each of whom have begun clinical practice, leadership and teaching roles in their home country. Although several obstacles were identified by fellows, all agreed that the experience boosted their clinical and teaching abilities, and was worth the effort. Conclusion: This endeavour in global pediatric surgical training represents a significant innovation in surgical education partnerships and would be reproducible across different surgical subspecialties and contexts. Such collaborative efforts represent a feasible upskilling opportunity towards addressing global surgical service capacity. Level of evidence: V. [ABSTRACT FROM AUTHOR]

Case Presentation: A 55-year-old woman with COPD, heart failure with preserved ejection fraction (congestive heart failure), diabetes mellitus, and hypertension presented with baseline dyspnea at rest that had worsened over the last week. She reported associated runny nose, congestion, and cough productive of green sputum. She smoked six cigarettes per day and denied alcohol, drugs, or occupational exposure. She was admitted and initiated on treatment for acute exacerbation of COPD; however, her condition did not improve with steroid, ceftriaxone, and nebulized albuterol and budesonide treatments. She had been diagnosed with asthma and COPD without ever undergoing pulmonary function testing. She presented 11 times to the ED with six hospital admissions in the last 1.5 years for worsening dyspnea at rest, wheezing, and lower extremity edema deemed secondary to exacerbation of her COPD or congestive heart failure. She reported medication compliance, which included fluticasone-vilanterol, tiotropium bromide, and furosemide. She repeatedly demonstrated mild vascular congestion on imaging without hyperinflation, a normal to mildly elevated brain natriuretic peptide (<10 to 200 pg/mL), and dyspnea without hypoxia. She was treated normally for both COPD and congestive heart failure exacerbations simultaneously with methylprednisolone, albuterol, and furosemide with rapid improvement over the course of 1 to 2 days. No significant improvement was noted with steroid therapy, despite receiving them as an inpatient and outpatient. At the time of discharge, her symptoms would be at her baseline. [ABSTRACT FROM AUTHOR]

Inguinal hernia surgery is one of the most common electively performed surgeries in infants. The common nature of inguinal hernia combined with the high‐risk population involving a predominance of preterm infants makes this a particular area of interest for those concerned with their perioperative care. Despite a large volume of literature in the area of infant inguinal hernia surgery, there remains much debate amongst anesthetists, surgeons and neonatologists regarding the optimal perioperative management of these patients. The questions asked by clinicians include; when should the surgery occur, how should the surgery be performed (open or laparoscopic), how should the anesthesia be conducted, including regional versus general anesthesia and airway devices used, and what impact does anesthesia choice have on the developing brain? There is a paucity of evidence in the literature on the concerns, priorities or goals of the parents or caregivers but clearly their opinions do and should matter. In this article we review the current clinical surgical and anesthesia practice and evidence for infants undergoing inguinal hernia surgery to help clinicians answer these questions. [ABSTRACT FROM AUTHOR]

Background Despite a high burden of staphylococcal skin disease in children and high incidence of Staphylococcus aureus bacteremia in adult Indigenous populations in northern Australia, there are few studies describing incidence or clinical information of invasive S aureus (ISA) infections in children. Methods We conducted a retrospective review for all cases of S aureus bacteremia and sterile site infections, for children under 15 years, in northern Australia over a 4-year period (2007–2010). Cases were categorized as neonatal (<28 days) and pediatric (≥28 days). Results Forty-four cases (9 neonatal, 35 pediatric) were identified. The annual incidence of ISA was 27.9 cases per 100 000 population. Among pediatric cases, the annual incidence was significantly higher in the Indigenous (46.6) compared with the non-Indigenous (4.4) population (IRR: 10.6 [95% confidence interval, 3.8–41.4]). Pediatric infections were predominantly community-associated (86%). Clinical infection sites included osteoarticular (66%), pleuropulmonary (29%), and endocarditis (9%), and multifocal disease was common (20%). Eighty-three percent of pediatric cases presented with sepsis; 34% resulted in intensive care admission. Neonatal cases were all born prematurely; 89% were late-onset infections. Overall, 27% of infections were due to methicillin-resistant S aureus (MRSA). Compared with methicillin-sensitive S aureus (MSSA), there was no difference in severity or presentation in pediatric MRSA cases, but a higher proportion of MRSA cases were readmitted. Conclusions The annual incidence of ISA infection in this study is among the highest described, largely due to a disproportionate burden in Indigenous children. Infections are frequently severe and infection with MRSA is common. Children presenting with suspected ISA in this region should be treated empirically for MRSA. [ABSTRACT FROM PUBLISHER]

Background: Sliding hip screw (SHS) fixation traditionally involves the use of 4-hole side plates; however, 4-hole plates have disadvantages, including longer surgery and greater postoperative pain, and there is little evidence that they provide increased stability. We compared 2- and 4-hole side plates in stable and unstable pertrochanteric fractures. Methods: We prospectively enrolled consecutive patients with pertrochanteric femoral fractures treated between Jan. 1, 2004, and Apr. 30, 2009, with a 135° SHS using either a 2- or 4-hole side plate, based on surgeon preference. Results: A total of 327 patients were managed with an SHS device (252 women, 75 men). There were 208 stable fracture patterns (AO/OTA 31 A1, A2.1) and 119 unstable (AO/OTA 31 A2.2, A2.3, A3). We managed 172 patients with 2-hole plates and 155 with 4-hole plates. The average duration of surgery (30.44 v. 51.45 min), blood loss (26.0 v. 31.3 g/L) and transfusion requirements (43% v. 31. 60% transfusion) were significantly lower with the 2-hole than the 4-hole plate. There was no significant difference in length of stay (19 v. 16 d). With stable fractures there was no significant difference in failure rate (6.3% v. 4.9%). In unstable fractures there was a significantly higher rate of failure using 2-hole side plates (24.4% v. 10.8%). Conclusion: In stable fractures, use of an SHS with a 2-hole side plate results in shorter surgery and less blood loss/transfusion than a 4-hole side plate, with equivalent survival. In unstable fractures, there is a greater than 2-fold rate of failure when a 2-hole side plate is used. [ABSTRACT FROM AUTHOR]

Anastomotic strictures (ASs) complicate the postoperative course of roughly one-third of all patients with esophageal atresia with or without tracheoesophageal fistula. Its development is multifactorial, but is due in part to tension on the anastomosis, gastroesophageal reflux disease, and the presence of a leak in the early postoperative period. Efforts at reducing the rate of AS have been largely unsuccessful, although meticulous technique and aggressive acid suppression remain the cornerstones of perioperative care. Once an AS has been confirmed, the first-line treatment remains a course of esophageal dilatation. Adjuncts to dilatation are frequently required, including steroid injection or the topical application of mitomycin C. Currently, there is insufficient evidence to promote one at the expense of the other. Esophageal stenting has recently been added to the algorithm of treatment, although additional literature is required to confirm its safety and efficacy. Finally, stricture resection followed by primary esophageal anastomosis or, rarely, esophageal replacement with an interposition graft remain options for AS refractory to all other forms of treatment. [ABSTRACT FROM AUTHOR]

Background/purpose: Neonates with gastroschisis make up an increasing proportion of prolonged surgical NICU admissions. While infectious complications are known to increase patient morbidity, it is unclear whether they vary according to abdominal closure method, or can be predicted by initial patient assessment. Methods: A national, prospective, disease-specific database was evaluated for episodes of wound infection (WI) and catheter-related infection (CRI). Antibiotic use and timing, as well as method and location of abdominal closure were studied. The gastroschisis prognostic score (GPS) was calculated and evaluated as a predictor of infectious complications. Results: Of 395 patients, 48 (12.6%) had a documented abdominal WI, and 59 patients (14.9%) had at least one episode of CRI-most commonly coagulase negative staphylococcus. Most abdominal closures took place within 6 h of admission (194 = 51.3%), while 132 (34.9%) were delayed greater than 24 h. The WI rate was greater in the delayed group (21.2 vs. 8.2%, p = 0.0006). The GPS was found to predict development of an infectious complication (WI + CRI, p = 0.04). Conclusion: Infectious complications remain an important consideration in the management of gastroschisis. GPS correlates with the development of infectious complications. Prophylaxis for skin flora and early closure, when feasible, may reduce WI rates. [ABSTRACT FROM AUTHOR]

Self-identity, in the sense of who one now is or who one may become, is widely recognized as a matter of both discovery and creativity. This understanding of self-identity is reflected in the often repeated admonition of Friedrich Nietzsche to become who one is. Against the background of a brief discussion of Nietzsche's admonition, two claims are advance. First, noting the role others play in our becoming who we are helps explicate the notion that self-identity involves both discovery and creativity. Second, emphasizing that self formation involves both discovery and creativity illuminates several moral dimensions of the unfolding drama, perhaps the most important of which is the importance of creating a self which makes ongoing recreations of the self possible. [ABSTRACT FROM AUTHOR]

To characterise the trends in dermatophyte isolation from specimens sourced from metropolitan Melbourne over a 48-year time period. Analysis of submitted specimens from three time periods. Trends identified include: an increasing mean age of the patients; increased numbers of onychomycosis isolates; a significant age difference among patients with Trichophyton interdigitale isolates compared with patients who had other dermatophyte species; and an increasing number of previously rarely isolated imported dermatophytes. Significant shifts are occurring in dermatophyte epidemiology. [ABSTRACT FROM AUTHOR]

Background: Fetal tracheal occlusion (TO) has been investigated as a treatment option for lung hypoplasia secondary to congenital diaphragmatic hernia (CDH). TO increases lung size, but it is unclear whether TO stimulates mature lung growth or simply induces alveolarization without concomitant bronchial development. In this study, we characterize bronchial branch development in fetal rats with CDH with or without TO through conventional histological and morphometric analysis as well as lung casting. Materials and methods: Rat dams were gavaged nitrofen at gestational day 9.5, and 3 to 4 fetuses per dam underwent fetal TO on gestational day 19 (term = 22 days). Fetuses were sacrificed on day 21, the presence of CDH was confirmed, and the lung weight to body weight ratio (LW/BW) was calculated. Lung casts of all research groups were created using liquid silicon and bronchial branches were quantified from lung periphery to carina. Results: CDH fetuses had smaller LW/BW ratios and a lesser percentage (%) of airspace when compared to controls, and manifested less lung branching than controls. Fetuses treated by TO had a greater LW/BW ratio and % airspace, but did not have a different number of branch iterations. Fetuses with CDH and TO demonstrated a restoration in LW/BW ratio to control levels (P = 0.42), but the number of bronchial branch iterations remained less than control animals. Conclusion: The results of this study suggest that TO in this animal model at gestational day 19 promotes distal airway proliferation but does not reverse the underdevelopment of bronchial branching seen in lung hypoplasia due to CDH. [Copyright &y& Elsevier]

Struggle with self identity is a life-long moral undertaking, an essential dimension of which is connecting one's past and future in a way that preserves integrity and wholeness. The argument of this paper is that one reading of Sartre's understanding of bad faith and authenticity can illuminate this project. More specifically, the essay provides an interpretation of Sartre's claim that "I am not what I am and I am what I am not" that avoids understanding the self as an ontological nothingness poised between past and future. Rather, Sartre's phrase is interpreted as recognizing that we experience ourselves as a rich, complex continuum that connects past and future. This understanding of the self acknowledges the tension between past and future, but sees that tension as the matrix out of which a responsible self emerges. [ABSTRACT FROM AUTHOR]

Addresses the issue of some schools' decision to downgrade the teaching of evolution in public schools in an effort to foster fairness between scientific knowledge and religious faith in the United States. Opposing theories regarding the origin of the earth; History of the leveling of evolution and creationism.

Examines the startle effect in films, and its implications for spectator cognition and media theory. Film audiences' reaction to threatening film scenes; Threat scene and the formal conventions of the startle effect; Importance of pacing to generating film startles; Startling scenes in the film 'Alien.'

Purpose: Pediatric surgical care in low- and middle-income countries is often hindered by systemic gaps in healthcare resources, infrastructure, training, and organization. This study aims to develop and validate the Global Assessment of Pediatric Surgery (GAPS) to appraise pediatric surgical capacity and discriminate between levels of care across diverse healthcare settings. Methods: The GAPS Version 1 was constructed through a synthesis of existing assessment tools and expert panel consultation. The resultant GAPS Version 2 underwent international pilot testing. Construct validation categorized institutions into providing basic or advanced surgical care. GAPS was further refined to Version 3 to include only questions with a > 75% response rate and those that significantly discriminated between basic or advanced surgical settings. Results: GAPS Version 1 included 139 items, which, after expert panel feedback, was expanded to 168 items in Version 2. Pilot testing, in 65 institutions, yielded a high response rate. Of the 168 questions in GAPS Version 2, 64 significantly discriminated between basic and advanced surgical care. The refined GAPS Version 3 tool comprises 64 questions on: human resources (9), material resources (39), outcomes (3), accessibility (3), and education (10). Conclusion: The GAPS Version 3 tool presents a validated instrument for evaluating pediatric surgical capabilities in low-resource settings. [ABSTRACT FROM AUTHOR]

Background In Australia, invasive meningococcal disease (IMD) incidence rapidly increased between 2014 and 2017 due to rising serogroup W (MenW) and MenY infections. We aimed to better understand the genetic diversity of IMD during 2017 and 2018 using whole genome sequencing data. Methods Whole genome sequencing data from 440 Australian IMD isolates collected during 2017 and 2018 and 1737 international MenW:CC11 isolates collected in Europe, Africa, Asia, North America, and South America between 1974 and 2020 were used in phylogenetic analyses; genetic relatedness was determined from single-nucleotide polymorphisms. Results Australian isolates were as follows: 181 MenW (41%), 144 MenB (33%), 88 MenY (20%), 16 MenC (4%), 1 MenW/Y (0.2%), and 10 nongenogroupable (2%). Eighteen clonal complexes (CCs) were identified, and 3 (CC11, CC23, CC41/44) accounted for 78% of isolates (343/440). These CCs were associated with specific serogroups: CC11 (n = 199) predominated among MenW (n = 181) and MenC (n = 15), CC23 (n = 80) among MenY (n = 78), and CC41/44 (n = 64) among MenB (n = 64). MenB isolates were highly diverse, MenY were intermediately diverse, and MenW and MenC isolates demonstrated the least genetic diversity. Thirty serogroup and CC-specific genomic clusters were identified. International CC11 comparison revealed diversification of MenW in Australia. Conclusions Whole genome sequencing comprehensively characterized Australian IMD isolates, indexed their genetic variability, provided increased within-CC resolution, and elucidated the evolution of CC11 in Australia. [ABSTRACT FROM AUTHOR]

Presents the views of Ronald Dworkin on the issues of abortion, religious liberty and the spirit of enlightenment. Questions of political philosophy; Claims of Dworkin pertaining to abortions; Role of enlightenment in resolving controversies.

Examines the Constitution of India, in reference to its impact on traditional values, beliefs, and religion. Comparison of governmental and traditional values; Information on Article 17 of the Constitution; Examination of the religious aspects of the constitution.

We report a novel and enantioselective approach to 2,4-disubstituted tetrahydropyrans that utilises the asymmetric amino-Cope rearrangement as a key synthetic step. [Copyright &y& Elsevier]

Discusses case of cavitation and pleural rupture of a pulmonary cryptococcoma in an immunocompetent man. Details of case-history and treatment; Examination of cause of cavitation.

Purpose: Outpatient pediatric surgical practice often involves conditions of limited morbidity but significant parental concern. We explore existing evidence-based management recommendations and the mismatch with practice patterns for four common outpatient pediatric surgical conditions. Methods: Using the Cochrane Rapid Review Group recommendations and librarian oversight, we conducted a rapid review of four outpatient surgical conditions: dermoid cysts, epigastric hernias, hydroceles, and umbilical hernias. We extracted patient demographics, intervention details, outcome measures and evaluated justifications presented for chosen management options. A metric of evidence volume (patient/publication ratio) was generated and compared between diagnoses. Results: Out of 831 articles published since 1990, we identified 49 cohort studies (10-dermoid cyst, 6-epigastric hernia, 25-hydrocele, and 8-umbilical hernia). The 49 publications included 34,172 patients treated across 18 countries. The evidence volume for each outpatient condition demonstrates < 1 cohort/condition/year. The evidence mismatch rate varied between 33 and 75%; many existing recommendations are not evidence-based, sometimes conflicting and frequently misrepresentative of clinical practice. Conclusions: Published literature concerning common outpatient pediatric surgical conditions is sparse and demonstrates wide variations in practice. All individual practice choices were justified using either risk of complications or patient preference. Most early intervention practices were based on weak or outdated studies and "common wisdom" rather than genuine evidence. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Background: Fostering the success of surgical trainees from low- and middle-income countries (LMICs) plausibly addresses the existing workforce deficit in a sustainable manner, but it is unclear whether and how these trainees are targeted as strategic learners for educational exchanges. The purpose of this review was to assess the quality and outcomes of existing literature on exchanges of surgical trainees between high-income countries (HICs) and LMICs.Methods: We conducted a systematic review of reported instances of surgical training exchanges between HICs and LMICs. After database searching, 2 independent reviewers evaluated titles, abstracts and manuscripts. Selected studies were critically appraised with the use the Critical Assessment Skills Programme Qualitative Checklist and analyzed for trainee level, institutions, countries and subspecialties, as well as reported outcomes of the exchange.Results: Twenty-eight reports met the inclusion criteria and were analyzed. Most publications (18 [64%]) detailed North-to-South exchanges; 1 exchange was bidirectional. General surgery was the most common discipline identified, with 9 other subspecialties described involving learners at all phases of training. Reports were generally of good quality, although outcomes were reported variably, and most authors failed to acknowledge the ethical implications of their study.Conclusion: The articles identified described a variety of surgical exchanges across disciplines, learner types and host/home countries. Few of the exchanges prioritized the learning of surgical trainees from LMICs. There is an increasing need to formalize these exchanges via clear goals and objectives, as well as to prioritize the proper matching of educational goals with local clinical needs.Level of evidence: V - Evidence from systematic reviews of descriptive and qualitative studies. [ABSTRACT FROM AUTHOR]

Background: Fostering the success of surgical trainees from low- and middle-income countries (LMICs) plausibly addresses the existing workforce deficit in a sustainable manner, but it is unclear whether and how these trainees are targeted as strategic learners for educational exchanges. The purpose of this review was to assess the quality and outcomes of existing literature on exchanges of surgical trainees between high-income countries (HICs) and LMICs. Methods: We conducted a systematic review of reported instances of surgical training exchanges between HICs and LMICs. After database searching, 2 independent reviewers evaluated titles, abstracts and manuscripts. Selected studies were critically appraised with the use the Critical Assessment Skills Programme Qualitative Checklist and analyzed for trainee level, institutions, countries and subspecialties, as well as reported outcomes of the exchange. Results: Twenty-eight reports met the inclusion criteria and were analyzed. Most publications (18 [64%]) detailed North-to-South exchanges; 1 exchange was bidirectional. General surgery was the most common discipline identified, with 9 other subspecialties described involving learners at all phases of training. Reports were generally of good quality, although outcomes were reported variably, and most authors failed to acknowledge the ethical implications of their study. Conclusion: The articles identified described a variety of surgical exchanges across disciplines, learner types and host/home countries. Few of the exchanges prioritized the learning of surgical trainees from LMICs. There is an increasing need to formalize these exchanges via clear goals and objectives, as well as to prioritize the proper matching of educational goals with local clinical needs. Level of evidence: V – Evidence from systematic reviews of descriptive and qualitative studies. [ABSTRACT FROM AUTHOR]

The article describes the case of a 15-year-old white female who experienced ruptured ectopic pregnancy. The patient suffered from a syncopal episode coupled with persistent vaginal bleeding. She underwent single incision laparoscopic surgery (SILS) under general anesthesia. The authors concluded that SILS is feasible for a ruptured ectopic pregnancy with an unconventional modification to single access port.