Pediatric Interventions Research Articles

Quality and safe anesthesia for all children : That is their right!

In 1989 the United Nations passed the "United Nations Convention on the Rights of the Child" (UNCRC) and, among others, demanded the highest attainable standard of health for children. Safe Anesthesia for Every Tot (SAFETOTS, www.safetots.org ), an association of internationally active pediatric anesthetists, has derived 10rights, the 10R's, which are of essential importance for the pediatric anesthetic practice. The first right (R1) postulates: "Children have the right to enjoy the highest possible standard of health. Children below the age of three years in particular should be treated by experienced anesthesiologists with profound and continuous training and regular activity in pediatric anesthesia. Children with significant comorbidities and those who need highly specialized or major interventions benefit from specialized pediatric anesthesia in pediatric centers". The current situation in pediatric anesthesia care in Germany, Austria and Switzerland does not always meet the requirements demanded by the UNCRC. Anesthesia-related complications are approximately 10times more frequent in children than in adults. In contrast to adults, children who are injured during anesthesia are often healthy. Severe complications in pediatric anesthesia have amortality that is several times higher than in adult anesthesia. There are hardly any statistics on this for German-speaking countries but corresponding cases frequently occur in the context of expert opinions in liability litigation and in the press. Anesthesiologists are often charged with the anesthetic care of newborns, infants and small children without having sufficient child-specific expertise, which results in morbidity and mortality. In some places, only afew babies per year undergo general anesthesia in clinics without aspecialized pediatric anesthesia team or asmall number of infant anesthesia cases are divided among alarge number of anesthesiologists. These case numbers are not even sufficient to maintain asingle pediatric anesthesiologist in training in this age group.Changes are needed to guarantee children the right to enjoy the highest attainable standard of health. We need decision-makers, politicians and professional representatives who rethink and who are willing to implement the UNCRC. This includes changing the current financing of hospitals in order that the quality actually provided is financed. The "pay for performance" must change to "pay for quality". In addition to broad basic pediatric care, all complex forms of pediatric treatment must be carried out in specialized pediatric centers, particularly for small and severely ill children.Significant improvement can be achieved at the local level by reorganization, bundling of pediatric surgical interventions within aclinical unit together with the concentration on adedicated team.

Association between index complication and outcomes after inpatient pediatric surgery

PurposeA cascade of complications is believed to be the primary mechanism underlying failure to rescue (FTR), or death of a patient after a postoperative complication. It is unknown whether specific types of index complications are associated with the incidence of secondary complications and FTR after pediatric surgery. MethodsNational cohort study of patients within the National Surgical Quality Improvement Program–Pediatric database who underwent inpatient surgery (2012–2019). Index complications were grouped into nine categories (cardiovascular, venous thromboembolism, pulmonary, bleeding/transfusion, renal, central nervous system, wound, infectious, or minor [defined as having an associated mortality rate <1%]). The association between the type of index complication with FTR, secondary complications, reoperation, unplanned readmission, and postoperative length of stay was evaluated with multivariable logistic regression and generalized linear modeling. ResultsAmong 425,386 patients, 15.5% had at least one complication, 16.6% had one or more secondary complications, 13.9% reoperation, 14.5% readmission, and 2.4% FTR. Secondary complication (10.8–59.7%) and FTR (0.3–31.1%) rates varied by type of index complication. Relative to patients who had an index minor complication, those with an index infectious complication were most likely to have secondary complication (Odds Ratio [OR] 10.3, 95% CI [9.36–11.4]). Index CV complications were most strongly associated with FTR (OR 30.7 [24.0–39.4]). Index wound complications had the greatest association with reoperation (OR 21.9 [20.5–23.4]) and readmission (OR 18.7 [17.6–19.9]). Index pulmonary complications had the strongest association with length of stay (coefficient 9.39 [8.95–9.83]). ConclusionsDifferent types of index complications are associated with different perioperative outcomes. These data can help identify patients potentially at risk for suboptimal outcomes and can inform pediatric quality improvement interventions. Type of studyCohort study. Level of evidenceLevel II.

The impact of COVID-19 on rural treatment-seeking families with children with overweight or obesity

ABSTRACT To examine the early impact of the COVID-19 pandemic on rural parental stress and family behaviors, parents who participated in a 2nd-4th grade pediatric obesity intervention completed a survey in May 2020. Parents (N = 77) experienced 7.8 ± 2.7 events on the COVID-19 Exposure and Family Impact Scales (CEFIS) with an average impact of 2.5 ± 0.5, with many parents reporting moderate stress (73%). Parental stress was predictive of personal well-being getting “worse” while loss of income events were predictive of family routines getting “better.” Professionals working with rural families may want to assess for these factors when promoting positive changes in family health behaviors.

Robotic Anxiety-Parents' Perception of Robot-Assisted Pediatric Surgery.

In contrast to many other countries, robot-assisted (RA) pediatric surgery is not yet very common in Germany. Although the first pediatric RA intervention was published in 2001, RA pediatric surgery is still perceived as a “new technology”. As a consequence, little is known about parents’ perception of this operation method. In this study, we analyzed parents‘ intention to let their child undergo RA and laparoscopic (LA) surgery. Two subsamples (online and at the University Medical Center Goettingen) received a questionnaire addressing attitude towards RA and LA pediatric surgery with the help of a case example. Results showed that parents had a higher intention to consent to LA surgery. Perceiving more benefits, assuming a positive attitude of the social environment, and feeling less anxiety increased intention. A mediation analysis indicated that the type of surgery affected intentions through assumed attitude of the social environment. Exploratory analyses showed that the perception of risks and anxiety reduced intention for only RA surgery. These findings should be considered in preoperational discussions with parents. Anxiety and perceived risks should especially be addressed in order to encounter hesitancy.

Maternal early exposure to violence, psychopathology, and child adaptive functioning: pre- and postnatal programming.

The pre- and postnatal programming mechanisms, timing, and direction of effects linking maternal early exposure to violence (MEEV), psychopathology, and child adaptive functioning are understudied. Thus, the following hypotheses were tested: (H1) higher pre- and postnatal maternal psychopathology will predict lower adaptive functioning, (H2) lower adaptive functioning will predict higher subsequent maternal psychopathology, (H3) cumulative effects of MEEV on maternal psychopathology and adaptive functioning will be observed, and (H4) higher MEEV will predict lower adaptive functioning via maternal psychopathology both pre- and postnatally. Prospective pregnancy cohort study including 1503 mother-child dyads with associations between MEEV, psychopathology, and child adaptive functioning examined using cross-lagged panel analysis. Assessment occurred in the third trimester and annually across the first four years of life. Higher pre- and postnatal maternal psychopathology predicted lower child adaptive functioning at 12 and 24 months, respectively. MEEV predicted maternal psychopathology cumulatively and offered a repeated prediction of adaptive functioning across the first two years of the child's life, operating predominantly through maternal psychopathology during pregnancy. Child effects on mothers were not observed. Like in socioemotional assessment, pediatric assessment of child adaptive functioning should consider the intergenerational transmission of MEEV. Associations between maternal early exposure to violence (MEEV), psychopathology, and child socioemotional development is well documented. Much less is known about the pre- and postnatal programming mechanisms, timing, and direction of effects between MEEV, maternalpsychopathology, and child adaptive functioning. Findings suggest associations of both prenatal and postnatal maternal psychopathology with child adaptive functioning, though the effects of MEEV were more strongly operative through the prenatal pathway. Pediatric assessment and interventions surrounding adaptive functioning should consider the potential role of MEEV in shaping children's health and development, in addition to potential consequences of pre- and postnatal maternal mental health.

Eisenmenger Syndrome: JACC State-of-the-Art Review.

Although major breakthroughs in the field of pediatric cardiology, cardiac surgery, intervention, and overall care improved the outlook of congenital heart disease, Eisenmenger syndrome (ES) is still encountered and remains a complex clinical entity with multisystem involvement, including secondary erythrocytosis, increased thrombotic and bleeding diathesis, high arrhythmogenic risk, progressive heart failure, and premature death. Clearly, care for ES is best delivered in multidisciplinary expert centers. In this review, we discuss the considerable recent progress in understanding the complex pathophysiology of ES, means of prognostication, and improvement in clinical outcomes achieved with pulmonary arterial hypertension-targeted therapies. Additionally, we delineate areas of uncertainty in various aspects of care, discuss gaps in current evidence, and review current status in less privileged countries and propose initiatives to reduce disease burden. Finally, we propose the application of emerging technologies to enhance the delivery and quality of health care related to ES and beyond.

"It Is a Whole Different Life from the Life I Used to Live": Assessing Parents' Support Needs in Paediatric Palliative Care.

Aims: This feasibility study aimed to systematically identify and address the support needs of parents of children with life-limiting illnesses and to assess whether the systematic approach was acceptable and relevant to parents. Methods: The CSNAT (Paediatric) intervention consisted of two assessment visits with the paediatric palliative care team, 2–8 weeks apart, comprising conversations about sources for support in a tertiary children hospital in Western Australia (2018–2019). Audio-recorded telephone interviews were conducted with parents, and inductive thematic analysis was undertaken. Results: All 28 parents who were involved in the intervention agreed to be interviewed. Five themes summarised their experience: caregiving challenges, perceived gaps and feelings of isolation; the usefulness and practicality of the systematic assessment; emotional responses to self-reflection; feelings of validation and empowerment; and received supports responsive to their needs. Conclusions: Parents appreciated the value of this systematic approach in engaging them in conversations about their needs and solutions to address them. While clinical service support was affirmed by parents, they were left wanting in other areas of practical, psychosocial, and emotional support. Palliative care services need to build stronger partnerships with supportive community networks through compassionate communities volunteer models of care to address the non-clinical needs of these families.

Single-dose antibiotic prophylaxis compared with multiple-dose protocol in clean pediatric neurosurgical interventions: a nonrandomized, historically controlled equivalence trial.

Guidelines recommend antimicrobial prophylaxis (AMP) preoperatively for "clean" spinal and cranial surgeries, while dose and timing remain controversial. The use of multiple-dose AMP for such surgeries is under debate in the pediatric context. In this clinical study, the authors aimed to compare single-dose with multiple-dose prophylactic antibiotic usage in cranial and spinal neurosurgical interventions of pediatric patients. All neurosurgical patients aged 28 days to 18 years who underwent surgery at a single tertiary center were assessed. Three cohorts (noninstrumented clean spinal, noninstrumented cranial, and instrumented cranial interventions), each of which comprised two 50-patient arms (i.e., single-dose AMP and multiple-dose AMP), were included after propensity score-matched retrospective sampling and power analysis. Records were examined for surgical site infections. Using a previously published meta-analysis as the prior and 80% acceptance of equivalence (margin of OR 0.88-1.13), logistic regression was carried out for the total cohort and each subcohort and adjusted for etiology by consideration of multiple-dose AMP as reference. The overall sample included 300 age- and sex-matched patients who were evenly distributed in 3 bi-arm cohorts. There was no statistical intercohort difference based on etiology or type of operation (p < 0.05). Equivalence analysis revealed nondiscriminating results for the total cohort (adjusted OR 0.65, 95% CI 0.27-1.57) and each of the subcohorts (noninstrumented clean spinal, adjusted OR 0.65, 95% CI 0.12-3.44; noninstrumented cranial, adjusted OR 0.52, 95% CI 0.14-2.73; and instrumented cranial, adjusted OR 0.68, 95% CI 0.13-3.31). No significant benefit for multiple-dose compared with single-dose AMPs in any of the pediatric neurosurgery settings could be detected. Since unnecessary antibiotic use should be avoided as much as possible, it seems that usage of single-dose AMP is indicated.

139 Absence of Coding in an Outpatient Paediatric Orthopaedic Department – Where Does the Money Go?

Abstract Aim Paediatric orthopaedics conditions are often managed in the outpatient department (OPD) setting. Due to the lack of official coding for these minor procedures in our OPD, the hospital receives neither financial benefit nor evidence for a formal auditing process. With the Paediatric Get It Right First Time (GIRFT) report underway, we have looked at building a coding pathway for paediatric interventions in our OPD. Method The number of paediatric orthopaedic interventions were collated and grouped in a 6-month period, and a clinical outcome form was created accordingly. After consulting with the coding department, a cost analysis of prospective earnings was conducted, as well as comparisons to current standard tariff rates for OPD attendance. Results From January 2021 to June 2021, 100 interventions were performed in our OPD with the breakdown of: 21 clubfoot serial casting, 70 serial casting for pathology such as tip toe walkers, 6 Botox injections in spastic contracture limbs and 3 Pavlik harnesses for developmental dysplasia of the hip. With the assistance of coding department, a new paediatric procedural coding form was created with 14 relevant interventions listed. A loss of £6110 was calculated due to tariff rates being solely attendance based compared to interventional based. Conclusions Paediatric orthopaedic OPD should have clinical coding outcomes in place for each intervention that is performed to ensure that the hospital trust receives appropriate financial commission as well as ensure a formal audit trial can be produced.

Application of the RE-AIM Framework for the Pediatric Mild Traumatic Brain Injury Evaluation and Management Intervention: A Study Protocol for Program Evaluation.

BackgroundChildren who experience a mild Traumatic Brain Injury (mTBI) may encounter cognitive and behavioral changes that often negatively impact school performance. Communication linkages between the various healthcare systems and school systems are rarely well-coordinated, placing children with an mTBI at risk for prolonged recovery, adverse impact on learning, and mTBI re-exposure. The objective of this study is to rigorously appraise the pediatric Mild Traumatic Brain Injury Evaluation and Management (TEaM) Intervention that was designed to enhance diagnosis and management of pediatric mTBI through enhanced patient discharge instructions and communication linkages between school and primary care providers.MethodsThis is a combined randomized and 2 × 2 quasi-experimental study design with educational and technology interventions occurring at the clinician level with patient and school outcomes as key endpoints. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework will be utilized as a mix methods approach to appraise a multi-disciplinary, multi-setting intervention with the intent of improving outcomes for children who have experienced mTBI.DiscussionUtilization of the RE-AIM framework complemented with qualitative inquiry is suitable for evaluating effectiveness of the TEaM Intervention with the aim of emphasizing priorities regarding pediatric mTBI. This program evaluation has the potential to support the knowledge needed to critically appraise the impact of mTBI recovery interventions across multiple settings, enabling uptake of the best-available evidence within clinical practice.

Integrating Telehealth Into Neurodevelopmental Assessment: A Model From the Cardiac Neurodevelopmental Outcome Collaborative.

ObjectiveIn the wake of the COVID-19 pandemic, psychologists were pushed to look beyond traditional in-person models of neurodevelopmental assessment to maintain continuity of care. A wealth of data demonstrates that telehealth is efficacious for pediatric behavioral intervention; however, best practices for incorporating telehealth into neurodevelopmental assessment are yet to be developed. In this topical review, we propose a conceptual model to demonstrate how telehealth can be incorporated into various components of neurodevelopmental assessment.MethodsHarnessing existing literature and expertise from a multidisciplinary task force comprised of clinicians, researchers, and patient/parent representatives from the subspecialty of cardiac neurodevelopmental care, a conceptual framework for telehealth neurodevelopmental assessment was developed. Considerations for health equity and access to care are discussed, as well as general guidelines for clinical implementation and gaps in existing literature.ResultsThere are opportunities to integrate telehealth within each stage of neurodevelopmental assessment, from intake to testing, through to follow-up care. Further research is needed to determine whether telehealth mitigates or exacerbates disparities in access to care for vulnerable populations as well as to provide evidence of validity for a wider range of neurodevelopmental measures to be administered via telehealth.ConclusionsWhile many practices are returning to traditional, face-to-face neurodevelopmental assessment services, psychologists have a unique opportunity to harness the momentum for telehealth care initiated during the pandemic to optimize the use of clinical resources, broaden service delivery, and increase access to care for pediatric neurodevelopmental assessment.

Meeting families where they sleep: a collaborative approach to improving sleep health for urban children.

Meeting families where they sleep: a collaborative approach to improving sleep health for urban children.

Improving Asthma Care Together (IMPACT) mobile health intervention for school-age children with asthma and their parents: a pilot randomised controlled trial study protocol

IntroductionAsthma is an incurable, lifelong condition that places children at increased risk for exacerbation, hospitalisation and school absences. Most paediatric asthma interventions target parents alone and are overly prescriptive. Improving...

A Systematic Review of the Scope of Study of mHealth Interventions for Wellness and Related Challenges in Pediatric and Young Adult Populations.

BackgroundDespite the purported advantages and potential efficacy of mHealth interventions to promote wellness in children, adolescents, and young adults, it is not clear what areas have been explored and the challenges reported in the biomedical literature.MethodsWe conducted a scoping review of publications between 2015 and 2019.ResultsWe identified 54 papers that met our inclusion criteria. Studies were conducted in 21 countries and ranged in size from six to 9851 participants (median: 184). A total of 41% of studies enrolled adolescents only (n = 19). Of the seven types of mHealth interventions identified, apps were the most common intervention (59%; n = 32) evaluated and 44% of the studies evaluated two or more interventions. The most common topic of the studies reviewed was sexual and reproductive health (24%; n = 13).ConclusionMost pediatric mHealth intervention studies are conducted in adolescents in large part, and sexual and reproductive health is the most commonly studied topic. With the easy and widespread accessibility to smartphone technology, the use of mobile apps for wellness interventions will likely continue to expand to other wellness topics.

Prevention of Pediatric Overweight and Obesity: Position of the Academy of Nutrition and Dietetics Based on an Umbrella Review of Systematic Reviews

This Academy of Nutrition and Dietetics Position Paper reports current evidence on pediatric overweight and obesity prevention interventions and discusses implications for registered dietitian nutritionists (RDNs). An overview of current systematic reviews provided evidence-based results from a range of nutrition interventions according to developmental age group (ages 2 to 5, 6 to 12, and 13 to 17 years). Twenty-one current systematic reviews of nutrition interventions demonstrated a beneficial effect of nutrition and physical activity interventions on body mass index measures and no adverse events were identified. RDNs impart nutrition expertise in a wide range of settings to provide comprehensive care for children and adolescents as their nutrition and developmental needs change over time. This Position Paper outlines the current roles of, and proposed directions for, RDNs engaged in pediatric overweight and obesity prevention. Prevention of pediatric overweight and obesity requires comprehensive strategies ranging from policy-level to individual-level interventions in settings that will have the most beneficial impact for children according to their developmental stage. This Position Paper advocates for increased availability of nutrition and food access programs and interventions to reduce risk of pediatric obesity and associated adverse health outcomes both now and for future generations.

The Impact of Virtual Reality in Enhancing the Quality of Life of Pediatric Oncology Patients.

Pediatric oncology interventions involve many challenges, such as multiple hospitalizations, invasive procedures, and adverse physical and psychological treatment side effects. Treatment burden, including administration of general anesthesia, contributes to high levels of psychological distress among pediatric patients and their families. Virtual reality (VR) is a distraction method, which offers an extremely realistic and interactive virtual environment and helps reduce pain and distress by means of a head-mounted display and headphones. VR is based on two crucial dimensions: immersion and presence, which results in the complete suspension of disbelief that the experience is artificial and allows a greater degree of presence and reaction to the stimulations. The VR technology has become a common practice in scientific and clinical research due to its affordability and ease of use. In pediatric settings, the most widely researched clinical application of VR has focused on the effectiveness of VR distraction therapy in the attenuation of acute pain, anxiety, and distress during invasive medical procedures. It has also been hypothesized to be a nonpharmacological form of analgesia that positively influences the body's intricate pain modulation system during painful medical procedures. In this review, we showed the potential benefits of VR technology during radiotherapy and intrathecal procedures on pediatric oncology patients and its involvement in enhancing their quality of life during and after the treatment. Therefore, a collaboration between researchers, clinicians, and programmers is crucial for the inclusion of VR technology in more clinical procedures, which would consequently enhance the patient's quality of life.

Barriers to implementation of pediatric emergency department interventions for parental tobacco use and dependence: a qualitative study using the theoretical domains framework

BackgroundPediatric emergency department (PED) and urgent care (UC) professionals can play a key role in delivering evidence-based guidelines to address parental tobacco use and child tobacco smoke exposure (TSE). Understanding PED/UC professionals’ perceptions regarding these guidelines is the first step in developing and implementing a TSE screening and counseling intervention in these settings. This study aimed to use the theoretical domains framework (TDF) to identify current screening and counseling behaviors of PED/UC professionals related to parental tobacco use and child TSE, and determine barriers and enablers that influence these behaviors.MethodsSemi-structured, focused interviews were conducted with 29 actively practicing PED/UC clinical staff who worked at one large, Midwestern children’s hospital. The interview guide was informed by the TDF and included open-ended questions. Content analysis of interview transcripts was guided by the TDF. Nurses, physicians, and healthcare administrators were assessed overall and by group membership to ensure each group was represented based on their varying PED/UC roles.ResultsFifty-one percent were nurses, 38% were physicians, and 11% were healthcare administrators. Most PED/UC professionals did not currently follow the guidelines, but perceived addressing parental tobacco use as part of their role. All 14 TDF domains were identified by nurses, physicians, and administrators in relation to counseling for parental tobacco use and child TSE. Domains with the most sub-themes were (1) knowledge: lack of knowledge about tobacco counseling, including implementing counseling, cessation resources/referrals, and thirdhand smoke; (2) beliefs about capabilities: not comfortable counseling parents, easier to discuss with parents who are receptive and to ask and advise when patients have a TSE-related complaint, and more likely to discuss if there were resources/referrals; and (3) environmental context and resources: barriers include lack of time, training, and resources and referral information to give to parents, and an enabler is using TSE-related complaints as a context to offer counseling.ConclusionsStudy findings provide a strong foundation for developing and implementing clinical practice guidelines regarding parental tobacco use and child TSE in the PED/UC setting. Future intervention development will address all TDF domains and test the implementation of the intervention in the PED/UC setting.

Uniportal Video-Assisted Thoracic Surgery in a Pediatric Hospital: Early Results and Review of the Literature

Background: Uniportal video-assisted thoracic surgery (U-VATS) is an implemented technique in adult surgery that may aid to extend offer the benefits of thoracoscopy to a wide number of pediatric patients. Materials and Methods: Consecutive cases treated between July 2019 and July 2021 were retrospectively analyzed. Simultaneously, a MEDLINE systematic search was conducted. Results: Twelve patients (median age 13 years, median weight 44.5 kg) underwent 4 major procedures (n = 2 lobectomy, n = 2 segmentectomy) and 11 minor procedures (n = 1 bronchogenic cyst resection, n = 4 apical wedge resections and pleurodesis for pneumothorax, n = 4 wedge resections for lung nodules, and n = 2 debridement for empyema). The median observed operative time was 77 minutes. We recorded one conversion to biportal VATS. No intraoperative complications or 30-day morbidity-mortality was reported. A rate of 40% adverse postoperative events was observed (Clavien-Dindo grade I-IVa). Visual analog scale for postoperative pain recorded a median value of 0 on days 1, 2, and 3. The systematic review provided 15 full-text articles reporting 76 pediatric interventions (4 major and 72 minor procedures); among them, 1 biportal conversion, 3 mild postoperative complications, and 1 redo surgery are presented. Conclusions: As emerged from the literature review, U-VATS remains scarcely adopted by pediatric surgeons. Its feasibility is supported by the four reported major lung resections plus the four cases added on by our series. Thanks to a more rapid learning curve over conventional VATS, the uniportal technique could be accessible to a wider number of centers.

Prehospital Pediatric Respiratory Distress and Airway Management Interventions: An NAEMSP Position Statement and Resource Document

Devices and techniques such as bag-valve-mask ventilation, endotracheal intubation, supraglottic airway devices, and noninvasive ventilation offer important tools for airway management in critically ill EMS patients. Over the past decade the tools, technology, and strategies used to assess and manage pediatric respiratory and airway emergencies have evolved, and evidence regarding their use continues to grow. NAEMSP recommends: Methods and tools used to properly size pediatric equipment for ages ranging from newborns to adolescents should be available to all EMS clinicians. All pediatric equipment should be routinely checked and clearly identifiable in EMS equipment supply bags and vehicles. EMS agencies should train and equip their clinicians with age-appropriate pulse oximetry and capnography equipment to aid in the assessment and management of pediatric respiratory distress and airway emergencies. EMS agencies should emphasize noninvasive positive pressure ventilation and effective bag-valve-mask ventilation strategies in children. Supraglottic airways can be used as primary or secondary airway management interventions for pediatric respiratory failure and cardiac arrest in the EMS setting. Pediatric endotracheal intubation has unclear benefit in the EMS setting. Advanced approaches to pediatric ETI including drug-assisted airway management, apneic oxygenation, and use of direct and video laryngoscopy require further research to more clearly define their risks and benefits prior to widespread implementation. If considering the use of pediatric endotracheal intubation, the EMS medical director must ensure the program provides pediatric-specific initial training and ongoing competency and quality management activities to ensure that EMS clinicians attain and maintain mastery of the intervention. Paramedic use of direct laryngoscopy paired with Magill forceps to facilitate foreign body removal in the pediatric patient should be maintained even when pediatric endotracheal intubation is not approved as a local clinical intervention.

What's missing in sex chromosome aneuploidies? Representation and inclusion

What's missing in sex chromosome aneuploidies? Representation and inclusion