Pediatric Procedures Research Articles

Results and analysis of examination doses for paediatric CT procedures based on a nationwide survey in China.

To report the results of a dose survey conducted across 31 provinces in mainland China from 2017 to 2018 and to analyse the dose level to determine the national diagnostic reference levels (DRLs) for paediatric CT procedures. At least ten patients for each age group (0- < 1, 1- < 5, 5- < 10, 10- < 15years) and each procedure (head, chest and abdomen) for each CT scanner were selected from four to eight hospitals in each province. The dose information (CTDIvol and DLP) was collected from the HIS or RIS-PACS systems. The median values in each CT scanner were considered the representative dose values for the paediatric patients in CT scanning. The national DRLs were estimated based on the 75th percentile distribution of the median values. A total of 24,395 patients and 319 CT scanners were investigated across 262 hospitals. For paediatric CT scanning in 4 different age groups, the median (P50) and the 75th percentile (P75) of CTDIvol and DLP for each scanning procedure were calculated and reported. National DRLs were then proposed for each procedure and age group. The dose level of CT scanning for children in mainland China was reported for the first time. The DRLs for paediatric CT in the present study are similar to those in some Asian countries but higher than those in European countries. The paediatric CT is an extensively used tool in diagnosing paediatric disease; however, children are more sensitive to radiation. Establishing the diagnostic reference level of paediatric CT examination is necessary to reduce the dose of CT in children and promote the optimisation of medical exposure. • The DRLs for 3 paediatric CT procedures (head, chest and abdomen) and 4 age groups (0- < 1, 1- < 5, 5- < 10, 10- < 15years) were proposed in mainland China first time. • The examination parameter and dose for children need to be further optimised in China, especially to lower the tube voltage in paediatric CT.

The effects of gastric acid on pediatric restorative materials: SEM analysis.

In this study, we aimed to demonstrate changes in the surface roughness and microhardness of three different restorative materials routinely used in pediatric dentistry (composite, compomer and resin-modified glass ionomer cement (RMCIS)) in response to continuous daily exposure to gastric acid. Twelve samples of each of type of restorative material were prepared. Eleven of the specimens were included in the gastric acid cycle. The microhardness and surface roughness of ten samples were measured before and after the cycle. Another sample included in the cycle was compared with the sample not included in the cycle by scanning electron microscopy (SEM). There was a significant difference between the groups in terms of roughness scores following gastric acid cycle (p = 0.039). RMCIS material possessed the highest roughness value. A significant difference was identified in terms of microhardness levels before and after the gastric acid cycle (p = 0.001). The most significant change was observed in the compomer material. SEM analysis, performed after the gastric acid cycle, revealed that most cracks were identified in RMCIS material; this was followed by compomer and composite materials, respectively. Our analysis indicates that the restorative materials used frequently in pediatric dental procedures, show increased surface roughness and reduced microhardness when exposed to gastric acid.

The eXpectations of Parents regarding Anesthesiology Study (XPAS) from a parental perspective: a two-phase observational cross-sectional cohort study.

Uncertainty concerning anesthetic procedures and risks in children requiring anesthesia may cause concerns in parents and caregivers. To explore parental expectations and experiences regarding their child's anesthesia using questionnaires designed with parental input. This observational cross-sectional cohort study included parents (including caregivers) of children undergoing anesthesia in a tertiary pediatric referral university hospital. The study consisted of two phases. In Phase 1, we developed three questionnaires with parental involvement through a focus group discussion and individual interviews. The questionnaires focused on parental satisfaction, knowledge, concerns, and need for preparation regarding their child's anesthesia. In Phase 2, independent samples of parents completed the questionnaires at three time points: before the preanesthesia assessment (T1), 2 days after the preanesthesia assessment (T2), and 4 days after the anesthetic procedure (T3). In Phase 1, 22 parents were involved in the development of the questionnaires. The three questionnaires contained 43 questions in total, of which 10 had been proposed by parents. In Phase 2, 78% (474 out of 934) parents participated at T1, 36% (610 out of 1705), at T2 and 34% (546 out of 1622) at T3. Parental satisfaction scores were rated on a visual analogue scale for the preanesthesia assessment with a median of 87/100, and with a median of 90/100 for the anesthetic procedure (0: not satisfied and 100: satisfied). Parental concerns were rated with a median of 50/100 (0: no concerns and 100: extremely concerned). Parental answers from the questionnaire at T2 revealed significant knowledge deficits, with only 73% reporting that the anesthesiologist was a physician. Parents preferred to receive more information about the procedure, especially regarding the intended effects and side effects of anesthesia. Overall, parental satisfaction scores regarding the pediatric anesthesiology procedure were high, with a minority expressing concerns. Parents indicated a preference for their child's anesthesiologist to visit them both before and after the anesthetic procedure. Parental expectations regarding anesthesia did not completely correspond with the information provided; more information from the clinician about the intended effects and side effects of anesthesia was desired.

Reviewing and Exploring the Prospects of Platelet-Rich Plasma (PRP) Therapy in the Context of Pediatric Surgical Wound Management

Pediatric surgical wound care is a critical aspect of medical practice, necessitating innovative approaches to optimize healing and minimize complications. Platelet-rich plasma (PRP) therapy has emerged as a promising intervention for enhancing wound healing in pediatric patients. This review comprehensively evaluates the efficacy, underlying mechanisms, and challenges associated with platelet-rich plasma (PRP) therapy in the context of pediatric surgical wounds. Platelet-rich plasma (PRP), a biologic concentrate enriched with growth factors and cytokines, plays a pivotal role in wound healing by promoting cell proliferation, differentiation, and tissue regeneration. This article explores the mechanisms of action of this therapy in detail, focusing on its immunomodulatory effects and interaction with growth factors, and highlighting the significance of factors influencing platelet-rich plasma (PRP) efficacy, This article also gives examples of platelet-rich plasma (PRP) therapy in various pediatric surgical procedures, summarizes outcomes from clinical studies and trials, and addresses safety concerns and potential adverse effects associated with platelet-rich plasma (PRP) therapy in pediatric surgical wound management. In conclusion, this review underscores the potential of platelet-rich plasma (PRP) therapy as an adjunctive treatment in pediatric surgical wound care. By elucidating its mechanisms, clinical efficacy, and challenges, the review provides insights for clinicians and researchers to guide evidence-based practice. Recommendations for future research and the integration of platelet-rich plasma (PRP) therapy into clinical guidelines emphasize the importance of refining protocols, ensuring cost-effectiveness, and adhering to ethical standards in pediatric surgical wound care.

Nurse-led Preoperative Education With Home-based Internet Resources for Pediatric Patients and Their Parents

The majority of pediatric patients and their parents experience fear and anxiety related to their surgical experience. Traditionally, anesthesia providers addressed this anxiety with pharmacologic therapy, such as benzodiazepines, to provide amnesia and anxiolysis. However, this approach has been questioned due to the potential for developmental neurotoxicity, among other drawbacks. Further, the pharmacological approach does not remove preexisting anxiety that the child and parent experience before arrival and during check-in. Pediatric and parental preparation before surgery is an important step that continues to be inconsistently addressed, particularly in lower-resource community hospitals where the majority of routine pediatric outpatient procedures occur. This care gap provides an opportunity for preanesthesia nurses to intervene with valid, evidence-based preoperative education tools aimed at pediatric patients and their parents. Providing these resources before the day of surgery allows time for child-directed, at-home practice as often as the parent(s) and patient choose. Use of available resources from a leading children’s hospital, nurses can create a tailored, developmentally appropriate preoperative education plan for pediatric patients and their parents, providing families with the power to create a positive surgical experience.

Reducing Retained Foreign Objects in the Operating Room: A Quality Improvement Initiative.

Although the incidence of pediatric retained foreign objects (RFOs) during surgery is diminutive (1/32,000), RFOs are often the most common sentinel events reported. In 2021, our institution noted an increase in RFOs evidenced by a substantial decrease in days between events. We aimed to minimize the incidence of RFO which was measured as an increase of days between events at our institution by implementation of a Quality Improvement initiative. This effort was conducted across 4 surgical centers within a tertiary children's healthcare system in December 2021. Patients undergoing surgery within this healthcare system across all surgical specialties were included. The quality improvement initiative was developed by a multidisciplinary team and included 6 steps focusing on quiet time, minimizing interruptions, and closed-loop communication during final surgical count. Seven Plan-Do-Study-Act cycles were used to test, refine, and implement the protocol. Adherence to the final surgical count protocol was monitored throughout the study period. In 2021, before protocol implementation, average time between RFO events was 29 days. After implementation of our quality initiative, the final surgical count protocol, we improved to 451 days between RFO events by February 2023, exceeding the upper control limit (235 days). After implementation, the number of RFO events dropped from 7 in 2021 to 0 in 2022. Adherence to the final surgical count protocol implementation was 96.4% by the end of cycle 7. RFOs during pediatric surgical procedures can be successfully reduced using quality improvement methodology focusing on standardizing the procedure of the final surgical count.

The Impact of Parental Presence on Invasive Procedures in the Pediatric Emergency Department: A Prospective Study.

Parental presence during invasive pediatric procedures is controversial, and its benefits are under-researched. The objective of this study was to assess the effects of parental presence during invasive procedures on the parents themselves and the physician performing the procedure. This prospective study was conducted at a single tertiary center in Jerusalem, Israel. During 10 shifts, all physicians and the families of patients who underwent invasive procedures in the pediatric emergency department (PED) were asked to fill in questionnaires related to their experiences. A total of 98 parental questionnaires and 101 physician questionnaires were collected. The most commonly performed procedures were laceration repair (65%) and abscess drainage (18%). Sedation was required in 75% of cases. In total, 73% of the cited family members were present during these procedures. The main reason for refusing to allow family members access was the physicians' concern that the procedure would be hard for parents to watch. However, in more than 85% of cases, the physicians felt that the presence of a family member contributed to the success of the procedure, augmented the child's sense of safety and lessened the family members' feelings of anxiety. All parents who opted to be present during the procedure felt very satisfied, compared to 67% of parents who were not present (p < 0.0001). When asked if, in retrospect, they would have made the same decision, 100% of the parents who were present during the procedure indicated that they would have made the same decision, compared to only 68% of the parents who were not present (p < 0.001). Overall, these findings highlight the positive effects of parental presence during invasive procedures performed in the PED, even when procedures were performed under sedation. Encouraging parental attendance during invasive procedures may, thus, enhance family-centered practices in the PED.

Endoscopic coblation adenoidectomy and conventional adenoidectomy: a comparative study

Background: Adenoidectomy is most common paediatric surgical procedures. Commonly used methods for adenoidectomy are conventional curettage adenoidectomy and endoscopic coblator assisted adenoidectomy. The technique of coblation adenoidectomy has considerable influence on the duration of surgery, the blood lost intra operatively, pain on the first postoperative period. Methods: Sample selected for study were children of age group 3 to 11 years attending ENT OPD with clinical signs of adenoid hypertrophy, who underwent adenoidectomy during the time period from October 2019 to June 2021. We compared the efficacy of ECA with CCA based on the intra-operative (operative time and bleeding) and post-operative parameters (pain on the first post operative day). Results: Our study revealed that intra operative bleeding was more in CCA compared to ECA (p&lt;0.001). ECA took more operative time than CCA group (p&lt;0.001). Pain on the first post-operative day was more in CCA than ECA. Conclusions: Primary objective was comparison of intra operative bleeding among both groups and the outcome was blood loss in ECA was less than CCA. Secondary objective was comparison of operative duration and pain on the first post-operative day and the outcome was, operative duration was less in CCA and pain in the first post-operative day was more in CCA. Our conclusion is that ECA was efficient on the basis of intra operative blood loss and post- operative pain in the first day. CCA was effective in operative duration.

Comparison between Tonsillectomy by Coblation, Bipolar and Surgical Dissection

Abstract Background Tonsillectomy is one of the most common paediatric surgical procedures performed worldwide. Although it is one of the most widely performed procedures in otorhinolaryngology, none of the commonly used techniques for tonsillectomy is considered optimal till now. Objective To compare coblation, bipolar diathermy, and surgical dissection approaches for tonsillectomy in terms of operative time, surgical blood loss, postoperative pain and the incidence of postoperative complications. Methods A systematic review and meta-analysis in accordance to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) statement. Guidelines and an electronic search of information was conducted to identify studies that compare between coblation, cold dissection and bipolar diathermy techniques. Results This study showed that bipolar diathermy tonsillectomy was the lowest risk of primary bleeding followed by coblation then cold dissection tonsillectomy but with insignificant difference. Coblation technique was the highest secondary bleeding risk followed by cold dissection and the lowest risk was figured in bipolar diathermy procedure also the difference did not reach statistical significance. Coblation tonsillectomy was the best technique regarding blood loss and operative time with significant difference in the comparison with cold dissection and insignificant in the comparison with bipolar diathermy. Because of using a different postoperative pain measures in the studies we could not pool its data, but the majority of studies showed that coblation technique was better as regard postoperative pain than cold dissection and bipolar diathermy. While there was no significant difference between cold dissection and bipolar diathermy in the most studies Conclusion Overall, bipolar diathermy procedure for tonsillectomy was considered the best technique regarding primary and secondary bleeding outcomes, but the difference did not reach statistical significance. Coblation procedure for tonsillectomy was considered the best technique regarding intraoperative blood loss with significant difference except in comparison between bipolar diathermy and coblation the difference was not significant. Coblation technique also considered the best one regarding operative time with significant difference in direct comparison between coblation and cold, and insignificant in other comparisons. By systematic review on 21 studies coblation technique shows less postoperative pain than cold dissection and bipolar diathermy in the majority of studies comparing coblation with every technique. And there was no significant difference between studies compared cold dissection with bipolar diathermy regarding postoperative pain.

Safety of pediatric cardiac catheterisation procedures performed in rural India in a catheterisation lab setup for adult work.

Safety of pediatric cardiac catheterisation procedures performed in rural India in a catheterisation lab setup for adult work.

Evaluation and comparison of anxiety levels after using Guided Imagery technique for relaxation and modified Guided Imagery-Hypnotherapy technique in 6 to 14 year-old children undergoing local anesthesia administration

Anxiety has been defined as a “vague, unpleasant feeling accompanied by a premonition that something undesirable is about to happen”. Dental anxiety is driven by a strong negative or unpleasant emotion towards a dental office or dental procedures. Children with a high level of dental anxiety are more resistant to treatment, and due to this avoidance in dental care can lead to needing more dental treatments. The quality of a treatment being carried out, as well as what materials that are to be used, is directly influenced by a child’s level of cooperation and ability to follow instructions. Behaviour management techniques play a major role during all paediatric treatment procedures, and it is the clinician who is responsible to properly and safely guide the child’s behaviour. Guided Imagery is a visual and sensory-based complementary and alternative medicine (CAM) technique. In hypnotherapy which is a type of mind-body intervention; increased suggestibility is used in the treatment of a medical or psychological disease or condition. Therefore, there is a need of a newer modality based on guided imagery and hypnotherapy to be used in as a whole or in tandem with other conventional behaviour management techniques. The aim of this study is to evaluate and compare anxiety levels after using Guided Imagery for relaxation and modified Guided Imagery-Hypnotherapy techniques in 6-14 year-old children undergoing local anesthesia administration.

Applications of indocyanine green (ICG) fluorescence technology in open surgery: preliminary experience in pediatric surgery.

Indocyanine green fluorescence technology (ICG) in pediatric minimally invasive surgery has undergone an important improvement in the last 5 years. However, its use in open surgery is still limited. In this paper, we aim to report our preliminary experience with Rubina® lens ICG fluorescence technology in combination with the IMAGE1 S™ system from KARL STORZ in open excision of masses in children. The records of 18 patients undergoing open surgery for head, neck and thorax masses between September and November 2022 were retrospectively reviewed. Rubina® lens ICG fluorescence technology system was used in all the cases. In 10 cases we adopted the holding arm system and in 8 cases the hand-held technique. Data about patients' demographics, surgery and outcomes were collected and analyzed through the following criteria: mass localization, intraoperative time (min), ICG administration (ml), intraoperative complications, postoperative complications. A total of 18 patients were operated: 4 thyroglossal duct cysts, 3 supraorbital cysts, 2 neck masses, 2 pre-auricular and 2 scalp cysts, 2 gynecomastias, 2 lymphangiomas, 1 nose mass. In all the cases, intralesional injection of 0.5-1 ml of ICG solution was performed peri-operatively. Mean operative time was 58.4 min (35-134 min). Postoperative complications included seroma formation in 2 cases. Surgical pathology reports confirmed complete mass excision in all the cases. Based on our preliminary experience, ICG fluorescence guided surgery using Rubina® lens system was very helpful also in open surgery procedures. Rubina® lens system permits to have a very low complication rate, a time-saving surgery, a real time reliability of anatomic structures and an excellent clinical safety. In our experience, holding arm system seems more comfortable than hand-held system. However, further cases need to be performed to evaluate the exact role and to identify new indications of this technique in open pediatric surgical procedures.

Opioid Use, Disposition, and Parent Satisfaction Following Common Pediatric Surgical Procedures.

There is wide variability in prescribing practices among providers, even for patients undergoing the same operations. Our study aims to analyze the variation in opioid prescription practices using a patient-centered approach to establish more appropriate prescribing guidelines for health care providers. We conducted phone surveys 30days after surgery to assess patient-reported opioid use. Over a two-year collection period, we identified patients that had undergone common outpatient pediatric surgery procedures in our 4-surgeon group. Included in the survey tool was the narcotic prescribed (if any), the amount used, and patient/family rating of pain control. We collected data for 189 separate procedures (88 umbilical hernias, 30 laparoscopic inguinal hernias, 2 open inguinal hernias, 41 appendectomies, 15 laparoscopic cholecystectomies, and 13 pectus bar removals). Patient age ranged from less than 1month to 246months. 83.5% of patients had a narcotic prescribed. The average number of doses used was 4, ranging from 0 (11.3%) to 30 (1.5%). 72.6% of families surveyed felt pain control was appropriate. However, 19.6% did feel they received too much pain medication. 10.6% reported completing their entire prescription; however, only 13.6% of families with excess narcotics reported proper disposal. Despite heightened awareness of the opioid epidemic, there is still a poor understanding of appropriate pain control regimens in the pediatric surgical population. We demonstrate that most patients are discharged home with excess opioids and that many families save the leftover pills/liquid. Further research and education are encouraged to limit the use of opioids in standard pediatric surgical procedures.

Perspectives on preparedness for pediatric emergencies after residency: A needs assessment.

General emergency physicians provide most pediatric emergency care in the United States yet report more challenges managing emergencies in children than adults. Recommendations for standardized pediatric emergency medicine (PEM) curricula to address educational gaps due to variations in pediatric exposure during emergency medicine (EM) training lack learner input. This study surveyed senior EM residents and recent graduates about their perceived preparedness to manage pediatric emergencies to better inform PEM curricula design. In 2021, senior EM residents and graduates from the classes of 2020 and 2019 across eight EM programs with PEM rotations at the same children's hospital were recruited and surveyed electronically to assess perceived preparedness for 42 pediatric emergencies and procedures by age: infants under 1 year, toddlers, and children over 4 years. Preparedness was reported on a 5-point Likert scale with 1 or 2 defined as "unprepared." A chi-square test of independence compared the proportion of respondents unprepared to manage each condition across age groups, and a p-value < 0.05 demonstrated significance. The response rate was 53% (129/242), with a higher response rate from senior residents (65%). Respondents reported feeling unprepared to manage more emergency conditions in infants compared to other age groups. Respondents felt least prepared to manage inborn errors of metabolism and congenital heart disease, with 45%-68% unprepared for these conditions across ages. A heat map compared senior residents to recent graduates. More graduates reported feeling unprepared for major trauma, impending respiratory failure, and pediatric advanced life support algorithms. This study, describing the perspective of EM senior residents and recent graduates, offers unique insights into PEM curricular needs during EM training. Future PEM curricula should target infant complaints and conditions with lower preparedness scores across ages. Other centers training EM residents could use our findings and methods to bolster PEM curricula.

Changing Landscape of Routine Pediatric Surgery for Rural and Urban Children: A Report From the Child Health Evaluation of Surgical Services (CHESS) Group.

To describe the changes to routine pediatric surgical care over the past 2 decades for children living in urban and rural environments. A knowledge gaps exists regarding trends in the location where routine pediatric surgical care is provided to children from urban and rural environments over time. Children (age 0-18) undergoing 7 common surgeries were identified using State Inpatient Databases (SID, 2002-2017). Rural-Urban Commuting Area codes were used to classify patient and hospital zip codes. Multivariable regression models for distance traveled >60 miles and transfer status were used to compare rural and urban populations, adjusting for year, age, sex, race, and insurance status. Among 143,467 children, 13% lived in rural zip codes. The distance traveled for care increased for both rural and urban children for all procedures but significantly more for the rural cohort (eg, 102% vs 30%, P <0.001, cholecystectomy). Transfers also increased for rural children (eg, transfers for appendectomy increased from 1% in 2002 to 23% in 2017, P <0.001). Factors associated with the need to travel >60 miles included year [adjusted odds ratio (aOR)=2.18, 95% CI: 1.94-2.46: 2017 vs 2002], rural residence (aOR=6.55, 95% CI: 6.11-7.01), age less than 5 years (aOR=2.17, 95% CI: 1.92-2.46), and Medicaid insurance (aOR=1.35, 95% CI: 1.26-1.45). Factors associated with transfer included year (aOR=5.77, 95% CI: 5.26-6.33: 2017 vs 2002), rural residence (aOR=1.47, 95% CI: 1.39-1.56), age less than 10 years (aOR=2.34, 95% CI: 2.15-2.54), and Medicaid insurance (aOR=1.49, 95% CI: 1.42-1.46). Rural children, younger age, and those on Medicaid disproportionately traveled greater distances and were more frequently transferred for common pediatric surgical procedures.

Umbilical hernioplasty under transverse abdominis plane and rectus block: a case report

Umbilical hernia is a common diagnosis in surgery. Approximately, 10% of all abdominal wall hernias are defined as umbilical hernia. The European hernia society defines a primary umbilical hernia as a ventral hernia present at birth or developed spontaneously without trauma to the abdominal wall as the cause of the hernia and with its center at the umbilicus. Rectus sheath block has been traditionally used to provide analgesia for anterior abdominal wall surgeries, as it spares the visceral pain component. It’s been used efficiently for intraoperative, post-operative analgesia, providing stable hemodynamic. The emergence of ultrasound has potentially increased the rate of success, while avoiding complications like bleeding, peritoneal puncture, visceral injury. Rectus sheath block is emerging as a valuable regional. Anesthesia technique. It can be used as an adjuvant or alternative to central neuraxial block and general anesthesia for surgeries of anterior abdominal wall, pediatric umbilical hernia, incisional hernia, laparoscopic surgeries and abdominal gynecological procedures and for analgesia. This is a case report of 47-year-old male with multiple comorbidities posted for umbilical hernia repair performed under combined rectus sheath and tap block.

Improving Procedural Skill Confidence in Pediatric Residents: A Longitudinal Simulation-Based Workshop Curriculum.

Exit surveys among our pediatric residency graduates found 50% were not confident performing required procedures. While procedural competency poses many curricular challenges, simulation is an effective educational modality many programs have adopted, though often only through onetime workshops limited to single procedures, clinical settings, or levels of training. We sought to develop a comprehensive, recurring, yearlong, simulation-based curriculum covering many important pediatric procedures. We created a longitudinal curriculum of recurring monthly workshops using both low- and high-fidelity simulators, highlighting 17 pediatric procedures. Comprehensive facilitator guides contained equipment lists, instructions, competency checklists, and quizzes for each workshop. Correlation between attendance and confidence was assessed for skills in which residents attended two or more workshops on the same skill. ACGME exit surveys compared graduates' confidence regarding procedural skills before and after curriculum implementation. On exit surveys, graduates who agreed or strongly agreed to feeling comfortable with the procedures in our curriculum improved from 50% to 66% after 2 years, and those who disagreed or strongly disagreed decreased from 40% to 22%. A positive correlation existed between repeated workshop attendance and confidence in many procedures (R2 range, .60-.99). Longitudinal simulation is an effective educational modality that increases learner confidence in performing procedures. Our curriculum addresses adult learners' need for repetition and can be adopted by other programs to improve graduates' confidence. The curriculum's sustainability is underscored by use of cost-reducing low-fidelity simulators and comprehensive guides that allow any instructor to conduct the workshop.

Elaboration and development of a realistic 3D printed model for training in ultrasound-guided placement of peripheral central venous catheter in children.

Simulation for training is becoming a trend topic worldwide, even if its applications are commonly limited to adulthood. Ultrasound-guided procedures require practice and experience-especially in the pediatric field, where the small size of the involved anatomical structures poses major problems. In this context, a realistic 3D printed pediatric phantom for training of the ultrasound-guided placement of peripheral central venous catheters in children was developed. Starting from Computed Tomography scans of an 8 years-old girl, her left arm was virtually reconstructed-including bones, arteries, and veins-through a semi-automatic segmentation process. According to preliminary results, the most suitable 3D printing technologies to reproduce the different anatomical structures of interest were selected, considering both direct and indirect 3D printing techniques. Experienced operators were asked to evaluate the efficacy of the final model through a dedicated questionnaire. Vessels produced through indirect 3D printing latex dipping technique exhibited the best echogenicity, thickness, and mechanical properties to mimic real children's venous vessels, while arteries-not treated and/or punctured during the procedure-were directly 3D printed through Material Jetting technology. An external mold-mimicking the arm skin-was 3D printed and a silicone-based mixture was poured to reproduce real patient's soft tissues. Twenty expert specialists were asked to perform the final model's validation. The phantom was rated as highly realistic in terms of morphology and functionality for the overall simulation, especially for what concerns vessels and soft tissues' response to puncturing. On the other hand, the involved structures' US appearance showed the lower score. The present work shows the feasibility of a patient-specific 3D printed phantom for simulation and training in pediatric ultrasound-guided procedures.

Price spillovers and specialization in health care: The case of children's hospitals.

Specialty hospitals tend to negotiate higher commercial insurance payments, even for relatively routine procedures with comparable clinical quality across hospital types. How specialty hospitals can maintain such a price premium remains an open question. In this paper, we examine a potential (horizontal) differentiation effect in which patients perceive specialty hospitals as sufficiently distinct from other hospitals, so that specialty hospitals effectively compete in a separate market from general acute care hospitals. We estimate this effect in the context of routine pediatric procedures offered by both specialty children's hospitals as well as general acute care hospitals, and we find strong empirical evidence of a differentiation effect in which specialty children's hospitals appear largely immune to competitive forces from non-children's hospitals.

Spinal versus general anesthesia: Comparing outcomes in pediatric patients undergoing urologic procedures

Available literature comparing spinal anesthesia (SA) to general anesthesia (GA) in the pediatric population describes multiple benefits in appropriately selected patients including cost reduction, lower incidence of complications, and shorter operative times. In patients undergoing urologic procedures, data are sparse. Our goal was to expand on the paucity of existing urologic literature as SA appears to be uniquely suited for a substantial number of its common pediatric procedures. Within a single institution, patients who had a urologic procedure performed under SA between May 2019 and July 2021 and were less than 18 months old were compared with a matched cohort of patients who had GA. The SA and GA groups were compared by two-sample t-tests, chi-square test for independence, and Fisher's exact test. There were a total of 184 SA and 202GA patients. There was no significant difference in the demographics except that SA patients were younger and weighed less than GA patients. The patients in the SA group needed less opioids both during the surgery (0% vs 26.1% p N/A) and in the immediate postoperative period when compared with GA patients (0% vs 18.2% p N/A). The patients who had SA had fewer complications necessitating PICU admission, or cancellation of surgery (0% vs 6.8% p=0.03). Total anesthesia and emergence time were lower for SA patients (41 vs 50.2 p=0.001 & 3.4 vs 6.1 p=0.001). Both surgery and total OR time were not different between the groups (37.6 vs 35.5 p=0.35 and 56.3 vs 54.4 p=0.49). Overall, raw material cost was also found to be lower per procedure in the SA group vs the GA group ($8.90 vs $38.8: 77% reduction). Adjusted total mean costs for the surgery were not different between groups. The reduction in opioid use postoperatively also suggests reduced cost in the management of postoperative pain in the SA group. Total anesthesia time, opioid use, and serious complications were all significantly lower in the SA group. We did not find significant difference in total surgery cost between two groups. However, patients who had SA had better pain control and needed less rescue analgesics in the immediate postoperative period. No patients in either group were sent home with opioids. Spinal anesthesia was found to be an equally effective and appropriate alternative to GA with many proposed benefits for common pediatric urologic procedures. With further research, SA may prove to be a safer alternative in patients at risk for complications related to GA general anesthesia while also offering a cost benefit.