Microsurgery in pediatric upper limb reconstructions: An overview

The use of microsurgery has spread during the last decades, making resolvable many complex defects considered hitherto inapproachable. Although the small vessel diameter in children was initially considered a technical limitation, the increase in microsurgical expertise over the past three decades allowed us to manage many pediatric conditions by means of free tissue transfers. Pediatric microsurgery has been shown to be feasible, gaining a prominent place in the treatment of children affected by limb malformations, tumors, nerve injuries, and post-traumatic defects. The aim of this current concepts review is to describe the more frequent pediatric upper limb conditions in which the use of microsurgical reconstructions should be considered in the range of treatment options.     

Anesthetic concerns for pediatric patients in the era of COVID‐19

After a novel human coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), was reported in China in December 2019, the disease quickly reached pandemic level. On January 30, 2020, the World Health Organization (WHO) declared that the SARS‐CoV‐2 outbreak constituted a Public Health Emergency of International Concern. The caseload has increased exponentially, with WHO reporting 182 000 global cases by March 17, 2020, and over 2.6 million by 23 April. The clinical situation is complex, with children presenting different clinical features compared to adults. Several articles with recommendations on the anesthetic management of adult patients with COVID‐19 have been published, but no specific recommendations for pediatric anesthesiologists have been made yet. This article addresses specific concerns for the anesthetic management of the pediatric population with COVID‐19.     

Pain relief in the palm of your hand: Harnessing mobile health to manage pediatric pain

The development and implementation of mobile health (mHealth) interventions provide an opportunity for more optimal management of pediatric pain in the home setting. Leveraging the popularity, mobility, and technological capabilities of digital mobile devices may reduce pediatric pain. Several mHealth applications have already been developed that target the reduction of acute and chronic pediatric pain by digitally delivering intervention strategies in an engaging manner, accumulating pain assessment data, facilitating patient‐provider communication, and providing interactive training. Although several mHealth programs have begun to make strides in the management of pediatric pain, there are still many more possibilities for improvement as greater development and adoption of mHealth practices is on the horizon. Recommendations are provided that advocate for continued advancement of pediatric pain mHealth implementation with an emphasis on robust scientific evaluation, a structured approach to development and design elements that enhance engagement. Increased awareness about the positive influence of mHealth along with the encouragement of researchers and healthcare providers to promote and develop mHealth programs has the potential to transform pediatric pain management. This merger of evidence‐based pain management strategies and digital technology positions pediatric mHealth to have a profound impact by effectively augmenting standard of care and benefiting healthcare providers, parents, and especially children in need.     

A quantitative analysis of the spatial and temporal evolution patterns of the bluetongue virus outbreak in the island of Lesvos,Greece, in 2014

Bluetongue virus (BTV) causes an infectious disease called bluetongue, a vector‐borne viral disease of ruminants, which has major implications and causes severe economic damage due to its effect on livestock. These economic costs are mostly ascribed to the trade restrictions imposed during the epidemic period. In August 2014, an epidemic of bluetongue occurred in the island of Lesvos, Greece. The epidemic was severe and evolved over time, lasting until December 2014. The total cases of infected farms were 490, including a total number of 136,368 small ruminants. In this paper, we describe a bluetongue virus serotype 4 (BTV‐4) epidemic and utilize Bayesian epidemic models to capture the spatio‐temporal spread of the disease. Our study provides important insights into the drivers of BTV transmission and has implications for designing control strategies. The results showed strong spatial autocorrelations, with BTV being more likely to spread between farms located nearby. The spatial modelling results proposed a certain spatial radius (~12 km) around the onset of a similar epidemic for imposing restrictions on animal movement, which can be sufficient for the control of the disease and limit economic damage.     

Proposal for the management of the unexpected difficult pediatric airway

The incidence of unanticipated difficult or failed airway in otherwise healthy children is rare, and routine airway management in pediatric patients is easy in experienced hands. However, difficulties with airway management in healthy children are not infrequent in nonpediatric anesthetists and are a main reason for pediatric anesthesia‐related morbidity and mortality. Clear concepts and strategies are, therefore, required to maintain oxygenation and ventilation in children. Several complicated algorithms for the management of the unanticipated difficult adult and pediatric airway have been proposed, but a simple structured algorithm for the pediatric patient with unanticipated difficult airway is missing. This paper proposes a simple step‐wise algorithm for the unexpected difficult pediatric airway based on an adult Difficult Airway Society (DAS) protocol, discusses the role of recently introduced airway devices, and suggests a content of a pediatric airway trolley. It is intended as an easy to memorize and a practical guide for the anesthetist only occasionally involved in pediatric anesthesia care as well as a call to stimulate discussion about the management of the unanticipated difficult pediatric airway.     

Simulation in pediatric anesthesiology

Simulation‐based training, research and quality initiatives are expanding in pediatric anesthesiology just as in other medical specialties. Various modalities are available, from task trainers to standardized patients, and from computer‐based simulations to mannequins. Computer‐controlled mannequins can simulate pediatric vital signs with reasonable reliability; however the fidelity of skin temperature and color change, airway reflexes and breath and heart sounds remains rudimentary. Current pediatric mannequins are utilized in simulation centers, throughout hospitals in‐situ, at national meetings for continuing medical education and in research into individual and team performance. Ongoing efforts by pediatric anesthesiologists dedicated to using simulation to improve patient care and educational delivery will result in further dissemination of this technology. Health care professionals who provide complex, subspecialty care to children require a curriculum supported by an active learning environment where skills directly relevant to pediatric care can be developed. The approach is not only the most effective method to educate adult learners, but meets calls for education reform and offers the potential to guide efforts toward evaluating competence. Simulation addresses patient safety imperatives by providing a method for trainees to develop skills and experience in various management strategies, without risk to the health and life of a child. A curriculum that provides pediatric anesthesiologists with the range of skills required in clinical practice settings must include a relatively broad range of task‐training devises and electromechanical mannequins. Challenges remain in defining the best integration of this modality into training and clinical practice to meet the needs of pediatric patients.     

Assessing the potential spread and maintenance of foot‐and‐mouth disease virus infection in wild ungulates: general principles and application to a specific scenario in Thrace

Foot‐and‐mouth disease (FMD), due to infection with serotype O virus, occurred in wild boar and within eleven outbreaks in domestic livestock in the south‐east of Bulgaria, Thrace region, in 2011. Hence, the issue of the potential for the spread and maintenance of FMD virus (FMDV) infection in a population of wild ungulates became important. This assessment focused on the spread and maintenance of FMDV infection within a hypothetical wild boar and deer population in an environment, which is characterized by a climate transitional between Mediterranean and continental and variable wildlife population densities. The assessment was based on three aspects: (i) a systematic review of the literature focusing on experimental infection studies to identify the parameters describing the duration of FMDV infection in deer and wild boar, as well as observational studies assessing the occurrence of FMDV infection in wild deer and wild boar populations, (ii) prevalence survey data of wild boar and deer in Bulgaria and Turkey and (iii) an epidemiological model, simulating the host‐to‐host spread of FMDV infections. It is concluded, based on all three aspects, that the wildlife population in Thrace, and so wildlife populations in similar ecological settings, are probably not able to maintain FMD in the long term in the absence of FMDV infection in the domestic host population. However, limited spread of FMDV infection in time and space in the wildlife populations can occur. If there is a continued cross‐over of FMDV between domestic and wildlife populations or a higher population density, virus circulation may be prolonged.     

A practical approach to cerebral near‐infrared spectroscopy (NIRS) directed hemodynamic management in noncardiac pediatric anesthesia

Safeguarding cerebral function is of major importance during pediatric anesthesia. Premature, ex‐premature, and full‐term neonates can be vulnerable to physiological changes that occur during anesthesia and surgery. Data from studies performed during pediatric cardiac surgery and in neonatal/pediatric intensive care units have shown the benefits of near‐infrared spectroscopy (NIRS) monitoring of regional cerebral oxygenation (c‐rSO₂). However, NIRS monitoring is seldom used during noncardiac pediatric anesthesia. Despite compelling evidence that blood pressure does not reflect end‐organ perfusion, it is still regarded as the most important determinant of cerebral perfusion and the most relevant hemodynamic management target parameter by most (pediatric) anesthetists. The principle of NIRS monitoring is not self‐explanatory and sometimes seems even counterintuitive, which may explain why many anesthesiologists are reserved regarding its use. The first part of this paper is dedicated to a clinical introduction to NIRS monitoring. Despite scientific efforts, it has not yet been possible to define individual lower limit c‐rSO₂ values and it is unlikely this will succeed in the near future. Nonetheless, published treatment algorithms usually specify c‐rSO₂ values which may be associated with cerebral hypoxia. Our treatment guideline for maintaining sufficient cerebral oxygenation differs fundamentally from all previously published approaches. We define a baseline c‐rSO₂ value, registered in the awake child prior to anesthesia induction, as the lowest acceptable limit during anesthesia and surgery. The cerebral rSO₂ is the single target parameter, while blood pressure, heart rate, P_aCO₂, and SaO₂ are major parameters that determine the c‐rSO2. Cerebral NIRS monitoring, interpreted together with its continuously available contributing parameters, may help avoid potentially harmful episodes of cerebral desaturation in anesthetized pediatric patients.     

Novel real‐time feedback and integrated simulation model for teaching and evaluating ultrasound‐guided regional anesthesia skills in pediatric anesthesia trainees

Objectives: To assess, teach, and improve core competencies and skills sets associated with ultrasound‐guided regional anesthesia (UGRA) of pediatric anesthesia trainees. Aim: To effectively assess and improve UGRA‐associated cognitive and technical skills and proficiency of pediatric anesthesia trainees using simulators and real‐time feedback. Background: Ultrasound usage has been increasingly adopted by anesthesiologists to perform regional anesthesia. Pediatric UGRA performance significantly lags behind adult UGRA practice. Lack of effective UGRA training is the major reason for this unfortunate lag. Integration of ultrasound imaging, target location, and needling skills are crucial in safely performing UGRA. However, there are no standards to ensure proficiency in practice, nor in training. Methods: We implemented an UGRA instructional program for all trainees, in two parts. First, we used a unique training model for initial assessment and training of technical skills. Second, we used an instructional program that encompasses UGRA and equipment‐associated cognitive skills. After baseline assessment at 0 months, we retested these trainees at 6 and 12 months to identify progression of proficiency over time. Results: Cognitive and technical UGRA skills of trainees improved significantly over the course of time. UGRA performance average accuracy improved to 79% at 12 months from the baseline accuracy of 57%. Cognitive UGRA‐related skills of trainees improved from baseline results of 52.5–79.2% at 12 months. Conclusions: Implementing a multifaceted assessment and real‐time feedback‐based training has significantly improved UGRA‐related cognitive and technical skills and proficiency of pediatric anesthesia trainees.     

Review of the Global Distribution of Foot‐and‐Mouth Disease Virus from 2007 to 2014

Foot‐and‐mouth disease (FMD) virus affects livestock worldwide. There are seven different serotypes, each with a diversity of topotypes, genetic lineages and strains. Some lineages have different properties that may contribute to sporadic spread beyond their recognized endemic areas. The objective of this study was to review the most significant FMD epidemiological events that took place worldwide between 2007 and 2014. Severe epidemics were caused by FMD virus (FMDV) lineage O/Asia/Mya‐98 in Japan and South Korea in 2010, both previously free of disease. In India, where FMD is endemic, the most important event was the re‐emergence of lineage O/ME‐SA/Ind‐2001 in 2008. Notably, this lineage, normally restricted to India, Bangladesh, Nepal and Bhutan, was also found in Saudi Arabia and Libya in 2013 and has caused several outbreaks in Tunisia and Algeria in 2014–2015. In January 2011, FMDV‐positive wild boars were found in Bulgaria, where the disease last occurred in 1996, followed by 12 outbreaks in livestock infected with FMDV O/ME‐SA/PanAsia2. In 2012, FMDV SAT2 caused outbreaks in Egypt and the Palestinian Autonomous Territories. Another significant event was the emergence of FMDV Asia1 Sindh‐08 in the Middle East. In South America, one outbreak of FMDV serotype O, topotype Euro‐SA was reported in Paraguay in 2011, which was recognized as FMD‐free with vaccination at the time. Lessons learned from past events, point out the need for an integrated strategy that comprises coordinated global and regional efforts for FMDV control and surveillance. Specific local characteristics related to host, environment and virus that condition FMD occurrence should be carefully considered and incorporated to adapt appropriate strategies into local plans. In this review, we compiled relevant epidemiological FMD events to provide a global overview of the current situation. We further discussed current challenges present in different FMD areas.     

New technologies in pediatric anesthesia

This article reviews potential pediatric applications of 3 new technologies. (1) Pulse oximetry‐based hemoglobin determination: Hemoglobin determination using spectrophotometric methods recently has been introduced in adults with varied success. This non‐invasive and continuous technology may avoid venipuncture and unnecessary transfusion in children undergoing surgery with major blood loss, premature infants undergoing unexpected and complicated emergency surgery, and children with chronic illness. (2) Continuous cardiac output monitoring: In adults, advanced hemodynamic monitoring such as continuous cardiac output monitoring has been associated with better surgical outcomes. Although it remains unknown whether similar results are applicable to children, current technology enables the monitoring of cardiac output non‐invasively and continuously in pediatric patients. It may be important to integrate the data about cardiac output with other information to facilitate therapeutic interventions. (3) Anesthesia information management systems: Although perioperative electronic anesthesia information management systems are gaining popularity in operating rooms, their potential functions may not be fully appreciated. With advances in information technology, anesthesia information management systems may facilitate bedside clinical decisions, administrative needs, and research in the perioperative setting.     

Managing complexity: Simplifying assumptions of foot‐and‐mouth disease models for swine

Compartmental models have often been used to test the effectiveness and efficiency of alternative control strategies to mitigate the spread of infectious animal diseases. A fundamental principle of epidemiological modelling is that models should start as simple as possible and become as complex as needed. The simplest version of a compartmental model assumes that the population is closed, void of births and deaths and that this closed population mixes homogeneously, meaning that each infected individual has an equal probability of coming into contact with each susceptible individual in the population. However, this assumption may oversimplify field conditions, leading to conclusions about disease mitigation strategies that are suboptimal. Here, we assessed the impact of the homogeneous mixing/closed population assumption, which is commonly assumed for within‐farm models of highly contagious diseases of swine, such as foot‐and‐mouth disease (FMD ), on predictions about disease spread. Incorporation of farm structure (different barns or rooms for breeding and gestation, farrowing, nursery and finishing) and demography (piglet births and deaths, and animal movement within and off of the farm) resulted in transmission dynamics that differed in the latter portion of an outbreak. Specifically, farm structure and demography, which were included in the farrow to finish and farrow to wean farms, resulted in FMD virus persistence within the population under certain conditions. Results here demonstrate the impact of incorporating farm structure and demography into models of FMD spread in swine populations and will ultimately contribute to the design and evaluation of effective disease control strategies to mitigate the impact of potential incursions.     

Adaptations in pediatric anesthesia care and airway management in the resource‐poor setting

The need for safe and quality pediatric anesthesia care in low‐ and middle‐income countries (LMICs) is huge. An estimated 1.7 billion children do not have access to surgical care, and the majority are in LMICs. In addition, most LMICs do not have the requisite surgical workforce including anesthesia providers. Surgery is usually performed at three levels of facilities: district, provincial, and national referral hospitals. Unfortunately, the manpower, equipment, and other resources available to provide surgical care for children vary greatly at the different level facilities. The majority of district level hospitals are staffed solely by non‐physician anesthesia providers with variable training and little support to manage complicated pediatric patients. Airway and respiratory complications are known to account for a large portion of pediatric perioperative complications. Management of the difficult pediatric airway pathology is a challenge for anesthesia providers regardless of setting. However, in the low‐resource setting poor infrastructure, lack of transportation systems, and crippled referral systems lead to late presentation. There is often a lack of pediatric‐sized anesthesia equipment and resources, making management of the local pathology even more challenging. Efforts are being made to offer these providers additional training in pediatric anesthesia skills that incorporate low‐fidelity simulation. Out of necessity, anesthesia providers in this setting learn to be resourceful in order to manage complex pathologies with fewer, less ideal resources while still providing a safe anesthetic.     

An exploratory analysis of pediatric anesthesia activity on Twitter using the #pedsanes hashtag

Background

The use of social media within the medical field has rapidly evolved over the past two decades, with Twitter being one of the most common platforms of engagement. The use of hashtags such as #pedsanes has been reported as a community builder around the subject of pediatric anesthesia. Understanding the use of #pedsanes can inform dissemination of pediatric anesthesia content and discourse. We aimed to describe the distribution and patterns of tweets and contributors using #pedsanes across the globe.

Methods

Using Tweetbinder ( https://www.tweetbinder.com ) and the R package “academictwitteR,” we extracted tweets that included the hashtag “#pedsanes” from March 14, 2016 to March 10, 2022. Tweets were analyzed for frequency, type, unique users, impact and reach, language, content, and the most common themes.

Results

A total of 58 724 tweets were retrieved; 22 071 (38.8%) were original tweets including 3247 replies, while 35 971 (61.2%) were retweets all generated by over 5946 contributors located in at least 122 countries. The frequency distribution of tweets gradually increased over time with peaks in activity corresponding to major pediatric anesthesia societal meetings and during the early phases of the COVID-19 pandemic. The most retweeted and most liked posts included images.

Discussion

We report the widespread and increasing use of social media and the “#pedsanes” hashtag within the pediatric anesthesia and medical community over time. It remains unknown the extent to which Twitter hashtag activity translates to changes in clinical practice. However, the #pedsanes hashtag appears to play a key role in disseminating pediatric anesthesia information globally.     

Developments in pediatric liver transplantation since implementation of the new allocation rules in Eurotransplant

Liver allocation in the Eurotransplant (ET) region has changed from a waiting time to an urgency‐based system using the model of end‐stage liver disease (MELD) score in 2006. To allow timely transplantation, pediatric recipients are allocated by an assigned pediatric MELD independent of severity of illness. Consequences for children listed at our center were evaluated by retrospective analysis of all primary pediatric liver transplantation (LTX) from deceased donors between 2002 and 2010 (110 LTX before/50 LTX after new allocation). Of 50 children transplanted in the MELD era, 17 (34%) underwent LTX with a high‐urgent status that was real in five patients (median lab MELD 22, waiting time five d) and assigned in 12 patients (lab MELD 7, waiting time 35 d). Thirty‐three children received a liver by their assigned pediatric MELD (lab MELD 15, waiting time 255 d). Waiting time in the two periods was similar, whereas the wait‐list mortality decreased (from about four children/yr to about one child/yr). One‐ and three‐yr patient survival showed no significant difference (94.5/97.7%; p = 0.385) as did one‐ and three‐yr graft survival (80.7/75.2%; and 86.5/82%; p = 0.436 before/after). Introduction of a MELD‐based allocation system in ET with assignment of a granted score for pediatric recipients has led to a clear priorization of children resulting in a low wait‐list mortality and good clinical outcome.     

Male circumcision for HIV prevention: current evidence and implementation in sub‐Saharan Africa

Heterosexual exposure accounts for most HIV transmission in sub‐Saharan Africa, and this mode, as a proportion of new infections, is escalating globally. The scientific evidence accumulated over more than 20 years shows that among the strategies advocated during this period for HIV prevention, male circumcision is one of, if not, the most efficacious epidemiologically, as well as cost‐wise. Despite this, and recommendation of the procedure by global policy makers, national implementation has been slow. Additionally, some are not convinced of the protective effect of male circumcision and there are also reports, unsupported by evidence, that non‐sex‐related drivers play a major role in HIV transmission in sub‐Saharan Africa. Here, we provide a critical evaluation of the state of the current evidence for male circumcision in reducing HIV infection in light of established transmission drivers, provide an update on programmes now in place in this region, and explain why policies based on established scientific evidence should be prioritized. We conclude that the evidence supports the need to accelerate the implementation of medical male circumcision programmes for HIV prevention in generalized heterosexual epidemics, as well as in countering the growing heterosexual transmission in countries where HIV prevalence is presently low.     

Control of avian influenza in China: Strategies and lessons

In recent decades, multiple subtypes (i.e. H9N2, H5N1 and H7N9) of avian influenza virus (AIV) have become widespread in China, which has caused enormous economic losses and posed considerable threats to public health. In this review, with the aim to provide insights into and guidelines for the control of AIV spread in China and globally in the future, we analysed the reasons why AIV has persisted in China based on socio‐economic features, including poultry biosecurity, live bird markets, live bird transportation, wild birds, poultry waterfowl, poultry density, poultry population and infected birds. We also described the present status of the AIV subtypes H9, H5 and H7 in China to elucidate the effectiveness of the strategies currently employed in China (i.e. culling, mass vaccination and biosecurity improvement) to control the disease based on a literature review and our unpublished surveillance data collected over a 12‐year period from 2007 to 2018. We then summarized the lessons to be learned from the control experience in China, including whether culling of infected birds is of limited value for disease control and whether improved biosecurity is a better option than culling and vaccination for the long‐term control of AIV, and when the vaccine strain should be updated.     

Close to zero preventable in-hospital deaths in pediatric trauma patients – An observational study from a major Scandinavian trauma center

BackgroundIn line with international trends, initial treatment of trauma patients has changed substantially over the last two decades. Although trauma is the leading cause of death and disability in children globally, in-hospital pediatric trauma related mortality is expected to be low in a mature trauma system. To evaluate the performance of a major Scandinavian trauma center we assessed treatment strategies and outcomes in all pediatric trauma patients over a 16-year period.MethodsA retrospective cohort study of all trauma patients under the age of 18 years admitted to a single institution from 1st of January 2003 to 31st of December 2018. Outcomes for two time periods were compared, 2003–2009 (Period 1; P1) and 2010–2018 (Period 2; P2). Deaths were further analyzed for preventability by the institutional trauma Mortality and Morbidity panel.ResultsThe study cohort consisted of 3939 patients. A total of 57 patients died resulting in a crude mortality of 1.4%, nearly one quarter of the study cohort (22.6%) was severely injured (Injury Severity Score > 15) and mortality in this group decreased from 9.7% in P1 to 4.1% in P2 (p<0.001). The main cause of death was brain injury in both periods, and 55 of 57 deaths were deemed non-preventable. The rate of emergency surgical procedures performed in the emergency department (ED) decreased during the study period. None of the 11 ED thoracotomies in non-survivors were performed after 2013.ConclusionA dedicated multidisciplinary trauma service with ongoing quality improvement efforts secured a low in-hospital mortality among severely injured children and a decrease in futile care. Deaths were shown to be almost exclusively non-preventable, pointing to the necessity of prioritizing prevention strategies to further decrease pediatric trauma related mortality.     

Transgender pediatric surgical patients—Important perioperative considerations

Transgender describes a variety of identities in which an individual's gender identity is different from expected based on the sex assigned at birth. In the United States, it is estimated that over 1 million adults and 150 000 youth identify as transgender, with increasing numbers being seen in healthcare and surgical settings. These numbers will continue to rise as visibility and acceptance grow. Current guidelines recommend transition‐related surgeries be reserved for older adolescents and adults. However, this is not the only circumstance in which the pediatric anesthesiologist may find themselves caring for a transgender patient. In order to provide the safest and most affirming care, it is crucial that the pediatric anesthesiologist develop a working knowledge of this unique and vulnerable population, including the potential impacts of gender‐affirming treatment on their perioperative care.