107 statements
· 6 topics
· summaries given as host listed separately
Featured statements
▶Ep 1 · 3:51
once you have A defined uh emyema, i.e., oculations with, you know, greater than 100,000 white cells, then you're down the pathway. Is, is really antibiotics the right choice and probably not, honestly, you need to do something to get, get the, uh, the fibrinous X8 out of the chest
For patients with multiple recurrences after VATS, thoracoscopic pleurectomy (stripping parietal pleura from apex to near-diaphragm) is performed; this is a bloody, painful operation requiring epidural analgesia and hospitalization for a week to 10 days.
93% of all pediatric surgeons in the United States are dependent on some sort of hospital support through affiliation agreements, directorships, or call contracts
Before the era of VATS, the standard was to wait for a second pneumothorax before performing anterior thoracotomy for bleb resection and pleural abrasion
clinicalOnce stage 2 empyema is present, antibiotics alone are insufficient and intervention is needed to remove fibrinous exudate↗
▶Ep 1 · 3:51
quoteonce you have A defined uh emyema, i.e., oculations with, you know, greater than 100,000 white cells, then you're down the pathway. Is, is really antibiotics the right choice and probably not, honestly, you need to do something to get, get the, uh, the fibrinous X8 out of the chest↗
▶Ep 1 · 3:51
clinicalStage 2 empyema is defined by loculated pleural effusion with greater than 100,000 white cells↗
▶Ep 1 · 7:09
clinicalThe Kansas City trial using TPA showed length of stay 6.8 days, cost $11.6K, 7.5% complication rate, and 15% failure rate↗
▶Ep 1 · 8:14
clinicalBoth fibrinolytic trials demonstrate 85% success rate, meaning 15% of patients require subsequent surgical intervention↗
▶Ep 1 · 11:30
clinicalIn the Kansas City VATS cohort, 2 children required oscillator support and 1 developed renal failure requiring hemodialysis; no such complications occurred in the TPA arm↗
▶Ep 1 · 15:47
clinicalUltrasound can sometimes fail to distinguish intraparenchymal necrotic lung from pleural effusion, requiring CT for accurate diagnosis↗
▶Ep 1 · 24:25
clinicalBefore the era of VATS, the standard was to wait for a second pneumothorax before performing anterior thoracotomy for bleb resection and pleural abrasion↗
▶Ep 1 · 24:51
quoteI don't think it makes a lot of sense to say you're going to prophylactically do the other side↗
▶Ep 1 · 26:34
quotethe talc lap thoracoscopically just snows so beautifully everywhere↗
▶Ep 1 · 28:15
clinicalMechanical pleurodesis is considered adequate when small blood vessels become prominent on the pleural surface↗
Dan's statements about Esophageal Atresia19 statements
epidemiologicalOne-third of pediatric surgery cases come from being on call↗
▶Ep 16 · 16:20
epidemiological93% of all pediatric surgeons in the United States depend on hospital support through affiliation agreements, directorships, or call contracts↗
▶Ep 16 · 17:00
epidemiologicalHospital reimbursement is DRG-based (tied to Medicare), but pediatric surgeons operate in a Medicaid world where uninsured/Medicaid patients have increased from 30% to 70% in Miami over 25 years↗
▶Ep 16 · 17:45
epidemiologicalPhoenix Children's Hospital Medicaid percentage increased from 45% to 54% in just 4 years↗
▶Ep 16 · 18:05
quoteI would say that we have a supply and demand conundrum in pediatric surgery. We believe there's demand for pediatric surgeons, so we're supplying them. But maybe we've got something a little bit worrisome that I would call a demand and supply crisis.↗
▶Ep 16 · 26:20
opinionRRC approves programs algorithmically based on criteria with minimal interest in pediatric surgery workforce health (0-5% interest level)↗
▶Ep 16 · 26:55
clinicalAmerican Board of Surgery only certifies whether individuals are safe surgeons, without regard to training program characteristics or workforce needs↗
▶Ep 16 · 48:20
opinionAcademic success per capita in pediatric surgery is very high compared to other surgical specialties↗
▶Ep 16 · 53:40
quoteIf my son comes to me and says I want to be a pediatric surgeon, that does not mean that I have any intention to not support them down that pathway. But you can be darn sure that they're going to know every single thing that I shared with you today.↗
#APSA 50: Robert E. Gross Debate
▶Ep 20 · 14:10
epidemiologicalOne-third of pediatric surgery cases come from being on call↗
▶Ep 20 · 15:50
epidemiological93% of all pediatric surgeons in the United States are dependent on some sort of hospital support through affiliation agreements, directorships, or call contracts↗
▶Ep 20 · 16:20
clinicalHospital reimbursement is DRG-based, not professional fees, and DRGs are based on Medicare↗
▶Ep 20 · 17:10
epidemiologicalIn Miami, uninsured Medicaid patients in children's hospitals have gone from 30% to 70% over the last 25 years↗
▶Ep 20 · 17:40
epidemiologicalPhoenix Children's Hospital Medicaid population increased from 45% to 54% in the last 4 years, an 18% increase↗
▶Ep 20 · 18:05
quoteI have a demand and supply crisis because we have a demand in this country to provide highly trained, incredibly competent pediatric surgeons, and I'm not sure we can actually supply it, given our current environment in pediatric surgery over the next two decades.↗
▶Ep 20 · 25:00
epidemiologicalIn 20 years, concerns about fellowship numbers growing have been heard at program directors meetings and from the RRC and American Board of Surgery, but nothing has been done↗
▶Ep 20 · 26:20
opinionThe RRC approves programs based on algorithmic criteria with 0-5% interest in the health of pediatric surgery as a specialty↗
▶Ep 20 · 26:45
clinicalThe American Board of Surgery's entire goal is to certify whether individuals are safe surgeons, regardless of where or how they trained↗
▶Ep 20 · 53:40
quoteIf my son comes to me and says, or my daughter comes to me and says, I want to be a pediatric surgeon, that does not mean that I have any intention to not support them down that pathway. But you can be darn sure that they're going to know every single thing that I shared with you today.↗
Dan's statements about Esophageal Atresia19 statements
epidemiologicalOne-third of pediatric surgery cases come from being on call↗
▶Ep 22 · 16:20
epidemiological93% of all pediatric surgeons in the United States depend on hospital support through affiliation agreements, directorships, or call contracts↗
▶Ep 22 · 17:00
epidemiologicalHospital reimbursement is DRG-based (tied to Medicare), but pediatric surgeons operate in a Medicaid world where uninsured/Medicaid patients have increased from 30% to 70% in Miami over 25 years↗
▶Ep 22 · 17:45
epidemiologicalPhoenix Children's Hospital Medicaid percentage increased from 45% to 54% in just 4 years↗
▶Ep 22 · 18:05
quoteI would say that we have a supply and demand conundrum in pediatric surgery. We believe there's demand for pediatric surgeons, so we're supplying them. But maybe we've got something a little bit worrisome that I would call a demand and supply crisis.↗
▶Ep 22 · 26:20
opinionRRC approves programs algorithmically based on criteria with minimal interest in pediatric surgery workforce health (0-5% interest level)↗
▶Ep 22 · 26:55
clinicalAmerican Board of Surgery only certifies whether individuals are safe surgeons, without regard to training program characteristics or workforce needs↗
▶Ep 22 · 48:20
opinionAcademic success per capita in pediatric surgery is very high compared to other surgical specialties↗
▶Ep 22 · 53:40
quoteIf my son comes to me and says I want to be a pediatric surgeon, that does not mean that I have any intention to not support them down that pathway. But you can be darn sure that they're going to know every single thing that I shared with you today.↗
#APSA 50: Robert E. Gross Debate
▶Ep 27 · 14:10
epidemiologicalOne-third of pediatric surgery cases come from being on call↗
▶Ep 27 · 15:50
epidemiological93% of all pediatric surgeons in the United States are dependent on some sort of hospital support through affiliation agreements, directorships, or call contracts↗
▶Ep 27 · 16:20
clinicalHospital reimbursement is DRG-based, not professional fees, and DRGs are based on Medicare↗
▶Ep 27 · 17:10
epidemiologicalIn Miami, uninsured Medicaid patients in children's hospitals have gone from 30% to 70% over the last 25 years↗
▶Ep 27 · 17:40
epidemiologicalPhoenix Children's Hospital Medicaid population increased from 45% to 54% in the last 4 years, an 18% increase↗
▶Ep 27 · 18:05
quoteI have a demand and supply crisis because we have a demand in this country to provide highly trained, incredibly competent pediatric surgeons, and I'm not sure we can actually supply it, given our current environment in pediatric surgery over the next two decades.↗
▶Ep 27 · 25:00
epidemiologicalIn 20 years, concerns about fellowship numbers growing have been heard at program directors meetings and from the RRC and American Board of Surgery, but nothing has been done↗
▶Ep 27 · 26:20
opinionThe RRC approves programs based on algorithmic criteria with 0-5% interest in the health of pediatric surgery as a specialty↗
▶Ep 27 · 26:45
clinicalThe American Board of Surgery's entire goal is to certify whether individuals are safe surgeons, regardless of where or how they trained↗
▶Ep 27 · 53:40
quoteIf my son comes to me and says, or my daughter comes to me and says, I want to be a pediatric surgeon, that does not mean that I have any intention to not support them down that pathway. But you can be darn sure that they're going to know every single thing that I shared with you today.↗
Dan's statements about Necrotizing Enterocolitis19 statements
epidemiologicalOne-third of pediatric surgery cases come from being on call↗
▶Ep 6 · 16:20
epidemiological93% of all pediatric surgeons in the United States depend on hospital support through affiliation agreements, directorships, or call contracts↗
▶Ep 6 · 17:00
epidemiologicalHospital reimbursement is DRG-based (tied to Medicare), but pediatric surgeons operate in a Medicaid world where uninsured/Medicaid patients have increased from 30% to 70% in Miami over 25 years↗
▶Ep 6 · 17:45
epidemiologicalPhoenix Children's Hospital Medicaid percentage increased from 45% to 54% in just 4 years↗
▶Ep 6 · 18:05
quoteI would say that we have a supply and demand conundrum in pediatric surgery. We believe there's demand for pediatric surgeons, so we're supplying them. But maybe we've got something a little bit worrisome that I would call a demand and supply crisis.↗
▶Ep 6 · 26:20
opinionRRC approves programs algorithmically based on criteria with minimal interest in pediatric surgery workforce health (0-5% interest level)↗
▶Ep 6 · 26:55
clinicalAmerican Board of Surgery only certifies whether individuals are safe surgeons, without regard to training program characteristics or workforce needs↗
▶Ep 6 · 48:20
opinionAcademic success per capita in pediatric surgery is very high compared to other surgical specialties↗
▶Ep 6 · 53:40
quoteIf my son comes to me and says I want to be a pediatric surgeon, that does not mean that I have any intention to not support them down that pathway. But you can be darn sure that they're going to know every single thing that I shared with you today.↗
#APSA 50: Robert E. Gross Debate
▶Ep 8 · 14:10
epidemiologicalOne-third of pediatric surgery cases come from being on call↗
▶Ep 8 · 15:50
epidemiological93% of all pediatric surgeons in the United States are dependent on some sort of hospital support through affiliation agreements, directorships, or call contracts↗
▶Ep 8 · 16:20
clinicalHospital reimbursement is DRG-based, not professional fees, and DRGs are based on Medicare↗
▶Ep 8 · 17:10
epidemiologicalIn Miami, uninsured Medicaid patients in children's hospitals have gone from 30% to 70% over the last 25 years↗
▶Ep 8 · 17:40
epidemiologicalPhoenix Children's Hospital Medicaid population increased from 45% to 54% in the last 4 years, an 18% increase↗
▶Ep 8 · 18:05
quoteI have a demand and supply crisis because we have a demand in this country to provide highly trained, incredibly competent pediatric surgeons, and I'm not sure we can actually supply it, given our current environment in pediatric surgery over the next two decades.↗
▶Ep 8 · 25:00
epidemiologicalIn 20 years, concerns about fellowship numbers growing have been heard at program directors meetings and from the RRC and American Board of Surgery, but nothing has been done↗
▶Ep 8 · 26:20
opinionThe RRC approves programs based on algorithmic criteria with 0-5% interest in the health of pediatric surgery as a specialty↗
▶Ep 8 · 26:45
clinicalThe American Board of Surgery's entire goal is to certify whether individuals are safe surgeons, regardless of where or how they trained↗
▶Ep 8 · 53:40
quoteIf my son comes to me and says, or my daughter comes to me and says, I want to be a pediatric surgeon, that does not mean that I have any intention to not support them down that pathway. But you can be darn sure that they're going to know every single thing that I shared with you today.↗
Dan's statements about Necrotizing Enterocolitis19 statements
epidemiologicalOne-third of pediatric surgery cases come from being on call↗
▶Ep 6 · 16:20
epidemiological93% of all pediatric surgeons in the United States depend on hospital support through affiliation agreements, directorships, or call contracts↗
▶Ep 6 · 17:00
epidemiologicalHospital reimbursement is DRG-based (tied to Medicare), but pediatric surgeons operate in a Medicaid world where uninsured/Medicaid patients have increased from 30% to 70% in Miami over 25 years↗
▶Ep 6 · 17:45
epidemiologicalPhoenix Children's Hospital Medicaid percentage increased from 45% to 54% in just 4 years↗
▶Ep 6 · 18:05
quoteI would say that we have a supply and demand conundrum in pediatric surgery. We believe there's demand for pediatric surgeons, so we're supplying them. But maybe we've got something a little bit worrisome that I would call a demand and supply crisis.↗
▶Ep 6 · 26:20
opinionRRC approves programs algorithmically based on criteria with minimal interest in pediatric surgery workforce health (0-5% interest level)↗
▶Ep 6 · 26:55
clinicalAmerican Board of Surgery only certifies whether individuals are safe surgeons, without regard to training program characteristics or workforce needs↗
▶Ep 6 · 48:20
opinionAcademic success per capita in pediatric surgery is very high compared to other surgical specialties↗
▶Ep 6 · 53:40
quoteIf my son comes to me and says I want to be a pediatric surgeon, that does not mean that I have any intention to not support them down that pathway. But you can be darn sure that they're going to know every single thing that I shared with you today.↗
#APSA 50: Robert E. Gross Debate
▶Ep 8 · 14:10
epidemiologicalOne-third of pediatric surgery cases come from being on call↗
▶Ep 8 · 15:50
epidemiological93% of all pediatric surgeons in the United States are dependent on some sort of hospital support through affiliation agreements, directorships, or call contracts↗
▶Ep 8 · 16:20
clinicalHospital reimbursement is DRG-based, not professional fees, and DRGs are based on Medicare↗
▶Ep 8 · 17:10
epidemiologicalIn Miami, uninsured Medicaid patients in children's hospitals have gone from 30% to 70% over the last 25 years↗
▶Ep 8 · 17:40
epidemiologicalPhoenix Children's Hospital Medicaid population increased from 45% to 54% in the last 4 years, an 18% increase↗
▶Ep 8 · 18:05
quoteI have a demand and supply crisis because we have a demand in this country to provide highly trained, incredibly competent pediatric surgeons, and I'm not sure we can actually supply it, given our current environment in pediatric surgery over the next two decades.↗
▶Ep 8 · 25:00
epidemiologicalIn 20 years, concerns about fellowship numbers growing have been heard at program directors meetings and from the RRC and American Board of Surgery, but nothing has been done↗
▶Ep 8 · 26:20
opinionThe RRC approves programs based on algorithmic criteria with 0-5% interest in the health of pediatric surgery as a specialty↗
▶Ep 8 · 26:45
clinicalThe American Board of Surgery's entire goal is to certify whether individuals are safe surgeons, regardless of where or how they trained↗
▶Ep 8 · 53:40
quoteIf my son comes to me and says, or my daughter comes to me and says, I want to be a pediatric surgeon, that does not mean that I have any intention to not support them down that pathway. But you can be darn sure that they're going to know every single thing that I shared with you today.↗
Dan's statements about Primary Spontaneous Pneumothorax20 statements
epidemiologicalPrimary spontaneous pneumothorax is more common in males by approximately 3 to 1.↗
▶Ep 5 · 3:45
clinicalChest tubes for primary spontaneous pneumothorax work approximately 50% of the time.↗
▶Ep 5 · 5:01
clinicalPatients who receive a chest tube, resolve, and go home have approximately a 50% failure rate (recurrence requiring further intervention).↗
▶Ep 5 · 5:01
quoteWhat we know now is that the failure rate for patients that get a chest tube and resolve is about 50%.↗
▶Ep 5 · 5:21
clinicalPatients who fail chest tube management in the hospital and subsequently undergo VATS have a recurrence rate of approximately 25-30%.↗
▶Ep 5 · 8:02
clinicalPatients who undergo immediate VATS have a recurrence rate of approximately 10-15%.↗
▶Ep 5 · 11:09
quoteI'm not aware of a published paper that Documents tension physiology for a spontaneous pneumothorax↗
▶Ep 5 · 11:29
clinicalIn a multi-institutional retrospective study of 81 patients across 3 institutions over 13 years, no patients with primary spontaneous pneumothorax presented with tension physiology.↗
▶Ep 5 · 14:10
clinicalIn the Midwest Consortium prospective study of 33 patients across 9 institutions over 2 years, 50% of patients failed initial aspiration (recurrent pneumothorax within 6 hours).↗
▶Ep 5 · 15:33
clinicalOf 12 patients who failed aspiration and were managed with chest tubes, 83% (approximately 10 patients) ultimately failed chest tube management and required VATS or had recurrent pneumothorax.↗
▶Ep 5 · 15:33
quote83% of the patients who failed and got a chest tube failed their chest tube.↗
▶Ep 5 · 16:39
clinicalOf 5 patients who failed aspiration and went directly to VATS, none had recurrence.↗
▶Ep 5 · 16:59
quoteI don't think there are enough numbers. To make definitive conclusions from because I'm pretty sure that there would be people that got immediate VATs that ultimately will fail. But I think that's enough numbers for us to seriously consider. Whether keeping a patient in the hospital who fails an aspiration for days on end for chest tube management. is what we should be doing↗
▶Ep 5 · 18:40
clinicalOf 16 patients who passed the aspiration test and were discharged, 40% (approximately 6-7 patients) returned with recurrent pneumothorax.↗
▶Ep 5 · 19:07
clinicalThe positive predictive value of aspiration for successful treatment is 83%, with a negative predictive value of 56%.↗
▶Ep 5 · 23:30
clinicalIn the retrospective three-institution study, patients who underwent pleurodesis had the same recurrence rate as those who underwent VATS without pleurodesis.↗
▶Ep 5 · 24:41
quoteI think the evidence beyond, now, this is just pleurodesis, OK? Pleurodesis for an initial operations for spontaneous pneumothorax, I'm, I'm not sure that there's any evidence that supports that that's gonna decrease your, your recurrence rates.↗
▶Ep 5 · 26:41
opinionCT scans may identify blebs that are incidental findings and not clinically relevant, similar to traumatic pneumatoceles which rarely rupture.↗
▶Ep 5 · 27:45
clinicalFor patients with multiple recurrences after VATS, thoracoscopic pleurectomy (stripping parietal pleura from apex to near-diaphragm) is performed; this is a bloody, painful operation requiring epidural analgesia and hospitalization for a week to 10 days.↗
▶Ep 5 · 30:15
opinionFor a patient with a small (2 cm) apical pneumothorax after previous pleurodesis, if asymptomatic and stable on repeat imaging at 48 hours, observation is appropriate; aspiration carries risk of lung injury and worsening the air leak.↗
Summaries Dan gave as host
· 9 summaries
Recaps of other experts' statements, not Dan's own clinical position.
host summaryDan Ostlie summarizing the discussion: A meta-analysis of 170 patients showed primary VATS (M3 arm) had better outcomes than chest tube with fibrinolytic followed by delayed thoracoscopy/thoracotomy, but the VATS cases were concentrated in later years creating temporal bias↗
▶Ep 1 · 7:09
host summaryDan Ostlie summarizing the discussion: The London (Great Ormond Street) trial using urokinase showed length of stay 6 days, cost 13 (units unclear), 9% complication rate, and 16% failure rate↗
▶Ep 1 · 7:09
host summaryDan Ostlie summarizing the discussion: A trial of 60 patients comparing urokinase versus saline with small versus large drains showed small tube with urokinase performed better than other combinations, with no operations required↗
▶Ep 1 · 19:50
host summaryDan Ostlie summarizing the discussion: 2001 Adelphi consensus guidelines stated there was no role for simple aspiration in pneumothorax management↗
▶Ep 1 · 19:50
host summaryDan Ostlie summarizing the discussion: 2010 British Thoracic Society guidelines recommend simple aspiration as first-line therapy for pneumothorax↗
▶Ep 1 · 19:50
host summaryDan Ostlie summarizing the discussion: A Cochrane review (2007) with one RCT comparing manual aspiration versus chest tube in patients aged 16 and older showed 59% immediate success rate with aspiration, 50% avoided hospitalization, and no difference in overall hospital stay or recurrence rate↗
Summaries Dan gave as host · Primary Spontaneous Pneumothorax3 summaries
host summaryDan Ostlie summarizing a resource: The Society of Thoracic Surgery recommends primary aspiration for spontaneous pneumothorax in adult patients.↗
▶Ep 5 · 10:05
host summaryDan Ostlie summarizing a resource: In most large studies of primary spontaneous pneumothorax, the mean age is around 20 to 22 years.↗
▶Ep 5 · 23:52
host summaryDan Ostlie summarizing a resource: A large randomized trial from China of 289 patients (average age 22) showed no difference in recurrence rates between wedge resection alone versus wedge resection with mechanical pleurodesis using standardized sandpaper abrasion of the parietal pleura.↗
