All right. We are done with, with Todd and Rod, I think. Is there another slide? I'll see. I think we're done. Um, so let's go to, um, uh, the final, um, Let's go to the the next talk, which is, uh, Doctor Jose Campos. Um, now, uh, actually, I lied, uh, to Garrett and the Rock the House team. This does actually have, uh, audio as well. So, um, it's gonna be the same sort of thing. So, um, Let's pull this up. Let me explain, uh, uh, let me give you some background in Doctor Campos. Uh, Jose is a pediatric surgeon in Chile. Um, Uh, I used to think because I only knew Miguel Gilfan, I didn't think there were any good pediatric surgeons down there, but I realized that there actually are. Um, so, uh, Jose Campos, uh, has done something miraculous. He came up to me at an IPEC meeting and said, you know, Todd, you're, you're, you're, you're, you're doing a terrible job. Uh, Uh, he said, you're, you're just highlighting, you know, Journal of Pediatric Surgery. What about all the other journals out there? We're missing those papers. We need to highlight the non-core journals. So Jose's been doing that, and he's gonna pick some, uh, some, some of the top ones he's been presenting throughout the year in the Stay Current app. Jose, take it away. Hi everyone. Thank you. Thank you everyone at the Global Cast and D and State uarantine Pediatric Surgery app for this invite. I've, I've been following this course for the last few years as an attendee and even as a trainee the first year. So I'm, I'm really honored to be here and I want to thank the Chilean Society of Pediatric Surgery and also the 23 volunteers that work with me, uh, in, in creating this filter. Uh, let me see if I can. Next slide, please, while I get set this up. Uh, so let me just, I, I think, uh, Todd explained how we briefly how we do it, but Just in 30 seconds we're taking 33 of the most important pediatric general pediatric journals, the most important surgical journals, and the top 3 clinical ones New England Journal of Medicine, Lancet, and JAMA. That, that's on average 1200 articles each month. So we're going through tittle abstract just to find those perils, those, um, pediatric surgical articles. That are really high quality or really relevant that we shouldn't miss that leaves us with 25 to 50 that's really a lot to, to choose still I think so we do some filtering we do some rankings, we, we, we filter by specialty by quality by methodology and then by popularity we send out a poll to ask all general surgeons around, uh, Chile, but everyone can can join in and to find out whether they. I think that's a relevant article, yes or no, and then we distribute this information we come up with a very narrow selection of 10 to 15 articles. Our main two channels are of course the current pediatric surgery app and, um, social media. So this is how it looks. We're doing some posts on Instagram, Facebook and Twitter. We're doing some infographics. We're doing some videos that are unfortunately only in Spanish. At the moment, but we can change that and this is where we can, you can find this information on, uh on the app, uh, so you hit the menu button, then you go to articles on that second screen there you see all your, all of your sources, your pediatric surgical journals, and if you go to the right, then you find that icon which is curated, um, curated content and then you'll find the articles that we're highlighting. So that's, that's, that's enough for, for the intro, so we'll just do. Uh, Todd gave us the difficult challenge of highlighting only 5 articles. It's, it's, it, it was a mess to go through all of this again and just find 5. so these are the 5 ones that I will share with you and. We'll do it just as Todd did it recently as a case then a poll we, we want everyone's opinions, so please, the, the people of the faculty just shout out which, which is your option. Let's, let's fight a little bit just like fight us, just like Todd said. So the first. Case is a 6 month old male. He was previously healthy, but he comes to emergency department with uh Bilo's emesis. He looks lethargic and tachycardic on arrival, but he's stable after a, a normal saline bolus. His X-ray is non-specific. Um, a bit weird but not specific labs and urine are completely normal just for the sake of this case. Let's say we're, we're suspicion of, of, uh, midcat volvulus, mid midgut mal rotation and volvulus. So what would be your next image investigation? That's the question, so. Um, A would be an upper GI con control study, B would be a, a CAT scan, uh, C would be an abdominal ultrasound, and D, would you take, would someone take this child through, uh, directly to a laparotomy or laparoscopy. And while we're getting those poll options up, uh, let me ask Doctor Holcomb, what would you do? Is Doctor Hol with us? I have to try to find him. I think. Oh, sorry, sorry, in the wrong room somewhere. We're trying to figure that out. Yeah, Doctor Salins. What would you do? I would call my radiologist and have him do an upper GI and stand there watching it. OK. Do you find that easy to get? Like, is it readily available at your hospital anytime, any hour, or? I think most, uh, at, at UCLA at Mattel Children's Hospital, it is, but, um, you know, we cover some. Um, community hospitals as well, it takes a little bit more to in direct communication and sort of an urgency and a couple extra phone calls, but I think most people, at least in the community hospitals, understand the urgency when you say that what you're trying to rule out, it just takes a little bit more handholding. Um, but, uh, so I would say definitely at the higher volume centers, but some of the community hospitals take a little bit more. Maybe people at the chat can, because it's an international audience, maybe people can see how, how easy it is for them to get an upper GI control study or Ellen, you can stop me at any time if you think the poll is already there. Yeah, it was, it's actually, well, it was tied for a while between upper GI and the ultrasound. Now it looks like more than 50% of people are saying upper GI. OK, why don't we just take the next slide and, and show the video of this article that might or might not change what people think about this. Este relevante public archives of disease in childhood and of milventionolamaroinal reque diagnostico portuno jacko consequencias bodenje garse graves el studio deta a condo classicamente en el transito esophago estomagododenal pero utilisa reacionizante est in the interpretar in re eloque de te tudio is the min tilia de la sonograph parnostico de ma. analysis prime is audios total ilos de cuadro unaido and then diagnostico de mat stevia te alternativa diagnostica patologia molo practical. I'm not sure if someone uh here would like to comment on that. Would you change your management to up to ultrasound first or would you just keep getting the upper GI first? Jose, I'm happy to comment. I, I think that there has been intrasound, interest in using ultrasound for a long time, but ultrasound is one of those, uh, imaging studies that is very, very dependent on the person who performs the ultrasound. So, I mean, we're fortunate we can get ultrasounds in the middle of the night and that kind of thing, but the other challenge is the availability. So, personally, I would rely way more on an upper GI than I would on an ultrasound. And the issue of switch, you know, the, the reversal of the, of the vessels at the root of the mesentery, you know, I, I, I'm not familiar with this article, so this is great to see this, but my understanding was that that was not a very reliable way to, um, to make the diagnosis. And since I don't speak Spanish, I have to admit that I didn't potentially get all of the information from the, uh, from the presentation. Oh, the video was captioned. Did, did, did you not, OK. It's a little small for us here in the Zoom room. Oh, the other, the other article, the other videos are in English. That was the only one. OK, let's You wanna say something, Todd, sorry? No, let's go on to the next one. Let's go on to the next one, please. Uh, let's see if I can click here. OK, case number 2. Let's say we're on call. It's 11:00 p.m. and we get a 7 year old female with a 24, 24 hour history of right lower quadrant pain. She's stable but she's tender on the right lower quadrant. White blood cell is 17,000, urine is normal, and we get an ultrasound. We're lucky enough to get an ultrasound at that point in during the night and it shows non-complicated appendicitis. So what would you, what would your management be? A laparotomy or laparoscopy tonight. Book the case for tomorrow, laparotomy or laparoscopy tomorrow. Admit and give her IV antibiotics or even treat her as an outpatient with oral antibiotics. Jose, appendiculus or not? Appendiculus or not, uh, no appendiculus. Let's make it more difficult, yeah, I'm, I'm just, do you wanna, you wanna explain to us why, why would you ask that? I, I, I think I, I, I, I, I understand what you're trying to point out here. Right. The, the studies, uh, currently, I think, uh, you know, what this, uh, is hoping to highlight is the ability to use non-operative management of appendicitis in certain cases, but, um, uh, the studies that we have, uh, show that, uh, having the presence of an appendiculli actually has about a 50% failure rate. Uh, so, um, that's, uh, you know, uh, not good enough, uh, for me. Uh, so, uh, most of us actually use the presence of that appendicolith as a no go, uh, for, uh, non-operative management. So I think Doctor Arca gave a really good summary of the video we're just about to see and she is updated on this topic, so why don't we just roll the video. This is a relevant article published in the Annals of Surgery in June 2020. For decades, surgery has been the gold standard for treatment for appendicitis. Recently, the idea of using medical management with antibiotics in selected patients has been described in several studies, mostly in other populations. However, there's still not strong evidence to support the change. In the way we treat appendicitis, the study shows the results of a 5 year follow-up of a randomized clinical trial applied to 50 patients with uncomplicated appendicitis. They reported that the group randomized to surgery had no complications, while in the group randomized to non-surgical management, 46% of patients required. ect om y in the follow-up time. The surgical group had no readmissions while half of the non-surgical group presented to the emergency room. Based on the results of the study, we can conclude that non-surgical management of appendicitis seems to be safe. However, almost half of patients required appendectomy in a 5-year follow-up time. Approximately 70% would do a laparotomy, laparoscopy either today or tomorrow, but there's a 20%, uh, being this, uh, surgical audience that would actually treat with IV antibiotics, and I find that very interesting, and I, this, this could come from the results of this trial. I, I personally, I agree with Doctor, with Doctor Arca and so Jose, yeah, I think for this, we're just gonna have to fly through. We're already pretty far over, um. So let's just, um, without discussion, without discussion, just throw it out there and we'll watch it and keep going. Sure, cool. Sorry, this is a, a 22 year old boy with a neuroblastoma. It's a high-risk neuroblastoma. It has image defined risk factors in the cases both renal arteries. Uh, let's say the tumor responded well to chemotherapy but still a very large mass, so we're at the 5th cycle reassessment for surgery. What would be the options be? Uh, more chemotherapy, debulking surgery, local radiotherapy, and surgical resection as complete as possible. Um, so let's go with it, yeah, let's just go play the video and put the pole up at the same time. So play the next slide. Published in the Journal of Clinical Oncology in 2020. Complete resection of intermediate risk neoblastoma doesn't provide any surgical benefit, but it is not known whether this applies to high-risk neuroblastoma, especially because complete resection of this type of tumor can involve a really complex and morbid procedure. In this report by the CON Group, they evaluated the impact of the extent of primary tumor resection on survival and local progression. 1,531 patients with Stage 4 high-risk neuroblastoma were categorized as complete or incomplete microscopic resection at the moments of surgery. The results showed that 5-year event-free survival and overall survival were significantly higher with complete resection. Local progression was also lower with complete resection when compared with incomplete resection. So as a conclusion, in patients with stage 4 neuroblastoma, complete resection, even if risky, provides better overall and event-free survival. I see Dan Van Almen clapping, so there you go. Let's keep going, yeah, he agreed. Doctor Van Alman actually published this in 2017, but this is coming from a European group. So can someone just click the next slide and with So we're at prenatal counseling. We're, uh, we're looking at a baby 24 week scan with left diaphragmatic hernia. Her, um, prognostic factors look really terrible. Liver's up, uh, look to her radius is 1.0. Lung volume is less than 15 mLs. What would you recommend? A would be referral to EMO center, standard care intensior center, and referral only if ECMO is needed post postnatally, fetal treatment with tracheal occlusion or fetal treatment with intrauterine surgery. Let's see the poll results and play the video, please. This article was published in July 2021 in the New England Journal of Medicine. Observational studies have shown that fetal fetoscopic endoluminal tracheal occlusion has been associated with increased survival among infants with severe pulmonary hyperplasia, but also increased preterm delivery. This article evaluated whether fetal increases postnatal. Survival compared to expectant prenatal care in a randomized controlled trial, 80 women carrying fetuses with severe isolated left-sided congenital diaphragmatic hernia were randomized to fetal at 27 to 29 weeks of gestation or to expectant care. Both treatment arms were followed by standardized postnatal care. The primary outcome was survival to discharge. Fetal resulted in a significant benefit over expectant care with respect to survival to discharge, 40% versus 15% respectively. At 6 months of age, the survival was the same. Feto was associated with an increased risk of preterm, pre-labor rupture of membranes and preterm labor. If you are caring for babies with severe congenital diaphragmatic hernia, fetal should be considered for prenatal management. This art Uh, MVA, uh, passenger, Glasgow scale is 12. She's unstable. She's gonna be transferred to you. She's arriving in 10 minutes. And again, the topic of what would be your transfusion, your first choice of transfusion, 20 mL saline bolus, 40 mL kilo saline bolus, uh, whatever your favorite ratio is of component therapy, red blood cells, frozen plasma and platelets, or alternative D, whole blood. Let's play the video, please. This is a relevant article published in the Journal of Trauma and Acute Care Surgery in June 2021. Trauma is the leading cause of death in children older than one year. Among adult trauma patients, whole blood as the initial resuscitation fluid has shown promising results in children, there's positive data regarding this stuff. This article investigated whether whole blood. Transfusion as an adjunct to component therapy in early resuscitation improved outcomes in critically injured children. 135 children aged between 1 and 17 years from the trauma Quality Improvement Program in the 2017 database who received whole block as an adjunct to component therapy where propensity score matched to 270. Children receiving only component therapy. The main result of this study was a decrease in the transfusion volume at 24 hours, even though mortality, length of stay, and major complications were the same, the whole blood group required fewer ventilation days. So to improve outcomes in trauma patients, consider whole blood as a part of your initial resuscitation strategy. Um, this is whole blood, uh, instead of, no, this is after saline, but this is instead of component transfusion, OK, yeah, because it said what would your first be, so I think that's why most people said saline. Then after that would be whole blood. So that's the big point there is you give, it sounds like the summary here we're gonna hear Rob talk about it more. Saine first for 20 ccs per kilo, then whole blood. Is that, is that it? But because the other question said type specific blood. Uh, it doesn't say any type of whole blood or whatever it was a pack red blood cells, but it's whole blood. It sounds like it's whole blood, yeah, well, that, yeah, that's Rob. You agree? I, I, I would agree that we should be going with normal sailing based on the ATLS protocols. I, I will tell you though, um, that nationwide in adults we are starting to see ambulance rigs. Travel with whole blood capabilities in adults and people are starting to use whole blood even earlier. So is this coming down, is it correct? Is this coming down the pipeline potentially, but in the pediatric literature right now, ATLS guidelines, um, would suggest initial bolus with, uh, with normal saline or crystalloid solution and then moving over. I have to tell you this is, I love this course. It's changing. It's an evolution, yeah, cause I, I, I mean, I don't know if it's pediatrics is different than adults. It seems like things change every single year we meet. Uh, Dan, were you gonna say something? I was just gonna ask that, you know, the challenge for whole blood is availability, but, you know, if you're saying that rigs are starting, you know, EMS folks are carrying that, I don't understand that. Uh, I guess it's universal donor, uh, blood and whole. Blood, that's, that's great. And um that'll be great to see that evolve because I think the data supports it. It's just getting it. That's the challenge. It is. And that's been the big thing with regard to the pediatric, and we can talk about this later on and probably talk about it for the whole day if you wanted to, um, but having blood bank capabilities, especially. Uh, because thankfully for children, we don't use a lot of massive transfusion protocols. So I, I think you're seeing more of this in adults. Um, some of the pediatric centers are coming along, um, slowly, but, but definitely we're seeing more. All right, yeah, go ahead. Is there an age limit, Rob, that you would use this for? For, I'm sorry, for a whole blood? Yeah. So that, that's, that's a good question as well. Some centers are limiting to males, um, some centers are limiting to, um, children older than 15. It, it really, um, just depends on your institution, um, and how you're partnering. So I, I think my recommendation, if you're looking at whole blood right now is to partner, um, with your adult trauma surgeons, um, that area to, to kind of work on it because it is a, a big utilization of the blood bank and, and see what their protocol would be. All right, this is awesome. We're running 15 minutes behind and we're only on the 2nd talk. So this is what I, I warn everyone, everyone knows around the world, the discussion is much more fun than the presentation. So be prepared to, to discuss, but we'll have to cut it short. Jose, uh, clearly, everyone either said they either majorly changed or mostly changed. This was phenomenal. I appreciate the work you're doing. We're opening our eyes to not only our core journals, but the other journals. Thank your team. The team is phenomenal. Uh, congratulations and thank you for the presentation. Thank you, Tuck.
