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As testes weight is a strong indicator of male fertility in seasonally breeding mammals, we suggest the inclusion of such effects in population level impact assessments involving PCB exposures. Given the re-emergent PCB threat our findings are globally significant, with potentially serious implications for long-lived mammals. We show that more effective PCB controls could have a substantial impact on the reproductive health of coastal cetacean species and that management actions may need to be escalated to ensure adequate protection of the most vulnerable cetacean populations.While 50% of lung adenocarcinoma patients in Asia have mutations in the epidermal growth factor receptor (EGFR) site, there are few patients with the EGFR mutation accompanied by de novo mesenchymal-epithelial transition (MET) amplification. Due to the low incidence rate, there is no consensus regarding treatment. Here, a case of a 62-year-old never smoker presented with EGFR Exon19del and de novo MET amplification. A radiographic examination and computed tomography (CT) imaging were conducted on the chest and middle abdomen. A pulmonary puncture was performed and a sample of the lung tissue was used for pathologic diagnosis. Immunohistochemistry was performed for the expression of CK, P40, P63, ttf-1, NapsinA, alk-d5f3, and ki-67 on the cancer cells. Craniocerebral magnetic resonance and whole body bone imaging were completed. Second-generation gene sequencing (next-generation sequencing [NGS]) and fluorescence in situ hybridization examination were also performed to further characterize the cancer cells. A radiographic examination was performed and revealed space-occupying lesions in the lungs. CT results revealed a mass in the upper lobe of the left lung. The pathologic diagnosis was non-small cell carcinoma T3N2M1a. Second-generation gene sequencing (NGS) indicated EGFR Exon 19del (p.E746_A750del, mutant abundance 13.99%) with de novo MET amplification (CHR q31.2, CN = 4.0). Fluorescence in situ hybridization examination confirmed MET amplification. Targeted therapy with gefitinib combined with crizotinib was administered as treatment. Four weeks later, the CT results revealed a substantial reduction in the lesion size. The patient was followed up with favorable complete recovery and no tumor-related symptoms. Although crizotinib is efficacious when used alone in follow-up treatment; however, these results of this case and others indicate that it is likely safe to use both drugs together in the case of drug resistance.Percutaneous endoscopic gastrostomy (PEG) tube insertion is commonplace in head and neck cancer (HNC) patients. A rare but serious complication of PEG insertion in HNC is PEG site metastasis (PSM), which may precipitate rapid deterioration. We present the first case of PSM in a HNC patient managed without chemoradiotherapy and/or surgery, but rather with concurrent radiotherapy and cetuximab, followed by second-line pembrolizumab. Following histopathologic diagnosis of PSM, positron emission tomography confirmed primary site recurrence and multiple metastases in the axilla, abdomen and pelvis, managed palliatively with focal abdominal wall radiotherapy, pembrolizumab and carboplatin. The patient deteriorated and passed away 20 months after initial HNC diagnosis, 5 months after confirmation of PSM. Patients and clinicians should be aware of PSM in HNC. Though a proven prevention strategy is yet to be confirmed, prompt PSM diagnosis spares the patient unnecessary antibiotics for presumed infection and suggests the possibility of intra-abdominal metastases.

Tuberculous otitis media (TB OM) is a rare disease. We present here our experience of TB OM on its clinical presentation, investigation and treatment outcome.

A retrospective observational study was performed and clinical data of patients in whom TB OM was diagnosed at our center between 2008 and 2019 was analyzed.

Five cases of TB OM were identified. Otorrhoea was the most consistent presenting chief complaint while one of the cases presented with right post-auricular swelling. All the cases were successfully treated with anti-tuberculous medication with outcome of dry middle ear but only one case achieved full recovery of hearing loss.

Due to the disparity of presentations in all our patients, we would like to emphasize the high index of suspicion of TB OM in acute or chronic cases of otitis media with unusual presentation or poor response to standard treatment.

Due to the disparity of presentations in all our patients, we would like to emphasize the high index of suspicion of TB OM in acute or chronic cases of otitis media with unusual presentation or poor response to standard treatment.

Pediatric tympanoplasty is still a matter of controversy. Many factors have been associated with the surgical outcome of tympanoplasty in children, including age, size and location of the perforation, surgical technique and Eustachian tube dysfunction. The optimal approach and timing of this surgery remains controversial. This study aims to evaluate the outcomes of pediatric tympanoplasty and analyze factors that may influence the success of this surgery.

A retrospective review was conducted which included children from 5 to 15 years old that underwent tympanoplasty with or without ossiculoplasty for chronic tympanic perforation in a tertiary care university hospital over a 6-year period. Patients were divided in two age groups (5 to ≤10 years old and >10 to 15 years old). Children with cholesteatoma or that underwent simultaneous mastoidectomy were excluded.

83 cases were included. Average age was 10.7±2.1 years and mean follow-up time was 9 months. Of the cases, 21.7% were revision surgeries. Succe failure.

Exomphalos major (EM) is associated with significant morbidity and even mortality with an important risk of long-term pulmonary disease.

To assess the outcomes of exomphalos in a single tertiary pediatric unit and to identify prognostic factors for patients with respiratory insufficiency who still require ventilatory assistance at six months.

All infants admitted to our institution over a 10-year period (2005 to 2015) with exomphalos were retrospectively reviewed. EM was defined when the abdominal wall defect measured >= 5cm and/or contained liver within the sac. Data were collected on patient demographics, prenatal course and imaging, birth information, immediate and long-term outcomes. Those with long-term respiratory insufficiency were identified as the primary outcome and reviewed to assess prognostic factors. A p value of ≤0.05 was regarded as significant. Data are quoted as median(range).

A total of 46 infants were diagnosed with exomphalos during the study period, with most (n=30, 65%) definng with resuscitation at birth are the most important prognostic factors for long-term respiratory insufficiency. Acknowledgement of these factors allows for better parental counselling regarding respiratory outcomes.

Recurrent tracheoesophageal fistula (rTEF) after esophageal atresia requires complex management across different specialties. This study reviews our experience and discusses a multidisciplinary (MDT) approach adopted in the past 4 years.

We reviewed the medical records of 100 patients with rTEF managed by an MDT approach (post-MDT group) from 2016 to 2019. These cases were compared to a historical group of 35 patients with rTEF from 2012 to 2015 (pre-MDT group).

Of the 135 patients with rTEF, 124 were referred from other hospitals. Preoperative examination found tracheomalacia in 23 patients, vocal fold immobility in 19 patients, and laryngomalacia in five patients. The incidence of postoperative anastomotic leak, anastomotic stricture, and repeat recurrences was 28.1%, 23.0%, and 8.9%, respectively. The overall mortality rate was 4.4%. No statistical difference in postoperative complications was noted between the two groups. PIK-90 The duration of stay in the pediatric intensive care unit (P=0.038), the duration of intubation (P=0.049), the postoperative hospital stay (P=0.011), and the total length of hospital stay (P=0.001) were significantly lower in the post-MDT group. Mid-term follow-up showed 23 patients had pathological gastroesophageal reflux. Five of them underwent fundoplication and recovered.

The MDT approach by fostering coordination of surgical, medical, radiological, and nutritional management is beneficial in the management of rTEF and leads to a satisfactory outcome .

The MDT approach by fostering coordination of surgical, medical, radiological, and nutritional management is beneficial in the management of rTEF and leads to a satisfactory outcome .

We describe the effect of a state mandated opioid consent on opioid utilization and multimodal pain use for major pediatric genitourinary surgeries.

All patients who underwent an inpatient pediatric genitourinary surgery at the Children's Hospital of Pittsburgh between August 2015 and February 2020 were identified. Inpatient and outpatient multimodal pain control utilization were assessed. Delayed prescriptions or emergency department visits within 30 days were identified and when applicable referenced against National Surgical Quality Improvement Program data.

After accounting for a 6-month transition period following policy implementation, 462 major pediatric genitourinary procedures were identified. The frequency of discharge opiate prescriptions decreased from 68.4% prior to the transition period to 10.7% afterward(p<0.001). Morphine milligram equivalents per prescription decreased from 75(IQR 45-150) to 45(IQR 22.5-75)(p<0.001). The rate of delayed non-opioid analgesic prescriptions (6.6% vs 7.4%), delayed opioid prescriptions (1.5% vs 0.3%), or emergency department visits (11.8% vs 12.6%)(p=0.809) remained unchanged. Data agreed with National Surgical Quality Improvement Program data in 98.5% of cases. After excluding one surgeon who departed after the transition period, regional block utilization did not change from 61/115(53%) to 147/320(45.9%)(p=0.425).

A state mandated opioid consent safely reduced opioid utilization for most major pediatric genitourinary surgeries.

Level III.

Level III.

Failure to recover after a medical error is a major contributor to burnout. The degree to which pediatric surgeons experience errors and the barriers and facilitators to successful recovery are largely unknown.

We conducted a survey of American Pediatric Surgical Association (APSA) members to measure frequency of personal experience with medical errors resulting in significant patient harm, describe coping mechanisms, and explore surgeon satisfaction with institutional support in the wake of an error.

We found that 80% of respondents have personally experienced a medical error resulting in significant patient harm or death, and that only about one-quarter were satisfied with the support provided by their institution. Only 11% of surgeons would prefer not to be contacted after an adverse event, and most would want to be contacted by their partners. Barriers to providing and receiving support included lack of knowledge, "shame and blame" culture, and lack of trust in the institution as an ally.

Pediatric surgeons routinely experience intense and stressful clinical scenarios and face challenging paths to recovery after adverse events. Institutions and national societies can play a critical role in creating infrastructure to help surgeons recover, in order to prevent burnout and promote well-being.

Pediatric surgeons routinely experience intense and stressful clinical scenarios and face challenging paths to recovery after adverse events. Institutions and national societies can play a critical role in creating infrastructure to help surgeons recover, in order to prevent burnout and promote well-being.