BACKGROUND:Pediatric trauma patients often require interfacility transfer for subspecialty management of presumed isolated injuries. Understanding the frequency of additional injury in these low-acuity patients may improve resource utilization. METHODS:Pediatric trauma patients transferred to a level 1 trauma center in 2019 were compared by type of presenting injury in a retrospective review. Primary outcome was additional traumatic injuries identified. RESULTS:530 pediatric trauma patients were transferred, most commonly for an isolated orthopedic injury (56.5 ​%). The overall rate of additional injuries identified was 2.8 ​%, with the highest rate in patients transferred with neurosurgical injuries (6.7 ​%). When compared to other transfer patients, patients with isolated orthopedic injuries were least likely to have any additional injuries (1.0 ​% vs. 4.8 ​%, p ​= ​0.01). CONCLUSIONS:Pediatric trauma patients transferred with isolated injuries rarely had additional injuries identified after transfer. Streamlining care for this population while maintaining vigilance for missed injuries is a target for future interventions.

Background: Pediatric patients treated at trauma centers demonstrate improved outcomes, but investigation of optimal resource utilization surrounding the transfer is ongoing. We evaluated characteristics of operative pediatric trauma transfer patients for resource optimization.Methods: A retrospective review of pediatric trauma patients transferred to a level 1 pediatric trauma center from 2009 to 2019 was performed. Patients were categorized by initial operative subspecialty.Results: Of 4164 transferred patients, 33.9 % required operative intervention. 65 % of operations were performed on orthopedic patients, who were significantly less injured compared to other patients. General surgery patients were more likely to undergo surgery on day of transfer compared to orthopedic patients (39.4%vs 56.3 %, OR 2.0, CI 1.4-2.8).Conclusions: One-third of pediatric trauma transfer patients required operative intervention. The majority of surgeries were on orthopedic patients, who were less likely to undergo surgery on day of transfer. Critical evaluation of this patient population is required to safely utilize a less resource-intensive transfer process.

Background: Cervical spinal cord injuries (SCIs) are the most common type of human SCI. Although various animal SCI contusion models have been developed to mirror human pathology, few have described cervical-level injuries. This study aims to validate and establish optimal impact parameters to produce consistent incomplete cervical SCIs for testing novel therapies. Methods: Using a precise impactor, 3 cervical spinal cord hemi-contusions of varying severities were induced by modifying penetration depths and controlling dwell times. Penetration depths of 2.11 mm (n = 4), 2.24 mm (n = 4), and 2.36 mm (n = 3) were used with a dwell time of 0.05 s to create mild, moderate, and severe injuries. Behavioral assessments in weeks 1, 2, 5, and 8 included grooming test, forelimb asymmetry test, and the Irvine, Beatties, and Bresnahan forelimb scale (IBB). After 8 weeks, rats were euthanized, and spinal cord histology was performed. Results: Within each group, animals exhibited consistent motor deficits and functional recovery. Mean IBB scores varied significantly between each group at week 8 (p < 0.0001). Ipsilateral forelimb usage significantly improved throughout the study period in the mild (2.11 mm) and moderate (2.24 mm) groups, while the severely (2.36 mm) injured group continued to exhibit 100% asymmetrical forelimb usage. Conclusions: This study demonstrates that a precise impactor can create reproducible models of incomplete cervical SCIs. A penetration depth of 2.24 mm resulted in moderate injury with significant motor deficits that slowly improved over time, permitting future therapeutic studies in functional recovery.

The embryologic development of the chest and airways is complex and errors in prenatal development can lead to an extensive variety of congenital malformations in both the upper and lower respiratory tract. Among these disorders, there is a wide range in the severity of the malformation with some being uniformly fatal while others are more of a nuisance. The prompt diagnosis of these disorders is key in recognizing the problem and working toward a treatment. Many of the disorders of the airways and chest are now diagnosed prenatally with the increasing accuracy of prenatal sonography. Early prenatal diagnosis not only allows for appropriate parental counseling during pregnancy but in some cases allows for prenatal interventions including both in utero interventions and planned ex utero intrapartum treatments (EXIT). For those infants born with disorders of the chest and airways, the interventions to correct these anomalies have become increasingly less invasive. Thoracoscopic and endoscopic techniques have been refined and adapted to address multiple disorders including sequestrations, congenital pulmonary airway malformations (CPAMs), congenital diaphragmatic hernia (CDH), and complex chest wall disorders. These minimally invasive techniques have revolutionized the treatment of these disorders and made surgical intervention on the infant airway and chest less invasive and more tolerable.

Introduction: There has not been a recent evaluation of the association between racial and gender and surgical outcomes in children. We aimed to evaluate improvements in race -and gender-related pediatric postoperative outcomes since a report utilizing the Kids' Inpatient Database data from 2003 to 2006. Methods: Using Kids' Inpatient Database (2009, 2012, 2016), we identified 245,976 pediatric patients who underwent appendectomy for acute appendicitis (93.6%), pyloromyotomy for pyloric stenosis (2.7%), empyema decortication (1.6%), congenital diaphragmatic hernia repair (0.7%), small bowel resection for intussusception (0.5%), or colonic resection for Hirschsprung disease (0.2%). The primary outcome was the development of postoperative complications. Multivariable logistic regression was used to evaluate risk-adjusted asso-ciations among race, gender, income, and postoperative complications. Results: Most patients were male (61.5%) and 45.7% were White. Postoperative complica-tions were significantly associated with male gender (P < 0.0001) and race (P < 0.0001). After adjustment, Black patients were more likely to experience any complication than White patients (adjusted odds ratio 1.3, confidence interval 1.2-1.4), and males were more likely than females (adjusted odds ratio 1.3, confidence interval 1.2-1.4). Conclusions: No clear progress has been made in eliminating race-or gender-based dis-parities in pediatric postoperative outcomes. New strategies are needed to better under-stand and address these disparities.(c) 2022 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

INTRODUCTION:Cloacal dysgenesis occurs from failure of embryological division of urogenital sinus and hindgut, leading to a single common perineal opening for genitourinary and gastrointestinal tracts. The prenatal diagnosis of cloacal malformation is imprecise, but the clinical correlation of postnatal findings to prenatal history can help reveal explanations for unusual pathological findings in patients with urogenital abnormalities.CASE PRESENTATION:A 21-year-old woman was referred after her 20-week ultrasound demonstrated anhydramnios and concern for dilated fetal bowel. Fetal MRI confirmed anhydramnios and a dilated fetal colon, in addition to hydronephrosis and a pelvic cyst. Repeat ultrasound at 27 weeks showed unexpected complete resolution of her anhydramnios but new fetal ascites. The newborn girl was postnatally diagnosed with a cloacal malformation and an unusual near-complete fusion of her labia. She underwent proximal sigmoid colostomy and a tube vaginostomy at birth followed by cloacal reconstruction at 1.5 years old.CONCLUSION:In female fetus with a pelvic cyst, one should have a high index of suspicion for cloacal anomaly and consider the possibility of urinary obstruction leading to alteration in amniotic fluid.

Significant progress has been made in designing bone materials capable of directing endogenous cells to promote vascularized bone regeneration. However, current strategies lack regulation of the specific endogenous cell populations for vascularized bone regeneration, thus leading to adverse tissue formation and decreased regenerative efficiency. Here, we engineered a biomaterial to regulate endogenous cell adhesion and promote vascularized bone regeneration. The biomaterial works by presenting two synthetic ligands, LLP2A and LXW7, explicitly targeting integrins α4β1 and αvβ3, respectively, expressed on the surfaces of the cells related to bone formation and vascularization, such as mesenchymal stem cells (MSCs), osteoblasts, endothelial progenitor cells (EPCs), and endothelial cells (ECs). In vitro, the LLP2A/LXW7 modified biomaterial improved the adhesion of MSCs, osteoblasts, EPCs, and ECs via integrin α4β1 and αvβ3, respectively. In an adult rat calvarial bone defect model, the LLP2A/LXW7 modified biomaterial enhanced bone formation and vascularization by synergistically regulating endogenous cells with osteogenic and angiogenic potentials, such as DLX5+ cells, osteocalcin+ cells, CD34+/CD45- cells and CD31+ cells. In a fetal sheep spinal bone defect model, the LLP2A/LXW7 modified biomaterial augmented bone formation and vascularization without any adverse effects. This innovative biomaterial offers an off-the-shelf, easy-to-use, and biologically safe product suitable for vascularized bone regeneration in both fetal and adult disease environments.

Introduction: In attempts to quell the spread of COVID-19, shelter-in-place orders were employed in most states. Increased time at home, in combination with parents potentially balancing childcare and work-from-home duties, may have had unintended consequences on pediatric falls from windows. We aimed to investigate rates of falls from windows among children during the first 6 mo of the COVID-19 pandemic. Methods: Patients <18 y old admitted to three pediatric trauma centers (two -level 1, one -level 2) between 3/19/20 and 9/19/20 (COVID-era) were compared to a pre-COVID cohort (3/19/19 to 9/19/19). The primary outcome was the rate of falls from windows. Secondary outcomes included injury severity score (ISS), injuries sustained, and mortality. Results: Of 1011 total COVID-era pediatric trauma patients, 36 (3.6%) sustained falls from windows compared to 23 of 1108 (2.1%) pre-COVID era patients (OR 1.7, P = 0.05). The median ISS was seven pre-COVID versus four COVID-era (P = 0.43). The most common injuries sustained were skull fractures (30.5%), extremity injuries (30.5%), and intracranial hemorrhage (23.7%). One-fifth of patients underwent surgery (21.7% pre-COVID versus 19.4% COVID-era, P = 1.0). There was one mortality in the COVID-era cohort and none in the pre-COVID cohort (P = 1.0). Conclusions: Despite overall fewer trauma admissions during the first 6 mo of the COVID-19 pandemic, the rate of falls from windows nearly doubled compared to the prior year, with substantial associated morbidity. These findings suggest a potential unintended conse-quence of shelter-in-place orders and support increased education on home safety and increased support for parents potentially juggling multiple responsibilities in the home.(c) 2022 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Background:There are over 150,000 transgender adolescents in the United States, yet research on outcomes following gender-affirming mastectomy in this age group is limited. We evaluated gender-affirming mastectomy incidence, as well as postoperative complications, including regret, in adolescents within our integrated health care system. Methods:Gender-affirming mastectomies performed from January 1, 2013 - July 31, 2020 in adolescents 12-17 years of age at the time of referral were identified. The incidence of gender-affirming mastectomy was calculated by dividing the number of patients undergoing these procedures by the number of adolescents assigned female at birth ages 12-17 within our system at the beginning of each year and amount of follow-up time within that year. Demographic information, clinical characteristics (comorbidities, mental health history, testosterone use), surgical technique, and complications, including mention of regret, of patients who underwent surgery were summarized. Patients with and without complications were compared to evaluate for differences in demographic or clinical characteristics using chi-squared tests. Results:The incidence of gender-affirming mastectomy increased 13-fold (3.7 to 47.7 per 100,000 person-years) during the study period. Of the 209 patients who underwent surgery, the median age at referral was 16 years (range 12-17) and the most common technique was double-incision (85%). For patients with greater than 1-year follow-up (n=137, 65.6%), at least one complication was found in 7.3% (n=10), which included hematoma (3.6%), infection (2.9%), hypertrophic scars requiring steroid injection (2.9%), seroma (0.7%), and suture granuloma (0.7%); 10.9 % underwent revision (n=15). There were no statistically significant differences in patient demographics and clinical characteristics between those with and without complications (p>0.05). Two patients (0.95%) had documented postoperative regret but neither underwent reversal surgery at follow-up of 3 and 7 years postoperatively. Conclusion:Between 2013-2020, we observed a marked increase in gender-affirming mastectomies in adolescents. The prevalence of surgical complications was low and of over 200 adolescents who underwent surgery, only two expressed regret, neither of which underwent a reversal operation. Our study provides useful and positive guidance for adolescent patients, their families, and providers regarding favorable outcomes with gender-affirming mastectomy.

We would like to thank Drs. Boybeyi and Soyer for their interest in our study on pediatric gastrostomy tubes [ [1] Jackson J.E. Theodorou C.M. Vukcevich O. Brown E.G. Beres A.L. Patient selection for pediatric gastrostomy tubes: are we placing tubes that are not being used?. J Pediatr Surg. 2022; 57: 532-537 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar ]. Herein we provide a response to your letter. Regarding the indications for gastrostomy tube (GT) placement, we classified them into the following categories: cardiac, pulmonary, neurological, renal, gastrointestinal, genetic, anatomic, traumatic, failure to thrive, and malignancy. In the short-term GT group, the patients classified as gastrointestinal indications had meconium ileus or anorectal malformations. The patients in the short-term group with an anatomic indication both had laryngomalacia. With regards to esophageal atresia, there was one patient in the long-term group who had esophageal atresia. As you mentioned, there may be difficulty passing a nasogastric (NG) tube into the stomach for this specific population of children and therefore they may not be candidates for NG feeds. In addition, this is likely why this patient with esophageal atresia was in the long-term group, requiring use of the GT for greater than 6 months, and why there were no such patients in the short-term group.

results warrant validation in a prospective cohort

Background: While fetal repair of myelomeningocele (MMC) revolutionized management, many children are still unable to walk independently. Preclinical studies demonstrated that research-grade placental mesenchymal stromal cells (PMSCs) prevent paralysis in fetal ovine MMC, however this had not been replicated with clinical-grade cells that could be used in an upcoming human clinical trial. We tested clinical-grade PMSCs seeded on an extracellular matrix (PMSC-ECM) in the gold standard fetal ovine model of MMC.& nbsp;Methods: Thirty-five ovine fetuses underwent MMC defect creation at a median of 76 days gestational age, and defect repair at 101 days gestational age with application of clinical-grade PMSC-ECM (3 x 10(5) cells/cm(2), n = 12 fetuses), research-grade PMSC-ECM (3 x 10(5) cells/cm(2), three cell lines with n = 6 (Group 1), n = 6 (Group 2), and n = 3 (Group 3) fetuses, respectively) or ECM without PMSCs ( n = 8 fetuses). Three normal lambs underwent no surgical interventions. The primary outcome was motor function measured by the Sheep Locomotor Rating scale (SLR, range 0: complete paralysis to 15: normal ambulation) at 24 h of life. Correlation of lumbar spine large neuron density with SLR was evaluated.& nbsp;Results: Clinical-grade PMSC-ECM lambs had significantly better motor function than ECM-only lambs (SLR 14.5 vs. 6.5, p = 0.04) and were similar to normal lambs (14.5 vs. 15, p = 0.2) and research-grade PMSC-ECM lambs (Group 1: 14.5 vs. 15, p = 0.63; Group 2: 14.5 vs. 14.5, p = 0.86; Group 3: 14.5 vs. 15, p = 0.50). Lumbar spine large neuron density was strongly correlated with motor function ( r = 0.753, p < 0.001).& nbsp;Conclusions: Clinical-grade placental mesenchymal stromal cells seeded on an extracellular matrix rescued ambulation in a fetal ovine myelomeningocele model. Lumbar spine large neuron density correlated with motor function, suggesting a neuroprotective effect of the PMSC-ECM in prevention of paralysis. A first-in-human clinical trial of PMSCs in human fetal myelomeningocele repair is underway. (C)& nbsp;2021 Elsevier Inc. All rights reserved.

INTRODUCTION: Spinal cord injury (SCI) is a devasting disease associated with severe disability and no effective cure. SCI involves a primary traumatic injury followed by a secondary injury characterized by inflammation, ischemia, and formation of a glial scar. Cellular therapies aim to minimize the secondary injury by protecting the remaining cells and promoting neuronal and glial regeneration. We have shown placental mesenchymal stromal cells (PMSCs) applied in utero improve ambulatory function and preserve motor neurons in an ovine model of spina bifida and have begun a first-in-human clinical trial for fetal spina bifida. METHODS: Female Sprague Dawley rats were given a right C5 hemi-contusion injury using an RWD Precise Impactor and 8 rats served as sham surgery controls. Immediately following injury, rats were treated with an ECM only (n = 9) or an ECM seeded with 3 x 105 PMSCs (PMSC-ECM, n = 11). Weekly motor function testing included Irvine, Beatties, and Bresnahan (IBB) Forelimb Recovery Scale testing by blinded reviewers. After 8 weeks, rats were euthanized, and tissue collected for histology. RESULTS: Four second trimester PMSC cell lines were evaluated with our established anti-apoptotic neuroprotection assay and a single cell line was chosen based on increased neurite outgrowths. Within the PMSC-ECM group, rats had statistically significant improvement in their IBB scores between week 1 and week 8 (p = 0.002) compared to ECM only group, where rats did not show improvement (p = 0.063). When comparing IBB scores between groups at week 8, PMSC-ECM rats had a significantly higher IBB score compared to ECM only rats (p = 0.015). CONCLUSION: PMSCs improved motor function recovery in a rodent model of SCI. Further studies include immunohistochemical analysis and delivering PMSC derived exosomes as a cell-free treatment.

Introduction: The COVID-19 pandemic has widespread effects, including enhanced psy-chosocial stressors and stay-at-home orders which may be associated with higher rates of child abuse. We aimed to evaluate rates of child abuse, neglect, and inadequate supervision during the COVID-19 pandemic.Methods: Patients <5 y old admitted to a level one pediatric trauma center between 3/19/20-9/19/20 (COVID-era) were compared to a pre-COVID cohort (3/19/19-9/19/19). The primary outcome was the rate of child abuse, neglect, or inadequate supervision, determined by Child Protection Team and Social Work consultations. Secondary outcomes included injury severity score (ISS), mortality, and discharge disposition.Results: Of 163 total COVID-era pediatric trauma patients, 22 (13.5%) sustained child abuse/ neglect, compared to 17 of 206 (8.3%) pre-COVID era patients (P = 0.13). The ISS was similar between cohorts (median 9 pre-COVID versus 5 COVID-era, P = 0.23). There was one mor-tality in the pre-COVID era and none during COVID (P = 0.45). The rate of discharge with someone other than the primary caregiver at time of injury was significantly higher pre-COVID (94.1% versus 59.1%, P = 0.02). In addition, foster family placement rate was twice as high pre-COVID (50.0% versus 22.7%, P = 0.10).Conclusions: The rate of abuse/neglect among young pediatric trauma patients during COVID did not differ compared to pre-pandemic, but discharge to a new caregiver was significantly lower. While likely multifactorial, this data suggests that resources during COVID may have been limited and the clinical significance of this is concerning. Larger studies are warranted to further evaluate COVID-19's effect on this vulnerable population.(c) 2022 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction: Fetal myelomeningocele (MMC) repair improves lower extremity motor function. We have previously demonstrated that augmentation of fetal MMC repair with placental mesenchymal stromal cells (PMSCs) seeded on extracellular matrix (PMSC-ECM) further improves motor function in the ovine model. However, little progress has been made in improving bowel and bladder function, with many patients suffering from neurogenic bowel and bladder. We hypothesized that fetal MMC repair with PMSCECM would also improve bowel and bladder function. Methods: MMC defects were surgically created in twelve ovine fetuses at median gestational age (GA) 73 days, followed by defect repair at GA101 with PMSC-ECM. Fetuses were delivered at GA141. Primary bladder function outcomes were voiding posture and void volumes. Primary bowel function outcome was anorectal manometry findings including resting anal pressure and presence of rectoanal inhibitory reflex (RAIR). Secondary outcomes were anorectal and bladder detrusor muscle thickness. PMSC-ECM lambs were compared to normal lambs ( n = 3). Results: Eighty percent of PMSC-ECM lambs displayed normal voiding posture compared to 100% of normal lambs ( p = 1). Void volumes were similar (PMSC-ECM 6.1 ml/kg vs. normal 8.8 ml/kg, p = 0.4). Resting mean anal pressures were similar between cohorts (27.0 mmHg PMSC-ECM vs. normal 23.5 mmHg, p = 0.57). RAIR was present in 3/5 PMSC-ECM lambs that underwent anorectal manometry and all normal lambs ( p = 0.46). Thicknesses of anal sphincter complex, rectal wall muscles, and bladder detrusor muscles were similar between cohorts. Conclusion: Ovine fetal MMC repair augmented with PMSC-ECM results in near-normal bowel and bladder function. Further work is needed to evaluate these outcomes in human patients. (c) 2022 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ )

Introduction: Identifying pediatric patients who may benefit from gastrostomy tube (GT) placement can be challenging. We hypothesized that many GTs would no longer be in use after 6 months. Methods: Inpatient GT placements in patients < 18 years old at a tertiary children's hospital from 9/2014 to 2/2020 were included. The primary outcome was GT use <6 months (short-term). Secondary outcomes included age at placement, indication for GT, and operations for GT-related issues. Results: Fifteen percent (22/142) of GTs were used for <6 months post-operatively. The median duration of short-term GT use was 1.6 months (IQR 0.9-3.4 months). Short-term GTs were more likely to be placed in patients with traumatic brain injury (TBI) (18.2% vs. 4.2%, p = 0.03) and adolescents (>= 12 years old, 22.7% vs. 4.0%, p = 0.005). Gastrocutaneous fistula closure was required in 33.3% of short-term patients who had their GTs removed (n = 6/18), with median total hospital charges of $29,989 per patient. Conclusion: Fifteen percent of pediatric GTs placed as inpatients were used for <6 months, more commonly among adolescents and in TBI patients. One-third of patients with short-term GTs required gastrocutaneous fistula closure. Adolescents and TBI patients may benefit from consideration of short-term nasogastric tube (NGT) feeds rather than surgical GT placement. (C) 2021 The Author(s). Published by Elsevier Inc.

Purpose: Augmentation of in utero myelomeningocele repair with human placental mesenchymal stromal cells seeded onto extracellular matrix (PMSC-ECM) improves motor outcomes in an ovine myelomeningocele model. This study evaluated the safety of PMSC-ECM application directly onto the fetal spinal cord in preparation for a clinical trial. Methods: Laminectomy of L5-L6 with PMSC-ECM placement directly onto the spinal cord was performed in five fetal lambs at gestational age (GA) 100-106 days. Lambs and ewes were monitored for three months following delivery. Lambs underwent magnetic resonance imaging (MRI) of the brain and spine at birth and at three months. All organs from lambs and uteri from ewes underwent histologic evaluation. Lamb spinal cords and brains and ewe placentas were evaluated for persistence of PMSCs by polymerase chain reaction for presence of human DNA. Results: MRIs demonstrated no evidence of abnormal tissue growth or spinal cord tethering. Histological analysis demonstrated no evidence of abnormal tissue growth or treatment related adverse effects. No human DNA was identified in evaluated tissues. Conclusion: There was no evidence of abnormal tissue growth or PMSC persistence at three months following in utero application of PMSC-ECM to the spinal cord. This supports proceeding with clinical trials of PMSC-ECM for in utero myelomeningocele repair. Level of evidence: N/A Type of study: Basic science

Background Recent work has demonstrated that an accelerated pathway for pediatric patients with blunt solid organ injuries is safe; however, this is not well-studied in a dual trauma center. We hypothesized that implementation of an accelerated pathway would decrease length of stay (LOS) and hospitalization cost without increased mortality. Methods Retrospective review of patients < 15 years presenting to a dual level 1 trauma center between 2015 and 2020 with traumatic blunt liver and splenic injuries. Patients presenting pre- and post-protocol implementation were compared. The primary outcome was total hospital LOS. Secondary outcomes were number of lab draws, intensive care unit (ICU) LOS, cost of hospitalization, readmissions within 30 days, and mortality. Results 103 patients were evaluated, 67 pre-protocol and 63 post-protocol. LOS was significantly shorter post-protocol (2 days vs. 4 days, p < 0.001). The ICU LOS was unchanged. There was a decrease in direct hospitalization cost per patient from $6,246 pre-protocol to $4,294 post-protocol (p = 0.001). There was one readmission post-protocol and none pre-protocol. There were no deaths. Conclusion Implementation of an accelerated pathway for management of blunt solid organ injury at a dual trauma center was associated with decreased LOS and decreased costs with no increased morbidity or mortality.

Background: The inherent morbidity associated with fetal ovine models of myelomeningocele (MMC) has created challenges for long-term survival of lambs. We aimed to develop a fetal ovine surgical spinal exposure model which could be used to evaluate long-term safety after direct spinal cord application of novel therapeutics for augmentation of in utero MMC repair. Methods: At gestational age (GA) 100–106, fetal lambs underwent surgical intervention. Laminectomy of L5–L6 was performed, dura was removed, and an experimental product was directly applied to the spinal cord. Paraspinal muscles and skin were closed and the fetus was returned to the uterus. Lambs were delivered via cesarean section at GA 140–142. Lambs were survived for 3 months with regular evaluation of motor function by the sheep locomotor rating scale. Spinal angulation was evaluated by magnetic resonance imaging at 2 weeks and 3 months. Results: Five fetal surgical intervention lambs and 6 control lambs who did not undergo surgical intervention were included. All lambs survived to the study endpoint of 3 months. No lambs had motor function abnormalities or increased spinal angulation. Conclusion: This model allows for long-term survival after fetal spinal cord exposure with product application directly onto the spinal cord.

BACKGROUND:One of the most competitive surgical sub-specialty fellowships remains Pediatric Surgery (PS), which requires candidates to develop a strong and research-oriented curriculum vitae. Although some objective factors of matriculation are known, factors for the interview selection and ranking per the program directors (PDs) have not been reviewed in over a decade. METHODS:A web-based survey of US and Canadian PS program directors (PDs) (n = 58) was used to evaluate a comprehensive list of factors in the selection criteria for PS fellowships. A mix of dichotomous, ranking, five-point Likert scale, and open-ended questions evaluated applicant characteristics, ABSITE scores, research productivity, interview day, and rank order criteria. RESULTS:Fifty-five programs responded to the survey for a 95% participation rate. PDs desired an average of two years in dedicated research and weighted first authorship and total number of publications heavily. Only 38% of programs used an ABSITE score cutoff for offering interviews; however, the majority agreed that an overall upward trend was important. Quality letters of recommendation, especially from known colleagues, carried weight when deciding to offer interviews. Interview performance, being a team player, observed interpersonal interactions, perceived operative skills and patient care, and leadership were some of the notable factors when finalizing rank lists. CONCLUSIONS:A multitude of factors define a successful matriculant, including quality of letters of recommendation, quality and quantity of publications, supportive phone calls, observed interactions, interview performance, perceptions of being team player with leadership skills as well as perceptions of good operative skills and patient care. LEVEL OF EVIDENCE:Type II. TYPE OF STUDY:Prognostic (retrospective).