W. Michael Southgate

Lactobezoars: A Patient Series and Literature Review

Lactobezoar is a compact mass of undigested milk concretions located within the gastrointestinal tract. Most often found in infants, they can precipitate gastric outlet obstruction, mimicking a variety of medical and surgical conditions. A common etiology and method of cure have yet to be elucidated. A review of the literature provides some insight into causes, clinical presentations, diagnosis, and management. Data from the Medical University of South Carolina further help dispel the belief that lactobezoars are isolated to pre-term infants on caloric-dense formulas. Findings suggest bezoar formation may be more common than previously thought and a high index of suspicion could help avoid costly evaluations for obstructive symptoms.

Evaluation of a flat panel digital radiographic system for low-dose portable imaging of neonates.

The purpose of this study was to evaluate the clinical utility of an investigational flat-panel digital radiography system for low-dose portable neonatal imaging. Thirty image-pairs from neonatal intensive care unit patients were acquired with a commercial Computed Radiography system (Agfa, ADC 70), and with the investigational system (Varian, Paxscan 2520) at one-quarter of the exposure. The images were evaluated for conspicuity and localization of the endings of ancillary catheters and tubes in two observer performance experiments with three pediatric radiologists and three neonatologists serving as observers. The results indicated no statistically significant difference in diagnostic quality between the images from the investigational system and from CR. Given the investigational systems superior resolution and noise characteristics, observer results suggest that the high detective quantum efficiency of flat-panel digital radiography systems can be utilized to decrease the radiation dose/exposure to neonatal patients, although post-processing of the images remains to be optimized. The rapid availability of flat-panel images in portable imaging was found to be an added advantage for timely clinical decision-making.

Putting the pediatrics milestones into practice: a consensus roadmap and resource analysis.

The Accreditation Council for Graduate Medical Education has partnered with member boards of the American Board of Medical Specialties to initiate the next steps in advancing competency-based assessment in residency programs. This initiative, known as the Milestone Project, is a paradigm shift from traditional assessment efforts and requires all pediatrics residency programs to report individual resident progression along a series of 4 to 5 developmental levels of performance, or milestones, for individual competencies every 6 months beginning in June 2014. The effort required to successfully make this shift is tremendous given the number of training programs, training institutions, and trainees. However, it holds great promise for achieving training outcomes that align with patient needs; developing a valid, reliable, and meaningful way to track residents’ development; and providing trainees with a roadmap for learning. Recognizing the resources needed to implement this new system, the authors, all residency program leaders, provide their consensus view of the components necessary for implementing and sustaining this effort, including resource estimates for completing this work. The authors have identified 4 domains: (1) Program Review and Development of Stakeholders and Participants, (2) Assessment Methods and Validation, (3) Data and Assessment System Development, and (4) Summative Assessment and Feedback. This work can serve as a starting point and framework for collaboration with program, department, and institutional leaders to identify and garner necessary resources and plan for local and national efforts that will ensure successful transition to milestones-based assessment.

Arrhythmia during Kangaroo Care

A term male infant was admitted to the neonatal intensive care unit following resuscitation for a spontaneous pneumothorax. Needle decompression was performed and after brief supplemental oxygen support he improved quickly. At 18 hours of life he was stable on room air, with normal oxygen saturations, and began breastfeeding and kangaroo care. Shortly after the infant was placed on the mother’s chest, the bedside nurse noted a significant change in the heart rhythm on the cardiorespiratory monitor and alerted the physician team. The tracing on the bedside monitor and telemetry was of concern for supraventricular tachycardia or atrial fibrillation (Figure, A). The infant had no apparent distress, cyanosis, or change in respiratory pattern. Auscultation revealed regular S1 and S2 sounds. During the physical exam, theQRS complexes resolved into 2 distinct morphologies (Figure, B). Upon moving the infant back to the radiant warmer for electrocardiogram, the dysrhythmia resolved. Careful examination of the telemetry revealed that the plethysmography tracing retained a regular pattern throughout the apparent arrhythmia. The diagnosis was made of a spurious arrhythmia attributable to unintended transduction of the mother’s heart rate. The tracings can be resolved into 2 regular rhythms superimposed to give the appearance of arrhythmia (Figure).