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Objective: To update pediatric subspecialty workforce data to support evidence-based legislation and public policy decisions by replicating the American Academy of Pediatrics' 1998 Future of Pediatric Education (FOPE II) workforce survey., Methods: A descriptive and comparative analysis of survey responses from 9950 US pediatric subspecialists who completed an electronic survey., Results: Pediatric subspecialists are working fewer hours and spending less of their time in direct patient care than they did in 1998 but the mean hours worked differs significantly according to subspecialty. Most subspecialists continue to be board-certified, white, non-Hispanic men, although the percentage who are women and from minority groups has increased. The proportion of subspecialists practicing in an academic medical center has increased since 1998. Thirty percent of pediatric subspecialists reported appointment wait times of >2 weeks and pediatric subspecialists in developmental pediatrics, endocrinology, and neurology identified much longer wait times than other subspecialists., Conclusion: The demographic and practice characteristics of pediatric subspecialists have changed since the FOPE II survey and access to subspecialty care in a family's community remains a challenge. However, pediatric subspecialties are not monolithic and solutions to workforce shortages will need to take into account these differences to improve access to subspecialty care., (Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Cardiac asthma describes symptoms of airflow obstruction due to heart failure. Chronic heart failure is associated with decreased FEV 1 , and FEV 1 improves after heart transplantation. Fibrotic remodeling of the heart and airways is mediated, in part, through transforming growth factor (TGF)- β . Blood TGF- b 1 concentration correlates with ventricular remodeling in cardiac disease, and TGF- β decreases after repair., Methods: We established a coculture of normal human bronchial epithelial (NHBE) cells differentiated at air-liquid interface with submerged basal cardiomyoblasts. Airway cells were immunostained with cytokeratin, actin, and involucrin. TGF- β synthesis was assayed using enzyme-linked immunosorbent assay. Phosphorylation of Smad in NHBE cells was determined by Western blotting.Mice given doxorubicin developed cardiac failure, and their airways were histologically examined., Results: Coculture induced involucrin-positive squamous metaplasia of NHBE cells, and this was attenuated by TGF- β antibody. Total TGF- β 1 was increased in coculture conditioned medium( P < .001). After 14 days of exposure to recombinant TGF- β 1 , there was squamous transformation of NHBE cells. One week after removing cardiomyoblasts from culture, squamous metaplasia resolved into normal ciliated epithelia. Smad was phosphorylated in NHBE cells with cardiomyoblasts or with recombinant TGF- β 1 exposure. The airways of mice with heart failure also demonstrated involucrin-positive squamous transformation., Conclusions: TGF- β from cardiomyoblasts or from the failing heart can cause airway squamous metaplasia via Smad signaling, and this is blocked by anti-TGF- b antibody and reversed when cardiac cells are removed from culture. This appears to be an important mechanism for airflow obstruction with heart failure, sometimes described as cardiac asthma.

Fistulas between the airways and the digestive tract are a rare complication of esophagectomy. We describe such a fistula complicated by recurrent pneumonia. We successfully closed the fistula with an Amplatzer Septal Occluder (AGA Medical Corp, Plymouth, MN), a nitinol device designed for percutaneous closure of congenital heart defects. The device was deployed under direct visualization through rigid bronchoscopy., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)