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Patients with congenital heart disease (CHD) that have surgical repair with cardiopulmonary bypass (CPB) reflect a unique population with multiple pulmonary and systemic factors that may contribute to increased alveolar dead space and low cardiac output syndrome. This study aimed to assess and compare changes in the alveolar dead space fraction (AVDSf) in the immediate postoperative period with outcomes in children with CHD who underwent repair on CPB. A single-center retrospective review study of critically ill children with CHD, younger than 18 years of age admitted to the Pediatric Intensive Care Unit (PICU) after undergoing surgical repair on CPB and received invasive mechanical ventilation for at least 24 h. One hundred and two patients were included in the study. Over the first 24 h, mean AVDSf was significantly higher in patients who had longer hospital length of stay (LOS) (> 21 days) p = 0.02, and longer duration of invasive mechanical ventilation (DMV) (> 170 h) p = 0.01. Cross-sectional analyses at 23-24 h revealed that AVDSf > 0.25 predicts mortality and DMV (p = 0.03 and P = 0.02 respectively); however, it did not predict prolonged hospital LOS. For every 0.1 increase in the AVDSf, the odds of mortality, DMV, and hospital LOS increased by 4.9 [95% CI = 1.45-16.60, p = 0.002], 2.06 [95% CI = 1.14-3.71, p = 0.01], and 1.43[95% CI = 0.84-2.45, p = 0.184], respectively. The area under the ROC curve at 23-24 h for AVDSf was 0.868 to predict mortality as an outcome. AVDSf > 0.25 at 23-24 h postoperatively was an independent predictor of mortality with sensitivity and specificity of 83% and 80%, respectively and was superior to other commonly used surrogates of cardiac output. In the immediate postoperative period of pediatric patients with CHD, high AVDSf is associated with longer hospital length of stay and duration of invasive mechanical ventilation. Increased AVDSf values at 23-24 h postoperatively is associated with mortality in patients with CHD exposed to CPB., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: High-flow nasal cannula (HFNC) is commonly used to provide respiratory support to pediatric patients with respiratory failure. Although the use of bronchodilators via HFNC has been described, the feasibility and safety of aerosolized bronchodilator delivery via HFNC are controversial. In this study, we sought to evaluate whether the HFNC system can be used to deliver nebulized bronchodilators at lower gas flow of 2-4 L/min, increase patient comfort, and minimize respiratory therapist (RT) bedside time when compared to traditional interfaces., Methods: A retrospective chart review of all pediatric subjects who were admitted to the pediatric ICU in a tertiary care children's hospital and required nebulized bronchodilators between December 2017 and June 2018., Results: A total of 205 nebulizations were administered to 28 children; 31% of nebulized bronchodilators were given using a nebulization system integrated into the HFNC. Nebulized treatments resulted in an average increase in heart rate of 9.98 (95% CI 3.72-16.2) beats/min when HFNC was used and 0.64 (95% CI -1.65 to 2.93) beats/min when traditional interfaces were used, a difference of 9.34 (95% CI 2.30-16.4) beats/min ( P < .001). RT bedside time was significantly longer for HFNC nebulized treatments ( P = .031). Subjective level of comfort was not statically different when nebulized bronchodilators were delivered via HFNC or via traditional interfaces. Length of pediatric ICU stay was not statistically different between subjects who received some aerosol nebulized bronchodilators via HFNC versus those who received all bronchodilators through traditional interfaces ( P = .11)., Conclusions: Aerosol bronchodilator delivery using HFNC is feasible at low gas flow (ie, 2-4 L/min). However, the use of HFNC did not improve subjects' comfort, and it increased RT bedside time. Further prospective randomized studies are needed to determine the efficacy and efficiency of aerosol therapy delivered through HFNC and potential patient-oriented outcomes., (Copyright © 2020 by Daedalus Enterprises.)

Planning for sea level rise (SLR) is a complex process that involves scientific uncertainty and local and regional political tradeoffs. As part of a 6-year transdisciplinary research project in the northern Gulf of Mexico, we conducted focus groups with coastal stakeholders (natural resource managers, community planners, and environmental communicators) to gain a better understanding of their planning and adaptation activities for SLR. This paper reports on participants' perceptions about adaptation and their current adaptation activities and strategies. While stakeholders were concerned about SLR and thought adaptation had challenges, they still shared optimism and a commitment to planning. The findings identify different types of SLR adaptation initiatives in which participants were involved as well as types of perceived barriers to adaptation planning, and major recommended strategies to address them. The paper concludes with a discussion of findings, connections to related SLR adaptation literature, practical implications for coastal resiliency, and directions for future research.

Shortness of breath and wheezing are common presenting signs for children in the emergency department. In adolescence, it is often due to asthma or lower respiratory tract infections. We present a rare pediatric case of an adolescent with biphasic stridor and progressive exercise-induced shortness of breath who was found to have severe idiopathic subglottic stenosis.

Two distinct microtidal estuarine systems were assessed to advance the understanding of the coastal dynamics of sea level rise in salt marshes. A coupled hydrodynamic-marsh model (Hydro-MEM) was applied to both a marine-dominated (Grand Bay, Mississippi) and a mixed fluvial/marine (Weeks Bay, Alabama) system to compute marsh productivity, marsh migration, and potential tidal inundation from the year 2000 to 2100 under four sea level rise scenarios. Characteristics of the estuaries such as geometry, sediment availability, and topography, were compared to understand their role in the dynamic response to sea level rise. The results show that the low sea level rise scenario (20 cm) approximately doubled high-productivity marsh coverage in the marine-dominated estuary by the year 2100 due to an equilibrium between the rates of sea level rise and marsh platform accretion. Under intermediate-low sea level rise (50 cm), high-productivity marsh coverage in the year 2100 increased (doubled in the marine-dominated estuary and a seven-fold increase in the mixed estuary) by expanding into higher lands followed by the creation of interior ponds. The results also indicate that marine-dominated estuaries are vulnerable to collapse as a result of low, relatively uniform topography and lack of sediment sources, whereas mixed estuaries are able to expand due to higher elevations and sediment inputs. The results from the higher sea level rise scenarios (the intermediate-high (120 cm) and high (200 cm)) showed expansion of the bays along with marsh migration to higher land, producing a five-fold increase in wetland coverage for the mixed estuary and virtually no net change for the marine-dominated estuary. Additionally, hurricane storm surge simulations showed that under higher sea level rise scenarios, the marine-dominated estuary demonstrated weaker peak stage attenuation indicating that the marsh's ability to dissipate storm surge is sensitive to productivity changes and bay expansion / marsh loss., Competing Interests: The authors have declared that no competing interests exist.

The authors describe a multiinstitutional collaborative project to address a gap in global health training by creating a free online platform to share a curriculum for performing procedures in resource-limited settings. This curriculum called PEARLS (Procedural Education for Adaptation to Resource-Limited Settings) consists of peer-reviewed instructional and demonstration videos describing modifications for performing common pediatric procedures in resource-limited settings. Adaptations range from the creation of a low-cost spacer for inhaled medications to a suction chamber for continued evacuation of a chest tube. By describing the collaborative process, we provide a model for educators in other fields to collate and disseminate procedural modifications adapted for their own specialty and location, ideally expanding this crowd-sourced curriculum to reach a wide audience of trainees and providers in global health.

River deltas all over the world are sinking beneath sea-level rise, causing significant threats to natural and social systems. This is due to the combined effects of anthropogenic changes to sediment supply and river flow, subsidence, and sea-level rise, posing an immediate threat to the 500-1,000 million residents, many in megacities that live on deltaic coasts. The Mississippi River Deltaic Plain (MRDP) provides examples for many of the functions and feedbacks, regarding how human river management has impacted source-sink processes in coastal deltaic basins, resulting in human settlements more at risk to coastal storms. The survival of human settlement on the MRDP is arguably coupled to a shifting mass balance between a deltaic landscape occupied by either land built by the Mississippi River or water occupied by the Gulf of Mexico. We developed an approach to compare 50 % L:W isopleths ( L:W is ratio of land to water) across the Atchafalaya and Terrebonne Basins to test landscape behavior over the last six decades to measure delta instability in coastal deltaic basins as a function of reduced sediment supply from river flooding. The Atchafalaya Basin, with continued sediment delivery, compared to Terrebonne Basin, with reduced river inputs, allow us to test assumptions of how coastal deltaic basins respond to river management over the last 75 years by analyzing landward migration rate of 50 % L:W isopleths between 1932 and 2010. The average landward migration for Terrebonne Basin was nearly 17,000 m (17 km) compared to only 22 m in Atchafalaya Basin over the last 78 years ( p  < 0.001), resulting in migration rates of 218 m/year (0.22 km/year) and <0.5 m/year, respectively. In addition, freshwater vegetation expanded in Atchafalaya Basin since 1949 compared to migration of intermediate and brackish marshes landward in the Terrebonne Basin. Changes in salt marsh vegetation patterns were very distinct in these two basins with gain of 25 % in the Terrebonne Basin compared to 90 % decrease in the Atchafalaya Basin since 1949. These shifts in vegetation types as L:W ratio decreases with reduced sediment input and increase in salinity also coincide with an increase in wind fetch in Terrebonne Bay. In the upper Terrebonne Bay, where the largest landward migration of the 50 % L:W ratio isopleth occurred, we estimate that the wave power has increased by 50-100 % from 1932 to 2010, as the bathymetric and topographic conditions changed, and increase in maximum storm-surge height also increased owing to the landward migration of the L:W ratio isopleth. We argue that this balance of land relative to water in this delta provides a much clearer understanding of increased flood risk from tropical cyclones rather than just estimates of areal land loss. We describe how coastal deltaic basins of the MRDP can be used as experimental landscapes to provide insights into how varying degrees of sediment delivery to coastal deltaic floodplains change flooding risks of a sinking delta using landward migrations of 50 % L:W isopleths. The nonlinear response of migrating L:W isopleths as wind fetch increases is a critical feedback effect that should influence human river-management decisions in deltaic coast. Changes in land area alone do not capture how corresponding landscape degradation and increased water area can lead to exponential increase in flood risk to human populations in low-lying coastal regions. Reduced land formation in coastal deltaic basins (measured by changes in the land:water ratio) can contribute significantly to increasing flood risks by removing the negative feedback of wetlands on wave and storm-surge that occur during extreme weather events. Increased flood risks will promote population migration as human risks associated with living in a deltaic landscape increase, as land is submerged and coastal inundation threats rise. These system linkages in dynamic deltaic coasts define a balance of river management and human settlement dependent on a certain level of land area within coastal deltaic basins ( L ).

Marine tar residues originate from natural and anthropogenic oil releases into the ocean environment and are formed after liquid petroleum is transformed by weathering, sedimentation, and other processes. Tar balls, tar mats, and tar patties are common examples of marine tar residues and can range in size from millimeters in diameter (tar balls) to several meters in length and width (tar mats). These residues can remain in the ocean environment indefinitely, decomposing or becoming buried in the sea floor. However, in many cases, they are transported ashore via currents and waves where they pose a concern to coastal recreation activities, the seafood industry and may have negative effects on wildlife. This review summarizes the current state of knowledge on marine tar residue formation, transport, degradation, and distribution. Methods of detection and removal of marine tar residues and their possible ecological effects are discussed, in addition to topics of marine tar research that warrant further investigation. Emphasis is placed on benthic tar residues, with a focus on the remnants of the Deepwater Horizon oil spill in particular, which are still affecting the northern Gulf of Mexico shores years after the leaking submarine well was capped.

Background: Preparation for residents participating in global health (GH) experiences is critical. Active preparatory curricula allowing residents to experience and debrief emotional challenges they may encounter abroad are generally lacking. We sought to evaluate a novel simulation curriculum designed to prepare residents for emotions they may experience in response to challenges abroad., Methods: Pediatric GH educators from 7 institutions developed case vignettes incorporating common challenges residents experience abroad. Residents participating in a GH training track or planning to participate in a GH rotation from the 7 institutions were eligible to participate in the simulation curriculum. Participants and trained facilitators completed postsimulation evaluations that were analyzed using descriptive statistics and thematic analysis of written comments to assess the utility of the curriculum, emotions evoked, and changes residents anticipated making to their GH rotation preparation., Results: Fifty-one residents and 16 facilitators completed 160 and 52 evaluations, respectively. Overall, respondents found the simulations useful (mean [SD] resident score 4.49 [0.82] and facilitator score 4.85 [0.36] on a 5-point scale [1 = completely useless, 5 = very useful]). Residents reported strong emotions in 153 (98%) of 156 comments. After the sessions, 131 (96%) of 137 comments reflected anticipated changes to GH rotation preparation plans., Conclusions: Active preparation for GH rotations using simulated cases appears to be a useful tool that can be implemented across a variety of sites with minimal facilitator training or simulation experience. The curriculum successfully elicited powerful emotions in residents and provided an opportunity to debrief these experiences before encountering them abroad., (Copyright © 2014 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: In the world emergencies occur everywhere, and each day they consume ressources regardless of whether there are systems capable of achieving good outcomes. Low-income countries suffer the most highest rates of every category of injury--from traffic and the highest rates of acute complications of communicable diseases including tuberculosis, malaria and HIV., Objective: To describe the development of pediatrics emergency medicine at Tikur Anbesa Specialized Hospital, Methods: A twinning partnership model was used in developing a pediatric emergency medicine training program helps in development of pediatrics emergency system., Results: Strengthening the capacity of Addis Ababa University (AAU), Tikur Anbessa Hospital (TASH) to provide pediatric emergency medical services through improved organization of the pediatrics emergency department and strengthening of continuing education opportunities for faculty and staff capacity building by this improving quality of care in pediatrics patients in the country., Conclusion: The Addis Ababa University, University of Wiscosin and People to People partners intend to continue working together to strengthening and developing effetive systems to deliver quality pediatrics emergency medicine care troughout all regions of Ethiopia.