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Background Allergic fungal rhinosinusitis (AFRS) is an endotype of chronic rhinosinusitis (CRS) with nasal polyps characterized by eosinophilic mucin laden with fungal hyphae entrapped in expanded sinus cavities with an exaggerated hypersensitivity to fungal elements. The last decade has elucidated fungi-driven inflammatory pathways contributing to the pathophysiology of chronic inflammatory respiratory diseases. In addition, novel therapeutic biologic options have become available for CRS over the last several years. Objective To review the current literature examining AFRS, focusing on recent developments in our understanding of its pathophysiology and implications for treatment options. Methods Review article. Results Fungi-driven respiratory inflammation has been linked to fungal proteinases and toxin activity. In addition, AFRS patients demonstrate a local sinonasal immunodeficiency in antimicrobial peptides and hence limited antifungal activity, along with an exaggerated type 2 inflammatory response, highlighting a possible imbalanced type 1, type 2, and type 3 profile. The elucidation of these dysregulated molecular pathways has highlighted novel potential therapeutic targets. As such, the clinical management of AFRS, which once included surgery and extended courses of oral corticosteroids, is transitioning away from long courses of oral corticosteroids to incorporate novel delivery mechanisms of topical therapeutic targets and biologics for recalcitrant disease. Conclusion AFRS is an endotype of CRS with nasal polyps (CRSwNP) for which the molecular pathways leading to its inflammatory dysfunction are beginning to be illuminated. In addition to affecting treatment options, these understandings may shape necessary changes to diagnostic criteria and the extrapolated effects of environmental changes on AFRS. More critically, a better appreciation of fungi-driven inflammatory pathways may have implications for the understanding of broader CRS inflammation.

There is a significant unmet need for children’s surgical care in low- and middle-income countries (LMICs). Multidisciplinary collaboration is required to advance the surgical and anesthesia care of children’s surgical conditions such as congenital conditions, cancer and injuries. Nonetheless, there are limited examples of this process from LMICs. We describe the development and 3-year outcomes following a 2015 stakeholders’ meeting in Uganda to catalyze multidisciplinary and multi-institutional collaboration. The stakeholders’ meeting was a daylong conference held in Kampala with local, regional and international collaborators in attendance. Multiple clinical specialties including surgical subspecialists, pediatric anesthesia, perioperative nursing, pediatric oncology and neonatology were represented. Key thematic areas including infrastructure, training and workforce retention, service delivery, and research and advocacy were addressed, and short-term objectives were agreed upon. We reported the 3-year outcomes following the meeting by thematic area. The Pediatric Surgical Foundation was developed following the meeting to formalize coordination between institutions. Through international collaborations, operating room capacity has increased. A pediatric general surgery fellowship has expanded at Mulago and Mbarara hospitals supplemented by an international fellowship in multiple disciplines. Coordinated outreach camps have continued to assist with training and service delivery in rural regional hospitals. Collaborations between disciplines, both within LMICs and with international partners, are required to advance children’s surgery. The unification of stakeholders across clinical disciplines and institutional partnerships can facilitate increased children’s surgical capacity. Such a process may prove useful in other LMICs with a wide range of children’s surgery stakeholders.

Background: Eyal and Hurst proposed that locally relevant medical education can offset the prevalence of physician “brain drain” in resource-poor regions of the world, and presented a framework of the ethical and pragmatic benefits and concerns posed by these initiatives. The present study explored the framework’s utility through a case study of the University of Guyana Diploma in Surgery (UGDS) programMethods: The framework’s utility was evaluated using a case study designthat included review and analysis of documents and semi-structured interviews with graduates, trainees, faculty members, and policy makers associated with the UGDS program. Data were analyzed from constructivist and interpretivist perspectives, and compared against the benefits and concerns described by Eyal and Hurst.Results: The framework is a useful template for capturing the breadth of experience of locally relevant training in the Guyanese setting. However, the results suggest that delineating the framework factors as either beneficial or concerning may constrict its applicability. The case study design also provided specific insights about the UGDS program, which indicate that the Program has promoted the retention of graduates and a sustainable culture of postgraduate medical education in Guyana.Conclusion: It is suggested that the framework be modified so as to represent the benefits and concerns of locally relevant training along a continuum of advantage. These approaches may help us understand retention within a resource-poor country, but also within particularly remote areas and public health care systems generally.

According to the Diagnostic and Statistical Manual of Mental Disease (DSM-5), delirium is an acute fluctuating disturbance in attention and awareness. Due to physiologic perturbations, delirium results in cerebral dysfunction and cognitive impairment (1). Among hospitalized patients delirium is associated with increased morbidity, length of stay (LOS), costs and mortality (2). Moreover, there is evidence that patients who develop delirium experience an accelerated degree of long-term cognitive decline compared to those that do not experience delirium while hospitalized (3). In their paper, “Preoperative STOP-BANG Scores and Postoperative Delirium and Coma in Thoracic Surgery Patients,” Wang and colleagues sought to assess the relationships between obstructive sleep apnea (OSA), delirium and postoperative outcomes among thoracic surgery intensive care unit (ICU) patients.

Purpose The "cut and push" technique for removal of percutaneous endoscopic gastrostomy (PEG) tubes with collapsible bumpers offers an alternative to the standard traction method of removal. This study compared the outcomes of these techniques. Methods We completed a research ethics board-approved retrospective cohort study, identifying all patients less than 18years of age who underwent PEG tube removal at a children's hospital between December 2013 and December 2016. Outcomes included need for sedation and complications. Results We identified 127 children who had PEG tubes removed. Significantly fewer children required sedation with the cut and push group (1.1% vs. 60.6%, p≤0.001). Ten complications occurred, including 9 in the cut and push group (9.6% vs. 3%, p=0.23). Mean age at time of complication was significantly younger in the cut and push group (2.2 vs. 6.3years p=0.004). Conclusion This is the largest reported series comparing the cut and push vs. traction removal methods. The cut and push technique significantly reduced the need for procedural sedation but was associated with increased risk of complications. While these data suggest that the technique is safe in older children, caution should be taken in younger children who appear to be more likely to vomit the residual bumper. Levels of evidence Level III—Treatment study, Retrospective comparative study.

Part 6: Experience Reports; International audience; Enterprise Architecture is the process of translating business vision into strategy. Hence, Enterprise Modeling is the process of translating an organization’s strategic intent into mandated socio-technological innovation projects required to reach an agreed future state of the firm’s operation.This paper uses four longitudinal case studies at DHL Express Europe to introduce a significant paradigm shift to modeling of the enterprise at the work system level as an abstract representation of the desired future state of the enterprise. This representation specifies in full the business capabilities serving current and future customer needs and the work system configuration enhancements needed to satisfy the customer needs. The associated project has four p steps: (1) Assessment of Status Quo, (2) Agreeing on the desired End-State, (3) Evolution of legacy work-systems, (4) Removal of Obsolete components. This process model explicitly includes the necessity to search for, address and remove all strategic, financial, operational and technical legacy issues identified during the baseline of the status quo. Enterprise Architects should be embedded in each implementation project for Project Assurance purposes in order to monitor the delivery of the agreed end-state.

Background Burden of disease (BoD) as measured by Disability-Adjusted Life Years (DALYs) is one of the criteria for priority-setting in health care resource allocation. DALYs incorporate disability weights (DWs), which are currently expert-derived estimates or non-existent for most pediatric surgical conditions. The objective of this study is to establish DWs for a subset of key pediatric congenital anomalies using a range of health valuation metrics with caregivers in both high- and low-resource settings. Method We described 15 health states to health professionals (physicians, nurses, social workers, and therapists) and community caregivers in Kenya and Canada. The health states summaries were expert- and community-derived, consisting of a narrated description of the disease and a functional profile described in EQ-5D-5 L style. DWs for each health state were elicited using four health valuation exercises (preference ranking, visual analogue scale (VAS), paired comparison (PC), and time trade-off (TTO)). The PC data were anchored internally to the TTO and externally to existing data to yield DWs for each health state on a scale from 0 (health) to 1 (dead). Any differences in DWs between the two countries were analyzed. Results In total, 154 participants, matched by profession, were recruited from Kijabe, Kenya (n = 78) and Hamilton, Canada (n = 76). Overall calculated DWs for 15 health states ranged from 0.13 to 0.77, with little difference between countries (intra-class coefficient 0.97). However, DWs generated in Kenya for severe hypospadias and undescended testes were higher than Canadian-derived DWs (p = 0.04 and p

Background The Canadian 4-year native liver survival rate for biliary atresia (BA) after Kasai Portoenterostomy (KP) is 39%. The Canadian Biliary Atresia Registry (CBAR) was used to examine variability of surgical and medical management of BA. Methods Gastroenterologists and surgeons in all 14 Canadian pediatric tertiary centers were invited to complete an online survey of their BA management practices. Results Of gastroenterologists, diagnostic procedures included liver biopsy (92%), HIDA scan (58%), and percutaneous cholangiogram (46%). Surgeons reported Roux-en-Y lengths of 20–50cm with 78% avoiding diathermy at the portal plate; 16% performed laparoscopic exploration, but none laparoscopic KP. Postoperative corticosteroids and antibiotics were used by 24% and 85% of gastroenterologists, respectively, with similar rates for surgeons. At discharge, gastroenterologists prescribed oral antibiotics (80%), and ursodeoxycholic acid (95%), while surgeons reported lower rates (62% and 55%). Considerable variation existed in follow-up monitoring. No center had a standard protocol for evaluating suspected cholangitis. There was a lack of consensus for defining failed KP and referral criteria for transplant evaluation. Conclusion In Canada, treatment of BA is not centralized, and there is variability in diagnostic approaches and management. Collaboration through CBAR will allow for implementation and evaluation of standardized surgical and medical management with a goal to improve outcomes. Level of evidence Survey study. Level IV evidence.

E-learning – the use of the Internet and multimedia technology – is completely transforming the learning environment of the twenty-first century. The global penetration of computers, smart phones, and access to the Internet is reaching even the remotest parts of the least developed countries. As learner-educators, global surgeons can take advantage of new technologies by accessing existing online learning resources or developing their own. E-learning tools have unique advantages in distance learning, such as allowing learners to be engaged synchronously with an online lecture, or review and respond through an asynchronous discussion board. This chapter discusses e-learning instructional design and describes successful projects, evaluation approaches, and future directions for e-learning in global surgery. Formal online courses, webinars, and remote telementoring all provide examples of surgical leadership and north-south partnerships in surgical education. Evaluation of surgical e-learning partnership initiatives will provide opportunities for bilateral mutual learning and “reverse innovation.” Globally minded surgeons are on the cutting edge using innovation and new technology to teach their craft.

Purpose Patent Ductus Arteriosus (PDA) ligation in premature infants is an urgent procedure performed by some but not all pediatric surgeons. Proficiency in PDA ligation is not a requirement of Canadian pediatric surgery training. Our purpose was to determine the outcomes of neonatal PDA ligation done by pediatric surgeons. Methods We performed a retrospective review of premature infants who underwent PDA ligation by pediatric surgeons in 3 Canadian centers from 2005 to 2009. Outcomes were compared to published controls. Results The review identified 98 patients with a mean corrected GA and weight at repair of 29weeks and 1122g, respectively. There were no intraoperative deaths. The 30-day and inhospital mortality rates were 1% and 5%. Mortality and morbidity were comparable to the published outcomes. Conclusions This study documents that a significant number of preterm infant PDA ligations are safely done by pediatric surgeons. To meet the Canadian needs for this service by pediatric surgeons, proficiency in PDA ligation should be considered important in pediatric surgery training programs.

Background Professionalism is an important part of the hidden curriculum that is gaining attention in surgical education. McMaster University, Hamilton, Ontario, Canada, has introduced a small group discussion model using critical incident reports (CIRs) to elicit students' reflections on ethical, communication, and professionalism challenges during surgical clerkship. We described the themes identified by surgical clerks in their CIRs. Methods Using thematic analysis, 4 investigators coded 64 CIRs iteratively until conceptual saturation. Rigor and validity were ensured throughout the process. Data were further explored to compare the CIRs of junior and senior clerks. Results Twenty-seven themes and 4 relationship domains emerged: the clerk's relationship to patients, the health care team, the health care system, and self. Challenges with communication, the consent process, and breaking bad news were most commonly cited. Theme frequencies differed between junior and senior clerks. Conclusions Small group discussions of critical incident reports allow surgical clerks to reflect on their developing professional relationships. The themes that have been identified can be used to guide professionalism education and uncover the hidden curriculum.

Background We evaluated the retention of trauma knowledge and skills after an interprofessional Trauma Team Training (TTT) course in Guyana and explored the course impact on participants. Methods A mixed-methods design evaluated knowledge using a multiple-choice quiz test, skills and trauma moulage simulation with checklists, and course impact with qualitative interviews. Participants were evaluated at 3 time points; before, after, and 4 months after TTT. Results Forty-seven course participants included 20 physicians, 17 nurses, and 10 paramedical providers. All participants had improved multiple-choice quiz test scores after the course and retained knowledge after 4 months, with nonphysicians showing the most improved scores. Trauma skill and moulage scores declined slightly after 4 months, with the greatest decline observed in complex skills. Qualitatively, course participants self-reported impact of the TTT course included improved empowerment, knowledge, teamwork, and patient care. Conclusions Interprofessional team-based training led to the retention of trauma knowledge and skills as well as the empowerment of nonphysicians. The decline in performance of some trauma skills indicates the need for a regular trauma update course.

OBJECTIVE: To describe the authors’ experience with the implementation of a multidisciplinary approach and use of fish oil emulsion (FOE) in the management of infants with short bowel syndrome (SBS) and parenteral nutrition-associated liver disease (PNALD).METHODS: Between August 2006 and June 2009, four cases of SBS and severe PNALD were managed by the team using specifically developed protocols. The FOE was initiated if serum direct bilirubin levels were ≥100 μmol/L. To quantify the degree of exposure to high serum direct bilirubin levels over time, the area under the curve (AUC) for each patient was calculated before and after initiation of FOE. Linear regression analyses were performed to evaluate correlations between the AUC, duration of cholestasis and initiation of FOE.RESULTS: All patients survived and no complications were observed during the study period. After the first patient, FOE was initiated progressively earlier, but poor correlation between the AUC before and after its introduction was observed (r2=0.41924). However, there was strong correlation between the duration of PNALD before FOE initiation and time to resolution (r2=0.72133): the earlier the FOE was initiated, the shorter the time to resolution.CONCLUSION: The authors report a positive experience with the implementation of a multidisciplinary approach and the use of FOE in infants with SBS and severe PNALD. The earlier the FOE was initiated during the cholestatic process, the shorter the time to resolution. The present study is a hypothesis generator, raising the question of whether an earlier introduction of this particular therapy can effectively shorten the cholestasis process in these patients.

In industry, up to 40% of an IS budget can be spent on Storage technology, making it the fastest growing segment of IT/IS. While industry has recognised the need to diffuse this technology, academia has been slow to respond to this diffusion need. Universities are not teaching courses in this area and a variety of reasons are presented ranging from lack of skills to cost (the cost of installing a Storage system for use by students is a massive expenditure well beyond the budgets of most IS academic departments).This paper concentrates on the lack of skills (knowledge barriers in the parlance of diffusion of innovation theory) and examines ways to overcome this. The knowledge skills are present in industry, so collaboration between industry and academia is a suggested solution. Collaboration between industry and academia, though, is fraught with problems. The aim of this research therefore is to examine how this collaboration can be effective. Interestingly, the result of this research suggests true collaboration is not the solution, but a win-win situation is still possible for all stakeholders. Copyright © 2009, IGI Global.

Coil occlusion (CO) and video-assisted thoracoscopic surgery (VATS) have both emerged as minimal access therapies for patent ductus arteriosus (PDA). These techniques have not previously been statistically compared.Twenty-four consecutive children undergoing VATS for PDA were each retrospectively matched by PDA diameter and child weight to two children undergoing CO (total 48) during the same time period. The two modalities were compared with respect to outcome and cost. Statistical analysis was performed using a Student's t-test and Mantel-Haenszel relative risk. Cost analysis from an institutional perspective was used to compare resource consumption.Mean PDA diameter was 3.6 +/- 1.2 mm in both groups. Mean age and weight for VATS and CO children were 2.7 and 2.9 yrs and 13.2 and 13.1 kg, respectively. Mean surgical times were 94 +/- 34 min for VATS and 50 +/- 23 min for CO (p0.0001). Mean length of stay was 1.6 +/- 0.2 days for VATS and 0.6 +/- 0.2 days for CO (Mantel-Haenszel RR (95% CI) = 0.15 [0.07, 0.29], p0.0001). Mean fluoroscopy time with CO was 13 +/- 7 min. No VATS or CO children required conversion to open surgical ligation. Two children in each arm (8% VATS, 4% CO) required indefinite antibiotic endarteritis prophylaxis for a persistent shunt. The cost per child was C$ 4282.80 (Canadian dollars) for VATS and C$ 3958.08 for CO.VATS is as efficacious for PDA closure as CO but requires longer surgical times and lengths of stay. Costs for each procedure are similar.

Pediatric surgical practice is different in low- and middle-income countries as compared to North America. While resources are limited, the impact of pediatric surgical procedures is significant. The objective of this study was to calculate and compare disability-adjusted life years (DALYs) averted in a Kenyan and Canadian surgical unit for a subset of pediatric congenital anomalies. Medical records of children having undergone surgical procedures for 13 congenital conditions in both surgical units were collected over 12 months. DALYs for each condition were calculated using previously obtained disability weights derived in each country. Age-adjusted life expectancy rates from the WHO were used to determine years of life lost. Risk of permanent disability without surgery and probability of successful treatment values were obtained from the literature and included in the DALY calculation. The conditions accounting for the largest total number of averted DALYs in Kenya were hydrocephalus (60.8 %) and spina bifida (18.1 %), whereas in Canada they were hydrocephalus (24.2 %) and undescended testes (19.2 %). A total of 23,169 DALYs were averted through 1042 surgical procedures (22.2 DALYs per procedure) during the study period in Kenya, compared to 5497 DALYs through 373 procedures (14.7 DALYs per procedure) in Canada. Using recent developments in burden of disease measurement, the results point to the significant impact of pediatric surgical centers in addressing the global burden of congenital surgical disease. The study carries significant implications for resource allocation and training.

Background Disability-adjusted life years (DALYs) have become the standard metric for estimating burden of disease (BoD), but have not yet been applied to delayed access to surgical procedures. This study estimates the DALYs accrued from delayed access to surgical care in two pediatric surgical units in Kenya and Canada. Methods Records of operations for 13 congenital health states in a Kenyan and a Canadian hospital were prospectively collected for 2012. DALYs caused by delayed presentation were estimated using disability weights and ideal and actual age at surgery. Results 1208 first-time procedures in general surgery, neurosurgery, plastic surgery, and urology were included. Delays were longest in general surgery and longer in Kenya than in Canada in all specialties. The longest delays in Kenya were for orchidopexy (72 months) and anorectoplasty (PSARP) (74 months), and in Canada for orchidopexy (40 months). Corresponding total delayed BoD was highest in general surgery and neurosurgery and higher again in Kenya than in Canada (484 cf. 84 DALYs). Conclusions Estimating BoD resulting from delayed surgery is feasible and reflects both late presentation and limited access to care. Further exploration of these factors can make delayed DALYs a useful measure of health care coverage and waitlist prioritization.

Background For individual IT professionals, the demands associated with constantly learning and adjusting/updating their skill sets can be stressful and compromise overall productivity in a number of ways (Lee, Trauth, & Farwell, 1995). On the whole, changes in technology significantly affect overall burnout in IT jobs. Sixty two percent of IT professionals claim to operate in "crisis mode" most or all of the time (Fischer, 1998). Given the effect of coping with change among IT professionals, IT managers have to be concerned with methods of keeping employees up-to-date on new technologies, as well as providing some form of infrastructure for answer-seeking when problems arise. While academic studies of how organizations manage change and take on the challenges of employee training abounds, there is a dearth of research into the strategies employed by IT professionals themselves. Many authors have also focused specifically on women in the IT workforce, but those studies typically address the problems women face in IT, rather than exploring what makes them successful. Research has sought to identify gender differences that may explain the low participation rate among women in the IT profession, but consistent patterns of differences rarely emerge. Moore (2000) was able to make a connection between low job satisfaction and gender. It was hypothesized that women perceived little benefit to themselves or their organizations in the effort required of them to maintain an updated skill set that would allow them to perform adequately. Further analysis of that data suggests, however, that when controlling for job rank, the gender effect goes away. While Moore's initial hypothesis is complicated by the introduction of job rank as a variable, there does seem to be agreement that rank is at least somewhat tied to gender, perhaps making this a second-order effect. Many authors have identified and addressed the "glass ceiling" that prevents women in IT (and several other professions as well) from advancing beyond a certain point in rank and wages (Ahuja, 2002; Baroudi & Igbaria, 1995; Harris & Wilkinson, 2004; Igbaria & Baroudi, 1995; Kaminski & Reilly, 2004; Perrons, 2002; Ranson & Reeves, 1996; Smits, McLean, & Tanner, 1993; Sumner & Niederman, 2003). The potential explanations for the glass ceiling are too numerous to list here, ranging from educational interests at a young age, to gender roles in personal lives, to blatant discrimination. With respect to the IT field specifically, women tend to enter the professional workforce with less training (Francis, 2000), but tend to demonstrate no significant differences in productivity among high-performing men and women (Smits et al., 1993). This seems to indicate that, despite different educational foundations, women in the workforce are capable of compensating for the difference in background. This may be due, in part, to women's increased willingness to admit to a lack of knowledge or understanding, and to seek help (Baroudi & Igbaria, 1995; Venkatesh, & Morris, 2000). The extent to which women will utilize technology to seek help when confronted with a problem or to meet an information need has been explored by a number of researchers studying overall IT use. Gefen and Straub (1997) found that women and men differed in their perceptions of e-mail, but not their use of it, because differences between genders lie in their expectations for performance. Women place more communicative value on e-mail and are more inclined to give more time and care to composing and reading e-mails. Venkatesh and Morris (2000) were able to identify usage differences between men and women, tied to perceptions and level of adoption. Men's technology usage decisions were strongly influenced by their perception of the usefulness of the technology, while women were more strongly influenced by perceived ease of use. Venkatesh and Morris' findings on the communicative value of e-mail for women can be extended to information and communication technologies in general, thanks to data collected by national agencies in the United States and Japan and summarized by Ono and Zavodny (2005). …

Giant omphaloceles often present with a loss of abdominal domain. An intact sac may permit simple daily dressings to promote epithelialization for a delayed operative closure; a ruptured sac presents challenges. There may be insufficient native tissue for adequate coverage; tissue expanders or grafts may be needed. We present a case of a ruptured omphalocele sac in which non-operative management was not possible – silo placement and reduction was unsuccessful due to a lack of abdominal domain. We used an acellular human dermal matrix (Alloderm, Life Cell, Branchburg, NJ), sutured to the patient's fascia to provide coverage of the omphalocele contents. There was insufficient skin to cover the majority of the graft. Tissue expanders had to be removed due to infection. With regular dressing changes, the tissue underneath the graft granulated and epithelialized and the graft lifted off. Skin grafting was not required. Alloderm's biologic properties render it less prone to infection than a synthetic graft; there was no evidence of graft infection in this patient. This ruptured omphalocele was managed with Alloderm coverage and minimal native skin.

Background and Purpose: Gastric volvulus in children may be a surgical emergency or may present more subtly. The classic symptoms of gastric volvulus include the triad of unproductive retching, epigastric distention, and the inability to pass a nasogastric tube, but these symptoms are inconsistent in children. The accepted surgical treatment for acute, subacute, or intermittent gastric volvulus is anterior gastropexy, and others have reported that this can be accomplished laparoscopically. We present further clinical experience documenting the safety and efficacy of a laparoscopic approach to gastric volvulus. Methods: This is a case series of 4 children (2 girls and 2 boys, ranging in age from 8 months to 12 years) with gastric volvulus. Two presented as emergencies, one was asymptomatic, and one presented with a feeding problem. Results: Gastric volvulus was successfully treated by laparoscopic gastropexy in all cases. Two children also had a gastrostomy tube placed for postoperative feeding. Postoperat...

This chapter describes an Experiential Learning model that I developed and have used for several years in our IST senior-level Advanced Enterprise Integration capstone course. I have written and presented on this model many times over the last several years and in this chapter I will describe the rationale for the model, explain the components of the model, and discuss student reactions to the model.

Background: Video-assisted thoracoscopic debridement (VATD) is a new method of managing pediatric empyema. The purpose of this retrospective study was to determine the relation between the timing of VATD and its success in avoiding the need for open decortication. Study Design: Twenty-one children aged 3 to 16 years (mean, 8 years) with symptomatic, loculated, parapneumonic empyema were treated with VATD at two tertiary pediatric centers between 1994 and 1997. The preoperative duration of symptoms, hospitalization, and previous need for thoracostomy drainage were compared between patients having VATD only and those who subsequently required a thoracotomy and decortication. Statistical analysis used the Wald chi-square test or Fisher's exact test with p Results: Video-assisted thoracoscopic debridement was successful in 15 patients (group 1) and unsuccessful in six patients (group 2), who required a thoracotomy and decortication. Group 1 had a shorter mean duration of preoperative symptoms (13 versus 27 days; p=0.03), a shorter median duration of preoperative hospitalization (6 versus 18 days; p=0.04), and a lower incidence of previous thoracostomy drainage (4/15 versus 5/6; p=0.05). Conclusions: The technique of VATD is most likely to be successful when used within one week of diagnosis of a loculated parapneumonic empyema. A prospective trial comparing VATD with intrapleural fibrinolytic agents for the initial treatment of pediatric empyema is needed.

Perinephric abscesses in children are rare. Infection can come from various areas, and clinical signs overlap with more common etiologies, such as pyelonephritis. Imaging modalities and laboratory investigations help lead to a definitive diagnosis. We present a case of a 5-month-old infant presenting with a febrile illness and eventual diagnosis of a perinephric abscess causing abdominal compartment syndrome. The infant had no known risk factors, i.e., congenital genitourinal abnormalities or immunosuppression, and was treated successfully following initial resuscitation, appropriate antibiotics, and open surgical drainage. Cultures obtained from the abscess and peritoneal fluid were positive for S. aureus, while blood and urine cultures were negative. A literature review found 13 studies looking at diagnosis and/or treatment of idiopathic perinephric abscess. With non-specific clinical signs and symptoms, diagnosis can be delayed and rests heavily on clinical suspicion and appropriate imaging. Treatment includes antibiotics alone, or in conjunction with percutaneous or open surgical drainage. In summarizing these studies, a suggestion for diagnosis and basic treatment approach is outlined.

Preterm infants needing patent ductus arteriosus (PDA) ligation are transferred to a pediatric cardiac center (CC) unless the operation can be done locally by a pediatric surgeon at a non-cardiac center (NCC). We compared infant outcomes after PDA ligation at CC and NCC.We analyzed 990 preterm infants who had PDA ligation between 2005 and 2009 using the Canadian Neonatal Network database. In-hospital mortality and major morbidities were compared between CC (n=18) and NCC (n=9).SNAP-II-adjusted mortality rates were similar (CC=8.7% vs NCC=10.7%, P=.32). Significant cranial ultrasound abnormalities (CC=24.1% vs NCC=32.1%, P.01) and culture-proven sepsis (CC=39.7% vs NCC=54.8%, P.01) were more frequent in infants treated at NCC. Infants transferred to CC had higher rates of cranial ultrasound abnormalities (transferred 31.6% vs non-transferred 20.4%, P.01). NSAIDs prior to PDA ligation were used more often at NCC (CC 36.6% vs NCC 75.6%, P.001).Mortality rates after PDA ligation were similar at CC and NCC, but cranial ultrasound abnormalities and sepsis rates were higher at NCC. Higher morbidity may be associated with different PDA management strategies, including NSAID use or infant transfer. Further studies are needed to investigate the reasons for these differences in morbidity.

Neurologically impaired children frequently require a feeding gastrostomy. Few reports are available comparing the incidence of postoperative complications and symptomatic gastroesophageal reflux after endoscopic versus operative Stamm gastrostomy in this group of children. We undertook a retrospective study of 63 consecutive neurologically impaired children requiring a feeding gastrostomy, with an average of 23 months of follow-up. No child had symptomatic gastroesophageal reflux. Thirty children had a percutaneous endoscopic gastrostomy and 33 had a Stamm gastrostomy, depending on the preference of the surgeon. The two groups were comparable in age range, cause of neurologic impairment, and indication for gastrostomy. Minor complications occurred in 30%. All three major complications occurred after Stamm gastrostomy, including two postoperative deaths. Symptomatic gastroesophageal reflux developed in 60%. The incidence of fundoplication after gastrostomy was 10% in the percutaneous endoscopic gastrostomy group and 39% after Stamm gastrostomy (p.025). Morbidity was lower after percutaneous endoscopic gastrostomy than after Stamm gastrostomy in this group of neurologically impaired children. Fundoplication for symptomatic gastroesophageal reflux was infrequent after percutaneous endoscopic gastrostomy and significantly more common after Stamm gastrostomy. Percutaneous endoscopic gastrostomy is recommended as the initial procedure in neurologically impaired children without symptomatic gastroesophageal reflux who require a feeding gastrostomy.

Background and Purpose The Near Needle Holder (NNH) (Near Manufacturing, Camrose, Alberta, Canada) is a reusable tool to introduce a standard hollow needle for pediatric intraosseous (IO) infusion. We compared the NNH to the Cook Dieckmann (Cook Critical Care, Bloomington, IN) manual IO needle in a simulation setting. Methods Study subjects were 32 physicians, nurses, and medical students participating in a trauma course in Guyana. After watching a training video and practicing under supervision, subjects were observed inserting each device into a pediatric leg model using a randomized crossover design. Outcome measures were time to successful insertion, technical complications, ease of use, and safety of each device. Results The mean time for IO insertion (32 ± 13 seconds) was similar for both devices ( P = .92). Subjects rated the NNH device equivalent in ease of use to the Cook IO needle but slightly lower in perceived safety to the user. Conclusions After training, all subjects successfully inserted the NNH IO device in a simulation environment, and most rated it as easy to use and safe. The NNH is a significant advance because IO needles are often not available in emergency departments in developing countries. Further studies are needed to evaluate clinical effectiveness of the NNH.

We describe ReKon, a platform that contains fine-granular templates, each describing a process knowledge chunk, which may be combined, as needed, to support ad hoc processes needed in large projects. The platform allows user-lead (re)-construction of a process to deal with the unique and emergent needs of a project by leveraging prior knowledge encoded in process chunks. We have populated ReKon with process chunks created from more than 1200 real-world project templates contributed by four consulting organizations. The fine-granularity of process chunks contained in ReKon represents a direct response to the emergent nature of large projects that defies high-volume production processes. The paper develops the underlying meta-model and operations for ReKon that adapt and extend the combination quadrant in Nonaka and Takeuchi’s knowledge creation framework. A two-phase evaluation illustrates the need for ReKon and points to its potential usefulness.

Business process portfolio management is an emerging field of research and practice, opening the door to new and ever more exciting process-oriented modes of management, tracking, planning, and knowledge management. This paper focuses on the strategic alignment of strategic, social, processual, and technical factors as enablers of business process portfolio development and management, and highlights the linkages associated with the alignment and integration of these factors. The authors also pose a combination of key questions and decision criteria that may be taken into account when planning and structuring business process portfolio initiatives.

Instructional gaming has historically been used as a means of rehearsal and motivation. A majority of research in this area has attempted to identify the most effective method of rehearsal that maximizes student achievement and minimizes information loss over a specified time period. A few studies have suggested that instructional gaming environments have the ability to provide corrective feedback and reinforcement of previously taught information. The author is interested in investigating whether or not instructional online and computer gaming and the use of different forms of feedback produce a significant difference in improving delayed retention of different instructional objectives.

Our case will describe two small to medium enterprises which are located within the same region and sharing the broad industry sector but at a different ‘growth stage’ perceive the role of Information Systems differently. We describe how these two firms, at different growth stages and at different levels of maturity with respect to their information systems, perceive the usefulness of information systems differently. We extend the interpretations to discuss sub-sections within SMEs, which are at different stages of growth, and how the nature of information systems’ risks is likely to differ depending on these growth stages. We emphasize the importance of owner/manager’s “sensemaking of risks” as a key variable that influences the demarcation between entrepreneurs and small business owners, beyond the oft-discussed variables such as “achievement motivation,” “risk-taking propensity,” and “preference for innovation.” We conclude with the proposition that SMEs should not be considered as unitary entities; and suggest that there are likely to be different varieties of risks that SMEs face, and suggest the growth stage and organizational filters as key determinants of the owner/managers’ understanding of these risks.

Small and Medium Enterprises (SMEs) in legacy industrial era regions face unique challenges that vary from the challenges faced by SMEs in other regions. Especially, SMEs in legacy industrial regions face problems with respect to the access to knowledge networks. The authors discuss an approach that focuses on enabling the SMEs in legacy regions towards accessing these knowledge networks. The authors base their discussion upon the ongoing debate within the IS community regarding ‘rigor-relevance’ gap, and they take the specific case of SME’s in I-99 corridor to illustrate this. The chapter highlights the challenges faced by SMEs in legacy industrial era regions, and briefly describe the ongoing research project called LAIR (Leveraging Advanced IT Research), aimed at understanding the risks that SMEs in the I-99 Corridor are likely to face as they grow, with a specific focus on risks associated with upgrading, implementing and integrating their existing and new Information Systems.

Like many developing countries, Guyana has a severe shortage of surgeons. Rather than rely on overseas training, Guyana developed its own Diploma in Surgery and asked for assistance from the Canadian Association of General Surgeons (CAGS). This paper reviews the initial results of Guyana's first postgraduate training program.We assisted with program prerequisites, including needs assessment, proposed curriculum, University of Guyana and Ministry of Health approval, external partnership and funding. We determined the outputs and outcomes of the program after 2 years, and we evaluated the impact of the program through a quantitative/qualitative questionnaire administered to all program participants.Five residents successfully completed the 2-year program and are working in regional hospitals. Another 9 residents are in the training program. Twenty-four modules or short courses have been facilitated, alternating Guyanese with visiting Canadian surgical faculty members coordinated through CAGS. A postgraduate structure, including an Institute for Health Sciences Education and Surgical Postgraduate Education Committee, has been developed at the Georgetown Public Hospital Corporation (GPHC). An examination structure similar to Canada's has been established. Hospital staff morale is greater, surgical care is more standardized and academic opportunities have been enhanced at GPHC. Four regional hospitals have welcomed the new graduates, and surgical services have already improved. Canadian surgeons have a greater understanding of and commitment to surgical development in low-income countries.Guyana has proven that, with visiting faculty assistance, it can mount its own postgraduate training suitable to national needs and will provide a career path to encourage its own doctors to remain and serve their country.

An accessory spleen is present in about 10-30% of the population and, usually, does not cause symptoms. We present a case report of an unusual presentation of accessory spleen infarction, with a literature review. A 12-year old male presented with acute left-upper quadrant pain that slowly resolved. An ultrasound and computed tomography scan showed a 3.5 x 2.5 x 2 cm solid mass abutting and displacing the splenic flexure of the colon, with surrounding inflammatory changes. This was interpreted as a colonic duplication cyst, and the boy was treated with antibiotics and underwent elective laparoscopic exploration. It was removed laparoscopically without complication and, on pathologic examination, proved to be consistent with an infarcted accessory spleen. Less than two dozen similar cases of accessory spleen infarction have been reported in the literature, most presenting with acute abdominal pain. Preoperative diagnoses included appendicitis, ovarian torsion, neoplasm, and, in our case, colonic duplication. The natural course of infarcted accessory spleen would be to atrophy, but, even with advanced imaging techniques, it may be impossible to diagnose infarcted accessory spleen with enough confidence to avoid surgery.