Search

Advances in measuring and understanding separated, nominally two-dimensional (2D) shock-wave/turbulent-boundary-layer interactions (STBLI) have triggered recent campaigns focused on three-dimensional (3D) STBLI, which display far greater configuration diversity. Nonetheless, unifying properties emerge for semi-infinite interactions, taking the form of conical asymptotic behavior where shock-generator specifics become insignificant. The contrast between 2D and 3D separation is substantial; the skewed vortical structure of 3D STBLI reflects the essentially 2D influence of the boundary layer on the 3D character of the swept shock. As with 2D STBLI, conical interactions engender prominent spectral content below that of the turbulent boundary layer. However, the uniform separation length scale, which is crucial to normalizing the lowest-frequency dynamics in 2D STBLI, is absent. Comparatively, the spectra of 3D STBLI are more representative of the mid-frequency, convective, shear-layer dynamics in 2D, while phenomena associated with 2D separation-shock breathing are muted. Asymptotic behavior breaks down in many regions important to 3D-STBLI dynamics, occurring in a configuration-dependent manner. Aspects of inceptive regions near shock generators and symmetry planes are reviewed. Focused efforts toward 3D modal and nonmodalanalyses, moving-shock/boundary-layer interactions, fluid/structure interactions, and flow control are suggested as directions for future work.

To examine the association between type of analgesic block and incidence of complications following primary hypospadias correction. Data sources included MEDLINE, Embase, Web of Science and the Cochrane Library, inception-01/2021. Randomized clinical trials, cohort and case control studies reporting original data for patients18 years of age undergoing primary hypospadias correction with either a penile or caudal block for which outcomes (urethrocutaneous fistula or glans dehiscence) were reported. Two researchers independently extracted data and assessed quality for inclusion. The primary outcome was the incidence of complication within six-months postoperatively based on block performed. Ten studies (3201 patients; range: 54-983) were included. Six studies (cumulative weight 28.6%) favored penile block while 4 studies (cumulative weight 71.4%) favored caudal block. Compared to the reference group of penile blocks, caudal blocks had no significant association with development of complications following primary hypospadias correction (relative risk 1.11, 95% CI (0.88, 1.41); P = .38). When adjusting for meatal location (distal vs proximal) there was no significant association with development of fistulae or glanular dehiscence following primary hypospadias correction with caudal blocks in comparison to the reference group, penile blocks for distal, (relative risk 1.46, 95%CI (0.98, 2.17); P = .065) and proximal (relative risk 0.95, 95% CI (0.58, 1.54); P = .823). The type of analgesic block is not associated with the risk of developing complications following primary hypospadias correction in children. Caudal block should be considered for these urological interventions.

Objective To identify the incidence of difficult intubation in patients with adult congenital heart disease (ACHD) undergoing cardiac surgery or catheterization. Design A retrospective cohort study. Setting A single-center academic quaternary pediatric hospital. Participants All patients were >18 years of age with ACHD undergoing endotracheal intubation within the Heart Center at Texas Children's Hospital between January 2012 and December 2019. Interventions None. Measurement and Main Results A retrospective chart review was performed, including patient demographics, preoperative airway assessment and intraoperative airway management characteristics. Airways were categorized as difficult using the Pediatric Difficult Intubation registry operational definitions. For patients classified as having a difficult airway, the preoperative airway examination findings were recorded in addition to factors associated with difficult airway in the adult. The study authors identified 1,029 patients with ACHD who underwent procedures with anesthesia at their institution and were analyzed for the presence of difficult airway. In total, 878 patients were intubated, with 4.3% (n = 38) identified to have difficult airway. The presence of concomitant syndromes was greater in patients with difficult intubations and those who were not intubated compared with those who were not difficult intubations (23.7% and 17.2 v 7.5; p Conclusions The study authors identified an incidence of difficult laryngoscopy in their cohort of ACHD patients to be 4.3%. Their incidences of difficult laryngoscopy were fewer than that reported in adult patients with noncongenital heart disease. Most importantly, the risk factors associated with difficult laryngoscopy in the normal adult may be different from those presenting with ACHD, necessitating further investigation.

Hyperalgesia may be an iatrogenic consequence of surgery or pain management. Thus, it is essential for anesthesiologists, pain management specialists, surgeons, and primary care physicians to regularly update their awareness and strategies for addressing this problem. This educational review of hyperalgesia provides up-to-date knowledge of the contributing mechanisms, differential diagnoses, and medical therapy. A particular focus is placed on common types of postoperative hyperalgesia and recent evidence that anesthesiologists and surgeons should be aware of. Hyperalgesia may acutely manifest due to tissue injury and peripheral sensitization; it can progress to a chronic condition developing from central nervous system sensitization. While clinical evaluation begins with a detailed history, physical examination, and sensory testing, an improved understanding of the clinical and cellular mechanisms involved in hyperalgesia pathology continues to drive future research and advance our understanding of this complex presentation. Opioid-induced hyperalgesia may be confused with opioid tolerance and withdrawal and must also be differentiated from other diagnoses to optimize patient management and promote disease regression. Hyperalgesia is a common clinical condition with evolving guidelines for testing and treatment. Opioid-induced hyperalgesia is a potential cause of hyperalgesia and must be differentiated to optimize therapeutic decision-making.

Shock/turbulent-boundary-layer interactions (STBLIs) are ubiquitous in high-speed flight and propulsion applications. Experimental and computational investigations of swept, three-dimensional (3-D) interactions, which exhibit quasi-conical mean-flow symmetry in the limit of infinite span, have demonstrated key differences in unsteadiness from their analogous, two-dimensional (2-D), spanwise-homogeneous counterparts. For swept interactions, represented by the swept–fin-on-plate and swept–compression–ramp-on-plate configurations, differences associated with the separated shear layers may be traced to the intermixing of 2-D (spanwise independent) and 3-D (spanwise dependent) scaling laws for the separated mean flow. This results in a broader spectrum of unsteadiness that includes relatively lower frequencies associated with the separated shear layers in 3-D interactions. However, lower frequency ranges associated with the global “breathing” of strongly separated 2-D interactions are significantly less prominent in these simple, swept 3-D interactions. A logical extension of 3-D interaction complexity is the compound interaction formed by the merging of two simple interactions. The first objective of this work is therefore to analyze the more complex picture of the dynamics of such interactions, by considering as an exemplar, wall-resolved simulations of the double-fin-on-plate configuration. We show that in the region of interaction merging, new flow scales, changes in separation topology, and the emergence of lower-frequency phenomena are observed, whereas the dynamics of the interaction near the fin leading edges are similar to those of the simple, swept interactions. The second objective is to evolve a unified understanding of the dynamics of STBLIs associated with complex configurations relevant to actual propulsion systems, which involve the coupling between multiple shock systems and multiple flow separation and attachment events. For this, we revisit the salient aspects of scaling phenomena in a manner that aids in assimilating the double-fin flow with simpler swept interactions. The emphasis is on the influence of the underlying structure of the separated flow on the dynamics. The distinct features of the compound interactions manifest in a centerline symmetry pattern that replaces the quasi-conical symmetry of simple interactions. The primary separation displays topological closure to reveal new length scales, associated unsteadiness bands, and secondary flow separation.

Background Emergence delirium (ED) is common in pediatric anesthesia. This dissociative state in which the patient is confused from their surroundings and flailing can be self-injurious and traumatic for parents. Treatment is by administration of sedatives which can prolong recovery. The aim of this study was to determine if exposure to monochromatic blue light (MBL) in the immediate phase of recovery could reduce the overall incidence of emergence delirium in children following general inhalational anesthesia. Methods This double blinded randomized controlled study included patients ages 2–6 undergoing adenotonsillectomy. Postoperatively, 104 patients were randomization (52 in each group) for exposure to sham blue or MBL during the first phase (initial 30 min) of recovery. The primary outcome was the incidence of emergence delirium during the first phase. We also examined Pediatric Anesthesia Emergence Delirium (PAED) scores throughout the first phase. Results Emergence Delirium was reported in 5.9% of MBL patients versus 33.3% in the sham group, p = 0.001. Using logistic regression adjusting for age, weight, gender, ASA classification and PAED scores provided an adjusted relative risk ratio of 0.18; 95% CI (0.06, 0.54); p = 0.001 for patients in the MBL group. 23.5% of MBL patients versus 52.9% of sham patients had either ED or PAED scores of 12 or more throughout the first phase of recovery, p = 0.002. This produced an adjusted relative risk of 0.46, 95% CI (0.29, 0.75), p = 0.001. Conclusions Monochromatic blue light represents a non-pharmacologic method to reduce the incidence of emergence delirium and PAED scores in children. Trial Registration #NCT03285243 registered on 15/09/2017

The management of intraoperative blood loss in the surgical treatment of paediatric hip dysplasia is resource intensive. There are numerous clinical factors that impact the need for intraoperative transfusion. Identification of patient and surgical factors associated with increased blood loss may reduce the unnecessary use of resources. This study aimed to identify factors predictive of intraoperative transfusion in children undergoing hip dysplasia surgery.This is a single-centre retrospective review of patients undergoing surgery for hip dysplasia from 1 January 2012 to 15 April 2021. Patient demographic factors, anaesthetic, surgical and transfusion histories were reviewed. Multivariable logistic regression analysis was performed to identify factors predictive of allogeneic red blood cell transfusion requirements during the intraoperative period.This study includes 595 patients who underwent open surgery for hip dysplasia, including 297 (52.6%) classified as developmental dysplasia (DD) and 268 (47.3%) as neuromuscular (NM) with a mean age of 9.1 years (interquartile range 3-14). Intraoperative allogeneic transfusion was identified in 26/297 (8.8%) DD and 73/268 (27.2%) NM patients. Adjusted factors associated with increased odds of intraoperative transfusion were NM (odds ratio [OR] = 2.96, 95% confidence interval [CI] [1.76, 5.00]) and the number of osteotomies performed (OR = 1.82/osteotomy, 95% CI [1.40, 2.35]). Adjusted factors that reduced the odds of transfusion were the use of antifibrinolytics (OR = 0.35, 95% CI [0.17, 0.71]) and regional anaesthesia (OR = 0.52, 95% CI [0.29, 0.94]).For children undergoing surgery for hip dysplasia, the number of osteotomies performed is predictive of the need for allogeneic blood transfusion. Antifibrinolytics and regional anaesthesia are associated with reduced risk for allogeneic blood transfusion. Blood management initiatives, such a preoperative optimization of haemoglobin and the use of antifibrinolytics, could target patients at increased risk of intraoperative bleeding and transfusion.

To determine whether a postoperative prescription for opioids affects parental assessment of pain control following pediatric circumcision.This postoperative survey assessed the parental assessment of pain control in 199 patients, ages18 years undergoing circumcision. This study was conducted at a quaternary care children's hospital in Houston, Texas from December 2018 to January 2020. Postoperative pain regimens included acetaminophen and ibuprofen or combination hydrocodone/acetaminophen in addition to ibuprofen for postoperative analgesia based on the surgical preference. The primary study outcome was identification of the proportion of parents rating their child's analgesia following pediatric circumcision as poor or inadequate based on the postoperative analgesic regimen.Of the 502 surveys sent, the response rate was 40% (199/502) of those who received the survey email, and 64% (199/308) for those who opened the email. Between the opioid and nonopioid groups, there was no difference in, race/ethnicity (Caucasian; 28% vs 37%; P = .43) or insurance status (insured; 51% vs 45%; P = .44). The proportion of parents who rated their child's pain as poor or inadequately controlled following circumcision was relatively rare:5.5% and 1.1% in the nonopioid and opioid groups, respectively. Parents rating their child's pain as excellent with regards to pain control following circumcision were 61% and 53% in the nonopioids and opioid groups, respectively.The results of this study indicate that nonopioid analgesic regimens following pediatric circumcision were not associated with decreased parental satisfaction or an increasing assessment of poor or inadequately controlled pain. Limiting opioid exposure following pediatric circumcision is feasible and does not result in worse parental satisfaction with the analgesic plan.

Opioid-induced hyperalgesia (OIH) occurs when opioids paradoxically enhance the pain they are prescribed to ameliorate. To address a lack of perioperative awareness, we present an educational review of clinically relevant aspects of the disorder. Although the mechanisms of OIH are thought to primarily involve medullary descending pathways, it is likely multifactorial with several relevant therapeutic targets. We provide a suggested clinical definition and directions for clinical differentiation of OIH from other diagnoses, as this may be confusing but is germane to appropriate management. Finally, we discuss prevention including patient education and analgesic management choices. As prevention may serve as the best treatment, patient risk factors, opioid mitigation, and both pharmacologic and non-pharmacologic strategies are discussed.Lay abstract Opioid-induced hyperalgesia (OIH) occurs when opioid medications worsen rather than decrease pain. We present an educational review of the disorder. Although mechanisms of OIH are thought to primarily start in the brain or brainstem before traveling through the spinal cord to the area of pain in the body, there are likely many causes. We provide a suggested clinical definition and a pathway for clinical differentiation of OIH from other diagnoses to help with management. Finally, we discuss prevention including patient education and medication management choices. As prevention may serve as the best treatment, patient risk factors for OIH, decreased opioid use, and both medication and non-medication strategies are discussed.

Self/informant-report and performance-based instruments are typically used to measure activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Minimal attention has focused on clinician-rated measures. Executive functioning (EF) contributes significantly to functional independence, and the validity of functional status measures has been examined through its relationship to EF scores. The current study used a clinical sample of older U.S. Veterans who completed a neurocognitive evaluation (

Primary repair of hypospadias is associated with risk of complications, specifically urethrocutaneous fistula and glanular dehiscence. Caudal block may potentially increase the risk of these complications. Therefore, we studied the incidence of hypospadias complications in children who underwent correction at our institution having received either penile or caudal block.We analyzed all primary hypospadias repair cases from December 2011 through December 2018 at Texas Children's Hospital with a minimum of 1-year followup for the presence of complications: urethrocutaneous fistula and glanular dehiscence. Surgical (surgeon, operative time, block type, local anesthetic, meatal position) and patient (age at correction, prematurity) factors were additionally analyzed.For the primary aim, 983 patients underwent primary hypospadias correction with a minimum of 1 year of postoperative followup data. There were 897 patients (91.3%) in which no complications were identified and 86 (8.7%) with either urethrocutaneous fistula (81) or glanular dehiscence (5). Of the 86 identified complications, 45/812 (5.5%) were distal, 41/171 (24%) were proximal (p0.001) with a complication. Rate of complications was not associated with caudal block (OR 0.67, 95% CI 0.41-1.09; p=0.11). On univariable analysis, age (OR 1.12, 95% CI 1.04-1.20; p=0.04), surgical duration (OR 1.02; 95% CI 1.01-1.02; p0.001), prematurity32 weeks (OR 4.38, 95% CI 1.54-4.11 p0.001) and position of meatus as proximal (OR 5.38 95% CI 3.39-8.53; p0.001) were associated with an increased rate of complications. However, on multivariable analysis, associations of age (OR 1.13, 95% CI 1.05-1.22; p=0.001), surgery duration (OR 1.01, 95% CI 1.01-1.02; p0.001) and meatal position (OR 3.85, 95% CI 2.32-6.39; p0.001) were associated with increased rate of complications.Our data suggest that meatal location, older age, extreme prematurity and surgical duration are associated with increased incidence of complications (urethrocutaneous fistula and glanular dehiscence) following hypospadias correction. Analgesic block was not associated with increased hypospadias complication risk.

The coronavirus disease 2019 (COVID-19) pandemic has seen>48 million confirmed cases worldwide as ofNovember 6, 2020.The infection rate amongst children was initially reported to be low, with children constituting only 2% of recorded cases. However, this reflected testing for COVID-19 only when symptomatic or with known close contact with an infected person(1). The purpose of this reportis to describe the characteristics of pediatric patients undergoing universal testing for COVID-19 during routine preoperativescreening at threetertiarychildren's hospitals across the United States.

This review provides an update on the neurocognitive phenotype of pediatric obstructive sleep apnea (OSA). Pediatric OSA is associated with neurocognitive deficits involving memory, learning, and executive functioning. Adenotonsillectomy (AT) is presently accepted as the first line surgical treatment for pediatric OSA, but the executive function deficits do not resolve post-surgery, and the timeline for recovery remains unknown. This finding suggests that pediatric OSA potentially causes irreversible damage to multiple areas of the brain. The focus of this review is the hippocampus, one of the 2 major sites of postnatal neurogenesis, where new neurons are formed and integrated into existing circuitry and the mammalian center of learning/memory functions. Here, we review the clinical phenotype of pediatric OSA, and then discuss existing studies of OSA on different cell types in the hippocampus during critical periods of development. This will set the stage for future study using preclinical models to understand the pathogenesis of persistent neurocognitive dysfunction in pediatric OSA.

The prevalence of antimicrobial-resistant bacteria and methicillin-sensitive Staphylococcus aureus (MSSA) in healthy newborns and the role of maternal transmission are scarcely discussed. The objec...

Understanding the role that children play in the clinical burden and propagation of severe acute respiratory syndrome coronavirus 2, responsible for coronavirus disease 2019 (COVID-19) infections, is emerging. While the severe manifestations and acute clinical burden of COVID-19 have largely spared children compared with adults, understanding the epidemiology, clinical presentation, diagnostics, management, and prevention opportunities and the social and behavioral impacts on child health is vital. Foremost is clarifying the contribution of asymptomatic and mild infections to transmission within the household and community and the clinical and epidemiologic significance of uncommon severe post-infectious complications. Here, we summarize the current knowledge, identify resources, and outline research opportunities. Pediatric infectious diseases clinicians have a unique opportunity to advocate for the inclusion of children in epidemiological, clinical, treatment, and prevention studies to optimize their care as well as to represent children in the development of guidance and policy during pandemic response.

Background The COVID-19 pandemic has substantially altered the typical process around performing surgery to ensure protection of health care workers, patients, and their families. One safety precaution has been the implementation of universal preoperative screening for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This study examines the results of universal screening on children undergoing orthopaedic surgery. Methods This is a retrospective cohort study evaluating the incidence and symptomatology of COVID-19 in all patients presenting for orthopaedic surgery at 3 pediatric tertiary care children's hospitals during the COVID-19 pandemic (March to June 2020). All patients underwent universal screening with a nasopharyngeal swab to detect presence of SARS-CoV-2. Bivariate and multivariate logistic regression analysis was performed to identify risk factors for positive COVID-19 screening. Results In total, 1198 patients underwent preoperative screening across all 3 institutions and 7 (0.58%) had detection of SARS-CoV-2. The majority of patients (1/7, 86%) were asymptomatic. Patients that tested positive were significantly more likely to be Hispanic (P=0.046) and had greater number of medical comorbidities (P=0.013), as scored on the American Society of Anesthesiologists (ASA) physical status score. A known COVID-19 positive contact was found to be a significant risk factor in the multivariate analysis (P=0.004). Conclusions Early results of universal preoperative screening for COVID-19 demonstrates a low incidence and high rate of asymptomatic patients. Health care professionals, especially those at higher risk for the virus, should be aware of the challenges related to screening based solely on symptoms or travel history and consider universal screening for patients undergoing elective surgery. Level of evidence Level II.

Obstructive sleep apnea (OSA) affects up to 7.5% of the pediatric population and is associated with a variety of behavioral and neurocognitive sequelae. Prompt diagnosis and treatment is critical to halting and potentially reversing these changes. Depending on the severity of the OSA and comorbid conditions, different treatment paradigms can be pursued, each of which has its own unique risk:benefit ratio. Adenotonsillectomy is first-line recommended surgical treatment for pediatric OSA. However, it carries its own perioperative risks and the decision regarding surgical timing is therefore made in the context of procedural risk versus patient benefit. This article presents the seminal perioperative and neurocognitive risks from pediatric OSA to aid with perioperative management.

Introduction: Fetal intervention/surgery constitutes a relatively new field of maternal-fetal medicine in which monitored anesthesia care (MAC) or general anesthesia (GA) are utilized as anesthetic techniques when feasible. In this study, we sought to calculate the usage of MAC and GA in various fetal procedures as well as investigate any anesthetic complications and conversions from MAC to GA. Methods: All intrauterine fetal intervention cases performed at the Texas Children’s Hospital Pavilion for Women from 2012 to 2016 were retrospectively analyzed and categorized by mode of anesthesia. Anesthetic complications, conversions to GA, preoperative patient physical status, average number of intraoperative medications required, and average duration of procedure were compared between the MAC and GA groups. Results: A total of 480 fetal interventions were performed with 432 under MAC (90%) and 37 under GA (7.7%). There were 11 conversions from MAC to GA (2.3%). These conversions were due to poor visualization with ultrasound and change of surgical approach to laparoscopic-assisted technique (n = 5), inability to lay flat due to back pain (n = 3), persistent vomiting (n = 2), and unresponsiveness after a spinal block (n = 1). One anesthetic complication occurred due to a medication administration error and did not require conversion to GA. The average preoperative American Society of Anesthesiologists (ASA) physical status classification was 1.97 for the MAC group and 1.87 for the GA group (p = 0.23). Duration of the interventions averaged 129 min under MAC and 138 min under GA (p = 0.23). An average of 7.8 different medications were administered during MAC cases compared to 13.1 during GA cases (p < 0.0001). Discussion: This analysis suggests that MAC is the most commonly used anesthetic option for fetal interventions with a low complication rate and minimal conversion rates to GA. It is therefore preferable to use MAC when feasible due to the low complication rate and decreased drug exposure.

Quantifying rates of climate change in mountain regions is of considerable interest, not least because mountains are viewed as climate “hotspots” where change can anticipate or amplify what is occurring elsewhere. Accelerating mountain climate change has extensive environmental impacts, including depletion of snow/ice reserves, critical for the world's water supply. Whilst the concept of elevation-dependent warming (EDW), whereby warming rates are stratified by elevation, is widely accepted, no consistent EDW profile at the global scale has been identified. Past assessments have also neglected elevation-dependent changes in precipitation. In this comprehensive analysis, both in situ station temperature and precipitation data from mountain regions, and global gridded data sets (observations, reanalyses, and model hindcasts) are employed to examine the elevation dependency of temperature and precipitation changes since 1900. In situ observations in paired studies (using adjacent stations) show a tendency toward enhanced warming at higher elevations. However, when all mountain/lowland studies are pooled into two groups, no systematic difference in high versus low elevation group warming rates is found. Precipitation changes based on station data are inconsistent with no systematic contrast between mountain and lowland precipitation trends. Gridded data sets (CRU, GISTEMP, GPCC, ERA5, and CMIP5) show increased warming rates at higher elevations in some regions, but on a global scale there is no universal amplification of warming in mountains. Increases in mountain precipitation are weaker than for low elevations worldwide, meaning reduced elevation-dependency of precipitation, especially in midlatitudes. Agreement on elevation-dependent changes between gridded data sets is weak for temperature but stronger for precipitation.

Corneal cross-linking (CXL) is a well-known procedure for treating certain eye disorders such as keratoconus. However, characterization of the biomechanical changes in the cornea as a result of this procedure is still under active research. Specifically, there is a clinical need for high-resolution characterization of individual corneal layers.A high-resolution elastography method in conjunction with a custom optical coherence tomography system is used to track these biomechanical changes in individual corneal layers. Pre- and post-treatment analysis for both low-dose and high-dose CXL experiments are performed.A recently developed elastography technique that utilizes the theory of reverberant shear wave fields, with optical coherence tomography as the modality, is applied to pig corneas ex vivo to evaluate elasticity changes associated with corneal CXL. Sets of low-dose and high-dose CXL treatments are evaluated before and after treatments with three pairs of pig corneas per experiment.The reverberant three-dimensional (3D) optical coherence elastography (OCE) technique can identify increases in elasticity associated with both low-dose and high-dose CXL treatments. There is a notable graphical difference between low-dose and high-dose treatments. In addition, the technique is able to identify which layers of the cornea are potentially affected by the CXL procedure and provides insight into the nonlinearity of the elasticity changes.The reverberant 3D OCE technique can identify depth-resolved changes in elasticity of the cornea associated with CXL procedures. This method could be translated to assess and monitor CXL efficacy in various clinical settings.

To characterize penile arterial and venous blood flow in association with caudal block.A prospective observational study was conducted in children undergoing primary circumcision at Texas Children's Hospital between September 10, 2020 and November 23, 2021. The penile artery and venous flow velocity were assessed using Doppler ultrasound pre and post caudal block under state-state anesthetic depth.Ten healthy patients were included in the study with a mean age and weight of 1.3 years and 10.7 kg, respectively. There was no significant difference in mean penile arterial blood flow velocity 0.18 m/s, (95% confidence interval: -1.55 to 1.92; P = .81) or mean dorsal penile vein flow velocity 0.11 m/s (95% confidence interval: -1.12 to 1.33; P = .84) prior to and following caudal block in our pediatric cohort. there was no correlation in the direction of change between the arterial flow and venous flow from before and after caudal block (RWe did not identify an association between penile arterial or venous blood flow and performance of a caudal block in children undergoing circumcision.

With a difficult National Institutes of Health (NIH) funding climate, the pipeline of physician-scientists in Anesthesiology is continuing to get smaller with fewer new entrants. This article studies current NIH funding trends and offers potential solutions to continue the historical trend of academic innovation and research that has characterized academic Anesthesiology. Using publicly available data, specifically the NIH REPORTeR and Blue Ridge Institute for Medical Research, we examined NIH trends in funding in academic Anesthesiology departments that have Anesthesiology residency training programs. When adjusted for inflation, median NIH funding of departments of Anesthesiology declined approximately 15% between 2008 and 2017. The majority (55%) of NIH funding to academic Anesthesiology departments, including R01 and K-series grants, went to 10 departments in the United States. This trend has remained relatively constant for the 9-year period we studied (2009-2017). There is an inequitable distribution of NIH funding to Anesthesiology departments. Arguably, this may be a case of the "rich get richer," but the implications for those who are trying to become or remain NIH-funded investigators are that success may depend, in part, on securing a faculty position in one of these well-funded departments.

Medication administration errors that take place in the home are common, especially when liquid preparations are used and complex medication schedules with multiple medications are involved; children with chronic conditions are disproportionately affected. Parents and other caregivers with low health literacy and/or limited English proficiency are at higher risk for making errors in administering medications to children in their care. Recommended strategies to reduce home medication errors relate to provider prescribing practices; health literacy–informed verbal counseling strategies (eg, teachback and showback) and written patient education materials (eg, pictographic information) for patients and/or caregivers across settings (inpatient, outpatient, emergency care, pharmacy); dosing-tool provision for liquid medication measurement; review of medication lists with patients and/or caregivers (medication reconciliation) that includes prescription and over-the-counter medications, as well as vitamins and supplements; leveraging the medical home; engaging adolescents and their adult caregivers; training of providers; safe disposal of medications; regulations related to medication dosing tools, labeling, packaging, and informational materials; use of electronic health records and other technologies; and research to identify novel ways to support safe home medication administration.