Introduction: Testicular torsion (TT) is a common emergency that warrants immediate exploration to prevent infertility or testicular loss. To improve diagnostic reliability, various scoring systems have been published. The aim of this study was to evaluate and validate different testicular torsion scores in a large cohort of children with acute scrotum.Methods: Retrospective analysis of all male children that were admitted for acute scrotum at the Pediatric Surgery Department of the Altonaer Kinderkrankenhaus and University medical Center Hamburg-Eppendorf from 01/2013 to 03/2019. Two testicular torsion scores (Boettcher Alert Score, Testicular Workup for Ischemia and Suspected Torsion Score) were applied to all data sets. Furthermore, an artificial intelligence (AI)-based score was developed and compared to the two current scores.Results: In total, 460 boys were included in the study. Of those, 48 (10.4%) had TT. Children with TT suffered most often from short duration of pain, nausea and vomiting, high riding testicle and absent cremasteric reflex. The BALS and the AI-based score had excellent predictive values and all patients with TT would have been detected.Conclusion: The BAL and the AI score show excellent predictive capabilities and may be used to identify all cases of TT in a pediatric population. The scores are easy to apply. As the BALS was slightly better, we advocate to use this score but to validate our findings in prospective multicenter studies.

Introduction Acoustic distractions have been shown to increase the level of stress and workload in the operating room (OR). Noise significantly reduces surgical performance, but experienced surgeons are able to reduce the acoustic perception of their surroundings to maintain a high level of performance in complex surgical tasks. However, music has been shown to improve learning and performance of complex motor skills. The aim of this study was to evaluate the influence of music on transferability and long-term acquisition of laparoscopic suturing skills. Materials and Methods To evaluate the effects of music on training, subjects were asked to perform four surgeon's square knots on a bowel model within 30 minutes—prior and post 3 hours of hands-on training. To examine long-term skills, the same students were asked to perform a comparable, but more complex, task (four slip knots in a model of esophageal atresia) 6 months post initial training, as a follow-up measurement. Total time, knot stability (evaluated via tensiometer), suture accuracy, knot quality (Muresan scale), and laparoscopic performance (Munz checklist) were assessed. Results Twenty-four students were included in the study; after simple randomization, 16 were trained while exposed to music (eight to Bach and eight to Bushido) and eight with traditional methods. Seven were lost due to follow-up. Both groups had comparable baseline characteristics and significantly improved after training, in all parameters assessed in this study. Subjects that trained with classical music were superior in terms of speed (p = 0.006), knot quality (p = 0.014), and procedural performance (p = 0.034) compared with controls. Conclusion Music during acquisition of complex motor skills, like laparoscopic suturing and knot tying, is superior to traditional training. Especially music considered nondisturbing significantly improved speed, knot quality, and performance. Thus, incorporation of pleasant music into surgical skills training and the OR should be considered.

Background: The aim of this study was to evaluate anastomotic complications after primary one-staged esophageal atresia (EA) repair relating to the patients`gestational age (GA). Methods: Retrospective data analyses of patients who underwent closure of tracheoesophageal fistula (TEF) and primary esophageal anastomosis from 01/2007 to 12/2018 in two pediatric surgical centers. Exclusion of EA other than Gross type C, long-gap EA, minimal invasive or staged approach. Postoperative complications during the first year of life were assessed. Associated malformations, the incidence of infant respiratory distress syndrome (IRDS) and intraventricular bleeding were analyzed. Results: Inclusion of 75 patients who underwent primary EA repair. Low GA was associated with significantly lower incidence of anastomotic complications (p = 0.019, r = 0.596, 95% CI 0.10-0.85). Incidence of anastomotic leakage (0% vs. 5.5%; p = 0.0416), recurrent TEF (0% vs. 5.5%; p = 0.0416) und anastomotic stricture (0% vs. 14.5%; p = 0.0019) was significantly lower in patients < 34 gestational weeks. Incidence of IRDS (55% vs. 0%; p < 0.0001) and intraventricular bleeding (25% vs. 3.6%; p = 0.0299) was significantly higher in patients < 34 gestational weeks. Conclusions: Despite prematurity-related morbidity, low GA did not adversely affect surgical outcome after primary EA repair. Low GA was even associated with a better anastomotic outcome indicating feasibility and safety of primary esophageal reconstruction.

Appendicitis is one of the most frequent emergencies in pediatric surgery, yet current biomarkers for diagnosis are unspecific and have low predictive values. As neutrophils and extracellular traps (ETs) are an essential component of the immune defense against bacterial infections, and appendicitis is considered an inflammation reaction of the appendix, we hypothesized that neutrophil activation and NET formation play an essential role in appendicitis development and maintenance. Therefore, this pilot study aimed to establish a murine model of appendicitis and to evaluate ETs markers to diagnose appendicitis in mice and humans. The study used 20 (12 appendicitis- and 8 controls) 6-week old mice which underwent advanced appendicitis induction using a modified caecal ligation puncture procedure. During the study, cell-free DNA, neutrophil elastase (NE), myeloperoxidase (MPO), and citrullinated Histone H3 (H3cit) were assessed. Additionally, samples of 5 children with histologically confirmed appendicitis and 5 matched controls with catarrhal appendicitis, were examined for the same biomarkers. Moreover, NE, MPO, and H3cit were assessed histologically via immunofluorescence in mice and humans. All mice in the appendicitis group developed an advanced form of appendicitis with focal peritonitis. In mice and humans with appendicitis, markers of neutrophil activation and ETs formation (especially cfDNA, NE and H3cit) were significantly elevated in blood and tissue compared to controls. Ultimately, biomarkers correlated extremely well with tissue expression and thus disease severity. It appears that neutrophil activation and possibly NETs contribute to appendicitis development and biomarkers of neutrophil activation and ET formation reflect disease severity and thus could be used as biomarkers for appendicitis. However, large prospective clinical studies are needed to confirm our findings.

Introduction Skin lacerations are common in children and their repair is a very unpleasant experience for a child. While pain management has been recognized as a key element of high-quality patient care, recent studies report that pain management in the pediatric emergency departments is still suboptimal. Lidocaine-epinephrine-tetracaine (LET) gel could potentially improve the traumatic experience caused by skin repair as it obviates the need for infiltration. Thus, the aim of the current study was to compare local eutectic mixture of local anesthetics (EMLA) plus mepivacaine infiltration with topical anesthetics (LET-gel). Materials and Methods Prospective, propensity score-matched multicenter study including all children between 3 and 16 years presented at two centers. After anesthetics (LET vs. EMLA and infiltration) standardized skin repair was performed. Pain assessment was performed using the faces pain rating scale or visual analogue scale. Follow-up, performed 2 weeks after initial presentation, assessed wound infection rates and overall satisfaction. Results Of 73 subjects 59 children (37 LET vs. 22 EMLA) were included after propensity score matching. Groups had similar baseline characteristics. Pretreatment was significantly less painful in LET versus local anesthetics group. Pain during skin repair was similar between groups (LET and EMLA with mepivacaine infiltration) and both groups demonstrated similar efficacy (procedure time, need for secondary infiltration, infection rate). Ultimately, pain levels during pretreatment and the surgical procedure were perceived significantly higher by the children than estimated by parents or surgeons. Conclusion In conclusion, it appears that LET is superior to conventional anesthesia including mepivacaine infiltration in the pediatric emergency departments. Pretreatment with LET is significantly less painful but equally effective. Hence, we recommend LET as a topical anesthetic in the pediatric emergency department.

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Introduction To date, several genes involved in the pathogenesis of HD have been recognized. Out of these, the RET gene (chromosomal locus 10q11), one of the first genes identified in combination with HD, is still considered the basis for HD development. However, even with over a hundred RET gen coding sequence mutations identified, the mutations do not fully explain the observed sex bias of HD and the elevated risk of developing HD among siblings. Thus, our aim was to evaluate the clinical relevance of an as yet undescribed genotype in a family with HD to improve genetic counseling for families with RET mutation-associated HD.Patients This case report provides an overview of a family with a history of HD with a novel, unreported autosomal dominant RET mutation.Results/Summary The family examined in this study clearly demonstrates that (1) the genotype to phenotype correlation of patients with RET mutation-associated HD is not directly related, and (2) genetic mechanisms underlying the different HD phenotypes, as well as the model of inheritance of HD, are complex and not yet fully understood. As such, a multifactorial genesis of HD appears more likely and should be the center of genetic counseling for concerned families. Having identified another RET mutation with a possible correlation of severity of HD and gender will aid in filling the gaps of the incomplete picture of the pathogenesis of HD.