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The most accurate and practical imaging algorithm for the diagnosis of intestinal malrotation can be a complex and sometimes controversial topic. Since 1900, significant advances have been made in the radiographic assessment of infants and children suspected to have anomalies of intestinal rotation. We describe the current methods of abdominal imaging of malrotation along with their pros and cons. When associated with volvulus, malrotation is a true surgical emergency requiring rapid diagnosis and treatment. We emphasize the importance of close cooperation and communication between radiology and surgery to perform an effective and efficient diagnostic evaluation allowing prompt surgical decision making. Key words: Malrotation; Midgut volvulus; Treitz; Ladd; Heterotaxy; Infant Core tip: Malrotation, especially when associated with midgut volvulus, is a surgical emergency that must be astutely recognized, quickly diagnosed, and emergently treated operatively. While the diagnosis depends heavily on clinical acumen and suspicion, radiologic imaging is critical in determining which patients need surgery. Surgeons and radiologists must cooperate and communicate effectively during the radiographic evaluation of a child with malrotation. Additionally, the algorithm for imaging malrotation must be adapted based upon the tools and staff available at any given institution. INTRODUCTIONSurgeons are often consulted for evaluation of pediatric abdominal problems presenting to the emergency department. It is common for these patients to be evaluated by radiographic imaging in addition to a focused history and physical examination. The surgeon and radiologist must always have a particularly high-level of suspicion in cases of possible malrotation that may require emergency surgery after evaluation. CASE PRESENTATIONA 5-day-old full term male infant presents to the emergency department with continuous bilious non-bloody vomiting and irritability after his last three feeds. He was born by normal spontaneous vaginal delivery without complications and was noted to be breast-feeding well prior to discharge on day-of-life 2; he continued breastfeeding and passing stools at home for the past 4 d until this evening. On exam, his abdomen is minimally distended and he is crying constantly. The clinical picture suggests an obstruction distal to the ampulla of Vater,

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Objective The recently implemented integrated 6-year (I-6) format represents a significant change in cardiothoracic surgical residency training. We report the results of the first nationwide survey assessing I-6 program directors' impressions of this new format. Methods A 28-question web-based survey was distributed to program directors of all 24 Accreditation Council for Graduate Medical Education-accredited I-6 training programs in November 2013. The response rate was a robust 67%. Results Compared with graduates of traditional residencies, most I-6 program directors with enrolled residents believed that their graduates will be better trained (67%), be better prepared for new technological advances (67%), and have superior comprehension of cardiothoracic disease processes (83%). Just as with traditional program graduates, most respondents believed their I-6 graduates would be able to independently perform routine adult cardiac and general thoracic operations (75%) and were equivocal on whether additional specialty training (eg, minimally invasive, heart failure, aortic) was necessary. Most respondents did not believe that less general surgical training disadvantaged I-6 residents in terms of their career (83%); 67% of respondents would have chosen the I-6 format for themselves if given the choice. The greater challenges in training less mature and experienced trainees and vulnerability to attrition were noted as disadvantages of the I-6 format. Most respondents believed that I-6 programs represent a natural evolution toward improved residency training rather than a response to declining interest among medical school graduates. Conclusions High satisfaction rates with the I-6 format were prevalent among I-6 program directors. However, concerns with respect to training relatively less experienced, mature trainees were evident.

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