The APSA Annual Meeting offers a robust educational program covering the depth and breadth of the pediatric surgery field. You'll be inspired by the work and dedication of your colleagues and walk away with new ideas and fresh perspectives.
Virtual sessions are Tuesdays and Thursdays beginning Thursday, May 14. All sessions take place 5:00 p.m. EDT | 4:00 p.m. CDT | 3:00 p.m. MDT | 2:00 p.m. PDT.
NOTE: We will update this page as information becomes available. All registered attendees will also receive a weekly email with the details for the upcoming sessions.
Kickoff! Thursday, May 14
5:00 p.m. EDT
Introduction from APSA President Joseph P. Vacanti, MD
- The APSA meeting has gone virtual! APSA president Jay Vacanti introduces the APSA 2020 meeting including a preview of the evening's program and a visit to the historic Ether Dome. Welcome to APSA 2020.
Robert E. Gross Lecture "The Moral Compass" presented by Mary L. Brandt, MD, Baylor College of Medicine
- These are tumultuous times. Mary Brandt, chair of the APSA Wellness committee, discusses a strategy to successfully negotiate today's challenges. Develop your own moral compass to lead you on a path forward.
COVID-19 Data Sharing Update presented by Loren Berman, MD, Nemours/Alfred I. DuPont Hospital for Children; Martha-Conley E. Ingram, MD, MPH, Ann and Robert H. Lurie Children's Hospital of Chicago; Christopher R. Newton, MD, UCSF Benioff Children's Hospital Oakland
- What are pediatric surgeons and institutions doing in response to the pandemic? This report describes the latest real-time data from the APSA Quality and Safety committee's COVID-19 data sharing online spreadsheet, as well as an update from New York. Spoiler alert - it’s not all bad news.
JPS Top Educational Content: 2019 Review presented by Steven L. Lee, MD, Harbor - UCLA Medical Center
- Pediatric surgeons need repeated exposure to a topic in order to change their practice. This is a summary of the most popular session of the APSA 2019 meeting: the Top Educational Content or TEC talks. Last year’s topics were cervical spine injury clearance, fertility preservation, antibiotic stewardship and the Surviving Sepsis guidelines. Now go save some lifetimes.
Case Debates and Controversies Part I: Necrotizing Enterocolitis presented by Carroll M. Harmon, MD, PhD, John R. Oishei Children's Hospital; Todd A. Ponsky, MD, Cincinnati Children's Hospital Medical Center
- Always a highlight of the meeting, this installment of the case debate sessions for 2020 asks “How do you take care of infants with NEC?" Opinions, and maybe a little evidence, will be shared. Let us know what you think. Hint - not everyone will agree.
Tuesday, May 19
5:00 p.m. EDT
- Plenary I
- Moderators: P. Stephen Almond, MD, and Kathleen van Leeuwen, MD
- Including a presentation "The Role of Adjuvant Induced Myeloid-Derived Suppressor Cells in Allograft Tolerance" from 2019 Jay Grosfeld, MD Scholar Alex G. Cuenca, MD, PhD, Boston Children's Hospital
- Plenary II
- Moderators: Bethany J. Slater, MD, MBA, and Kasper Wang, MD
Thursday, May 21
5:00 p.m. EDT
Program Introduction presented by Ronald B. Hirschl, MD, CS Mott Children's Hospital
Introduction of New Members presented by Jay Vacanti, MD, and Max Langham, MD
- Welcome to the new APSA members! Recognizing our newest members is important so this ceremony comes early in the program. We look forward to their participation and moving pediatric surgery forward. Thanks for saying “I Will” and welcome to APSA.
Passing of the Presidential Gavel presented by Joseph P. Vacanti, MD, outgoing president and John H.T. Waldhausen, MD, incoming president
Outcomes and Quality Systematic Reviews and Toolkit: Intussusception presented by Lorraine Kelley-Quon, MD, Children's Hospital Los Angeles; Akemi L. Kawaguchi, MD, University of Texas, HSC Houston; Regan F. Williams, MD, LeBonheur Children's Hospital; L. Grier Arthur, III, MD, St. Christopher's Hospital for Children; Colleen M. Fitzpatrick, MD, Cardinal Glennon Children's Hospital.
- What does the evidence say about intussusception? Representatives of the Outcomes and Evidence-based Practice committee discuss their recommendations with respect to pre-reduction antibiotics, delayed repeat enemas and avoiding inpatient admission.
- What to make a change to your practice? The Quality and Safety committee share the resources available in the toolkit on intussusception. Don’t just learn something but use the evidence to take better care of your patients.
Cancer Committee: Technical Challenges in Rhabdomyosarcoma presented by Roshni A. Dasgupta, MD MPH, Cincinnati Children's Medical Center, Timothy B. Lautz, MD, Ann & Robert H. Lurie Children's Hospital of Chicago, Emily R. Christison-Lagay, MD, Yale School of Medicine, David Rodeberg, MD, East Carolina University, Daniel S. Rhee, MD MPH, Johns Hopkins University School of Medicine.
- Choosing the wrong biopsy or surgical approach adversely effects the outcome in children with rhabdomyosarcoma. An expert team from the Cancer committee discuss the optimal management of both extremity and paratesticular rhabdomyosarcoma. Do you know when and how to do a sentinel lymph node biopsy?
JPS Top Educational Content (TEC) Talk: The (Uncharted) Path Forward in Congenital Diaphragmatic Hernia presented by Matthew T. Harting, MD, McGovern Medical School at UTHealth
- Repair early on ECLS, repair late on ECLS or wait until they're off pump? Although every patient with congenital diaphragmatic hernia presents a unique challenge, protocols can assist clinical judgment in these complicated patients. Protocol management of CDH has have been identified by the Professional Development committee as one of the four most important practice gaps for 2020.
GERD 1: Evaluation, Medical Management and the Gastrojejunostomy Option presented by Eunice Y. Huang, MD, University of Tennessee Health Science Center, Rachel Rosen, MD, Matthew S. Clifton, MD, Emory University/Children's Healthcare of Atlanta, Benjamin Zendejas-Mummert, MD MSc, Boston Children's Hospital, Sherif Emil, MD CM, The Montreal Children's Hospital, McGill University Health Centre, Tim Jancelewicz, MD, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Jonathan A. Meisel, MD, Emory University School of Medicine.
- Some children’s hospitals perform 250 fundoplications each year and others perform none. We can’t all be right. In this first session in a series on variability in care, members of the Education committee discuss evaluation, medical management and the gastrojejunostomy tube option for patients with severe reflux disease. On May 28 the panel will discuss specific complicated patient scenarios. Use the chat function to be part of the discussion.
Tuesday, May 26
NO LIVE SESSIONS
So everyone can enjoy the long Memorial Day holiday, we will not air any live sessions Tuesday, May 26. However, the virtual lobby is always open; enjoy session recordings, and the virtual Poster Hall, Exhibit Hall and Social Lounge at your leisure.
Thursday, May 28
5:00 p.m. EDT
Program Introduction presented by Edward M. Barksdale, Jr., MD, UH Case Medical Center.
APSA’s new president-elect introduces the program for May 28, 2020.
JPS Top Educational Content (TEC) Talk: Is Gas Embolus a Real Concern or Just a Bunch of Hot Air? presented by Todd A. Ponsky, MD, Cincinnati Children's Hospital Medical Center
- Although rare, gas embolus during infant laparoscopy can be a devastating complication. Dr. Ponsky discusses how to prevent it, how to recognize it and what to do when it happens. This is a thing.
GERD 2: Complicated Patients presented by Eunice Y. Huang, MD, University of Tennessee Health Science Center, Rachel Rosen, MD, Matthew S. Clifton, MD, Emory University/Children's Healthcare of Atlanta, Benjamin Zendejas-Mummert, MD MSc, Boston Children's Hospital, Sherif Emil, MD CM, The Montreal Children's Hospital, McGill University Health Centre, Tim Jancelewicz, MD, Le Bonheur Children's Hospital, University of Tennessee Health Sciences Center, Jonathan A. Meisel, MD, Emory University School of Medicine.
- In the second part of the panel discussion on variations in the care of patients gastroesophageal reflux disease, the panelists from the Education committee discuss several specific cases including children with congenital heart disease, neurologic impairment and previous esophageal atresia. Taking care of these complicated patients involves complicated decision-making so let us know what you think.
Inclusion and Social Justice Series - Part 1: Representation and Equity in the Time of COVID-19 Presented by the Diversity, Equity and Inclusion Committee.
Speaker: Ala Stanford, MD, Jenkintown, Pennsylvania.
Discussants: Cynthia Reyes, MD, St. Joseph Children's Hospital, Kathryn L. Martin, MD, Penn State Health, Erika A. Newman, MD, CS Mott Children's Hospital
- Dr. Stanford received national attention when she began her own program for COVID-19 testing in underserved areas of Philadelphia. As part of the Inclusion and Social Justice sessions for the meeting, she discusses her experience with the inequities of the pandemic - and the response.
Ethical Issues During the COVID-19 Pandemic Presented by the Ethics Committee. Charles E. Bagwell, MD, Medical College of Virginia, Farokh R. Demehri, Boston Children's Hospital, Mindy B. Statter, MD, Children's Hospital at Montefiore, Jason Sulkowski, MD, Children's Hospital of Richmond, Franklin C. Margaron, MD, Naval Medical Center Portsmouth, Baddr Shakhsheer, MD, Washington University - St. Louis, Erica M. Carlisle, MD, University of Iowa, Annie H. Fecteau, MD, University of Toronto, Catherine J. Hunter, MD, University of Oklahoma Children's Hospital, Ronnie Sullins, MD, University of California Los Angeles, Patrick J. Javid, MD, Seattle Children's Hospital and Demetri J. Merianos, MD, Weill Cornell Medical Center.
- The pandemic has presented physicians with unique ethical challenges. Members of the Ethics committee discuss coping with COVID-19, triage and resource utilization as well as personal and professional responsibility.
Case Debates and Controversies Part 2: Abdominal Trauma presented by Carroll M. Harmon, MD, PhD, John R. Oishei Children's Hospital; Todd A. Ponsky, MD, Cincinnati Children's Hospital Medical Center
- In the second installment of the case debates, Drs. Harmon and Ponsky ask “How do you take care of patients with abdominal trauma?” Computerized tomography or ultrasound? Observe or operate? Intensive care unit or floor. Transfusion? When? Activity restrictions? Do you really think any kids follow them?
Tuesday, June 2
5:00 p.m. EDT
- Scientific Session 1: Quality and Safety
- Moderators: Jeffrey W. Gander, MD, University of Virginia Children's Hospital, and Barrie S. Rich, MD, Cohen Children's Medical Center
- Scientific Session 2: ECLS and CDH
- Moderators: Shaun M. Kunisaki, MD, MSc, John Hopkins University, and David A. Lazar, MD, University of California, San Diego
Thursday, June 4
5:00 p.m. EDT
Virtual Town Hall
Program Introduction presented by Andrea A. Hayes-Jordan, MD, North Carolina Children's Hospital
Session Opening presented by Adam J. Foss, Esq, Prosecutor Impact
Moderated by Erika A. Newman, MD, CS Mott Children's Hospital and Adam J. Foss, Esq, Prosecutor Impact
Ronald B. Hirschl, MD, CS Mott Children's Hospital, Edward M. Barksdale, Jr., MD, UH Case Medical Center, Marion C.W. Henry, MD MPH, University of Arizona, Sean E. McLean, MD, University of North Carolina, Cynthia Reyes, MD, St. Joseph Children's Hospital, Dan von Allmen, MD, Cincinnati Children's Hospital, Hanna Alemayehu, MD, University of South Alabama, Ala Stanford, MD, Stanford Pediatric Surgery, LLC, Andrea A. Hayes-Jordan, MD, North Carolina Children's Hospital, Victor F. Garcia, MD, Cincinnati Children's Hospital, John H. T. Waldhausen, MD, Seattle Children's Hospital
- Committing to being an ally and an antiracist every day
- Creating jobs through anchor institutions
- Civic engagement
- Voting and engaging with your local DA and representatives
- Leveraging our influence as leaders
Tuesday, June 9
5:00 p.m. EDT
- Scientific Session 3: Oncology I - Neuroblastoma and Hepatic Tumors
- Moderators: Christa N. Grant, MD, Penn State Children's Hospital, and Timothy B. Lautz, MD, Lurie Children's Hospital, and Jennifer H. Aldrink, MD, Nationwide Children's Hospital
- Scientific Session 4: Oncology II - Sarcoma and Renal Tumors
- Moderators: Elisabeth T. Tracy, MD, Duke University Medical Center, Dave R. Lal, MD, Medical College of Wisconsin, and Richard D. Glick, MD, Cohen Children's Medical Center
- Scientific Session 12: Pediatric Gynecologic Surgery
- Moderators: Erin E. Rowell, MD, Lurie Children's Hospital, Reto M. Baertschiger, MD PhD, Hospital for Sick Children
Thursday, June 11
5:00 p.m. EDT
Introduction presented by Casey M. Calkins, MD, Children’s Wisconsin. The Program committee chair gets to brag about his meeting and tonight’s sessions.
JPS Top Educational Content (TEC) Talk: Biologics and the Surgical Management of Inflammatory Bowel Disease presented by Jason S. Frischer, MD, Cincinnati Children’s Hospital
- The medical management of inflammatory bowel disease has changed considerably with the advent of biologic agents. In this TEC talk, the Professional Development committee asks Jason Frischer to discuss how biologics have affected the surgical management of pediatric patients with IBD. Or have they?
Cancer Committee: Complex Wilms Tumor Patients presented by Peter F. Ehrlich, MD Msc, University of Michigan, and Jennifer H. Aldrink, MD, Nationwide Children’s Hospital
- Several years ago, APSA identified that the surgical management of Wilms tumor was a practice gap based a significant number of protocol violations. Peter Ehrlich and Jennifer Aldrink from the Cancer committee will discuss a couple of complex patients that illustrate the finer points of management of patients with Wilms tumor including patients with lung metastases, bilateral tumors, caval involvement and DHPLN. If you don’t know what that acronym stands for then you need this session.
Enteral Access: Systematic Review and Quality Improvement Toolkit presented by Loren Berman, MD, Nemours – A.I. DuPont Hospital for Children, Adam B. Goldin, MD MPH, Seattle Children’s Hospital, Maria Olivere, Robert J. Baird, MD MSc MDCM, British Columbia Children’s Hospital, and Derek S. Wakeman, MD, University of Rochester School of Medicine
- In another first for this year’s meeting, members of the Outcomes and Quality committees are joined by a parent who gives her perspective on taking care of a child who requires enteral access. Her perspective and the review of the evidence may affect when and how you place a gastrostomy.
Everyday Bias at Work presented by Jessica A. Halem, MBA, LGBTQ Outreach and Engagement Director, Harvard Medical School
- In the third installment of the inclusion and social justice series, Jessica Halem is joined by members of the Benjy Brooks and Diversity, Equity and Inclusion committees for a great discussion on bias in the workplace. After recognizing that bias is a normal human process, acknowledging its presence is the first step in overcoming it.
Thursday, June 16
5:00 p.m. EDT
- Scientific Session 5: Trauma
- Moderators: Kenneth C. Walters, MD, Children's Hospital of Georgia, and Anthony Stallion, MD, Beaumont Children's Hospital
- Scientific Session 9: Thoracic Surgery
- Moderators: Peter T. Yu, MD, Children's Hospital of Orange County, Nicole M. Chandler, MD, Johns Hopkins All Children's Hospital
- Scientific Session 7: Practice and Education
- Moderators: David H. Rothstein, MD, John R. Oishei Children's Hospital, Andreas H. Meier, MD MEd, SUNY Upstate Medical University, and Drew A. Rideout, MD, Johns Hopkins All Children's Hospital
Thursday, June 18
5:00 p.m. EDT
Introduction presented by Benedict C. Nwomeh, MD MPH, Nationwide Children's Hospital
The President of the Association of Pediatric Surgery Training Program Directors introduces tonight’s sessions.
Informatics Committee Session presented by Francois I. Luks, MD PhD, Brown Medical School/Hasbro Children's Hospital, Allison L. Speer, MD, McGovern Medical School at University of Texas Health, Alexander Peters, MD, Cornell University, and Jason C. Fisher, MD, NYU Langone Medical Center
- Pediatric surgeons have always led the way in using technology to communicate with our colleagues. This virtual meeting is a great example. Tonight’s opening session is a timely program from the Informatics committee and discusses how you can use APSA’s websites, visual abstracts and Twitter to keep up with the rapidly changing world of pediatric surgery. Two abstracts related to informatics are also reviewed.
Jay and Margie Grosfeld Scientific Symposium on Stem Cells and Tissue Engineering presented by the Research Committee
- We are truly grateful to Ms. Grosfeld and her continued support of pediatric surgery science. Tonight, the Research committee reviews three important scientific abstracts that illustrate novel approaches to difficult pediatric surgical problems. Often it takes both science and surgery to treat a child.
How to Start an Adolescent Bariatric Program presented by Jeff L. Zitsman, MD, Columbia University, Mark L. Wulkan, MD, Emory Children's Healthcare of Atlanta, and Evan P. Nadler, MD, Children's National Medical Center
- Representatives of the Childhood Obesity committee discuss how to start a program. Your hospital adminstration may want you to do this but these experts give you the facts. They present a huge number of great tips and tricks. In addition to bariatric surgery, these are lessons learned that apply equally well to the development of any clinical program.
Resident and Student Session presented by the Education Committee
- With great virtual meetings such as this, it is no wonder that many general surgery residents and medical students are interested in pediatric surgery. A panel of pediatric surgery training program directors discuss the path to successfully matching in pediatric surgery. Hint, you probably don’t need twelve letters of recommendation, but you do need a mentor.
Tuesday, June 23
5:00 p.m. EDT
- Scientific Session 6: Basic Science
- Moderators: David J. Hackam, MD, PhD; Johns Hopkins Children's Center, Biren P. Modi, MD, Boston Children's Hospital; and Jamie Golden, MD, Northwell Health
- Scientific Session 8: General Pediatric Surgery
- Moderators: Edward P. Tagge, MD, Loma Linda University Children's Hospital; Sohail R. Shah, MD, Texas Children's Hospital; and Pablo Laje, MD, Children's Hospital of Philadelphia
Thursday, June 25
5:00 p.m. EDT
Introduction presented by Max R. Langham, Jr., MD, University of Tennessee Health Science Center
Trauma Committee Session presented by Christian J. Streck, Jr., MD, Medical University of South Carolina; Shannon L. Castle, MD, Valley Children's Hospital; Adam M. Vogel, MD, Texas Children's Hospital; and Mauricio A. Escobar, Jr., Mary Bridge Children's Hospital
- Pediatric trauma care has always been an important part of our specialty. This session combines three trauma scientific abstracts with three practice guidelines. The recommendations cover imaging in blunt abdominal trauma, the use of thromboelastography in goal directed transfusion and screening for physical child abuse. Spoiler alert: We are doing too many CTs. You need to learn how to interpret TEG results and early identification of child abuse saves lives.
New Technology Committee Session presented by Nam Nguyen, MD, Children's Hospital Los Angeles; Bethany J. Slater, MD, University of Chicago; Sean J. Barnett, MD, MS, Eastern Maine Medical Center; and James D. Geiger, MD, University of Michigan, CS Mott Children's Hospital
- This session reviews two innovative scientific abstracts, including presentations on healthcare value analysis and the voyage to developing a new instrument. If you like being on the cutting edge, this is very exciting stuff.
Social Justice Symposium: Disparities in Access to Care (Part 1) presented by Kenneth W. Gow, MD, University of Washington; Sanjay Krishnaswami, MD, Oregon Health & Sciences University; Victor F. Garcia, MD, Cincinnati Children's Hospital; Danielle S. Walsh, MD, East Carolina University; and Shant Shekherdimian, MD, University of California Los Angeles
- The first pillar in APSA’s strategic plan is to promote quality pediatric surgical care . . . and that means quality care for all. This session is the first part of the Health Policy and Advocacy and Global Pediatric Surgery Committees’ combined program on disparities in access to care. They discuss an injured patient and the different, and sometimes similar, issues they face with accessibility, affordability and acceptability within urban, rural and global environments. As you’ll see, these are big issues. Fortunately, APSA has never shied away from big issues, and there are some things we can do.
Case Controversies: Pediatric Surgery in the COVID-19 Era presented by Mac Harmon, MD PhD, John R. Oishei Children's Hospital; and Todd A. Ponsky, MD, Cincinnati Children's Hospital
- The final installment of the Case Controversies program discusses the care of pediatric surgical patients in the COVID-19 universe. It appears that COVID-19 has changed everything — even something as basic as the management of acute appendicitis.
Tuesday, June 30
5:00 p.m. EDT
- Scientific Session 10: Neonatal Surgery
- Moderators: Erin M. Garvey, MD, Phoenix Children's Hospital; and Nathan M. Novotny, MD, Beaumont Children's Hospital
- Scientific Session 11: Colorectal Surgery
- Moderators: Timothy C. Lee, MD, Texas Children's Hospital; Jason S. Frischer, MD, Cincinnati Children's Hospital; and Christopher P. Gayer, MD, Children's Hospital of Los Angeles
Thursday, July 2
5:00 p.m. EDT
Introduction presented by John H.T. Waldhausen, MD, Seattle Children's Hospital. The incoming APSA president introduces tonight's session.
Journal of Pediatric Surgery Top Educational Content
The Evolution of Care for Patients with Differences of Sex Development: When Can We Leave the Gonads in? presented by Kathleen van Leeuwen, MD, Phoenix Children's Hospital
- Disorders of sex development are a perennial knowledge gap for pediatric surgeons. This gap gets larger as the optimal treatment evolves. In this final installment of the JPS TEC talks for 2020, Kathleen van Leeuwen presents the current management of children with complete androgen insensitivity syndrome. She suggests a patient centered approach that lets the patient decide about gonadectomy.
Surgical Critical Care Committee
Resuscitation, Fluid, Blood: Be Careful What You Wish For presented by Alexander Feliz, LeBonheur Children's Hospital, Laura A. Boomer, MD, Children's Hospital of Richmond, Robert J. Vandewalle, Emory University, Natalie A. Drucker, MD, Riley Children's Hospital, Keith Thatch, MD, John Hopkins All Children's Hospital, Howard I. Pryor, II, MD, Walter Reed National Military Medical Center and Alejandro Garcia, MD, Johns Hopkins Hospital
- Another frequently cited practice gap is perioperative and critical care – just ask any oral board examiner. This session is presented by members of the Surgical Critical Care committee and discusses three important topics – sepsis care, transfusion and fluid management. These may seem like basic concepts but we guarantee that you will learn something. How low will you allow a patient’s hemoglobin to go before a transfusion is indicated? We probably transfuse too soon but the real answer, of course, is “it depends.”
Wellness Task Force presented by Kristy Rialon, MD, Texas Children's Hospital, Loren Berman, MD Nemours - A.I. DuPont Hospital for Children and Kurt F. Heiss, MD, Emory Children's Center
- This issue affects us all – and we rarely give it the time it deserves. Members of the Wellness task force share the results if its survey of the APSA membership and a preview of their peer counseling workshop planned for July 14th. It appears as if we are not well, my friends. But there are things we can do about it.
Social Injustice Symposium: Disparities in Access to Care Part 2 presented by Sanjay Krishnaswami, MD, Oregon Health & Science University, Robin T. Petroze, MD, University of Florida, Ellen M. Reynolds, MD, St. Luke's Children's Hospital and R. Lawrence Moss, MD, Nemours Children's Health System
- The first pillar in APSA’s strategic plan is to promote quality pediatric surgery care and that means addressing the social determinants of health that impact providing quality care for all. In these tumultuous times, it therefore seems fitting that the final session of the 2020 virtual meeting is the second part of the Health Policy and Advocacy and Global Pediatric Surgery committees’ program on disparities in access to care. An infant with an anorectal malformation is discussed and the issues they might face with accessibility, affordability and acceptability within urban, rural and global perspectives. Doing a good operation is only part of taking care of this child.
Closing Remarks presented by Joseph P. Vacanti, MD, Massachusetts General Hospital
The outgoing APSA president makes some closing remarks and awards the APSA Surgical Humanitarian Award to Stephen W. Bickler, MD, Univ of California, San Diego.
- The Humanitarian Award recognizes an APSA member whose career has been dedicated to ensuring the provision of surgical care to underserved children without expectation of commensurate reimbursement.
Thursday, July 9
5:00 p.m. EDT
Town Hall Agenda
- APSA Response to Racism presented by Dr. Edward M. Barksdale, Jr. and Dr Erika A. Newman
- APSA Strategic Plan Updates presented by Dr. John H.T. Waldhausen and Dr. Barksdale
- Governance and Bylaws Update presented by Dr. Waldhausen
- Finances presented by Dr. Waldhausen
Town Hall and Business Meeting Handouts