An audit of transfers for neonatal surgical care in England in 2007

The burden of excluding malrotation in term neonates with bile stained vomiting

PURPOSE

To determine the number of term infants with bilious vomiting (BV) referred to a neonatal surgical centre for exclusion of malrotation by upper gastrointestinal contrast (UGI) examination.

METHODS

Retrospective review of term (>37/40) neonates <28 days of age undergoing UGI for exclusion of malrotation between Jan 2010 and Dec 2014 in a neonatal network with 30,000 term deliveries annually. Only infants with BV in the absence of alternative clinical/radiological diagnosis were included.

RESULTS

One hundred and sixty-six infants met the inclusion criteria. Fourteen (9 %) infants had malrotation diagnosed by UGI and confirmed at laparotomy. Only 1 of 110 infants referred at 0-2 days of age had positive UGI compared to 13 of 56 infants referred after this age (p < 0.01). An increase in referrals followed the death of an infant from midgut volvulus and as a result one in 500 term infants are currently being referred.

CONCLUSION

Increasing awareness of the potential consequences of bilious vomiting appears to have resulted in increased referrals with no increase in detection of malrotation. Prospective studies are required to determine whether investigation of all infants with unexplained bilious vomiting is required and if it is possible to select cases for surgical referral.

Outcomes of full-term infants with bilious vomiting: observational study of a retrieved cohort

Bilious vomiting in a neonate may be a sign of intestinal obstruction often resulting in transfer requests to surgical centres. The aim of this study was to assess the use of clinical findings at referral in predicting outcomes and to determine how often such patients have a time-critical surgical condition (eg, volvulus, where a delay in treatment is likely to compromise gut viability).

METHODS

4-year data and outcomes of all term newborns aged ≤7 days with bilious vomiting transferred by a regional transfer service were analysed. Specificity, sensitivity, likelihood ratios, correlations, prior and posterior probability of clinical findings in predicting newborns with surgical diagnosis were calculated.

RESULTS

Of 163 neonates with bilious vomiting, 75 (46%) had a surgical diagnosis and 23 (14.1%) had a time-critical surgical condition. The diagnosis of a surgical condition in neonates with bilious vomiting was significantly associated with abdominal distension (χ(2)=5.17, p=0.023), abdominal tenderness (χ(2)=5.90, p=0.015) and abnormal abdominal X-ray findings (χ(2)=5.68, p=0.017) but not with palpation findings of a soft as compared with a tense abdomen (χ(2)=3.21, p=0.073). Abnormal abdominal X-ray, abdominal distension and tenderness had 97%, 74% and 62% sensitivity, respectively, with regard to association with an underlying surgical diagnosis. Normal abdominal X-ray reduced the posterior probability of surgical diagnosis from 50% to 16%. Overall, clinical findings at referral did not differentiate between infants with or without surgical or time-critical condition.

CONCLUSIONS

We recommend that term neonates with bilious vomiting referred for transfer are prioritised as time critical.

Central roles of apoptotic proteins in mitochondrial function

Mitochondria have been classically characterized as organelles with responsibility for cellular energy production in the form of ATP, but they are also the organelles through which apoptotic signaling occurs. Cell stress stimuli can result in outer membrane permeabilization, after which mitochondria release numerous proteins involved in apoptotic signaling, including cytochrome c, apoptosis-inducing factor, endonuclease G, Smac/DIABLO and Omi/HtrA2. Cell fate is determined by signaling through apoptotic proteins within the Bcl-2 (B-cell lymphoma 2) protein family, which converges on mitochondria. Many cancerous cells display abnormal levels of Bcl-2 protein family member expression that results in defective apoptotic signaling. Alterations in bioenergetic function also contribute to cancer as well as numerous other disorders. Recent evidence indicates that several pro-apoptotic proteins localized within mitochondria, as well as proteins within the Bcl-2 protein family, can influence mitochondrial bioenergetic function. This review focuses on the emerging roles of these proteins in the control of mitochondrial activity.