Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

SP2.1.11Real-world use of workplace-based assessments in surgical training: a UK nationwide exploration of trainee perspectives and consensus recommendations from the Association of Surgeons in Training

Background

The utility of Workplace-Based Assessments (WBAs) in surgical training depends on the way they are completed. This study aims to ascertain the real-world usage of WBAs, as perceived by UK surgical trainees.

Methods

An anonymous national online questionnaire was conducted via the Association of Surgeons in Training (ASiT). The evaluation employed mixed methods to interpret quantitative and qualitative data. Suggestions for improvement were identified from free-text comments and considered through a formal two-round modified Delphi consensus process by ASiT council members.

Results

Analysis included 906 complete responses from all surgical specialities across all training levels. WBA use was perceived to deviate markedly from the Joint Committee on Surgical Training standards with significantly identified misuse across all surgical specialities. Inaccurate completion was acknowledged by 89.6% of respondents, and some trainers appear complicit with 40.9% of respondents aware of 'unobserved sign-off', and 33.6% aware of 'password disclosure' by trainers.

Most trainees felt the Annual Review of Competency Progression (ARCP) respected WBA quantity above quality (55.4%), and a third felt pressure to overstate the number completed (32.0%). Main reasons for misuse were time restraints, lack of engagement and the will to achieve career progression targets.

Conclusions

UK surgical trainees perceive a significant deviation from WBAs standards due to multiple factors. The frequency and nature of misuse are worrying and undermines the existing evidence for the WBAs role in training. We present consensus recommendations from ASiT for the improvement of WBA use in UK surgical training.

834 What’s The SCORE? Surgeons’ Approach to Treating Symptomatic, Clinically Occult, Radiologically Evident Inguinal Hernias

Introduction

The management of symptomatic, clinically occult, radiologically evident inguinal hernias (SCORE-IH) is challenging. This pathology lacks a validated definition and a standardised treatment paradigm to prevent risks of operative management. This study explores current practice amongst surgeons treating SCORE-IH.

Method

STEER collaborators disseminated a validated online survey amongst their UK consultants. Responses to the survey were collated on a spreadsheet and analysed with basic percentages.

Results

Seventy-three responses were received, including six (8%) international surgeons. UGI and colorectal surgeons were the predominant sub-specialities at 33% and 32%, respectively. Only 26% reported they performed more than 100 IH repairs annually. Less than half of the responders (41%) of surgeons reported more than 50% laparoscopic IH repairs. Nearly two thirds (62%) were unaware of guidelines on the management of SCORE-IH. Imaging chose to manage SCORE-IH included US, MRI, and CT at 71%, 44% and 29%, respectively. Only 14% of surgeons reported they would not consider any imaging. Only 19% would manage conservatively, while 37% would manage operatively.

Conclusions

There is skill diversity when treating IH. A lack of guidance and consensus amongst the surveyed surgeons is evident by the heterogeneity in imaging utilisation and varied treatment pathways offered to SCORE-IH patients.

879 Establishing the First Eoe Deanery-Wide Trainee Led Virtual Journal Club: Keeping Up Morale by Encouraging Trainee Interaction and Continuous Professional Development During the Hiatus to Teaching Activities Enforced by Coronavirus

Introduction

Over the initial COVID months and with the cancellation of several teaching programs / courses/ conferences; we identified a NEED for trainee interaction and continuous professional development, despite staff redeployments. We since established a deanery-wide trainee led VIRTUAL journal club, run by the Surgical Trainees of East of England Research collaborative (STEER) group.

Method

Following decision in May2020, the STEER group collated curriculum topics and related landmark papers, drafting a programmed-schedule for sessions (45mins – 1hour). CPD accreditation was sought and received from RCSEd prior to some sessions. Sessions were delivered using the Microsoft Teams app (via desktop/tablet/phone). Targeted audience included FYs, CTs, STs, JCFs, SCFs (candidates preparing for MRCS/FRCS or interested in academia). Live polling / feedback forms and attendance certificates were distributed.

Results

Six journal club sessions have been run to-date. A minimum of 15-20 participants attended each session with spread of junior/senior trainees. Sessions were video recorded for repeat playback for those unable to attend. Feedback was overwhelmingly positive, with good engagement from participants.

Conclusions

A deanery wide virtual journal club was positively received by trainees and benefits included: critique and dissemination of evidence (especially recently with COVID-related literature), trainee interaction and keeping up-to-date and understanding and analysing information.

778 Management of Colorectal Anastomotic leaks: The East of England Experience

Introduction

Colorectal anastomotic leaks (AL) are an unfortunate occurrence and are associated with a high mortality. The aim of this multi-centre study is to explore the different management strategies used and compare outcomes in the management of AL.

Method

All patients who had an AL were included at seven hospitals across the East of England. Morbidity, mortality, and survival were compared across the different management strategies.

Results

A total of 247 consecutive patients were included of which 60.3% were male and the median age was 68 (IQR 57-77). Half of patients were initially managed conservatively, a further 10.5% had a radiological procedure. 39.7% required surgery as an initial treatment. Of those who initially did not have a surgical intervention (n = 149), 10.7% (n = 16/149) eventually required laparotomy. Ultimately, 42.7% (n = 106/248) required a laparotomy. The 30- and 90-day across the entire population mortality were 3.6% and 4.9% respectively. There were no significant differences in mortality or long-terms survival between the different initial treatment modalities.

Conclusions

Despite initial conservative, antibiotic and radiological intervention being successful in the majority of patients, two out of five patients will still require a laparotomy. A consensus approach is required to standardise management in these difficult scenarios.

Liposomal Bupivacaine (Bupigel) Demonstrates Minimal Local Nerve Toxicity in a Rabbit Functional Model

We previously reported the development of a novel formulation of an ultra-long-acting local anesthetic based on bupivacaine encapsulated in large multivesicular liposomes (Bupisomes) embedded in hydrogel. This formulation (Bupigel) prolonged bupivacaine release from the formulation in dissolution-like studies in vitro and analgesia in vivo in mouse, rat, and pig models. In this study we assessed Bupigel neurotoxicity on rabbit sciatic nerve using histopathology and electrophysiologic testing. Sciatic nerves of both hind limbs were injected dropwise with different formulations. Nerve conduction studies and needle electromyography two weeks after perineural administration showed signs of neural damage after injection of free lidocaine and bupivacaine, while there was no sign of neural damage after injection with saline, demonstrating the validity of the method. This test also did not show evidence of motor or sensory nerve damage after injection with liposomal bupivacaine at a dose 10-times higher than free bupivacaine. Histologically, signs of neural damage could be observed with lidocaine. Nerves injected with Bupigel showed mild signs of inflammation and small residues of hydrogel in granulomas, indicating a long residence time of the hydrogel at the site of injection, but no histopathological signs of nerve damage. This demonstrated that early signs of neural damage were detected electrophysiologically, showing the usefulness and sensitivity of electrodiagnostic testing in detection of neural damage from new formulations.

Current technical surgical practice of emergency appendicectomy: a cross-sectional survey of surgical registrars in the UK

INTRODUCTION

Appendicectomy remains one of the most commonly performed procedures in general surgery. The aim of this study was to explore variation in operative techniques of an appendicectomy among surgical registrars in England.

MATERIALS AND METHODS

An anonymised survey was sent out to surgical registrars in the UK via email and social media. Subgroup analyses were performed comparing respondents based on their level of seniority and subspecialty background.

RESULTS

A total of 168 respondents completed the survey, of whom 77.4% (130/168) were specialty trainees years 3-8 and 44.6% (75/168) were colorectal trainees. The majority (98.8%) preferred a laparoscopic approach to appendicectomy. Overall, 73.2% opted to use diathermy to divide an uninflamed mesoappendix. Half of the respondents (50%) preferentially used diathermy to control the appendicular artery, followed by 44% preferring use of metal or polymeric clips. The appendicular stump was most often secured with Endoloops (85.7%) when removing a macroscopically uninflamed appendix but less readily used in the visibly inflamed appendix (75.6%, p = 0.01). Colorectal and upper gastrointestinal registrars were more likely to use diathermy on the mucosa of the appendix stump compared with other subspecialties (p = 0.03). The majority (82.1%) of respondents extracted the appendix via a retrieval bag. Regarding skin closure, most respondents (69%) adopted absorbable subcuticular sutures. Preferential duration of postoperative antibiotic use following appendicectomy for complicated appendicitis varied among the respondents.

CONCLUSION

There are similarities and differences across surgical registrars in terms of technical practice in appendicectomy, partially attributed to prior experience and training.

Impaired Regeneration in Dystrophic Muscle-New Target for Therapy

Muscle stem cells (MuSCs), known as satellite cells (SCs) have an incredible ability to regenerate, which enables the maintenance and growth of muscle tissue. In response to damaging stimuli, SCs are activated, proliferate, differentiate, and fuse to repair or generate a new muscle fiber. However, dystrophic muscles are characterized by poor muscle regeneration along with chronic inflammation and fibrosis. Indications for SC involvement in muscular dystrophy pathologies are accumulating, but their contribution to muscle pathophysiology is not precisely understood. In congenital muscular dystrophy type 1A (LAMA2-CMD), mutations in Lama2 gene cause either complete or partial absence in laminin-211 protein. Laminin-211 functions as a link between muscle extracellular matrix (ECM) and two adhesion systems in the sarcolemma; one is the well-known dystrophin-glycoprotein complex (DGC), and the second is the integrin complex. Because of its protein interactions and location, laminin-211 has a crucial role in muscle function and survival by maintaining sarcolemma integrity. In addition, laminin-211 is expressed in SCs and suggested to have a role in SC proliferation and differentiation. Downstream to the primary defect in laminin-211, several secondary genes and pathways accelerate disease mechanism, while at the same time there are unsuccessful attempts to regenerate as compensation for the dystrophic process. Lately, next-generation sequencing platforms have advanced our knowledge about the secondary events occurring in various diseases, elucidate the pathophysiology, and characterize new essential targets for development of new treatment strategies. This review will mainly focus on SC contribution to impaired regeneration in muscular dystrophies and specifically new findings suggesting SC involvement in LAMA2-CMD pathology.

Pax7, Pax3 and Mamstr genes are involved in skeletal muscle impaired regeneration of dy2J/dy2J mouse model of Lama2-CMD

Congenital muscular dystrophy type-1A (Lama2-CMD) and Duchenne muscular dystrophy (DMD) result from deficiencies of laminin-α2 and dystrophin proteins, respectively. Although both proteins strengthen the sarcolemma, they are implicated in clinically distinct phenotypes. We used RNA-deep sequencing (RNA-Seq) of dy2J/dy2J, Lama2-CMD mouse model, skeletal muscle at 8 weeks of age to elucidate disease pathophysiology. This study is the first report of dy2J/dy2J model whole transcriptome profile. RNA-Seq of the mdx mouse model of DMD and wild-type (WT) mouse was carried as well in order to enable a novel comparison of dy2J/dy2J to mdx. A large group of shared differentially expressed genes (DEGs) was found in dy2J/dy2J and mdx models (1834 common DEGs, false discovery rate [FDR] < 0.05). Enrichment pathway analysis using ingenuity pathway analysis showed enrichment of inflammation, fibrosis, cellular movement, migration and proliferation of cells, apoptosis and necrosis in both mouse models (P-values 3E-10-9E-37). Via canonical pathway analysis, actin cytoskeleton, integrin, integrin-linked kinase, NF-kB, renin-angiotensin, epithelial-mesenchymal transition, and calcium signaling were also enriched and upregulated in both models (FDR < 0.05). Interestingly, significant downregulation of Pax7 was detected in dy2J/dy2J compared to upregulation of this key regeneration gene in mdx mice. Pax3 and Mamstr genes were also downregulated in dy2J/dy2J compared to WT mice. These results may explain the distinct disease course and severity in these models. While the mdx model at that stage shows massive regeneration, the dy2J/dy2J shows progressive dystrophic process. Our data deepen our understanding of the molecular pathophysiology and suggest new targets for additional therapies to upregulate regeneration in Lama2-CMD.

Use of the eLogbook in surgical training in the United Kingdom: A nationwide survey and consensus recommendations from the Association of Surgeons in Training

INTRODUCTION

Accurate recording of operative cases is essential during training to demonstrate experience. However, indicative numbers delineating minimum desirable experience may incentivise exaggeration or misrepresentation of experience. This study aimed to determine perceptions of real-world eLogbook use among UK surgeons in training.

MATERIAL AND METHODS

An anonymous online questionnaire was disseminated electronically using a pre-planned yield-maximisation strategy, incorporating regional champions, email and social media. Evaluation employed mixed methods in a combined interpretation of quantitative and qualitative data from the questionnaire. Recommendations for development of the eLogbook were itemised from respondents' free text items and a modified Delphi process, conducted within the Council of the UK national trainee representative body, the Association of Surgeons in Training, determined the strength of each recommendation.

RESULTS

Analysis included 906 complete responses from training-grade surgeons (34.8% female) from all UK recognised specialties and all grades of training. More than two-thirds (68.5%) believed that overstatement or misrepresentation of case involvement occurs. A fifth (20.8%) reported witnessing trainees logging cases they had not actually participated in and almost a third (32.7%) had witnessed overstatement, yet few (15.1%) had raised such an issue with a supervisor. Most (85.2%) respondents had few or no eLogbook entries validated. More than a quarter of respondents felt pressure to overstate their involvement in cases (28.6%) and the number recorded (28.1%). Almost a third (31.5%) felt the required case number for completion of training was not achievable. Female trainees were less likely to feel well supervised (p = 0.022) and to perceive targets for completion of training were achievable (p = 0.005). Thematic analysis identified four key themes to explain logbook misuse: Pressure to achieve training milestones; eLogbook functionality issues; training deficiencies and probity.

CONCLUSIONS

Inaccurate operative recording was widely reported, primarily in response to perceived pressure to achieve targets for career progression. Operative logbooks may not be as accurate as intended. Consensus recommendations are made for improvement in the eLogbook and its use.

Improvement of motor conduction velocity in hereditary neuropathy of LAMA2-CMD dy2J/dy2J mouse model by glatiramer acetate

OBJECTIVE

Glatiramer acetate (GA), an agent modulating the immune system, has been shown to cause significantly improved mobility and hind limb muscle strength in the dy^2J/dy^2J mouse model for LAMA2-congenital muscular dystrophy (LAMA2-CMD). In view of these findings and the prominent peripheral nervous system involvement in this laminin-α2 disorder we evaluated GA's effect on dy^2J/dy^2J motor nerve conduction electrophysiologically.

METHODS

Left sciatic-tibial motor nerve conduction studies were performed on wild type (WT) mice (n = 10), control dy^2J/dy^2J mice (n = 11), and GA treated dy^2J/dy^2J mice (n = 10) at 18 weeks of age.

RESULTS

Control dy^2J/dy^2J mice average velocities (34.49 ± 2.15 m/s) were significantly slower than WT (62.57 ± 2.23 m/s; p < 0.0005), confirming the clinical observation of hindlimb paresis in dy^2J/dy^2J mice attributed to peripheral neuropathy. GA treated dy^2J/dy^2J mice showed significantly improved average sciatic-tibial motor nerve conduction velocity versus control dy^2J/dy^2J (50.35 ± 2.9 m/s; p < 0.0005).

CONCLUSION

In this study we show for the first time improvement in motor nerve conduction velocity of LAMA2-CMD dy^2J/dy^2J mouse model's hereditary peripheral neuropathy following GA treatment.

SIGNIFICANCE

This study suggests a possible therapeutic effect of glatiramer acetate on hereditary peripheral neuropathy in this laminin-α2 disorder.

Atypical Clinical Presentations of Pediatric Acute Immune-Mediated Polyneuropathy

Guillain-Barré syndrome (GBS) is the most common cause of acute flaccid paralysis in children. During the acute phase, the disorder can be life-threatening by involving the respiratory muscles and the autonomic nervous system. Nevertheless, the prognosis is good, and most children achieve full recovery. The aim of this study was to characterize the clinical and electrophysiologic findings in children with Guillain-Barré syndrome referred to a tertiary center in Israel. A retrospective database review from 2009 to 2015 identified 39 children. Data on clinical presentation, respiratory complications, and long-term neurologic outcomes were collected. Atypical clinical findings at admission included asymmetric weakness in 23%, nonascending weakness in 30%, and normal deep tendon reflexes in 28%. Eight children were later diagnosed with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Electrophysiologic findings, available in 12 patients with Guillain-Barré syndrome, revealed acute inflammatory demyelinating polyradiculoneuropathy (AIDP) in 4 (33.5%), AIDP with secondary axonal changes in 3 (25%), and acute motor axonal neuropathy (AMAN) subtype in 4 (33.5%); 8% had no abnormal findings. On follow-up, 71% of the children with Guillain-Barré syndrome fully recovered compared to 14% of the children with CIDP. Corresponding rates of neurologic sequelae were 29% and 86%. Clinicians should be alert to the atypical presenting symptoms of Guillain-Barré syndrome, which occur in a significant proportion of children.

Detection and molecular characterization of tomato yellow leaf curl virus naturally infecting Lycopersicon esculentum in Egypt

Tomato yellow leaf curl virus (TYLCV) infections of tomato crops in Egypt were widely spread in 2014. Infected symptomatic tomato plants from different governorates were sampled. TYLCV strains Israel and Mild (TYLCV-IL, TYLCV-Mild) were identified by multiplex and real-time PCR. In addition, nucleotide sequence analysis of the V1 and V2 protein genes, revealed ten TYLCV Egyptian isolates (TYLCV from TY1 to 10). Phylogenetic analysis showed their high degree of relatedness with TYLCV-IL Jordan isolate (98%). Here we have showed the complete nucleotide sequence of the TYLCV Egyptian isolate TY10, sampled from El Beheira. A high degree of similarity to other previously reported Egyptian isolates and isolates from Jordan and Japan reflect the importance of phylogenetic analysis in monitoring virus genetic diversity and possibilities for divergence of more virulent strains or genotypes.

Congenital myasthenic syndrome in Israel: Genetic and clinical characterization

The objective of the study was to evaluate the epidemiology of patients with congenital myasthenic syndrome (CMS) in Israel. Targeted mutation analysis was performed based on the clinical symptoms and electrophysiological findings for known CMS. Additional specific tests were performed in patients of Iranian and/or Iraqi Jewish origin. All medical records were reviewed and clinical data, genetic mutations and outcomes were recorded. Forty-five patients with genetic mutations in known CMS genes from 35 families were identified. Mutations in RAPSN were identified in 13 kinships in Israel. The most common mutation was c.-38A>G detected in 8 patients of Iranian and/or Iraqi Jewish origin. Four different recessive mutations in COLQ were identified in 11 kinships, 10 of which were of Muslim-Arab descent. Mutations in CHRNE were identified in 7 kinships. Less commonly detected mutations were in CHRND, CHAT, GFPT1 and DOK7. In conclusion, mutations in RAPSN and COLQ are the most common causes of CMS in our cohort. Specific mutations in COLQ, RAPSN, and CHRNE occur in specific ethnic populations and should be taken into account when the diagnosis of a CMS is suspected.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Life or death by NFκB, Losartan promotes survival in dy2J/dy2J mouse of MDC1A

Inflammation and fibrosis are well-defined mechanisms involved in the pathogenesis of the incurable Laminin α2-deficient congenital muscular dystrophy (MDC1A), while apoptosis mechanism is barely discussed. Our previous study showed treatment with Losartan, an angiotensin II type I receptor antagonist, improved muscle strength and reduced fibrosis through transforming growth factor beta (TGF-β) and mitogen-activated protein kinases (MAPK) signaling inhibition in the dy^2J/dy^2J mouse model of MDC1A. Here we show for the first time that Losartan treatment up-regulates and shifts the nuclear factor kappa B (NFκB) signaling pathway to favor survival versus apoptosis/damage in this animal model. Losartan treatment was associated with significantly increased serum tumor necrosis factor alpha (TNF-α) level, p65 nuclei accumulation, and decreased muscle IκB-β protein level, indicating NFκB activation. Moreover, NFκB anti-apoptotic target genes TNF receptor-associated factor 1 (TRAF1), TNF receptor-associated factor 2 (TRAF2), cellular inhibitor of apoptosis (cIAP2), and Ferritin heavy chain (FTH1) were increased following Losartan treatment. Losartan induced protein expression toward a pro-survival profile as BCL-2 expression levels were increased and Caspase-3 expression levels were decreased. Muscle apoptosis reduction was further confirmed using terminal deoxynucleotidyltransferase-mediated dUTP nick end labeling (TUNEL) assay. Thus, along with TGF-β and MAPK signaling, NFκB serves as an important regulatory pathway which following Losartan treatment promotes survival in the dy^2J/dy^2J mouse model of MDC1A.

Three-body correlation functions and recombination rates for bosons in three dimensions and one dimension

We investigate local three-body correlations for bosonic particles in three dimensions and one dimension as a function of the interaction strength. The three-body correlation function g(3) is determined by measuring the three-body recombination rate in an ultracold gas of Cs atoms. In three dimensions, we measure the dependence of g(3) on the gas parameter in a BEC, finding good agreement with the theoretical prediction accounting for beyond-mean-field effects. In one dimension, we observe a reduction of g(3) by several orders of magnitude upon increasing interactions from the weakly interacting BEC to the strongly interacting Tonks-Girardeau regime, in good agreement with predictions from the Lieb-Liniger model for all strengths of interaction.

Childhood acute and chronic immune-mediated polyradiculoneuropathies

Immune-mediated polyradiculoneuropathies are divided into Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). In children subacute inflammatory demyelinating polyradiculoneuropathy is included in CIDP. Immune polyradiculoneuropathies are not exclusively demyelinating, and axonal forms also responding favourably to immunotherapy occur. Evidence-based data on efficacy of therapy in children is lacking, relying on retrospective data, open label studies on small numbers of children, and mainly adult derived data. Immunotherapy (intravenous human immunoglobulin [IVIg] and plasmapheresis) shortens GBS recovery time with most children recovering completely. Childhood CIDP usually responds to corticosteroids and slow tapering is required to prevent relapses. IVIg and plasmapheresis are also effective. CIDP children resistant to steroids, IVIg, and steroid-dependent patients present a therapeutic challenge. Immunosuppressive agents including methotrexate, azathioprine and cyclosporine are helpful in some cases. Anecdotal reports of treatment with interferons alpha or beta and monoclonal antibodies against specific B-cell antigens (Rituximab, Alemtuzumab) have been described in limited case reports. Childhood CIDP prognosis is mostly favourable. However, a proportion of cases have residual neurological deficit.

Electromyography (EMG) accuracy compared to muscle biopsy in childhood

Reports show wide variability of electromyography (EMG) in detecting pediatric neuromuscular disorders. The study's aim was to determine EMG/nerve conduction study accuracy compared to muscle biopsy and final clinical diagnosis, and sensitivity for myopathic motor unit potential detection in childhood. Of 550 EMG/nerve conduction studies performed by the same examiner from a pediatric neuromuscular service, 27 children (ages 6 days to 16 years [10 boys; M:F, 1:1.7]) with muscle biopsies and final clinical diagnoses were compared retrospectively. Final clinical diagnoses were congenital myopathies (5 of 27,18%), nonspecific myopathies (biopsy myopathic, final diagnosis uncertain; 6 of 27, 22%), congenital myasthenic syndrome (3 of 27, 11%), juvenile myasthenia gravis (1 of 27, 4%), arthrogryposis multiplex congenita (2 of 27, 7%), hereditary motor and sensory neuropathy (1 of 27, 4%), bilateral peroneal neuropathies (1 of 27, 4%), and normal (8 of 27, 30%). There were no muscular dystrophy or spinal muscular atrophy patients. EMG/nerve conduction studies had a 74% agreement with final clinical diagnoses and 100% agreement in neurogenic, neuromuscular junction, and normal categories. Muscle biopsies concurred with final diagnoses in 87%, and 100% in myopathic and normal categories. In congenital myasthenic syndrome, muscle biopsies showed mild variation in fiber size in 2 of 3 children and were normal in 1 of 3. EMG sensitivity for detecting myopathic motor unit potentials in myopathies was 4 of 11 (36%), greater over 2 years of age (3 of 4, 75%), compared to infants less than 2 years (1 of 7, 14%), not statistically significant (P = .0879). EMGs false-negative for myopathy in infants < 2 years of age were frequently neurogenic (3 of 6, 50%). In congenital myopathies EMG detected myopathic motor unit potentials in 40%, with false-negative results neurogenic (20%) or normal (40%). Because our study has no additional tests for active myopathies, for example Duchenne muscular dystrophy genetic testing, our sensitivity for myopathies is lower than if we used a more global view. In conclusion, EMG detection rate of myopathic motor unit potentials at a young age was low, improving in children over 2 years of age. In neurogenic and neuromuscular junction disorders, the EMG has a very high detection rate. In children with mild to moderate neurogenic EMG findings and normal nerve conduction, a myopathy should always be considered.

Hereditary hypotonia, muscle weakness, failure to thrive, and cognitive delay in a large moslem kindred

Five infants of a Moslem-Arab extended family were evaluated for common and characteristic clinical findings of failure to thrive, extreme muscle weakness, severe motor delay, and moderate to severe cognitive and verbal delay. All children were below the third percentile in weight and height, and three of them had head circumference below the third percentile. Neurologic examination revealed severe hypotonia, muscle weakness, and absent deep tendon reflexes. Two children died at 2 years of age, and none of the children acquired full head control and the motor milestones of rolling and sitting. Laboratory evaluation including muscle biopsies, genetic studies, and metabolic evaluation was nondiagnostic.

A test for the evaluation of the lateral cutaneous branch of the iliohypogastric nerve using somatosensory evoked potentials

Iliohypogastric nerve (IHN) lesions are rare and usually due to abdominal surgery or trauma. There is no established electrophysiologic test for evaluating this nerve. A method is proposed to evaluate the IHN lateral cutaneous branch using somatosensory evoked potentials (SSEP). SSEP were elicited in 20 subjects using electrical stimulation from the greater trochanter up to 7 cm posterior to a point on the posterior axillary line, at the level of the greater trochanter. The active recording electrodes were placed 2 cm behind the Cz electrode in the midline, and the reference electrode midway between the Fpz and Fz electrodes in the midline. Stable responses were elicited in 19/20 subjects (12 male), aged 19-52 years (mean 32+/-6.6). Average positive peak onset latency was 32.5+/-3.7 msec, average amplitude 0.96+/-0.4 microV. Side-to-side latency difference range was 0-3.7 msec and amplitude difference range 0.06-1.04 microV. The technique proved sensitive in two cases with IHN injury following trauma, a 24-year-old male with a large hematoma over the right hip from the iliac crest to the greater trochanter tested twice one year apart, with stable repeat responses, and a 26-year-old female who sustained a crush injury to the right lateral pelvis. A side-to-side latency difference >3.7 msec or a unilateral absent response should be regarded as abnormal. This test may be useful for confirming the clinical picture of IHN lateral cutaneous branch lesions.

Infant feeding pattern and weaning practices in Kuwait

A survey was carried out to investigate infant feeding pattern and weaning practices in Kuwait. The study covered 2833 mothers of children less than three years old. The results showed that 60.6% of the infants were breast-fed, 14.0% were bottle-fed and 25.4% received mixed feeding. The mean duration of breast feeding was 5.8 months and varied from 9.5 to 4.3 months among illiterate and educated mothers respectively. The results also showed that older mothers were more likely to breast-feed their infants for a longer duration. On the contrary, mothers from high-income families were less likely to practise breast-feeding. In addition, the study revealed that 37.4% of the infants were weaned suddenly; the reasons for weaning were stated as: insufficient milk (30.7%), new pregnancy (14.7%), infant reaching weaning age (12.3%), mothers' sickness (12.0%), infant refusal (10.6%) and mothers' desire (6.6%).

Neurotoxicity due to the bite of the shield-nose snake (Aspidelaps scutatus). A case report

The bite of the elapid snake Aspidelaps scutatus has previously been regarded as medically unimportant. We report a case in which its bite resulted in neurotoxicity.