Transcriptomic analysis of the effect of remote ischaemic conditioning in an animal model of necrotising enterocolitis

Necrotising enterocolitis (NEC) has a complex pathophysiology but the common end-point is ischaemia reperfusion injury (IRI) and intestinal necrosis. We have previously reported that RIC significantly reduces the intestinal injury in a rat model of NEC. Here we describe the changes in intestinal mRNA occurring in the intestine of animals exposed to IRI, both with and without RIC. Related rat-pups were randomly assigned to four groups: SHAM, IRI only, RIC only and RIC + IRI. IRI animals, underwent 40 min of intestinal ischaemia, and 90 min of reperfusion. Animals that underwent RIC had three cycles of 5 min of alternating ischaemia/reperfusion by means of a ligature applied to the hind limb. Samples from the terminal ileum were immediately stored in RNA-preserving media for later next generation sequencing and transciptome analysis using R v 3.6.1. Differential expression testing showed that 868 genes differentially expressed in animals exposed to RIC alone compared to SHAM and 135 in the IRI and RIC group compared to IRI alone. Comparison between these two sets showed that 25 genes were differentially expressed in both groups. Pro-inflammatory molecules: NF-ĸβ2, Cxcl1, SOD2 and Map3k8 all show reduced expression in response to RIC. Targeted gene analysis revealed increased expression in PI3K which is part of the so-called RISK-pathway which is a key part of the protective mechanisms of RIC in the heart. Overall, this transcriptomic analysis shows that RIC provides a protective effect to the intestine via anti-inflammatory pathways. This could be particularly relevant to treating and preventing NEC.

Managing magnets: An audit of introduction of the Royal College of Emergency Medicine Best Practice Guideline

AIM

To evaluate management of children and young people presenting to the Emergency Department (ED) with magnet ingestion before and after new guidance.

METHODS

In May 2021, a National Patient Safety Agency and Royal College of Emergency Medicine (RCEM) Best Practice Guideline about management of ingested magnets was published. This was implemented in our department. Children and young people presenting after magnet ingestion were identified from SNOMED (coded routinely collected data) and X-ray requests between January 2016 and March 2022. Management was compared to national guidance.

RESULTS

There were 138 patient episodes of magnet ingestion, with a rising incidence over the 5-year period. Following introduction of the guideline, there was a higher incidence of admission (36% vs. 20%) and operative intervention (15.7% vs. 8%). Use of follow-up X-ray increased from 56% to 90%. There was substantial variation in the management prior to guidance which reduced after introduction of the RCEM guidance.

CONCLUSION

Management of magnet ingestion has become more standardised since introduction of the National RCEM Best Practice Guideline, but there is still room for improvement.

Remote ischaemic pre-conditioning reduces intestinal ischaemia reperfusion injury in a newborn rat

OBJECTIVE

Remote ischaemic conditioning (RIC) has been shown to reduce ischaemia-reperfusion injury(IRI) in multiple organ systems. IRI is seen in multiple bowel pathologies in the newborn, including NEC. We investigated the potential of RIC as a novel therapy for various intestinal pathologies in the newborn.

METHODS

We used an established intestinal IRI model in rat pups which results in similar intestinal injury to necrotising enterocolitis (NEC). Animals were randomly allocated to IRI only(n = 14), IRI + RIC(n = 13) or sham laparotomy(n = 10). The macroscopic extent of intestinal injury is reported as a percentage of total small bowel. Injury severity was measured using Chiu-Park scoring. Neutrophil infiltration/activation was assayed by myeloperoxidase activity. Immunohistochemistry was used to assess the expression of hypoxia-inducible factor alpha (HIF-1α). Data are median (interquartile range).

RESULTS

Animals that underwent RIC showed a decreased extent of macroscopic injury from 100%(85-100%) in the IRI only group to 58%(15-84%, p = 0.003) in the IRI + RIC group. Microscopic injury score was significantly lower in animals that underwent RIC compared to IRI alone (3.5[1.25-5] vs 5.5[4-6], p = 0.014). Intestinal myeloperoxidase activity in animals exposed to IRI was 3.4 mU/mg of tissue (2.5-3.7) and 2.1 mU/mg(1.5-2.8) in the IRI + RIC group(p = 0.047). HIF-1α expression showed a non-significant trend towards reduced expression in the IRI + RIC group.

CONCLUSIONS

RIC reduces the extent and severity of bowel injury in this animal model, supporting the hypothesis that RIC has therapeutic potential for intestinal diseases in the newborn.

Laparoscopy uptake for paediatric appendicectomy: a comparison of general surgeons versus specialist paediatric surgeons in England from 1997 to 2015

INTRODUCTION

Laparoscopy is used in as many as 95% of adult appendicectomies. There is level I evidence showing that it reduces wound infection, postoperative ileus and length of inpatient stay in children compared with the open approach. The aim of this study was to report the uptake of laparoscopy for paediatric appendicectomy in England and to determine whether this was similar for general surgeons (GS) and specialist paediatric surgeons (SPS).

METHODS

Hospital Episode Statistics data were obtained for all children aged <16 years who had an OPCS 4.6 code for emergency appendicectomy from 1997 to 2015 (18 years). Data are analysed to compare rate of laparoscopic vs open procedures for GS and SPS over time and to investigate factors associated with the use of laparoscopy.

RESULTS

There were 196,987 appendicectomies and where specialty was available, 133,709 (79%) cases were undertaken by GS and 35,141 (21%) by SPS. The rate of cases undertaken with laparoscopy for both specialties combined increased from 0.8% in 1998 to 50% in 2014 (p<0.0001). In 2014, this rate was 41% for GS compared with 71% for SPS (p<0.0001). Female gender (odds ratio (OR)=1.84, 95% confidence interval (CI) 1.80-1.90), increasing age (OR=1.18, 95% CI 1.18-1.19 per year) and treatment by SPS (OR=3.71, 95% CI 3.60-3.82) were all factors positively associated with use of laparoscopy in multivariate analysis.

CONCLUSIONS

There has been a vast increase in the proportion of appendicectomies undertaken laparoscopically in children. Despite adjusting for patient factors, laparoscopy was used significantly less by GS when compared with SPS. This difference is most apparent in younger children.

Barrett's oesophagus and oesophageal cancer following oesophageal atresia repair: a systematic review

BACKGROUND

Concern exists that patients born with oesophageal atresia (OA) may be at high risk for Barrett's oesophagus (BO), a known malignant precursor to the development of oesophageal adenocarcinoma. Screening endoscopy has a role in early BO identification but is not universal in this population. This study aimed to determine prevalence of BO after OA repair surgery, to quantify the magnitude of this association and inform the need for screening and surveillance.

METHODS

A systematic review, undertaken according to PRISMA guidelines, was preregistered on PROSPERO (CRD42017081001). PubMed and EMBASE were interrogated using a standardized search strategy on 31 July 2020. Included papers, published in English, reported either: one or more patients with either BO (gastric/intestinal metaplasia) or oesophageal cancer in patients born with OA; or long-term (greater than 2 years) follow-up after OA surgery with or without endoscopic screening or surveillance.

RESULTS

Some 134 studies were identified, including 19 case reports or series and 115 single- or multi-centre cohort studies. There were 13 cases of oesophageal cancer (9 squamous cell carcinoma, 4 adenocarcinoma) with a mean age at diagnosis of 40.5 (range 20-47) years. From 6282 patients under long-term follow-up, 317 patients with BO were reported. Overall prevalence of BO was 5.0 (95 per cent c.i. 4.5 to 5.6) per cent, with a mean age at detection of 13.8 years (range 8 months to 56 years). Prevalence of BO in series reporting endoscopic screening or surveillance was 12.8 (95 per cent c.i. 11.3 to 14.5) per cent.

CONCLUSION

Despite a limited number of cancers, the prevalence of BO in patients born with OA is relatively high. While limited by the quality of available evidence, this review suggests endoscopic screening and surveillance may be warranted, but uncertainties remain over the design and effectiveness of any putative programme.

Consensus exercise identifying priorities for research in the field of general surgery of childhood in the UK

BACKGROUND

The evidence base underlying clinical practice in children's general surgery is poor and high-quality collaborative clinical research is required to address current treatment uncertainties. The aim of this study was, through a consensus process, to identify research priorities for clinical research in this field amongst surgeons who treat children.

METHODS

Questions were invited in a scoping survey amongst general surgeons and specialist paediatric surgeons. These were refined by the study team and subsequently prioritized in a two-stage modified Delphi process.

RESULTS

In the scoping survey, a total of 226 questions covering a broad scope of children's elective and emergency general surgery were submitted by 76 different clinicians. These were refined to 71 research questions for prioritization. A total of 168 clinicians took part in stage one of the prioritization process, and 157 in stage two. A 'top 10' list of priority research questions was generated for both elective and emergency general surgery of childhood. These cover a range of conditions and concepts, including inguinal hernia, undescended testis, appendicitis, abdominal trauma and enhanced recovery pathways.

CONCLUSION

Through consensus amongst surgeons who treat children, 10 priority research questions for each of the elective and emergency fields have been identified. These should provide a basis for the development of high-quality multicentre research projects to address these questions, and ultimately improve outcomes for children requiring surgical care.

Diagnostic laparoscopy to exclude malrotation following inconclusive upper gastrointestinal contrast study in infants

PURPOSE

We report the use of diagnostic laparoscopy as an alternative to laparotomy in the investigation of infants with clinical features concerning for malrotation and inconclusive upper gastrointestinal contrast study.

METHOD

Case note review of all infants in whom laparoscopy was performed during 2016-2020 to investigate for possible malrotation.

RESULTS

Eight infants were identified. All presented with acute clinical features of malrotation (bilious vomit) without evidence of an alternate explanatory diagnosis. All underwent upper gastrointestinal contrast study, with three also undergoing abdominal ultrasound. The radiological examinations could not exclude malrotation and all proceeded to laparoscopy. At laparoscopy, the small intestine was run to exclude the presence of midgut volvulus. In six cases, normal rotation was confirmed and no abnormal pathology was found. Two proceeded to laparotomy and underwent correction of malrotation. All infants recovered without complication.

CONCLUSION

Laparoscopy is an excellent modality for further investigation of infants presenting acutely in whom intestinal malrotation cannot be formally excluded radiologically. The positive identification of the DJ flexure and cecum in correct anatomical sites, both fixed to the posterior abdominal wall, provides adequate reassurance of low risk of volvulus and avoids a full laparotomy. We recommend diagnostic laparoscopy in cases of inconclusive upper gastrointestinal contrast study.

Repair of oesophageal atresia by consultants and supervised trainees results in similar outcomes

INTRODUCTION

Consultants and trainees require exposure to complex cases for maintaining and gaining operative experience. Oesophageal atresia (OA) repair is a neonatal surgical procedure with indicative numbers for completion of training. A conflict of interest may exist between adequate training, maintaining consultant experience and achieving good outcomes. We aimed to review outcomes of procedures performed primarily by trainees and those performed by consultants.

METHODS

We carried out a retrospective case note review of all consecutive infants who underwent surgical repair of OA with distal tracheooesophageal fistula (TOF) between January 1994 and December 2014 at our institution. Only cases that underwent primary oesophageal anastomosis were included. Surgical outcomes were compared between cases that had a trainee and those that had a consultant listed as the primary operator.

RESULTS

One hundred and twenty-two cases were included. A total of 52 procedures were performed by trainees, and 68 by consultants. Two cases were undeterminable and excluded. Infant demographics, clinical characteristics and duration of follow-up were similar between groups. All infants survived to discharge. Procedures performed by trainees and those performed by consultants as primary operators had a similar incidence of postoperative pneumothorax (trainees 4, consultants 3; p=0.46), anastomotic leak (trainees 5, consultants 3; p=0.29) and recurrent TOF (trainees 0, consultants 2; p=0.5). Overall 52% of cases had an anastomotic dilatation during follow-up, with no difference between the trainee and consultant groups (50% vs 53%; p=0.85).

CONCLUSIONS

Surgical outcomes for repair of OA/TOF are not adversely affected by trainee operating. Trainees with appropriate skills should perform supervised OA/TOF repair. These data are important for understanding the interrelationship between provision of training and surgical outcomes.

Core outcome set for uncomplicated acute appendicitis in children and young people

Background

Research studies to inform clinical practice and policy in children and young people with appendicitis are hampered by inconsistent selection and reporting of outcomes. The aim of this study was to develop a core outcome set for reporting all studies of uncomplicated acute appendicitis in children and young people.

Methods

Systematic literature reviews, qualitative interviews with parents and patients treated for uncomplicated acute appendicitis, and a Study‐Specific Advisory Group informed a long list of outcomes. Outcomes were then prioritized by stakeholders based in the UK (patients, parents, and paediatric and general surgeons) in an online three‐round Delphi consensus process, followed by face‐to‐face consensus meetings.

Results

A long list of 40 items was scored by 147 key stakeholders in the first Delphi round, of whom 90 completed the two subsequent Delphi rounds. The final core outcome set comprises 14 outcomes: intra‐abdominal abscess, reoperation (including interventional radiology procedure), readmission to hospital, bowel obstruction, wound infection, antibiotic failure, wound complication, negative appendicectomy, recurrent appendicitis, death, patient stress/psychological distress, length of hospital stay, time away from full activity and child's quality of life.

Conclusion

A core outcome set comprising 14 outcomes across five key domains has been developed for reporting studies in children and young people with uncomplicated acute appendicitis. Further work is required to determine how and when to measure these outcomes.

Behavioral persistence is associated with poorer olfactory discrimination learning in domestic dogs

Domestic dogs are trained for a wide variety of jobs; however, half of dogs that enter working dog training organizations never become certified. The aim of this study was to identify whether a basic measure of behavioral persistence was associated with sixteen dogs' performance on an odor discrimination learning task. Further, we evaluated whether dogs that adopted more of a win-stay or win-shift strategy during discrimination learning was associated with greater persistence. Lastly, we tested if measures of a standardized canine behavior questionnaire (the CBARQ) predicted discrimination learning. We found greater persistence during extinction was associated with poorer discrimination learning. Further, dogs that employed more of a win-stay strategy (compared to win-shift) during the discrimination learning phase showed greater persistence in the persistence task and poorer performance on the odor discrimination task. Lastly, the CBARQ measure of trainability showed a trend association with odor discrimination performance, but no other behavioral characteristics were related. Overall, high levels of behavioral persistence is detrimental to olfactory discrimination learning.

A qualitative synthesis of pharmacist, other health professional and lay perspectives on the role of community pharmacy in facilitating care for people with long-term conditions

BACKGROUND

There is increasing interest in an enhanced role for community pharmacy (CP) in facilitating care for people with long-term conditions (LTCs). It is important to understand the perspectives of stakeholders in order to identify key issues that may impact on future development of the role and related services.

OBJECTIVES

Explore pharmacist, other health professional and lay perspectives on the role of CP in facilitating care for people with LTCs.

METHODS

Synthesis of qualitative research from UK based studies published between 2007 and January 2017 using a meta-ethnographic interpretative approach.

RESULTS

Variation in the conceptualisation of the role of CP in facilitating the care of people with LTCs was apparent across and within lay and health professional accounts. Despite evidence of positive attitudes and a culture amenable to change, there remains a lack of clarity about the existing and potential role of the pharmacist in this area. A theoretical framework is proposed that highlights the dynamic nature of the process involved in the development of lay and health professionals' understanding of the role and engagement with services. Influences on this process include experience and perceived need, service operationalisation, and ongoing developments within wider healthcare policy and commercial environments. Perceived integration with existing professional and peer support structures, views about traditional medical hierarchies and concerns about potential duplication are important influences on the value attributed to the role of CP and the services provided.

CONCLUSIONS

There is acknowledged potential for an extended role in CP to support the care of people with LTCs. To ensure the likelihood of successful engagement with patients and positive health outcomes, developments should acknowledge influences within and beyond the CP setting. Potential overlap with other healthcare services should be explicitly addressed, ensuring this is framed and delivered as valued reinforcement with clearly defined boundaries of responsibility.

Outcome of appendicectomy in children performed in paediatric surgery units compared with general surgery units

BACKGROUND

Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units.

METHODS

This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures.

RESULTS

Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0.37, 95 per cent confidence interval 0.23 to 0.59; P < 0.001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0.34, 0.21 to 0.57; P < 0.001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1.90, 1.18 to 3.06; P = 0.011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1.59, 0.93 to 2.73; P = 0.091).

CONCLUSION

The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30-day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units.

The canid genome: behavioral geneticists' best friend?

We review a range of studies on the genetic contribution to behavior in canid species. We begin by identifying factors that make canids a promising model in behavioral genetics and proceed to review research over the last decade that has used canids to identify genetic contributions to behavior. We first review studies that have selectively bred dogs to identify genetic contributions to behavior and then review studies that estimate heritability from populations of non-laboratory bred dogs. We subsequently review studies that used molecular genetics to identify gene-behavior associations and note associations that have been uncovered. We then note challenges in canid behavioral genetics research that require further consideration. We finish by suggesting alternative phenotyping methods and identify areas in which canids may have as yet unexploited advantages, such as in gene-environment interaction studies where genetic factors are found to moderate the effects of environmental variables.

Scope and feasibility of operating on the neonatal intensive care unit: 312 cases in 10 years

PURPOSE

To report the scope, feasibility and learning experience of operating on neonates on the neonatal intensive care unit (NICU).

METHODS

(1) Review of all NICU operations performed by general neonatal surgeons over 10 years; (2) 6-month prospective comparison of procedures performed in NICU or operating room; (3) structured interviews with five surgeons with 1-13 years experience of operating on NICU.

RESULTS

312 operations were performed in 249 infants. Median birth weight was 1,494 g (range 415-4,365), gestational age 29 weeks (22-42), and age at operation 25 days (0-163). Nearly half (147) were laparotomy for acute abdominal pathology in preterm, very low birth-weight infants There were no surgical adverse events related to location of surgery. Surgeon satisfaction with operating on NICU for this population was high (5/5). Several factors contribute to making this process a success.

CONCLUSIONS

This is the largest reported series of general neonatal surgical procedures performed on NICU. Operating on NICU is feasible and safe, and a full range of neonatal operations can be performed. It removes risks associated with neonatal transfer and is likely to reduce physiological instability. We recommend this approach for all ventilated neonates and urge neonatal surgeons to operate at the cotside of unstable infants.

A review of conservative treatment of acute appendicitis

Appendicitis is a common condition in the pediatric population and appendectomy has been the traditional treatment. Both the urgency of the operation and the need for the appendectomy have recently been challenged. In children, this controversy focuses on operative management of perforated appendicitis and appendix abscesses. In adults, the debate has extended to management of nonperforated appendicitis. This review describes the evidence behind these challenges and updates a per-protocol meta-analysis of randomized controlled trials in adults. In the per-protocol meta-analysis, there was no difference between operative versus nonoperative management in failure of treatment. The complication rate was significantly lower in patients treated nonoperatively. However, in the nonoperative group, 10% of patients needed immediate surgery and 17% developed a recurrence during the 1-year follow-up. Overall, 73% of adults with suspected acute appendicitis may not need operative treatment. There are no data in the literature to support nonoperative treatment of acute appendicitis in children.

Advanced necrotizing enterocolitis part 2: recurrence of necrotizing enterocolitis

AIM OF THE STUDY

The aim of this study was to report incidence and clinical outcomes of recurrent necrotizing enterocolitis (NEC).

METHODS

Review of infants treated for recurrent episode(s) of NEC at a tertiary Neonatal Surgical Intensive Care Unit over 8 years (January 2002 to February 2011). Demographic, clinical, radiological, and operative data were analyzed and compared using Mann-Whitney or Fisher's exact tests. Data are reported as median (range).

RESULTS

A total of 212 consecutive infants were referred for surgical evaluation and treatment of NEC (Bell stage II or III). Of these patients, 22 (10%) had suspected recurrent NEC: in 11 of these the primary episode was Bell stage I successfully treated before coming to our institution (suspected recurrent NEC); in the remaining 11, the primary episode was confirmed (Bell stage II or III) NEC successfully treated in our hospital. Birth weight, gestational age at birth, corrected gestational age, weight on admission, gender, need for surgery, stricture, and mortality rates were similar between infants with recurrent NEC and those with a single episode. Long-term parenteral nutrition (PN) dependency (>28 days) was significantly more common following recurrent NEC compared with a single episode. Among the infants with recurrent NEC, medical therapy alone was not successful in the majority (82%) of cases during the first episode and all required surgery during the recurrent episode.

CONCLUSION

Infants (10%) referred for surgical treatment of NEC develop recurrence of the disease. Surprisingly, these infants have similar mortality and stricture rates to those with a single episode. However, the incidence of long-term PN dependency was significantly increased in those with recurrent episodes of NEC.

Core temperature falls during laparotomy in infants with necrotizing enterocolitis

AIM OF THE STUDY

Intraoperative hypothermia may have a detrimental clinical effect. Preterm infants undergoing laparotomy for necrotizing enterocolitis (NEC) are particularly at risk. We investigated the relationship between intraoperative temperature and morbidity and outcome in infants with NEC.

METHODS

A review of all laparotomies for NEC (n = 82, 69 infants) performed between Jan 2008 and Jan 2011 in our institution was done. Relationships between intraoperative temperature and intra- and postoperative fluid and blood product requirements, postoperative clinical status (sequential organ failure assessment [SOFA] score) and outcome were determined. Data (mean [range]) were compared using paired t-test and regression analysis.

RESULTS

Data were available for 52 laparotomies (49 infants). The lowest intraoperative core temperature was significantly lower than the preoperative temperature (peri-op 34.9 °C [31.5-37.0] vs. pre-op 37.0 °C [35.8-38.0]; p < 0.0001). There was a statistically significant inverse relationship between mean intraoperative temperature and intraoperative blood transfusion requirement (p = 0.01). There were no statistically significant relationships between intraoperative temperature and other blood product or volume requirements, postoperative infective complications, change in SOFA score following surgery, length of stay, or mortality.

CONCLUSIONS

During laparotomy for NEC, there is a significant and profound drop in core temperature. The effect of this on short-term morbidity and long-term outcome (e.g., neurodevelopment) warrants further investigation.

Advanced necrotizing enterocolitis part 1: mortality

AIM OF THE STUDY

The aim of this study was to investigate the factors associated with mortality in infants referred for the surgical treatment of advanced necrotizing enterocolitis (NEC).

METHODS

Retrospective review of all infants with confirmed (Bell stage II or III) NEC treated in our unit during the past 8 years (January 2002 to December 2010). Data for survivors and nonsurvivors were compared using Mann-Whitney test and Fisher's exact test and are reported as median (range).

RESULTS

Of the 205 infants with NEC, 35 (17%) were medically managed; 170 (83%) had surgery; 66 (32%) infants died; all had received surgery. Survivors and nonsurvivors were comparable for gestational age, birth weight, and gender distribution. Overall mortality was 32%, the highest mortality was in infants with pan-intestinal disease (86%) but remained significant in those with less severe disease (multifocal 39%; focal disease 21%). The commonest cause of mortality was multiple organ dysfunction syndrome and nearly half of the nonsurvivors had care withdrawn.

CONCLUSION

Despite improvement in neonatal care, overall mortality (32%) for advanced NEC has not changed in 10 years. Mortality is significant even with minimal bowel involvement.

Trans-anastomotic tubes reduce the need for central venous access and parenteral nutrition in infants with congenital duodenal obstruction

PURPOSE

To determine the effect of trans-anastomotic tube (TAT) feeding on outcome following repair of congenital duodenal obstruction (CDO).

METHODS

Retrospective comparative study of all infants with CDO over 10 years. Data are median (range). Mann-Whitney U test and Fisher's exact test were used.

RESULTS

Of 55 infants with CDO (48 atresia, 7 stenosis), 17 were managed with a TAT, 38 without. Enteral feeds were commenced earlier in infants with a TAT compared to those without (TAT 2 days post-repair [1-4] vs. no-TAT 3 days post-repair [1-7]; p = 0.006). Infants with a TAT achieved full enteral feeds significantly sooner than those without (TAT 6 days post-repair [2-12] vs. no-TAT 9 days post-repair [3-36]; p = 0.005). Significantly fewer infants in the TAT group required central venous catheter (CVC) placement and parenteral nutrition (PN) than in the no-TAT group (TAT 2/17 vs. no-TAT 28/38, p < 0.0001). There were six CVC-related complications (5 infections, 1 PN extravasation) and four TATs became displaced and were removed before achieving full enteral feeds. One infant with a TAT with trisomy 21 and undiagnosed Hirschsprung disease developed an anastomotic leak and jejunal perforation requiring re-operation.

CONCLUSIONS

A TAT significantly shortens time to full enteral feeds in infants with CDO significantly reducing the need for central venous access and PN.

Systematic review: adherence to a gluten-free diet in adult patients with coeliac disease

BACKGROUND

Coeliac disease is increasingly diagnosed in adult patients who present with atypical symptoms or who are asymptomatic and detected by case screening. Its treatment, a gluten-free diet, can have a considerable impact on daily living. Understanding the factors associated with non-adherence is important in terms of supporting patients with their condition.

AIM

To investigate factors associated with adherence to a gluten-free diet in adults with coeliac disease.

METHODS

A literature search of multiple electronic databases using a pre-determined search string for literature between 1980 and November 2007 identified a possible 611 hits. After checking for relevance, 38 studies were included in this review.

RESULTS

Rates for strict adherence range from 42% to 91% depending on definition and method of assessment and are the lowest among ethnic minorities and those diagnosed in childhood. Adherence is most strongly associated with cognitive, emotional and socio-cultural influences, membership of an advocacy group and regular dietetic follow-up. Screen and symptom-detected coeliac patients do not differ in their adherence to a gluten-free diet.

CONCLUSIONS

The existing evidence for factors associated with non-adherence to a gluten-free diet is of variable quality. Further and more rigorous research is needed to characterize those individuals most likely to be non-adherent to assist them better with their treatment.

Plasma soluble e-selectin in necrotising enterocolitis

AIM

E-selectin is an important mediator of leukocyte-endothelial adhesion. It is expressed on activated endothelium, and shed into the circulation in its soluble form. In babies with necrotising enterocolitis (NEC), increased intestinal expression of E-selectin has been associated with multiple organ failure and an adverse outcome. The aim of this study was to determine whether increased circulating soluble E-selectin (sE-selectin) was associated with a worse prognosis.

METHODS

With ethical approval, plasma samples from 20 infants with Bell stage II and III NEC were analysed. Both pre- and postoperative samples were available in 6 infants. The severity of illness was assessed using a sequential organ failure assessment score (SOFA) specifically designed for use in NEC. Plasma concentration of sE-selectin was determined by ELISA. Data, which were not normally distributed, were compared by Spearman's rank correlation coefficient and Wilcoxon signed rank test.

RESULTS

Plasma sE-selectin was strongly negatively correlated with corrected gestational age at the time of sampling (r = - 0.425, p = 0.006). There was no association between plasma sE-selectin and outcome (death or survival to discharge), severity of intestinal disease (focal, multifocal or pan-intestinal), or SOFA score. Surgery for suspected perforation, however, caused a significant elevation in sE-selectin levels (p = 0.031).

CONCLUSIONS

Plasma sE-selectin, a described marker of endothelial activation, is increased following surgery for NEC. However, prematurity appears to be the cause of an increase in sE-selectin level, confounding the potential use of sE-selectin levels as a predictor of severity of illness in NEC.

Resection and primary anastomosis is a valid surgical option for infants with necrotizing enterocolitis who weigh less than 1000 g

HYPOTHESIS

Primary anastomosis following intestinal resection is a valid surgical option in the treatment of infants with necrotizing enterocolitis (NEC) who weigh less than 1000 g.

DESIGN

Retrospective case series.

SETTING

Tertiary neonatal surgery referral center.

PATIENTS

All infants with confirmed NEC weighing less than 1000 g admitted to our intensive care unit over 4 years.

INTERVENTION

For infants requiring laparotomy and intestinal resection, primary anastomosis was performed whenever the clinical condition permitted.

MAIN OUTCOME MEASURES

Short- and long-term survival, length of intensive care unit stay, and complications.

RESULTS

Fifty-one infants with NEC who weighed less than 1000 g were admitted during the study period. Twelve infants underwent intestinal resection and primary anastomosis (median weight at surgery, 0.83 kg; range, 0.6-0.96 kg). One infant developed recurrent NEC, requiring further surgery, but there were no anastomotic leakages and no strictures. The median postoperative stay on our intensive care unit was 14 days (range, 2-49 days). All 12 infants survived their episode of acute NEC, and 8 are alive, with a median follow-up of 34.2 months (range, 4.7-48.4 months). Only 1 death was related to NEC. During the same period, 14 infants underwent intestinal resection and stoma formation. Ten survived the acute episode, and 6 are alive at a median follow-up of 24.0 months (range, 13.1-33.9 months). The median postoperative intensive care unit stay was 18 days (range, 2-74 days). Necrotizing enterocolitis-related complications occurred in 8 of these infants.

CONCLUSIONS

The outcome of infants with NEC who weigh less than 1000 g and undergo primary anastomosis is comparable to that of infants treated using alternative techniques. It is, therefore, a valid surgical option in selected infants. The mortality in this group of infants is high.

Intestinal Ischemia-Reperfusion Injury Does Not Lead to Acute Central Nervous System Damage

BACKGROUND

The detrimental effects of intestinal ischemia reperfusion (IIR) injury on secondary organs including the liver, lungs, heart, and kidney have been widely investigated in animal models. However, the effect of IIR on the central nervous system (CNS) is largely unknown. We investigated the effect of IIR on the CNS as it may be of clinical relevance to patients at high risk of neurological injury.

MATERIALS AND METHODS

Adult male rats underwent IIR (60 min superior mesenteric artery occlusion followed by 120 min reperfusion, n = 7) or sham operation (n = 6) under anesthesia. Following the procedure, the cerebral hemispheres were removed for histological assessment and measurement of N-acetyl-aspartate (NAA), a marker of neuronal damage, by HPLC. Blood was taken for determination of plasma S100B concentration, a measure of glial cell damage by ELISA. Data are median (range).

RESULTS

Cerebral tissue from all animals from both groups was macroscopically and microscopically normal with no evidence of inflammation. NAA in brain homogenate was similar in the IIR group (0.2 [0.1-0.32] nmol/mg protein) and sham-operated group (0.19 [0.12-0.34], P = 0.83). Plasma S100B levels were higher in the IIR group compared to sham-operated animals but this difference was not statistically significant (1.13 [0.24-7.26] versus 0.55 [0.23-2.84] mug/l, P = 0.18).

CONCLUSIONS

In this model, IIR injury did not produce histological CNS changes nor biochemical changes suggestive of neuronal damage. Further work is required to elucidate any functional effect of IIR injury on the CNS.

Lactobezoar with perforation in a premature infant

An unusual case of neonatal gastric perforation secondary to a large milk curd bezoar (lactobezoar) in a premature infant is reported. Following surgical treatment the infant made a full and uncomplicated recovery. Aetiological factors associated with the development of lactobezoars and their diagnosis and treatment are discussed.

Bacterial contamination of central venous catheters during insertion: a double blind randomised controlled trial

Static electricity within sterile packaging may result in bacterial contamination of central venous catheters (CVCs) prior to insertion. To prevent this, some surgeons inject saline into the pack before opening it. This trial was designed to determine the effect of this procedure. A double blind randomised controlled trial of 47 CVCs comparing injection of 2 ml of sterile saline into the pack prior to opening with no injection was performed. Five centimetre lengths cut from the tip of the catheter before and after subcutaneous tunnelling were sent for microbiological culture. Eight catheters (17%) showed evidence of bacterial contamination prior to insertion into the vein. Two (4.2%) were contaminated prior to tunnelling and seven (14.9%) afterwards. One catheter was contaminated before and after tunnelling. All but one of the contaminating bacteria were coagulase negative staphylococci. There was no significant difference in the contamination rate between catheters from packs that had been injected (5/25) and those that had not (3/22), P = 0.56. Just under one-fifth of the catheters were contaminated with bacteria prior to insertion into the vein but this was not influenced by prior injection of saline into the pack. We conclude that there is no evidence to support the practice of injecting the catheter pack prior to opening.

Antenatally diagnosed duplication cyst of the tongue: modern imaging modalities assist perinatal management

When a foetal abnormality is detected during routine antenatal screening, further information is required in order to plan the remainder of the pregnancy and perinatal management. If a lesion is detected in the foetal mouth or neck, there may be compromise of the foetal airway. The ex-utero intrapartum (EXIT) procedure has recently been developed to allow lifesaving foetal surgery to be performed during delivery of such cases whilst relying on placental support. Detailed antenatal assessment is essential when planning the EXIT procedure, and modern imaging modalities may be implemented. We illustrate this by reporting a rare case of enteric duplication cyst arising from the base of the tongue, which was detected on routine antenatal ultrasound scan. Subsequent imaging using foetal MRI and colour Doppler ultrasound reassured us that the foetal airway was patent, and an EXIT procedure was avoided.

Surgical strategies for necrotising enterocolitis: a survey of practice in the United Kingdom

BACKGROUND

Strategies for the surgical management of necrotising enterocolitis are various and controversial.

OBJECTIVE

To characterise variation in surgical management of this disease across the United Kingdom.

METHODS

Postal survey of 104 consultant paediatric surgeons with a 77% response rate.

RESULTS

Duration of antibiotic treatment (median 10 days, range 6-14), time until the start of enteral feeding (median 10 days, range 4-21), and absolute indications for surgery all vary between surgeons. Peritoneal drainage is used by 95% of surgeons. Forty two percent use it in neonates of all weights, whereas 36% restrict its use to those <1000 g. Peritoneal drainage is used for stabilisation by 95% and as definitive treatment by 58%. At laparotomy, operative procedures include diverting jejunostomy, resection and stoma, resection with primary anastomosis, and "clip and drop". All procedures are used in infants of all weights except resection and primary anastomosis, which is used predominantly in larger infants (55% in <1000 g; 77% in >1000g; p=0.005). Infants may be considered too unwell for peritoneal drainage by 11% of surgeons compared with 90% for laparotomy (p<0.0001).

CONCLUSIONS

There is considerable variation in surgical strategies for necrotising enterocolitis. Peritoneal drainage is used by most surgeons, with controversial indications and expectations. The use of resection and primary anastomosis is influenced by the weight of the neonate.

Retrospective comparison of open versus laparoscopic pyloromyotomy

BACKGROUND

Laparoscopic pyloromyotomy is gaining popularity in the management of pyloric stenosis. However, there is no unequivocal evidence in favour of the laparoscopic over the open approach. This paper reports an experience with laparoscopic pyloromyotomy and an attempt to identify any benefit over the open procedure.

METHODS

This was a retrospective review of all 87 pyloromyotomies performed at this institution for pyloric stenosis over the 39 months since the first laparoscopic pyloromyotomy was performed.

RESULTS

Data for 39 infants who underwent laparoscopic pyloromyotomy were compared with those for 38 infants who underwent pyloromyotomy via a periumbilical incision. Patient demographics were similar between the two groups. The duration of operation was longer for laparoscopic pyloromyotomy than for the open procedure (median 50 versus 30 min; P = 0.001). There were no differences in recovery time, postoperative length of hospital stay, complication rates and postoperative analgesia requirements between the two groups.

CONCLUSION

Laparoscopic pyloromyotomy has been incorporated successfully into the authors' standard working practice. Complication rates recovery times were similar to those achievable with the open procedure. There was no clear benefit of one approach over the other.

Hyperglycemia is associated with increased morbidity and mortality rates in neonates with necrotizing enterocolitis

BACKGROUND PURPOSE

An association between hyperglycaemia and poor outcome has been reported in critically ill adults and children. The authors investigated the incidence of hyperglycemia in infants with necrotizing enterocolitis (NEC) and the relationship between glucose levels and outcome in these infants.

METHODS

All glucose measurements (n = 6508) in 95 neonates with confirmed NEC admitted to the surgical intensive care unit (ICU) were reviewed. Maximum glucose concentration during admission (Gmax) was determined for each infant and correlated with outcome. Eleven infants in whom treatment was withdrawn within 24 hours owing to unsalvageable panintestinal NEC were excluded from the analysis.

RESULTS

Glucose levels ranged from 0.5 to 35.0 mmol/L and 69% of infants became hyperglycemic (>8 mmol/L) during their admission. Thirty-two infants died. Mortality rate tended to be higher in infants with Gmax greater than 11.9 mmol/L compared with those with Gmax less than 11.9 mmol/L, and late (>10 days admission) mortality rate was significantly higher in these infants (29% v, 2%; P =.0009). Median length of stay was 9.3 days. Linear regression analysis indicated that Gmax was significantly related to length of stay (P <.0001).

CONCLUSIONS

Hyperglycemia is common in infants with NEC admitted to the ICU and is associated with an increase in late mortality and longer intensive care stay. Aggressive glycemic control may improve outcome in this group of infants.

Patient delay in seeking care for heart attack symptoms: findings from focus groups conducted in five U.S. regions

BACKGROUND

Patient delay in seeking health care for heart attack symptoms is a continuuing problem in the United States.

METHODS

Investigators conducted focus groups (N = 34; 207 participants) in major U.S. regions (NE, NW, SE, SW, MW) as formative evaluation to develop a multi-center randomized community trial (the REACT Project). Target groups included adults with previous heart attacks, those at higher risk for heart attack, and bystanders to heart attacks. There were also subgroups reflecting gender and ethnicity (African-American, Hispanic-American, White).

FINDINGS

Patients, bystanders, and those at higher risk expected heart attack symptoms to present as often portrayed in the movies, that is, as sharp, crushing chest pain rather than the more common onset of initially ambiguous but gradually increasing discomfort. Patients and those at higher risk also unrealistically judge their personal risk as low, understand little about the benefits of rapid action, are generally unaware of the benefits of using EMS/9-1-1 over alternative transport, and appear to need the "permission" of health care providers or family to act. Moreover, participants reported rarely discussing heart attack symptoms and appropriate responses in advance with health care providers, spouses, or family members. Women often described heart attack as a "male problem," an important aspect of their underestimation of personal risk. African-American participants were more likely to describe negative feelings about EMS/9-1-1, particularly whether they would be transported to their hospital of choice.

CONCLUSIONS

Interventions to reduce patient delay need to address expectations about heart attack symptoms, educate about benefits and appropriate actions, and provide legitimacy for taking specific health care-seeking actions. In addition, strategy development must emphasize the role of health care providers in legitimizing the need and importance of taking rapid action in the first place.

Bilateral breast carcinomas: do they have similar mammographic features?

AIMS

This study compared the mammographic appearance, site and histological features of synchronous and metachronous bilateral breast carcinomas.

METHODS

Site, type of abnormality and background pattern seen on the diagnostic mammograms of 63 women with bilateral breast carcinoma were compared. The histological type and grade of all the carcinomas were verified by histological review.

RESULTS

There was a tendency for the contralateral tumour to have similar mammographic features to those of the initial tumour. In patients in whom the first carcinoma was visible purely as a mass, the contralateral carcinoma had a similar appearance in 82% (P < 0.001). When the original tumour showed mammographic calcification the contralateral tumour did so in 65% (P< 0.001). Normal mammography or calcification alone were seen almost exclusively in women with a dense background pattern (100% and 92% respectively) while masses and calcification with masses were seen in women with dense and fatty patterns (58% and 35% dense respectively). When the mammographic site of the contralateral tumour was compared with that of the first tumour no significant correlation could be demonstrated. There was a significant trend for contralateral carcinomas to be of the same histological grade (P < 0.005) but not histological type.

CONCLUSIONS

Contralateral carcinomas often have a similar mammographic appearance to the first tumours. Two factors may be responsible: (i) the tendency for contralateral carcinomas to be of the same histological grade and (ii) the influence of mammographic background pattern on the radiological appearance of breast carcinoma. This knowledge may assist in the interpretation of follow-up mammography in patients with a previous breast carcinoma.

Stenosis of the accessory renal artery: Doppler ultrasound findings

Stenosis of an accessory renal artery has been cited as a significant source of false-negative results with conventional renal artery Duplex sonography in the investigation of renal artery stenosis. Two case reports of accessory renal artery stenosis that were detectable using the newer intrarenal Doppler ultrasound technique with sampling from both poles and the hilum are presented. The cases illustrate a further advantage of Doppler ultrasound of the intrarenal arteries over the conventional technique.