The Role of Oral Health in the Acquisition and Severity of SARS-CoV-2: A Retrospective Chart Review

Objective

Studies have shown that gingival crevices may be a significant route for SARS-CoV-2 entry. However, the role of oral health in the acquisition and severity of COVID-19 is not known.

Design

A retrospective analysis was performed using electronic health record data from a large urban academic medical center between 12/1/2019 and 8/24/2020. A total of 387 COVID-19 positive cases were identified and matched 1:1 by age, sex, and race to 387 controls without COVID-19 diagnoses. Demographics, number of missing teeth and alveolar crestal height were determined from radiographs and medical/dental charts. In a subgroup of 107 cases and controls, we also examined the rate of change in alveolar crestal height. A conditional logistic regression model was utilized to assess association between alveolar crestal height and missing teeth with COVID-19 status and with hospitalization status among COVID-19 cases.

Results

Increased alveolar bone loss, OR = 4.302 (2.510 - 7.376), fewer missing teeth, OR = 0.897 (0.835-0.965) and lack of smoking history distinguished COVID-19 cases from controls. After adjusting for time between examinations, cases with COVID-19 had greater alveolar bone loss compared to controls (0.641 ± 0.613 mm vs 0.260 ± 0.631 mm, p < 0.01.) Among cases with COVID-19, increased number of missing teeth OR = 2.1871 (1.146- 4.174) was significantly associated with hospitalization.

Conclusions

Alveolar bone loss and missing teeth are positively associated with the acquisition and severity of COVID-19 disease, respectively.

Identifying systems delays in assessment, diagnosis, and operative management for testicular torsion in a single-payer health-care system

INTRODUCTION

Testicular torsion (TT) is a common pediatric urologic emergency. Management of TT is time sensitive and often confirmed on scrotal Doppler ultrasound (DUS). Acquiring DUS, however, can result in delays in the management of TT, affecting testicular salvage rates.

OBJECTIVE

The objective of this study is to identify delays in the assessment and diagnosis for patients presenting with TT to a Canadian academic hospital using patient flow analysis.

STUDY DESIGN

A retrospective review was performed for patients presenting to the emergency department (ED) who received a scrotal DUS to rule out possible TT between 2012 and 2017. The primary outcome measured cycle-time measurements (median time) between points along the clinical flow pathway for a patient with suspected TT. The secondary outcome assessed diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of standard scrotal DUS components (Doppler flow, arterial waveform, heterogeneous echotexture).

RESULTS

A total of 609 patients presented with an acute scrotum warranting a scrotal DUS to rule out TT; of which, 46 underwent scrotal exploration. Testicular salvage rate was 82.6% in the series (38 testes salvaged, 8 required orchiectomy). Median time from symptom onset to ED presentation for patients with possible TT was 4 h. After triage, a median of 79.8 min was required for ED physician assessment and an additional 48 min for scrotal DUS to be performed. Absence of Doppler flow on scrotal DUS had a 97.4% PPV for diagnosing TT confirmed during scrotal exploration.

DISCUSSION

Almost 4 h of in-ED time is required from triage to surgical intervention for potential TT at the institution. One area of delay is the time needed to conduct a scrotal DUS (48-128 min; Fig. 1). This represents an area of opportunity for patient flow optimization through the use of standardized clinical pathways and diagnostic adjuncts, such as point-of-care ultrasound. This study is limited in its retrospective nature and does not include patients with overt signs of TT who underwent surgical detorsion without need for scrotal DUS.

CONCLUSION

Patient flow delays to surgical intervention for patients with TT represent a preventable cause of orchiectomy in young men. This study identifies intervention points in patient-care flow pathways where delays to surgical intervention can be potentially reduced by up to 2 h. The findings support the need for further studies into the optimization of patient flow and management protocols to reduce delays in the diagnosis and management of TT.

A retrospective population-based cohort study to evaluate the impact of an older sibling with undescended testis and hypospadias on the known maternal and fetal risk factors for undescended testis and hypospadias in Ontario, Canada, 1997-2007

INTRODUCTION

There are several reported risk factors for undescended testis (UDT) and hypospadias (HYP). Also, a family history of UDT or HYP has not been accounted for in prior studies, and doing so may influence these independent risk estimates.

STUDY DESIGN

A population-based retrospective cohort study was conducted using linked administrative databases in Ontario, Canada, to identify all live male newborns born between 1997 and 2007, and it was determined whether they underwent an orchidopexy or HYP repair within 5 years of birth. Baseline maternal and fetal risk factors were obtained using appropriate ICD codes. A statistical analysis using a generalized estimating equation with a logit link was performed, adjusting for clustering in mothers with a previous child born in the 5 years before the proband with UDT or HYP, to evaluate the adjusted risk factors of UDT and HYP.

RESULTS

A total of 709,968 male infants were followed up from birth for 5 years, of which 5830 underwent an orchidopexy and 2722 had an HYP repair. On multivariable analysis, factors associated with a higher risk of UDT included prematurity, small for gestational age (SGA), associated HYP, gestational hypertension, use of assisted fertility techniques, increased maternal age, Cesarean section, previous sibling with UDT, and disorders of sexual differentiation (DSDs). After adjusting for clustering in mothers with a previous baby with UDT, DSD, associated HYP (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.0-4.1), and a previous sibling with UDT (OR, 3.6; 95% CI, 2.5-5.2) remained significant risk factors. The risk factors on multivariable analysis predicting the risk of HYP included SGA, prematurity, higher income families, and associated anomalies such as UDT. After adjusting for clustering in mothers with a previous sibling with HYP, SGA (OR, 1.8; 95% CI, 1.0-3.1), higher income families (OR, 1.5-1.6), associated UDT (OR, 7.1; 95% CI, 4.9-10.0), and a previous sibling with HYP (OR, 12.8; 95% CI, 9.1-18.1) remained significant risk factors.

DISCUSSION

Studies estimating risk factors for UDT and HYP have used variable methodologies to identify index cases and perform statistical analysis. This study suggests that having an older sibling with UDT or HYP is a significant independent risk factor. Performing an analysis adjusting for clustering in mothers with a previous child with UDT or HYP leads to loss of statistical significance for other described risk factors.

CONCLUSION

Underlying genetic or similar environmental exposures may be a key risk factor for UDT and HYP, which confounds known maternal and fetal risk factors for these anomalies.

Racial and Ethnic Differences in Graft Loss Among Female Liver Transplant Recipients

BACKGROUND

Racial differences in post-liver transplantation (LT) outcomes are identified in predominantly male cohorts. Despite known sex differences in a spectrum of liver-related outcomes, it is not known how race influences graft outcomes in women.

METHODS

Using the Scientific Registry of Transplant Recipients, we examined race and ethnicity and graft loss (death or retransplant) in women transplanted from 2002 to 2012. Covariates included recipient and donor characteristics, socioeconomics, and medical comorbidities.

RESULTS

The eligible cohort (n = 15,860) included 11,051 Caucasians, 2171 Hispanics, 1876 African Americans (AAs), and 762 Asian women with median follow-up of 3.1 years. Five-year graft survival was lower in AA women (60%) compared with Caucasians (71%), Hispanics (70%), and Asians (73%) (P < .001). Graft loss was 45% higher among AA women <40 years at transplant compared with AA women aged 50 to 59 (hazard ratio 1.45, 95% confidence interval 1.17-1.81) and aged 60 to 69 years (hazard ratio 1.33, 95% confidence interval 1.03-1.71), and risk increased after age 60 among Caucasians (P < .001 for race-age interactions). Increased graft loss among young AA women was limited to the first 2 years post-LT (P = .002).

CONCLUSION

Younger AA women are at particularly high risk for graft loss, which predominates in the first 2 years post-LT. Prospective studies of immunosuppression adherence and pharmacokinetics, particularly in relation to patient age, may help to explain the mechanisms underlying the higher rates of graft loss in younger AA women.

1/f neural noise and electrophysiological indices of contextual prediction in aging

Prediction of upcoming words during reading has been suggested to enhance the efficiency of discourse processing. Emerging models have postulated that predictive mechanisms require synchronous firing of neural networks, but to date, this relationship has been investigated primarily through oscillatory activity in narrow frequency bands. A recently-developed measure proposed to reflect broadband neural activity - and thereby synchronous neuronal firing - is 1/f neural noise extracted from EEG spectral power. Previous research has indicated that this measure of 1/f neural noise changes across the lifespan, and these neural changes predict age-related behavioral impairments in visual working memory. Using a cross-sectional sample of young and older adults, we examined age-related changes in 1/f neural noise and whether this measure predicted ERP correlates of successful lexical prediction during discourse comprehension. 1/f neural noise across two different language tasks revealed high within-subject correlations, indicating that this measure can provide a reliable index of individualized patterns of neural activation. In addition to age, 1/f noise was a significant predictor of N400 effects of successful lexical prediction; however, noise did not mediate age-related declines in other ERP effects. We discuss broader implications of these findings for theories of predictive processing, as well as potential applications of 1/f noise across research populations.

The effect of intrauterine HCG injection on IVF outcome: a systematic review and meta-analysis

In this systematic review and meta-analysis, the effect of intrauterine HCG infusion before embryo transfer on IVF outcomes (live birth rate, clinical pregnancy rate and spontaneous aboretion rate) was investigated. Searches were conducted on MEDLINE, EMBASE and The Cochrane Library. Randomized studies in women undergoing IVF and intracytoplasmic sperm injection comparing intrauterine HCG administration at embryo transfer compared with no intrauterine HCG were eligible for inclusion. Eight randomized controlled trials were eligible for inclusion in the meta-analysis. A total of 3087 women undergoing IVF and intracytoplasmic sperm injection cycles were enrolled (intrauterine HCG group: n = 1614; control group: n = 1473). No significant difference was found in the live birth rate (RR 1.13; 95% CI 0.84 to 1.53) and spontaneous abortion rate (RR 1.00, 95% CI 0.74 to 1.34) between women who received intrauterine HCG and those who did not receive HCG. Although this review was extensive and included randomized controlled trials, no significant heterogeneity was found, and the overall included numbers are relatively small. In conclusion the current evidence does not support the use of intrauterine HCG administration before embryo transfer. Well-designed multicentre trials are needed to provide robust evidence.

Non-biological determinants of paediatric bladder bowel dysfunction: A pilot study

OBJECTIVES

Children with bladder and bowel dysfunction (BBD) constitute a significant proportion of referrals at paediatric urology clinics worldwide, presenting with a wide range of symptom severity that may significantly affect quality of life. Non-biological factors may play a key role in triggering BBD severity, but these underpinning causes of BBD during childhood are still unknown. The aim of this study was to identify the effects of personal, family related and environmental variables on the severity of BBD symptoms in school-aged children.

STUDY DESIGN

A pilot, prospective, observational study was conducted on 53 children diagnosed with BBD, and their legal guardian(s), on their first referred visit to a paediatric BBD clinic led by nurse practitioners. Upon receiving consent, patients and their legal guardian(s) completed three study questionnaires, with the guidance of research coordinators. The first questionnaire was the Dysfunctional Voiding Scoring System (DVSS); the second, a three-part questionnaire used to collect demographic information and data on the patient, their family and environmental characteristics; and the third gathered a detailed history of the child's lifestyle regimen, focusing on their bowel and bladder function.

RESULTS

Most of the children were female (66%), with an average age of 8.35 years. Most children attended public schools (74%) and none reported failing a grade. The mean parental age was 41.4 years (SD = 4.9 years), 62% of the families had two children and 53% were Caucasian. The mean DVSS score for this sample was 9.9 (SD = 4.2, range 2-21). Daycare attendance, school problems and unplanned pregnancy showed statistically significant influences on the severity of BBD and were associated with higher DVSS scores according to the Table below.

CONCLUSIONS

Children with BBD attending urology outpatient clinics as new referrals had more severe symptoms when they were born from an unplanned pregnancy, attended daycare and/or had school problems. These findings suggest that interventions aimed at decreasing BBD severity, or preventing its onset in school-aged children, should focus on the environment surrounding them, specifically on the interaction between personal, familial and environmental factors. These factors seem to have an important effect on paediatric continence, as children grow and develop under numerous societal influences and social interactions.

Supervision Of International Medical Graduates

Introduction

Doctors qualified outside the UK constitute > 40% workforce in psychiatry. Differential examinations’ attainment and poor career progression are key issues for International Medical Graduates (IMGs). Due to increased migration, this is transversal to many countries. Varying ethical standards and values in different countries can create difficulties in the workplace and impact quality of patient-care.

Objectives

To understand current support available for IMGs across countries; identify areas of best practice.

Methods

We ran a preliminary open consultation to establish which initiatives were available across Europe and worldwide to address IMGs’ training abroad impact on their training/work in the host country and if any support exists for supervisors of IMGs. Representatives of European trainees were contacted through European Federation of Psychiatric Trainees network and early career psychiatrists through World Psychiatric Association network. Emphasis was given to identified host countries of IMGs.

Results

No specific initiatives were identified in Europe. Out of the six main host countries – Denmark, Finland, Norway, Sweden, Switzerland, UK – one did not provide information. Many countries reported specific requirements for a doctor to be accepted to work. There are courses on language and medicolegal processes. Some support is available for doctors doing short clinical placements. However, once an IMG has been accepted to work in the host country, there is no special support given by way of supervision.

Conclusions

Reports suggest IMGs welcome initiatives to help them gain skills related to the system, its culture, and appreciate feedback on their performance. There is a need to help host countries better support IMGs.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The importance of distinguishing between black Caribbeans and Africans in understanding sexual risk and care-seeking behaviours for sexually transmitted infections: evidence from a large survey of people attending genitourinary medicine clinics in England

BACKGROUND

In the UK, black Caribbean and African populations experience disproportionately high rates of sexually transmitted infections (STIs) and HIV. Often studies do not differentiate between these populations notwithstanding differences in STI epidemiology and sociodemographics.

METHODS

Patterns of care-seeking behaviour for STIs were explored separately for black Caribbean (n = 345), black African (n = 193) and white people through a cross-sectional survey of 2824 people attending five genitourinary medicine (GUM) clinics in England.

RESULTS

Black Caribbean men were least likely to use, or try to use, their general practice surgery prior to GUM clinic attendance (16.6%). Symptomatic black Caribbean and African men were least likely to delay seeking care (30.8 and 26.3%, respectively). Symptomatic black Caribbean men faced the least provider delay in accessing care (27.3%). Black Caribbean men and women were most likely, and black African men and women least likely, to be diagnosed with an STI (49.7 and 32.0% versus 26.8 and 16.3%, respectively). Among symptomatic women, black Caribbeans and, among symptomatic men, black Africans were most likely to report abstaining from sex (46.3 and 73.1%, respectively).

CONCLUSIONS

Our analyses highlight the importance of distinguishing between black ethnic groups and the need for future studies to ensure sufficiently large samples to permit such analyses.

Why me? A missing girl

Demographic imbalance created because of the declining sex ratio in India is a cause of concern to policy makers, implementers, demographers and social reformers. To take situation under control, Pre Natal Diagnostic Techniques (PNDT) Act is operational since 1996. Authors have critically reviewed the status of women and socio-cultural factors influencing their status based on data from NFHS III and census 2001 and challenges faced in the operationalisation of PNDT Act in India.

Effect of donor pneumoperitoneum on early allograft perfusion following renal transplantation in pediatric patients: an intraoperative Doppler ultrasound study

Decreased perfusion and trauma during laparoscopic harvesting are proposed causative factors for DGF and rejection in children following renal transplantation with laparoscopic donor nephrectomy (LDN) allograft. We performed a retrospective review of 11 children who underwent LDN transplant and 11 preceding patients who underwent ODN transplant. Intraoperative DUS findings, creatinine values and clearance, time to nadir creatinine and AR episodes were compared. There were no significant differences in the BMI, vascular anatomy, side of nephrectomy, or warm ischemia time in the two groups. Mean follow-up duration was 11.4 and 30.4 months in LDN and ODN groups. DUS showed initial turbulent flow in five of the LDN and four of the ODN group with an average RI of 0.59 and 0.66 in the ODN and LDN groups, respectively (NS). Three patients in the ODN group had an abnormal RI compared to none in the LDN group (p = 0.034). The creatinine values, creatinine clearances (at 24 h, one, four wk and last follow-up) and AR episodes were similar in both groups. Pneumoperitoneum during LDN does not appear to have an adverse impact on early graft reperfusion.

Perineal skin bridge and levator muscle preservation in neutral sagittal anorectoplasty (NSARP) for vestibular fistula

The incision in limited posterior sagittal anorectoplasty for vestibular fistula (VF) extends from the coccyx to the fistula with the rectum identified by partial sagittal division of the levator muscle. In anterior sagittal anorectoplasty, the perineal incision extends from the fistula opening to the posterior margin of the external sphincter complex while preserving intact the levator muscle. We describe a modification of the operation for repair of VF, the neutral sagittal anorectoplasty (NSARP), which preserves both a perineal skin bridge between the neo-anus and the posterior fourchette and the levator muscle. Leaving the perineal skin bridge and the levator muscle intact could be important both from the aspects of perineal wound-healing and functional outcome. The skin incision in NSARP extends from the coccyx to the anterior limit of the external sphincter muscle complex as defined by muscle stimulation. An artery forceps passed through the VF facilitates the location and exposure of the rectum. The levator muscle is left intact. The dissection and closure of the VF is done entirely from within the opened rectum. There is an intact perineal skin bridge between the neo-anus and the posterior fourchette at the completion of the NSARP. In 12 consecutive patients with VF, NSARP prevented the risk of wound complications occurring between the neo-anus and the posterior fourchette. A diverting colostomy was safely avoided in our last five patients. NSARP does not involve any division of the levator muscle and it also retains an undisturbed wad of tissue that could function as the perineal body. All five patients who are 3 years or older demonstrate voluntary bowel movements. Preserving the perineal skin bridge and the levator muscle in NSARP have contributed to the improvement of aesthetic appearance of the perineum and faecal continence in our patients.

The management of combined oesophageal and duodenal atresia

Duodenal atresia (DA) in babies with oesophageal atresia (OA) is associated with significant morbidity and mortality. The management protocol for this combination of anomalies is not well defined and evolving. The aim of this study was to review our experience with combined OA and DA and to note the evolving trend in management at Sydney Children's Hospital. Over the last 30 years, 225 babies with OA have been treated at our institution. Ten babies had associated DA. A total of 19 anomalies were noted; one child had multiple lethal anomalies and received no treatment. In three babies the diagnosis of associated DA was missed initially. For the nine babies who were treated, four had a primary OA repair followed by a delayed DA repair; one had cervical oesophagostomy, gastrostomy and DA repair; and two had a simultaneous repair of OA and DA with a gastrostomy. The last two patients in this series have had a primary simultaneous repair of both anomalies without a gastrostomy. The complications noted in the nine patients treated included anastomotic strictures in five, recurrent tracheo-oesophageal fistula in one, food bolus obstruction in one, and a megaduodenum requiring tapering in one. We believe that adopting a management protocol of primary simultaneous repair of both anomalies without a gastrostomy is justified. There was no apparent increase in morbidity and mortality with such an approach.

Neonatal gastric pull up: reality or myth?

Between 1991 and 1998, 28 out of 356 neonates with esophageal atresia and tracheoesophageal fistula (EATEF) required esophageal substitution. As only 8 returned (28%) for the esophageal replacement after initial esophagostomy and gastrostomy at our center, we were prompted to offer single-stage esophageal replacement when the primary repair had either failed or was not found feasible. Twelve full-term neonates (mean birth weight 2.32 kg) with EATEF who underwent esophageal replacement by gastric pull-up between 1998 and 2000 were reviewed. The indications were: major leak after primary repair (n=9); pure EA (n=2); and EATEF with a very wide gap (n=1). The average ages at presentation and gastric pull-up were 6.0 and 8.5 days, respectively. The patients were evaluated for gastric transit by a colloid radiopharmaceutical, for duodenogastric reflux (DGR) by hepatic immunodiacetic acid (HIDA) scan, and for gastric clearance and transit by contrast studies. Three patients had minimal leaks from the neck site, all of which healed well. Follow-up with nuclear scans and contrast studies to evaluate gastric emptying revealed obstruction in 1 case and DGR in 25% of cases. There were 2 deaths (16%), 1 due to complex congenital cardiac disease and the other due to septicemia. In view of the acceptable morbidity, mortality, and functional outcome following gastric pull-up, we recommend this procedure if it becomes inevitable in the neonatal period.

Localized lepromatous leprosy presenting as a painful nodule in a muscle

Lepromatous leprosy is a generalized disease usually presenting with numerous macules, papules, nodules or plaques involving wide areas of the skin. It is generally believed that in India lepromatous leprosy often originates from the borderline spectrum (Jha et al, 1991). Localized lepromatous or borderline lepromatous disease is a rare variant of multibacillary leprosy (Yoder et al, 1985; Jha et al, 1991; Pfaltzgraff & Ramu, 1994; Vijaikumar et al, 2001). This variant usually presents as a single nodule or a localized area of nodules and papules, while most of the body surface appears normal (Pfaltzgraff & Ramu, 1994; Vijaikumar et al, 2001). Its occurrence in our case as a single painful nodule in the bicep muscle of left forearm was indeed intriguing, such presentation being rarely reported in the literature.

Routine examination of the newborn and maternal satisfaction: a randomised controlled trial

OBJECTIVE

To determine whether the routine examination of the newborn by a midwife compared with a junior paediatrician (SHO) affects maternal satisfaction with this examination.

METHODS

Randomised controlled trial: 826 mother and baby pairs in a district general hospital in south east England were randomised to a paediatric SHO or a midwife for the routine newborn examination. Maternal satisfaction with the examination was analysed in relation to intervention group, process, and background variables.

RESULTS

Some 81% of mothers reported that they were satisfied or very satisfied with the newborn examination. Mothers assigned to a midwife were more satisfied with the newborn examination (crude odds ratio (OR) 0.54 (95% confidence interval (CI) 0.39 to 0.75), p < 0.001). However, after provision of health education during the examination, continuity of care provided, and history of miscarriage had been controlled for, status of examiner was no longer related to maternal satisfaction (adjusted OR 0.82 (95% CI 0.57-1.20), NS). The discussion of healthcare issues by the examiner (adjusted OR 0.49 (95% CI 0.34 to 0.70), p < 0.001) and continuity of care (adjusted OR 0.43 (95% CI 0.23 to 0.81), p < 0.01) were both related to enhanced satisfaction, and history of miscarriage (adjusted OR 1.61 (1.08 to 2.40), p < 0.05) was associated with lower maternal satisfaction with the newborn examination. Midwives (61%) were more likely than SHOs (33%) to discuss healthcare issues, such as feeding, sleeping, and skin care.

CONCLUSIONS

Mothers were more likely to be satisfied with the newborn examination by a midwife than an SHO because midwives were more likely to discuss healthcare issues during the examination and were able to provide continuity of care. However, midwife examinations according to exclusion criteria agreed with trial midwives excluded half of all newborns, and criteria may have to be reconsidered for practice implementation.

The role of imipramine therapy in bladder exstrophy after bladder neck reconstruction

OBJECTIVE

To assess the role of imipramine therapy after bladder neck reconstruction in patients with bladder exstrophy.

PATIENTS AND METHODS

Seventeen children with bladder exstrophy who achieved partial continence after bladder neck reconstruction received imipramine (1.5-2 mg/kg body weight) for a mean duration of 9.5 months. Assessment before and after therapy included an objective classification of the continence status and artificial slow-fill cystometry.

RESULTS

Eleven of the 17 patients had a good clinical response to imipramine, with an increase in the continent period to > 2 h, and in nocturnal continence. The urodynamic findings showed a significant improvement in the capacity, end-fill pressure, uninhibited contractions and '20 below' capacity. Only minor side-effects of the drug were reported.

CONCLUSION

Imipramine has a role in patients who achieve partial continence after reconstruction, and who have a moderately small capacity bladder with poor compliance and uninhibited contractions.

Augmentation colocystoplasty in bladder exstrophy

A good bladder capacity and adequate outlet resistance determine success after staged reconstruction of bladder exstrophy (BE). Augmentation cystoplasty (AC) is an established salvage procedure to treat the small, noncompliant bladders of some of these children. In a series of 89 patients with BE treated over the last 12 years, 19 underwent detubularized augmentation colocystoplasty (ACC) as an adjunctive procedure. Nine underwent ACC at the time of bladder-neck reconstruction (BNR) for small bladder capacity and poor compliance; 10 underwent ACC as a secondary procedure after BNR for persistent urinary incontinence or poor bladder compliance and upper-tract deterioration. The follow-up period ranged between 6 months and 12 years (mean 41 months). Complications included symptomatic urinary-tract infection in 4 patients, recurrent epididymo-orchitis in 2, calculi in 3, colonic anastomotic dehiscence in 1, bladder-patch fistula in 2, and secondary coloureteric-junction obstruction in 1. There was no postoperative reservoir perforation or mortality. The upper tract remained normal or stable in all patients. Nine of the 19 patients are dry both day and night; 4 others are dry during the day but have occasional nocturnal wetting. Three patients have nocturnal wetting with stress incontinence and 2 remain incontinent. Seven patients can void effectively using abdominal contractions and 12 require clean intermittent catherization to ensure complete voiding. The indications and results of AC in BE from other series are reviewed. AC is an important and safe adjunctive procedure in a subset of BE patients with small and poorly compliant bladders. Despite the known complications, more liberal use of AC in BE is warranted.

Betamethasone in plus phenobarbitone prior to hepatobiliary scintigraphy increases diagnostic accuracy in infants with jaundice

OBJECTIVE

In the diagnostic work up of the child with neonatal obstructive cholangiopathy (NOC), hepatobiliary scintigraphy (HBS) determines the need for peroperative cholangiography (POC). Traditionally, phenobarbitone is recommended to prime the liver to HBS. This retrospective study was designed to evaluate whether addition of the betamethasone (BM) alters the diagnostic accuracy of the HBS in distinguishing neonatal hepatitis (NH) from extra hepatic biliary atresia (EHBA).

METHODS

Between 1993-1999, 202 patients presented with NOC and this study was not designed as a prospective randomized clinical trial. Of these, 126 patients had received Phenobarbitone (Group I) and the remaining 76 (Group II) had received BM in addition to the PB in a dose of 5 mg/k/d and 2.2 mg/k/d respectively for 7 days prior to HBS.

RESULTS

Retrospective analysis revealed that, in the Group I, 41 showed excretion and 85 did not show any excretion of the radiopharmaceutical and the latter underwent POC which revealed that 31 patients (36%) of them showed patent biliary tract. In group II, 32 patients revealed excretion and 44 did not show any excretion of the radiopharmaceutical and the latter had undergone POC, which revealed that only 8 patients (18%) showed patent biliary tract. The percentages of false positives (36% vs 18%) was statistically significant (p < 0.03).

CONCLUSION

Addition of BM increases the diagnostic accuracy of the HBS and this would lead to decreased need for POC to distinguish NH from EHBA.

Cystometric evaluation of reconstructed classical bladder exstrophy

OBJECTIVE

To evaluate the association of urodynamic variables with continence and upper tract status after reconstruction in patients with classical bladder exstrophy.

PATIENTS AND METHODS

Thirty-one patients with bladder exstrophy were assessed 1 year after a modified bladder neck reconstruction. The evaluation included a detailed history, radioisotope renography, voiding cysto-urethrography, ultrasonography and artificial slow-filling cystometry.

RESULTS

Fifteen of the 31 patients were satisfactorily continent; their maximum cystometric capacity was higher than that of the incontinent patients. The compliance, assessed as the maximum bladder capacity at a detrusor pressure of < 20 cmH2O, was significantly higher in the continent patients. There was a 45% incidence of unstable contractions in the 31 patients. Persistent sphincteric activity was detected on electromyography in 10 patients during voiding. Twenty-one patients could initiate a detrusor contraction during voiding. The residual volume was significant in nine of the 21 patients who attempted to void. Patients with a high end-fill pressure (> 40 cmH2O) had a significantly higher incidence of unobstructive hydronephrosis than had patients who had an end-fill pressure of < 40 cmH2O.

CONCLUSIONS

Bladder abnormalities are common after reconstruction of bladder exstrophy, with poor compliance, small capacity and unstable contractions. These factors hinder any increase in capacity and cause persistent incontinence. Hypocompliance and high end-fill pressure can lead to upper tract damage even in continent patients. Detailed urodynamic evaluation is vital to assess the results and to plan subsequent treatment.

Evaluation of transplanted hepatocytes using HIDA scintigraphy

BACKGROUND

Hepatocyte transplantation has generated interest because of potential clinical application in enzyme deficiency disorders and acute hepatic failure. Ex-vivo HIDA scintigraphy has been used to assess graft survival after hepatocyte transplantation. The present study evaluates in-vivo99mTc-HIDA scintigraphy to assess graft function after hepatocyte transplantation.

METHODS

Rat hepatocytes were isolated by a modified collagenase digestion technique and injected intrasplenically into 6 syngenic rats; 4 control rats received intrasplenic saline injections. In-vivo HIDA scintigraphy and histological evaluation were done 90 days after transplantation.

RESULTS

Five of the six rats in the study group showed prompt and progressive accumulation of HIDA in the spleen. Histological examination showed presence of hepatocytes in the splenic red pulp. None of the control group animals had splenic uptake of HIDA.

CONCLUSION

HIDA scintigraphy may be a useful modality for assessment of graft function after intrasplenic hepatocyte transplantation.

Myosin IIB is required for growth cone motility

Growth cones are required for the forward advancement and navigation of growing axons. Modulation of growth cone shape and reorientation of the neurite are responsible for the change of outgrowth direction that underlies navigation. Change of shape involves the reordering of the cytoskeleton. Reorientation of the neurite requires the generation of tension, which is supplied by the ability of the growth cone to crawl on a substrate. The specific molecular mechanisms responsible for these activities are unknown but are thought to involve actomyosin-generated force combined with linkage to the cell surface receptors that are responsible for adhesion (Heidemann and Buxbaum, 1998). To test whether myosin IIB is responsible for the force generation, we quantified shape dynamics and filopodial-mediated traction force in growth cones from myosin IIB knock-out (KO) mice and compared them with neurons from normal littermates. Growth cones from the KO mice spread less, showed alterations in shape dynamics and actin organization, and had reduced filopodial-mediated traction force. Although peak traction forces produced by filopodia of KO cones were decreased significantly, KO filopodia occasionally developed forces equivalent to those in the wild type. This indicates that other myosins participate in filopodial-dependent traction force. Therefore, myosin IIB is necessary for normal growth cone spreading and the modulation of shape and traction force but acts in combination with other myosins for some or all of these activities. These activities are essential for growth cone forward advancement, which is necessary for outgrowth. Thus outgrowth is slowed, but not eliminated, in neurons from the myosin IIB KO mice.

PspC, a pneumococcal surface protein, binds human factor H

PspC was found to bind human complement factor H (FH) by Western blot analysis of D39 (pspC(+)) and an isogenic mutant TRE108 (pspC). We confirmed that PspA does not bind FH, while purified PspC binds FH very strongly. The binding of FH to exponentially growing pneumococci varied among different isolates when analyzed by fluorescence activated cell sorting analysis.

Advanced biliary atresia: is portoenterostomy justified in all infants?

During 1989-98, of the 127 patients with biliary atresia, 23 were seen with advanced biliary atresia (ABA) presenting with (i) at more than 120 days of age (ii) established cirrhosis and (iii) features of portal hypertension. Sixteen of these underwent exploratory laparotomy, dissection at the porta hepatis and hepatico-portoenterostomy (HPE) (group I). The remaining 7 infants underwent portal dissection and sump drainage only (instead of HPE). The drainage if any was evaluated for any change in colour, volume and concentration in the post-operative period (group II). Age and presentation were the same in both the groups. In group-II, HPE was considered only if the bile flow was noted after portal dissection. Bile flow was seen in 3/16 in group I and 0/7 in group II. The fall in serum bilirubin during the first seven post operative days was noted in 2/16 in group I and 0/7 in group II. No drain output was recorded in any of the group II infants. The incidence of complications and the duration of hospital stay was significantly higher in group I patients. The sump drainage as an alternative procedure to HPE not only served the purpose of evaluating the patients with ABA for the possible bile flow in the post operative period but also avoided the need for a major operative procedure like HPE.

Factors affecting outcome in the management of posterior urethral valves

Children with posterior urethral valves (PUV) are at high risk for renal failure (RF). The outcome of renal function is significantly influenced by early diagnosis and the choice of primary therapy. We reviewed the outcome of renal function in 58 children with PUV. The choice of therapy in each case primary valve fulguration, vesicostomy, or high ureterostomy--was individually decided on the basis of the response to initial catheter drainage of the bladder. Patient age at diagnosis varied from newborn to 5.5 years, and follow-up ranged from 1.6 to 6 years (mean 3.9 years). The most common procedure was primary endoscopic valve ablation, which was carried out in 56.8% of cases. The other procedures were vesicostomy in 32.75% and high ureterostomy in 10.45%. Most neonates (66.6%) had RF at presentation, but one-half of them had achieved normal serum creatinine values at last follow-up. The recovery of renal function was lowest (33%) in older children where the diagnosis was delayed. A comparison between two groups of neonates and infants who differed on the basis of creatinine concentrations at 1 year of age suggested a statistically significant trend: children with normal or near-normal serum creatinine (0.8 mg/dl or less) by 12 months of age maintained good renal function at the time of final evaluation (1.0 mg/dl or less). Children with higher creatinine values at 1 year of age continued to have progressive RF. Seventy-five percent of the patients who had undergone early high ureterostomy after failure to respond to initial catheter drainage had regained normal renal function. We conclude that: serum creatinine at presentation is not predictive of subsequent renal function, but the values after a period of urinary-tract decompression are prognostically more useful; delay in diagnosis results in a poor outcome of renal function; and for optimal recovery of renal function, the choice of the primary procedure varies from case to case and can be determined by a systematic, stepwise approach (stepladder protocol).

Hepatocyte isolation and transplantation in syngenic rats

Refinement of techniques to isolate viable hepatocytes began in the late 1960's. It was established that perfusion of the intact liver as opposed to incubation of liver slices or chopped tissue increased the yield of cells. The present study aims to establish a simple, two-step, collagenase digestion method for hepatocyte isolation. A single inbred Fisher rat was used for hepatocyte isolation. The liver was perfused in-situ with perfusion buffer containing ethylene glycol bis N, N1, tetra acetic acid (EGTA), followed by the collagenase buffer. The liver was excised and gently minced. The tissue was resuspended in the collagenase buffer to complete dissociation. The cell suspension obtained was washed, centrifuged and filtered to complete the isolation procedure. The trypan blue exclusion test showed 80-85% cell viability. The isolated cells were transplanted into the splenic parenchyma of syngenic rats. Survival of the transplanted hepatocytes was confirmed by histological examination at the end of 90 days. This two step technique of in-situ liver perfusion gives a high yield of viable hepatocytes which show long term survival after transplantation.

Patterns of recurrence in anal canal carcinoma

HYPOTHESIS

The initial modality of treatment of anal canal carcinoma (ACC) influences the pattern of recurrence of disease.

DESIGN

A retrospective analysis comparing patterns of recurrence in patients with ACC undergoing either surgery or chemoradiotherapy as their initial therapeutic intervention. Anal margin cancers and adenocarcinomas were excluded.

SETTING

A university-affiliated urban medical center.

PATIENTS

Eighty-one patients were given a diagnosis of ACC between February 1, 1952, and December 31, 1998. Fifty-one (63%) of the patients initially underwent surgery: abdominoperineal resection in 38 patients (75%) and local excision in 13 patients (25%). Chemoradiotherapy was the initial therapeutic intervention in 30 patients (37%).

MAIN OUTCOME MEASURES

The patterns of recurrence (local vs distant disease) and survival were compared between the group that underwent palliative surgery (hereafter referred to as the surgical group) and the group that received chemoradiotherapy (hereafter referred to as the chemoradiotherapy group).

RESULTS

The mean follow-up was 40 months. Local recurrence occurred in 7 patients (14%) in the surgical group vs 7 patients (23%) in the chemoradiotherapy group (P =.46). Using Kaplan-Meier actuarial analysis, local recurrence rates for the surgical and chemoradiotherapy groups at 1 year were 0% and 6%, respectively (P =.32), and at 5 years were 17% and 36%, respectively (P =.02). The average (+/-SD) time to local recurrence in the surgical group was 23 +/- 0.7 months and for the chemoradiotherapy group 16 +/- 2.9 months (P =.27). Five (71%) of the 7 patients with local recurrences in the chemoradiotherapy group underwent salvage abdominoperineal resection with 100% disease-free survival at a mean follow-up of 35 months. When patients presenting with metastatic disease were excluded, distant recurrences developed in 7 patients (16%) in the surgical group and 2 (7%) in the chemoradiotherapy group (P =.31). Actuarial 5-year distant recurrence rates for the surgical and chemoradiotherapy groups were 26% and 19%, respectively (P =.65). Five-year survival was 42% in the surgical group and 74% in the chemoradiotherapy group (P =.01).

CONCLUSION

There was a higher rate of local recurrence in patients with ACC treated with chemoradiotherapy vs surgical resection as the initial therapeutic intervention. However, when this occurred, abdominoperineal resection was effective salvage therapy and was associated with a 100% disease-free survival at 3 years. Therefore, chemoradiotherapy is justified as the initial treatment for ACC and has an overall 5-year survival that is significantly higher than that attained with initial surgical treatment.

Sprengels deformity: anaesthesia management

A 28 years old lady presented with Sprengels deformity and hemivertebrae for Fothergills surgery. Clinically there were no anomalies of the nervous, renal or the cardiovascular systems. She had a short neck and score on modified Mallapati test was grade 2. She was successfully anaesthetised using injection Propofol as a total intravenous anaesthetic agent after adequate premedication with injection Midazolam and injection Pentazocine. Patient had an uneventful intraoperative and postoperative course.

Surgery in tuberculosis

Tuberculosis in children involves many organs and systems including lymphatics, lungs, CNS, GIT and genitourinary. Although the mainstay of treatment is medical, surgery has a definite role under specific circumstances. It is important to differentiate atypical mycobacterial infection wherein surgery is the primary modality of treatment. The lung is most commonly involved in tuberculosis and besides bronchoscopy, thoracic procedures range from tube thoracostomy to decortication and lung resection. Neurotuberculosis constitutes almost half the cases of extrapulmonary tuberculosis and tuberculous meningitis (TBM) is the commonest type of CNS involvement. Hydrocephalus is a late complication of TBM and shunt surgery is indicated when signs and symptoms of raised intracranial pressure persist despite adequate medical therapy. Abdominal tuberculosis could be peritoneal or gastrointestinal. Either form can complicate the other and each can present in acute, subacute or chronic form. Surgical therapy is reserved for complications like strictures, fistulae and GI bleed. Genitourinary tuberculosis constitutes 15-20% of all extrapulmonary disease and epididymitis is the most common manifestation in the males. Surgery is generally reserved for management of complications such as ureteral strictures, perinephric abscesses and nonfunctioning kidneys.

Gastric teratoma in children

Gastric teratoma (GT) comprises less than 1% of all teratomas in children. Though GT in the presence of immature neuroepithelial elements is regarded as malignant, the prognosis is excellent after complete excision of the tumor. Because of its rarity the world literature lacks a large study. Clinical experience with ten cases of GT is presented and discussed. Only one patient was female; the mean age at presentation was 3.2 months. Two cases were immature grade III GT; one of these had infiltrated the left lobe of the liver and the transverse colon while the other had metastasized to the regional lymph nodes and omentum. All the patients underwent complete excision. There were no deaths, and after a mean follow-up period of 4.2 years, all the patients had no recurrence and were healthy. Both the mature and immature types of GT have an excellent prognosis after complete excision of the tumor. Even when the immature type infiltrates surrounding structures, complete excision offers recurrence-free survival without requiring chemo- or radiotherapy.

Esophageal atresia and tracheo-esophageal fistula: a review

The improved survival of neonates with esophageal atresia and tracheo-esophageal fistula reflects the advancement in neonatal care and anaesthesia over the years. Chick embryo studies have given new insights in the embryopathy of esophageal atresia. It is now apparent that the various types of esophageal atresia could be explained due to selective discrepancy in the growth of the 3 folds in the region of tracheo-esophageal separation. The early disturbances in organogenesis which result in esophageal atresia also lead to other associated anomalies, the incidence of which varies from 40 to 55%. These anomalies have an important bearing on the survival outcome. The physiological aspects of esophageal atresia such as esophageal dysmotility and gastro-esophageal reflux are also vital in the long term and proper treatment of the associated defects. The criteria for an ideal esophageal substitute in long gap esophageal atresia have been determined and several options are now available with good results, such as: gastric transposition, colon, gastric tube and small intestine. IN developing countries, however, a high mortality is still attributed to late referrals, low birth weight, hypothermia and chest infection.

Application of ozone for enhancing the microbiological safety and quality of foods: a review

Ozone (O3) is a strong antimicrobial agent with numerous potential applications in the food industry. High reactivity, penetrability, and spontaneous decomposition to a nontoxic product (i.e., O2) make ozone a viable disinfectant for ensuring the microbiological safety of food products. Ozone has been used for decades in many countries and recently, the generally recognized as safe (GRAS) status of this gas has been reaffirmed in the United States. Ozone, in the gaseous or aqueous phases, is effective against the majority of microorganisms tested by numerous research groups. Relatively low concentrations of ozone and short contact time are sufficient to inactivate bacteria, molds, yeasts, parasites, and viruses. However, rates of inactivation are greater in ozone demand-free systems than when the medium contains oxidizable organic substances. Susceptibility of microorganisms to ozone also varies with the physiological state of the culture, pH of the medium, temperature, humidity, and presence of additives (e.g., acids, surfactants, and sugars). Ozone applications in the food industry are mostly related to decontamination of product surface and water treatment. Ozone has been used with mixed success to inactivate contaminant microflora on meat, poultry, eggs, fish, fruits, vegetables, and dry foods. The gas also is useful in detoxification and elimination of mycotoxins and pesticide residues from some agricultural products. Excessive use of ozone, however, may cause oxidation of some ingredients on food surface. This usually results in discoloration and deterioration of food flavor. Additional research is needed to elucidate the kinetics and mechanisms of microbial inactivation by ozone and to optimize its use in food applications.

Vision disturbances after operative hysteroscopy

Vision disturbance after transurethral resection of the prostate using glycine (1.5% aminoacetic acid) as the irrigating fluid is well known (TURP syndrome). Not so commonly seen or reported is transient blindness after operative hysteroscopy with glycine. It occurred in a 38-year-old woman who underwent hysteroscopic myomectomy and endometrial resection in which the distention medium was glycine. (J Am Assoc Gynecol Laparosc 6(2):213-215, 1999)

Duodeno-renal fistula due to a nasogastric tube in a neonate

Major complications due to nasogastric tubes (NGT) are uncommon. Esophageal and duodenal perforations have been described. We describe a newborn in whom a NGT led to a duodenal perforation, causing duodeno-renal fistula.