Granuloma Presence at Initial Surgery Predicts Need for Repeat Surgery Independent of Rutgeerts Score in Crohn's Disease

BACKGROUND

Approximately half of Crohn's disease (CD) patients experience recurrence and need for repeat resections, highlighting need for prognostic biomarkers. Presence of epithelioid granuloma on surgical tissue and high Rutgeerts endoscopic score are associated with postoperative CD clinical recurrence. We sought to evaluate presence of epithelioid granuloma at first surgery and Rutgeerts score as a combined risk assessment for CD surgical recurrence.

METHODS

Our study included consented CD patients who underwent initial ileocecal resection and were prospectively followed postoperatively. From 2009 to 2019, 418 CD patients underwent initial ileocecal resection with >4 years of follow-up, including postoperative endoscopic assessment (Rutgeerts score).

RESULTS

Postoperative CD patients were grouped based on granuloma presence (30.6%; n = 128) or absence (69.4%; n = 290). Endoscopic recurrence (defined as Rutgeerts score ≥i2) was similar between the granuloma (26%) and no granuloma (25%) groups, respectively (P = .82). Patients with granuloma and CD endoscopic recurrence at first postoperative endoscopy had higher number of bowel surgeries compared with all other groups (no granuloma or CD endoscopic recurrence, P = .007; no granuloma but CD endoscopic recurrence present, P = .04; granuloma present and no CD endoscopic recurrence, P = .04). Epithelioid granuloma presence was associated with 1.65 times higher risk of subsequent surgery independently from first postoperative endoscopic recurrence Rutgeerts score.

CONCLUSIONS

Granuloma presence on initial surgical histology is immediately available and identifies high-risk CD patients who may benefit from early postoperative treatment, and these precision intervention trials are warranted.

Drainage of anorectal abscesses in the operating room is associated with a decreased risk of abscess recurrence and fistula formation

BACKGROUND

Timely incision and drainage (I&D) is first line management for anorectal abscesses. We aimed to define current practices in anorectal abscess management and identify factors associated with abscess recurrence and fistula formation.

METHODS

Index episodes of anorectal abscesses treated with I&D in 2014-2018 at a multi-hospital healthcare system were included. Association with one-year abscess recurrence or fistula formation was evaluated using Cox proportional hazard regression. Fistulae were captured only among patients without fistulae at the index operation.

RESULTS

A total of 458 patients met study criteria. One-year rate of abscess recurrence or fistula formation was 20.3%. When compared to bedside procedures, drainage in the operating room was associated with a reduced risk of either recurrence or fistula formation (aHR 0.20 [95%CI 0.114-0.367]).

CONCLUSIONS

Improved exposure and patient comfort in the operating room may allow more complete drainage contributing to decreased rates of abscess recurrence or fistula formation.

Source, fate and management of recreational fishing marine debris

Marine debris, directly and indirectly, threatens marine habitat and biota. Fishing activity is generally recognised as a contributor to marine debris, but the relative input from recreational fishing remains unassessed. Here we provide the first comprehensive literature review of recreational fishing marine debris (RFMD) on a global scale. A systematic literature review identified 70 studies related to RFMD, and plastic and metal respectively were the dominant debris materials found. Nearshore coastal areas and reefs, acted as both sources and sinks of RFMD and a diverse suite of potential impacts such as ghost fishing and entanglement were identified at local scales. Overall, research of RFMD is lacking globally, however, its role in marine debris input is likely underestimated. We recommend more research on the volumes and risks, using a standardised classification approach. Where intervention is required, we suggest cooperative approaches between the sector and authorities.

Transanal excision with adjuvant therapy for pT1N0 rectal tumors with high-risk features offers equivalent survival to radical resection: A National Cancer Database analysis

BACKGROUND

Current guidelines favor transabdominal radical resection (RR) over transanal local excision (TAX) followed by adjuvant therapy (TAXa) for pT1N0 rectal tumors with high-risk features. Comparison of oncologic outcomes between these approaches is limited, although the former is associated with increased postoperative morbidity. We hypothesize that such treatment strategies result in equivalent long-term survival.

METHODS

A retrospective cohort study was conducted using the National Cancer Database (2010-2016) to identify patients with pT1N0 rectal adenocarcinoma with high-risk features who underwent TAX or RR for curative intent. The primary outcome was 5-year overall survival (OS), evaluated with log-rank and Cox-proportional hazards testing.

RESULTS

A total of 1159 patients (age 67.4 ± 12.9 years; 56.6% male; 83.3% White) met study criteria, of which 1009 (87.1%) underwent RR and 150 (12.9%) underwent TAXa. Patients undergoing TAXa had shorter lengths of stay (RR = 6.5 days, TAXa = 2.7 days, p < 0.001). The 5-year OS was equivalent between groups. TAX without adjuvant therapy was associated with an increased risk of mortality (hazard ratio 1.81, 95% confidence interval 1.17-2.78, p = 0.01).

CONCLUSIONS

This is the largest study to demonstrate equivalent 5-year OS between TAXa and RR for T1N0 rectal cancer with high-risk features. These findings may guide the development of prospective, randomized trials and influence changes in practice recommendations for early-stage rectal cancer.

The Incisionless Totally Laparoscopic Total Abdominal Colectomy: How I Do It?

Laparoscopic total abdominal colectomy (TAC) is the optimal operative approach for patients with medically refractory inflammatory bowel disease and other benign colon conditions. Minimally invasive techniques for TAC are safe, appropriate, and associated with faster recovery than open surgery. This may be of particular importance in patients who ultimately undergo proctectomy with or without intestinal pouch reconstruction. We describe approaches to the laparoscopic TAC.

Telerounding Has Clinical Value and Enables the Busy Surgeon: A Colorectal Surgeon's Ten-Year Experience

BACKGROUND

Study of telemedicine and telerounding in surgical specialties is limited. The push for telemedicine during the COVID-19 pandemic has challenged the face-to-face rounding paradigm and creates an opportunity for reflection on the benefits of telemedicine, especially for balancing competing corporate and clinical demands.

METHODS

The 117-month video-based inpatient telerounding experience of a colorectal surgeon in an academic medical system was recorded, including patient characteristics, diagnoses, technology, content of telerounding encounters, and logistical considerations. Data were analyzed using descriptive statistics.

RESULTS

163 patients were seen in 201 telerounding encounters, primarily for routine postoperative care (90.5%). Most were admitted for inflammatory bowel disease (63.2%). Changes were made to plans of care during 28.9% of encounters, and discharge planning was part of 26.4%. Encounters were conducted primarily from the surgeon's administrative office (68.7%) or other work-related locations (10.9%), while 6.5% originated from the surgeon's home. Technologic issues occurred in 5.5% of encounters. 89.1% of patient feedback was positive and none was negative.

CONCLUSION

Telerounding is technologically feasible and has clinical value, including for patients with complex surgical problems. Technologic problems are rare and patient satisfaction is high. Surgeons should consider telerounding as a means to balance competing demands.

Racial Differences in Postpartum Blood Pressure Trajectories Among Women After a Hypertensive Disorder of Pregnancy

IMPORTANCE

Maternal morbidity and mortality are increasing in the United States, most of which occur post partum, with significant racial disparities, particularly associated with hypertensive disorders of pregnancy. Blood pressure trajectory after a hypertensive disorder of pregnancy has not been previously described.

OBJECTIVES

To describe the blood pressure trajectory in the first 6 weeks post partum after a hypertensive disorder of pregnancy and to evaluate whether blood pressure trajectories differ by self-reported race.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study included deliveries between January 1, 2018, and December 31, 2019. Women with a clinical diagnosis of a hypertensive disorder of pregnancy were enrolled in a postpartum remote blood pressure monitoring program at the time of delivery and were followed up for 6 weeks. Statistical analysis was performed from April 6 to 17, 2020.

MAIN OUTCOMES AND MEASURES

Mixed-effects regression models were used to display blood pressure trajectories in the first 6 weeks post partum.

RESULTS

A total of 1077 women were included (mean [SD] age, 30.2 [5.6] years; 804 of 1017 White [79.1%] and 213 of 1017 Black [20.9%]). Systolic and diastolic blood pressures were found to decrease rapidly in the first 3 weeks post partum, with subsequent stabilization (at 6 days post partum: mean [SD] peak systolic blood pressure, 146 [13] mm Hg; mean [SD] peak diastolic blood pressure, 95 [10] mm Hg; and at 3 weeks post partum: mean [SD] peak systolic blood pressure, 130 [12] mm Hg; mean [SD] peak diastolic blood pressure, 85 [9] mm Hg). A significant difference was seen in blood pressure trajectory by race, with both systolic and diastolic blood pressure decreasing more slowly among Black women compared with White women (mean [SD] peak systolic blood pressure at 1 week post partum: White women, 143 [14] mm Hg vs Black women, 146 [13] mm Hg; P = .01; mean [SD] peak diastolic blood pressure at 1 week post partum: White women, 92 [9] mm Hg vs Black women, 94 [9] mm Hg; P = .02; and mean [SD] peak systolic blood pressure at 3 weeks post partum: White women, 129 [11] mm Hg vs Black women, 136 [15] mm Hg; P < .001; mean [SD] peak diastolic blood pressure at 3 weeks post partum: White women, 84 [8] mm Hg vs Black women, 91 [13] mm Hg; P < .001). At the conclusion of the program, 126 of 185 Black women (68.1%) compared with 393 of 764 White women (51.4%) met the criteria for stage 1 or stage 2 hypertension (P < .001).

CONCLUSIONS AND RELEVANCE

This study found that, in the postpartum period, blood pressure decreased rapidly in the first 3 weeks and subsequently stabilized. The study also found that, compared with White women, Black women had a less rapid decrease in blood pressure, resulting in higher blood pressure by the end of a 6-week program. Given the number of women with persistent hypertension at the conclusion of the program, these findings also appear to support the importance of ongoing postpartum care beyond the first 6 weeks after delivery.

Altered DNA methylation associated with a translocation linked to major mental illness

Recent work has highlighted a possible role for altered epigenetic modifications, including differential DNA methylation, in susceptibility to psychiatric illness. Here, we investigate blood-based DNA methylation in a large family where a balanced translocation between chromosomes 1 and 11 shows genome-wide significant linkage to psychiatric illness. Genome-wide DNA methylation was profiled in whole-blood-derived DNA from 41 individuals using the Infinium HumanMethylation450 BeadChip (Illumina Inc., San Diego, CA). We found significant differences in DNA methylation when translocation carriers (n = 17) were compared to related non-carriers (n = 24) at 13 loci. All but one of the 13 significant differentially methylated positions (DMPs) mapped to the regions surrounding the translocation breakpoints. Methylation levels of five DMPs were associated with genotype at SNPs in linkage disequilibrium with the translocation. Two of the five genes harbouring significant DMPs, DISC1 and DUSP10, have been previously shown to be differentially methylated in schizophrenia. Gene Ontology analysis revealed enrichment for terms relating to neuronal function and neurodevelopment among the genes harbouring the most significant DMPs. Differentially methylated region (DMR) analysis highlighted a number of genes from the MHC region, which has been implicated in psychiatric illness previously through genetic studies. We show that inheritance of a translocation linked to major mental illness is associated with differential DNA methylation at loci implicated in neuronal development/function and in psychiatric illness. As genomic rearrangements are over-represented in individuals with psychiatric illness, such analyses may be valuable more widely in the study of these conditions.

Verbal working memory and functional large-scale networks in schizophrenia

The aim of this study was to test whether bilinear and nonlinear effective connectivity (EC) measures of working memory fMRI data can differentiate between patients with schizophrenia (SZ) and healthy controls (HC). We applied bilinear and nonlinear Dynamic Causal Modeling (DCM) for the analysis of verbal working memory in 16 SZ and 21 HC. The connection strengths with nonlinear modulation between the dorsolateral prefrontal cortex (DLPFC) and the ventral tegmental area/substantia nigra (VTA/SN) were evaluated. We used Bayesian Model Selection at the group and family levels to compare the optimal bilinear and nonlinear models. Bayesian Model Averaging was used to assess the connection strengths with nonlinear modulation. The DCM analyses revealed that SZ and HC used different bilinear networks despite comparable behavioral performance. In addition, the connection strengths with nonlinear modulation between the DLPFC and the VTA/SN area showed differences between SZ and HC. The adoption of different functional networks in SZ and HC indicated neurobiological alterations underlying working memory performance, including different connection strengths with nonlinear modulation between the DLPFC and the VTA/SN area. These novel findings may increase our understanding of connectivity in working memory in schizophrenia.

An examination of the language construct in NIMH's research domain criteria: Time for reconceptualization!

The National Institute of Mental Health's Research Domain Criteria (RDoC) Initiative "calls for the development of new ways of classifying psychopathology based on dimensions of observable behavior." As a result of this ambitious initiative, language has been identified as an independent construct in the RDoC matrix. In this article, we frame language within an evolutionary and neuropsychological context and discuss some of the limitations to the current measurements of language. Findings from genomics and the neuroimaging of performance during language tasks are discussed in relation to serious mental illness and within the context of caveats regarding measuring language. Indeed, the data collection and analysis methods employed to assay language have been both aided and constrained by the available technologies, methodologies, and conceptual definitions. Consequently, different fields of language research show inconsistent definitions of language that have become increasingly broad over time. Individually, they have also shown significant improvements in conceptual resolution, as well as in experimental and analytic techniques. More recently, language research has embraced collaborations across disciplines, notably neuroscience, cognitive science, and computational linguistics and has ultimately re-defined classical ideas of language. As we move forward, the new models of language with their remarkably multifaceted constructs force a re-examination of the NIMH RDoC conceptualization of language and thus the neuroscience and genetics underlying this concept. © 2016 The Authors. American Journal of Medical Genetics Part B: Neuropsychiatric Genetics Published by Wiley Periodicals, Inc.

Effects of a Balanced Translocation between Chromosomes 1 and 11 Disrupting the DISC1 Locus on White Matter Integrity

Objective

Individuals carrying rare, but biologically informative genetic variants provide a unique opportunity to model major mental illness and inform understanding of disease mechanisms. The rarity of such variations means that their study involves small group numbers, however they are amongst the strongest known genetic risk factors for major mental illness and are likely to have large neural effects. DISC1 (Disrupted in Schizophrenia 1) is a gene containing one such risk variant, identified in a single Scottish family through its disruption by a balanced translocation of chromosomes 1 and 11; t(1;11) (q42.1;q14.3).

Method

Within the original pedigree, we examined the effects of the t(1;11) translocation on white matter integrity, measured by fractional anisotropy (FA). This included family members with (n = 7) and without (n = 13) the translocation, along with a clinical control sample of patients with psychosis (n = 34), and a group of healthy controls (n = 33).

Results

We report decreased white matter integrity in five clusters in the genu of the corpus callosum, the right inferior fronto-occipital fasciculus, acoustic radiation and fornix. Analysis of the mixed psychosis group also demonstrated decreased white matter integrity in the above regions. FA values within the corpus callosum correlated significantly with positive psychotic symptom severity.

Conclusions

We demonstrate that the t(1;11) translocation is associated with reduced white matter integrity in frontal commissural and association fibre tracts. These findings overlap with those shown in affected patients with psychosis and in DISC1 animal models and highlight the value of rare but biologically informative mutations in modeling psychosis.

The empirical foundations of telemedicine interventions for chronic disease management

The telemedicine intervention in chronic disease management promises to involve patients in their own care, provides continuous monitoring by their healthcare providers, identifies early symptoms, and responds promptly to exacerbations in their illnesses. This review set out to establish the evidence from the available literature on the impact of telemedicine for the management of three chronic diseases: congestive heart failure, stroke, and chronic obstructive pulmonary disease. By design, the review focuses on a limited set of representative chronic diseases because of their current and increasing importance relative to their prevalence, associated morbidity, mortality, and cost. Furthermore, these three diseases are amenable to timely interventions and secondary prevention through telemonitoring. The preponderance of evidence from studies using rigorous research methods points to beneficial results from telemonitoring in its various manifestations, albeit with a few exceptions. Generally, the benefits include reductions in use of service: hospital admissions/re-admissions, length of hospital stay, and emergency department visits typically declined. It is important that there often were reductions in mortality. Few studies reported neutral or mixed findings.

Association between telephone activity and features of patients with inflammatory bowel disease

BACKGROUND & AIMS

Telephone communication is common between healthcare providers and patients with inflammatory bowel disease (IBD). We analyzed telephone activity at an IBD care center to identify disease and patient characteristics associated with high levels of telephone activity and determine if call volume could identify individuals at risk for future visits to the emergency department (ED) or hospitalization.

METHODS

We performed a prospective observational study in which we categorized telephone calls received by nursing staff over 2 years at a tertiary care IBD clinic (2475 patients in 2009 and 3118 in 2010). We analyzed data on 21,979 ingoing and outgoing calls in 2009 and 32,667 calls in 2010 and assessed associations between clinical factors and logged telephone encounters, and between patterns of telephone encounters and future visits to the ED or hospitalization.

RESULTS

Telephone encounters occurred twice as frequently as office visits; 15% of the patients generated >10 telephone encounters per year and were responsible for half of all telephone encounters. A higher percentage of these high telephone encounter (HTE) patients were female, had Crohn's disease, received steroid treatment, had increased levels of C-reactive protein and rates of erythrocyte sedimentation, had psychiatric comorbidities, and had chronic abdominal pain than patients with lower telephone encounters. The HTE patients were also more frequently seen in the ED or hospitalized over the same time period and in subsequent years. Forty-two percent of patients with >8 telephone encounters within 30 days were seen in the ED or hospitalized within the subsequent 12 months.

CONCLUSIONS

Based on an analysis of telephone records at an IBD clinic, 15% of patients account for half of all calls. These HTE patients are a heterogeneous group with refractory disease who are likely to visit the ED or be hospitalized.

Use of second-person pronouns and schizophrenia

A masked analysis of videotaped assessments of people at high genetic risk of schizophrenia revealed that those who subsequently went on to develop schizophrenia used significantly more second-person pronouns. This was evident before diagnosis, at two separate assessments approximately 18 months apart. This supports the view that people who go on to develop schizophrenia may have an abnormality in the deictic frame of interpersonal communication - that is, the distinction between concepts being self-generated or from elsewhere may be blurred prior to the onset of a diagnosis of schizophrenia.

Surgical Morbidity and Mortality Conference using teleconferencing allows for increased faculty participation and moderation from satellite campuses and saves costs

INTRODUCTION

Surgical faculty participation in Morbidity and Mortality Conference (MMC) satisfies criteria for Continuing Medical Education (CME) credit. We hypothesize that using teleconferencing between the main campus to 2 satellite campuses will quantitatively increase faculty attendance and participation as a moderator at surgical MMC. We also want to perform a cost-benefit analysis of teleconferencing.

METHODS

In this retrospective descriptive study, faculty attendance at MMC at the main campus and 2 satellite campuses was observed from January 1, 2010 through December 31, 2010. Groups were compared with nonparametric statistics, using an α = 0.05. We performed an annual cost-benefit analysis of teleconferencing with consultation of an economist/financial advisor. The explicit and implicit costs of teleconferencing were compared with the opportunity cost-benefit of travel prevention.

RESULTS

In 2010, there were 45 MMC activities. A total of 236 Continuing Medical Education credit hours were reported, with 186 credit hours at the main campus and 68 credit hours at the satellite campuses. A Mann-Whitney U test showed an increase in the median total attendance (5 per conference) with the addition of the satellite campus attendance (2 per conference) (p < 0.001). There were no differences between the number of moderators at the main campus and the satellite campuses (p > 0.99). Cost benefits per faculty member was $96.70 per conference at 1 satellite campus and $193.60 per conference at the second satellite campus. A total of 73.1 hours of travel time was prevented, with a total annual net benefit of $7624.

CONCLUSIONS

Teleconferencing allows for increased faculty attendance at MMC and allows for faculty to stay at their respective hospitals for patient care. Teleconferencing also results in significant cost savings. We recommend that institutions with similar resources consider teleconferencing as a way to increase faculty member attendance at surgical MMC and to save hospital costs.

Minimal-access technique for distal catheter insertion during ventricular peritoneal shunt procedures: a review of 100 cases

The authors report the safety and efficacy of using a percutaneous minimal-access insertion technique for distal shunt catheter placement in 100 cases. From June 2007 to March 2008, they attempted 100 minimal-access insertions of distal shunt catheters in 91 patients who required ventriculoperitoneal shunting. Using the minimal-access approach, they avoided utilizing laparoscopic assistance or a mini-laparotomy in 91% of the cases. There were no bowel injuries or misplaced distal catheters. Additional outcomes in terms of operative times, cases that required conversion to open or laparoscopically assisted implantation, and infection rates are presented. They conclude that intraperitoneal shunt catheter placement can be safely and effectively accomplished using a simplified percutaneous minimal-access insertion method that does not require direct laparoscopic visualization.

Worldwide variation of dialysis-associated peritonitis in children

Peritonitis is the most common cause of dialysis failure in children on chronic peritoneal dialysis. We performed a prospective study of 501 peritonitis episodes in 44 pediatric dialysis centers located in 14 countries that examined peritonitis etiology, efficiency of opinion-based management guidelines, and final outcomes. Culture-negative incidence varied significantly from 11% in North America to 67% in Mexico. Argentina and North America had the highest rate of Gram-negative episodes. Pseudomonas-based peritonitis was eightfold more common in the United States than in Europe, and correlated with the frequency of exit site cleansing and topical mupirocin administration. Significant regional variation in antibiotic susceptibility was noted for the first generation cephalosporins and aminoglycosides. Initial response rates to standardized empiric antibiotic treatment did not differ between regions; however, final outcomes were significantly less favorable in Eastern Europe. The wide regional variation in culture-negative peritonitis, and the distribution and antibiotic susceptibilities of causative bacteria needs to be taken into consideration when the guidelines for empiric therapy of pediatric dialysis-associated peritonitis are revised.

Increased interactive format for Morbidity & Mortality conference improves educational value and enhances confidence

OBJECTIVES

The Mortality and Morbidity (M&M) conference is a staple of surgical training programs. With reduced resident work hours, maximizing limited educational opportunities has become essential. We attempted to determine whether increasing the perceived educational value in M&M conference is associated with enhanced confidence levels in the future. We analyzed which features of M&M case reviews are associated with greater perceived educational value and enhanced confidence to deal with similar future clinical scenarios.

DESIGN

Educational process variables were prospectively collected for 47 consecutive cases reviewed over a 16-week period at a single institution's surgical M&M conference. General surgery residents completed self-reporting surveys rating the educational value of cases and impact on confidence in managing similar future clinical situations. Univariate regression analysis and multivariate regression analysis were calculated to study the relationship between various process variables and perceived educational and confidence values surveyed by residents.

SETTING

Tertiary academic medical center.

PARTICIPANTS

General surgery residents PGY1 to PGY5.

RESULTS

Increased perceived educational value was associated with increased confidence (p < 0.001). Perceived educational value was increased with more questioning of the audience, increasing explanations of cases, use of slides, increase in number of questions directed to attendings, use of radiologic images, the more junior the resident surveyed, and when teaching points were made specifically for the medical students in attendance. (p < 0.05) Level of confidence was increased with increased questioning to the audience, increased explanations, increased questioning of the attendings, and more junior the resident surveyed. Increased questioning of presenter did not increase perceived educational value or resident perceived confidence value.

CONCLUSIONS

These data demonstrate that audience interaction, not directed questioning of the presenter, may improve surgical resident perceived educational value and confidence in managing problems discussed at M&M. These data suggest that M&M moderators can play a central role in maximizing audience interaction and improve the educational value of this important conference.

Unilateral multicystic dysplastic kidney: long term outcomes

AIMS

To report the long term follow up of children with antenatally detected unilateral multicystic dysplastic kidney (MCDK) with documentation of complications, involution rate with time, and renal function at 10 years.

METHODS

Data were retrieved from a prospective regional registry of patients with MCDK between 1985 and 2004. Children were followed using a common protocol of investigation with follow up ultrasound scans (USS) at 2 (165 patients), 5 (117 patients), and 10 years (43 patients).

RESULTS

Serial USS showed that 33% of the MCDK kidneys had completely involuted at 2 years of age, 47% at 5 years, and 59% at 10 years. No patients developed hypertension, significant proteinuria, or malignancy, but two developed pelviureteric junction obstruction in the contralateral kidney. Twenty seven of 143 children (19%) had vesicoureteric reflux (VUR) (96% mild to moderate VUR) into the contralateral kidney with no difference in the incidence of urinary tract infections or renal scarring between those with or without VUR. The mean estimated glomerular filtration rate (GFR) was 86.4 ml/min/1.73 m2 (range 48-125) in 31 of 43 patients followed to 10 years.

CONCLUSIONS

Conservative management of unilateral MCDK is justified with clinical review and infrequent USS but longer term follow up continues in the 41% still with renal remnants at 10 years and those with impaired GFR. It is suggested that the initial micturating cystogram is deferred unless abnormal USS features are present in the contralateral kidney or ureter.

The impact of laparoscopic bariatric workshops on the practice patterns of surgeons

BACKGROUND

This study was designed to evaluate the impact of a 2-day laparoscopic bariatric workshop on the practice patterns of participating surgeons.

METHODS

From October 1998 to June 2002, 18 laparoscopic bariatric workshops were attended by 300 surgeons. Questionnaires were mailed to all participants.

RESULTS

Responses were received from 124 surgeons (41%), among whom were 56 bariatric surgeons (open) (45%), 30 advanced laparoscopic surgeons (24%), and 38 surgeons who performed neither bariatric nor advanced laparoscopic surgery (31%). The questionnaire responses showed that 46 surgeons (37%) currently are performing laparoscopic gastric bypass (LGB), 38 (31%) are performing open gastric bypass, and 39 (32%) are not performing bariatric surgery. Since completion of the course, 46 surgeons have performed 8,893 LGBs (mean, 193 cases/surgeon). Overall, 87 of the surgeons (70%) thought that a limited preceptorship was necessary before performance of LGB, yet only 25% underwent this additional training. According to a poll, the respondents thought that, on the average, 50 cases (range, 10-150 cases) are needed for a claim of proficiency.

CONCLUSION

Laparoscopic bariatric workshops are effective educational tools for surgeons wishing to adopt bariatric surgery. Open bariatric surgeons have the highest rates of adopting laparoscopic techniques and tend to participate in more adjunctive training before performing LGB. There was consensus that the learning curve is steep, and that additional training often is necessary. The authors propose a mechanism for post-residency skill acquisition for advanced laparoscopic surgery.

Predicting Cutting Forces for Oblique Machining Conditions

Using orthogonal (plane strain) machining theory together with certain simplifying assumptions based on experimental observations it is shown how the three components of cutting force in oblique machining can be predicted from a knowledge of the work material flow stress and thermal properties and the cutting conditions. A comparison of predicted and experimental cutting force results is given.

Ethics support in clinical practice

Ethical considerations have long been a part of clinical decision making. However, just as doctors and healthcare professionals are being increasingly challenged about the evidence base for their practice, there is increasing focus on the ethical dimension of clinical care.

Results of laparoscopic gastric bypass in patients with cirrhosis

BACKGROUND

The safety and efficacy of bariatric surgery in patients with cirrhosis has not been well studied.

METHODS

A retrospective review was conducted of patients with cirrhosis who underwent weight-loss surgery at a single institution.

RESULTS

Out of a total of 2119 patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP), 30 patients (1.4%) with cirrhosis were identified. When compared with the entire cohort, patients with cirrhosis were significantly more prone to be heavier (BMI 53 vs 48), older in years (age 50 vs 45), more likely to be male (RR=1.3), and have a higher incidence of diabetes (70% vs 21%) and hypertension (67% vs 21%), P<0.05. The diagnosis of cirrhosis was made intra-operatively in 90% of patients. There were no perioperative deaths, conversions to laparotomy, or liver-related complications. Early complications occurred in 9 patients and included anastomotic leak (1), acute tubular necrosis (4), prolonged intubation (2), ileus (1), and blood transfusion (2). Mean length of hospital stay was 4 days (2-18). There was one late unrelated death and one patient with prolonged nausea and protein malnutrition. The average follow-up time was 16 months (1-48). For patients >12 months postoperatively (n=15), the average percent excess weight loss was 63+/-15%.

CONCLUSION

Laparoscopic RYGBP in the cirrhotic patient has an acceptable complication rate and achieves satisfactory early weight loss. Patients tend to be heavier, older, male and more likely to have diabetes and hypertension. Long-term studies are necessary to examine how weight loss impacts established cirrhosis.

Clinical agreement between automated and calculated ultrasound measurements of bladder volume

Non-invasive urine volume measurement is an important tool in the management of dysfunctional and neuropathic bladders in children. Ultrasound imaging devices have been used for many years for this purpose. An automated scanner (Bladderscan) is now available and has been recommended by a number of authors, but there is conflicting evidence in the literature regarding the accuracy and appropriate clinical application of the device. We aimed to assess the level of clinical agreement between the two methods. 36 urine volume measurements were made on 11 children using both instruments. Although there was a good correlation between the methods (r=0.97), the clinical agreement was poor (limits of agreement +/-77 ml). 13 voided volumes were directly measured and compared with the difference between pre- and post-void ultrasound measurements. The systematic errors were small but the mean absolute errors were 54 ml and 23 ml, respectively, for the automated and ultrasound imaging methods. If used correctly, ultrasound imaging provides more accurate results and can compete with the cost, convenience and ease of use of the automated method. Low cost, highly portable ultrasound imaging devices are now available and should be used in preference to the Bladderscan.

Do gastrostomies close spontaneously? A review of the fate of gastrostomies following successful renal transplantation in children

Previous published data have shown the benefit of nutritional support delivered via a gastrostomy button (GB) for children on chronic dialysis. The use of the GB is suspended following renal transplantation (RT) in most children and it is usually removed 2-3 months later together with the chronic dialysis catheter when the child is on alternate-day steroids. We reviewed the outcome of gastrostomies following successful RT in children. The gastrostomies were created by an open technique (Stamm) with the child under general anaesthesia, usually at the time of insertion of a chronic dialysis catheter. Growth data and complications of the GB were collected in a prospective registry. Following RT, the GB was removed with the expectation that the tract would close spontaneously. Those in whom a gastrocutaneous fistula persisted underwent formal surgical closure. A total of 18 children have had gastrostomy buttons removed: 11 gastrostomies (61%) closed spontaneously, but 7 (39%) required operative closure at a median of 2 months (range 3 weeks-4 years) post-removal. The need for formal closure was significantly related to the duration that the gastrostomy had been in situ pre-transplant (non-parametric statistics, 0.05 > p > 0.01). Although nearly two-thirds of gastrostomies in this study closed spontaneously following RT, less than one-half of those that had been in situ for more than 1 year did so. We thus recommend formal closure of all gastrostomies that have been in situ for more than 1 year. This can be done at the same operation as the removal of the chronic dialysis catheter.

Snapshots of five clinical ethics committees in the UK

Each of the following papers gives an account of a different UK clinical ethics committee. The committees vary in the length of time they have been established, and also in the main focus of their work. The accounts discuss the development of the committees and some of the ethical problems that have been brought to them. The issues raised will be relevant for other National Health Service (NHS) trusts in the UK that wish to set up such a committee.

Congenital midureteric stricture

Congenital midureteric obstruction is a rare entity which can be caused by either ureteric valves or strictures. We report our experience with four patients with midureteric obstruction due to stricture over a six-year period. The condition needs to be differentiated from obstruction of the pelviureteric and vesicoureteric junctions. Obstruction can be initially screened by ultrasound and confirmed by a radionuclide scan with furosemide challenge. Retrograde ureteropyelography and/or intravenous urography may be required to define the level of the stricture.

Nutrition and growth in relation to severity of renal disease in children

Practical joint medical/dietetic guidelines are required for children with chronic renal insufficiency (CRI). Nutritional status and growth were compared in 95 children (59 male) > 2 years age with CRI, grouped following [51Cr]-labelled EDTA glomerular filtration rate (GFR, ml/min/1.73 m2) estimations into 'normal' kidney function [GFR > 75 (mean 104 (SD 18.9), n = 35], mild (GFR 51-75, n = 23), moderate (GFR 25-50, n = 19) and severe CRI (GFR < 25, n = 18). Anthropometry [weight (wt.), height (ht.), and body mass index (BMI)], laboratory investigations and a 3-day dietary record were obtained. All anthropometric indices deteriorated with worsening renal function, from mean SD scores for wt., ht. and BMI in 'normal' children of 0.32 (SD 1.2), 0.4 (SD 1.0) and 0.1 (SD 1.3), respectively, to values of -1.28 (SD 1.1; P < 0.001), -1.52 (SD 1.1; P < 0.001) and -0.42 (SD 1.1; NS) in severe CRI. Mean total energy intake decreased from 103% (SD 17) estimated average requirement (EAR) in 'normal' children to 85% EAR (SD 27; P = 0.004) in severe CRI. Mean serum PTH concentrations (normal laboratory range 12-72 ng/l) were higher in moderate [67 ng/l (SD 58), P < 0.001] and severe CRI [164 ng/l (SD 164), P < 0.001] and mean serum phosphate concentrations were higher in severe CRI (1.54 mmol/l (SD 0.17), P = 0.009) compared to 'normal'. Disturbances in nutritional intakes, bone biochemistry and growth occur early in CRI and suggest the need for joint medical/dietetic intervention in children with mild and moderate CRI, in addition to those with more severe CRI.

Gastrostomy buttons for nutritional support in children with cystinosis

Poor growth in children with cystinosis may be a combination of sub-optimal nutritional intake, gastrointestinal dysfunction and polypharmacy. We report our experience with gastrostomy buttons (GBs) in five children (4 male) with cystinosis treated at a median age of 3 years (range 1.4-8.8 years). All children received overnight GB feeding for a mean duration of 27 months (range 7-42 months). During 135 patient-months of observation, the mean life of the GB was 5.7 months (range 3-7.7 months), with a mean of 3.4 GB changes (range 1-6) per patient. An average of five (range 3-7) medications were administered daily via the button. The mean energy intake achieved was 118% of the estimated average requirement (range 86%-183%), with 58% of total energy and 55% of protein intake being delivered via the GB during the study period. Mean height standard deviation score (SDS) was -3.79 at the start of GB feeding and -3.08 at the end of the study period, with mean weight SDS of -3.79 and -2.17 (P=0.042), respectively. The buttons have been welcomed by the families and should be considered as a treatment option for providing the nutritional prescription and administering medications.

Unilateral multicystic dysplastic kidney disease: defining the natural history. Anglia Paediatric Nephrourology Group

Controversy exists as to what is the optimal management of antenatally detected multicystic dysplastic kidney disease (MCDK): conservative or operative. We report 70 (31M, 39F) children with unilateral MCDK in whom the initial micturating cystourethrography revealed vesicoureteric reflux into the contralateral kidney in 16/63 (25%). Involution of the MCDK kidney was noted at birth in 4 and occurred by 2 y of age in 11/46 (24%), with 16/46 (35%) showing a significant reduction in size. Of 21 children followed to 5 y, the MCDK had disappeared in 3 (14%) and 8 (38%) had shown a further reduction in size. No child has developed hypertension or proteinuria. Four children had urinary tract infections with lower tract symptoms, but no scarring of the normal hypertrophied kidney. We conclude that conservative management of unilateral MCDK is justified with long-term follow-up consisting of annual clinical review and ultrasound evaluation at 2, 5 and 10 y.

Non-compliance and transfer from paediatric to adult transplant unit

Adolescents and young adults appear to be a particularly high-risk group for problems of non-compliance and associated graft loss. We reviewed the progress of 20 young adults (9 female) who had been transferred to three different adult centres at a mean age of 17.9 years (range 15.7-20.9 years) having been transplanted at a mean age of 14.3 years (range 9.6-18.1 years) in the paediatric unit. Eight transplants failed within 36 months of transfer, and in 7 of 20 (35%) the transplant failure was unexpected (3 < 12 months, 3 12-24 months, 1 31 months post transfer). Although many of the patients had recognised problems in family dynamics, only 1 had had a major rejection episode prior to transfer due to admitted non-compliance. In 3 others low cyclosporin levels had been noted. Two young men had been transplanted preemptively in the paediatric unit at 15.3 and 16.7 years, and 3 patients had been transferred to the adult unit via the recently established transition clinic. The results suggest that close attention needs to be paid to this group of patients who require ongoing education and support. Improved dialogue between staff of the paediatric and adult units about transition issues is also essential.

Growth posttransplantation in children previously treated with chronic dialysis and gastrostomy feeding

Nasogastric and gastrostomy feeding are beneficial in providing nutritional support to children on chronic dialysis, but concerns have been raised about transfer to exclusive oral nutrition postrenal transplantation (TX). The present study reports the growth data and feeding outcomes in 14 children (9 male) who received combined dialysis [continuous cycling peritoneal dialysis (CCPD): n = 12; hemodialysis (HD): n = 2] and gastrostomy button (GB) feeding for a mean duration of 15.6 months, and who were transplanted at a mean age of 5.4 years. In 12 patients GB feeding was discontinued shortly after TX, and in 2 it was maintained for 3 and 8 months, respectively. No infective episodes were attributable to the GB post-TX, and the buttons were usually removed within 3 months with the dialysis catheter. The mean height and weight standard deviation scores (SDS) were -2.44 and -2.29, respectively, prior to dialysis and GB feeding; -2.19 and -1.22, respectively, prior to TX; and had improved to -1.6 and -0.79, respectively, 12 months post-TX. The mean percentage weight-for-height at the time of TX was 105% (range: 86%-128%), and was unchanged 1 year post-TX. We conclude that GB feeding in this group of children resulted in few complications or feeding problems post-TX. The use of GB feeding without growth hormone maintained growth parameters in most children while on dialysis, and a significant improvement in growth occurred after the renal transplantation.

Hemolytic uremic syndrome: defining the need for long-term follow-up

BACKGROUND

Diarrhea-associated (D+) hemolytic uremic syndrome (HUS) is a common cause of acute renal failure in children. Progressive renal insufficiency has been documented on prolonged follow-up of selected patients. However, it is uncertain whether all children recovering from varying degrees of HUS require long-term follow-up.

PATIENTS AND METHODS

We reviewed the outcome of 114 patients with D+ HUS presenting to a regional pediatric unit between January 1986 and December 1996. Yearly clinical review post illness included measurement of blood pressure and urinalysis for proteinuria with planned GFR assessments by 51Cr EDTA slope clearance at 1 and 5 years.

RESULTS

Treatment of the HUS was conservative in 27%, by peritoneal dialysis in 62%, hemodialysis in 4% and both peritoneal and hemodialysis in 7%. Ninety-two patients were assessed at 1 year - of these, 1 remained on chronic peritoneal dialysis, 5 (5%) had moderate to severe chronic renal failure (CRF) (GFR 25 - 50 ml/min/1.73 m2), 20 (22%) had mild CRF (GFR 50-80) and 66 (72%) had normal renal function (> or =80 ml/min/1.73 m2). Forty patients have had GFRs performed at 1 and 5 years. Of the 28 patients with a normal GFR at 1 year, 3 deteriorated into mild CRF at 5 years. One patient has a single kidney and one had significant proteinuria at 1 year, factors which would have led to long-term follow-up. There was a negative correlation between number of days of dialysis and GFR at 1 year with a Pearson's correlation coefficient of -0.453 (p<0.01).

CONCLUSION

We conclude that renal function at I year following HUS cannot be predicted with any certainty from the initial illness and should be formally assessed. However, renal function was within normal limits and remained stable between 1 and 5 years following HUS in most children. The results suggest that longer-term follow-up can probably be restricted to those with proteinuria, hypertension, abnormal ultrasound and/or impaired GFR at 1 year.