An examination of nest-building behaviour using five different nesting materials in C57BL/6J and BALB/c mice

The aim of our study was to assess the nest-building behaviour of two mouse (Mus musculus) strains using different nesting materials and examine possible sex- and housing-specific effects. Adult mice of two strains (C57BL/6J; n = 64 and BALB/cAnNCrl; n = 99) were randomly allocated to the following housing groups: single-housed male, single-housed female, pair-housed male and pair-housed female. One of the following nest-building materials was placed in each home-cage in a random order: nestlets (Plexx BV, The Netherlands), cocoons (Carfil, Belgium), wooden wool, crinklets and compact (all three, Safe, Germany). The following day, nests were rated applying a nest-scoring scale ranging from 0 to 10, the nests were removed, and a different nest-building material provided. In both tested strains, nestlets achieved the highest nest-building scores when compared to the other four nest-building materials. All nest-building materials scored higher in BALB/c mice compared to C57BL/6J animals reaching statistical significance in crinklets only. Sex comparison revealed that female C57BL/6J mice only scored significantly higher using crinklets than males and BALB/c female mice were rated significantly higher using wooden wool, cocoons and compact than their male counterparts. While pair-housed C57BL/6J animals built higher-rated nests than single-housed mice in the C57BL/6J strain in all five materials tested, the scores were not significantly different in the BALB/c strain. Results of the present study reveal significant strain-, sex- and housing-related influences on the complexity of nests using different standardised building materials. Such observations need to be taken into account when planning the optimal enrichment programme for laboratory animals.

The local microbiome after pediatric bladder augmentation: intestinal segments and the native urinary bladder host similar mucosal microbiota

INTRODUCTION

Next-generation sequencing (NGS) techniques have provided novel insights into the microbiome of the urinary bladder (UB). In children after bladder augmentation using either ileum (ileocystoplasty, ICP) or colon (colocystoplasty, CCP), the fate of the mucosal microbiome introduced into the urinary tract remains unknown.

OBJECTIVE

The aim was to compare the mucosal microbiome of the native UB vs the augmented intestinal segment (IS) using NGS.

STUDY DESIGN

Twelve children after bladder augmentation (ICP n = 6, CCP n = 6) were included. Biopsies were taken during routine postoperative cystoscopy from the native UB and the IS. Specimens underwent whole-genome DNA extraction, 16S rRNA gene amplification, NGS, and Quantitative Insights Into Microbial Ecology (QIIME) data analysis. Downstream statistical data analyses were performed in Calypso.

RESULTS

Patients' median age at the time of surgery was 11 years (6-17 years), and the median interval between augmentation and sampling was 7 years (4-13 years). α-Diversity (Shannon diversity index) was not significantly different between IS vs UB, ICP vs CCP, and male vs female. No general differences in the overall bacterial pattern (β-diversity) were found between IS, UB, ICP, and CCP groups. The groups overlapped in principal coordinate analysis (PCoA) and non-metric multidimensional scaling (NMDS) analysis (Figure). Age at sampling had a statistically significant influence on β-diversity at the genus level. Corynebacterium, Pseudoxanthomonas, Lactobacillus, Flavobacterium, and Micrococcus were the most dominating taxa detected over all samples. There was an obvious dominance of the genus Corynebacterium in the samples taken from the UB and IS in both ICP and CCP patients. Limitations of this study include the relatively small number of patients.

CONCLUSION

After bladder augmentation, the native UB and augmented ISs (ICP and CCP) host similar microbiota despite their distinct differences of originating mucosal anatomy.

Racial and Gender Influences on Pass Rates for the UK and Ireland Specialty Board Examinations

INTRODUCTION

We explored effects of gender, ethnic origin, first language, and training status on scores in the Intercollegiate Specialty Board examinations in the UK and Ireland across the computer-marked written section and in the face-to-face oral and clinical section.

METHODS

Demographic characteristics and examination results from 9987 attempts across 177 sittings from 2009 to 2013 were analyzed in an analysis of variance by training status, gender, ethnic origin, first language, and section (computer-marked multiple-choice examination vs face-to-face oral and clinical examination).

RESULTS

We found increasing alignment between examiner and candidate characteristics during this period, with a 50% increase in examiners of Asian ethnic origin and a 60% increase in examiners whose first language is not English. The strongest factor in the analysis of variance was training status (F[2, 9818] = 27.67, p < 0.001), with candidates in training significantly outperforming others. Within "core candidates" (first attempt, in training), we found significant main effects for ethnic origin (F[5, 4809] = 2.36, p = 0.04), and first language (F[2, 4809] = 5.29, p = 0.003), but no interaction effects between these factors and section (both F < 1, p > 0.05).

CONCLUSIONS

Training status was the most important factor in candidates' results. Although the analysis showed significant effects of ethnic origin and first language within "core candidates," these differences were statistically indistinguishable between the 2 sections of the examination, suggesting that the differential attainment by these factors cannot be attributed to examiner bias in a face-to-face examination.

Constructing and evaluating a validity argument for the final-year ward simulation exercise

The authors report final-year ward simulation data from the University of Dundee Medical School. Faculty who designed this assessment intend for the final score to represent an individual senior medical student's level of clinical performance. The results are included in each student's portfolio as one source of evidence of the student's capability as a practitioner, professional, and scholar. Our purpose in conducting this study was to illustrate how assessment designers who are creating assessments to evaluate clinical performance might develop propositions and then collect and examine various sources of evidence to construct and evaluate a validity argument. The data were from all 154 medical students who were in their final year of study at the University of Dundee Medical School in the 2010-2011 academic year. To the best of our knowledge, this is the first report on an analysis of senior medical students' clinical performance while they were taking responsibility for the management of a simulated ward. Using multi-facet Rasch measurement and a generalizability theory approach, we examined various sources of validity evidence that the medical school faculty have gathered for a set of six propositions needed to support their use of scores as measures of students' clinical ability. Based on our analysis of the evidence, we would conclude that, by and large, the propositions appear to be sound, and the evidence seems to support their proposed score interpretation. Given the body of evidence collected thus far, their intended interpretation seems defensible.

Improving student selection using multiple mini-interviews with multifaceted Rasch modeling

PURPOSE

The authors report multiple mini-interview (MMI) selection process data at the University of Dundee Medical School; staff, students, and simulated patients were examiners and investigated how effective this process was in separating candidates for entry into medical school according to the attributes measured, whether the different groups of examiners exhibited systematic differences in their rating patterns, and what effect such differences might have on candidates' scores.

METHOD

The 452 candidates assessed in 2009 rotated through the same 10-station MMI that measured six noncognitive attributes. Each candidate was rated by one examiner in each station. Scores were analyzed using Facets software, with candidates, examiners, and stations as facets. The computer program calculated fair average scores that adjusted for examiner severity/leniency and station difficulty.

RESULTS

The MMI reliably (0.89) separated the candidates into four statistically distinct levels of noncognitive ability. The Rasch measures accounted for 31.69% of the total variance in the ratings (candidates 16.01%, examiners 11.32%, and stations 4.36%). Students rated more severely than staff and also had more unexpected ratings. Adjusting scores for examiner severity/leniency and station difficulty would have changed the selection outcomes for 9.6% of the candidates.

CONCLUSIONS

The analyses highlighted the fact that quality control monitoring is essential to ensure fairness when ranking candidates according to scores obtained in the MMI. The results can be used to identify examiners needing further training, or who should not be included again, as well as stations needing review. "Fair average" scores should be used for ranking the candidates.

MOTA Syndrome: Molecular Genetic Confirmation of the Diagnosis in a Newborn with Previously Unreported Clinical Features

MOTA syndrome, the acronym for Manitoba-oculo-tricho-anal syndrome (OMIM 248450), is a distinct autosomal recessive multiple malformation syndrome caused by mutations in the FREM1 gene (OMIM 608944). Eight patients with MOTA syndrome and a pathogenic FREM1 mutation have previously been documented. We report on a new male patient, 3.5 months old, with MOTA syndrome, who presented with the following features: bilateral incomplete cryptophthalmos with a completely fused, ill-defined upper eyelid and a keratinized cornea, hypertelorism, a broad tip of the nose, a circle-shaped whirl of hair on the forehead, and a low anorectal malformation, which could be corrected on day 2 of life without a colostomy. In expansion to the previously reported phenotype of MOTA syndrome, the patient showed characteristic features reported in patients with Fraser syndrome, including dysplastic ears, cutaneous syndactyly 3/4 of the hands and syndactyly 2/3 of the right foot. Molecular analysis of FREM1 identified compound heterozygosity for a new frameshift deletion in exon 24 (c.4629delC, p.F1544SfsX62) and a previously reported missense mutation in exon 21 (c.3971T>G, p.L1324R). This report further extends the phenotype of MOTA syndrome and underscores the overlapping clinical spectrum of FRAS-FREM complex diseases.

The multiple mini-interview in the U.K. context: 3 years of experience at Dundee

BACKGROUND

The multiple mini-interview (MMI) is a new interview process that Dundee Medical School has recently adopted to assess entrants into its undergraduate medicine course. This involves an 'objective structured clinical examination' like rotational approach in which candidates are assessed on specific attributes at a number of stations.

AIMS

 To present methodological, questionnaire and psychometric data on the transitional process from traditional interviews to MMIs over a 3-year period and discuss the implications for those considering making this transition.

METHODS

 To facilitate the transition, a four-station MMI was piloted in 2007. Success encouraged consideration of desirable attributes which were used to develop a full 10-station process which was implemented in 2009 with assessors being recruited from staff, students and simulated patients. A questionnaire was administered to all assessors and candidates who participated in the 2009 MMIs. Cronbach's alpha and Pearson's r and analysis of variances were used to determine the MMI's psychometric properties. Multi-faceted Rasch modelling (MFRM) was modelled to control for assessor leniency/stringency and the impact of using 'fair scores' determined. Analysis was conducted using SPSS 17 and FACETS 3.65.0.

RESULTS

 The questionnaire confirmed that the process was acceptable to all parties. Cronbach's alpha reliability was satisfactory and consistent. Graduates/mature candidates outperformed U.K. school-leavers and overseas candidates. Using MFRM fair scores would change the selection outcome of 6.2% and 9.6% of candidates in 2009 and 2010, respectively. Students were less lenient, made more use of the full range of the rating scales and were just as reliable as staff.

CONCLUSIONS

 The strategy of generating institutional support through staged introduction proved effective. The MMI in Dundee was shown to be feasible and displayed sound psychometric properties. Student assessors appeared to perform at least as well as staff. Despite a considerable intellectual and logistical challenge MMIs were successfully introduced and deemed worthwhile.

Reduced oxygen stress promotes propagation of murine postnatal enteric neural progenitors in vitro

BACKGROUND

Neural stem and progenitor cells of the Enteric Nervous System (ENS) are regarded as a novel cell source for applications in regenerative medicine. However, improvements to the current ENS cell culture protocols will be necessary to generate clinically useful cell numbers under defined culture conditions. Beneficial effects of physiologically low oxygen concentrations and/or the addition of anti-oxidants on propagation of various types of stem cells have previously been demonstrated. In this study, we tested the effects of such culture conditions on ENS stem and progenitor cell behavior.

METHODS

Enteric neural progenitor cells were isolated from postnatal day 3 mouse intestine and propagated either as monolayers or neurosphere-like bodies. The influence of hypoxic culture conditions and/or anti-oxidants on enteric cell propagation were studied systematically using proliferation, differentiation and apoptosis assays, whereas effects on gene expression were determined by qRT-PCR, western blot, and immunocytochemistry.

KEY RESULTS

Both hypoxic culture conditions and anti-oxidants supported a significantly improved enteric cell propagation and the generation of differentiated neural cell types. Enteric neural progenitors were shown to be specifically vulnerable to persistent oxidative stress.

CONCLUSIONS & INFERENCES

Our findings are consistent with previous reports of improved maintenance of brain stem cells cultured under reduced oxygen stress conditions and may therefore be applied to future cell culture protocols in ENS stem cell research.

[Cystic abdominal mass as a complication due to posterior urethral valves]

A case of urinoma with posterior urethral valves and its management is presented. Diagnostic investigations and therapy strategies are discussed. Though rare, this possibility should be considered in the differential diagnosis of neonates presenting with rapidly expanding cystic masses in the abdomen. Early diagnosis and management are the most important prognostic factors that ensure a good outcome in such cases.

Foetal hepatocyte transplantation in a vascularized AV-Loop transplantation model in the rat

The use of foetal liver cells (FLC) in the context of hepatic tissue engineering might permit efficient in vitro expansion and cryopreservation in a cell bank. A prerequisite for successful application of bioartificial liver tissue is sufficient initial vascularization. In this study, we evaluated the transplantation of fibrin gel-immobilized FLC in a vascularized arterio-veno-venous (AV)-loop model. FLC were isolated from embryonic/foetal (ED 16) rat livers and were enriched by using magnetic cell sorting (MACS). After cryopreservation, FLC were labelled by pkh-26. Cells were transplanted in a fibrin matrix into a subcutaneous chamber containing a microsurgically created AV-loop in the femoral region of the recipient rat. The chambers were explanted after 14 days. Subcutaneous implants without an AV-loop and cell-free implants served as controls. Fluorescence microscopy of the constructs was used to identify pkh-26(+)- donor cells. Characterization was performed by RT-PCR and immunhistology (IH) for CK-18 and CD31. Transplantation of FLC using the AV-loop permitted a neo-tissue formation in the fibrin matrix. A high-density vascularization was observed in the AV-loop constructs as shown by CD31 IH. Viable foetal donor cells were detected which expressed CK-18. FLC can be successfully used for heterotopic transplantation. Fibrin matrix permits rapid blood vessel ingrowth from the AV-loop and supports engraftment of FLC. It is therefore an appropriate environment for hepatocyte transplantation in combination with microsurgical vascularization strategies. Transplantation of fibrin gel-immobilized FLC may be a promising approach for the development of highly vascularized in vivo tissue-engineering-based liver support systems.

[Fetoscopic surgery as prenatal intervention for isolated congenital diaphragmatic hernia]

Congenital diaphragmatic hernia (CDH) occurs sporadically with an incidence of 1:2,500 live births. Despite the progress in neonatal intensive care, CDH remains associated with a mortality of at least 30 % in isolated cases. The in essence surgically correctable defect of the diaphragm enables the prenatal herniation of abdominal organs into the thoracic cavity. The resulting abnormal development of the airways and pulmonary vessels causes neonatal respiratory insufficiency and persistent pulmonary hypertension. The condition can be diagnosed prenatally and the degree of pulmonary hypoplasia, which determines the postnatal course, can be measured to make an -individual prognosis. In severely affected patients, prenatal surgery may improve neonatal outcome by reversing pulmonary hypoplasia. This is currently implemented by percutaneous fetoscopic endoluminal tracheal occlusion (FETO) to trigger fetal lung growth. Although there are no maternal complications, preterm rupture of the membranes remains the major drawback of the procedure (20 % < 34 weeks). However, as compared to historical controls of a similar severity, survival as well as early neonatal morbidity are significantly improved by FETO. As a consequence, a multicentre randomised-controlled trial in fetuses with moderate hypoplasia on FETO compared to expectant management has been started ( www.totaltrial.eu). Primary outcome measure is survival without chronic lung disease (i. e., with-out bronchopulmonary dysplasia). A trial in severely affected -fetuses with survival as main outcome is currently under review by ethics committee. A standardised neonatal management enables optimal treatment and multicentre compatibility. It remains to be proven if fetoscopic surgery can maintain a solid position in the prenatal treatment of CDH to improve both mortality and morbidity of the affected children.

[Thoracic surgery in neonates and infants with congenital malformations]

Congenital malformations of the lung and diaphragm are a challenge in paediatric surgery. Depending on the malformation they show a broad spectrum of symptoms and a varying age at manifestation. Thus there are many diagnostic and therapeutic options, which require a good knowledge of the pathology. The treatment of these complex cases should lead to early referral to paediatric centres containing an interdisciplinary team with neonatologists, paediatric pulmonologists and cardiologists, ENT surgeons, anaesthesiologists, radiologists and paediatric surgeons. Some malformations are diagnosed prenatally and need intrauterine interventions. Decisive is the early diagnosis and treatment of these malformations. Nowadays the surgical therapy of neonates and infants with malformations of the lung and diaphragm is enriched by a number of endoscopic and endoluminal techniques, which are discussed critically in this article.

[Bariatric surgery in children and adolescents]

Obesity in childhood and adolescents has gained epidemic proportions; in Germany 15-20 % of boys and girls are overweight, more than 6 % are known to be obese. By now, 25 % of relevant people show a pathological glucose intolerance, 4-5 % are developing type 2 diabetes mellitus (T2DM). In addition, metabolic disorders leading to hypertension and cardiac, renal or ophthalmological complications could be named as serious comorbidities. Medical and behavioural intervention as treatment for obesity in childhood remains largely ineffective: 5-10 % weight loss within 2 years rarely results in significant durable success. In adults, bariatric surgery is being used increasingly as an effective approach to achieve weight loss and to improve serious medical comorbidities, in particular T2DM. Enhancement of quality of life and explicit extension of survival are concomitant phenomenons. To date, a range of different types of bariatric procedures has been performed in adolescents, but studies evaluating and analysing preoperative data, postoperative course and follow-up in a representative number of patients younger than 18 years are still lacking. Nevertheless, current experience suggests significant weight loss and improving obesity-related medical comorbidities after bariatric surgery in adolescents too. Moreover, bariatric surgery in adolescents seems to induce less complications and a shorter hospital stay than in adults. Al-though surgical therapy for obesity in this group of patients remains an individual decision, even though explicit guidelines have been published specifying inclusion and exclusion criterias. Analysis of our own patient group and results of the study of the quality assurance "surgical treatment of morbid obesity" are appropriate tools to evaluate surgical techniques and to provide long-term follow-up.

[Minimally invasive paediatric surgery in other than paediatric surgical departments]

Minimally invasive techniques are well established in numerous paediatric surgical departments. They are safely applied to children of all age groups. Numerous types of procedures have been established specifically for children and, therefore, the necessary expertise cannot be derived from general surgical experience. Advantages in postoperative symptoms, convalescence and cosmesis have been confirmed. However, data or recommendations concerning the use outside of centres of paediatric surgery are lacking. In the opinion of the authors, minimally invasive paediatric surgery should only be considered for departments with a volume of paediatric specialty operations similar to that of paediatric surgical centres. In addition, an adequate number of operations, specific expertise of the surgeons in minimally invasive paediatric surgery, and specific expertise of anaesthesiologists is mandatory. Today, these prerequisites can only be assumed for non-paediatric specialty operations, such as laparoscopic appendectomy. In conclusion, before recommendations can be made for minimally invasive techniques in specialty paediatric operations outside of paediatric surgical centres, the feasibility and safety under these conditions has to be investigated.

In vitro and in vivo evaluation of photodynamic techniques for the experimental treatment of human hepatoblastoma and neuroblastoma: preliminary results

PURPOSE

The purpose of this study was to test the susceptibility of human hepatoblastoma and neuroblastoma cells to photodynamic diagnostics (PDD) and photodynamic therapy (PDT) using 5-aminolevulinic acid (5-ALA) as a photosensitizer.

METHODS

Cell cultures of human hepatoblastoma (HuH6) and neuroblastoma (MHH-NB-11) were incubated with 5-ALA at increasing concentrations to measure the cellular kinetics of photosensitization. After optimizing incubation parameters, the cell cultures were then irradiated with increasing light doses and cell viability was measured by CTB assay. Human fibroblastic cells served as controls. So far, only the hepatoblastoma cell line has been tested in vivo. After injection of HUH6 cells in immunoincompetent rats, the efficacy of PDT was assessed. Photosensitization was achieved by intraperitoneal injection of 5-ALA. The pharmacokinetics of different tissues was studied. In a second study, a PDT of implanted hepatoblastoma, liver and peritoneum was performed. The irradiated areas were excised 48 h after treatment and studied by microscopy.

RESULTS

Cell culture experiments demonstrated a selective fluorescence for both tumor lines compared to controls. The photosensitized tumor cells demonstrated marked reductions in cell viability at significantly lower irradiation doses than the fibroblasts under PDT. The specificity of fluorescence was confirmed in vivo for hepatoblastoma, and all the sensitized and irradiated tumors showed marked phototoxic necrosis.

CONCLUSION

Human hepatoblastoma and neuroblastoma demonstrate marked and specific fluorescence after the application of 5-ALA, making PDD possible. Cell death occurred in both cell lines after PDT in vitro. Additionally, hepatoblastoma was susceptible to PDT in an animal model. Further studies will be necessary to determine the role of PDT and PDD in a clinical setting.

Efficacy of laparoscopic sleeve gastrectomy (LSG) as a stand-alone technique for children with morbid obesity

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is basically unknown as a stand-alone technique for bariatric surgery in children and adolescents. It may be advantageous for this age group though, since it requires neither foreign body placement nor life-long malabsorption. We present the first report about the efficacy of LSG in a small pediatric series.

METHODS

All patients (n = 4, female) had been in a multi-modal weight loss program for several years without long-term success. At referral, the mean age was 14.5 years (range 8-17), mean body mass index (BMI in kg/m(2)) was 48.4 (range 40.6-56.3). All suffered from various features of a metabolic-vascular syndrome like diabetes, dislipidemia, cholecystolithiasis, arterial hypertension. The 8-year-old girl was diagnosed Prader-Willi Syndrome at the age of 2. The decision for bariatric surgery was taken unanimously by the parents, patient, and the obesity team. LSG was performed in a five-trocar technique. With a gastroscope (size 40-F) protecting the lesser curvature, the stomach was resected from the proximal antrum to the angle of His using an ENDO-GIA stapler. The stapler line was secured by a continuous suture 3-0 vicryl.

RESULTS

There were no intra- or postoperative complications. Contrast studies confirmed a J-like gastric remnant (mean volume 76 ml) and ruled out leaks in all cases. After a mean follow-up time of 12 months (range 6-19 months), all the patients had reduced weight (mean BMI to 37.2). The girl with the longest postoperative period went from 121 to 83 kg (BMI from 40.6 to 28.4). Laboratory studies ruled out malnutrition or vitamin deficiency. Monitoring of metabolic parameters showed gradual improvement or even resolution for most features.

CONCLUSION

At a 1-year follow-up, LSG proved a safe and effective option for bariatric surgery in children, achieving moderate weight loss and improvement of comorbidities. Thus, it may be considered as stand-alone technique. Long-term studies however must compare these results with time-tested procedures like gastric banding and Roux-en-Y gastric bypass.

[Therapeutic strategies for chronic constipation in childhood: pediatric gastroenterological and surgical aspects]

Chronic constipation in childhood results from (1) psychological/behavioural causes, (2) functional or organic gastrointestinal outlet obstruction, or (3) slowing of transit within the colon. Functional chronic constipation is treated by a complex conservative bowel management. Constipation refractory to routine medical treatment reveals, in a significant number of cases, organic causes. Histology of bowel biopsies is essential for the preoperative diagnosis of chronic constipation. Defective innervated bowel segments require surgical treatment. Intraoperative histological staining of bowel biopsies allows proper resection of aganglionic or dysganglionic bowel. This contribution describes the interdisciplinary, clinicopathological interactions involving children with chronic constipation.

Curriculum reform in a public health course at a chiropractic college: are we making progress toward improving clinical relevance?

Improving education in health promotion and prevention has been identified as a priority for all accredited professional health care training programs, an issue recently addressed by a collaboration of stakeholders in chiropractic education who developed a model course outline for public health education. Using a course evaluation questionnaire, the authors surveyed students in the public health course at the Canadian Memorial Chiropractic College (CMCC) before and after the implementation of new course content based on the model course outline. Following the new course, there were significant improvements in perceived relevance to chiropractic practice and motivation to learn the material as a foundation for clinical practice. Changes made to the content and delivery of the course based on the model course outline were well received in the short term.

Predictors of performance of students from the Canadian Memorial Chiropractic College on the licensure examinations of the Canadian Chiropractic Examining Board

PURPOSE

The purpose of this study was to determine if the Canadian Memorial Chiropractic College (CMCC) structured admissions interview and other student measures predict success on the Canadian Chiropractic Examining Board (CCEB) examinations.

METHODS

An independent researcher combined CMCC and CCEB data by student name and then anonymized the data and destroyed the linking information. Backward stepwise multiple linear regressions were applied to external dependent variables from the CCEB and internal independent variables from the CMCC.

RESULTS

Forty percent of the variance in the basic science examination (R2 = 0.405) was explained by the independent variables of third year objective structured clinical examination practical and second-year grade point average (chi rhoGPA). Forty-five percent of the variance in the applied science examination (R2 = 0.448) was explained by the fourth year final examination and chi rhoGPA for years 4, 2, and 3. Twenty-four percent of the variance in the clinical decision making examination (R2 = 0.239) was explained by chi rhoGPAs of years 4, 1, 2, and 3. Sixteen percent of the variance in the clinical skills examination (R2 = 0.160) was explained by the third year objective structured clinical examination theory and chi rhoGPA for year 2.

CONCLUSION

For this educational institution, the admissions interview is not a predictor of success on the outcome measures of the CCEB. Student chi rhoGPA in year 2 is critical to success on CCEB licensure examinations. This information infers that students should only continue in their education after they have demonstrated a mastery level at the end of year 2.

Tumor model for laparoscopy in pediatric oncology: subperitoneal inoculation of human hepatoblastoma cells in nude rats

BACKGROUND

Minimally invasive surgery (MIS) for diagnostic or even ablative purposes in pediatric oncology is gradually evolving, but little is known about its biological consequences and surgical complications. Especially for hepatoblastoma (HB), no study on the influence of laparoscopy is available yet. A special tumor model could facilitate a variety of investigations. The present study introduces a laparoscopic technique to create subperitoneal metastases of human HB.

METHODS

7 immuno-incompetent (rnu/rnu) rats (mean weight 198 g) received a stab incision in the lower abdomen to insert a 4 mm scope. Under laparoscopic guidance (CO2 pressure of 1 mmHg, flow of 0.2 l/min) an 18 G needle was introduced, to inject several subperitoneal deposits of the tumor cell suspension (HuH6, 3 x 10 (6) in 1 ml of RPMI-1640 medium). Tumor growth was allowed for 6 - 7 weeks and finally the animals were laparoscopically evaluated for peritoneal metastases. Each suspicious lesion was harvested for histology.

RESULTS

One animal was investigated after 6 weeks without evidence of tumor growth. After 7 weeks, in 4 out of 6 animals at least one lesion could be detected. Histology revealed HB in all specimens.

CONCLUSION

Subperitoneal inoculation of human HB cells in nude rats achieves intraabdominal tumor growth. The present model allows a variety of laparoscopic strategies and their oncological impact to be studied. Thus it may contribute to the development of distinct oncological concepts for MIS in children with HB.

Is the anorectal sphincter damaged during a transanal endorectal pull-through (TERPT) for Hirschsprung's disease? A 3-dimensional, vector manometric investigation

BACKGROUND/PURPOSE

The transanal endorectal pull-through technique (TERPT) for Hirschsprung's disease (HD) exercises considerable traction on the anorectal tissue during dissection. So the question arises as to whether TERPT impairs the integrity of the anorectal sphincter. Computerised 8-channel vector manometry allows a segmental, 360 degrees analysis of muscular defects along the anal canal. Such data after TERPT are not available yet.

METHODS

Between 2002 and 2004, 7 children underwent primary TERPT for HD of the rectosigmoid. All could be recruited for follow-up examinations. Stooling pattern, rectal examination, conventional 4-channel and computerised 8-channel vector manometry were assessed; the anal sphincter pressure at rest (ASPR), rectoanal inhibitory reflex (RIR), anal canal length (ACL), high pressure zone (HPZ), maximal segmental pressure (max SP), segmental/total asymmetric index (SAI/TAI), vector volume at rest (VV) were studied. Mean pre- and postoperative values were compared (pre/post).

RESULTS

After a mean of 14 months (range 3-21 months) all children had spontaneous bowel movements, with no complaints of encopresis or constipation. 4-channel manometry revealed an unchanged ASPR (48.1/49.2 mmHg). RIR was present in 1/7. Computerised 8-channel comparison revealed no changes for ACL (15.4/16 mm), HPZ (60/53.19 % of ACL), SAI (17.6/18.63 %) and TAI (35.8/35.63 %). A postoperative increase was noted for max SP squeeze (141.4/178.7 mmHg) and VV (38 161/46 680 mmHg/cm (2)). In conclusion, the TERPT for HD preserves the functional integrity of the anorectal sphincter complex and has a favourable clinical and manometric outcome.

Comparison of different training models for laparoscopic surgery in neonates and small infants

BACKGROUND

Minimally invasive surgery in small children and infants requires special skills and training. This experimental study compares the efficiency of an in vitro pelvic trainer (PT) and an a in vivo animal model (AM).

METHODS

For this study, 12 residents were prospectively randomized into two groups. Initially, all had to pass a basic skill assessment (3 tasks). Then endoscopic small bowel biopsy was performed (8 times) either with the in vitro PT (group A) or the in vivo AM (group B). Finally, all had to demonstrate this procedure in the in vivo AM and repeat the basic skill assessment. A quality index (complications, suture, biopsy) was evaluated.

RESULTS

Initially, there was no difference between the two groups. Interestingly, the mean regression gradient of the index for the in vitro PT (group A) was significantly better than for the in vivo AM (group B). In the final in vivo operation, however, the mean index for the in vitro PT (group A) worsened significantly, whereas it increased for the in vivo AM (group B) (p = 0.037).

CONCLUSION

Adequate training for an isolated mechanical task such as gut biopsy can be supplied using a pelvic trainer or animal model with similar effects. However in vivo performance of the same task requires secondary surgical skills, which are conveyed during live training with greater success. Consequently, stepwise teaching with both modules seems reasonable before these procedures are approached in neonates or small children.

Videoscopic fluorescence diagnosis of peritoneal and thoracic metastases from human hepatoblastoma in nude rats

BACKGROUND

Various medical disciplines are employing photodynamic diagnosis (PDD) when searching for malignancies. It is still unknown whether pediatric solid tumors such as hepatoblastoma are susceptible to this technique as well.

METHODS

Human hepatoblastoma cells were injected into the abdomen or right thoracic cavity of nude rats. Tumor growth was allowed for 7 weeks. Then, photosensitization was induced by peritoneal lavage with 5-aminolevulinic acid (ALA). Applying the Storz PDD system and one 4-mm scope, all animals were investigated by videoscopic white light diagnosis (WD) and PDD. Suspicious lesions were marked and analyzed by spectrometry and histology.

RESULTS

Positive fluorescence was documented for every tumor seen by WD in the abdomen or right thoracic cavity. Spectrometry of lesions showed a 6.34-fold increased fluorescence intensity. Histology revealed hepatoblastoma in all specimens.

CONCLUSIONS

Human hepatoblastoma can be detected by PDD in a rat model. Considering the clinical success of this method in other specialties, our findings indicate that further investigations to evaluate the benefit of PDD for children with hepatoblastoma should be performed.

Functional imaging for determination of nephroblastoma: an obligatory diagnostic program

In Europe, 1.7 % of children with predicted nephroblastoma undergo neoadjuvant chemotherapy without being correctly diagnosed. It is necessary to reduce the number of misdiagnoses. In a girl who was referred to our institute with the diagnosis of nephroblastoma of the right kidney, DMSA scan revealed a hypertrophic compensation of the contralateral nephropathy in the lower part. Functional imaging studies of the kidney should be performed in patients in whom the type of pathology of a suspect mass in the kidney region is unclear, including a careful scrutiny of the MRI scan.

Juvenile granulosa cell tumour (JGCT) of the ovary in a 6-year-old girl: laparoscopic resection achieves long-term oncological success

Juvenile granulosa cell tumours (JGCT) represent a rare malignancy in childhood and their laparoscopic resection has not been advocated yet. We report on a 6-year-old girl with signs of precocious pseudo-puberty and an abdominal tumour. Work-up revealed premature thelarche, vaginal discharge, elevated estrogen levels, and a solid tumour in the lower pelvis (6 x 4 x 3 cm in MRI). The girl underwent laparoscopy (3 ports, 5-mm instruments), during which a non-invasive, mobile tumour of the left ovary was found. Since all margins of resection could be clearly identified, salpingo-oophrectomy was performed, using the harmonic scalpel for dissection and 5-mm clips to ligate the fallopian tube. Histopathology revealed a JGCT with an intact capsule (FIGO 1 a) which required no further chemotherapy. Within 3 months postoperatively the girl's signs of precocious puberty had resolved and at present, after a follow-up of more than 3 years, there is no evidence of tumour recurrence. Minimally invasive surgery of solid ovarian tumours in children remains controversial. However in the present case, laparoscopic resection did not compromise the surgical and oncological safety.

Advanced paediatric laparoscopic surgery: repetitive training in a rabbit model provides superior skills for live operations

TOPIC

The rapid development of advanced laparoscopic techniques is a strong challenge for the skills and competence of the paediatric surgeon. It is therefore mandatory that training must offer adequate preparation. The present experimental study investigates how surgical residents perform laparoscopic bowel biopsy and defect repair after training with a pelvitrainer versus a rabbit model.

METHODS

New Zealand white rabbits, 3 mm instruments, a 5 mm scope and a 6 - 0 prolene suture were used. Twelve surgical residents were randomised into two groups. Their basic task was to take a seromuscular bowel biopsy laparoscopically and to repair the defect using an intracorporeal suture. Group I trained 8 times (on 8 occasions) with a pelvitrainer (PT), group II trained similarly using a rabbit model (RM). Each participant took a final test to demonstrate the operation in the rabbit. Operating time, suture time and perforation of the bowel were analysed.

RESULTS

In the PT group, mean operating times decreased from 11.18 (+/- 5.04) min to 4.91 (+/- 0.89) min (p < 0.01), however the final test procedure in the rabbit model lasted 9.62 (+/- 5.11) min. In the RM group mean operating times also decreased from 10.04 (+/- 3.39) min to 6.38 (+/- 1.40) min (p < 0.01) during the eight training operations. Within this group the final live operation lasted 5.45 (+/- 0.67) min and was significantly faster than in the PT group 9.62 (+/- 5.11) min (p < 0.1). The suture times showed a similar pattern. A significant difference with respect to the rate of perforation was not found.

CONCLUSIONS

Repetitive training in the rabbit provides superior skills for live operations. In paediatric surgical centres with advanced laparoscopic procedures, an animal model should be considered as an important step in training which may contribute to a beneficial outcome in patients.

Climate studies: can students' perceptions of the ideal educational environment be of use for institutional planning and resource utilization?

As educational climate strongly affects student achievement, satisfaction and success, it is important to get regular feedback from students on how they experience the educational environment. The Dundee Ready Education Environment Measure (DREEM) Inventory was administered on the same day to all first-, second- and third-year students at the Canadian Memorial Chiropractic College (CMCC) and the students were requested to complete the questionnaire as they were actually experiencing the educational environment at CMCC, and then to say what they would have wanted, or preferred it to be like. Valid returns were received from 146 (95%) first-, 123 (82%) second- and 73 (48%) third-year students (n = 342). The results indicated that the DREEM Inventory used in the Ideal mode, together with the responses in the Actual mode, could be used effectively to determine the dissonance between what they had and what they would have liked to have. It was found that there was a strong similarity in the areas of the educational environment that the different groups of students indicated as falling short of their ideal. The results of this study provided a useful basis for strategic planning and resource utilization.

Recurrent intussusceptions in an infant that were terminated by laparoscopic ileocolonic pexie

For children with ileocolic intussusceptions, laparoscopy has been proposed as an emergency intervention, but it has not been elaborated for elective prevention of recurrencies. We report about an infant who developed his first ileocolic intussusception at the age of 12 months. Radiologic devagination was successful, but had to be repeated for two consecutive recurrences within several days. Six months later, he presented with another episode of intussusception, which again was managed conservatively. At this time, preventive surgery seemed indicated. Diagnostic laparoscopy using three trocars and 5-mm instruments showed an insufficient closure of the ileocecal valve, allowing the surgeon easily to provoke an intussusception. Consequently, the distal ileum was attached to the ascending colon with several interrupted 3-0 sutures. The infants postoperative course was uneventful. Oral feeding was started immediately, and he could be discharged after 3 days. Within a follow-up period of 1 year, no evidence of intussusception was noted. We conclude that for children with recurrent episodes of intussusception, laparoscopic ileocolonic pexie presents a beneficial strategy for protective surgery.

Conscious sedation: Off-label use of rectal S(+)-ketamine and midazolam for wound dressing changes in paediatric heat injuries

BACKGROUND

Wound dressing changes after heat injuries expose the patient to repeated painful and frightening procedures in short intervals. Safe, adequate, and easily administered analgesia and sedation are required. The goal of this study was to evaluate the off-label use of rectally administered S(+)-ketamine and Midazolam by paediatric surgeons during repeated outpatient dressing changes for paediatric burns and scalding.

PATIENTS AND METHODS

A total of 47 dressing changes of 30 children with I - IIa degrees burns were evaluated. Vital signs, side-effects, complications, anxiolysis, and analgesia were recorded during the procedure and for the following two hours. Patients were assessed by a discharge scoring system and an age-appropriate pain scoring system at regular intervals. Before discharge, parents were interviewed on their level of satisfaction with the protocol.

RESULTS

Adequate sedation and analgesia was achieved in 44 procedures (94 %). No complications and, in particular, no compromise of breathing, ventilatory, and cardiovascular functions were recorded. The discharge scoring system indicated a return to baseline function 30 minutes after the procedure in all patients. The parents were generally very satisfied with the protocol. All children old enough to be questioned were found to have an anterograde amnesia for the duration of the procedure.

CONCLUSION

Conscious sedation with rectally applied S(+)-ketamine and Midazolam allows safe and painless dressing changes after heat injuries in children.

Partial laparoscopic decapsulation of congenital splenic cysts. A medium-term evaluation proves the efficiency in children

BACKGROUND

In children, laparoscopic decapsulation of large congenital splenic cysts has occasionally been advocated, but substantial series focusing on its long-term success are still lacking. We report the follow-up experiences from two pediatric surgical centers.

METHODS

The decision to proceed to surgery was based on patient symptoms and cyst size (>4 cm and/or progression), after strictly exclusion of a parasitic cause (by serology and CT scan). With the use of three ports (5-10-mm) and a Harmonic Scalpel, the epithelial portion of the cyst was radically excised. The remaining hilar epithelium was coagulated carefully. After discharge, the children were examined regularly by ultrasound to detect recurrences.

RESULTS

From 1998 until 2002, eight children (mean age, 11.1 years; range, 3.1-16.4) were treated for cysts ranging from 4 to 15 cm in diameter. All procedures were completed without significant intraoperative complications (no major bleeding, no conversions). The mean operating time was 75 min (range, 56-184). Postoperatively, one child developed a cystic remnant (2 cm), which remained unchanged during 30 months of observation. After a mean follow-up of 2.2 years (range, 13-38 months), none of the patients showed any evidence of recurrent growth, and all of them had healthy splenic remnants.

CONCLUSION

Partial laparoscopic decapsulation is an advantageous approach to large splenic cysts in children, because it is effective, preserves splenic tissue, and provides good medium-term results.

Identifying the perceived weaknesses of a new curriculum by means of the Dundee Ready Education Environment Measure (DREEM) Inventory

The Canadian Memorial Chiropractic College is in the fourth year of implementing a new four-year Integrative Curriculum. In order to determine how the students experienced the educational environment generated by the new curriculum, the Dundee Ready Education Environment (DREEM) Inventory was administered on the same day to 148 (96%) first-year, 131 (87%) second-year, and 128 (84%) third-year students (n = 407). Resultant scores indicated many areas of concern. However, bimodal and large numbers of 'uncertain' responses also occurred. In order to establish and compare areas of most concern between the three year groups, responses were calculated as percentages indicating for each item those who agree, disagree or are uncertain. This result clearly indicated areas of joint concern for each of the five domains addressed by the DREEM Inventory. Analysis of these concerns formed the basis of strategic planning in order to institute remedial action, and on which to focus institutional resources.

Intrauterine repair of gastroschisis in fetal rabbits

OBJECTIVE

Infants with gastroschisis (GS) still face severe morbidity. Prenatal closure may prevent gastrointestinal organ damage, but intrauterine GS repair (GSR) has not been established yet.

METHODS

In New Zealand White rabbits we developed and compared GS versus GSR: creation of GS was achieved by hysterotomy, right-sided laparotomy of the fetus and pressure on the abdominal wall to provoke evisceration. GSR was accomplished by careful reposition of eviscerated organs and a running suture of the fetal abdominal wall. For study purposes, 18 animals were divided equally into 3 groups: GS, GS with GSR after 2 h, and unmanipulated controls (C). Vitality was assessed by echocardiography. After 5 h all animals were sacrificed.

RESULTS

GSR inflicted no increased mortality, because all fetuses survived GS or GS with GSR. All fetuses with GS demonstrated significant evisceration of abdominal organs. In contrast, the abdominal wall of the fetuses from GSR was intact.

CONCLUSION

The present animal model demonstrated the technical feasibility and success of an intrauterine repair of GS for the first time. However, further long-term studies (leaving GS and GSR in utero for several days) will be necessary to compare survival rates and intestinal injury, motility or absorption. The clinical application of GSR in utero remains a vision so far.

Ileoileal intussusception caused by a Ewing sarcoma tumour. An unusual case report

Intussusception typically occurs in childhood, presenting with a well-known medical history and clinical symptoms. Pathologically, a "leading point" may be attributed to lymphadenomatosis, polyps, or a tumour. In older patients and adolescents, the diagnosis can be complicated due to the lower incidence and variable subacute symptoms. We report on an 18-year-old patient with increasing abdominal discomfort over several weeks. External diagnostics showed no pathological signs or were misinterpreted as a malfunction of intestinal motility. The patient experienced increasing colics, recurrent vomiting, dehydration and weight loss. Finally he was transferred to our paediatric surgical department and laparotomy had to be performed for the clinical and radiological signs of an ileus. An ileoilealic intussusception was found, caused by a small bowel tumour, which almost completely obstructed the intestinal lumen. It was resected and bowel continuity was re-established. Histopathology revealed a very rare, highly malignant mesenchymal Ewing sarcoma, infiltrating the complete bowel wall. After the postoperative course, the patient was transferred to our oncological department for chemotherapy. In older children or young adults, intestinal malignancies are extremely rare. Nevertheless, if these patients suffer from unspecific complaints of chronic intestinal obstruction, a tumour must be ruled out. A Ewing sarcoma may be responsible for an intussusception.