Factors Related to the Development of Small-Bowel Bacterial Overgrowth in Pediatric Intestinal Failure: A Retrospective Cohort Study

BACKGROUND

Small bowel bacterial overgrowth (SBBO) is a challenge in the management of pediatric intestinal failure (PIF). Our goal was to determine the proportion of patients treated for SBBO and factors related to its development.

METHODS

We completed a retrospective analysis of PIF patients referred between 2008 and 2014. Data were collected on factors related to intestinal failure (IF) and SBBO. The cohort was stratified on the diagnosis of SBBO and refractory SBBO. Statistical testing completed using t-test, χ² test, and logistic regression.

RESULTS

Thirty-five of 102 patients developed SBBO (34%), and 16 (16%) had refractory SBBO. SBBO was more likely in gastroschisis (40.0% vs 19.4%, P = .025), a shorter residual small bowel (SB) (45.4% vs 66.5%, P = .004), and patients were less likely to wean from parenteral nutrition (PN) (51.4% vs 85.1%, P < .0001). Refractory SBBO patients were likely to have gastroschisis (50.0% vs 22.1%, P = .020) and a shorter residual SB and large bowel remaining (23.2% vs 65.9%, P < .0001 and 60.6% vs 79.4%, P = .03, respectively) and less likely to wean from PN (37.5% vs 80.2%, P = .001). Logistic regression demonstrated that longer SB residual was protective (P = .001; odds ratio [OR], 0.95; 95% CI, 0.93-0.99), and short bowel syndrome (SBS) as a cause of IF was a risk factor (P = .001; OR, 0.04; 95% CI, 0.01-0.27).

CONCLUSION

A longer SB remnant was protective against SBBO. Patients with SBBO were more likely to have PIF caused by SBS.

An Observational Study of Smoflipid vs Intralipid on the Evolution of Intestinal Failure-Associated Liver Disease in Infants With Intestinal Failure

BACKGROUND

SMOFlipid has a more diverse lipid profile than traditional Intralipid and has become the standard lipid for patients in our intestinal rehabilitation program. Our objective was to compare outcomes in neonates with intestinal failure (IF) who received SMOFlipid against those receiving Intralipid.

METHODS

This was a retrospective cohort study of infants with IF with a minimum follow-up of 12 months in 2008-2016. Patients were stratified into 2 groups: group 1 received SMOFlipid; group 2 was a historical cohort who received Intralipid. The primary outcome was liver function evaluated using conjugated bilirubin (CB) levels. Statistical analysis included the Mann-Whitney U and χ² tests, with an α value < 0.05 considered significant. Approval was obtained from our institutional review board.

RESULTS

Thirty-seven patients were evaluated (17 = SMOFlipid, 20 = Intralipid). SMOFlipid patients were less likely to reach CB of 34 (24% vs 55%, P = 0.05), 50 µmol/L (11.8% vs 45%; P = 0.028), and did not require Omegaven (0% vs 30%; P = 0.014). CB level at 3 months after initiation of parenteral nutrition (PN) was lower in patients receiving SMOFlipid (0 vs 36 µmol/L; P = 0.01). Weight z-scores were improved for patients receiving SMOFlipid at 3 months (-0.932 vs -2.092; P = 0.028) and 6 months (-0.633 vs -1.614; P = 0.018). There were no differences in PN-supported patients or demographics between the groups.

CONCLUSION

Use of SMOFlipid resulted in decreased development of IF-associated liver disease in patients with IF when assessed using biochemical tests.

Neurodevelopmental outcomes of infants with intestinal failure at 12 and 26 months corrected age

BACKGROUND

Survival rates of infants with intestinal failure (IF) are increasing, yet multiple medical factors may impact development.

AIMS

This study examines neurodevelopmental outcomes at 12-15 and 26-32 months corrected age in a cohort of children with IF.

STUDY DESIGN

Prospective single centre neurodevelopmental assessments of children admitted to an intestinal rehabilitation program between 2011 and 2013. Outcome measures include: Mullen Scales of Early Learning (12 and 26 months), and Vineland-II Adaptive Behaviour Scales - Caregiver Report (26 months). Standard scores were correlated with medical and demographic factors.

RESULTS

Thirty-one children (17 males), median gestational age 34 weeks (IQR 30-36) with birth weight (BW) 2.12 kg (IQR 1.24-2.52). Ten (32.2%) were dependent on parental nutrition (PN) at the second assessment. At 12 months, 11/30 (36.7%) scored below average (>1SD below mean) on the early learning composite and 24/30 (80%) were below average on the gross motor subscale. Comparatively, at 26 months, mean early learning scores were significantly lower with >50% scoring below average. Mean gross motor scores remained low, and 14/27 (51.9%) were below average on the Vineland-II motor domain. At 12 months, factors significantly associated with lower scores are primarily related to prematurity. At 26 months, the impact of IF-related variables such as bowel length and PN days are more apparent.

CONCLUSION

Children with IF are at risk of developmental delay in multiple domains. While gross motor skills appear to be most significantly affected, cognitive deficits become more apparent at 26 months, highlighting the importance of early developmental follow up.

Persistence of hepatic fibrosis in pediatric intestinal failure patients treated with intravenous fish oil lipid emulsion

BACKGROUND

Pediatric intestinal failure (PIF) is a life-altering chronic condition with significant morbidity and mortality. Omegaven® therapy has been used to treat children with advanced intestinal failure associated liver disease. Our objective was to determine the evolution of hepatic fibrosis in PIF patients who received Omegaven® and describe their clinical outcome.

METHODS

A retrospective review in PIF patients who received Omegaven® was performed. Patients were included if they had liver biopsies completed before Omegaven® therapy and after resolution of hyperbilirubinemia. Biopsy results were evaluated to determine the degree of fibrosis, inflammation, and cholestasis. Clinical and biochemical data was collected.

RESULTS

Six patients were identified. Assessment of fibrosis at last follow-up demonstrated improvement in 2 patients and progression or stable fibrosis in 4/6. All patients demonstrated reduction in cholestasis and inflammation. One patient received a liver/intestine transplant and a second is listed, both of them with progressive fibrosis. One patient achieved full enteral nutrition, while the rest remain partially parenteral nutrition dependent.

CONCLUSION

Use of Omegaven® is associated with reduced cholestasis and inflammation, but with persistence or worsening of fibrosis in some patients. A subset of patients with progressive fibrosis may develop portal hypertension and progressive liver disease.

Early neurodevelopmental outcomes of infants with intestinal failure

BACKGROUND

The survival rate of infants and children with intestinal failure is increasing, necessitating a greater focus on their developmental trajectory.

AIMS

To evaluate neurodevelopmental outcomes in children with intestinal failure at 0-15months corrected age.

STUDY DESIGN

Analysis of clinical, demographic and developmental assessment results of 33 children followed in an intestinal rehabilitation program between 2011 and 2014. Outcome measures included: Prechtl's Assessment of General Movements, Movement Assessment of Infants, Alberta Infant Motor Scale and Mullen Scales of Early Learning. Clinical factors were correlated with poorer developmental outcomes at 12-15months corrected age.

RESULTS

Thirty-three infants (17 males), median gestational age 34weeks (interquartile range 29.5-36.0) with birth weight 1.98kg (interquartile range 1.17-2.50). Twenty-nine (88%) infants had abnormal General Movements. More than half had suspect or abnormal scores on the Alberta Infant Motor Scale and medium to high-risk scores for future neuromotor delay on the Movement Assessment of Infants. Delays were seen across all Mullen subscales, most notably in gross motor skills. Factors significantly associated with poorer outcomes at 12-15months included: prematurity, low birth weight, central nervous system co-morbidity, longer neonatal intensive care admission, necrotizing enterocolitis diagnosis, number of operations and conjugated hyperbilirubinemia.

CONCLUSION

Multiple risk factors contribute to early developmental delay in children with intestinal failure, highlighting the importance of close developmental follow-up.

Preventing the Progression of Intestinal Failure-Associated Liver Disease in Infants Using a Composite Lipid Emulsion: A Pilot Randomized Controlled Trial of SMOFlipid

BACKGROUND

To examine whether SMOFlipid prevents progression of intestinal failure-associated liver disease (IFALD) in parenteral nutrition (PN)-dependent infants with early IFALD (conjugated bilirubin 17-50 µmol/L, 1-3 mg/dL).

STUDY DESIGN

Pilot multicenter blinded randomized controlled trial comparing SMOFlipid with Intralipid. Patients received the trial lipid for up to 12 weeks, unless they achieved full enteral tolerance sooner. The primary clinical outcome was the serum conjugated bilirubin.

RESULTS

Twenty-four infants (mean age, 6 weeks) participated in the trial (13 Intralipid and 11 SMOFlipid). At the time of trial enrollment, patients in both groups were receiving 90% of their calories by PN. Mean duration on trial was 8 weeks and did not differ according to treatment ( P = .99). At trial conclusion, patients who received SMOFlipid had a lower conjugated bilirubin than those who received Intralipid (mean difference, -59 µmol/L; P = .03). Patients receiving SMOFlipid were also more likely to have a decrease in serum conjugated bilirubin to 0 µmol/L than those in the Intralipid group over the entire observation period (hazard ratio, 10.6; 95%; P = .03). The time to achievement of full enteral tolerance did not differ statistically (hazard ratio, 1.3; P = .59) between the groups. There was no significant difference in safety outcomes between the groups.

CONCLUSIONS

Compared with Intralipid, SMOFlipid reduces the risk of progressive IFALD in children with intestinal failure. This trial was registered at clinicaltrials.gov as NCT00793195.

Secondary plastic closure of gastroschisis is associated with a lower incidence of mechanical ventilation

INTRODUCTION

Nonsurgical closure after primary silo placement, secondary plastic closure (SPC), has been used as an alternative to secondary surgical closure (SSC) in gastroschisis. The benefits described were closure without formal surgical procedure, cosmetic aspect, and minimization of intra-abdominal pressures. This study compared requirements for mechanical ventilation and general anesthesia, nutritional care, and outcomes between SPC and SSC.

PATIENTS AND METHODS

We included patients with primary staged-silo reduction with a 1-year minimum follow-up. SPC was performed at bedside with sedation using a nonadherent dressing. SSC was performed in operating room under general anesthesia using standard surgical techniques.

RESULTS

This retrospective study included 64 patients, 23 SPC and 41 SSC. The characteristics of the two groups were comparable. Mechanical ventilation was used for 15 SPC and 41 SSC (p=0.0001) with a comparable median duration (5.5 and 6.0 days, not significant [NS]). General anesthesia was required for 9 SPC and 41 SSC (p<0.0001). Complications included one SPC and six SSC with necrotizing enterocolitis, zero SPC and four SSC with intestinal atresia, two SPC and four SSC with small bowel obstruction, zero SPC and one SSC with abdominal compartment syndrome resulting in a short bowel syndrome (NS). Median duration of parenteral nutrition (30 and 27 days), time to first feeds (14 and 14 days), time at or above minimal enteral feeding (22 and 17 days), time to full feeds (31 and 28 days), length of stay (LOS) in neonatal intensive care unit (24 and 23.5 days) and overall hospital LOS (37 and 36 days) were not statistically different between SPC and SSC patients without complications, respectively. These data were comparable for SPC and SSC patients with complications. Five SPC and six SSC developed an umbilical hernia (NS); two patients in each group required a surgical repair (NS).

CONCLUSION

Plastic closure of gastroschisis after primary silo reduction is simple, safe, reproducible, and associated with a significant lower incidence of mechanical ventilation. Nutritional management and length of hospital stay were similar to conventional surgical closure for patients. Plastic closure allows nonoperative management without general anesthesia at patient's bedside, in comparison with surgical closure that must be performed under general anesthesia in the operating room. Plastic closure does not appear to be associated with more umbilical hernias in this retrospective study.

Five-year outcomes after serial transverse enteroplasty in children with short bowel syndrome

AIM

The aim of this study is to report 5-year outcomes in patients who have received serial transverse enteroplasty (STEP) using clinical and biochemical assessments of intestinal function.

METHODS

Thirty-one STEP procedures have been performed at our institution. Twelve patients who received STEP before January 2005 were analyzed. Clinical and biochemical outcomes were performed pre-STEP and post-STEP on an annual basis. Paired t tests were used to compare post-STEP outcomes to pre-STEP values (P < .05 was significant).

MAIN RESULTS

There were 12 patients (3 females; median age, 5.5 months). Serial transverse enteroplasty resulted in mean increase in length of dilated bowel segment of 89% ± 26% and increase in total small bowel length of 46% ± 40%. Two patients received liver-intestinal transplants post-STEP (at 4 and 5 months), and 2 patients died of liver failure at 3 and 8 months. The remaining 8 of 12 patients all show stable intestinal absorptive capacity (data not shown). Of 8 patients, 7 were weaned off parenteral nutrition by 4 years. No patient has required repeat STEP or bowel tapering. Two patients developed staple line leak, and 1 patient developed gastrointestinal bleed from staple line ulcers.

CONCLUSION

This report represents the largest series of STEP patients followed up beyond 5 years. Long-term clinical, biochemical, and radiologic outcomes appear to be robust.

Preserving bowel length with a transluminal stent in neonates with multiple intestinal anastomoses: a case series and review of the literature

BACKGROUND/PURPOSE

In neonatal surgery, preserving small bowel length is important to avoid short bowel syndrome. Our aim was to assess the outcomes of intraluminal stenting of neonatal multiple intestinal anastomoses.

METHODS

We conducted a retrospective review of 9 patients (5, single institution; 4, published literature) who received multiple anastomoses stented by a silicon tube. Demographics, surgical anatomy and complications, nutritional outcomes, and follow-up were reviewed.

RESULTS

Diagnosis was multiple intestinal atresias in 8 patients and necrotizing enterocolitis in 1. A silicon catheter entered either the mucous fistula (5 patients received a jejunostomy/mucous fistula) or a proximal opening on the dilated bowel and was threaded through viable segments of the bowel. The bowel ends were approximated. Stent was externalized in 7 patients. Final mean small bowel length was 63.9 cm. All complications (3 patients, leak/stricture) required surgery. Mean time to stent removal, feeds initiation, and parenteral nutrition (PN) discontinuation was 31.2 days, 17.3 days, and 159 days, respectively. Only 1 patient remains on PN (mean follow-up, 25.4 months).

CONCLUSIONS

Multiple intestinal anastomoses stenting is an excellent technique to avoid short bowel syndrome in the setting of multiple viable segments of gut, such as type IV intestinal atresia or necrotizing enterocolitis. Both our experience and the published literature show no mortality and PN-free survival.

Ethanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients with intestinal failure: preliminary experience

BACKGROUND

Catheter-related bloodstream infections (CRBSI) cause morbidity and mortality in patients with intestinal failure dependent on parenteral nutrition. Ethanol lock of central venous catheters may decrease CRBSI, but limited pediatric data are available.

METHODS

Home parenteral nutrition patients with at least one previous CRBSI were initiated on a 70% ethanol lock protocol for a minimum of 4 hours. Infection rates (per 1000 catheter days) before and after initiation of ethanol locks were compared using a paired t test.

RESULTS

Ten patients (4 girls; median age, 44 months [range, 31-129 months]) began ethanol lock therapy after a total of 91 CRBSIs (37 gram-positive, 30 gram-negative, and 24 fungal) with a mean of 10.2 ± 6.2 per 1000 catheter days. Patients received ethanol lock for an average of 227 ± 64 days with only 3 CRBSI occurring (CRBSI rate of 0.9 ± 1.8 per 1000 catheter days [P = .005]). Central venous catheter replacements decreased from 5.6 per 1000 days to 0.3 per 1000 days posttherapy (P = .038). Ethanol lock was discontinued in 2 of 10 patients because of catheter thrombosis.

CONCLUSION

Preliminary results demonstrate a significant decrease in CRBSI with a 70% ethanol lock protocol. Catheter thrombosis may be a limitation that needs to be addressed. With such a dramatic therapeutic effect, a randomized trial is feasible and should be performed.

Human growth hormone and glutamine for patients with short bowel syndrome

BACKGROUND

There has been clinical enthusiasm for treating short bowel patients with human recombinant growth hormone and/or glutamine in hopes of reducing parenteral nutrition dependency. It has been more than a decade since Byrne and colleagues reported enhanced absorption of nutrients, improved weight gain, and reduction in parenteral nutrition requirements with the administration of a combination of human growth hormone (HGH) and glutamine in patients with short bowel syndrome. Other studies have reported inconsistent results.

OBJECTIVES

The purpose of this systematic review was to evaluate the efficacy of growth hormone with or without glutamine supplementation for adult patients with short bowel syndrome.

SEARCH STRATEGY

Electronic searches were performed to identify all publications describing randomised controlled trials of the use of human growth hormone with or without glutamine for the treatment of patients with short bowel syndrome.

SELECTION CRITERIA

Randomised controlled trials of human growth hormone with or without glutamine for patients with short bowel syndrome were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data from the published studies. The statistical analyses were performed using RevMan 5 software. Follmann's method was used for cross-over studies.

MAIN RESULTS

Five studies were included in the review. Human growth hormone with or without glutamine appears to provide benefit in terms of increased weight (MD 1.66 Kg; 95% CI 0.69 to 2.63;P = 0.0008), lean body mass (MD 1.93 Kg; 95% CI 0.97 to 2.90; P = 0.0001) energy absorption (MD 4.42 Kcal; 95% CI 0.26 to 8.58; P = 0.04) and nitrogen absorption (MD 44.85 g; 95%CI 0.20 to 9.49; P = 0.04) for patients with short bowel syndrome. The single RCT that focused on parenteral nutrition (PN) requirements demonstrated decreased PN volume and calories and number of infusions in patients who received HGH with or without glutamine supplementation. Only patients who received HGH with glutamine maintained statistically significant PN reductions at 3 month follow-up.

AUTHORS' CONCLUSIONS

The results suggest a positive effect of human growth hormone on weight gain and energy absorption. However, in the majority of trials, the effects are short-lived returning to baseline shortly after cessation of therapy. The temporary benefit calls into question the clinical utility of this treatment. To date, the evidence is inconclusive to recommend this therapy. Consideration should be made to studying patients during the active phase of intestinal adaptation rather than in the setting of chronic intestinal failure. The role of HGH in paediatric short bowel syndrome remains unknown.

Content validity of a process evaluation checklist to measure intervention implementation fidelity of the EPIC intervention

BACKGROUND

The Evidence-Based Practice Identification and Change (EPIC) intervention is a complex multifaceted knowledge translation strategy that combines the use of evidence and continuous quality improvement to change health care professional practices. However, there is no measure to evaluate the fidelity (degree to which the intervention was implemented as planned) of the EPIC intervention.

AIM

To examine the content validity of the Process Evaluation Checklist (PEC), a newly developed measure to assess the fidelity of the EPIC intervention.

METHODS

Eight health care professionals with experience in the delivery of the EPIC intervention rated the importance/relevance of items in assessing the scale/subscales of the PEC. A content validity index was computed for each item (I-CVI) and for each scale/subscale (S-CVI) in the measure.

RESULTS

I-CVIs ranged from 0.6 to 1.0 and S-CVIs ranged from 0.3 to 1.0. Two items were eliminated, while nine items were retained.

CONCLUSIONS

Content validity of the PEC was established. The PEC will be used to evaluate the implementation fidelity of the EPIC intervention in future trials.

Non-operative management of gastroschisis: a case-matched study

Non-operative management of gastroschisis also known as plastic closure (PC) has been described as an alternative to conventional primary operative closure (POC) or staged silo closure (SSC). The aim of this study was to compare these techniques in neonates with gastroschisis. A retrospective review of neonates with gastroschisis who underwent PC was undertaken. The minimum follow-up was 1 year. Premature neonates (<35 weeks) and those with intestinal atresia or multiple congenital anomalies were excluded. Frequency matching of PC cases with two control groups with either POC or SSC was performed on 1:1 ratio, based on gestational age and birth weight. Statistical analysis using univariate analysis was performed. Three groups were assembled: PC, POC and SSC (n = 33). Median follow-up was 1,198 days. Groups were comparable with regard to: time to first feed, time to full enteral feeding, frequency of vascular access related infections, ventilation time, NICU LOS (length of stay) and hospital LOS. There was no difference observed in surgical complications. Almost all neonates in the PC group developed an umbilical hernia (83.8%). Umbilical hernias were highly associated with PC compared to the other two groups P = 0.001. To date only one patient has had to have an operative repair of the umbilical hernia in the PC group. Plastic closure is safe and comparable to conventional closure techniques. However, PC is associated with the development of more umbilical hernias. The natural history of these hernias remains to be defined.

Percutaneous cholangiography for the treatment of parenteral nutrition-associated cholestasis in surgical neonates: preliminary experience

OBJECTIVE

Parenteral nutrition-associated cholestasis (PNAC) occurs in up to 60% of surgical neonates with intestinal failure, and 10% will develop end-stage liver failure. Our aim was to evaluate the effectiveness of percutaneous transhepatic transcholecystic cholangiography (PTTC) in the treatment of PNAC in surgical neonates.

METHODS

A retrospective double cohort study of surgical neonates with PNAC was conducted. Patients with PNAC who received PTTC were compared to controls matched by gestational age, birth weight, sex, and parenteral nutrition duration. Percutaneous transhepatic transcholecystic cholangiography was performed under general anesthesia with ultrasound guidance. Analysis was performed using paired Student's t test and McNemar chi2 test.

RESULTS

Nine PTTC patients and 9 controls were similar in mean age (35.5 +/- 3.1 vs 35.6 +/- 4.2 weeks, P = .85), birth weight (2531 +/- 879 vs 2692 +/- 1052 g, P = .28), sex (all males), and parenteral nutrition duration (51.2 +/- 29.8 vs 53.3 +/- 33.3 days, P = .74). Percutaneous transhepatic transcholecystic cholangiography was performed in 9 patients at mean corrected age of 5.5 +/- 3.4 weeks and weight of 3621 +/- 546 g. All control patients and 8 (88.9%) of 9 PTTC patients had eventual resolution of hyperbilirubinemia. Percutaneous transhepatic transcholecystic cholangiography patients experienced a more rapid rate of resolution of their cholestasis, and the mean time to resolution of conjugated bilirubin was less in the PTTC group (8.5 +/- 3.2 vs 18.5 +/- 7.6 weeks, P = .02).

CONCLUSION

Therapeutic PTTC results in a 50% reduction in the time to PNAC resolution. Percutaneous transhepatic transcholecystic cholangiography may have a role as active therapy to slow progression of PNAC in surgical neonates with intestinal failure.

Neonatal short bowel syndrome outcomes after the establishment of the first Canadian multidisciplinary intestinal rehabilitation program: preliminary experience

BACKGROUND

A multidisciplinary intestinal rehabilitation team has been in place at our institution for 3 years. Our goal was to compare the preliminary outcomes of neonates with short bowel syndrome before with those after the establishment of our formalized intestinal failure program (Group for the Improvement of Intestinal Function and Treatment [GIFT]).

METHODS

We conducted a retrospective analysis of our intestinal failure registry comparing preGIFT (1997-1999) with GIFT (2003-2005) outcomes.

RESULTS

Fifty-four patients (mean gestational age = 33.5 weeks) were included in the GIFT cohort, and 40 patients (mean gestational age = 30.7 weeks) formed the preGIFT cohort. Overall mortality rates (33.3% vs 37.5%, P = .84) were equivalent in the 2 cohorts, although fewer patients died of liver failure after the establishment of the GIFT. Among those with liver failure, the mortality in the preGIFT group was 9/10 as compared with that of 6/13 in the GIFT group (P = .03). The decrease in liver-related deaths was partly attributable to earlier referral for and increased survival to transplant (4 for the GIFT group vs 0 for the preGIFT group).

CONCLUSIONS

Analysis of the preliminary outcomes of the GIFT program suggests that the natural history of neonatal short bowel syndrome remains unaltered to date despite a coordinated approach to care. However, improved communication and integration with the transplant service have resulted in earlier assessment, increased rates of transplantation, and decreased mortality from liver failure.

Hair cortisol as a potential biologic marker of chronic stress in hospitalized neonates

BACKGROUND

As preterm and term infants in the neonatal intensive care unit (NICU) undergo multiple stressful/painful procedures, research is required that addresses chronic stress.

OBJECTIVES

To determine whether (a) hair cortisol levels differed between term and preterm infants exposed to stress in the NICU and (b) an association exists between hair cortisol levels and severity of illness or indicators of acute stress.

METHODS

Hair cortisol levels were determined using the ELISA method (solid-phase enzyme-linked immunoassay, Alpco Diagnostics, Windham, N.H., USA) in 60 infants >25 weeks gestational age at birth.

RESULTS

No significant differences were found between the hair cortisol levels of term infants compared to preterm infants in the NICU. When compared to a group of healthy term infants, hospitalized infants had significantly higher hair cortisol levels (t (76) = 2.755, p = 0.004). A subgroup analysis of the term NICU infants showed a statistically significant association between total number of ventilator days and hair cortisol levels. For every extra day on the ventilator, hair cortisol levels increased on average by 0.2 nmol/g (p = 0.03). 21% of the variance in hair cortisol levels was explained by the total number of days on the ventilator.

CONCLUSIONS

Hair cortisol is influenced by days of ventilation in NICU term infants. This is a potentially valid outcome for chronic neonatal stress in these infants and warrants further investigation.

Human torovirus: a new virus associated with neonatal necrotizing enterocolitis

AIM

Toroviruses have been associated with gastroenteritis in both animals and humans. The aim of this study was to examine the fecal excretion of torovirus in infants with necrotizing enterocolitis (NEC).

METHODS

We reviewed all infants with NEC admitted to our tertiary care NICU over a 5-y period who had stool specimens sent for microbial culture and virology. Infants in the NICU during the same period with diagnoses other than NEC served as controls.

RESULTS

Forty-four infants with NEC stages I-III were identified, and pathogenic organisms were identified in 27 (61%). Toroviruses were identified in stool cultures in 48% of patients with NEC, and 17% of the non-NEC controls (p<0.001). There was no significant difference in illness severity or mortality between the torovirus-positive and -negative infants with NEC.

CONCLUSION

Torovirus should be added to the list of infectious agents associated with NEC in newborn infants. The exact role torovirus plays in the etiology and progression of NEC warrants further investigation.

Neonatal short bowel syndrome: a cohort study

BACKGROUND

To date, our knowledge of morbidity and mortality in neonatal short bowel syndrome (SBS) is based on individual case series. Shortcomings of the published literature include long patient recruitment time, selection bias, variable SBS definitions, failure to account for gestational age, and incomplete follow-up. By applying more rigorous methodology, our aim was to determine outcomes of SBS neonates compared with a control group of neonates without SBS.

METHODS

A cohort study of all neonates with abdominal pathology requiring laparotomy between January 1, 1997, and December 31, 1998, with observation through July 1, 2001. Short bowel syndrome was defined as patients requiring parenteral nutrition for more than 42 days or residual small bowel length of less than 25% predicted by gestational age. Student's t test, Mann-Whitney U test, and chi2 were used where appropriate. Kaplan-Meier curves were used to determine cumulative survival. Covariates important in the development of SBS were examined using forward step-wise logistic regression.

RESULTS

There were 175 patients (with SBS = 40, without SBS = 135) with a mean gestational age of 30.7 +/- 4.6 weeks vs 35.9 +/- 4.8 weeks, respectively (P < .0005). The patients with SBS suffered significantly more morbidity than the group without SBS in all categories of investigation (surgical complications, septic events, central venous line complications, duration to adaptation and parenteral nutrition independence, cholestasis and liver failure, and duration of hospitalization). The case fatality rate was 37.5% in patients with SBS vs 13.3% in patients without SBS (P = .001). Most of the deaths were caused by liver failure or sepsis and occurred within 1 year from the date of surgery. Presence of an ileostomy (exp(B) = 12.29; P < .0005) and a residual small bowel length less than 50% of the original length (exp(B) = 26.84; P < .0005) were the only 2 variables in a logistic regression analysis found to be independently associated with the development of SBS.

CONCLUSION

This cohort study clearly illustrates the tremendous morbidity experienced by infants with SBS relative to other surgical neonates. Accurate estimates of the morbidity associated with SBS enables clinicians to appropriately counsel parents, allocate resources and initiate therapeutic trials.

[Coronary revascularization with extracorporeal circulation, aortic clamping or OPCAB: does the method's choice influence the results?]

BACKGROUND AND OBJECTIVES

Off pump CABG-OPCAB is the most recent development in coronary surgery and is aimed to avoid the complications of extracorporeal circulation and to compete with interventional cardiology. The objective of this study is to compare 3 methods for cardiac support for CABG.

METHODS

Between February 2001 and December 2002 ninety consecutive patients were operated by the same surgeon and the same team with the following techniques: extracorporeal circulation (CEC) and ischaemic arrest, CEC and beating heart, and OPCAB.

RESULTS

There were no difference in mortality and morbidity for the 3 groups of patients. The OPCAB group showed less ventilation time, less blood transfusion needs and shorter hospital stays than the other 2 groups of patients that showed no differences between each other.

CONCLUSION

OPCAB is safe and showed slight advantage over CEC supported groups but the number of grafts per patient was smaller.

Neonatal short bowel syndrome: population-based estimates of incidence and mortality rates

BACKGROUND

Congenital or acquired neonatal short bowel syndrome (SBS) carries significant morbidity and mortality rates. No accurate population estimates of incidence and mortality exist because of differences in definition, follow-up, and regional referral patterns.

METHODS

A retrospective cohort study was performed involving 175 surgical neonates admitted to our institution from January 1, 1997 to December 31, 1999 and followed up until July 1, 2001. Institution and population-based estimates of incidence and mortality were performed using postcensal population figures (1997) from Statistics Canada.

RESULTS

The overall incidence of SBS was 22.1 per 1,000 neonatal intensive care unit (NICU) admissions (95% CI = 15.3, 28.9) and 24.5 per 100,000 live births (95% CI = 12.1, 36.9). The incidence was much greater in premature infants (less than 37 weeks). The SBS case fatality rate was 37.5% (95% CI = 22.5, 52.5) and the cause-specific and proportional mortality rates (for children less than 4 years old) were 2.0 of 100,000 population per year (0.4 to 3.6/100,000/year) and 1.4% (0.3% to 2.6%), respectively.

CONCLUSIONS

Patients with neonatal SBS pose a complex management challenge and are responsible for a significant cost to the health care system. To our knowledge, this study represents the first population-based estimates for neonatal SBS incidence and mortality rates. Accurate estimates will assist clinicians in counseling parents, allocating resources, and planning clinical trials.

A fluorescence energy transfer method for analyzing protein oligomeric structure: application to phospholamban

We have developed a method using fluorescence energy transfer (FET) to analyze protein oligomeric structure. Two populations of a protein are labeled with fluorescent donor and acceptor, respectively, then mixed at a defined donor/acceptor ratio. A theoretical simulation, assuming random mixing and association among protein subunits in a ring-shaped homo-oligomer, was used to determine the dependence of FET on the number of subunits, the distance between labeled sites on different subunits, and the fraction of subunits remaining monomeric. By measuring FET as a function of the donor/acceptor ratio, the above parameters of the oligomeric structure can be resolved over a substantial range of their values. We used this approach to investigate the oligomeric structure of phospholamban (PLB), a 52-amino acid protein in cardiac sarcoplasmic reticulum (SR). Phosphorylation of PLB regulates the SR Ca-ATPase. Because PLB exists primarily as a homopentamer on sodium dodecyl sulfate polyacrylamide gel electrophoresis, it has been proposed that the pentameric structure of PLB is important for its regulatory function. However, this hypothesis must be tested by determining directly the oligomeric structure of PLB in the lipid membrane. To accomplish this goal, PLB was labeled at Lys-3 in the cytoplasmic domain, with two different amine-reactive donor/acceptor pairs, which gave very similar FET results. In detergent solutions, FET was not observed unless the sample was first boiled to facilitate subunit mixing. In lipid bilayers, FET was observed at 25 degrees C without boiling, indicating a dynamic equilibrium among PLB subunits in the membrane. Analysis of the FET data indicated that the dye-labeled PLB is predominantly in oligomers having at least 8 subunits, that 7-23% of the PLB subunits are monomeric, and that the distance between dyes on adjacent PLB subunits is about 10 A. A point mutation of PLB (L37A) that runs as monomer on SDS-PAGE showed no energy transfer, confirming its monomeric state in the membrane. We conclude that FET is a powerful approach for analyzing the oligomeric structure of PLB, and this method is applicable to other oligomeric proteins.

Tryptophan dynamics of the FK506 binding protein: time-resolved fluorescence and simulations

The FK506-binding protein (FKBP12) is important in the immunosuppressant action of FK506 and rapamycin. We have investigated Trp side chain dynamics in FKBP12, with and without a bound immunosuppressant, by measuring the Trp time-resolved fluorescence anisotropy decay r(t). The r(t) for W59 in aqueous uncomplexed FKBP12 at 20 degrees C is well described by a single exponential with a recovered initial anisotropy, r(eff)o, of 0.192 and an overall rotational correlation time for the protein, phi p, of 4.7 ns; r(eff)o = 0.214 and phi p = 4.2 ns for the FKBP12/FK506 complex. Using an expression for the order parameter squared, namely S2 = r(eff)o/rTo, where rTo is the vitrified steady-state excitation anisotropy, we recovered an S2 of 0.75 for W59 fluorescence in uncomplexed FKBP12 and S2 approximately equal to 1 in the FKBP12/FK506 complex. Results obtained for the FKBP12/rapamycin complex are similar to those found for the FKBP12/FK506 complex. Minimum perturbation mapping simulations were performed on the free and complexed forms of FKBP12 and the results were generally in agreement with the experimental data.

In vitro inhibition of marginal caries-like lesions with fluoride-containing amalgam

Carious lesions surrounding restorations represent one of the main causes of restoration failure. The addition of fluoride compounds to dental restorative materials prevents or reduces recurrent caries. The purpose of this study was to compare the capacity of three restorative materials to inhibit the development of recurrent caries in vitro. Thirty unrestored, noncarious premolars that were being extracted for orthodontic reasons were sectioned in half buccolingually and divided into three groups. One of the groups was restored with conventional amalgam. The second group was restored with a fluoride-containing amalgam, and the third group was restored with a glass-ionomer cement. All the samples were submitted to a medium containing Streptococcus mutans (Ingbritt strain) for 8 weeks. At the end of the 8-week incubation period, the samples were cut into 100 microns sections, soaked in Quinoline (IR = 1.62), and observed with light transmission and polarized light microscopy. The development of artificial caries in the cavity walls was measured in microns. The results show that conventional amalgam had an average caries penetration of 160 microns, fluoride-containing amalgam 46 microns, and glass-ionomer cement 11 microns. Glass-ionomer cement gave the best protection against recurrent caries.

[Breast cancer in the pregnancy-puerperal cycle]

From 1978 to 1988, 611 cases of breast cancer were seen by the Mastology Department of the Beneficência Portuguesa Hospital in São Paulo, Brazil. Thirteen (2.12%) cases were associated to pregnancy, and nine (2.4%) became pregnant after treatment. The patients were submitted to surgery and the authors waited till the end of pregnancy to perform the Rt and/or Qt. Two cases could not be submitted to any kind of treatment. Whenever tests indicated fetal maturity, the option was to perform a caesarean section, and oophorectomy was performed in the most advanced cases. Among patients who became pregnant after treatment, initial cases were predominant and their pregnancies went to term with no problem. The authors compare their results to data found in literature and draw attention to anticonception in mastectomized patients.

[Microbiological study of salt (sodium chloride) of marine origin]

Foram analisadas 19 amostras de SAL (NaCl), tipo grosso, oriundas de diferentes salinas, para verificação da flora microbiana e presença de bactérias nocivas em Microbiologia Alimentar. O material apresentou grande contaminação por microrganismos saprófitas, bactérias aeróbias e anaeróbias, Gram positivas e negativas, proteolíticas, pigmentadas, esporuladas, leveduras e fungos. A alta incidência das bactérias halofílicas "vermelhas", responsáveis pela deterioração de carnes, pescados e outros produtos salgados foi estudada. A freqüência, em 15 amostras de SAL, de bactérias esporuladas termorresistentes foi calculada em 33%, possuindo um SAL germe termofílico. Para anaeróbios a positividade foi de 80%, havendo esporulação em 40% das culturas isoladas. Os índices para leveduras e fungos foram de 73% e 93%, respectivamente.