Fragility and resilience: parental and family perspectives on the impacts of extreme prematurity

OBJECTIVES

Extremely preterm babies have a significant risk of neurodevelopmental impairment (NDI). There has been little investigation regarding the impact of prematurity on families. The objective of this study was to explore parental perspectives regarding the impact of prematurity on themselves/their family.

METHODS

Over 1 year, parents of children born <29 weeks' gestational age (GA) who were between 18 months old and 7 years old and came for their follow-up visit were invited to participate. They were asked to categorise the impacts of prematurity on their life and their family as positive, negative or both and to describe those impacts in their own words. Thematic analysis was performed by a multidisciplinary group, including parents. Logistic regression was performed to compare parental responses.

RESULTS

Among parents (n=248, 98% participation rate), most (74%) reported that their child's prematurity had both positive and negative impacts on their life or their family's life, while 18% reported only positive impacts and 8% only negative impacts. These proportions were not correlated with GA, brain injury, nor level of NDI. The positive impacts reported included: an improved outlook on life, such as gratitude and perspective (48%), stronger family relationships (31%) and the gift of the child (28%). The negative themes were stress and fear (42%), loss of equilibrium due to medical fragility (35%) and concerns about developmental outcomes including the child's future (18%).

CONCLUSION

Parents report both positive and negative impacts after an extremely preterm birth, independent of disability. These balanced perspectives should be included in neonatal research, clinical care and provider education.

Prenatal Workshops and Support Groups for Prospective Parents Whose Children Will Need Neonatal Care at Birth: A Feasibility and Pilot Study

Introduction: Support groups in neonatal intensive care units (NICUs) are beneficial to parents. The usefulness of prenatal support groups for prospective parents who will have a newborn requiring admission to the NICU has never been investigated. Methods: We assessed the needs of NICU parents regarding topics they would have wished to discuss prenatally and developed the content of a prenatal support workshop. A standardized survey prospectively evaluated the perspectives of pregnant women admitted to a high-risk pregnancy unit who participated in the resulting workshops. Results: During needs assessment, 295 parents invoked themes they would have wished to discuss antenatally: parental guilt, future parental role, normalizing their experience/emotions, coping with many losses, adapting to their new reality, control and trust, information about the NICU, technology around the baby, common neonatal interventions, the NICU clinical team, and the role of parents in the team. These findings were used to develop the workshop, including a moderator checklist and a visual presentation. Practical aspects of the meetings were tested/finalized during a pre-pilot phase. Among 21 pregnant women who answered the survey (average gestational age 29.3 weeks), all agreed that the workshop was useful, that it made them feel less lonely (95%), that exchanges with other women were beneficial (95%) and gave them a certain amount of control over their situation (89%). All answers to open-ended questions were positive. Conclusion: Prenatal educational/support workshops provide a unique and useful means to support future NICU parents. Future investigations will explore whether these prenatal interventions improve clinical outcomes.

Redefining Neurodevelopmental Impairment: Perspectives of Very Preterm Birth Stakeholders

Children born very preterm are at risk of severe neurodevelopmental impairment, a composite endpoint that includes cerebral palsy, developmental delay, and hearing and visual impairment defined by medical professionals. We aimed to describe preterm birth stakeholders' perspectives on this classification. Ten clinical scenarios describing 18-month-old children with different components of severe neurodevelopmental impairment and one scenario of a typically developing child (control) were distributed to parents and stakeholders using a snowball sampling technique. For each scenario, participants rated health on a scale from 0 to 10 and whether the scenario represented a severe condition. Results were analyzed descriptively and mean differences from the control scenario were compared using a linear mixed-effects model. Stakeholders (number = 827) completed 4553 scenarios. Median health scores for each scenario varied from 6 to 10. The rating for the cerebral palsy and language delay scenario was significantly lower (mean difference -4.3; 95% confidence interval: -4.4, -4.1) than the control. The proportion of respondents rating a scenario as "severe" ranged from 5% for cognitive delay to 55% for cerebral palsy and language delay. Most participants disagreed with the rating used in research to describe severe neurodevelopmental impairment in preterm children. The term should be redefined to align with stakeholder perceptions.

Parental perspectives of outcomes following very preterm birth: Seeing the good, not just the bad

AIM

To describe parental perspective on health and developmental outcomes of their preterm child in relation to level of neurodevelopmental impairment (NDI).

METHODS

A parental survey about their children aged 15-36 months corrected age born ˂29 weeks' gestation investigated parental concerns and positive attributes. Parental responses in relation to their child's level of NDI were examined using Kruskal-Wallis and chi-square for trend tests.

RESULTS

One hundred ninety-nine parental responses were obtained for 163 children, including 44% with NDI. Vast majority of parents reported their children were developing well with good physical health. All parents, irrespective of NDI, reported their children were happy and had a positive personality. Appreciation of social interactions was higher for parents of children without versus with NDI (96% vs. 87%, p = 0.039). Parents of children with NDI were more likely to express concerns than those without NDI. Overall, development was the most common area of concern (45%), followed by the child's future (40%) and physical health (35%).

CONCLUSION

Parents of preterm children report many positive points and concerns, some of which are not examined in neonatal follow-up data. These parental perspectives could be used to inform parents of preterm infants, both antenatally and in the neonatal unit.

Pulmonary important outcomes after extremely preterm birth: Parental perspectives

AIM

To describe pulmonary important outcomes (PIO) reported by parents of children born extremely preterm.

METHODS

Over 1-year, all parents of children aged 18 months-7-years born <29 weeks' GA were asked regarding their perspectives. The proportion of parents who described PIO and the themes they invoked were examined. Results were analysed using mixed methods.

RESULTS

Among parental responses (n = 285, 98% participation rate), 44% spoke about PIO, invoking 24 themes pertaining to NICU hospitalisation and/or long-term respiratory health. Some themes had an impact primarily on the child (e.g. exercise limitation), while the majority had an impact on the whole family (e.g. hospital readmissions). None mentioned oxygen at 36 weeks nor bronchopulmonary dysplasia (BPD). The proportion of responses invoking PIO were statistically similar between parents of children with and without BPD, born before or after 25 weeks or with birthweight < or ≥750 g. PIO were more likely to be mentioned in males and among those readmitted for respiratory problems.

CONCLUSION

Parents describe many PIO, most related to the functional impact of lung disease on their child (and family), rather than the diagnosis of BPD itself. Most of these PIO are not primary outcomes in large neonatal trials nor collected in neonatal databases.

Guilt and Regret Experienced by Parents of Children Born Extremely Preterm

OBJECTIVES

To explore decisional regret of parents of babies born extremely preterm and analyze neonatal, pediatric, and parental factors associated with regret.

STUDY DESIGN

Parents of infants born <29 weeks of gestational age, aged between 18 months and 7 years, attending neonatal follow-up were enrolled. Hospital records were reviewed to examine morbidities and conversations with parents about levels of care. Parents were asked the following question: "Knowing what you know now, is there anything you would have done differently?" Mixed methods were used to analyze responses.

RESULTS

In total, 248 parents (98% participation) answered, and 54% reported they did not have regret. Of those who reported regret (n = 113), 3 themes were most frequently invoked: 35% experienced guilt, thinking they were responsible for the preterm birth; 28% experienced regret about self-care decisions; and 20% regretted decisions related to their parental role, generally wishing they knew sooner how to get involved. None reported regret about life-and-death decisions made at birth or in the neonatal intensive care unit. Impairment at follow-up, gestational age, and decisions about levels/reorientation of care were not associated with regret. More mothers reported feeling guilt about the preterm birth (compared with fathers); parents of children with severe lesions on ultrasonography of the head were less likely to report regret.

CONCLUSIONS

Approximately one-half of the parents of infants born extremely preterm had regrets regarding their neonatal intensive care unit stay. Causes of regret and guilt should be addressed and minimized.

Parental perspective on important health outcomes of extremely preterm infants

BACKGROUND AND OBJECTIVE

Neonatal outcome research and clinical follow-up principally focus on neurodevelopmental impairment (NDI) after extremely preterm birth, as defined by the scientific community, without parental input. This survey aimed to investigate parental perspectives about the health and development of their preterm children.

METHODS

Parents of children aged 18 months to 7 years born <29 weeks' gestational age presenting at a neonatal follow-up clinic over a 1-year period were asked to evaluate their children's health and development. They were also asked the following question: 'if you could improve two things about your child, what would they be?' Responses were analysed using mixed methods. Logistic regressions were done to compare parental responses.

RESULTS

248 parents of 213 children (mean gestational age 26.6±1.6 weeks, 20% with severe NDI) were recruited. Parents evaluated their children's health at a median of 9/10. Parental priorities for health improvements were (1) development, mainly behaviour, emotional health and language/communication (55%); (2) respiratory heath and overall medical fragility (25%); and (3) feeding/growth issues (14%). Nineteen per cent explicitly mentioned 'no improvements'. Parents were more likely to state 'no improvements' if child had no versus severe NDI OR 4.33 (95% CI 1.47 to 12.75)) or if parents had no versus at least a high school diploma (OR 4.01 (95% 1.99 to 8.10)).

CONCLUSIONS

Parents evaluate the health of their preterm children as being very good, with positive perspectives. Parental concerns outside the developmental sphere should also be addressed both in clinical follow-up and research.

The shifting educational landscape: science teachers' practice during the COVID-19 pandemic through an activity theory lens

In March 2020, the COVID-19 pandemic closed all educational institutions. Teachers were called upon to respond quickly to the needs of K-12 students. They had to learn how to navigate online learning systems while simultaneously delivering engaging inquiry-based activities in high-stakes school science courses. To understand how teachers navigated these dual tensions, we have drawn on Cultural-Historical Activity Theory (CHAT) to describe how teachers learned and mediated their professional practices to meet the educational needs of their students. We examine the rapidly changing school activity system and how these changes impacted teachers' epistemological beliefs about student engagement and evaluation. We report that teachers developed new styles and attitudes about teaching that reflected the new educational landscape imposed by the pandemic. We explore the pedagogical shifts that characterize this specific time and how the newly acquired pedagogies could find permanence in teachers' activities post-pandemic. This study reports on the experiences of ten teachers from two high schools as they adapt to change during the global pandemic. We followed the teachers' professional journey as they worked in a professional learning community to develop online practices. Professional learning meetings, semi-structured interviews, and participant journals captured teachers' successes and failures as they struggled to adapt inquiry-based science lessons to meet the challenges of teaching online. Their practices shifted as they engaged students in synchronous collaborative projects and laboratory activities, and they developed alternative formative and summative assessment practices. This study contributes to a growing body of research of teacher practice through a CHAT theoretical framework to understand teachers' professional learning during a time of change and upheaval.

Do Open Data Badges Influence Author Behaviour? a Case Study at Springer Nature

Digital badges have previously been shown to incentivise journal authors to share their data openly. In this paper we introduce an Open data badging project at the Springer Nature journal BMC Microbiology. The development of the Open data badge is described, as well as the challenges of developing standard badging criteria and ensuring authors’ awareness of the badges. Next steps for the badging project are outlined, which are based on the experiences of the team assessing the badges, the number of badges awarded at the journal to date, and the results of an author survey.

25 More than meets the eye: Parental perspectives on the health of their extremely preterm children when they reach 18 months, 5 and 7 years

Background

Extremely preterm birth is associated with death and a higher risk of adverse long-term outcomes. Neurodevelopmental impairment (NDI) has become the focus of neonatal follow-up and outcome research, with classifications chosen by clinicians and researchers. However, parents were never consulted about this classification.

Objectives

To examine parental perspectives about the health of their ex-preterm infants.

Design/Methods

Over a one-year period, at Sainte-Justine University Hospital’s Neonatal Follow-Up Clinic, all parents of children born &lt;29 weeks’ gestational age, aged between 18 months corrected age and 7 years were approached. They were asked two questions: “Please rate your child’s health from your point of view on a scale from 0 (very poor) to 10 (excellent)” and “If you could improve up to two things about your child’s health and/or development, what would they be?” Responses were analyzed using mixed methods.

Results

249 parental responses were obtained (98% participation rate). On average, parents rated their child’s health to be 8/10 (range 3-10/10, median 8/10). Main themes invoked about areas for improvement were developmental outcomes (65%):“if he could talk and hold his head up himself”; respiratory heath and overall medical fragility (35%): “improve the health of her lungs”; and behavior/emotional issues (21%): “his anxiety”. Twenty-three percent did not wish to improve anything: “I am very happy with his health and development. I hope he continues on the same path.” When examining developmental outcomes more closely, the recurrent sub-themes for improvement were: language/communication (22%), motor/movement (17%) and cognitive/learning (16%): “improving her attention in school”.

Conclusion

When they come to neonatal follow-up, parents generally perceive the health of their extremely preterm children in a positive way. While some parents have no wishes for improvement in their children, many are concerned by their children’s NDI. On the other hand, several parent-important outcomes, such as lung health and overall medical fragility, are insufficiently investigated during follow-up at the present time.

26 Not What Clinicians Thought: Decisional Regret in Parents of Extremely Preterm Children

Background

Preterm birth is associated with higher risk of death and severe neurodevelopmental impairment. There is an increased risk in extremely preterm infants, raising questions among ethicists and clinicians as to whether providing active care to infants born at the lower extreme is worth the outcomes, and if these outcomes are a source of decisional regrets for parents.

Objectives

Explore decisional regrets in parents of extremely preterm children.

Design/Methods

We consecutively recruited all parents of infants born &lt;29 weeks’ gestational age, aged between 18 months corrected age and 7 years, and seen for neonatal follow-up at a single tertiary center over a one-year period. We asked the following question: “Knowing what you know now, is there anything you would have done differently?” Answers were analyzed independently by two reviewers using qualitative methodology, and discrepancies were resolved by a third reviewer. Mixed methods were used to examine the frequency of each theme and associate parental answers to demographic and clinical factors.

Results

Responses were obtained from 249 parents (98% participation rate). The following main themes emerged: (1) Nothing – I did what I could or was told to do: 53%; (2) Regrets about self-care: 31%; “I would listen to the nurses’ advice to sleep more” (3) Guilt related to the impression preterm labor could have been prevented by them or the medical team: 19%; “I would have pushed for better care and monitoring during pregnancy. I felt as though I wasn’t listened to when I thought I was in labour when sure enough I was” (4) Regrets about parental role in decision-making: 15%; “I would speak up more at the beginning of the hospitalisation”. None of the parents reported on regretting any life-and-death decisions they made at birth and in the neonatal unit.

Conclusion

In our cohort, more than half of parents of surviving preterm infants did not have any regrets associated to their NICU experience. However, lessons can be learned to improve parental support, self-care and solutions to improve their role as parents. Unlike what can be stated using “opinion-based medicine”, limiting or forgoing intensive care is not a solution to eliminate decisional regrets in parents.

Predicting Return to Work in a Heterogeneous Sample of Recently Injured Workers Using the Brief ÖMPSQ-SF

Purpose (1) to examine the ability of the Örebro Musculoskeletal Pain Screening Questionnaire-short version (ÖMPSQ-SF) to predict time to return to pre-injury work duties (PID) following a work-related soft tissue injury (regardless of body location); and (2) to examine the appropriateness of 50/100 as a suitable cut-off score for case identification. Methods Injured workers (IW) from six public hospitals in Sydney, Australia, who had taken medically-sanctioned time off work due to their injury, were recruited by insurance case managers within 5-15 days of their injury. Eligible participants (N = 213 in total) were administered the ÖMPSQ-SF over the telephone by the case manager. For objective (1) Cox proportional hazards regression analysis was used to predict days to return to PID using the ÖMPSQ-SF. For objective (2) receiver operator characteristic (ROC) analysis was used to determine the ÖMPSQ-SF total score that optimises sensitivity and specificity in detecting whether or not participants had returned to PID within 2-7 weeks. Results The total ÖMPSQ-SF score significantly predicted number of days to return to PID, such that for every 1-point increase in the total ÖMPSQ-SF score the predicted chance of returning to work reduced by 4% (i.e., hazard ratio = 0.96), p < 0.001. Sensitivity and specificity for the ROC analysis comparing ÖMPSQ-SF total score to return to PID within 2-7 weeks suggested 48 as the optimal cut off (sensitivity = 0.65, specificity = 0.79). Conclusion The results provide strong support for the use of the ÖMPSQ-SF in an applied setting for identifying those IW likely to have delayed RTW when administered within 15 days of the injury. While a score of 48/100 was the optimal cut point for sensitivity and specificity, pragmatically, 50/100 should be acceptable as a cut-off in future studies of this type.

Long-lived immunity to canine core vaccine antigens in UK dogs as assessed by an in-practice test kit

OBJECTIVES

To determine the utility of an in-practice test kit to detect protective serum antibody against canine distemper virus, canine adenovirus and canine parvovirus type 2 in a sample of the UK dog population.

MATERIALS AND METHODS

Serum samples from 486 dogs, last vaccinated between less than 1 month and 124 months previously, were tested with the VacciCheck™ test kit for protective antibodies against distemper, adenovirus and parvovirus type 2.

RESULTS

A high proportion of the dogs tested (93·6%) had protective antibody against all three of the core vaccine antigens: 95·7% of the dogs were seropositive against canine distemper virus, 97·3% against canine adenovirus and 98·5% against canine parvovirus type 2. The small number of dogs that were seronegative for one or more of the antigens (n = 31) may have had waning of previous serum antibody or may have been rare genetic non-responders to that specific antigen.

CLINICAL SIGNIFICANCE

UK veterinarians can be reassured that triennial revaccination of adult dogs with core vaccines provides long-lived protective immunity. In-practice serological test kits are a valuable tool for informing decision-making about canine core revaccination.

Graphene gas sensing using a non-contact microwave method

We report a non-contact CVD graphene gas sensing method that utilises a high Q microwave dielectric resonator perturbation technique. A graphene sample is coupled to the evanescent field of a dielectric resonator whereupon nitrogen dioxide (NO₂), a p-doping gas, is detected by monitoring the change in the linewidth and frequency of the resonant mode. The resonant peak shape is dependent on the number of carriers in the graphene sheet. Therefore, the linewidth perturbation can be converted to a measurement of the graphene sheet resistance. To demonstrate the strength of this technique, sensor response curves for NO₂ at different concentrations and temperatures are measured showing sub ppm sensitivity. This technique eliminates interactions between the trace gas and metal contacts that otherwise effect the sensor response of the graphene device.

Measuring and communicating meaningful outcomes in neonatology: A family perspective

Medium- and long-term outcomes have been collected and described among survivors of neonatal intensive care units for decades, for a number of purposes: (1) quality control within units, (2) comparisons of outcomes between NICUs, (3) clinical trials (whether an intervention improves outcomes), (4) end-of-life decision-making, (5) to better understand the effects of neonatal conditions and/or interventions on organs and/or long-term health, and finally (6) to better prepare parents for the future. However, the outcomes evaluated have been selected by investigators, based on feasibility, availability, cost, stability, and on what investigators consider to be important. Many of the routinely measured outcomes have major limitations: they may not correlate well with long-term difficulties, they may artificially divide continuous outcomes into dichotomous ones, and may have no clear relationship with quality of life and functioning of children and their families. Several investigations, such as routine term cerebral resonance imaging for preterm infants, have also not yet been shown to improve the outcome of children nor their families. In this article, the most common variables used in neonatology as well as some variables which are rarely measured but may be of equal importance for families are presented. The manner in which these outcomes are communicated to families will be examined, as well as recommendations to optimize communication with parents.

7-year retrospective review of quad bike injuries admitted to Starship Children's Hospital

AIMS

To ascertain morbidity and mortality of children who presented to Starship Children's Hospital with injuries from a quad bike incident from 2007 to 2014, and to review whether current guidelines are sufficient to prevent injury.

METHODS

A retrospective case note review of all children under the age of 16 years who presented to Starship Hospital with an injury sustained whilst riding a quad bike between January 2007 and July 2014.

RESULTS

Twenty-seven patients were identified through both the Starship Children's Hospital Trauma and Paediatric Intensive Care databases with injuries resulting from a quad bike incident. Fifteen patients (56%) had multisystem injuries. The average injury severity score (ISS) was 14 (range 1-75). ISS was higher in those of younger age (<5 years), lower body weight (<20kg), requiring PICU admission and those sustaining head injuries with no helmet. Seven (25.9%) patients required PICU admission, two patients died (7.4%) and three patients (12%) survived to discharge with disability.

CONCLUSIONS

This study supports current published guidelines which recommend limiting the use of quad bikes by children. Current guidelines do not, however, prevent injury in the paediatric population.

Low energy fractures of the acetabulum

INTRODUCTION

Acetabular fractures due to high energy injuries are common and well documented; those secondary to low energy mechanisms are less well described. We undertook a retrospective study of the acetabular fracture referrals to our unit to evaluate the proportion of injuries resulting from a low energy mechanism.

METHODS

A total of 573 acetabular fractures were evaluated from 1 January 2005 to 31 December 2008. The plain radiography and computed tomography of those sustaining a low energy fracture were assessed and the fracture patterns classified.

RESULTS

Of the 573 acetabular fractures, 71 (12.4%) were recorded as being a result of a low energy mechanism. The male-to-female ratio was 2.4:1 and the mean patient age was 67.0 years (standard deviation: 19.1 years). There was a significantly higher number of fractures (p<0.001) involving the anterior column (with or without a posterior hemitransverse component) than in a number of previously conducted large acetabular fracture studies.

CONCLUSIONS

Our results demonstrate that low energy fractures make up a considerable proportion of acetabular fractures with a distinctly different fracture pattern distribution. With the continued predicted rise in the incidence of osteoporosis, life expectancy and an aging population, it is likely that this type of fracture will become increasingly more common, posing difficult management decisions and leading to procedures that are technically more challenging.

Evidence for a GVL effect following reduced-intensity allo-SCT in ALL: a British Society of Blood and Marrow Transplantation study

Myeloablative allo-SCT decreases relapse incidence (RI) in ALL. Reduced intensity conditioning (RIC) may extend allo-SCT to older and less fit patients. Sixty-nine ALL patients reported to the BSBMT underwent fludarabine-based RIC allo-SCT, 38 from unrelated donors (UD). Forty-four patients received alemtuzumab. ALL was in CR in 64 patients (93%). This was a second or third SCT in 23 patients. Two-year OS and PFS were 36% and 32%, respectively. In multivariate analysis male recipients demonstrated better OS and PFS (hazard ratio (HR) = 0.42, P = 0.008 and HR = 0.45, P = 0.012, respectively). Two-year TRM was 29%: higher with younger age (HR = 0.97/year, P = 0.041), female recipient (HR = 2.55, P = 0.049) and increasing grade of acute GVHD (HR = 1.87, P = 0.001). Two-year RI was 38% and was lower in patients with acute and chronic GVHD (HR = 0.62 per increasing grade, P = 0.035 and HR = 0.52, P = 0.025, respectively). Long-term ALL-free survival is achievable following fludarabine-based RIC allo-SCT. The association between GVHD and decreased RI suggests the presence of a GVL effect.

Markers of circulating tumour cells in the peripheral blood of patients with melanoma correlate with disease recurrence and progression

BACKGROUND

Multimarker quantitative real-time polymerase chain reaction (qRT-PCR) represents an effective method for detecting circulating tumour cells in the peripheral blood of patients with melanoma.

OBJECTIVES

To investigate whether the phenotype of circulating melanoma cells represents a useful indicator of disease stage, recurrence and treatment efficacy.

METHODS

  Peripheral blood was collected from 230 patients with melanoma and 152 healthy controls over a period of 3years and 9months. Clinical data and blood samples were collected from patients with primary melanoma (early stages, 0-II, n=154) and metastatic melanoma (late stages, III-IV, n=76). Each specimen was examined by qRT-PCR analysis for the expression of five markers: MLANA, ABCB5, TGFβ2, PAX3d and MCAM.

RESULTS

 In total, 212 of the patients with melanoma (92%) expressed markers in their peripheral blood. Two markers, MLANA and ABCB5, had the greatest prognostic value, and were identified as statistically significant among patients who experienced disease recurrence within our study period, being expressed in 45% (MLANA) and 49% (ABCB5) of patients with recurrence (P=0·001 and P=0·031, respectively). For patients administered nonsurgical treatments, MCAM expression correlated with poor treatment outcome.

CONCLUSIONS

Circulating tumour cells were detectable at all stages of disease and long after surgical treatment, even when patients were considered disease free. Specifically, expression of ABCB5 and MLANA had significant prognostic value in inferring disease recurrence, while MCAM expression was associated with poor patient outcome after treatment, confirming multimarker qRT-PCR as a potential technique for monitoring disease status.

Partial nephroureterectomy in a duplex system in children: the need for additional bladder procedures

INTRODUCTION AND OBJECTIVES

Heminephroureterectomy (HN) is our treatment of choice in a duplex system with non-functioning moiety. We examined the need for endoscopic incision (EI)/bladder reconstructive surgery (BRS) and whether ureteroceles and/or vesicoureteric reflux (VUR) influenced management options.

METHODS

Retrospective study of patients undergoing HN by a single surgeon (2003-2008). Patients were classified according to the presence (Group 1) or absence (Group 2) of ureterocele. The groups were subdivided with coexisting dilating VUR (a) or not (b). Statistical analysis included Fisher's exact test.

RESULTS

Thirty-one children were identified. Seventeen (54.8%) had ureterocele (Group 1) and 14 patients had no ureterocele (Group 2). Group 1 had eight with VUR (1a) and nine without (1b). Group 2 had seven with VUR (2a) and seven without (2b). Significantly more patients with ureterocele required EI/BRS (p = 0.006). Five (29%) in Group 1 required BRS versus none in Group 2 (p = 0.04). Six (75%) in Group 1a underwent EI/BRS versus three (33%) in Group 1b (p = 0.15). Significantly more in Group 1a required EI prior to HN versus Group 1b (p = 0.04). Similar numbers of patients required BRS in Groups 1a and 1b (p = 0.61).

CONCLUSIONS

In the absence of ureterocele, there is minimal likelihood of requiring surgery apart from HN, independent of VUR. Presence of ureterocele is an indicator for additional procedure within the bladder. There is a higher incidence of EI when ureterocele co-exists with dilating VUR.

Molecular monitoring of resistant dhfr and dhps allelic haplotypes in Morogoro and Mvomero districts in south eastern Tanzania

BACKGROUND

Resistance to the antimalarial drug sulfadoxine-pyrimethamine (SP) emerged in Plasmodium falciparum from Asia in the 1960s and subsequently spread to Africa. In Tanzania, SP use as a national policy began in 1983 as a second line to chloroquine (CQ) for the treatment of uncomplicated malaria, until August 2001 when it was approved to replace CQ as a national first line.

OBJECTIVE

The present study assesses the frequency of resistant dhfr and dhps alleles in Morogoro-Mvomero district in south eastern Tanzania and contrast their rate of change during 17 years of SP second line use against five years of SP first line use.

METHODOLOGY

Cross sectional surveys of asymptomatic infections were carried out at the end of rainy season during July-September of 2000, when SP was the national second line (CQ was the first line) and 2006 when SP was the national first line antimalarial treatment. Genetic analysis of SP resistance genes was carried out on 1,044 asymptomatic infections and the effect of the two policies on SP evolution compared.

RESULTS

The frequency of the most resistant allele, the double dhps-triple dhfr mutant genotype, increased by only 1% during 17 years of SP second line use, but there was a dramatic increase by 45% during five years of SP first line use.

CONCLUSION

We conclude that National policy change from second line to first line SP, brought about an immediate shift in treatment practice and this in turn had a highly significant impact on drug pressure. The use of SP in specific programs only such as intermittent preventive treatment of infants (IPTi) and intermittent preventive treatment of pregnant women (IPTp) will most likely reduce substantially SP selection pressure and the SP resistance alleles alike.

Outcomes of acetabular fracture fixation with ten years' follow-up

We report the outcome of 161 of 257 surgically fixed acetabular fractures. The operations were undertaken between 1989 and 1998 and the patients were followed for a minimum of ten years. Anthropometric data, fracture pattern, time to surgery, associated injuries, surgical approach, complications and outcome were recorded. Modified Merle D'Aubigné score and Matta radiological scoring systems were used as outcome measures. We observed simple fractures in 108 patients (42%) and associated fractures in 149 (58%). The result was excellent in 75 patients (47%), good in 41 (25%), fair in 12 (7%) and poor in 33 (20%). Poor prognostic factors included increasing age, delay to surgery, quality of reduction and some fracture patterns. Complications were common in the medium- to long-term and functional outcome was variable. The gold-standard treatment for displaced acetabular fractures remains open reduction and internal fixation performed in dedicated units by specialist surgeons as soon as possible.

Open reduction and internal fixation of a traumatic diastasis of the pubic symphysis: one-year radiological and functional outcomes

The aim of this study was to review the number of patients operated on for traumatic disruption of the pubic symphysis who developed radiological signs of movement of the anterior pelvic metalwork during the first post-operative year, and to determine whether this had clinical implications. A consecutive series of 49 patients undergoing internal fixation of a traumatic diastasis of the pubic symphysis were studied. All underwent anterior fixation of the diastasis, which was frequently combined with posterior pelvic fixation. The fractures were divided into groups using the Young and Burgess classification for pelvic ring fractures. The different combinations of anterior and posterior fixation adopted to stabilise the fractures and the type of movement of the metalwork which was observed were analysed and related to functional outcome during the first post-operative year. In 15 patients the radiographs showed movement of the anterior metalwork, with broken or mobile screws or plates, and in six there were signs of a recurrent diastasis. In this group, four patients required revision surgery; three with anterior fixation and one with removal of anterior pelvic metalwork; the remaining 11 functioned as well as the rest of the study group. We conclude that radiological signs of movement in the anterior pelvic metalwork, albeit common, are not in themselves an indication for revision surgery.

Idiopathic slow transit constipation is rare. But delayed passage of meconium is common in the constipation clinic

We hypothesise that constipated children would be more likely to come from a socially deprived background. We also hypothesise that a percentage of children with resistant constipation would have a congenital gut motility problem that might be recognised at birth, and that some of these would have slow transit constipation that could be recognised on nuclear transit study. One hundred and forty children with a constipation related diagnosis were seen in the last 4 years, and were reviewed as a retrospective audit. Twenty-six children who were felt likely to have a congenital cause for their constipation were offered nuclear colon transit study to search for slow transit constipation. One hundred and forty children from the constipation clinic were reviewed. There were 67 females (47.9%) and 73 males (52.1%), a sex ratio near equality. The mean age at presentation was 5.38 years. Forty-one percent were formally discharged, 36% were lost to follow up, and 23% are still being seen. There was a highly significant tendency for these children to have delayed passage of meconium, as compared normal newborns (P << 0.001). Twenty-six children were considered for possible transit study, and 14 were performed. Four of these were normal, seven showed hold up in the recto-sigmoid, and three showed more proximal slow transit. Two of these probably have non ISTC diagnoses. Social class seems similar to the general population on the criterion employed. Delayed passage of meconium in this group was significantly more frequent than in the general population, but only one of the group seems likely to have truly idiopathic slow transit constipation, and he did not have delayed passage of meconium. There is no evidence for an effect of social class in this population. Idiopathic slow transit constipation itself is rare.

An analysis of the optimal timing of peripheral blood stem cell harvesting following priming with cyclophosphamide and G-CSF

Increasing demand on the apheresis service makes efficient harvesting of peripheral blood stem cells (PBSCs) essential. A total of 168 adult patients with haematological malignancy were primed using low-moderate dose cyclophosphamide (1.5-3 g/m(2)) with G-CSF 5-10 microg/kg per day. Harvesting was booked and peripheral blood (PB) counts first checked between 6 and 10 days post-priming. One hundred and thirty (77%) patients harvested successfully (total harvest yield > or =2 x 10(6) CD34(+)/kg) and the median PBSC collection per procedure was 2.18 x 10(6)/kg (range 0.1-14.5). Only more lines of prior chemotherapy predicted failure to harvest in multivariate analysis (P=0.003). The PB CD34(+) cell count correlated significantly with harvest yield (r=0.8448, P<0.0001). A PB CD34(+) count > or =10/microl predicted a collection of > or =2 x 10(6)/kg (positive-predictive value of 61%, negative-predictive-value 100%). Patients first attending day 9 required significantly fewer visits to achieve a successful harvest than those first attending days 6-8 without increasing the risk of failure. No significant difference in failure rates, number of days attending and total harvest yield was found between days 9 and 10 attendees. Collection from day 9 may however enable higher target yields to be achieved. PB CD34(+) count monitoring should commence and harvesting booked from day 9 to optimize both the harvest and the efficiency of the PBSC harvesting service.

The role of high-dose therapy and stem cell rescue in the management of T-cell malignant lymphomas: a BSBMT and ABMTRR study

Peripheral T-cell lymphomas (PTCL) are a rare and heterogeneous subset of lymphomas with a poorer prognosis compared with B-cell lymphomas. We conducted a retrospective study of 82 patients who received high-dose therapy for PTCL (autologous SCT (ASCT) N=64; allogeneic SCT (Allo-SCT) N=18). With a median follow-up from ASCT of 37 months from transplant, 33 patients were alive; 20 died of progressive disease, 10 died from non-relapse mortality (NRM) with 1 unknown cause. Three-year overall survival (OS) and progression-free survival (PFS) were 53% (95% confidence interval (CI) 42, 67) and 50% (95% CI 39, 64), respectively. Factors significantly affecting OS and PFS on univariate analysis were histological subtype and chemotherapy sensitivity. In a multivariate analysis, the only factor with significant impact was chemotherapy sensitivity. After a median follow-up from Allo-SCT of 57 months, five patients were alive; five died of progressive disease and eight died from NRM. The 3-year OS and PFS were 39% (95% CI 22, 69) and 33% (95% CI 17, 64), respectively, and the 3-year relapse rate was 28% (95% CI 6, 50). These results demonstrate that high-dose chemotherapy with autologous stem cell rescue has a substantial role in the management of T-cell lymphoma. The use of full-intensity allogeneic transplantation is limited by high transplant-related mortality, and exploration of reduced intensity regimens is warranted.

The role of imported cases in the epidemiology of urban Plasmodium falciparum malaria in Quibdó, Colombia

OBJECTIVE

To assess the role of imported cases in the local epidemiology of malaria and population genetics of Plasmodium falciparum in an urban endemic area in Colombia.

METHOD

A total of 679 P. falciparum cases presenting in the city were interviewed, mapped, and genotyped using msp1 and msp2 molecular markers.

RESULTS

Among the cases, 75% were classified as imported and harboured single-clone infections. The P. falciparum parasite population had low genetic diversity with a preponderant haplotype (mean genetic diversity H = 0.36), even when microsatellite markers were used (H = 0.49), partly because of the small scale at which population movement was studied. Nevertheless, indigenous and potentially introduced cases were identified.

CONCLUSION

Migration is a confounder in planning malaria control in this endemic urban area. Longitudinal studies which monitor the P. falciparum population in imported and autochthonous cases at larger spatial scales would be necessary to study the effect of population movement on malaria transmission and, with suitable molecular markers, on the spread of drug resistance.

Major salivary gland agenesis in a young child: consequences for oral health

BACKGROUND

Salivary gland agenesis is a rare condition. It can be associated with some equally rare syndromes so that diagnosis can be delayed.

CASE REPORT

The authors describe a case report. A 3-year-old girl, presented with dry mouth, carious teeth, recurrent herpes labialis and tonsillitis to Newcastle Dental Hospital. This case highlights the diagnostic and therapeutic challenges posed by 'salivary gland agenesis'.

CONCLUSION

Primary and secondary paediatric healthcare professionals should be aware of the possibility of salivary gland agenesis in the setting of the 'non drooling baby'. Early detection of 'salivary gland agenesis' would do much to prevent the deleterious oral affects which follow the absence of salivary protection in the oral cavity.

Beatty's box

William Beatty, the surgeon aboard the Victory who tended Nelson in his final moments, had an unusual set of surgical instruments, put together to his own specification