Growth Hormone, Atherosclerosis and Peripheral Arterial Disease: Exploring the Spectrum from Acromegaly to Growth Hormone Deficiency

Growth hormone (GH) and insulin-like growth factor 1 (IGF-1) are increasingly recognised for their role in cardiovascular (CV) physiology. The GH-IGF-1 axis plays an essential role in the development of the CV system as well as in the complex molecular network that regulates cardiac and endothelial structure and function. A considerable correlation between GH levels and CV mortality exists even among individuals in the general population without a notable deviation in the GHIGF- 1 axis functioning. In addition, over the last decades, evidence has demonstrated that pathologic conditions involving the GH-IGF-1 axis, as seen in GH excess to GH deficiency, are associated with an increased risk for CV morbidity and mortality. A significant part of that risk can be attributed to several accompanying comorbidities. In both conditions, disease control is associated with a consistent improvement of CV risk factors, reduction of CV mortality, and achievement of standardised mortality ratio similar to that of the general population. Data on the prevalence of peripheral arterial disease in patients with acromegaly or growth hormone deficiency and the effects of GH and IGF-1 levels on the disease progression is limited. In this review, we will consider the pivotal role of the GH-IGF-1 axis on CV system function, as well as the far-reaching consequences that arise when disorders within this axis occur, particularly in relation to the atherosclerosis process.

Single-Incision Laparoscopic Appendectomy Using Standard 5 mm Trocars: Single Pediatric Center Experience

Purpose: Single-incision laparoscopic appendectomy (SILA) for the treatment of appendicitis has been documented. Typically, SILA requires the use of specialized ports, instruments, and materials. The SILA technique at our institution utilizes the same instrumentation as the conventional laparoscopic approach (CLA), thus obviating the need for these specialized products. This study aims to further demonstrate the noninferiority of our SILA technique for the treatment of uncomplicated appendicitis. Materials and Methods: This is a single-institution retrospective review of patients who underwent SILA from 2011 to 2020 to treat uncomplicated appendicitis. Outcomes including demographics, operative time, length of stay (LOS), and common postsurgical complications were evaluated. These SILA cases were matched with up to 3 CLA controls based on age, gender, and weight utilizing the Greedy match method. Patients with an operative diagnosis of perforated appendicitis were excluded. Results: A total of 137 patients underwent SILA at a single institution. A total of 128 patients were in the final cohort after excluding perforated appendicitis. Mean age was 11.9 years. Case-control matching was conducted with 349 controls included. Between cases and controls, SILA had shorter operative time (27.2 minutes versus 43.7 minutes, P < .001) with no difference in mean LOS (42.4 hours versus 42.4 hours, P = .88). There was no difference in complication rate (5.4% versus 8.5%, P = .06). There was no difference in readmission rate (0.8% versus 3.4%, P = .108). Conclusion: These data suggest that for appropriately selected patients, our SILA technique is noninferior to CLA with shortened operative time.

Predictors of long-term atrial fibrillation recurrence after catheter ablation: non-linear analytical approach for individualized prognostic stratification

Background

Recurrences are common in patients with atrial fibrillation (AF) during long-term follow-up after catheter ablation (CA) for pulmonary vein isolation (PVI). Recently, machine learning (ML) models identifying non-linear relationships among various patient parameters have been applied for prognostic stratification in different cardiac diseases.

Aim

This is a retrospective study aimed to determine whether ML-based models can identify non-linear relationships in individual clinical baseline characteristics and CT-quantified volumetric parameters of epicardial fat tissue (EFT) to aid in prognosing outcome of catheter ablation for PVI in patients with paroxysmal AF.

Methods

A cohort of 92 patients (median age 60.2 [51.9–64.0]; 74% male) with paroxysmal AF (a single persistent AF episode was accepted) undergoing catheter ablation targeting PVI was analysed. All patients underwent cardiac CT imaging and were fitted with implantable loop recorder (ILR) prior to CA. For PVI, radiofrequency CA with electro-anatomical mapping was used in 79 patients, cryoballoon ablation in 13 patients. AF recurrence, defined as AF burden &gt;0.1% after the blanking period (90 days), was continuously assessed by ILR. Feature selection on 23 baseline parameters was performed using random forest models (XGBoostRegressor). Mean absolute Shapley values (|mSHAP| – Shapley Additive expLanations) were used to quantify the relative discriminative power of analysed parameters.

Results

During a follow-up of 3-years, AF recurrence was detected in 58 (63%) patients, 29 (50%) of them underwent a repeat ablation. Five most important predictors of AF recurrence during 3-year follow-up were upper epicardial fat volume, BMI, baseline AF burden, age and pericardial volume (lower segment) (Fig. 1). Upper EFT volume was twice as important for males than females (0.44 and 0.21 |mSHAP| respectively). For a patient with no AF recurrence, low age (41 years) and low upper EFT volume (13.2 ml) were the most important drivers predicting positive ablation outcome (Fig. 2A). In contrast, in a patient with AF recurrence post CA, an above-average EFT volume of 55.5 ml and a high BMI had the most significant net contribution for predicting his failed CA outcome (Fig. 2B).

Conclusion

Non-linear ML analysis applied to our limited cohort of patients with paroxysmal AF undergoing CA suggests: i) a significant association of high EFT volume with ILR determined AF recurrence during a 3-year follow-up; ii) potential role of such analyses for a more granular and highly individualized prediction of outcome of planned CA. However, these results need further testing, and validation in prospective trials.

Funding Acknowledgement

Type of funding sources: None.

High epicardial fat volume is associated with atrial fibrillation recurrences after catheter ablation

Background

Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation therapy for atrial fibrillation (AF). However, even with important technological improvements, AF recurrences are common in long-term follow-up. Recently, epicardial fat tissue (EFT) has been proposed as a potential AF modulator promoting and sustaining atrial arrhythmogenic milieu.

Aim

In this retrospective single-centre study, we sought to evaluate the association between CT-quantified EFT volume and long-term primary PVI outcome assed by means of continuous ECG monitoring with implantable loop recorders (ILR) in paroxysmal AF patients.

Methods

A cohort of 92 patients (median age 60.2 [IQR 51.9–64.0]; 74% male) with paroxysmal AF (a single persistent AF episode was accepted) undergoing catheter ablation targeted at PVI was analysed. Prior to CA all patients underwent cardiac CT imaging with subsequent implantation of implantable loop recorder (ILR). Radiofrequency CA ablation with electro-anatomical mapping for PVI was used in 79 patients, balloon cryoablation was used in 13 patients. Verified complete PVI was defined as procedural endpoint. EFT volume was semi-automatically segmented and quantified on contrast enhanced CT studies. AF recurrence, defined as AF burden &gt;0.1% after the blanking period (90 days), was continuously assessed by ILR. Kaplan-Meier analysis of AF recurrence-free survival at 1-year, 2-year and 3-year follow-up periods compared patients stratified into EFT volume tertiles.

Results

During a median follow-up of 52.6 months [IQR 43–64], AF recurrence was detected in 58 (63%) patients, 29 (50%) of them underwent a repeat ablation. Patients in high, mid, and low total EFT volume tertiles had a median time to late AF recurrence of 154, 373, and 284 days (Fig. 1A). At a 1-year follow-up, patients in the high EFT volume tertile had the worst AF ablation outcome (p=0.023). However, this difference gradually faded-out and became non-significant at 2 and 3 years. ROC analysis revealed an EFT of 95 ml as an optimal cut-off (p=0.002) for expected arrhythmia recurrence post acutely successful PVI (Fig. 1B).

Conclusion

EFT volume quantification in a relatively homogenous, continuously monitored cohort of patients undergoing catheter ablation for paroxysmal AF revealed a significant association between AF recurrence at 1 year post ablation and volume of epicardial fat. These results suggest a possible role of epicardial adipose tissue as an adverse pro-fibrillatory factor. Identified EFT volume cut-offs have to be validated prospectively on a larger and balanced patient population.

Funding Acknowledgement

Type of funding sources: None.

A Case of Delayed Cecal Perforation After Abdominal (Seat Belt) Injury

Seatbelts have reduced the number of fatal head, facial, and chest injuries. They have, however, introduced a set of injuries comprising abdominal wall bruising, Intra-abdominal injuries, and lumbar spine fractures collectively termed the seat belt syndrome. Surgical repair is the treatment for encountered bowel injuries. We present a case of delayed bowel perforation following presentation with signs of seat belt trauma identifying a decisional dilemma in the surgical management of serosal tears with no apparent signs of perforation.

Deep learning for mortality prediction in patients with a de-novo or worsened heart failure

Background

Heart failure (HF) is a heterogenous syndrome with complex pathophysiology. Biomarkers and clinical risk scores often fail to provide optimal patient-level precision in the prognostic stratification. As utilizing single observational timepoint, they do not capture the entire care pathway with variations in individual patient management. Electronic patient records provide an opportunity to develop new artificial intelligence (AI) strategies for comprehensive prognostic re-stratification reflecting diagnostic and therapeutic management.

Purpose

We sought to use deep artificial intelligence (AI) and develop an unbiased predictive algorithm for all-cause mortality in a cohort of patients hospitalized with a de novo or worsened HF.

Methods

In a cohort of 2449 HF patients hospitalized between 2011–2017, we utilized 151 451 patient exams from 422 parameters. They included clinical phenotyping, medication, ECG, laboratory, echocardiography, catheterization data or percutaneous and surgical interventions gathered on a routine clinical basis reflecting standard of care as captured in individual electronic records. The AI model development consisted of 101 iterations of repeated random subsampling splits into balanced training and validation sets.

Results

AI models yielded performance ranging from 0.83 to 0.89 AUC on the outcome-balanced validation set in predicting all-cause mortality at 30-, 90-, 180-, 360- and 720-day time-limits (Figure 1). The primary endpoint, 1-year mortality prediction model, recorded an 0.85 AUC accuracy. We observed stable model performance across all HF phenotypes: HFpEF 0.83 AUC, HFmrEF 0.85 AUC and HFrEF 0.86 AUC, respectively).

Conclusion

Our findings present a novel, patient-level, AI-based risk prediction of all-cause mortality in heart failure with a robust accuracy across its phenotypes. This suggests the potential of AI based predictive models in a point-of-care approach to guide clinical risk stratification.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): VZW Cardiovascular Research Center Aalst

Substrate Supporting Disc Method for Confirmed Detection of Total Coliforms and E. coli in all Foods: Collaborative Study

The Coli Complete® substrate supporting disc (SSD) method for simultaneous confirmed total coliform count and Escherichia coli determination in all foods was compared with AOAC most probable number (MPN) methods, 966.23 and 966.24. Twenty-nine laboratories participated in this collaborative study in which 6 food types were analyzed. Four food types, raw ground beef, pork sausage, raw liquid milk, and nut meats, were naturally contaminated with coliform bacteria. Two foods, dry egg and fresh frozen vegetables, were seeded with coliforms. Three food types, ground beef, raw liquid milk, and pork sausage, were naturally contaminated with E. coli. Although pork sausage was naturally contaminated, the level was very low (&lt;10/50 g); therefore, additional E. coli were inoculated into 1 lot of this food type. Three food types, nut meats, dry egg, and fresh frozen vegetables, were inoculated with E. coli. For naturally contaminated samples, duplicate determinations were made on 3 separate lots for each food type. For inoculated samples, low, medium, and high contamination levels plus uninoculated control samples were examined in duplicate. Data were analyzed separately for total coliform bacteria and for E. coli. Mean log MPN counts were determined by the SSD method and the appropriate AOAC MPN method. Results were then analyzed for repeatability, reproducibility, and mean log MPN statistical equivalence. Results were statistically equivalent for all total coliform levels in all food types except frozen vegetable and raw nut meat uninoculated control samples and 1 lot of pork sausage where the SSD method produced statistically significant greater numbers. For the E. coli determinations, results were statistically equivalent across all samples and all levels for each food type. The SSD method has been adopted first action by AOAC International for confirmed detection of total coliforms and E. coli in all foods.

Ovarian Torsion in an Adolescent with Beckwith-Wiedemann Syndrome and Unilateral Tubo-ovarian Hyperplasia

BACKGROUND

Beckwith-Wiedemann syndrome (BWS) is the most common pediatric overgrowth syndrome. BWS has a broad phenotypic presentation along with an increased propensity to develop various embryonal tumors. There are very few reported cases of gonadal hyperplasia in BWS patients in the existing literature.

CASE

We describe a 13-year-old girl with BWS who presented with an episode of abdominal pain and was found to have torsion and necrosis of a markedly hyperplastic right ovary and fallopian tube. We present a brief literature review on ovarian hyperplasia in BWS patients for which we used an online search of the databases PubMed, Embase, Ovid Medline, and Cochrane.

RESULTS AND CONCLUSION

Through an extensive literature search, we only found 3 previous reports of ovarian hyperplasia in BWS patients, all in postmortem specimens. Our case highlights a potentially important aspect of visceral organ hyperplasia in patients with BWS that could remain indolent until adolescence and might present as an abrupt-onset abdominopelvic catastrophe.

Fertility preservation in pediatric female cancer patients

OBJECTIVE

To describe and demonstrate ovarian tissue cryopreservation (OTC) as an emerging fertility preservation technique DESIGN: Video presentation.

SETTING

University hospital.

PATIENT(S)

A 6 year-old female patient diagnosed with aplastic anemia with plan for bone marrow transplantation underwent laparoscopic unilateral oophorectomy in conjunction with surgical procedure for port placement by the pediatric surgeon, followed by cryopreservation of ovarian tissue.

INTERVENTION(S)

Laparoscopic unilateral oophorectomy followed by ovarian decortication in the operating room, and ovarian tissue freezing prior to undergoing bone marrow transplantation.

MAIN OUTCOME MEASURE(S)

To present principle surgical techniques of ovarian tissue harvesting prior to OTC in pediatric patients, and different surgical techniques for ovarian auto-transplantation of cryobanked ovarian tissue after completion of gonadotoxic treatment and when the patient is ready to conceive.

RESULT(S)

This video demonstrates the detailed surgical technique for ovarian tissue harvesting. This harvesting can be performed laparoscopically or via mini-laparotomy and can involve a complete oophorectomy versus removing a portion of the ovary (a procedure also known as ovarian decortication).

CONCLUSION(S)

In the prepubertal child, due to the small size of the ovaries, we recommend oophorectomy rather than decortication owing to the small size of prepubertal gonadal tissue. Many young cancer patients can be offered the option of ovarian tissue freezing. This tissue contains immature primordial follicles that can be stored. OTC requires surgical ovarian harvesting followed by cryopreservation of strips of ovarian tissue. The increased number of eggs in prepubertal children underscores the fact that smaller ovarian size in this population does not preclude OTC. At this time, ovarian auto-transplantation is the only option to utilize this stored tissue for fertility preservation. OTC is a relatively new procedure within the area of ART. The overall data from OTC is reassuring and further suggests that cryopreservation of ovarian tissue has the potential to become an established fertility preservation method in the near future.

Wound complications after chemo-port placement in children: Does closure technique matter?

PURPOSE

Wound dehiscence after chemo-port placement is a rare but potentially significant complication. We hypothesize that by using a simple running skin closure technique during chemo-port placement the rate of wound dehiscence and overall wound complications can be significantly decreased.

METHODS

IRB approval was obtained and patients <18years that received a tunneled central line with port from June 2012 to April 2016 were analyzed. Data collected on patients included patient demographics, skin closure type, and wound complications within 30days. Chi-square was performed to examine the univariate association with skin closure technique and wound dehiscence. Logistic regression was performed to examine the multivariable association between skin closure type and wound dehiscence and to compute odds ratios.

RESULTS

There were 259 ports placed in this cohort: 125 used simple running skin closure technique, and 134 used the subcuticular skin closure. Patients were found to not have any difference in rate of dehiscence or overall wound complications based on gender, age, location of port, or use of steroids or chemotherapy within 1week of port placement. When compared, only 1 case (0.80%) in the simple running group vs 10 cases (7.46%) in the subcuticular group experienced a wound dehiscence [unadjusted OR=14.07 (1.69, 116.99) p=0.0144]. When comparing overall wound complications the simple running group had 3 (2.4%) versus 12 (8.96%) in the subcuticular group [unadjusted OR=4.78 (1.27, 17.94) p=0.0203]. When adjusting for port-number both dehiscence and overall wound complications remained statistically significant.

CONCLUSION

We conclude that the simple running skin closure for chemo-port placement in children has superior outcomes in regards to prevention of dehiscence and overall wound related complications when compared to the subcuticular technique.

The Validity of the Clinical Diagnosis of Vestibular Dysfunction

Evaluation of depressed or impaired prone extension, equilibrium, muscle tone, cocontraction, gravitational security, and tolerance to movement are frequently used as clinical signs of vestibular dysfunction. This study sought to determine if controlled laboratory tests of visual-vestibular function would discriminate between normal subjects and a group of adult subjects with a majority of the clinical signs identified above. Vestibular nystagmus, elicited under dark conditions using a computerized rotary chair, was recorded using electronystagmography. The adults with suspected vestibular dysfunction were found to have depressed Scores, indicative of deficits in tonic processing of vestibular inputs within the brainstem. The score found to be the best discriminator between normal subjects and those with suspected impairment was the duration of postrotary nystagmus. Results were interpreted as supportive of a relationship between vestibular processing and learning/motor coordination deficits, and provided support for the validity of symptoms identified through clinical assessment.

Spelling in oral deaf and hearing dyslexic children: A comparison of phonologically plausible errors

A written single word spelling to dictation test and a single word reading test were given to 68 severe-profoundly oral deaf 10-11-year-old children and 20 hearing children with a diagnosis of dyslexia. The literacy scores of the deaf children and the hearing children with dyslexia were lower than expected for children of their age and did not differ from each other. Three quarters of the spelling errors of hearing children with dyslexia compared with just over half the errors of the oral deaf group were phonologically plausible. Expressive vocabulary and speech intelligibility predicted the percentage of phonologically plausible errors in the deaf group only. Implications of findings for the phonological decoding self-teaching model and for supporting literacy development are discussed.

Development of a novel approach to safely couple the intestine to a distraction-induced device for intestinal growth: use of reconstructive tissue matrix

BACKGROUND

Distraction-induced intestinal growth may be a novel treatment for short bowel syndrome. Longitudinal, distractive tension created by the application of force creates a significant challenge: to produce adequate force, yet not cause perforation at the fixation points. This paper describes our development of a coupling strategy to allow for successful bowel lengthening.

METHODS

A curvilinear hydraulic device was implanted in an isolated Roux limb of small bowel in young Yorkshire pigs. Bowel was lengthened over a 2-week period. Study groups included: Group 1: Twelve silk transmural anchoring sutures into an engineered-coupling ring at the ends of each device. Group 2: Addition of felt pledgets to the coupling rings on the serosal surface of the small bowel. Group 3: Extraluminal use of either thin AlloDerm(®), thick AlloDerm(®), or Strattice™ mesh to anchor the device.

RESULTS

Group 1 (suture-only) resulted in a gradual pulling through the suture with increasing tension and no lengthening. Felt pledgets eroded in a similar fashion, causing abdominal sepsis. Thin AlloDerm(®) failed to prevent erosion; however, it protected against gross contamination. Animals in which either thick AlloDerm(®) or Strattice™ mesh was used survived complication free to the study endpoint. Both thick AlloDerm(®) and Strattice™ prevented erosion and perforation allowing for an average of 10.85 cm expansion.

CONCLUSION

This study demonstrates the use of either thick AlloDerm(®) or Strattice™ reconstructive tissue matrix which allows for safe and effective coupling. Further, we suggest this approach could be an adjunct to esophageal lengthening procedures.

RUPERT: a Device for Robotic Upper Extremity Repetitive Therapy

We report the development and initial evaluation of a device for robotic assisted upper extremity repetitive therapy (RUPERT). Intense repetitive physical therapies provided by individualized interaction between the patient and a rehabilitation specialist to overcome upper extremity impairment after stroke are beneficial, however, they are expensive and difficult to evaluate quantitatively and objectively. The need is urgent and growing for a low cost, safe and easy to use robotic device to assist the patient and the therapist to fully achieve the potential benefit of task-based repetitive physical therapies. We designed a pneumatic muscle (PM) driven therapeutic device, the RUPERT, that is wearable and provides assistive forces required to move the arm during performance of several critical tasks of daily living. The robot has four degrees of freedom at shoulder, elbow and wrist. The sensors feedback position and force information for quantitative evaluation of task performance. It has the potential of providing a take-home method of supplementing therapy. The device can also provide real-time, objective assessment of functional improvement of therapy.

Feasibility studies of robot-assisted stroke rehabilitation at clinic and home settings using RUPERT

Task based repetitive therapy has been proposed to help stroke survivors to regain functional control of arm movement. We developed a wearable exoskeleton rehabilitation robot with associated control algorithm and safety protection mechanisms, and a graphic user interface that is easy to use and intuitive to patients and therapists, as the framework for automated and customizable robot-assisted rehabilitation system for clinic and home based therapy. The system was tested in two feasibility studies. The first study involved 6 patients to receive therapeutic training during three time weekly clinic visits for 4 weeks. The second study set up the robot-assisted rehabilitation system at patient's house, where the therapeutic training was practiced on a daily base. Two patients were recruited for the home application study. Patients' performances were assessed using clinical evaluation tools, including Wolf Motor Function Test and Fugl Meyer Assessment (FMA), both before and after the training. The performances of patients during the training weeks were also objectively evaluated by using the robot sensory data.

Rectal bleeding, deep venous thrombosis, and coagulopathy in a patient with Klippel-Trénaunay syndrome

Klippel-Trénaunay syndrome (KTS) is a rare noninheritable congenital disorder comprising vascular malformations that predispose patients to a paradoxical condition where bleeding occurs in a hypercoagulable state. A 16-year-old boy with a complicated lifetime course of KTS presented with massive rectal bleeding. He underwent a partial colectomy, endorectal resection, and splenectomy. Postoperatively, he developed a saddle pulmonary embolus, ultimately requiring placement of an inferior vena cava filter. He eventually did well and has since had his diverting ostomy reversed and resumed his usual activities. This report validates the use of endorectal resection for venous malformation of the rectum in patients with KTS and highlights the difficult balance of controlling bleeding by correction of a consumptive coagulopathy and the increased risk of thromboembolic complications.

Nutrition support in the pediatric surgical patient

This article deals with the nutritional needs of pediatric patients. It begins by discussing the caloric requirements of different pediatric patients and moves on to a breakdown of the specific nutrients required. It then progresses to a detailed description of the enteral and parenteral modalities for delivery of nutrition to pediatric patients. The article concludes with a discussion of specific problems and disorders encountered in pediatric surgical patients.

The use of peritoneal venous shunting for intractable neonatal ascites: a short case series

INTRODUCTION

Intractable ascites in neonates has a varied etiology; and often, the cause is idiopathic. The management usually consists of observation, diuretics, paracentesis, albumin replacements, and self correction. However, in some cases, the above treatment remains unsuccessful.

RESULTS

We present 2 cases of intractable ascites causing metabolic abnormalities, severe protein and immunoglobulin loss, and respiratory compromise. Although the use of peritoneovenous shunts for intractable ascites has been reported previously, our cases differ in both technique and patient size. Our first patient is an ex-28-week premature, 1.4-kg infant with intractable ascites for which a peritoneal drain was initially placed. After 3 weeks and putting out nearly 300 mL of ascitic fluid daily, we placed a peritoneal venous shunt attached to a Medtronic pump. A 6.6F Broviac was placed through the Internal Jugular. The Medtronic pump was placed subcutaneously on the right chest. The pump was compressed 5 to 10 times every 8 hours, keeping fluid actively being infused from the belly to the vascular system. The second patient was 5 months old, 2.8 kg, with a course complicated by necrotizing enterocolitis, prolonged total parenteral nutrition, and progressive liver failure and underwent the same procedure. Both patients had dramatic responses to the shunting postoperatively, with clinical, radiographic, and laboratory evidence of resolution of the ascites. The first patient had the shunt removed at 6 months of age and continues to do well, whereas our second patient had no recurrence of the ascites, but died about 1 year later from cardiopulmonary complications.

CONCLUSION

These 2 cases demonstrate that peritoneovenous shunting, with the assistance of a Medtronic pump, is an effective treatment of intractable neonatal ascites and should be considered early in the course before complications develop.

Utility of amylase and lipase as predictors of grade of injury or outcomes in pediatric patients with pancreatic trauma

INTRODUCTION

Grade of injury, serum amylase, and lipase are markers used to assess pancreatic injury. It is unclear how amylase and lipase relate to grade of injury or predict outcome. We hypothesize that serum amylase and lipase are good predictors of grade of injury and outcomes in patients with pancreatic trauma.

METHODS

This study is a multicenter review from 9 pediatric trauma centers of all children admitted to their institution over 5 years with a pancreatic injury. Initial as well as peak amylase and lipase values were analyzed with relation to pancreatic grade, length of stay, and outcomes.

RESULTS

One hundred thirty-one records were analyzed. There were 44 girls and 85 boys with an average age of 9.0 ± 0.4 years. The mean injury severity score (ISS) score was 15.5 ± 1.2 SE. The average length of stay (in days) was analyzed by grades 0 (3.93), 1 (7.73), 2 (13.4), 3 (18.4), 4 (31), and 5 (13.5). Neither initial nor peak amylase/lipase correlated with grade of injury. Neither amylase nor lipase predicted length of stay or mortality. Maximal amylase was highly predictive of developing a pseudocyst.

CONCLUSION

There seems to be limited value for repetitive routine amylase and lipase levels in the management of pediatric trauma patients with pancreatic injury.

Flow through a mechanical distraction enterogenesis device: a pilot test

BACKGROUND

We tested the coupling portion of a prototype intraluminal distraction enterogenesis device to allow flow-through of simulated enteric contents (SEC) in both pig and human jejunum.

MATERIALS AND METHODS

SEC was made using 80% corn syrup. Ten-cm pig and human intestinal segments had a spoke-shaped 2.2 cm coupling adaptor sutured in place, intraluminally. The adaptor had a flow-through area of 33.6 mm(2). SEC was pumped into the proximal part of the intestinal segment at 0.083 mL/s. The times to first passage of SEC through the coupler (first drop), 10 mL, and 20 mL of SEC eluted from the distal end were recorded.

RESULTS

Mean time to first drop elution was 155 ± 38 s with pig, and 149 ± 22 s with human bowel (P = 0.8). This corresponded to a hydrostatic pressure of 37.5 mmHg before the initial drop passed through. Mean flow rates were 0.094 mL/s in pig bowel and 0.084 mL/s in human bowel (P = 0.09). To account for occlusion from luminal debris, a 75% occlusion of coupler holes was studied in the smaller pig bowel to investigate if reductions in flow-through area could be tolerated. Mean time to first drop increased slightly to 171 ± 15 s, but the elution rate stayed the same (P = 0.5).

CONCLUSIONS

After a physiologic level of initial pressure buildup allowing the first drop of SEC to pass the coupling adaptor, our prototype intestinal coupling adaptor did not obstruct flow-through of SEC, even after a 75% decrease in flow-through area. This type of attachment represents a viable approach to placing a device in-continuity without obstructing flow of enteric contents.

RUPERT closed loop control design

Robot-assisted rehabilitation is an active area of research in the field of stroke rehabilitation. RUPERT is a wearable robotic exoskeleton powered by pneumatic muscle actuators. In this study, we described the structure of the controllers for the five degrees of freedom currently used by RUPERT. We applied the RUPERT on 6 stroke patients to provide robot-assisted rehabilitation therapy in a clinical study. Statistical χ(2) test on the proportion of successfully reaching targets showed that 3 out of the 6 patients demonstrated significant improvement in reaching targets successfully, and the remaining 3 did not show performance improvement or deterioration. We plan to implement the RUPERT in the patient's house for easier access and more frequent use. More significant performance results are expected.

Wandering spleen causing gastric outlet obstruction and pancreatitis

Excessive splenic mobility (i.e. wandering spleen) is a rare condition caused by laxity or deficiency of all the spleen's normal ligamentous attachments in the left hypochondrium. In the pediatric population, a wandering spleen may present as an incidental finding, an abdominal mass or torsion of the vascular pedicle causing venous congestion and acute abdominal pain, and eventually infarction. We present an unusual case of wandering spleen causing pancreatitis and gastric outlet obstruction via direct external compression.

A manner of characterizing the development of countries

An attempt is made to characterize the socio-economic state and the temporal evolution of countries by the use of labor force distribution data on a multidimensional phase plot so that the development of a country is represented by an evolutionary track of a phase point. The evolutionary tracks of several countries are examined, and the phase points of many countries are compared. Snowflake diagrams, which make easy comparison of the socio-economic character of various countries, have also been developed.