Upper Gastrointestinal Function in Morbidly Obese Adolescents Before and 6 Months After Gastric Banding

BACKGROUND

The effects of laparoscopic adjustable gastric band (LAGB) placement on upper gastrointestinal tract function in obese adolescents are unknown. Therefore, our aim was to determine the short-term effects of LAGB on esophageal motility, gastroesophageal reflux, gastric emptying, appetite-regulatory hormones, and perceptions of post-prandial hunger and fullness.

METHODS

This study was part of a prospective cohort study (March 2009-December 2015) in one tertiary referral hospital. The study included obese adolescents (14-18 years) with a body mass index (BMI) > 40 (or ≥ 35 with comorbidities). Gastric emptying was assessed by ¹³C-octanoic acid breath test, pharyngeal, and esophageal motor function by high-resolution manometry with impedance (HRIM), and appetite and other perceptions using 100-mm visual analogue scales. Dysphagia symptoms were scored using a Dakkak questionnaire. Data were compared pre- and post-LAGB placement and at a 6-month follow-up.

RESULTS

Based upon analysis of 15 adolescents, at the 6-month follow-up, LAGB placement: (i) led to a significant reduction in weight and BMI; (ii) increased fullness and decreased hunger post-meal; (iii) increased symptoms of dysphagia after solid food; and, despite these effects, (iv) caused little or no changes to appetite hormones, while (v) effects on gastric emptying, esophageal motility, esophageal bolus transport, and esophageal emptying were not significant.

CONCLUSION

In adolescents, LAGB improved BMI and altered the sensitivity to nutrients without significant effects on upper gastrointestinal tract physiology at the 6-month follow-up.

Long-term neurodevelopment outcome of caffeine versus aminophylline therapy for apnea of prematurity

OBJECTIVE

Methylxanthines are the most commonly prescribed drug in neonatal setups. However, Clinicians show indecision in choosing the right agent for Apnea of Prematurity in most of the developing countries. Present study aimed to compare rate of mortality and survival with normal neurodevelopment outcome at 18 to 24 months of corrected age, between Caffeine- and Aminophylline-treated infants for apnea of prematurity.

METHODS

240 infants were randomly allocated to caffeine and aminophylline for apnea of prematurity during February 2012 to January 2015. Long-term neurodevelopmental assessment was done only from children who had attained corrected age of 18 to 24 months during April 2014 to February 2016. Cognitive, language and motor deficits were assessed by Bayley Scale of infant and toddler development (BSID - III). Postnatal characteristics such as hearing and visual impairments during NICU stay were noted and same were followed up.

RESULTS

Infants allocated to caffeine group showed 83% less risk of getting cognitive impairment (RR 0.16; CI 95% range 0.02 to 1.36), 50% less risk of developing motor deficits (RR 0.50; CI 95% range 0.12 to 1.95) and 24% less risk of developing language problems (RR 0.76; CI 95% range 0.36 to 1.58). However in all the neurodevelopment domains the difference between groups was not statistically significant. Risk of mortality in caffeine group was 9% less over aminophylline group which was statistically non-significant (RR - 0.92; CI 95% range - 0.45 to 1.84; p = 0.81). Physical growth parameters were found to be similar in both the groups. Risk of developing visual abnormality and hearing impairments was also statistically non-significant between the groups.

CONCLUSION

Caffeine and aminophylline showed similar effects in reducing the rate of mortality and improving the survival without neurodevelopment delays; though the clinical significance of caffeine over aminophylline cannot be undermined.

A study of dysphagia symptoms and esophageal body function in children undergoing anti-reflux surgery

BACKGROUND

The role of high-resolution esophageal impedance manometry (HRIM) for establishing risk for dysphagia after anti-reflux surgery is unclear. We conducted a prospective study of children with primary gastroesophageal reflux (GER) disease, for whom symptoms of dysphagia were determined pre-operatively and then post-operatively and we examined for features that may predict post-operative dysphagia.

METHODS

Thirteen children (aged 6.8-15.5 years) undergoing work-up prior to 360o Nissen fundoplication were included in the study. A dysphagia score assessed symptoms at pre-operative study and post-operatively (mean 1.4 years). A HRIM procedure recorded 5-ml liquid, 5-ml viscous and 2-cm solid boluses. We assessed esophageal motility, esophago-gastric junction (EGJ) morphology, EGJ contractility and pressure-flow variables indicative of bolus distension pressures and bolus clearance pressures. A composite pressure-flow index score was also derived.

RESULTS

Pre-operative pressure-flow index was positively correlated with post-operative dysphagia score (viscous bolus r = 0.771, p < 0.005). Of three variables that comprise the pressure-flow index, the ramp pressure measured during bolus clearance was the main driver of the effect seen (viscous bolus r = 0.819, p < 0.005).

CONCLUSIONS

In order to mitigate symptoms in relation to anti-reflux surgery, dysphagia symptoms and esophageal function need to be pre-operatively assessed. In patients with normal motility, an elevated pressure-flow index may predict post-operative dysphagia.

Improving ability of RSV microneutralization assay to detect G-specific and cross-reactive neutralizing antibodies through immortalized cell line selection

Respiratory syncytial virus (RSV) is a significant cause of bronchiolitis and pneumonia. Protection against RSV is associated with neutralizing antibodies against the fusion (F) and attachment (G) glycoproteins. Several RSV vaccine candidates are in development, but their immunogenicity is hard to compare due to the little-understood differences between multiple RSV neutralizing antibody assays used. Existing assays utilize primarily Vero or HEp-2 cells, but their ability to detect G-neutralizing antibodies or antibodies against specific RSV strains is unclear. In this work, we developed an RSV microneutralization assay (MNA) using unmodified RSV and immortalized cell line derived from human airway epithelial cells (A549). Performance of A549-, HEp-2- and Vero-based MNA was compared under the same assay conditions (fixed amount of virus and cells) with regards to detection of neutralizing antibodies against RSV A or B viruses, G-reactive neutralizing antibodies, and effect of complement. Our results indicate that A549 cells yield the highest MNA titers, particularly in the RSV A/A2 MNA, are least susceptible to complement-enhancing effect of neutralizing titer readout and are superior to Vero or HEp-2 MNA at recognizing G-reactive neutralizing antibodies when no complement is used. Vero cells, however, can be more consistent at recognizing neutralizing antibodies against multiple RSV strains. The choice of substrate cells thus affects the outcome of MNA, as some immortalized cells better support detection of broader range of neutralizing antibodies, while others facilitate detection of G-targeting neutralizing antibodies, a long-thought prerogative of primary airway epithelial cells.

Effects of concurrent training on physical health and performance

The primary objective of this narrative review was to evaluate the current literature and to provide further insight into the role of concurrent training on various components of physical health or performance. Literature was obtained by electronic searches of databases using specific keywords. Combined effect of training sessions proved to be as beneficial as drug interactions. Results from cross-sectional, longitudinal, and intervention studies are reviewed and discussed with main focus on physical parameters, such as body composition, physiological parameters, molecular adaptation, athlete’s perspective, order of execution, interference phenomena and recovery. In conclusion, concurrent resistance and endurance training is an effective method for enhancing overall fitness as well as improving quality of life.

Chemotherapy and targeted therapy in the management of cervical cancer

Management of cervical cancer has undergone refinement in the past two decades; concurrent chemo-radiation (CCRT) (with cisplatin alone or in combination) is currently the standard treatment approach for patients with locally advanced disease (FIGO stage IIB-IVA). About 30%-40% of such patients fail to achieve complete response; alternative approaches are needed to improve outcome for them. Treatment with bevacizumab (an inhibitor of vascular endothelial growth factor) along with chemotherapy is associated with improved survival in patients with recurrent or metastatic cervical cancer. Weekly paclitaxel and carboplatin for 4-6 weeks as dose dense chemotherapy prior to CCRT is currently under study in a phase III, multicentric trial. Role of adjuvant chemotherapy after CCRT in patients with positive lymph nodes, larger tumor volume and those with stage III-IVA disease needs further exploration. Novel agents targeting molecular pathways are currently being studied. Recent development of immune check point inhibitors is exciting, results of ongoing studies are awaited with interest.

Can common serum biomarkers predict complicated appendicitis in children?

PURPOSE

As appendicitis in children can be managed differently according to the severity of the disease, we investigated whether commonly used serum biomarkers on admission could distinguish between simple and complicated appendicitis.

METHODS

Admission white blood cell (WBC), neutrophil (NEU), and C-reactive protein (CRP) levels were analysed by ROC curve, and Kruskal-Wallis and contingency tests. Patients were divided according to age and histology [normal appendix (NA), simple appendicitis (SA), complicated appendicitis (CA)].

RESULTS

Of 1197 children (NA = 186, SA = 685, CA = 326), 7% were <5 years, 55% 5-12, 38% 13-17. CA patients had higher CRP and WBC levels than NA and SA (p < 0.0001). NEU levels were lower in NA compared to SA or CA (p < 0.0001), but were similar between SA and CA (p = 0.6). CA patients had higher CRP and WBC levels than SA patients in 5-12- (p < 0.0001) and 13-17-year groups (p = 0.0075, p = 0.005), but not in <5-year group (p = 0.72, p = 0.81). We found CRP >40 mg/L in 58% CA and 37% SA (p < 0.0001), and WBC >15 × 10⁹/L in 58% CA and 43% SA (p < 0.0001).

CONCLUSIONS

Admission CRP and WBC levels may help the clinician predict complicated appendicitis in children older than 5 years of age. Early distinction of appendicitis severity using these tests may guide caregivers in the preoperative decision-making process.

Global trends in paediatric robot-assisted urological surgery: a bibliometric and Progressive Scholarly Acceptance analysis

The inaugural robot-assisted urological procedure in a child was performed in 2002. This study aims to catalogue the impact of this technology by utilizing bibliographic data as a surrogate measure for global diffusion activity and to appraise the quality of evidence in this field. A systematic literature search was performed to retrieve all reported cases of paediatric robot-assisted urological surgery published between 2003 and 2016. The status of scientific community acceptance was determined using a newly developed analysis model named progressive scholarly acceptance. A total of 151 publications were identified that reported 3688 procedures in 3372 patients. The most reported procedures were pyeloplasty (n = 1923) and ureteral reimplantation (n = 1120). There were 16 countries and 48 institutions represented in the literature. On average, the total case volume reported in the literature more than doubled each year (mean value increase 236.6% per annum). The level of evidence for original studies remains limited to case reports, case series and retrospective comparative studies. Progressive Scholarly Acceptance charts indicate that robot-assisted techniques for pyeloplasty or ureteral reimplantation are yet to be accepted by the scientific community. Global adoption trends for robotic surgery in paediatric urology have been progressive but remain low volume. Pyeloplasty and ureteral reimplantation are dominant applications. Robot-assisted techniques for these procedures are not supported by high quality evidence at present. Next-generation robots are forecast to be smaller, cheaper, more advanced and customized for paediatric patients. Ongoing critical evaluation must occur simultaneously with expected technology evolution.

Localized insulin amyloidosis with use of concentrated insulin: a potential complication

BACKGROUND

Insulin-derived amyloidosis is a rare form of amyloidosis composed of insulin fibrils. The pH and concentration of insulin are known to influence the conformational state of the insulin hormone, with an increasing concentration favouring a more complex conformation. Concentrated insulin delivers a large amount of insulin to a localized area, raising the possibility of inducing conformational changes, forming insulin fibrils and leading to localized insulin amyloidosis.

CASE REPORT

A middle-aged woman with long history of Type 2 diabetes mellitus, treated with concentrated human insulin (U-500 insulin) presented with nodular lesions at the site of her daily insulin injections. A punch biopsy of the nodules showed skin with dermal amyloidosis staining favourably with Congo Red stain. The amyloid tumours were resected and areas positive for Congo Red stain were sent for liquid chromatography tandem mass spectrometry, which showed a peptide profile consistent with amyloid insulin.

CONCLUSION

Concentrated insulin was first introduced in 1952, however, it is only over the last two decades that it has been used increasingly, in congruence with the increasing incidence of obesity and diabetes mellitus seen in the USA. Only a few cases of insulin amyloidosis at the site of injection have been described in literature. With the increase in the use of insulin, this complication seems to be occurring more frequently. This is the first case report of a person with diabetes mellitus who developed localized insulin amyloidosis with the use of concentrated insulin, and points towards a potential complication of developing insulin amyloidosis with the use of concentrated insulin.

Micturating cystourethrogram as a tool for investigating UTI in children - An institutional audit

BACKGROUND

Micturating cystourethrograms (MCUG) are the gold standard for evaluating vesicoureteric reflux (VUR). There is a growing consensus for increasing the threshold for performing MCUGs following urinary tract infections (UTI) in children. There are several varying guidelines. It is important to detect high-grade reflux in the setting of an UTI because of potential long-term complications.

OBJECTIVE

This audit aimed to retrospectively: (1) identify the conformance rate of local guidelines at the Women's and Children's Hospital (WCH); (2) assess predictors for an abnormal MCUG; and (3) compare local guidelines against the Royal Children's Hospital, Melbourne (RCH), National Institute for Healthcare and Excellence (NICE), and American Academy of Pediatrics (AAP) guidelines for selectively detecting high-grade reflux.

METHOD

The number of MCUGs performed from 2008 to 2012 at the WCH radiology department was collected. Patients undergoing MCUG during the 2012 calendar year were identified. Only children having an initial MCUG as part of an UTI investigation with prerequisite imaging as per guidelines were included. Each child's age, sex, referral source, reason, renal ultrasound (RUS) prior to the MCUG, MCUG result and VUR grade were recorded. The WCH guidelines were applied to determine conformance, to evaluate predictors for an abnormal MCUG, and compared against other retrospectively applied guidelines (RCH, NICE, AAP).

RESULTS/DISCUSSION

There was complete data for 168 children who underwent MCUG as part of an UTI investigation (median age 0.79 years, range 0.12-8.74, male:female 67:101). There were 67/168 abnormal MCUGs (62 children with VUR, five bladder diverticulum), and 97 refluxing renal units (43 high-grade VUR units). No posterior urethral valves (PUV) were identified as part of the UTI investigation. A total of 143/168 patients had prior RUS (normal:abnormal 67:76). The WCH guidelines had 82% conformance. There was no statistically significant association between an abnormal MCUG and age, sex, referral source, reason, or prior RUS result. The WCH guidelines may have missed five children with high-grade VUR (four children had surgery), compared with RCH, APP and NICE, with 8, 15, and 17 children, respectively, having high-grade VUR (two, five, and five children had surgery, respectively) show in the Summary Table. The retrospective study had limitations and possible selection bias (children with UTI without a MCUG). There were no standard treatment approaches for VUR; hence establishing a MCUG guideline is difficult. An alternative is the top-down approach.

CONCLUSION

Current institutional guidelines for considering MCUG following UTI in children vary considerably. The MCUG guidelines at any institution must take into account the local management guidelines for high-grade VUR.

Fast-track surgery for uncomplicated appendicitis in children: a matched case-control study

BACKGROUND

Standardized post-operative protocols reduce variation and enhance efficiency in patient care. Patients may benefit from these initiatives by improved quality of care. This matched case-control study investigates the effect of a multidisciplinary criteria-led discharge protocol for uncomplicated appendicitis in children.

METHODS

Key protocol components included limiting post-operative antibiotics to two intravenous doses, avoidance of intravenous opioid analgesia, prompt resumption of diet, active encouragement of early ambulation and nursing staff autonomy to discharge patients that met assigned criteria. The study period was from August 2015 to February 2016. Outcomes were compared with a historical control group matched for operative approach.

RESULTS

Outcomes for 83 patients enrolled to our protocol were compared with those of 83 controls. There was a 29.2% reduction in median post-operative length of stay in our protocol-based care group (19.6 versus 27.7 h; P < 0.001). The rate of discharges within 24 h improved from 12 to 42%. There was no significant difference in complication rate (4.8 versus 7.2%; P = 0.51). Mean oral morphine dose equivalent per kilogram requirement was less than half (46%) that of control group patients (P < 0.001). Mean number of ondansetron doses was also significantly lower. Projected annual direct cost savings following protocol implementation was AUD$77 057.

CONCLUSION

Implementation of a criteria-led discharge protocol at our hospital decreased length of stay, reduced variation in care, preserved existing low morbidity, incurred substantial cost savings, and safely rationalized opioid and antiemetic medication. These protocols are inexpensive and offer tangible benefits that are accessible to all health care settings.

Free living amoebae in water sources of critical units in a tertiary care hospital in India

BACKGROUND

Isolation of free-living amoebae (FLA) is reported sparsely from water taps, ventilators, air conditioners, haemodialysis units and dental irrigation systems of hospitals worldwide. Their prevalence in hospital environment especially in wards having immunocompromised patients may pose a risk to this group of susceptible population as they may cause disease themselves or may carry pathogens inside them. No study from India has performed such surveillance.

OBJECTIVE

To evaluate extent of FLA contamination in water sources of bone marrow transplant (BMT) intensive care unit (ICU), transplant ICU, haemodialysis unit and high dependency unit in a tertiary care hospital in India.

MATERIALS AND METHODS

A total of hundred samples including fifty each of tap water samples and swabs from mouth of taps used for drinking, bathing and hand washing purposes in these units were collected according to standard procedure. Samples were inoculated onto non-nutrient agar plates at room temperature followed by morphological confirmation. Molecular identification including polymerase chain reaction (PCR) and sequencing was performed in culture positive samples.

RESULTS

Four tap water samples and ten swab samples showed growth of trophozoites and cyst formation. Morphologically, four amoebae resembled Acanthamoeba spp. which was further confirmed by PCR and sequencing showed them to be of T3 and T4 genotypes.

CONCLUSION

The presence of these FLA in hospital water sources emphasises the urgent need of implementing effective preventive measures. Further studies are required to estimate the true prevalence of FLA in Indian hospitals by taking larger number of samples.

Development of touch down-multiplex PCR for the diagnosis of toxoplasmosis

PURPOSE

The diagnosis of toxoplasmosis is challenging since conventional methods like culture and immunofluorescence are not universally available. Serology, which is used regularly might be negative during early phase of infection and in immunosuppressed patients or may remain positive for a long time. Several molecular tests have been used for the diagnosis of toxoplasmosis, but none of them have an internal control which would inform us regarding the presence of polymerase chain reaction (PCR) inhibitors thus, undermining the confidence of a laboratory physician.

MATERIALS AND METHODS

We designed a multiplex PCR containing primers targeting human beta globin gene which would act as internal control and two primers against the B1 gene and 5s gene which aid in sensitive detection of T. gondii.

RESULTS

Multiplex PCR had a sensitivity of 83.3% and specificity of 100%.

CONCLUSION

Multiplex PCR may provide a sensitive and specific tool for diagnosis of human toxoplasmosis.

Emergence of Balamuthia mandrillaris meningoencephalitis in India

We report two cases of fatal chronic meningoencephalitis caused by Balamuthia mandrillaris in immunocompetent men. Diagnosis of amoebic meningoencephalitis was made ante-mortem in one case and postmortem in another by histopathological examination and confirmed by demonstration of B. mandrillaris deoxyribonucleic acid (DNA) by polymerase chain reaction (PCR).

Robotic surgery in children: adopt now, await, or dismiss?

The role of robot-assisted surgery in children remains controversial. This article aims to distil this debate into an evidence informed decision-making taxonomy; to adopt this technology (1) now, (2) later, or (3) not at all. Robot-assistance is safe, feasible and effective in selected cases as an adjunctive tool to enhance capabilities of minimally invasive surgery, as it is known today. At present, expectations of rigid multi-arm robotic systems to deliver higher quality care are over-estimated and poorly substantiated by evidence. Such systems are associated with high costs. Further comparative effectiveness evidence is needed to define the case-mix for which robot-assistance might be indicated. It seems unlikely that we should expect compelling patient benefits when it is only the mode of minimally invasive surgery that differs. Only large higher-volume institutions that share the robot amongst multiple specialty groups are likely to be able to sustain higher associated costs with today's technology. Nevertheless, there is great potential for next-generation surgical robotics to enable better ways to treat childhood surgical diseases through less invasive techniques that are not possible today. This will demand customized technology for selected patient populations or procedures. Several prototype robots exclusively designed for pediatric use are already under development. Financial affordability must be a high priority to ensure clinical accessibility.