Morbidity after ganglioneuroma excision: is surgery necessary?

INTRODUCTION

Ganglioneuroma (GN), the benign form of peripheral neuroblastic tumour, is often asymptomatic and the diagnosis can be incidental. Our aim was to evaluate the incidence of complications after surgical treatment following diagnosis of this tumour.

MATERIAL AND METHODS

24 consecutive children were diagnosed with GN in our centre between January 1989 and December 2009. All patients had negative urinary catecholamines and/or biopsy confirming the diagnosis of GN. Data are reported as mean ± SD.

RESULTS

Age at diagnosis was 73 ± 43 months. The most common presentation was respiratory symptoms and/or abdominal pain; 9 (38%) patients were asymptomatic. Tumour location was in the chest (n=14), abdomen (n=7), or pelvis (n=3). 23 children (9 asymptomatic) were operated on; 1 child with a thoracic mass did not undergo surgery because of severe neurological impairments from birth unrelated to GN. 13 children (4 asymptomatic) had a thoracotomy, 8 children (4 asymptomatic) had laparotomy, and 2 (1 asymptomatic) underwent perineal resection. A macroscopically complete surgical excision was performed in 17 cases (74%) and a macroscopically near-complete excision in 6 (26%). At histological examination, resection margins contained tumour in 10 patients (43%) and were free of tumour in the remaining 13 (57%). 7 children (30%) had complications after surgery including 3 patients with Horner's syndrome (which persisted in 2), 1 with chylothorax, 1 with pneumothorax, 1 with pain in the arm, and 1 who developed adhesive intestinal obstruction. 2 children received adjuvant chemotherapy. We re-evaluated the histology specimens according to the International Neuroblastoma Pathology Classification and found that the diagnosis of GN was confirmed in 20 cases (83%), while intermixed ganglioneuroblastoma (iGNB) was diagnosed in 4 patients (17%). At 33.5 ± 40 months (range 1-137) follow-up, all 24 patients, including the child not operated on and the children with incomplete resection or iGNB, are alive with no tumour progression or recurrence.

CONCLUSIONS

GN excision is associated with postoperative complications which can be persistent and may affect the quality of life of survivors. In our series we did not observe tumour progression in spite of incomplete excision. The rationale for GN excision should be revisited.

Mechanics and remodelling of cell packings in epithelia

Epithelia are sheets of cells that are dynamically remodelled by cell division and cell death during development. Here we describe the cell shapes and packings as networks of polygons: stable and stationary network configurations obey force balance and are represented as local minima of a potential function. We characterize the physical properties of this vertex model, including the set of ground states, and the energetics of topological rearrangements. We furthermore discuss a quasistatic description of cell division that allows us to study the mechanics and dynamics of tissue remodelling during growth. The biophysics of cells and their rearrangements can account for the morphology of cell packings observed in experiments.

Intestinal ischemia-reperfusion injury causes activation of bone marrow-derived progenitor cells

INTRODUCTION

Bone marrow-derived circulating granulocyte and macrophage progenitor cells can contribute to the regeneration of ischemic tissue. Mobilization after heart or brain ischemia is well established, but it is unclear if this occurs after intestinal ischemia-reperfusion injury. Our aim was to evaluate bone marrow granulocyte-macrophage proliferation and the possible beneficial effect of recombinant human granulocyte-colony stimulating factor (rhG-CSF) in a model of intestinal ischemia-reperfusion.

MATERIAL AND METHODS

After animal committee approval, anesthetized adult rats were divided into groups (n=4 per group) as follows: (i) control [C], (ii) 60 min intestinal ischemia [I], (iii) 60 min intestinal ischemia+360 min reperfusion [IR], (iv) 420 min sham operation [SH]. At sacrifice, bone marrow was removed, erythrocytes lysed and 1 50 000 nucleated cells plated in triplicate in 35 mm Petri dishes containing methylcellulose (MethoCult). After 11 days, granulocyte-macrophage colony-forming units (CFU-GM) were counted. In addition, to determine whether rhG-CSF injection stimulates progenitor cell activation, two further groups were studied: (v) 60 min intestinal ischemia+360 min reperfusion with injection of 50 microg/kg rhG-CSF at reperfusion [IR-G]; (vi) 420 min sham with rhG-CSF injected at 60 min [SH-G]. Data are expressed as median, range and IQR and compared using one-way ANOVA with Tukey's post-hoc test.

RESULTS

Neither sham operation nor ischemia alone influenced the activation of bone marrow. However, IR caused a significant increase in bone marrow activation compared to control animals (p<0.01), ischemic animals (p<0.01) and sham operated animals (p<0.05). Administered at a dose of 50 microg/kg, which is commonly used in animal studies, rhG-CSF had no effect on bone marrow activation, and did not augment the effects of ischemia-reperfusion. At a higher dose (100 microg/kg), however, rhG-CSF resulted in the mortality of IR animals.

CONCLUSIONS

Intestinal ischemia-reperfusion injury causes proliferation of bone marrow granulocyte-macrophage progenitors which contribute to long-term repair. This phenomenon is not augmented by the administration of exogenous rhG-CSF.

Metabolic response to surgery in infants and children

Considerable advances have been achieved in paediatric surgery during the last two decades, which can be partly ascribed to a better understanding of the physiological response to operations and the use of that knowledge to decrease the metabolic response where appropriate. Alongside this, minimally invasive surgery is now well established for many surgical conditions in the neonate, infant and child. The metabolic response to surgery differs in neonates to that seen in adults: there is a small increase in oxygen consumption and resting energy expenditure immediately after surgery with a return to normal levels by 12-24 h. The increase in resting energy expenditure is significantly greater in infants undergoing a major operation than in those subjected to a minor procedure. The limited increase in energy expenditure may be due to diversion of energy from growth to tissue repair. There are limited data available on older children, but they appear to have a different pattern of postoperative resting energy expenditure. There is a fall in the early postoperative period, similar to data collected in adults, but no late hypermetabolism. Protein metabolism mirrors energy expenditure and contributes to the overall changes observed. Various factors affect the magnitude of the response. It seems that in children intraoperative thermoregulation and metabolism are significant drivers of many of the postoperative changes. Minimally invasive surgery may maintain preoperative metabolic processes by altering the postoperative processes on a physiological level or by maintaining thermoregulation in children. The mechanism and potential benefit of these observations need further investigation.

A double-blind randomized trial of pyridoxine versus placebo for the prevention of pegylated liposomal doxorubicin hydrochloride-related palmar-plantar erythrodysesthesia

5594

Background: To compare the efficacy of pyridoxine versus placebo in the prevention of palmar-plantar erythrodysesthesia (PPE) and on quality of life (QOL) in patients treated with pegylated liposomal doxorubicin hydrochloride for ovarian, breast, or endometrial cancer. Methods: All patients received pegylated liposomal doxorubicin hydrochloride 40 mg/m2 IV q 4 weeks over 1 hour every 28 days for a maximum of 6 cycles. Patients received pyridoxine 100 mg (group A) by mouth or placebo (group B) twice daily. Nurses conducted standard PPE education for all patients. Patients with Grade 2 or 3 PPE that persisted despite dose reductions/delays were unblinded, and were given pyridoxine if taking placebo. Patients completed the Functional Assessment of Cancer Therapy (FACT) assessment tool. Analyses were conducted by group and comparisons were also made between patients who experienced grade 2/3 PPE versus grade 0/1. Chi-square or Fisher's exact test were used. Results: Thirty-four patients were enrolled with 18 randomized to group A and 16 to group B. Mean age was 64 years (SD=9.6; range 45–81 years). Five patients (group A, 3; group B, 2) were unevaluable (due to pegylated liposomal doxorubicin hydrochloride reaction during first chemotherapy cycle). Overall 15/29 (52%) patients had incidence of PPE (all grades), with 10/29 (34%) having grade 2/3 events (no grade 4 events observed). In group A, 8/15 (53%) patients had a PPE event and 7/14 (50%) in group B; p=0.857. For grade 2/3 events, there was no difference as 6/15 (40%) occurred in group A and 4/14 (29%) in group B; p=0.70. There were no differences in global or domain QOL scores between those patients with Grade 2/3 PPE versus Grade 0/1. Less than half [4/10 (40%)] of patients with Grade 2/3 PPE reported being bothered by side effects of pegylated liposomal doxorubicin hydrochloride treatment. Conclusions: As administered in this study, pyridoxine did not prevent PPE in patients treated with pegylated liposomal doxorubicin hydrochloride. Quality of life differences were not observed; however, not all patients with PPE reported being bothered by side effects of pegylated liposomal doxorubicin hydrochloride treatment. Pyridoxine is not indicated for prevention of PPE during chemotherapy.

[Table: see text]

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Gastric emptying is accelerated following laparoscopic Nissen fundoplication

AIM OF THE STUDY

The effects on gastric motility following Nissen fundoplication in children are poorly documented. Some paediatric surgeons advocate additional procedures at the same time as fundoplication, such as a pyloroplasty, to enhance gastric emptying. The aim of this study was to determine whether laparoscopic Nissen fundoplication without pyloroplasty affects gastric emptying.

METHODS

Gastric emptying was measured before laparoscopic Nissen fundoplication in 8 children after ingestion of a standardised volume of milk for age mixed with 150 mg of (13)C-octanoic acid. None of the patients had a gastrostomy insertion at the time of fundoplication and 2 patients had neurological impairment. Breath samples were collected by breathing into a mask at baseline and every 15 minutes up to 3 hours, and were analysed for (13)CO (2)/ (12)CO (2) ratio by mass spectrometry. Gastric emptying time (t (1/2)) was derived from the curve of (13)CO (2)/ (12)CO (2) ratio against time. The test was repeated in 6 children following Nissen fundoplication at the time of full feeds. Data are reported as mean +/- SD and were analysed by the Mann-Whitney test.

RESULTS AND CONCLUSIONS

There were 4 males and 4 females; mean age at surgery was 3.3 +/- 3.0 years. Mean gastric emptying time was 59 +/- 17 min prior to laparoscopic Nissen fundoplication and 45 +/- 4 min following surgery (p = 0.03). Gastric emptying was accelerated in all except one patient. Gastric emptying for liquids is accelerated following Nissen fundoplication in children. Procedures aimed at improving gastric emptying time such as pyloroplasty or pyloromyotomy might not be justified at the time of laparoscopic Nissen fundoplication.

Assessment of a neonatal rat model of necrotizing enterocolitis

INTRODUCTION

A neonatal rat model of necrotizing enterocolitis (NEC) is useful to investigate this devastating and obscure disease. The aim of this study was to assess a neonatal rat model of NEC to evaluate whether the histological appearance of the damaged intestine could be predicted by the clinical behaviour of the animals and the macroscopic appearance of the gut.

MATERIALS AND METHODS

Neonatal rats were delivered at term and assigned either to a control group consisting of breastfeeding and no stress factors, or to a NEC group in which NEC was induced by gavage feeding + hypoxia + oral lipopolysaccharide (4 mg/kg/day once daily for the first 2 days of life). Clinical status was assessed on day 4 using a clinical sickness score (general appearance, response to touch, natural activity, body colour; 0 - 3 for each variable). Neonatal rats were sacrificed at 4 different time points: day 1, day 2, day 3, and day 4. At sacrifice, a macroscopic assessment of the gut was performed using a new scoring system based on: colour (0 - 2), consistency (0 - 2) and degree of dilatation (0 - 2). The resected gut was stained with haematoxylin/eosin, and evaluated microscopically by 2 independent blinded scorers, including a consultant histopathologist. The histology results were used to validate the macroscopic gut assessment. Results were compared by ANOVA and linear regression analysis. Ethics Committee and Home Office approvals were obtained.

RESULTS

In the control group NEC was not present either macroscopically or histologically. The clinical sickness score was higher in the NEC group (median = 4.5; range = 2 - 6) compared to controls (median = 0; range = 0 - 1; p < 0.0001). In the NEC group the macroscopic appearance (from day 2) and histological score (from day 1) increased significantly (p < 0.0001) and were strongly correlated (r (2) = 0.74, p < 0.0001).

CONCLUSIONS

The clinical behaviour and macroscopic appearance of the intestine are valid tools to assess gut damage in our neonatal rat model of NEC. This allows future studies that are not exclusively based on histology.

Plasma soluble e-selectin in necrotising enterocolitis

AIM

E-selectin is an important mediator of leukocyte-endothelial adhesion. It is expressed on activated endothelium, and shed into the circulation in its soluble form. In babies with necrotising enterocolitis (NEC), increased intestinal expression of E-selectin has been associated with multiple organ failure and an adverse outcome. The aim of this study was to determine whether increased circulating soluble E-selectin (sE-selectin) was associated with a worse prognosis.

METHODS

With ethical approval, plasma samples from 20 infants with Bell stage II and III NEC were analysed. Both pre- and postoperative samples were available in 6 infants. The severity of illness was assessed using a sequential organ failure assessment score (SOFA) specifically designed for use in NEC. Plasma concentration of sE-selectin was determined by ELISA. Data, which were not normally distributed, were compared by Spearman's rank correlation coefficient and Wilcoxon signed rank test.

RESULTS

Plasma sE-selectin was strongly negatively correlated with corrected gestational age at the time of sampling (r = - 0.425, p = 0.006). There was no association between plasma sE-selectin and outcome (death or survival to discharge), severity of intestinal disease (focal, multifocal or pan-intestinal), or SOFA score. Surgery for suspected perforation, however, caused a significant elevation in sE-selectin levels (p = 0.031).

CONCLUSIONS

Plasma sE-selectin, a described marker of endothelial activation, is increased following surgery for NEC. However, prematurity appears to be the cause of an increase in sE-selectin level, confounding the potential use of sE-selectin levels as a predictor of severity of illness in NEC.

Validation of neural tube defects in the full featured--general practice research database

BACKGROUND

The General Practice Research Database (GPRD) has been used to identify associations between pregnancy medication exposures and birth defects, but experts have argued that databases such as this one cannot provide detailed information for the valid identification of complicated congenital anomalies. Our objective was to determine if the GPRD could be used to identify cases of neural tube defects (NTDs).

METHODS

First, we created algorithms for anencephaly, encephalocele, meningocele, and spina bifida and used them to identify potential cases. We used the algorithms to identify 217 potential NTD cases in either a child's or a mother's record. We validated cases by querying general practitioners (GPs) via questionnaire. Where cases of NTD were identified in the mother's record, in addition to confirming the diagnosis, we asked the GPs if the diagnosis was for the mother or that of her fetus or offspring.

RESULTS

Two hundred seventeen cases were identified, and 165 GP questionnaires were returned. We validated an NTD diagnosis for 117 cases, giving our algorithms a positive predictive value (PPV) of 0.71. The PPVs varied by NTD type: 0.81 for anencephaly, 0.83 for cephalocele, 0.64 for meningocele, and 0.47 for spina bifida.

CONCLUSIONS

Our identification algorithm was useful in identifying three of the four types of NTDs studied. Additional information is necessary to accurately identify cases of spina bifida.

Expenditure on diabetes treatments and achievement of glycaemic control: retrospective analysis

AIMS

To establish if a relationship exists between the prescribing costs of diabetes treatments and the achievement of Quality and Outcome Framework DM6 standards of glycaemic control.

METHODS

A retrospective cross-sectional study of all 92 primary care organizations in the north of England comparing net ingredient cost of diabetes treatments, corrected for diabetic population, with the percentage of patients achieving HbA(1c) < 7.4% (Quality and Outcome Framework DM6 indicator).

RESULTS

The overall net ingredient cost for diabetes treatments varies from pound 225 to pound 382 per person per year. On regression analysis, expenditure on all diabetes treatments, on glitazones or on blood glucose test strips have no significant impact upon the percentage of people achieving an HbA(1c) < 7.4%. There is an inverse relationship between spending on analogue insulins and target achievement (r = -0.08, P = 0.001).

CONCLUSIONS

At primary care organization level, there is no association between weighted expenditure on diabetes treatments and achievement of glycaemic control targets. Although there are limitations to what can be inferred from analyses of this type, these data support a judicious and carefully directed approach to the use of newer, more expensive treatments until clear evidence of added benefit is forthcoming.

Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a structured group education programme on biomedical, psychosocial, and lifestyle measures in people with newly diagnosed type 2 diabetes.

DESIGN

Multicentre cluster randomised controlled trial in primary care with randomisation at practice level.

SETTING

207 general practices in 13 primary care sites in the United Kingdom.

PARTICIPANTS

824 adults (55% men, mean age 59.5 years).

INTERVENTION

A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care.

MAIN OUTCOME MEASURES

Haemoglobin A(1c) levels, blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes at baseline and up to 12 months.

MAIN RESULTS

Haemoglobin A(1c) levels at 12 months had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (95% confidence interval -3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (95% confidence interval 1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (beta=0.12; P=0.008).

CONCLUSION

A structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A(1c) levels up to 12 months after diagnosis.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17844016 [controlled-trials.com].

Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a structured group education programme on biomedical, psychosocial, and lifestyle measures in people with newly diagnosed type 2 diabetes.

DESIGN

Multicentre cluster randomised controlled trial in primary care with randomisation at practice level.

SETTING

207 general practices in 13 primary care sites in the United Kingdom.

PARTICIPANTS

824 adults (55% men, mean age 59.5 years).

INTERVENTION

A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care.

MAIN OUTCOME MEASURES

Haemoglobin A(1c) levels, blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes at baseline and up to 12 months.

MAIN RESULTS

Haemoglobin A(1c) levels at 12 months had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (95% confidence interval -3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (95% confidence interval 1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (beta=0.12; P=0.008).

CONCLUSION

A structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A(1c) levels up to 12 months after diagnosis.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17844016 [controlled-trials.com].

Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a structured group education programme on biomedical, psychosocial, and lifestyle measures in people with newly diagnosed type 2 diabetes.

DESIGN

Multicentre cluster randomised controlled trial in primary care with randomisation at practice level.

SETTING

207 general practices in 13 primary care sites in the United Kingdom.

PARTICIPANTS

824 adults (55% men, mean age 59.5 years).

INTERVENTION

A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care.

MAIN OUTCOME MEASURES

Haemoglobin A(1c) levels, blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes at baseline and up to 12 months.

MAIN RESULTS

Haemoglobin A(1c) levels at 12 months had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (95% confidence interval -3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (95% confidence interval 1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (beta=0.12; P=0.008).

CONCLUSION

A structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A(1c) levels up to 12 months after diagnosis.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17844016 [controlled-trials.com].

Randomized trial of two physiotherapy interventions for primary care back and neck pain patients: cost effectiveness analysis

OBJECTIVES

To assess the cost-effectiveness of a brief physiotherapy pain management approach using cognitive-behavioural principles (Solution-Finding Approach) when compared with a commonly used traditional method of physical therapy (McKenzie Approach).

METHODS

Economic evaluation conducted alongside a randomized trial. The study related incremental differences in costs and benefits associated with the Solution Finding and McKenzie approaches over 12 months. Costs were measured in UK pounds sterling. Benefit was measured as health-related quality of life using the EQ-5D, which was used to estimate patient-specific quality adjusted life years (QALYs).

RESULTS

The McKenzie treatment required, on average, one extra physiotherapist visit (4.15 vs 3.10). Over a 12-month period, Solution Finding was associated with a lower per patient cost of pound-24.4 (95% CI pound-49.6 to 0.789 pounds). The mean difference in QALYs between the two groups was -0.020 (95% CI -0.057 to 0.017); favouring those receiving McKenzie. Relating incremental mean costs and QALYs gave an incremental cost effectiveness ratio of 1220 pounds (-24.4/-0.020) suggesting the McKenzie treatment is cost effective.

CONCLUSIONS

Results suggest that the additional cost associated with the McKenzie treatment when compared with the Solution Finding Approach may be worth paying, given the additional benefit the approach seems more likely to provide. Further research is needed to assess the extent to which the difference in physiotherapy visits between the two strategies is generalizable to other treatment settings.

Systematic review of the risk of developing a metachronous contralateral inguinal hernia in children

Background

This study aims to establish the risk of developing a metachronous contralateral inguinal hernia (MCIH) following open repair of a unilateral inguinal hernia in children.

Methods

A systematic review was performed using a defined search strategy. Studies in which children undergoing open repair of a unilateral inguinal hernia without contralateral exploration and who were followed up for MCIH development were included.

Results

Of 5937 titles and abstracts screened, 154 full-text articles were identified for review; 49 papers were analysed with data on 22 846 children. The incidence of MCIH was 7·2 per cent overall, 6·9 per cent in boys and 7·3 per cent in girls (P = 0·381). Children with a left-sided inguinal hernia had a significantly higher risk of developing a MCIH than those with a right-sided hernia (10·2 versus 6·3 per cent respectively; P &lt; 0·001).

Conclusion

Overall, in both boys and girls, 14 contralateral explorations are required to prevent one metachronous hernia. The risk of developing a MCIH appears unchanged in early childhood, with a slight reduction after 12 years of age. Children with a left-sided hernia have the greatest risk of developing a contralateral hernia, but ten explorations are still required to prevent one metachronous hernia. Most MCIHs occur in the first 5 years after unilateral inguinal hernia repair.

A novel starch for the treatment of glycogen storage diseases

OBJECTIVE

To determine whether a new starch offers better short-term metabolic control than uncooked cornstarch in patients with glycogen storage diseases (GSDs).

STUDY DESIGN

A short-term double-blind cross-over pilot study comparing uncooked physically modified cornstarch (WMHM20) with uncooked cornstarch in patients with GSD types Ia, Ib and III. Twenty-one patients (ages 3-47, 9 female) were given 2 g/kg cornstarch or WMHM20 mixed in water. Blood glucose, lactate and insulin, and breath hydrogen and (13)CO2 enrichment were measured, at baseline and after each load. The hourly biochemical evaluations terminated when blood glucose was < or = 3.0 mmol/L, when the study period had lasted 10 h or when the patient wished to end the test. The alternative starch was administered under similar trial conditions a median of 10 days later.

RESULTS

The median starch load duration was 9 h for WMHM20 versus 7 h for cornstarch. Glucose decreased more slowly (p = 0.05) and lactate was suppressed faster (p = 0.17) for WMHM20 compared with cornstarch. Peak hydrogen excretion was increased (p = 0.05) when cornstarch was taken.

CONCLUSION

These data indicate longer duration of euglycaemia and better short-term metabolic control in the majority of GSD patients with WMHM20 compared to cornstarch.

Randomized trial of two physiotherapy interventions for primary care neck and back pain patients: 'McKenzie' vs brief physiotherapy pain management

OBJECTIVES

Interventions that take psychosocial factors into account are recommended for patients with persistent back or neck pain. We compared the effectiveness of a brief physiotherapy pain management approach using cognitive-behavioural principles (Solution-Finding Approach-SFA) with a commonly used method of physical therapy (McKenzie Approach-McK).

METHODS

Eligible patients referred by GPs to physiotherapy departments with neck or back pain lasting at least 2 weeks were randomized to McK (n= 161) or to SFA (n= 154). They were further randomized to receive an educational booklet or not. The primary outcome was the Tampa Scale of Kinesiophobia (TSK) (Activity-Avoidance scale used as a proxy for coping) at 6 weeks, and 6 and 12 months.

RESULTS

Of 649 patients assessed for eligibility, 315 were recruited (219 with back pain, 96 with neck pain). There were no statistically significant differences in outcomes between the groups, except that at any time point SFA patients supported by a booklet reported less reliance on health professionals (Multidimensional Health Locus of Control Powerful Others Scale), while at 6 months McK patients showed slightly more improvement on activity-avoidance (TSK). At 6 weeks, patient satisfaction was greater for McK (median 90% compared with 70% for SFA). Both interventions resulted in modest but clinically important improvements over time on the Roland Disability Questionnaire Scores and Northwick Park Neck Pain Scores.

CONCLUSIONS

The McK approach resulted in higher patient satisfaction overall but the SFA could be more cost-effective, as fewer (three vs four) sessions were needed.

Absorption of carbon dioxide during laparoscopy in children measured using a novel mass spectrometric technique

BACKGROUND

Carbon dioxide (CO(2)) is absorbed during pneumoperitoneum and may cause adverse haemodynamic effects. The aim of this study was to measure the elimination of exogenous CO(2) during laparoscopy in children.

METHODS

Ten children [27.6 (56.5) months; mean (SD)] undergoing laparoscopic and nine [24.5 (17.3) months] undergoing open surgery were studied. Breath samples were collected at the line for end-tidal CO(2) and analysed for (13)CO(2)/(12)CO(2) ratio expressed as deltaPDB (difference from standard), by isotope-ratio mass spectrometry. The proportion of absorbed CO(2) was calculated comparing exhaled (13)CO(2)/(12)CO(2) before and during CO(2) pneumoperitoneum.

RESULTS

(13)CO(2)/(12)CO(2) in medical CO(2) was -32.7 (2.1) deltaPDB. (13)CO(2)/(12)CO(2) in breath of patients undergoing open procedures was -24.3 (2.4) deltaPDB at the start of operation and did not change during the operation (P > 0.2). (13)CO(2)/(12)CO(2) in breath of patients undergoing laparoscopy was -21.5 (5.4) deltaPDB at the start of insufflation, and decreased during pneumoperitoneum by 2.5 (1.6) deltaPDB, indicating absorption of exogenous CO(2). The percentage of expired CO(2) absorbed rose to 15.5 (7.7)% after 30 min of pneumoperitoneum and decreased rapidly after desufflation.

CONCLUSION

After 10 min of laparoscopy 10-20% of expired CO(2) derives from the exogenous CO(2). CO(2) absorption can be measured using a simple mass spectrometric technique.

Is grand multiparity associated with an increased risk of dysglycaemia?

AIMS/HYPOTHESIS

We sought to determine the risk of diabetes and IGT/IFG with grand multiparity.

SUBJECTS, MATERIALS AND METHODS

Women, aged > or =25 years, from the Australian Diabetes, Obesity and Lifestyle Study and the Crossroads Undiagnosed Disease Study (a rural study in Victoria, Australia), participated in a household census (response 67 and 70%, respectively), subsequently attending a biomedical examination that included an oral glucose tolerance test (58% [6198] and 69% [819]).

RESULTS

After adjusting for age, obesity and socio-economic status, diabetes, but not IGT/IFG, was less common among women with a parity of 1 to 2 (odds ratio [OR]=0.64 [0.48-0.84]) and 3 to 4 (OR=0.72 [0.53-0.96]) than in grand multiparous women. This relationship was unrelated to past hysterectomy, use of the oral contraceptive pill or menopausal status.

CONCLUSIONS/INTERPRETATION

Grand multiparity is associated with an increased risk of diabetes but not of IGT/IFG. We postulate that parity accelerates transition from IGT/IFG to diabetes, more than it does transition from normal glucose tolerance to IGT/IFG.