The Blunt Liver and Spleen Trauma (BLAST) audit: national survey and prospective audit of children with blunt liver and spleen trauma in major trauma centres

PURPOSE

To compare the reported and observed management of UK children with blunt liver or spleen injury (BLSI) to the American Pediatric Surgical Association (APSA) 2019 BLSI guidance.

METHODS

UK Paediatric Major Trauma Centres (pMTCs) undertook 1 year of prospective data collection on children admitted to or discussed with those centres with BLSI and an online questionnaire was distributed to all consultants who care for children with BLSI in those centres.

RESULTS

All 21/21 (100%) pMTCs participated; 131 patients were included and 100/152 (65%) consultants responded to the survey. ICU care was reported and observed to be primarily determined using haemodynamic status or concomitant injuries rather than injury grade, in accordance with APSA guidance. Bed rest was reported to be determined by grade of injury by 63% of survey respondents and observed in a similar proportion of patients. Contrary to APSA guidance, follow-up radiological assessment of the injured spleen or liver was undertaken in 44% of patients before discharge and 32% after discharge, the majority of whom were asymptomatic.

CONCLUSIONS

UK management of BLSI differs from many aspects of APSA guidance. A shift towards using clinical features to determine ICU admission and readiness for discharge is demonstrated, in line with a strong evidence base. However, routine bed rest and re-imaging after BLSI is common, contrary to APSA guidance. This disparity may exist due to concern that evidence around the incidence, presentation and natural history of complications after conservatively managed BLSI, particularly bleeding from pseudoaneurysms, is weak.

P52 Feasibility of “The Defect Study”: Neonatal diaphragmatic defect measurement and repair techniques in Congenital Diaphragmatic Hernia

Introduction

Defect size and closure technique in neonates with congenital diaphragmatic hernia (CDH) has long term consequences for morbidity in survivors. Although subjective operative reporting of defect size has been standardised, objective evaluation is lacking. There is no reported optimum closure technique related to size and position of diaphragmatic defect. We aimed to objectively describe diaphragmatic defects and repair methods at the time of neonatal CDH repair.

Methods

A national, three centre cohort feasibility study was undertaken over a 4-month period. Data collection was registered as service evaluation at participating centres. All surviving neonates with CDH undergoing defect closure were eligible. Anonymised data were collected using a RedCAP database. Data collection variables (n = 47) included both antenatal and postnatal measures. Data were checked for normality and reported as mean±SD or median (IQR).

Results

12 neonates were eligible for inclusion, 10 (83%) were included. Observed/Expected Lung Head Ratio (%) was reported in 5 cases (45±8), neonates were term, male (60%), birth weight (3.3±0.5kg). 80% of patients had a laparotomy, 80% had a left-sided defect, 60% a patch repair with PTFE and 60% graded defect size C. Poorly reported variables included pre-operative oxygenation and defect size was measured in 30%.

Discussion

Data collection through RedCAP was feasible and most variables were documented. Simplifying the intraoperative data collection form and providing clear instructions for taking measurements may improve reporting. A further pilot study with these modifications and improving engagement through advertisement, emails and online presence is intended to optimize the study before roll-out.

Introduction of paediatric laparoscopic cholecystectomy in Scotland: a national review of incidence, outcomes and training implications

BACKGROUND

We present a national data series to determine the incidence, outcomes and training opportunities for laparoscopic cholecystectomy among children <16yrs in Scotland as performed by paediatric surgeons.

METHODS

A retrospective cohort study was performed reviewing laparoscopic cholecystectomy performed at the three children's hospitals in Scotland. Using the National Records Scotland Database mid-year population estimates; age and sex specific annual incidence rates of laparoscopic cholecystectomy were calculated between 1998-2015. Trends in the observed case mix were tested using univariate linear regression and students t-test.

RESULTS

Between 1998-2015; 141 paediatric laparoscopic cholecystectomies were performed. The annual rate of cholecystectomy increased from 0.10/100,000 to 0.88/100,000 (p = 0.069). Sex specific incidences were identified; 0.00-0.90/100,000 (p = 0.098) in girls and 0.20-0.86/100,000 in boys (p = 0.28). Cholecystectomy was more frequent in girls (63%; p = 0.04). No major complications, defined as common bile duct injury or mortality were identified. Overall; 75% of cases were performed by consultants (n = 17 consultants, median = 5 cases, p < 0.05) and 25% by trainees.

CONCLUSION

We have demonstrated that despite a low national case load (8 laparoscopic cholecystectomies per year) paediatric surgeons have been able to perform laparoscopic cholecystectomy safely without major morbidity.

The impact of ethnicity/race on the association between the Veterans Aging Cohort Study (VACS) Index and neurocognitive function among HIV-infected persons

The Veterans Aging Cohort Study (VACS) Index was developed as a risk index for health outcomes in HIV, and it has been consistently associated with mortality. It shows a significant, yet relatively weak, association with neurocognitive impairment, and little is known about its utility among ethnic/racial minority groups. We examined whether the association between the VACS Index and neurocognition differed by ethnic/racial group. Participants included 674 HIV-infected individuals (369 non-Hispanic whites, 111 non-Hispanic blacks, and 194 Hispanics). Neurocognitive function was assessed via a comprehensive battery. Scaled scores for each neurocognitive test were averaged to calculate domain and global neurocognitive scores. Models adjusting for demographics and HIV disease characteristics not included in the VACS Index showed that higher VACS Index scores (indicating poorer health) were significantly associated with worse global neurocognition among non-Hispanic whites. This association was comparable in non-Hispanic blacks, but nonsignificant among Hispanics (with similar results for English and Spanish speaking). We obtained comparable findings in analyses adjusting for other covariates (psychiatric and medical comorbidities and lifestyle factors). Analyses of individual neurocognitive domains showed similar results in learning and delayed recall. For other domains, there was an effect of the VACS Index and no significant interactions with race/ethnicity. Different components of the VACS Index were associated with global neurocognition by race/ethnicity. In conclusion, the association between the VACS Index and neurocognitive function differs by ethnic/racial group. Identifying key indicators of HIV-associated neurocognitive impairment by ethnic/racial group might play an important role in furthering our understanding of the biomarkers of neuroAIDS.

Methylation of the FGFR2 gene is associated with high birth weight centile in humans

AIMS

This study examined links between DNA methylation and birth weight centile (BWC), and explored the impact of genetic variation.

MATERIALS & METHODS

Using HumanMethylation450 arrays, we examined candidate gene-associated CpGs in cord blood from newborns with low (<15th centile), medium (40-60th centile) and high (>85th centile) BWC (n = 12). Candidates were examined in an investigation cohort (n = 110) using pyrosequencing and genotyping for putative methylation-associated polymorphisms performed using standard PCR.

RESULTS

Array analysis identified 314 candidate genes associated with BWC extremes, four of which showed ≥ 4 BWC-linked CpGs. Of these, PM20D1 and MI886 suggested genetically determined methylation levels. However, methylation at three CpGs in FGFR2 remained significantly associated with high BWC (p = 0.004-0.027).

CONCLUSION

We identified a novel biologically plausible candidate (FGFR2) for with BWC that merits further study.

Suspected adverse events, 2012

Increase in serious adverse events; Increase in reports involving products marketed under the Small Animal Exemption Scheme; Decrease in injection site reactions. These are some of the results from the surveillance work carried out by the pharmacovigilance unit at the Veterinary Medicines Directorate (VMD), as discussed by Giles Davis and colleagues.

Combined influence of gene-specific cord blood methylation and maternal smoking habit on birth weight

Aim: Evidence suggests that folic acid intake affects birth weight and that these effects may be mediated via the fetal epigenome. Our previous array data indicate that methylation in human cord blood at gene-specific CpGs is associated with birth weight percentile (BWP). Our aims were to investigate associations with BWP in specific CpGs identified by the array analysis in a significantly larger cohort and investigate the effects of other relevant factors on this association. Materials & methods: Methylation status was examined in candidate CpGs in 129 cord blood samples using Pyrosequencing™. The effects of other potentially important factors; maternal smoking, folate-related metabolite levels and genetic variation in the MTHFR gene, were examined. Linear and logistic regression analyses were used to identify relationships between BWP and methylation levels in the context of other key factors. Results: Increased cord methylation at CpGs in GSTM5 and MAP2K3 was associated with a reduced risk of having a birth weight below the 50th percentile (p = 0.010; odds ratio [OR]: 0.33 and p = 0.024; OR: 0.24, respectively) while higher methylation levels in APOB were associated with an increased risk (p = 0.023; OR: 2.56). Smoking during pregnancy modified the effect of methylation on BWP. Thus, compared with nonsmokers with a GSTM5 methylation level of >25% (median BWP: 54.7%), those who had smoked during pregnancy and whose GSTM5 methylation was <25% had the lowest median BWP (12.0%; p = 0.001). Furthermore, this latter group had the highest proportion of cases with BWPs below 50% (92.9 compared with 47.8% in nonsmokers with a GSTM5 methylation level of >25%; p = 0.013; OR: 14.2). Similar results were identified for MAP2K3, while the link with APOB reflected the inverse relationship between methylation at this locus and BWP. Conclusion: Our data suggest that gene-specific methylation of cord DNA is associated with BWP and this methylation provides an additional effect on BWP to that of smoking during pregnancy.

An interdisciplinary mental health consultation team in a nursing home

The Mental Health Consultation Team (MHCT) at the Portland Veterans Affairs Medical Center nursing home is an interdisciplinary group of mental health professionals and primary care providers established to triage mental health consultations, improve communication between consultants and primary care providers, help staff translate consultants' recommendations into patient care, and furnish education in the management of mental health problems. The MHCT has decreased the demands for formal psychiatry and psychology consultations while increasing mental health services through innovative use of existing staff.

Characterization of endothelin receptors in mesangial cells: evidence for two functionally distinct endothelin binding sites

Endothelin (ET) peptides are growth factors that bind to G protein-coupled receptors and serve as a useful model to study mitogenic signal transduction by vasoactive peptides. To begin to define the molecular mechanisms underlying mitogenic signaling by ET-1, we analyzed expression of ET receptor subtypes in glomerular mesangial cells and antagonism of ET-1-induced mitogenic responses by ET receptor antagonists. Competitive displacement analysis of 125I-ET-1 binding revealed a shallow multicomponent curve consistent with the presence of two ET-1 binding sites (Kd values of 32 pM and 1.2 nM). Nonlinear regression analysis demonstrated that a two-site model fit the data better than a one-site model (p = 0.0063). Analysis of 125I-ET-1 binding sites by affinity cross-linking revealed incorporated radioactivity in two distinct protein bands in mesangial cell membranes. Both ETA-specific (BQ 123) and nonselective (PD 142893/PD 145065) receptor antagonists displaced 125I-ET-1 from the low affinity site. The Ki values for BQ 123 and PD 145065 were similar to the IC50 values for inhibition of ET-1-induced increases in the intracellular free Ca2+ concentration ([Ca2+]i) by these antagonists. The ETB-specific ligands S6c and [Ala1,3,11,15]ET-1(6-21) were unable to displace 125I-ET-1 from either low affinity or high affinity binding sites. Analysis of ET receptor mRNA by reverse transcription-polymerase chain reaction, using primers predicted from DNA sequences conserved through evolution in ETA and ETB genes, demonstrated that mesangial cells express a canonical ETA receptor. Collectively, these data suggest that the low affinity, high capacity 125I-ET-1 binding site is an ETA receptor and that the high affinity, low capacity site is not accounted for by canonical ET receptors. We further demonstrated that BQ 123 and PD 142893/PD 145065 inhibited ET-1-stimulated [3H]thymidine uptake but at higher concentrations than required for inhibition of [Ca2+]i increases. Preincubation (as opposed to coincubation) with antagonists was required to inhibit ETA-mediated increases in [Ca2+]i produced by ET-1. These results suggest that the unique, nearly irreversible binding of ET-1 to ETA receptors explains why high concentrations of ET receptor antagonists are required to block longer term actions such as mitogenesis.

Expression and differential regulation of Id1, a dominant negative regulator of basic helix-loop-helix transcription factors, in glomerular mesangial cells

Id is a family of dominant negative helix-loop-helix (HLH) proteins that block cell-specific transcription mediated by basic HLH (bHLH) transcription mediated by basic HLH (bHLH) transcription factors. We have analyzed Id1 expression in mesangial cells as a first step towards understanding the putative role of bHLH transcription factors in cell type-specific gene expression in the kidney. Glomerular mesangial cells expressed an abundant 1.1 kb mRNA transcript for Id1, but in contrast to other cell types Id1 mRNA was expressed in both randomly cycling cells and in serum-deprived, quiescent cultures. When quiescent mesangial cells were treated with serum to re-enter G1, Id1 mRNA levels were rapidly (2-4 h) and transiently down-regulated. Down-regulation of Id1 mRNA following addition of serum to mesangial cells was cell type-specific and contrasted with induction of Id1 by serum in BHK-21 and 3T3 fibroblasts. Down-regulation of Id1 mRNA correlated with mitogenesis and occurred when quiescent cells were treated with growth factors that activate G protein-coupled receptors and receptor protein tyrosine kinases but not with a non-mitogenic cAMP analog. Down-regulation of Id1 by growth factors required de novo protein synthesis, suggesting that a labile protein was involved. Appearance of E-box DNA binding activity in mesangial cell extracts followed down-regulation of Id1 message. Steady state Id1 mRNA levels and E-box DNA binding activity were not tightly correlated, suggesting complex regulation of Id1 activity. mRNA transcripts for E2A gene products were also expressed in mesangial cells, but these cells failed to express mRNAs for MyoA/MyoD-related genes. Collectively, these data demonstrate that Id1 is expressed in renal mesangial cells and suggest that bHLH complexes might be important for transcriptional regulation in the kidney. In addition, the observation that Id1 mRNA is transiently down-regulated by serum in mesangial cells suggests that Id1 gene expression is more complicated than previously appreciated and is tightly regulated in a cell-specific manner.