A tiny baby intubation team improves endotracheal intubation success rate but decreases residents' training opportunities

OBJECTIVE

To assess the educational and clinical impact of a tiny baby intubation team (TBIT).

STUDY DESIGN

Retrospective study comparing endotracheal intubation (ETI) performed: pre-implementation of a TBIT (T1), 6 months post-implementation (T2), and 4 years post-implementation (T3).

RESULTS

Post-implementation (T2), first-attempt success rate in tiny babies increased (44% T1; 59% T2, p = 0.04; 56% T3, p = NS) and the proportion of ETIs performed by residents decreased (53% T1; 37% T2, p = 0.001; 45% T3, p = NS). After an educational quality improvement intervention (prioritizing non-tiny baby ETIs to residents, systematic simulation training and ETI using videolaryngoscopy), in T3 residents' overall (67% T1; 60% T2, p = NS; 79% T3, p = 0.02) and non-tiny baby ETI success rate improved (72% T1; 60% T2, p = NS; 82% T3, p = 0.02).

CONCLUSION

A TBIT improves success rate of ETIs in ELBW infants but decreases educational exposure of residents. Educational strategies may help maintain resident procedural competency without impacting on quality of care.

1153 “To FNA Or to Not FNA, That Is the Question.” A 5-Year Retrospective Epidemiological Study Of 238 Surgical Parotid Cases Treated at An East Yorkshire OMFS Unit

Introduction

Fine needle aspiration (FNA) is a surgical procedure used to aid with diagnosis and subsequent treatment planning. This study compares FNA histology with final histology (gold standard) for diagnostic accuracy in parotid surgery patients.

Method

A retrospective investigation of patient records from January 2014-January 2019 was performed to find eligible patients that underwent parotid surgery. Histology reports of the ultrasound (US) FNA and final parotid sample were compared for diagnostic accuracy and ability to differentiate between malignant & benign tumours.

Results

240 parotid surgeries on 238 patients were undertaken between 2014-2019 under OMFS and ENT specialities. 137 US FNA’s were performed, of these, there was an 85% diagnostic rate. Of the diagnostic FNA’s 79% reach gold standard, with the histology matching that of the final histology. Of the 24 without diagnostic accuracy, 2/3 were still able to differentiate between malignant and benign lesions. Overall, the US FNA’s were able to differentiate malignant and benign parotid lesions in 93% of cases.

Conclusions

The audit has proven US FNA to be an accurate diagnostic test, it gives extra data to aid in the decision making and planning for parotid surgeries. Although US FNA has shown to be more accurate in diagnosing benign parotid tumours; it is useful in detecting cellular change which could be indicative of malignancy.

Surgical outcomes of anterior cerebellopontine angle meningiomas using the anterior transpetrosal approach compared with the lateral suboccipital approach

BACKGROUND

Anterior transpetrosal approach (ATPA) and lateral suboccipital approach (LSO) are the major surgical approaches for cerebellopontine angle (CPA) meningiomas. Particularly, anterior CPA meningiomas are challenging lesions to be treated surgically. To date, only a few studies have directly compared the outcomes of both approaches focusing on the anterior CPA meningiomas.

METHODS

For the comparative analysis, anterior CPA meningiomas that were eligible for both APTA and LSO were collected in our hospital from April 2005 to March 2017. Anterior CPA meningiomas targeted for this study were defined as follows: (1) without cavernous sinus, clivus, and middle cranial fossa extension, (2) the posterior edge is 1 cm behind the posterior wall of the internal auditory canal, and (3) the inferior edge is above the jugular tuberculum. Based on these criteria, the operative outcomes of 17 patients and 13 patients who were operated via ATPA and LSO were evaluated.

RESULTS

The complication rate of the LSO group was significantly higher than that of the ATPA group (30.7% vs. 0%, p = 0.033). The removal rate did not differ between the ATPA and LSO groups (97.35% vs. 99.23%, p = 0.12). The operative time was significantly shorter in the LSO group than in the ATPA group (304.3 min vs. 405.8 min, p = 0.036).

CONCLUSIONS

Although the LSO is more widely used for CPA meningiomas, ATPA is also considered for these anterior CPA meningiomas.

A randomized trial of induction docetaxel-cisplatin-5FU followed by concomitant cisplatin-RT versus concomitant cisplatin-RT in nasopharyngeal carcinoma (GORTEC 2006-02)

Background

Concomitant chemotherapy (CT)-radiotherapy (RT) is a standard of care in locally advanced nasopharyngeal carcinoma (NPC) and a role for induction CT is not established.

Methods

Patients with locally advanced NPC, WHO type 2 or 3, were randomized to induction TPF plus concomitant cisplatin-RT or concomitant cisplatin-RT alone. The TPF regimen consisted of three cycles of Docetaxel 75 mg/m2 day 1; cisplatin 75 mg/m2 day 1; 5FU 750 mg/m2/day days 1-5. RT consisted of 70 Gy in 7 weeks plus concomitant cisplatin 40 mg/m2 weekly.

Results

A total of 83 patients were included in the study. Demographics and tumour characteristics were well balanced between both arms. Most of the patients (95%) in the TPF arm received three cycles of induction CT. The rate of grade 3-4 toxicity and the compliance (NCI-CTCAE v3) during cisplatin-RT were not different between both arms. With a median follow-up of 43.1 months, the 3-year PFS rate was 73.9% in the TPF arm versus 57.2% in the reference arm [hazard ratio (HR) = 0.44; 95% confidence interval (CI): 0.20-0.97, P = 0.042]. Similarly the 3 years overall survival rate was 86.3% in the TPF arm versus 68.9% in the reference arm (HR = 0.40; 95% CI: 0.15-1.04, P = 0.05).

Conclusion

In conclusion, several important aspects can be emphasized: the compliance to induction TPF was good and TPF did not compromise the tolerance of the concomitant RT-cisplatin phase. The improved PFS and overall survival rates needs to be confirmed by further trials.

Staged repair of redo and crippled hypospadias: analysis of outcomes and complications

INTRODUCTION

Residual curvature, scarred or absent urethral plate, shortage of skin, and paucity of vascularized tissues and flaps are all obstacles to overcome during repair of redo and cripple hypospadias after failed reconstruction. Limited articles address the outcome of repair of these cases using different grafts.

OBJECTIVE

An analysis of outcomes and complications after the repair of redo and cripple hypospadias in a cohort of children operated by a single surgeon is presented, and data are retrieved from a prospectively designed database.

STUDY DESIGN

Thirty-one children with a median age of 96 months (18-216, interquartile range [IQR]: 78), who underwent previous surgeries three to five times, were operated in the period from late 2011 to August 2017 in a single center by a single surgeon (first author); the first-stage repair was performed by using an inner prepuce graft in three children and oral grafts in 28 children. Penile straightening by degloving and removal of ventral scarred tissues are followed by development of glanular wings and grafting of the ventral surface.

RESULTS

Eleven distal penile hypospadias and 20 posterior hypospadias were operated. First-stage repair was revised in three children; 25 children, eight distal and 17 posterior hypospadias, underwent second-stage repair with a median age of 84 months (18-216, IQR: 60). The success rate after the second-stage repair was 56% (14 children), and complications were encountered in 11 children in the form of penoscrotal fistulae in four, complete dehiscence in one, and glanular dehiscence in six children. After closure of fistulae, the overall success rate increased to 72%. Although complications were more common among children with posterior hypospadias (nine children) than children with distal hypospadias (two children), no statistical significance was reached (p = .234), with no effect of age on complications (p = .233), no effect of the position of the meatus on glanular dehiscence (p = .624), and no effect of age on glanular dehiscence (p = .114).

CONCLUSION

Repair of redo and crippled hypospadias using staged graft repair in children could be achieved with a satisfactory overall success rate of 72%. Glanular dehiscence is the main complication; however, it is not considered by parents of children in the series, necessitating intervention. The lowest complication rate is expected among those with a position of the meatus more distal, however, not proven statistically in the series.

The cosmic ray shadow of the Moon observed with the ANTARES neutrino telescope

One of the main objectives of the ANTARES telescope is the search for point-like neutrino sources. Both the pointing accuracy and the angular resolution of the detector are important in this context and a reliable way to evaluate this performance is needed. In order to measure the pointing accuracy of the detector, one possibility is to study the shadow of the Moon, i.e. the deficit of the atmospheric muon flux from the direction of the Moon induced by the absorption of cosmic rays. Analysing the data taken between 2007 and 2016, the Moon shadow is observed with 3.5 σ statistical significance. The detector angular resolution for downward-going muons is 0 . 73 ∘ ± 0 . 14 ∘ . The resulting pointing performance is consistent with the expectations. An independent check of the telescope pointing accuracy is realised with the data collected by a shower array detector onboard of a ship temporarily moving around the ANTARES location.

Improving neonatal intubation safety: A journey of a thousand miles

Neonatal intubation is one of the most common procedures performed by neonatologists, however, the procedure is difficult and high risk. Neonates who endure the procedure often experience adverse events, including bradycardia and severe oxygen desaturations. Because of low first attempt success rates, neonates are often subjected to multiple intubation attempts before the endotracheal tube is successfully placed. These factors conspire to make intubation one of the most dangerous procedures in neonatal medicine. In this commentary we review key elements in the journey to improve neonatal intubation safety. We begin with a review of intubation success rates and complications. Then, we discuss the importance of intubation training. Next, we examine quality improvement efforts and patient safety research to improve neonatal intubation safety. Finally, we evaluate new tools which may improve success rates, and decrease complications during neonatal intubation.

Comparative effectiveness of linezolid versus vancomycin as definitive antibiotic therapy for heterogeneously resistant vancomycin-intermediate coagulase-negative staphylococcal central-line-associated bloodstream infections in a neonatal intensive care unit

Objectives

Heterogeneously resistant vancomycin-intermediate coagulase-negative staphylococci (hVICoNS) are emerging pathogens causing central-line-associated bloodstream infections (CLABSIs) in neonatal intensive care unit (NICU) patients. Given the burden of disease associated with CLABSI and the current lack of therapeutic guidelines, we aimed to compare the effectiveness of linezolid versus vancomycin used as the definitive antibiotic therapy for hVICoNS CLABSI.

Methods

We performed a retrospective cohort study of infants with hVICoNS CLABSI from a single NICU between 2009 and 2014, treated with either linezolid or vancomycin as definitive antibiotic therapy. CLABSI duration, early and late recurrence and in-hospital mortality were compared using propensity score-adjusted proportional hazards and logistic regression models.

Results

Of 89 infants with hVICoNS CLABSI, 33 (37.1%) treated with linezolid were compared with 56 (62.9%) treated with vancomycin. The median duration of CLABSI was 5 (range 1-12) versus 4 days (range 0-14) ( P  =   0.11), early recurrences were 3.0% versus 7.1% ( P  =   0.42), late recurrences 0% versus 14.3% ( P  =   0.02) and mortality 27.3% versus 28.6% ( P  =   0.90), when treated with linezolid versus vancomycin, respectively. When adjusting using a continuous propensity score, linezolid had an HR of 0.78 (95% CI 0.48-1.27) for CLABSI duration, an OR of 0.23 (95% CI 0.02-2.56) for early recurrence and an OR of 0.9 (95% CI 0.3-2.67) for mortality, relative to vancomycin.

Conclusions

There was no statistically significant difference between linezolid and vancomycin when used as definitive treatment for hVICoNS CLABSI in NICU patients, in terms of CLABSI duration, recurrence or all-cause mortality.

An algorithm for the reconstruction of high-energy neutrino-induced particle showers and its application to the ANTARES neutrino telescope

A novel algorithm to reconstruct neutrino-induced particle showers within the ANTARES neutrino telescope is presented. The method achieves a median angular resolution of [Formula: see text] for shower energies below 100 TeV. Applying this algorithm to 6 years of data taken with the ANTARES detector, 8 events with reconstructed shower energies above 10 TeV are observed. This is consistent with the expectation of about 5 events from atmospheric backgrounds, but also compatible with diffuse astrophysical flux measurements by the IceCube collaboration, from which 2-4 additional events are expected. A [Formula: see text] C.L. upper limit on the diffuse astrophysical neutrino flux with a value per neutrino flavour of [Formula: see text] is set, applicable to the energy range from 23 TeV to 7.8 PeV, assuming an unbroken [Formula: see text] spectrum and neutrino flavour equipartition at Earth.

Sperm whale long-range echolocation sounds revealed by ANTARES, a deep-sea neutrino telescope

Despite dedicated research has been carried out to adequately map the distribution of the sperm whale in the Mediterranean Sea, unlike other regions of the world, the species population status is still presently uncertain. The analysis of two years of continuous acoustic data provided by the ANTARES neutrino telescope revealed the year-round presence of sperm whales in the Ligurian Sea, probably associated with the availability of cephalopods in the region. The presence of the Ligurian Sea sperm whales was demonstrated through the real-time analysis of audio data streamed from a cabled-to-shore deep-sea observatory that allowed the hourly tracking of their long-range echolocation behaviour on the Internet. Interestingly, the same acoustic analysis indicated that the occurrence of surface shipping noise would apparently not condition the foraging behaviour of the sperm whale in the area, since shipping noise was almost always present when sperm whales were acoustically detected. The continuous presence of the sperm whale in the region confirms the ecological value of the Ligurian sea and the importance of ANTARES to help monitoring its ecosystems.

Laparoscopic pyeloplasty versus open pyeloplasty for recurrent ureteropelvic junction obstruction in children

INTRODUCTION AND OBJECTIVES

Recurrent ureteropelvic junction obstruction (UPJO) in children is an operative challenge. Minimally invasive endourological treatment options for secondary UPJO have suboptimal success rates; hence, there is a re-emergence of interest about redo pyeloplasty. The present study presented experience with laparoscopic management of previously failed pyeloplasty compared with open redo pyeloplasty in children.

STUDY DESIGN

Twenty-four children with recurrent UPJO who underwent transperitoneal dismembered laparoscopic pyeloplasty were studied. Operative, postoperative, and follow-up functional details were recorded and compared with those of open pyeloplasty (n = 15) carried out for recurrent UPJO by the same surgeon during the same study period.

RESULTS

Demographic data were comparable in the laparoscopic and open groups, except for a significantly lower GFR in the open group (24.8 vs 38.2 ml/min, P = 0.0001). Mean time to failure of the original repair was 20.2 months (23.6 months for redo laparoscopic pyeloplasty, 18.8 months for redo open). The success rate of laparoscopic redo pyeloplasty was 91.7 vs 100% in open redo pyeloplasty. Compared with redo open pyeloplasty, the mean operative time was longer (211.4 ± 32.2 vs 148.8 ± 16.6, P = 0.002), estimated blood loss was higher (102 vs 75 ml, P = 0.06), while hospital stay was shorter and pain score was lower in the laparoscopy group (P = 0.02) in the laparoscopic group. There were no intraoperative complications, while the postoperative complication rate was similar in the two groups (20.8 vs 20.0%).

DISCUSSION

Before the laparoscopic approach became a viable option, endopyelotomy was widely used for managing recurrent UPJO. However, the success rate of endopyelotomy for secondary UPJO was approximately 10-25% lower than for open pyeloplasty. Redo pyeloplasty had excellent results, with reported success rates of 77.8-100%. Laparoscopic redo pyeloplasty is becoming a viable alternative to open redo pyeloplasty in many centers with experience in minimally invasive techniques. The present study revealed that redo laparoscopic pyeloplasty appeared to have advantages over redo open surgery, in that it was associated with shorter hospital stay (4 vs 6 days, P = 0.046), reduced postoperative pain score (P = 0.02), and less need for postoperative analgesia (P = 0.001), still with comparable successful outcomes and patient safety. However, the procedure had a longer operative times and more blood loss.

CONCLUSION

Laparoscopic pyeloplasty is a viable alternative to open pyeloplasty in children with recurrent UPJO, with shorter hospital stays and less postoperative pain. However, the procedure is technically demanding and should be attempted in high-volume centers by laparoscopists with considerable experience in laparoscopic reconstructive procedures.

Sildenafil for the Treatment of Pulmonary Arterial Hypertension in Infants with Bronchopulmonary Dysplasia

Sildenafil, a phosphodiesterase-5 inhibitor, is a controversial treatment option for pulmonary arterial hypertension (PAH), a significant complication of bronchopulmonary dysplasia (BPD). The objective of this study was to evaluate the use of sildenafil in infants with PAH secondary to BPD. This was a retrospective review of medical records of all premature infants with PAH associated with BPD treated with sildenafil between January 2009 and May 2013 in a level 3 neonatal intensive care unit. The primary outcomes were clinical response (20 % decreases in respiratory support score or oxygen requirements) and echocardiographic response (20 % decrease in tricuspid regurgitation gradient or change of at least 1° of septal flattening). Twenty-three infants were included in the study. Significant echocardiographic and clinical responses were, respectively, observed in 71 and 35 % of cases. Most clinical responses were observed in the first 48 h of treatment, and the median time to an echocardiographic response was of 19 days. The median dose of sildenafil used was 4.4 mg/kg/day, with a median time to reach the maximum dose of 9 days. Transient hypotension was the primary reported side effect, and it was observed in 44 % of our study population. Sildenafil treatment in patients with PAH secondary to BPD was associated with an echocardiographic improvement in the majority of patients, whereas clinical improvement was observed in a minority of patients. Many infants presented with transient hypotension during the course of the treatment. Further prospective studies are required to better assess safety and efficacy of this treatment in this population.

A rare cause of death in infancy: idiopathic infantile arterial calcification

The aim of this paper is to report the autopsy findings of an Idiopathic Infantile Arterial Calcification-new-born male and describe its follow-up. Y.R, a 23-days-old male, hasn't any relevant personal past medical or family history. The baby was weighing 3.2 kg at birth. He was breast fed and appeared to be perfectly normal. In the last 24 hours, he presented to the family doctor with vomitis, refuse of feeds without fever or diarrhea. He was diagnosed as having gastroenteritis and was medicated accordingly. A few hours later, he had an hematemese episode associated with facial cyanosis. Death occurred despite cardio-pulmonary resuscitation. Forensic autopsy was required. The macroscopic examination showed a bilateral pleural liquid effusion without any other abnormalities. Microscopic investigation revealed a generalized arterial calcification of all organs. Idiopathic arterial calcification is primarily a disease of infancy. It is characterized pathologically by generalized arterial calcification within the internal elastic lamina, associated with intimal fibrous proliferation. Death occur often in the first sixth months due to heart failure.

Primary cutaneous aggressive epidermotropic CD4/CD8 double-negative cytotoxic T-cell lymphoma

The classification of cutaneous T-cell lymphomas (CTCL) is based on clinical, histological and immunohistochemical findings. Diagnosis may be difficult given the significant heterogeneity of these tumours. We describe herein an original case of primary cutaneous aggressive epidermotropic CD4/CD8 double-negative cytotoxic T-cell lymphoma that illustrates the difficulty in classification.

[Malignant recurrence of "mature" sacrococcygeal teratoma. A clinicopathological study of 4 cases]

Sacrococcygeal teratomas (SCT) are uncommon neonatal tumours which are usually benign. Our interest was aroused by encountering patients with reportedly benign SCT which later, after surgery, recurred as malignant tumours. We conducted a retrospective study of 17 patients treated for benign SCT during a period of 9 years. Of these patients, 4 developed malignant recurrence (3 females and 1 male) with a mean age of 19 months. The average time to recurrence was 17 months. Recurrence presented as a gluteal mass in one case, urinary and digestive compression signs in another case and as elevated alpha-fetoprotein levels in the two remaining cases. Histologically, one of the original tumors included tiny immature foci but none contained a malignant component after reading slides. Recurrences were as endodermal sinus tumour in all cases. After surgery and adjuvant chemotherapy, only one child died from complications related to chemotherapy. The other three were alive and well at mean follow-up of 5 years. These results emphasise the need for close clinical and biological follow-up for at least 2 years in all patients who had undergone excision of a neonatal SCT.