Selective replication and vertical transmission of Ebola virus in experimentally infected Angolan free-tailed bats

The natural reservoir of Ebola virus (EBOV), agent of a zoonosis burdening several African countries, remains unidentified, albeit evidence points towards bats. In contrast, the ecology of the related Marburg virus is much better understood; with experimental infections of bats being instrumental for understanding reservoir-pathogen interactions. Experiments have focused on elucidating reservoir competence, infection kinetics and specifically horizontal transmission, although, vertical transmission plays a key role in many viral enzootic cycles. Herein, we investigate the permissiveness of Angolan free-tailed bats (AFBs), known to harbour Bombali virus, to other filoviruses: Ebola, Marburg, Taï Forest and Reston viruses. We demonstrate that only the bats inoculated with EBOV show high and disseminated viral replication and infectious virus shedding, without clinical disease, while the other filoviruses fail to establish productive infections. Notably, we evidence placental-specific tissue tropism and a unique ability of EBOV to traverse the placenta, infect and persist in foetal tissues of AFBs, which results in distinct genetic signatures of adaptive evolution. These findings not only demonstrate plausible routes of horizontal and vertical transmission in these bats, which are expectant of reservoir hosts, but may also reveal an ancillary transmission mechanism, potentially required for the maintenance of EBOV in small reservoir populations.

A single centre experience using internal traction sutures in managing long gap oesophageal atresia

AIM

Thoracoscopically placed internal traction sutures (ITS) for the initial management of long gap oesophageal atresia (LGOA), not amenable to primary anastomosis, was first described in 2015. Here we describe our experience using ITS both thoracoscopically and at thoracotomy where the gap between upper and lower oesophagus is too wide for primary anastomosis.

METHOD

The case notes of all infants treated with ITS for oesophageal atresia (01/10/2015 to 01/12/2019) were reviewed. Gaps considered too wide for an anastomosis had ITS placed between the two pouches as described by Patkowski in 2015. All patients were gastrostomy fed.  Patients returned to theatre with an expectation to complete the anastomosis or re-tighten the traction sutures.

RESULTS

Seven patients (4 OA, 1 OA with proximal fistula, 2 OA/distal TOF) median birthweight 2.28 kg (1.2-3.6 kg) were managed using ITS. Median gap length 4.5 (3-9) vertebral bodies.  ITS were placed thoracoscopically in 5 cases and at thoracotomy in 2 at median 46 days (1-120) old. In all cases, ITS was associated with significant intra-thoracic adhesions. Five patients leaked from the traction sutures. Four patients had a delayed primary anastomosis performed at thoracotomy and 3 required a cervical oesophagostomy. The median length of stay was 159 days (98-282).  All patients started thoracoscopically eventually required thoracotomy.

CONCLUSION

The use of ITS in our department was associated with significant complications, particularly intra-thoracic leaks and adhesions.  In our hands ITS did not improve the feasibility of thoracoscopic repair for LGOA and has been abandoned by us.

LEVEL OF EVIDENCE

Level IV Case Series.

Inoculation route-dependent Lassa virus dissemination and shedding dynamics in the natural reservoir - Mastomys natalensis

Lassa virus (LASV), a Risk Group-4 zoonotic haemorrhagic fever virus, affects sub-Saharan African countries. Lassa fever, caused by LASV, results in thousands of annual deaths. Although decades have elapsed since the identification of the Natal multimammate mouse (Mastomys natalensis) as a natural reservoir of LASV, little effort has been made to characterize LASV infection in its reservoir. The natural route of infection and transmission of LASV within M. natalensis remains unknown, and the clinical impact of LASV in M. natalensis is mostly undescribed. Herein, using an outbred colony of M. natalensis, we investigate the replication and dissemination dynamics of LASV in this reservoir following various inoculation routes. Inoculation with LASV, regardless of route, resulted in a systemic infection and accumulation of abundant LASV-RNA in many tissues. LASV infection in the Natal multimammate mice was subclinical, however, clinical chemistry values were transiently altered and immune infiltrates were observed histologically in lungs, spleens and livers, indicating a minor disease with coordinated immune responses are elicited, controlling infection. Intranasal infection resulted in unique virus tissue dissemination dynamics and heightened LASV shedding, compared to subcutaneous inoculation. Our study provides important insights into LASV infection in its natural reservoir using a contemporary infection system, demonstrating that specific inoculation routes result in disparate dissemination outcomes, suggesting intranasal inoculation is important in the maintenance of LASV in the natural reservoir, and emphasizes that selection of the appropriate inoculation route is necessary to examine aspects of viral replication, transmission and responses to zoonotic viruses in their natural reservoirs.

Children with congenital colorectal malformations during the UK Sars-CoV-2 pandemic lockdown: an assessment of telemedicine and impact on health

PURPOSE

This pilot study was designed to assess bowel function and quality of life (QoL) in children and adolescents with congenital colorectal malformations (CCM) during the first UK COVID lockdown period.

METHODS

Changes in health were assessed through semi-structured interviews, gastrointestinal functional outcomes using Krickenbeck scoring and QoL by the modified disease-specific HAQL (Hirschsprung's disease anorectal malformation quality of life questionnaire). The State-Trait Anxiety Inventory (STAI)™ for adults was used to assess parental anxiety.

RESULTS

Thirty-two families were interviewed; 19 (59%) reported no change in their child's health during the lockdown, 5 (16%) a deterioration and 8 (25%) an improvement. Neither the severity of the CCM, nor the degree of bowel dysfunction, correlated with any deterioration. The HAQL score was not correlated to a change in health. Anxiety scores ranged from no anxiety to clinical concerns. Telemedicine was well accepted by 28/32 parents (88%); however, in-person appointments were preferred if there were clinical concerns.

CONCLUSION

In the follow-up of children and adolescents with CCM during the first UK lockdown using telemedicine we found that over half had stable health conditions. Patients needing additional care could not be predicted by the severity of their disease or their bowel function alone.

Exomphalos major: Conservative management using Manuka honey dressings and an outreach surgical nursing team

INTRODUCTION

Controversy exists over the best dressing for conservative management of exomphalos major. Here we describe our experience of using Manuka Honey.

METHODS

Our regimen involved covering the sac with Manuka honey (Advancis Medical™) wrapped with gauze and crepe bandage. Initially, dressings were changed 3 times a week and then twice weekly until full epithelialisation. Babies went home after reaching full feeds, with our outreach nurses continuing dressings in clinic until the parents were trained to do them alone. Only patients needing management of co-morbidities were transferred to our unit. Patients would be reviewed by video consultation. Data was prospectively collected.

RESULTS

From 2011-2019, 24 consecutive patients (11:13 M:F; median gestation 37 weeks, birth weight 3.1 kg) with exomphalos major were managed with honey dressings. Fourteen babies had significant associated anomalies of which 10 died of problems unrelated to the exomphalos. Time to full feeds 6 (2-58) days; time to discharge 21(7-66) days if no associated anomalies; time to epithelialisation 73 (27-199) days. Dressings were well tolerated. Definitive closure occurred at 17(11-38) months and was uneventful. No patient required fundoplication and all patients were orally fed. Only one patient developed a clinically significant infection.

CONCLUSION

This is the largest report of using Manuka honey for the management of exomphalos major. Benefits include early feeding, early discharge and a 'normalisation' of the neonatal period. Key to our success was the surgical outreach service supporting parents doing the dressings, first at the local hospital and then at home.

440 Abdominal Heterotaxia: A More Nuanced Anatomy

Introduction

The cardiac anomalies associated with left and right atrial appendage isomerism (LAAI and RAAI) are systematically described. However, for the associated abdominal abnormalities, only the laterality of the organs, cardinality of the spleen (asplenia or polysplenia) and the presence or absence of intestinal malrotation are noted. This study aimed to describe in greater detail the abdominal anatomy in abdominal heterotaxia.

Method

A detailed review of the imaging and clinical records of 23 patients (16 LAAI, 7 RAAI) with abdominal heterotaxia in a cardiac database was performed.

Results

In no patient was a complete description of abdominal anatomy possible, with all patients displaying unique anatomical presentations.

There was a significant association between isomerism and splenic cardinality (12/16 LAAI had polysplenia and 6/7 RAAI had asplenia, p = 0.02). Right-sided stomachs were more commonly associated with gastro-oesophageal reflux (p = 0.048). The stomach and pylorus were ipsilateral in 15/20 patients, with marked variation in gastric orientation; these were novel observations. Ladd’s procedures were performed in 15/23 patients but terminology for intestinal malrotation was inconsistently used.

Conclusions

The heterotaxic anatomy demands better descriptions for scholarly reasons, but these may lead to a better understanding of upper intestinal dysfunction and the subsequent management of these patients.

Low-fidelity Paediatric Surgical Simulation: Description of Models in Low-Resource Settings

BACKGROUND

Surgical simulation is an important aspect of competency-based training. Recent trends in paediatric surgical simulations have migrated towards high-fidelity simulation with advanced technology resulting in models which are expensive and largely inaccessible in low- and middle-income countries.

METHODS

This article describes four wet simulation models of common surgical procedures in paediatric population created with animal tissue from local abattoir. The models are designed to provide a framework for others to make the models and benefit from the training opportunity they provide especially in low-middle-income countries.

RESULTS

The models created in the wet laboratory are neonatal bowel anastomosis, duodenoduodenostomy for discrepancy anastomosis, gastrostomy and pyeloplasty. These models are easily reproducible in resource-challenged healthcare setting as they are low cost, utilise locally available resources and require only a basic set of surgical instruments with which to perform the procedures.

CONCLUSION

These models provide locally accessible material for sustainable training programmes which are fundamental in developing safe and affordable surgical care worldwide.

Conservative management of exomphalos major with silver dressings: are they safe?

Historically, some dressings used in exomphalos major were associated with toxicity. These have been abandoned in favor of safer dressings. Silver toxicity has not been described following the use of silver dressings in infants. We, however, found disconcerting serum silver levels in 2 consecutive patients during treatment with silver salt containing dressings.

Appendicitis in children: a comparative study between a specialist paediatric centre and a district general hospital

PURPOSE

The study aimed to compare paediatric appendicectomy practice in a specialist paediatric centre (SPC) with a district general hospital (DGH).

METHODS

This was a retrospective study of children younger than 16 years treated between January 1, 2005, and September 30, 2007.

RESULTS

Two hundred seven patients (SPC) and 264 (DGH) had an operation for suspected appendicitis. Thirty-one percent of SPC patients were female vs 41% in the DGH (P = .03). Median age (range) was 10.3 years (1.2-15.9 years) in the SPC and 11.8 (3.3-16.0 years) in the DGH (P < or = .0001). The negative appendicectomy rate was 4% at the SPC and 20% at the DGH (P < or = .0001). Perforated appendicitis was found in 37% of children at the SPC compared with only 18% at the DGH (P < or = .0001). Median (range) length of stay was 5 days at the SPC (1-21 days) compared with 2 days at the DGH (1-21 days) (P < or = .0001).

CONCLUSION

Our findings have important implications for local practice in our 2 centres but may also have wider implications for the national organisation of the surgical care of children and for the training of general surgeons.

The role of imaging in children with suspected appendicitis: the UK perspective

The diagnosis of uncomplicated acute appendicitis is often straightforward, allowing timely appendicectomy without the need for expensive tests or imaging. Repeated clinical examination by an experienced surgeon has traditionally been the key to making the diagnosis in both straightforward and difficult cases. Nonetheless, all surgeons will remove some normal appendices. Sometimes it can be particularly difficult to make the diagnosis, especially in the child under 5 years of age, in teenage girls, in young women and in the elderly. When difficult to make, the diagnosis may be significantly delayed and since the pathology is progressive, the patient may suffer potentially avoidable complications. This paper looks at two potential roles for imaging. Firstly, can imaging, applied selectively, help make the difficult diagnosis less difficult and so reduce delays and morbidity? Secondly, could imaging all patients with suspected appendicitis reduce the number of normal appendices removed from children who seem to have all the signs and symptoms of straightforward uncomplicated acute appendicitis but who actually have presumed self-resolving non-appendiceal pathology? The answer to these questions may depend on three factors that are not entirely independent: a surgical unit's current audited negative appendicectomy rate, population base/case mix and the expertise of the examining surgeon. Individual surgeons and some surgical units, by policy, use modern imaging techniques with quite different frequencies that may be appropriate depending on these three factors. This article argues that a careful history and repeated clinical examination is the key to making the diagnosis, with imaging, primarily ultrasonography, being used in patients with a palpable mass or in those having had 48 h of hospital observation without progress. In Europe, imaging has played a limited role in the investigation of the child with suspected appendicitis with the diagnosis relying on repeated examination by an experienced clinician. Ongoing changes in surgical training in the UK may affect the acquisition of clinical expertise that is crucial to this clinical management. High-quality surgical training and surgical audit are needed to monitor the delivery of care and to ensure that the care pathway being used is appropriate for the local resources and population.

The use of high resolution magnetic resonance imaging in the prenatal diagnosis of fetal nuchal tumors

Fetal magnetic resonance imaging (fetal MRI) is an important adjunct to antenatal imaging especially when neonatal surgery is contemplated. We report two cases of fetal nuchal tumors, which were diagnosed incidentally on an ultrasound scan and had fetal MRI to aid diagnosis, prognosis, counseling and management planning. In the first case, fetal MRI aided diagnosis and prenatal multidisciplinary management of a cervical teratoma. Tracheal involvement could not be excluded and an ex-utero intrapartum treatment procedure was planned. Postnatal MRI and angiography provided further information prior to surgery. In the second case, fetal MRI assisted thorough counseling following the finding of a cervical lesion thought to be a cervical teratodermoid, a multicystic hygroma or congenital lymphectasia. The parents opted for termination of the pregnancy. Postmortem findings confirmed the extent of involvement of surrounding structures diagnosed prenatally. The mass was found to be a hamartomatous hemangiolymphangioma.

Chemosensitivity in pediatric dermatofibrosarcoma protuberans

Dermatofibrosarcoma protuberans (DFSP) is a rare tumor of fibrohistiocytic spectrum and uncommonly presents in infancy and childhood. The standard treatment is wide-margin surgical excision, but this is difficult to achieve in large tumors and may result in unacceptable cosmetic, structural, and functional consequences. The authors describe a child with recurring DFSP who, after extensive surgery, responded to treatment with vinblastine and oral methotrexate. This is the first reported case in literature of a chemotherapeutic response in pediatric DFSP.

Congenital malformations of the diaphragm: findings of the West Midlands Congenital Anomaly Register 1995 to 2000

OBJECTIVES

To describe trends in incidence, associated anomalies, clinical outcomes and sensitivity of prenatal diagnosis for congenital malformations of the diaphragm in the West Midlands Region between 1995 and 2000.

METHODS

Information was retrieved from a population-based register of major congenital malformations in a health region of England, the West Midlands Congenital Anomaly Register (WMCAR), between 1995 and 2000.

RESULTS

One hundred and sixty-one confirmed cases of congenital malformations of the diaphragm were notified from 396 577 births. This gives an incidence of 4.1 per 10,000 births. After natural losses and terminations, the incidence at birth was 2.9 per 10,000 registered births. For live-born cases, the infant mortality rate was 317 per 1000 births. 47% of the cases had additional structural or chromosomal anomalies; the infant mortality rate for these complex cases was 533 per 1000, an increased relative risk of 2.37 compared with isolated lesions. 66% of the cases were diagnosed prenatally, 51% of isolated lesions and 84% of complex cases. Fourteen prenatally diagnosed cases (12%) were false-positives; however, 11 of these cases had other significant pathology. These 14 cases were not included in the 161 confirmed cases.

CONCLUSION

Congenital malformations of the diaphragm remain associated with considerable infant mortality. Most cases are now diagnosed before birth and the prognosis is adversely affected by the presence of other structural or chromosomal anomalies. This presents significant challenges for those involved in counselling the parents of affected fetuses.

Unusual complication of a central venous line in a neonate

The placement of a central venous line in a low birthweight neonate led to a complication that highlights the need for continued vigilance after the position of the line is checked and thought satisfactory.

Single-system ectopic ureter: a 15-year review

Ectopic ureters present in childhood with symptoms related to an abnormal site or structure (refluxing, obstructed) of the ureteric orifice. The majority drain duplex kidneys. The diagnosis is relatively easy if the poles are functioning or hydronephrotic. Associated malformations are rarely seen and the results of surgery are gratifying. If an ectopic ureter drains a single kidney, it is called a single-system ectopic ureter (SSEU). We reviewed a 15-year experience (1980-1995) with 127 ectopic ureters from our hospital:11 SSEUs in ten consecutive children were managed during this period. Our data lead us to believe that SSEUs are a special subset of ectopic ureters. Diagnosis is often delayed because the ectopic ureter may be associated with a single small, dysplastic, poorly-functioning, non-visualised kidney and the child may be thought to have a contralateral normal "solitary kidney". Associated systemic malformations are common. Residual symptoms of wetting may persist in the early postoperative period. A high degree of suspicion must be maintained for this entity when a child presents with urinary symptoms of wetting or recurrent infection and a "solitary kidney". Early endoscopic examination of the genitourinary tract will clinch the diagnosis in the majority of cases. Residual symptoms of wetting in the postoperative period generally resolve with passage of time.

Exomphalos (omphalocele)

Exomphalos affects approximately 3 in 10,000 births and can arise from a number of developmental insults. The clinical outcome is dependent upon the associated structural and chromosomal anomalies and the gestation at delivery. Accurate antenatal ultrasound diagnosis and karyotyping are important and allow informed prenatal and postnatal management decisions to be made. Prenatal care and counselling should be multidisciplinary and information should ideally be given to parents regarding prognosis and outcome based on prospectively collected population-based data.

Left-right development: mammalian phenotypes and conceptual models

Consistent left-right asymmetry in a population requires a special kind of developmental specification. Models of this process must account for the complex phenotypes seen when left-right is abnormal. In some human and mouse mutations, there appears to be a randomisation of global situs to either solitus or inversus, whereas in the inv/inv mouse essentially all are inversus. However, in these and all additional examples there are frequently other anomalies, including symmetry (isomerism) and discordance between organs (heterotaxia). Current models invoke a molecular chiral referent as the source of the primary handed information. We describe a new two-gradient model which accommodates all defects of situs whilst leaving the primary asymmetry unaltered.

Cisapride reduces neonatal postoperative ileus: randomised placebo controlled trial

AIM

To assess the efficacy of cisapride in reducing ileus persisting to the tenth postoperative day after neonatal abdominal surgery.

METHODS

A prospective, randomised, double blind trial comparing rectal cisapride (1.4-2.3 mg/kg/day) with placebo over seven days was undertaken in 33 neonates.

RESULTS

Seven of 12 (58%) patients receiving placebo and eight of 11 (73%) receiving cisapride achieved a first sustained feed during treatment. Of those receiving cisapride, the first sustained feed occurred at 2.3 days (SEM 0.6) compared with 4.7 days (SEM 0.8) with placebo. By the seventh day the mean daily net enteral balance was 69 (SEM 18) ml/kg in the cisapride subgroup and 17 (SEM 8) ml/kg for those receiving placebo. Stool was passed on 6.3 (SEM 0.4) treatment days in the cisapride subgroup compared with 4.1 (SEM 1.0) treatment days in the placebo subgroup.

CONCLUSION

Cisapride is effective in neonates with a prolonged ileus after abdominal surgery.

Efficacy of ajoene, an organosulphur derived from garlic, in the short-term therapy of tinea pedis

The present report shows the efficacy of ajoene, a garlic-derived organic trisulphur, for short-term therapy of tinea pedis. The use of ajoene as a 0.4% (w/w) cream resulted in complete clinical and mycological cure in 27 of 34 patients (79%) after 7 days of treatment. The remaining seven patients (21%) achieved complete cure after seven additional days of treatment. All patients were evaluated for recurrence of mycotic infections 90 days after the end of treatment, yielding negative cultures for fungus. These results show that ajoene is an alternative, efficient and low-cost antimycotic drug for short-term therapy of tinea pedis. The fact that ajoene can be easily prepared from an alcoholic extract of garlic may make it suitable for Third World public health care.

Cell proliferation in mammalian gastrulation: the ventral node and notochord are relatively quiescent

During gastrulation, the node of the mammalian embryo appears to be an organising centre, homologous to Hensen's node in the chick and the dorsal lip of the amphibian blastopore. In addition, the node serves as a precursor population for the head process, notochord and foregut endoderm. We have studied node architecture and cell morphology by electron microscopy, and cell proliferation using bromodeoxyuridine incorporation and mitotic counts. The dorsal (ectodermal) and ventral (endodermal) components of the node are two distinct populations, separated by a basement membrane. The ventral node, contiguous with the head process, is characterised by a relatively low proliferation rate, with only approximately 10% of cells incorporating BrdU over 4 hr, compared to > 95% in surrounding mesodermal and ectodermal tissues. This is the case from the beginning of node formation, at the no-allantoic-bud stage, until the 7 somite stage, and is not compatible with the idea that the ventral node is a stem cell population. The dorsal node is highly proliferative, its rate of division being indistinguishable from the neurectoderm, with which it is contiguous. In the ventral node, two regions can be recognised: cells in the "pit" are columnar and all monociliated; around them lies a "crown" of cells arranged radially in a horseshoe shape and less often ciliated. Node derivatives share common features with the ventral node; the head process and the notochord are relatively quiescent; and some head process cells are also monociliated. Node and head process monocilia are immotile and appear to be associated with non-proliferation. We suggest that the ventral node contains all the properties of the organiser, while the dorsal node is indistinct from the surrounding epiblast. The cranial end of the foregut pouch, the thyroid diverticulum, and the promyocardium of early somite stage embryos are also areas of low cell division. All the described regions of relative quiescence are sites of expression of members of the TGF beta family, which may be involved in maintaining non-proliferation.

Interdomain interactions of radixin in vitro

We have assayed the domains of the ERM protein radixin for binding activities in vitro. Affinity columns bearing the amino-terminal domain of radixin selectively bound a small subset of the proteins of the chicken erythrocyte cytoskeleton. Two of those proteins were identified as radixin itself and band 4.1. In contrast, the carboxyl-terminal domain of the molecule bound neither protein, and full-length radixin did not bind band 4.1 (binding of full-length radixin to itself was not evaluated). Columns bearing a mixture of the amino- and carboxyl-terminal domains of radixin also failed to bind radixin and band 4.1. These results suggested that the amino- and carboxyl-terminal sequences can interact with one another either in cis or in trans, and so interfere with radixin's interactions with other ligands. Using affinity co-electrophoresis, we confirmed a direct interaction in solution between the two radixin domains; the data are consistent with the formation of a 1:1 complex with a dissociation constant of approximately 5 x 10(-8) M. Competition between intramolecular and intermolecular interactions may help to explain the provocative and dynamic localization of ERM proteins within cells.

Experimental pathogenicity of Sporothrix schenckii preserved in water (Castellani)

Five strains of Sporothrix schenckii preserved in sterile distilled water were found morphologically stable, viable and pure after a period ranging from 16 to 13 years, in the mycology section culture collection from the Instituto de Medicina Tropical, Universidad Central de Venezuela. Each strain was inoculated into the testes of 3 hamsters. All the animals developed disseminated sporotrichosis.

Intravascular haemolysis in association with necrotising enterocolitis

Severe haemolysis is an unusual occurrence in association with necrotising enterocolitis (NEC). Activation of the Thomsen-Friedenreich (T) antigen on the neonatal erythrocytes is proposed as the mechanism. This haemolytic process is precipitated by transfusion with serum-containing blood products, which should therefore be avoided. Once haemolysis has become established the outcome is usually fatal. This report describes the management of four neonates who had established haemolysis complicating severe NEC. T activation was confirmed in two infants, but could not be tested for in the other two. Exchange transfusion abolished the haemolysis in two patients, who survived. Despite reduced use of blood products the other two infants died. We believe that exchange transfusion was essential in the successful management of the infants who survived, and recommend early exchange transfusion when haemolysis complicates NEC.

Contacts with a Canadian "street level" drug and crisis centre, 1972-76

The Calgary Distress Centre/Drug Centre is a "street level" agency that deals with both drug and non-drug related crises. Telephone and drop-in service is available 24 hours a day, seven days a week. The Centre has approximately 60 non-professional volunteers and a paid staff of six. Data about crisis information and counselling contacts over the period 1972-76 are presented and discussed. The Distress Centre/Drug Centre is perhaps a useful model on which to base other crisis intervention facilities. Furthermore, the systematic compilation of data regarding contacts with the agency provides significant insight regarding trends in drug use and evolution of the agency.