Dorsal shortening vs. ventral lengthening procedure for correction of congenital ventral curvature in patients with and without severe hypospadias: A meta-analysis of comparative studies

INTRODUCTION

Debates remain on the ideal congenital ventral curvature correction among patients with and without severe hypospadias. Herein, we aimed to assess the comparative surgical outcome of dorsal shortening (DS) vs. ventral lengthening (VL) procedures for correcting congenital ventral curvatures.

METHOD

A systematic literature search was performed in September 2021 using the PubMed, EMBASE, Scopus, CENTRAL, ProQuest, and Clinicaltrials.gov databases. Comparative studies were identified and evaluated according to Cochrane Collaboration recommendations. Assessed outcomes included success and complication rates, which were extrapolated for the respective odds ratios (OR) with 95% confidence intervals (CIs). Subgroup analyses were performed according to congenital curvature, with or without severe hypospadias or recurrent curvatures (International Prospective Register of Systematic Reviews (PROSPERO): CRD42021276193).

RESULTS

Based on pooled effect estimates from 12 studies with 430 (DS 253, VL 177) cases of ventral curvature repair, VL was able to render a better success rate for curvature correction (OR 4.20, 95% CI 2.11, 8.33) than DS repair, with comparable composite surgical complication rates (OR 0.77, 95% CI 0.27, 2.18). Furthermore, subgroup analysis showed that the success rate remained significantly better for the VL approach among patients with associated severe hypospadias (OR 3.59, 95% CI 1.25, 10.26) and recurrent penile curvatures (OR 5.70, 95% CI 1.69, 19.21), but not among those with congenital curvature without hypospadias or those with mild hypospadias (OR 2.99, 95% CI 0.32, 27.57).

CONCLUSIONS

In correcting congenital curvature associated with severe hypospadias and recurrent curvatures, VL procedures might render a modestly better success rate; however, careful selection of appropriate patients seems to be the crucial key to the best outcome. The surgical complication rate seems to be comparable between the two approaches.

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

371 Use of Trello as a Project Management Tool for Collaborative Surgical Research and Audit

Introduction

Managing surgical research projects alongside clinical commitments requires organisation, prioritisation, and communication. Our unit is a tertiary plastic surgery centre with a large workforce, high volume case load and abundant research opportunity. In a busy department, co-ordination and communication is imperative for timely high-quality research and audit output and maximum productivity. Tools can be used to support this output; we trialled use of Trello project management software to increase productivity in this context.

Method

We set up a Trello account for our unit’s plastic surgery department. All consultants and trainees have access, and each project has a timeline and standardised progress checklist to support completion of projects to a uniform high standard.

Results

Our Trello for Surgical Research pilot has promoted organised collaborative working and reduced duplication and partial completion of audit and research projects within our department. It has encouraged engagement between smaller subgroups within the unit, and a platform to monitor progression through key stages of project development with oversight of an appointed Research Lead, resulting in an increase in completion of closed loop audits and research projects.

Conclusions

Similar experiences have been described in mathematics and engineering research groups, and delivery of educational material for English Literature study, but we have not identified description of Trello as a tool for medical research. Use of such platforms increases productivity and likelihood of completion of projects, as well as providing a clear outline of a departments’ research priorities and accessible opportunities for rotating juniors.

1465 Anaesthetic Preferences in a Tertiary Hand Surgery Unit & Aetiology of Hand Trauma Presentations During the First UK lockdown: Lessons for the Future

Introduction

Our tertiary plastics unit serves a 4.3 million population in the South East, providing a seven-day hand trauma service. Our aim was to assess differences in quantity and aetiology of hand trauma during the April 2020 lockdown compared with the equivalent period in 2019, and our ability to reduce risk by carrying out more procedures under local anaesthetic.

Method

Retrospective notes review for hand trauma surgery patients in April 2020 (3 weeks in first UK lockdown), with a comparative period in April 2019. Fisher’s Exact Test was applied to assess for difference in method of anaesthetia, injury location (workplace vs home) and DIY versus non-DIY aetiology.

Results

2020 group: n = 165. 2019: n = 239. (31% reduction). Mean age 45 during lockdown vs 49 in 2019. There was significant reduction in the proportion of workplace injuries in 2020 (22% vs 29%), but the proportion of power tool injuries was similar (31.6% 2020 vs 26.6%). DIY injuries increased significantly (33.5% versus 9.2%). Use of local anaeshesia including increased significantly in our unit (84.2% vs 66.1% 2019) with reduction in use of regional and general anaesthesia.

Conclusions

Caseload somewhat reduced during lockdown. Fewer injuries occurred in the workplace. Our unit made good use of local anaesthetic techniques to avoid regional anaesthesia (and risk of need for GA conversion) wherever possible. Public safety warnings existed (BAPRAS and BSSH), but perhaps were less publicly available than desirable. Improving awareness further could reduce trauma surgery burden as we enter a third wave of the pandemic.

Dilemmas in the management of rhinophyma in pigmented individuals

Rhinophyma affects predominantly the Caucasian population and is rare in those with Fitzpatrick skin type IV-VI. Diagnosis is based on clinical evaluation. Prominent features include abnormal coloration and texture of skin, impaired vascularity, irregular nodular exophytic growth and telangiectasia. Management can be surgical or dermatological. Surgery remains the mainstay of treatment but achieving an acceptable aesthetic result can be challenging, particularly in those with pigmented skin. Postsurgical hyper- and hypopigmentation make for unpredictable outcomes requiring appropriate preoperative counselling. We present a case that exemplifies this issue and discuss our recommended approach to counselling, consenting and managing such dilemmas in these patients, and a proposal for further investigation into the role of autologous melanocyte transplantation in reducing the effect particularly of hypopigmentation on aesthetic outcomes in this group.

Extracorporeal Shockwave Lithotripsy for Cystine Stones in Children: An Observational, Retrospective, Single-Center Analysis

Purpose: Cystinuria is a genetic disorder characterized by a defective reabsorption of cystine and dibasic amino acids leading to development of urinary tract calculi from childhood onward. Cystine lithiasis is known to be resistant to fragmentation. The aim was to evaluate our long-term experience with extracorporeal shockwave lithotripsy (ESWL) used as first-line urological treatment to treat cystine stones in children. Methods: We retrospectively reviewed the charts of all children who underwent ESWL for cystine stone. We assessed the 3-month stone-free rate, according to age, younger (group 1) or older (group 2) than 2 years old. Results: Between 2003 and 2016, 15 patients with a median (IQR) age at first treatment of 48 (15-108) months underwent ESWL in monotherapy. Median age was, respectively, 15 and 108 months in each group. The median (IQR) stone burden was 2,620 (1,202-8,265) mm³ in group I and 4,588 (2,039-5,427) mm³ in group II (p = 0.96). Eleven patients had bilateral calculi. ESWL was repeated on average 2.4 times, with a maximum of 4 for patients of group I, and 4.8 times, with a maximum of 9 for group II (p > 0.05). ESWL in monotherapy was significantly more efficient to reach stone-free status for children under 2 years of age: 83% vs. 6.2% (p = 0.040). The median (IQR) follow-up of the study was 69 (42-111) months. Conclusion: ESWL appears as a valid urological option for the treatment of cystine stones, in young children. Even if cystine stones are known to be resistant to fragmentation, we report 83% of stone-free status at 3 months with ESWL used in monotherapy in children under 2 years old with cystinuria. In older children, the success rate is too low to recommend ESWL as a first line approach.

Development and validation of a bladder trabeculation grading system in pediatric neurogenic bladder

Bladder trabeculation (BT) is commonly noted on cystogram images of patients with neurogenic bladder (NB). BT is associated with a hostile bladder often requiring prompt, more aggressive management. We aimed to define and validate a reliable grading system for BT severity. The proposed grading system will improve clinicians and radiologist's communication and serve as a foundation for future studies in the field of NB. The study was conducted in two phases: 1) Development of a grading system for BT and 2) testing of the proposed grading system for reliability and validity. Agreement between raters was assessed using Cohen's Kappa. Inter-rater reliability and intra-rater reliability was assessed using intra-class correlation coefficients (ICC) and Spearman's p (rho) correlation coefficient. The content of the grading system was assessed for face validity by senior pediatric urology and radiology experts. We observed inter-rater reliability with ICC of 0.998 (95%CI 0.996-0.999, p < 0.001), and a Cohen's Kappa ranging from 0.795 to 1.0, p < 0.001 and Spearman's p (rho) correlation coefficient ranging from 0.910 to 1.0, p < 0.001 between raters on the decided grades of BT. In conclusion, we established a defined grading system for BT severity that has substantial inter/intra-rater reliability and validity. This grading system could be useful for improving clinician and radiologist's communication about the status of a child's bladder wall and serve as a foundation for future studies assessing severity of NB.

Peritoneal Dialysis in the Prune Belly Syndrome

Objectives

To describe our experience with chronic ambulatory peritoneal dialysis in children with the prune belly syndrome (PBS).

Design

From our peritoneal dialysis (PD) program we were able to review the medical records of 6 boys with PBS. Data were collected on potential complications such as infections, hernias, growth, and problems encountered with PD catheter insertion.

Results

The ages of the 6 boys ranged from 10 months 17 years. The dialysis duration was from 9–22 months, with a total of 76 patient-months on PD. There was one death, possibly as a complication of an exit-site infection. Five received a renal transplant, and 4 have functioning grafts. Peritonitis occurred once in every 10.8 patient months, and exit-site or tunnel infection was diagnosed every 7.6 patient-months. Four patients required PD catheter replacement because of tunnel infection in 2, persistent exit-site infection in 1, and fluid leakage in 1. Of a total of nine catheters, three were inserted using a laparoscopic technique. There were no leaks in these three; however, there was one exit-site infection. Two patients had inguinal hernias that required surgery.

Conclusion

Deficiency of abdominal musculature in PBS poses potential problems for the use of PD, in particular, catheter anchorage, exit-site healing, and leakage. In our patients the most serious complications were infections of the exit site or catheter tunnel. Our experience suggests that a laparoscopic technique may provide improved catheter placement. PD offers a potentially successful form of dialysis for patients with PBS.

Prevalence of eosinophilic esophagitis: A multicenter study on a pediatric population evaluated at thirty-six Latin American gastroenterology centers

INTRODUCTION AND OBJECTIVE

Eosinophilic esophagitis is a chronic, immune-mediated disease described in case series and publications worldwide. Over the past twenty years, the authors of different studies have attempted to evaluate its incidence and prevalence. The objetive of the present study was to estimate the prevalence of eosinophilic esophagitis in a group of children seen at 36 pediatric gastroenterology centers in ten Latin American countries.

MATERIALS AND METHODS

A multicenter, observational, and cross-sectional study was conducted that estimated the period prevalence of eosinophilic esophagitis in children seen at outpatient consultation and that underwent diagnostic upper gastrointestinal endoscopy for any indication at 36 centers in 10 Latin American countries, within a 3-month time frame.

RESULTS

Between April and June 2016, 108 cases of eosinophilic esophagitis were evaluated. Likewise, an average of 29,253 outpatient consultations and 4,152 diagnostic upper gastrointestinal endoscopies were carried out at the 36 participating centers. The period prevalence of eosinophilic esophagitis in the population studied (n=29,253) was 3.69 cases×1,000 (95% CI: 3.04 to 4.44), and among the children that underwent routine upper gastrointestinal endoscopy (n=4,152), it was 26x1,000 (95% CI: 22.6 to 29.4).

CONCLUSIONS

The general period prevalence of eosinophilic esophagitis in a group of children evaluated at 36 Latin American pediatric gastroenterology centers was 3.69×1,000, and in the children that underwent endoscopy, it was 26×1,000. There was important prevalence variability between the participating countries and centers. The present analysis is the first study conducted on the prevalence of pediatric eosinophilic esophagitis in Latin America.

Avoiding routine postoperative voiding cystourethrogram: Predicting radiologic success for endoscopically treated vesicoureteral reflux

INTRODUCTION

Variability in the success rates for the endoscopic correction of vesicoureteral reflux (VUR) has prompted a debate regarding the use of routine postoperative voiding cystourethrogram (VCUG). This study examines the predictive performance of intraoperative mound morphology (IMM) and the presence of a postoperative ultrasound mound (PUM) on radiologic success, as well as investigates the role of using these two predictive factors as a composite tool to predict VUR resolution after endoscopic treatment.

METHODS

This retrospective study included children with primary VUR who underwent endoscopic correction with a double hydrodistension-implantation technique (HIT) and dextranomer/hyaluronic acid copolymer. IMM was assessed intraoperatively. The presence of a PUM and VUR resolution were assessed by postoperative ultrasound (US) and VCUG, respectively. Radiologic success was defined as VUR resolution.

RESULTS

A total of 70 children (97 ureters) were included in the study. The overall radiologic success rate was 83.5%. There was no statistically significant association between radiologic success and IMM (85.2% with excellent and 87.5% with "other" morphology; p=0.81). The sensitivity and specificity of PUM for radiologic success in this study was 98% and 71%, respectively, while the sensitivity and specificity of the combined prediction model were 81.9% and 85.7%, respectively.

CONCLUSIONS

We objectively demonstrated that IMM was a poor predictor of radiologic success and should be used with caution. In addition, the performance of a combined prediction model was inferior to the presence of a PUM alone. As such, selective use of postoperative VCUG may be guided solely by the presence of a PUM.

A Reanalysis of the RIVUR Trial Using a Risk Classification System

PURPOSE

The RIVUR (Randomized Intervention for Children with Vesicoureteral Reflux) trial showed a 50% decrease in the risk of urinary tract infection recurrence in children with reflux receiving continuous antibiotic prophylaxis. We reanalyzed the RIVUR data with the purpose of using a risk classification system to identify children who are more likely to benefit from continuous antibiotic prophylaxis.

MATERIALS AND METHODS

Data from 607 children enrolled in the RIVUR trial were obtained from the National Institute of Diabetes and Digestive and Kidney Diseases Central Repository and analyzed. We stratified these children into low and high risk categories. The proportion of children and risk of urinary tract infection recurrence in the stratified treatment groups were compared.

RESULTS

Of the children 385 (63.9%) were stratified into the low risk and 217 (36.1%) into the high risk category. The proportions of children with urinary tract infection recurrence were not significantly different in the low risk category between the placebo and continuous antibiotic prophylaxis groups (p = 0.151), while urinary tract infection recurrence was significantly higher in the placebo group (31.5% vs 11.4%, p = 0.001) for high risk children. Furthermore, high risk children on placebo had a 3.7-fold increased risk of urinary tract infection recurrence during 2 years of followup compared to those on continuous antibiotic prophylaxis.

CONCLUSIONS

Although the RIVUR trial concluded that children with vesicoureteral reflux benefit from continuous antibiotic prophylaxis, our reanalysis of the data demonstrates that high risk children benefit more, with a number needed to treat of 5 compared to 18 in low risk children. The clinical implications of these findings suggest a need to refine current indications for continuous antibiotic prophylaxis in children with reflux, supporting a shift toward a "selective" risk based approach for management.

Time to resolution: A prospective evaluation from the Society for Fetal Urology hydronephrosis registry

INTRODUCTION

The resolution rate of prenatal urinary tract dilation (UTD) has been documented in several retrospective studies. The present study analyzed prospective observational registry data, with the aim of determining time to resolution among patients prenatally identified with mild postnatal UTD.

MATERIALS AND METHODS

A total of 248 subjects, from four centers, were prospectively enrolled from 2008 to 2015. Exclusion criteria included other anomalies (n = 69), fewer than two ultrasounds, and/or <3 months follow-up (n = 26). Resolution was defined as Outcome A (SFU 0) and Outcome B (SFU 0/1). Fisher's exact test, Mann-Whitney U or Kruskal-Wallis test and Kaplan-Meier were used for analysis.

RESULTS/DISCUSSION

The median follow-up for 179 (n = 137 males) subjects was 15 months (IQR 7-24), range 0-56 months. VCUG was performed in 100 (57%) and VUR identified in 15 (15%). There was no association with reflux and resolution (P = 0.72). For resolution assessment (n = 153), lower grades were likely to resolve and demonstrated a higher rate in the Outcome B classification. Time to resolution also favored lower grades, with the majority resolving within 2 years (Figure). Surgical intervention was performed in 14 (8%). It is interesting to note that regardless of grade of UTD, there was no difference in frequency of US or the time that RUS was first performed. Practitioners performed the first RUS of life within a narrow window ranging from 0.27 RUS/month for Grade 1 UTD to 0.30 RUS/month for Grade 4 UTD. It was speculated that this practice pattern occurrence likely reflected the deficiency in knowledge by primary care providers, and identified a potential opportunity for education. The SFU registry substantiates that the vast majority of patients will demonstrate transient UTD and most cases that do not resolve will improve within 2 years of life. This data could be used to further an evidenced-based approach towards the evaluation and management of prenatal UTD, as outlined in the multidisciplinary consensus statement for prenatal urinary tract dilation.

CONCLUSIONS

This prospective registry confirms that the majority of prenatal UTD is transient, resolution occurs within the first 3 years of life, and most patients will not need intervention. Redefining SFU 1 as normal increased the resolution rate. A large proportion of patients were not evaluated with a VCUG, therefore impact of VUR could not be determined.

Diverse outcome following early prenatal diagnosis of pulmonary stenosis

OBJECTIVE

To assess the natural history and outcome of fetal pulmonary stenosis (PS), particularly that detected at 14-17 weeks' gestation.

METHODS

In this retrospective study we searched an electronic database of women from the general Israeli population attending a private ultrasound institute (Al-Kol ultrasound institute in Haifa) for routine complete early fetal ultrasound, including all fetal systems and a fetal echocardiogram, between 2004 and 2015. Ninety-seven percent of the women were at low risk of fetal malformations, and 3% had risk factors such as maternal Type-1 diabetes mellitus, exposure during pregnancy to teratogenic drugs, or anomalies in previous pregnancies or in other family members. At presentation at 14-17 weeks of gestation, color and pulsed Doppler imaging were performed across the four cardiac valves. We identified cases in which abnormal flow was detected, leading to suspicion of PS; in these cases, a follow-up examination was carried out at 17-19 weeks and then monthly until delivery or resolution of the finding, and postnatal echocardiography was performed at birth, 4-6 weeks thereafter, and yearly afterwards. Outcome data for suspicious cases, including postnatal diagnosis and general or specific symptoms, were collected by contacting the parents via email or telephone.

RESULTS

Among 24 185 early prenatal transvaginal ultrasound screening examinations, 23 cases of suspected PS were identified. They were classified into three groups, according to their ultrasound findings. In Group A (n = 8), the ultrasound screen was normal except for high flow velocity across the pulmonary valve. In six cases, this finding had resolved by 20-21 weeks of gestation and all were found to be normal at postnatal follow-up, one case underwent termination of pregnancy at 19 weeks and PS was confirmed at autopsy and one case was lost to follow-up. In Group B (n = 12), there was aliasing across the pulmonary valve. Two of these cases were normal postnatally and eight had mild-to-moderate PS; the remaining two cases developed hypoplastic right ventricle and pulmonary atresia at 19-20 weeks and the pregnancies were terminated. In Group C (n = 3) PS was associated with other anomalies; all three pregnancies were terminated. There were an additional six cases (Group D) not identified in early gestation, in which PS was late-onset. One had tricuspid regurgitation at the early screen, but was subsequently diagnosed with Ebstein's anomaly and pulmonary atresia, at 22 weeks, and was terminated. The other cases had completely normal early ultrasound screening examinations: one case had Ebstein's anomaly and PS was diagnosed at birth; four had isolated mild PS, of which one was diagnosed at 22 weeks' gestation and the other three were diagnosed postnatally, before 3 months of age. The sensitivity for detection of the ascertained cases of PS was 64% (11/17) and the specificity was > 99%.

CONCLUSION

There is a diverse spectrum of presentation of fetal PS in the early mid-trimester. A possible explanation for this could be different pathophysiological pathways. Further study is needed to explain the different prenatal sonographic presentations in an unselected population. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Femoral neck pseudoarthrosis in a polio patient treated with closed reduction and cell therapy

Poliomyelitis disease affects the anterior horns cells of the spinal cord and certain motor nuclei of the brain stem. Paralysis type is flaccid and asymmetrical and result in muscular imbalance.

Due to this, in case of having a hip muscles involvement, degenerative or posttraumatic, total hip arthroplasty is normally contraindicated because of the excessive risk of hip dislocation. In cases of subcapital femoral neck fractures the femoral head vascularization is a main concern, and in cases of neglected fracture with pseudoarthrosis the vascular status to the head must be investigated prior to further decisions.

We report the case of a femoral neck fracture non-union after a missed femoral neck fracture in a polio affected leg treated with cannulated screws and percutaneous autologous injection of processed total nuclear cells (TNC) mixed with putty demineralized bone matrix.

Outcome of femoral fractures care as a measure of trauma care between level I and level II trauma systems in Israel

Background

Our hypothesis in this study was that the outcome of patients with femur fractures would be favorable in a level I trauma center (LITC).

Methods

A prospective multicenter cohort study. 5 LITC and 6 regional (level II) trauma centers (RTCs) were enrolled to participate in the study. A total of 238 patients suffering from a femoral fracture were recruited to the study. 125 patients were treated in LITCs and 113 in RTCs. Data were extracted from the emergency medical services ambulances, emergency department records, patient hospitalization and discharge records, operating room records, and the national trauma registry (for LITCs). A study questionnaire was administered to all participating patients at discharge, 6 weeks and 6 months postoperatively. The following parameters were studied: mechanism of injury, time from injury to the hospital, Injury Severity Score, classification of femoral fracture, additional injuries, medical history, time to surgery, implant type, skill level of the surgical team, type of anesthesia, length of stay and intensive care unit (ICU) stay, postoperative and intraoperative complications and mortality.

Results

There was a significant difference in the modality of patient transfer between the 2 study groups-with the LITC receiving more patients transported by helicopters or medical intensive care. Time to surgery from admission was shorter in the LITC. Length of stay, ICU stay, and mortality were similar. In the LITCs, 47% of the procedures were performed by residents without the supervision of an attending surgeon, and in the RTCs 79% of the procedures were performed with an senior orthopaedic surgeon. Intraoperative and immediate complication rates were similar among the 2 groups.

Conclusions

A femoral shaft fracture can be successfully treated in an LITC and RTC in the state of Israel. Both research and policy implementation works are required. Also, a more detailed outcome analysis and triage criteria for emergency are desired.

Level of evidence

II.

Environmental enrichment rescues the effects of early life inflammation on markers of synaptic transmission and plasticity

Environmental enrichment (EE) has been successful at rescuing the brain from a variety of early-life psychogenic stressors. However, its ability to reverse the behavioral and neural alterations induced by a prenatal maternal infection model of schizophrenia is less clear. Moreover, the specific interactions between the components (i.e. social enhancement, novelty, physical activity) of EE that lead to its success as a supportive intervention have not been adequately identified. In the current study, standard housed female Sprague-Dawley rats were administered either the inflammatory endotoxin lipopolysaccharide (LPS; 100μg/kg) or pyrogen-free saline (equivolume) on gestational day 15. On postnatal day 50, offspring were randomized into one of three conditions: EE (group housed in a large multi-level cage with novel toys, tubes and ramps), Colony Nesting (CN; socially-housed in a larger style cage), or Standard Care (SC; pair-housed in standard cages). Six weeks later we scored social engagement and performance in the object-in-place task. Afterwards hippocampus and prefrontal cortex (n=7-9) were collected and evaluated for excitatory amino acid transporter (EAAT) 1-3, brain-derived neurotrophic factor (BDNF), and neurotrophic tyrosine kinase, receptor type 2 (TrkB) gene expression (normalized to GAPDH) using qPCR methods. Overall, we show that gestational inflammation downregulates genes critical to synaptic transmission and plasticity, which may underlie the pathogenesis of neurodevelopmental disorders such as schizophrenia and autism. Additionally, we observed disruptions in both social engagement and spatial discrimination. Importantly, behavioral and neurophysiological effects were rescued in an experience dependent manner. Given the evidence that schizophrenia and autism may be associated with infection during pregnancy, these data have compelling implications for the prevention and reversibility of the consequences that follow immune activation in early in life.

Three-week or one-week bladder catheterization for hypospadias repair? A retrospective-prospective observational study of 189 patients

PURPOSE

While there is little scientific evidence over the optimal duration for transurethral bladder catheterization after hypospadias repair, most surgeons leave the catheter for 7-10 days. We herein describe our experience with bladder catheterization for three weeks after hypospadias repair, an approach not previously described in the literature.

PATIENTS AND METHODS

We reviewed the charts of 189 patients who underwent hypospadias repair by a single pediatric urologist. The study population was divided as follows: group 1 consisted of children operated between March 2007 and September 2010 and whose catheters were left for one week (n=95); group 2 consisted of those operated between September 2010 and July 2013 and whose catheters were left for three weeks (n=94). The primary objective of the study was to compare complication rates between the two groups. Secondary outcomes were evaluation of the effect of age, surgical technique, curvature, and hypospadias degree as potential factors for postoperative complications.

RESULTS

Median age at hypospadias repair was 18 months (range, 3-100 months) in group 1, and 16 months (range, 2-96 months) in group 2, P=.209. The complication rate was 22.1% (n=21) for group 1 and 7.4% (n=7) for group 2, P=.005. Complications observed in group 1 and 2 were meatal stenosis (n=4 and 2, respectively) and urethro-cutaneous fistulas (n=17 and 5, respectively). Coronal fistulas manifested more frequently in patients in group 1 compared to those in group 2 (13.7% vs. 3.2%, P=.01). Complications were observed in 20 patients out of 139 (11.5%) after Duplay, and in 8 patients out of 15 (53.3%) after Duckett (P<.001). In Duplay cases, complications were significantly associated with one-week bladder catheterization (OR: 5.00; 95% CI: 1.53-16.32; P=.008) and higher age group at operation (OR: 1.88; 95% CI 1.07-3.28; P=.026). In Duckett cases, number of surgeries, age, severity, curvature and catheter duration were not found to be associated with complications.

CONCLUSION

In cases of Duplay, a three-week instead of one-week catheterization and age below 6 months at hypospadias repair are associated with a better outcome and fewer complications.

Performance of manual ventilation: how to define its efficiency in bench studies? A review of the literature

Bench studies have become the preferred way to evaluate the performance of airway equipment, since clinical trials are not specifically required before marketing these devices. However, it is difficult to assess the efficiency of ventilation without recording physiological data. This review analyses how efficiency of manual ventilation has been defined in recent studies, and how their results may be affected. We searched electronic databases from 2000 to April 2014. The main inclusion criterion was the analysis of performance of ventilation. Nine relevant articles were selected from 53 eligible publications. Most studies used the same parameters; tidal volume and ventilation rate. However, there were significant differences between the definitions of performance of ventilation, both in terms of criteria of judgement and methods of analysis. None of these approaches is able to provide a clear understanding of variability of ventilation during a given period. A new definition may increase the relevance of bench studies to clinical medicine, by more appropriately assessing the performance of ventilation.

Reliability of manikin-based studies: an evaluation of manikin characteristics and their impact on measurements of ventilatory variables

Findings from manikin-based studies on ventilation are commonly directly extrapolated to clinical practice. The aim of this study was to determine how the use of manikins affects measurements of ventilatory variables. We connected a lung simulator to a manikin, which was then ventilated at different inspiratory flows. We defined three experimental models to compare measurements of ventilatory variables between the mechanical ventilator and the lung simulator. Even when no leakage occurred, significant tidal volume deviations were observed; from a mean (SD) of 21 (2) ml to 49 (9) ml, and from 40 (4) ml to 88 (5) ml for invasive and non-invasive ventilation, respectively (p < 0.001). Significant peak pressure deviations from 0.7 (0.1) cmH2 O to 10.6 (0.3) cmH2 O were also recorded during non-invasive ventilation (p < 0.001). Evaluation of manikin resistance and airway dead space may be essential to limit study bias. We suggest a recalibration of the recorded data if comparisons are made between different tests performed at different inspiratory flows.

Growing teratoma syndrome: first case report in a 4-year-old girl

Growing teratoma syndrome (GTS) consists of germ cell tumors that grow following chemotherapy despite complete eradication of the malignant cells. They can metastasize to any site, particularly the retroperitoneum, mediastinum and cervical region. It typically affects young adults and adolescents. Here we describe the youngest case reported in a 4-year-old girl with an ovarian mixed germ cell tumor who underwent an oophorectomy. Her tumor markers normalized by the end of her chemotherapeutic treatment; however, she developed a retroperitoneal mass that was subsequently resected. Histopathology revealed a mature teratoma, consisting of a GTS. We stress the need for early recognition and treatment of GTS to avoid the subsequent morbidity and mortality associated with it. Although GTS has an excellent prognosis when completely resected, it is essential that the patient be regularly followed-up with serum tumor markers and imaging.

Generalized lock-in detection for interferometry: application to phase sensitive spectroscopy and near-field nanoscopy

A generalized lock-in detection method is proposed to extract amplitude and phase from optical interferometers when an arbitrary periodic phase or frequency modulation is used. The actual modulation function is used to create the reference signals providing an optimal extraction of the useful information, notably for sinusoidal phase modulation. This simple and efficient approach has been tested and applied to phase sensitive spectroscopy and near-field optical measurements. We analyze the case where the signal amplitude is modulated and we show how to suppress the contribution of unmodulated background field.

Application of continuous incisional infusion of local anesthetic after major pediatric urological surgery

OBJECTIVES

To determine the efficacy of the locally infused anesthetic, ON-Q(®) pain relief system (Kimberly-Clarke, GA-USA), in improving postoperative pain, reducing narcotic requirement, and shortening recovery time after major pediatric urological surgery.

MATERIAL AND METHODS

A case-control analysis comparing 20 patients undergoing major urological procedures who were treated postoperatively with the ON-Q system was compared to 20 patients treated with current hospital standard of care intravenous and oral analgesics. Pain was assessed in both groups by staff nurses using the different validated scales depending on the child's age. Information regarding analgesic consumption along with recovery parameters such as temperature, start of oral nutrition, and length of hospitalization (LOH) were collected.

RESULTS

The ON-Q group experienced significantly lower ratings of maximal pain on the first postoperative day as compared to the control group (3 vs. 5.2, p = 0.03) and a trend toward lower mean of maximal pain score on postoperative day two (1.8 vs. 3.5, p = 0.055). Systemic intravenous and oral analgesics were significantly lower on the day of surgery and the first postoperative day for the ON-Q group (p = 0.014; and p = 0.046 respectively). No differences in frequency of fever, start of oral nutrition and LOH were found between the study groups.

CONCLUSION

Continuous incisional infusion of local anesthetic with the ON-Q system is a viable option for postoperative pain management in children undergoing major urological surgeries. This technology significantly decreases the need for systemic analgesic consumption.

The morphological applicability of a novel endovascular aneurysm sealing (EVAS) system (Nellix) in patients with abdominal aortic aneurysms

OBJECTIVE

Endovascular aneurysm sealing (EVAS) using the Nellix system is a promising alternative to endovascular repair (EVR) and open surgery for abdominal aortic aneurysms (AAA). The aim of this study was to investigate the proportion of patients with AAA who are morphologically suitable for treatment with Nellix.

METHODS

Patients presenting with AAA were investigated at two regionalised vascular units. Separate cohorts were identified, who had undergone infrarenal EVR, open aneurysm repair, fenestrated endovascular repair (FEVR) or non-operative management. Pre-operative morphology was quantified using three-dimensional computed tomography according to a validated protocol. Each aneurysm was assessed for compliance with the instructions for use (IFU) of Nellix

RESULTS

776 patients were identified with mean age 75 ± 9 years. 730/776 (94.1%) had undergone infrarenal EVR, 6/776 (0.8%) open repair, 27/776 (3.5%) FEVR and 13/776 (1.7%) had been managed non-operatively. 544/776 (70.1%) of all AAA were morphologically suitable for Nellix. 533/730 (73.0%) of patients who had undergone infrarenal EVR were compliant with Nellix IFU, compared with 497/730 (68.1%), 379/730 (51.9%) and 214/730 (29.3%) with the IFU for Medtronic Endurant (p = .04) or Cook Zenith (p < .01) and Gore C3 Excluder (p < .01) endografts respectively.

CONCLUSIONS

Nellix technology appears widely applicable to contemporary infrarenal AAA practice, and may provide an option for patients that are outside current EVR device instructions for use. However, formal outcomes study is still required, and will ultimately dictate the clinical relevance of this feasibility study. The major limitation to anatomic suitability for Nellix is currently the maximum patent lumen diameter of large AAA.

Tracheostomy in the critically ill: the myth of dead space

Benefits and advantages of tracheostomy have been vigorously debated. There is a lack of consensus as to whether perceived clinical improvement is attributable to fundamental changes in respiratory dynamics. We compare the effect of tracheostomy versus endotracheal tube on dead space, airway resistance and other lung parameters in critically ill ventilated patients. Data collected included patients who were admitted to surgical, burn and neurosurgical intensive care units at the University of North Carolina. Twenty-four intubated patients were included in our analysis with various aetiologies of respiratory failure. Tracheostomy was deemed necessary either for severe neurological devastation or failure to wean from the ventilator. The diameter of the endotracheal tubes ranged from 6-8 mm and the tracheostomy tube diameters were from 6.4-8.9 mm. Internal diameters between endotracheal tube and tracheostomy tubes, ventilator settings and sedation were kept consistent throughout the study. Respiratory parameters were measured using the Respironics' non-invasive cardiac output 2 device (Phillips, Andover, MA) immediately prior to tracheostomy and repeated within 24 hours of tracheostomy. Only two (8%) of the patients had slight improvement (>6% decrease in dead space). The average dead space of endotracheal versus tracheostomy tubes was 41±12.6% and 40±14.6%, respectively (P=0.75). The remaining 22 patients (92%) had no significant change in dead space, compliance or other respiratory parameters. This study shows that there is no significant difference in respiratory mechanics and dead space with a tracheostomy versus endotracheal tube.

Orthogonal double plate fixation for long bone fracture nonunion

PURPOSE OF THE STUDY

The treatment of long bone diaphyseal fracture-nonunion is challenging. While taking into account biological needs, a stable mechanical environment is pertinent for fracture healing. This work aims at evaluating the surgical management of stubborn ununited fractures using orthogonal double plating of diaphyseal fractures with limited periosteal stripping and soft tissue dissection.

PATIENTS AND METHODS

Retrospective analysis in a level I trauma center. Between the years 2007-2009, 22 patients were treated with double plating due to nonunion of long bone fractures. Long bones included three clavicles, six humeri, three femora, seven ulnae, two tibiae and one radius. The mean period between index procedures (if existed) and revision procedures was 53.35 weeks (range 6 months-3 years). The same surgical technique, independent on the anatomical location was utilized. Perioperative intravenous antibiotics were withheld until intraoperative cultures were obtained in all patients. An approach to the fracture site was performed with removal of all previous existing hardware, including aggressive debridement of the nonunion site while keeping stripping to the necessary minimum. After primary plate fixation of the fracture with adequate compression, a second plate, with at least two well spaced screws on each side, was placed at a ninety degree angle to the primary plate. Autologous bone graft or bone graft substitute was placed in most, but not all cases. All procedures and assessment of union were done by fellowship trained trauma surgeons. In the infected cases, culture specific intravenous antibiotics were administered for six weeks. Quality of life measures included DASH score of the upper extremity, lower extremity functional score (LEFS) for the lower extremity and Short From 12 (SF-12) for all patients.

RESULTS

Union was achieved in all patients, with an average time to union of 5.8 months (range 2-24 months). One patient healed after a repeat double plating, since the first procedure was unsuccessful. Tissue culture were positive in 11 out of 22 patients. One clavicular plate was removed, due to irritation. No hardware failure was noted in these cases. Mean LEFS was 59%, quick DASH score -18.5 20 and SF-12 MCS and PCS were 50.37 15.22 and 49.96 8.5 receptively.

CONCLUSION

Double plating is a biomechanically sound option for treating long bone fracture nonunion with reasonable results, provided adequate biological conditions are met including eradication of infection.

The role of flaps and grafts in modern hypospadiology

The modern hypospadiologist must be proficient in the use of both vascularized flaps and free grafts. When choosing a repair for any given patient with hypospadias, one must consider the length of the urethroplasty, the presence and degree of ventral curvature and perhaps most importantly, the surgeon's own experience. Not all repairs are created equally and different complication rates and cosmetic outcomes can be seen among different surgeons utilizing the same technique. Each surgeon tends to infuse their own modifications to any given technique and many of these modifications go unreported. It is incumbent upon each surgeon to be familiar with a wide variety of techniques, which invariably includes the use of flaps and grafts. We present a spectrum of the uses of flaps and grafts in modern hypospadiology.

Household characteristics and allergen and endotoxin levels in Aleppo, Syrian Arab Republic

Few data are available from Eastern Mediterranean countries about levels of domestic allergens and endotoxins. Dust samples were collected from mattresses and floors of 457 homes in the Syrian city of Aleppo and analysed for antigens and endotoxins. The most important predictors for detectable levels of house-dust mite allergen Der p 1 were Arabic-style houses (OR 3.21) and newer houses (OR 1.56). In homes without cats, rubber mattresses were associated with detectable cat allergen Fel d 1 in mattress dust (OR 1.6). Cockroach allergen Bla g 2 was significantly more likely to be detected in houses over 20 years old than newer houses. Endotoxin levels were significantly higher in wool/cotton mattresses and older houses.

Out-of-hospital ventricular fibrillation in three adolescents

We describe three adolescents who experienced sudden cardiac arrest due to ventricular fibrillation in an out-of-hospital setting and survived with good neurological outcome despite delayed time to defibrillation. All three were treated with prolonged cardiopulmonary resuscitation (CPR) by certified basic life support providers prior to first defibrillation. This report stresses the importance of early, minimally interrupted, chest compression CPR in children who suffer sudden cardiac arrest in the out-of-hospital setting where defibrillation could be delayed.

Intraoperative cone-beam CT for image-guided tibial plateau fracture reduction

OBJECTIVES

A mobile isocentric C-arm was modified in our laboratory in collaboration with Siemens Medical Solutions to include a large-area flat-panel detector providing multi-mode fluoroscopy and cone-beam CT (CBCT) imaging. This technology is an important advance over existing intraoperative imaging (e.g., Iso-C(3D)), offering superior image quality, increased field of view, higher spatial resolution, and soft-tissue visibility. The aim of this study was to assess the system's performance and image quality in tibial plateau (TP) fracture reconstruction.

METHODS

Three TP fractures were simulated in fresh-frozen cadaveric knees through combined axial loading and lateral impact. The fractures were reduced through a lateral approach and assessed by fluoroscopy. The reconstruction was then assessed using CBCT. If necessary, further reduction and localization of remaining displaced bone fragments was performed using CBCT images for guidance. CBCT image quality was assessed with respect to projection speed, dose and filtering technique.

RESULTS

CBCT imaging provided exquisite visualization of articular details, subtle fragment detection and localization, and confirmation of reduction and implant placement. After fluoroscopic images indicated successful initial reduction, CBCT imaging revealed areas of malalignment and displaced fragments. CBCT facilitated fragment localization and improved anatomic reduction. CBCT image noise increased gradually with reduced dose, but little difference in images resulted from increased projections. High-resolution reconstruction provided better delineation of plateau depressions.

CONCLUSION

This study demonstrated a clear advantage of intraoperative CBCT over 2D fluoroscopy and Iso-C(3D) in TP fracture fixation. CBCT imaging provided benefits in fracture type diagnosis, localization of fracture fragments, and intraoperative 3D confirmation of anatomic reduction.

Neonatal atrial fibrillation after surgical repair of tracheoesophageal fistula with esophageal atresia

Atrial fibrillation is rare in childhood that had not been reported in neonates with normal cardiac morphology and function. The authors present a newborn who underwent surgical repair of a tracheoesophageal fistula with esophageal atresia at the age of 2 days and experienced atrial fibrillation 16 days after the procedure. A report of 35 pediatric patients in a single center over a period of 22 years identified atrial fibrillation in children with a variety of ailments including congenital cardiac anomalies before and after corrective surgery, rheumatic valve disease, Marfan's syndrome with mitral regurgitation, infective endocarditis, cardiomyopathy, endocardial fibroelastosis, paroxysmal atrial tachycardia of infants, and cardiac tumors [2]. All these patients had underlying cardiac disease.

The use of intraoperative three-dimensional imaging (ISO-C-3D) in fixation of intraarticular fractures

INTRODUCTION

The purpose of this study was to analyse the applicability and advantages of the intraoperative use of a mobile isocentric C-arm with three-dimensional imaging (Siremobil ISO-C-3D) in fixation of intraarticular fractures.

METHODS

After the fixation was judged to be satisfactory relying on the images provided by routine fluoroscopy, intraoperative CT visualisation with ISO-C-3D was performed to evaluate the fracture reduction and implant position. Intraoperative revision was performed based on the additional information ISO-C-3D provided beyond routine fluoroscopy. ISO-C-3D was used on a series of 72 closed-intraarticular fractures in 70 patients. Fracture distribution was: calcaneus (25), tibial plateau (17), tibial plafond (12), acetabulum (11), distal radius (3), ankle Weber-C (3) and femoral head (l). The primary outcome measure was revision rate after final ISO-C-3D data acquisition and prior to wound closure. Secondary objectives were to measure the additional time required for ISO-C-3D use and to determine the rate of further re-do surgeries.

RESULTS

Eight out of 72 (11%) fracture fixations were judged by the surgeon to require intraoperative revision following ISO-C-3D imaging. Prior to leaving the operating room, the surgeon was satisfied with fracture alignment in all the procedures. The mean additional operative time using ISO-C-3D was 7.5 min (8.2% of the mean total operative time). No patient required re-do surgery.

CONCLUSION

: Intraoperative three-dimensional visualisation of intraarticular fractures enables the surgeon to identify inadvertent malreductions or implant malpositions which may be overlooked by routine C-arm fluoroscopy and hence may eliminate the need for re-do procedures. ISO-C-3D adds little operative time and may preclude the need for pre-operative and post-operative CT-scans in selected cases.

Osteoid osteoma: CT-guided radiofrequency ablation using a water-cooled probe

BACKGROUND

The purpose of this study was to assess the safety and efficacy of computed tomography (CT) guided percutaneous radiofrequency (RF) ablation of osteoid osteoma by using the water-cooled probe.

METHODS

During the period from July 2002 to February 2006, fifty-one patients with osteoid osteomas localized in femur (29), tibia (10), calcaneus (2), talus (2), metatarsus (2), humerus (1), sacrum (1), scapula (1), olecranon (1), patella (1) and thoracic vertebra (1) were treated with CT-guided RF ablation using the Cooltiptrade mark Tyco Healthcare probe. Mean age was 20 (range, 3.5-57 years) and male to female ratio was 36/15. Mean follow-up period was reported 2 years (range, 9-51 months). The procedures were carried out under general anesthesia and the patients were discharged from the hospital within 24 h.

RESULTS

Technical failure was reported in only one procedure. Pain disappeared postoperatively in all the patients within 2-3 days and no patients needed analgesic treatment after a week. All patients were allowed fully weight bear and function without limitation after the procedure. Recurrence of the pain was observed in one patient who was treated successfully with a second ablation. Our primary and secondary clinical success rates were 98 and 100% respectively. In one case, wound infection was observed after the procedure as the only post-operative complication in our series.

CONCLUSION

CT-guided percutaneous RF ablation of osteoid osteomas using the water-cooled probe is a safe, effective and minimally invasive procedure with high success rate and lack of relapses.