Ahmed Nasr

Oocyte donation pregnancies and the risk of preeclampsia or gestational hypertension: a systematic review and metaanalysis

The purpose of this study was to determine whether pregnancies that were achieved via oocyte donation, compared with pregnancies achieved via other assisted reproductive technology methods or natural conception, demonstrate increased risk of preeclampsia or gestational hypertension. Comparative studies of pregnancies that were achieved with oocyte donation vs other methods of assisted reproductive technology or natural conception with preeclampsia or gestational hypertension were included as 1 of the measured outcomes. Abstracts and unpublished studies were excluded. Two reviewers independently selected studies, which were assessed for quality with the use of methodological index for non-randomized studies, and extracted the data. Statistical analysis was conducted. Of the 523 studies that were reviewed initially, 19 comparative studies met the predefined inclusion and exclusion criteria and were included in the metaanalysis, which allowed for analysis of a total of 86,515 pregnancies. Our pooled data demonstrated that the risk of preeclampsia is higher in oocyte-donation pregnancies compared with other methods of assisted reproductive technology (odds ratio, 2.54; 95% confidence interval, 1.98-3.24; P < .0001) or natural conception (odds ratio, 4.34; 95% confidence interval, 3.10-6.06; P < .0001). The risk of gestational hypertension was also increased significantly in oocyte donation pregnancies in comparison with other methods of assisted reproductive technology (odds ratio, 3.00; 95% confidence interval, 2.44-3.70; P < .0001) or natural conception (odds ratio, 7.94; 95% confidence interval, 1.73-36.36; P = .008). Subgroup analysis that was conducted for singleton and multiple gestations demonstrated a similar risk for preeclampsia and gestational hypertension in both singleton and multiple gestations. This metaanalysis provides further evidence that supports that egg donation increases the risk of preeclampsia and gestational hypertension compared with other assisted reproductive technology methods or natural conception.

Surgical versus conservative management of congenital pulmonary airway malformation in children: A systematic review and meta-analysis

BACKGROUND The ideal management of infants born with asymptomatic congenital pulmonary airway malformation (CPAM) is controversial. We performed a systematic review and meta-analysis comparing elective resection versus expectant management. METHODS We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and PubMed for studies describing the management of asymptomatic CPAM and reporting on postoperative morbidity, mortality, and length of hospital stay (LOS). We performed meta-analyses when possible and provide a narrative summary of results. RESULTS One nonrandomized prospective and eight retrospective studies met our inclusion criteria. Out of 168 patients, 70 underwent surgery before symptoms developed with seven experiencing postoperative complications (10.0%); 63 developed symptoms while being managed expectantly and subsequently underwent surgery with 20 complications (31.8%). Thirty-five patients continued to be followed nonsurgically (three months to nine years of follow-up). Morbidity was higher with surgery after symptom development (6 studies; odds ratio 4.59, 95% confidence interval (CI) 1.40 to 15.11, P<0.01); there was no difference in LOS (3 studies; mean difference 4.96, 95% CI -1.75 to 11.67, P=0.15). There were no related deaths. CONCLUSIONS Elective resection of asymptomatic CPAM lesions is safe and prevents the risk of symptom development, which may result in a more complicated surgery and recovery.

What is the ideal surgical approach for intra-abdominal testes? a systematic review

There is controversy regarding the ideal surgical management of intra-abdominal testes (IAT) to preserve fertility; we conducted a systematic review to address this problem. We performed a comprehensive electronic search of CENTRAL, MEDLINE, EMBASE, and CINAHL from 2008 to September 2014 (the date range was limited due to an abundance of literature), as well as reference lists of included studies. Two researchers screened all studies for inclusion, and quality assessed each relevant study using AMSTAR for systematic reviews (SRs), Cochrane ‘Risk of bias’ tool for randomized controlled trials (RCTs), and MINORS for non-randomized studies. We identified two relevant SRs and 29 non-randomized studies. Due to the heterogeneity of the data, meta-analysis was not possible. Ultrasound and magnetic resonance imaging are insufficient for identification or localization of IAT; laparoscopic or surgical exploration is necessary. Primary orchiopexy is effective for low IAT, and Fowler-Stephens orchiopexy (FSO) is effective for high IAT. There is no clear benefit of one- vs. two-stage FSO, or of open vs. laparoscopic technique. Several alternative or modified techniques also show promise. RCTs are needed to confirm the validity of these findings, and to assess long-term outcomes.

Update on molecular findings in rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is the most common malignant soft tissue tumour in children and adolescents. Histologically RMS resembles developing fetal striated skeletal muscle. RMS is stratified into different histological subtypes which appear to influence management plans and patient outcome. Importantly, molecular classification of RMS seems to more accurately capture the true biology and clinical course and prognosis of RMS to guide therapeutic decisions. The identification of PAX-FOXO1 fusion status in RMS is one of the most important updates in the risk stratification of RMS. There are several genes close to PAX that are frequently altered including the RAS family, FGFR4, PIK3CA, CTNNB1, FBXW7, and BCOR. As with most paediatric blue round cell tumours and sarcomas, chemotherapy is the key regimen for RMS therapy. Currently there are no direct inhibitors against PAX-FOXO1 fusion oncoproteins and targeting epigenetic cofactors is limited to clinical trials. Failure of therapy in RMS is usually related to drug resistance and metastatic disease. Through this review we have highlighted most of the molecular aspects in RMS and have attempted to correlate with RMS classification, treatment and prognosis.

Primary anastomosis or ostomy in necrotizing enterocolitis

In neonates requiring operation for necrotizing enterocolitis (NEC), the complications due to enterostomy (ES) and the need for another operation to restore continuity have prompted several surgeons to employ primary anastomosis (PA) after resection as the operative strategy of choice. Our objective was to compare primary anastomosis to stoma formation in this population using systematic review and meta-analysis. Publications describing both interventions were identified by searching multiple databases. Appropriate studies that reported outcomes after PA and ES for NEC were included for analysis that was performed using the MedCalc3000 software. Results are reported as odds ratios (OR, 95% CI). No randomized trials were identified. Twelve studies were included for the final analysis. Neonates who underwent PA were associated with significantly less risk of mortality when compared to those who underwent ES (OR 0.34, 95% CI 0.17–0.68, p 0.002), possibly due to differences in severity of NEC. Although the types of complications in these groups were different, there was no significant difference in risk of complication (OR 0.86, 0.55–1.33, p 0.50). In neonates undergoing an operation for severe NEC, there is no significant difference in the risk of complications between primary anastomosis and enterostomy. A definitive suggestion cannot be made regarding the choice of one operative strategy over another.

Feeding Post-Pyloromyotomy: A Meta-analysis.

CONTEXT: Postoperative emesis is common after pyloromyotomy. Although postoperative feeding is likely to be an influencing factor, there is no consensus on optimal feeding. OBJECTIVE: To compare the effect of feeding regimens on clinical outcomes of infants after pyloromyotomy. DATA SOURCES: Cumulative Index to Nursing and Allied Health Literature, The Cochrane Central Register of Controlled Trials, Embase, and Medline. STUDY SELECTION: Two reviewers independently assessed studies for inclusion based on a priori inclusion criteria. DATA EXTRACTION: Data were extracted on methodological quality, general study and intervention characteristics, and clinical outcomes. RESULTS: Fourteen studies were included. Ad libitum feeding was associated with significantly shorter length of stay (LOS) when compared with structured feeding (mean difference [MD] −4.66; 95% confidence interval [CI], −8.38 to −0.95; P = .01). Although gradual feeding significantly decreased emesis episodes (MD −1.70; 95% CI, −2.17 to −1.23; P < .00001), rapid feeding led to significantly shorter LOS (MD 22.05; 95% CI, 2.18 to 41.93; P = .03). Late feeding resulted in a significant decrease in number of patients with emesis (odds ratio 3.13; 95% CI, 2.26 to 4.35; P < .00001). LIMITATIONS: Exclusion of non-English studies, lack of randomized controlled trials, insufficient number of studies to perform publication bias or subgroup analysis for potential predictors of emesis. CONCLUSIONS: Ad libitum feeding is recommended for patients after pyloromyotomy as it leads to decreased LOS. If physicians still prefer structured feeding, early rapid feeds are recommended as they should lead to a reduced LOS.

The value of preoperative liver biopsy in the diagnosis of extrahepatic biliary atresia: A systematic review and meta-analysis

BACKGROUND In extrahepatic biliary atresia (EHBA) obstruction of the biliary tree causes severe cholestasis leading to cirrhosis and death if left untreated in a timely manner. Infants with cholestasis may undergo many tests before EHBA diagnosis is reached. The role and place of preoperative liver biopsy in the diagnostic paradigm for EHBA have not been established. METHODS We conducted a systematic review of MEDLINE, Embase, and CENTRAL to obtain all publications describing the sensitivity/specificity/accuracy/positive predictive value (PPV)/negative predictive value (NPV) of preoperative liver biopsy in infants with cholestasis. Screening, data extraction, and quality assessment were done in duplicate. Extracted data are described narratively and analyzed using forest plots and receiver operating characteristic curves. RESULTS A total of 22 articles were included. Overall, the pooled accuracy of preoperative liver biopsy was 91.7%, with a sensitivity of 91.2%, specificity of 93.0% (n=1231), PPV of 91.2%, NPV of 92.5% (n=1182), and accuracy of 91.6% (n=1106). In patients who were 60days or less at time of presentation or diagnosis, the pooled sensitivity, specificity, PPV, NPV, and accuracy were 96.4%, 96.3%, 95.8%, 96.3%, and 94.9%, respectively. CONCLUSION Quantitative analysis demonstrated preoperative biopsy to be both highly specific and sensitive in diagnosing EHBA preoperatively. It is a highly reliable test that offers a means of arriving at an early definitive diagnosis of EHBA.

Histologic analysis of eosinophils and mast cells of the gastrointestinal tract in healthy Canadian children.

Many gastrointestinal (GI) disorders, including GI eosinophilia and inflammatory bowel disease, can be characterized by increased mucosal eosinophils (EOs) or mast cells (MCs). Normal mucosal cellular counts along the GI tract in healthy children have not been established for a Canadian pediatric population. To establish a benchmark reference, we quantified EO and MC from 356 mucosal biopsies of the GI tract obtained during upper and lower endoscopic biopsies of 38 pediatric patients in eastern Ontario. Mean total counts of EO varied for the 11 tissues we examined, from a low of 7.6±6.5/high-power field (HPF) (×40 [×400, 0.55mm(2)]) in the body of the stomach to a high of 50.3±17.4/HPF in the cecum. The lower GI tract (ileum, cecum, colon, sigmoid, and rectum) generally had higher total EO counts than the upper GI tract (antrum and body of stomach, duodenum, and duodenal cap) (combined average of 32.1±20.6 versus 19.3±15.8, respectively). Similarly, the number of mucosal MC was different in the various regions of the GI tract ranging from 0.04±0.2/HPF in the duodenal cap to 0.9±2.6/HPF in the ileum. Total counts for EO and MC in the lamina propria were not significantly different between sexes when adjusted for multiple testing. EO polarity was absent in many cases, irrespective of the GI region. These numeration and localization of EO and MC will provide normative data for upper and lower endoscopic GI biopsies in the pediatric population of Eastern Ontario.

Optimal age for elective surgery of asymptomatic congenital pulmonary airway malformation: a meta-analysis

Controversy exists on the optimal age for elective resection of asymptomatic congenital pulmonary airway malformation. Current recommendations vary widely, highlighting the overall lack of consensus. A systematic search of Embase, MEDLINE, CINAL, and CENTRAL was conducted in January 2016. Identified citations were screening independently in duplicate and consensus was required for inclusion. Results were pooled using inverse variance fixed effects meta-analysis. Meta-analysis results indicate no statistically significant differences for complications within the 3-month and 6-month age comparison groups [odds ratio (OR) 4.20, 95% confidence interval (CI) 0.78–22.77, I2 = 0%; OR 2.39, 95% CI 0.63–9.11, I2 = 0%, respectively]. Older patients were significantly favoured for 3-month and 6-month age comparison groups for length of hospital stay [mean difference (MD) 4.13, 95% CI 2.31–5.96, I2 = 0%; MD 3.38, 95% CI 0.44–6.31, I2 = 0%, respectively]. Borderline statistical significance was observed for chest tube duration in patients ≥6 months of age (MD 1.06, 95% CI 0.02–2.09, I2 = 0%). No mortalities were recorded. Surgical treatment appears to be safe at all ages, with no mortalities and similar rates of complications between age groups. The included evidence was not sufficient to make a conclusive recommendation on optimal age for elective resection.

The impact of transfer on pediatric trauma outcomes

BACKGROUND Recently, concerns have been raised over delays that result from transferring patients to designated trauma centers. This study aimed to assess whether transfer status had an impact on pediatric trauma outcomes. METHODS Using a local 1996-2014 pediatric trauma database containing 1541 patients, the following outcomes were tested: death, major complication, time to definitive treatment (TDT), hospital length of stay (LOS), and ICU length of stay (ICU LOS). Logistic, generalized linear, and Poisson regression models were used. RESULTS Mortality and complication rates did not differ significantly between direct (mortality=52/1000, complications=54/1000) and transferred (mortality=59/1000; complications=67/1000) patients (mortality aRR: 1.17, 95% CI: 0.76-1.80, p=0.48; complication aRR: 1.13, 95% CI: 0.75-1.70, p=0.57). Transfer status was not a significant predictor of ICU LOS (p=0.72). Transfer status was a significant predictor of time to definitive treatment (transfer x-=17.4h vs. direct x-=2.6h, p=0.0035) and of LOS for severely injured patients (p=0.005). The significant predictors of pediatric trauma mortality were: ISS, transport mode, age, and TDT, and of major complication were ISS and TDT. CONCLUSIONS Although transferred patients had longer time to specialized care, there were no significant differences in the mortality or complication rates between transferred and direct patients after adjusting for injury severity.