Sarah A. Jones

EFFECTS OF CORTICOTROPIN-RELEASING HORMONE AND ADRENOCORTICOTROPIN ON PROSTAGLANDIN OUTPUT BY HUMAN PLACENTA AND FETAL MEMBRANES

We have examined the possibility that corticotropin-releasing hormone (CRH) and adrenocorticotropin (ACTH) might affect prostaglandin (PG) E2 and PGF2 alpha output by term placenta, amnion and decidua during short-term (48-hour) culture, and that effects of CRH might be mediated by ACTH. In all three tissues PG output was stimulated by both CRH and ACTH. These effects were inhibited in the presence of antisera to CRH and to ACTH. Moreover, in placenta, but not in amnion or decidua, the stimulatory effects of CRH on PGE2 and PGF2 alpha output were attenuated in the presence of an antibody to ACTH. Our results support the possibility of paracrine stimulation by CRH and ACTH of PG production in intrauterine tissues, and suggest that in part the effects of CRH on placental PG output might be mediated through ACTH.

Fundoplication and gastrostomy versus percutaneous gastrojejunostomy for gastroesophageal reflux in children with neurologic impairment: A systematic review and meta-analysis.

BACKGROUND Children with neurologic impairment often fail medical management of gastroesophageal reflux and proceed to fundoplication and gastrostomy (FG) or percutaneous gastrojejunostomy (GJ). Current guidelines do not recommend one treatment over the other, and there is ongoing uncertainty regarding clinical management. METHODS We conducted a structured search of Medline, Embase, trial registries, and the gray literature. We included studies that compared outcomes for FG and GJ in children with neurologic impairment. RESULTS We identified 556 children from three retrospective studies who underwent FG (n=431) or GJ (n=125). There were no differences in rates of pneumonia (17% vs 19%, p=0.74) or mortality (13% vs 14%, p=0.76). Few deaths were due to procedural complications (1%) or reflux (2%). There was a trend towards more major complications with FG (29%) compared to GJ (12%) (risk ratio=1.70, 0.85-3.41, p=0.14). Minor complications were more common with GJ (70%) than FG (45%), but this difference was also not statistically significant (risk ratio=0.38, 0.05-3.07, p=0.36). No studies reported quality of life using validated measures. CONCLUSIONS The quality of the evidence for outcomes of FG versus GJ is very low. Large comparative studies are needed to determine which approach is associated with the best quality-of-life outcomes.

Glycerin Enemas and Suppositories in Premature Infants: A Meta-analysis

BACKGROUND AND OBJECTIVE: Premature infants are often given glycerin enemas or suppositories to facilitate meconium evacuation and transition to enteral feeding. The purpose of this study was to assess the available evidence for this treatment strategy. METHODS: We conducted a systematic search of Medline, Embase, Central, and trial registries for randomized controlled trials of premature infants treated with glycerin enemas or suppositories. Data were extracted in duplicate and meta-analyzed using a random effects model. RESULTS: We identified 185 premature infants treated prophylactically with glycerin enemas in one trial (n = 81) and suppositories in two other trials (n = 104). All infants were less than 32 weeks gestation and had no congenital malformations. Treatment was associated with earlier initiation of stooling in one trial (2 vs 4 days, P = .02) and a trend towards earlier meconium evacuation in another (6.5 vs 9 days, P = .11). Meta-analysis demonstrated no effect on transition to enteral feeding (0.7 days faster, P = .43) or mortality (P = 0.50). There were no reports of rectal bleeding or perforation but there was a trend towards increased risk of necrotizing enterocolitis with glycerin enemas or suppositories (risk ratio = 2.72, P = .13). These three trials are underpowered and affected by one or more major methodological issues. As a result, the quality of evidence is low to very low. Three other trials are underway. CONCLUSIONS: The evidence for the use glycerin enemas or suppositories in premature infants in inconclusive. Meta-analyzed data suggest that treatment may be associated with increased risk of necrotizing enterocolitis. Careful monitoring of ongoing trials is required.

The increasing incidence of gallbladder disease in children: A 20year perspective.

OBJECTIVE The incidence of cholecystectomy in the pediatric population has increased over the last 20years but has not been described in a Canadian population. We conducted the first province-wide study to describe the incidence of cholecystectomy in children in Ontario. STUDY DESIGN A population-based, retrospective cohort using administrative databases in Ontario, Canada, was conducted. We included patients less than 18years of age who underwent cholecystectomy from 1993 to 2012. Trends in rates of cholecystectomy were assessed with the Cochrane-Armitage test. RESULTS There were a total of 6040 pediatric cholecystectomies performed over the study period in Ontario. The mean age was 14.3years, and 79.6% of patients were females. The crude incidence per 100,000 person-years increased from 8.8 to 13.0 (p<0.001) from 1993 96-2009-12, respectively. The sex-specific incidence showed a larger increase in the female population from 14.7 to 21.1 per 100,000 person-years (p<0.001). The vast majority (82%) of surgeries were performed in 13-17year olds and were largely performed in the community (>75%). CONCLUSIONS There has been a significant rise in the incidence of pediatric cholecystectomy in Ontario over the last 20years. The majority of surgeries are performed in the community, and pediatricians will likely see an increase of gallbladder disease in practice.

Validation of a novel intraoperative assessment tool: The Surgical Procedure Feedback Rubric.

BACKGROUND The Surgical Procedure Feedback Rubric (SPR) is a tool to document resident intraoperative performance and provide targeted feedback to support learning in a competency-based model of surgical education. It differs from other assessment tools because it defines performance criteria by increasing complexity through the use of behavioral anchors, thus embedding standards of performance within the tool. This study explores aspects of validity of the SPR as an assessment tool. METHODS A 14-month observational study was conducted in 2 surgical training programs. Factor structure of the SPR was examined using exploratory factor analysis. Discriminative ability of the SPR was examined using analysis of variance. RESULTS The SPR measures 3 factors: Operating Room Preparation, Technical skill, and intrinsic Competencies. Analysis of variance demonstrated the utility of the SPR to discriminate between intraoperative performances of residents by postgraduate training year. CONCLUSIONS This study contributes to the validity argument for the SPR by providing evidence for construct and discriminative validity.

Repair of congenital esophageal atresia with tracheoesophageal fistula repair in Ontario over the last 20 years: Volume and outcomes

BACKGROUND/PURPOSE This study was designed to determine the volume, postoperative surgical outcomes and, if possible, the relationship between outcome and institutional / surgeon volume in neonates undergoing repair of esophageal atresia with tracheoesophageal fistula (EA-TEF) over the last 20years in Ontario. METHODS Using administrative databases, a population based cohort study of patients undergoing EA-TEF repair in Ontario between 1993 and 2012 was conducted. RESULTS 465 patients with the diagnosis of EA-TEF met inclusion criteria. The mean number of EA-TEF repairs per year per was 5.8. There was a significant difference in hospital annual volume between institutions (range 12.3-3.35: p<0.05). The average number of cases/surgeon for the last 10 study years ranged between 0.5 and 2 cases/year. Primary outcome revealed that repair of recurrent fistula or intestinal interposition was 5.3%, with no reportable difference between institutions. Secondary outcomes revealed that 45.6% underwent dilatation for esophageal strictures, and 19.8% underwent some type of drainage procedure of the chest. These rates were not significantly different between institutions. CONCLUSION This study provides insight into the outcomes following EA-TEF repair in Ontario and the difficulty in determining surgeon or institution volume outcome relationships, as both primary and secondary outcome event rates are very low. LEVEL OF EVIDENCE 2.

The 48th annual meeting of the Canadian Association of Pediatric Surgeons

The 48th meeting of the Canadian Association of Pediatric Surgeons (CAPS)was held in Vancouver British Columbia, Canada, fromSeptember 22 to 24, 2016. Vancouver is one of the few places in the world where it is possible to ski in the morning and sail in the afternoon, not in September, but certainly at other times of the year. Vancouver is a bustling west coast seaport. It is among Canadas densest, most ethnically diverse cities. A popular filming location, it is surrounded by mountains and also has thriving art, theater, and music scenes. The local host Dr. Erik Skarsgard and themeeting coordinator Arlene Einworked tirelessly to organize an outstandingmeeting. Dr. Priscilla Chiu, Chair of the ProgramCommittee, along with the help of her committee members, provided members with an excellent high quality scientific program consisting of 73 presentations (oral and poster). Special thanks to the CAPS secretary Dr. BJ Hancock for all her hard work behind the scene. In keeping with the past few years, prior to the start of the CAPS meeting, the Canadian Pediatric Surgical Nurses Interest Group (CaPSNIG) met with a fantastic program that included a mix of quality and practice innovations and many different case studies. President Dr. Peter Fitzgerald officially opened the meeting with his welcoming address, and the afternoon then proceededwith oral and poster presentations. The audience was treated to an outstanding presentation by Dr. Grahman Fraser on the “History of CAPS on the Canadian West Coast, and the afternoon ended with an update on CAPSNet and CBAR. The first day of CAPS drew to a close with the Welcome reception at the Vancouver Rowing Club, which afforded a fantastic view of the city and mountains all from the same window!

Nonrandomized assessment of ingrown toenails treated with excision of skinfold rather than toenail (NAILTEST): An observational study of the Vandenbos procedure

BACKGROUND The Vandenbos procedure for ingrown toenails consists of excising the surrounding skinfold and allowing the wound to heal by secondary intention. Previous studies have documented low rates of recurrence, but patient-reported outcomes remain uncertain. METHODS This study was a prospective, observational assessment of children and adolescents who underwent the Vandenbos procedure for one or more ingrown toenails. Standardized assessments of pain, functional status, and quality of life were completed before surgery and then one, two, and six months postoperatively. RESULTS Thirty-nine participants (with 59 ingrown toenails) completed at least one postoperative assessment and were included in the analysis. Age ranged from 4 to 20years (mean 13.5years). Recovery time was a median of 7days for return to school or work and 23days for being able to wear enclosed shoes. Seven participants (18%) experienced one or more minor complications within the first two months of surgery. There were no recurrences. Ninety-five percent of participants and 100% of parents would recommend the Vandenbos procedure. CONCLUSIONS We conclude that the Vandenbos procedure is associated with a low recurrence rate in children, adolescents, and young adults with ingrown toenails. Patient-reported recovery time, complication rate, functional outcomes, and satisfaction are excellent. LEVEL OF EVIDENCE 3.

Non-pathological bilious vomiting complicating therapeutic hypothermia for hypoxic ischaemic encephalopathy in neonates: a retrospective cohort study

Objective Therapeutic hypothermia (TH) for moderate-to-severe neonatal hypoxic ischaemic encephalopathy (HIE) is generally described as safe. We performed this study to determine the incidence of bilious vomiting or bilious drainage (BVD) attributable to TH in this population. Design A single-centre, retrospective cohort study. Setting Neonatal and paediatric intensive care units (NICU and PICU) of a single tertiary care centre. Patients All newborns with HIE who met criteria for TH between 2009 and 2014. Interventions Cases were matched 1:1 for unit of care (NICU vs PICU), gestational age, gender, and Sarnat score with historic controls who did not receive TH. Groups were compared with Pearsons Χ2 analysis. Relative risk was calculated, and ORs were used to allow regression analysis. Results Forty-seven patients met all inclusion criteria. The incidence of BVD in patients who received TH was 26%. The group exposed to TH was more likely to experience BVD compared with the control group with a relative risk of 6.0(95% CI 1.4 to 25.4), even after accounting for improper or unchecked nasogastric position, opioids and muscle relaxant use, OR=7.8(95% CI 1.4 to 43.3), and when positive blood culture was included in the regression model, OR=11.6(95% CI 1.2 to 115.0). Three patients underwent investigation and no patients had surgical pathology. Conclusion TH appears to be associated with non-pathological bilious vomiting or gastric drainage. Further prospective data are needed to identify the patients in whom investigation and intervention may be avoided.

The treatment of problematic hemangiomas in children with propranolol and 940nm diode laser.

BACKGROUND Hemangiomas are common skin lesion, affecting 10-12% of children <1year of age. The purpose of this study was to determine the effect and safety of systemic propranolol (Pr) therapy in combination with 940nm diode laser for the treatment of severe hemangiomas. METHODS Patients (123: 11 with vascular malformations and 112 with infantile hemangiomas (IH)) were enrolled in the study. They were initially treated with: systemic Pr therapy (2-2.5mg/kg/day) for 6-8months. Following completion of Pr therapy, patients with significant residual lesions (n-61) were treated with photothermolysis (laser therapy). RESULTS Pr therapy had no effect on the color and volume of the vascular malformations. Pr therapy alone demonstrated a reduction in both volume and color of the IH. Laser therapy resulted in a continued improvement in the appearance of the IH with 84% of patients experiencing a residual volume of 0% compared to the original and 89% experiencing a decrease to between 0 and 20% of original color. There were no adverse events associated with laser therapy. CONCLUSIONS This study demonstrates that the addition of laser therapy to Pr therapy for the treatment of IH in children is well tolerated with a very acceptable cosmetic result.