Sarah L. Almond

Characterisation and transplantation of enteric nervous system progenitor cells

Aims: Enteric nervous system (ENS) progenitor cells have been postulated to be an appropriate source of cells for the treatment of Hirschsprung’s disease. In order for this to be successful, the techniques previously used for the isolation of rodent ENS progenitor cells need to be adapted for postnatal human tissue. In this paper, we describe a method suitable for the preparation of both mouse and human postnatal ENS progenitor cells and assess their transplantation potential. Method: Single cell suspensions were isolated from 11.5 days post-coitum embryonic mouse caecum and postnatal human myenteric plexus. These cells were cultured under non-adherent conditions to generate neurospheres which were implanted into aganglionic embryonic mouse hindgut explants. Cell proliferation, migration and differentiation were observed using immunofluorescence microscopy. Results: Neurospheres generated from both mouse and human tissues contained proliferating neural crest-derived cells that could be expanded in tissue culture to generate both glial cells and neurons. When implanted into aganglionic murine gut, cells migrated from the neurospheres using pathways appropriate for cells derived from the neural crest, and differentiated to become glia and neurons expressing neuronal phenotypic markers characteristic of the ENS including nitric oxide synthase and vasoactive intestinal polypeptide. Conclusion: We have developed a technique for the isolation and expansion of ENS progenitor cells from human neonates. These cells have the ability to differentiate into neurons and glia when transplanted into aganglionic gut, this demonstration being a necessary first step for their autologous transplantation in the treatment of Hirschsprung’s disease.

Autologous intestinal reconstructive surgery to reduce bowel dilatation improves intestinal adaptation in children with short bowel syndrome.

Objectives: Intestinal failure (IF) is a common consequence of neonatal small bowel pathology. In our experience, bowel dilatation is often responsible for the IF state in patients who fail to adapt despite adequate residual bowel length. The aim of the present study was to investigate the role of surgery to reduce bowel dilatation, and thus favour PN independence, for these children. Methods: Data were collected prospectively for all of the patients referred to our unit for a 7-year period (2004–2011). Eight patients (2 congenital atresia, 2 gastroschisis with atresia, 1 simple gastroschisis, 3 necrotising enterocolitis) with gut dilatation who failed adaptation despite a bowel length >40 cm were identified. Preoperatively, all patients were totally dependent on parenteral nutrition (PN). Patients were managed by longitudinal intestinal lengthening and tailoring (n = 3), serial transverse enteroplasty (n = 2), or tapering enteroplasty (n = 3). Results: Median age at time of surgery was 273 days (103–1059). Mean gut length increased from 51 (35–75) to 73 cm (45–120) following surgery (P = 0.02). Incidence of sepsis (P = 0.01) and peak serum bilirubin levels (P = 0.005) were reduced postoperatively. PN was discontinued after a median of 110 days (35–537) for 7 patients; 1 patient remains on PN 497 days after surgery. Conclusions: These data indicate that reconstructive surgery to reduce bowel diameter may be an effective technique for treating IF in patients with short bowel syndrome, without sacrificing intestinal length. We suggest that this technique may reduce the need for bowel transplantation in this group of patients.

Comparison of childhood appendicitis management in the regional paediatric surgery unit and the district general hospital

BACKGROUND/PURPOSE Ongoing debate surrounds the future provision of general paediatric surgery. The aim of this study was to compare outcomes for childhood appendicitis managed in a district general hospital (DGH) and a regional paediatric surgical unit (RU). METHODS Data collected retrospectively for a 2-year period in a DGH were compared with data collected prospectively for 1 year in an RU, where appendicitis management is guided by a care pathway. Children aged 6 to 15 years were included. RESULTS Four hundred and two patients were included (DGH ,196; RU, 206). There were more cases of gangrenous/perforated appendicitis in the RU (P < .0001). In the DGH, fewer patients received preoperative antibiotics (P < .0001) or underwent preoperative pain scoring (P < .0001). When adjusted for case mix, the relative risk of complications for a child managed at the DGH was 1.76 (95% confidence interval, 1.44-2.16; P < .0001) and that of readmission was 1.76 (95% confidence interval, 1.43-2.16; P < .0001) when compared with the RU. CONCLUSIONS Patients with appendicitis managed in the DGH had a higher risk of complications and readmission. However, this appears to be related to the use of a care pathway at the RU. Introduction of a care pathway in the DGH may improve outcomes and thus support the ongoing provision of general paediatric surgery.

It is not what you do, it is the way that you do it: impact of a care pathway for appendicitis

BACKGROUND/PURPOSE Appendicitis is the most common surgical emergency in children. However, management varies widely. The aim of this study was to assess the impact of introducing a care pathway on the management of childhood appendicitis. METHODS Data were collected prospectively for 3 successive cohorts: All patients operated for suspected appendicitis were included. The pathway was modified after interim analysis of group B data. P < .05 was significant. RESULTS Six hundred patients were included. When compared with group A, group C patients were more likely to receive preoperative antibiotics (P < .0001), undergo formal pain assessment (P < .0001), and be operated before midnight (P = .025). There was a significant decrease in readmission rates from 10.0% to 4.2% (P = .023) despite an increase in cases of gangrenous and perforated appendicitis (P = .010). CONCLUSIONS The introduction of a care pathway resulted in improved compliance with antibiotic regimens, more frequent pain assessment, and fewer post-midnight operations. Postappendicectomy readmission rates were reduced despite an increase in disease severity. This was achieved by critical reevaluation of outcomes and pathway redesign where appropriate.

Topography, stem cell behaviour, and organogenesis

The fundamental problem of development is to explain how the progeny of a single cell, the fertilised egg, differentiates to form all the tissues of the body in the right place at the right time. It has only been during the last couple of years that the mechanisms and molecules mediating interactions between cells and tissues have begun to be delineated. This article reviews some of these recent studies. Sequences of topoqraphically defined cellular interactions lead not only to the development of the body but also to the obvious and remarkable inference that the body more or less automatically builds itself.

Atropine sulphate: rescue therapy for pyloric stenosis

Infantile hypertrophic pyloric stenosis (IHPS) is a common condition which presents with non-bilious vomiting and failure to thrive secondary to gastric outlet obstruction. In the UK, management is by fluid resuscitation followed by pyloromyotomy. Incomplete myotomy complicates 0.3% of cases necessitating further surgery and exposing the patient to further risk. Medical management of IHPS with antimuscarinics to promote pyloric relaxation is a well-described treatment modality that is used as first-line therapy in some countries. The use of this technique is limited by the need for extended hospital admission with parenteral nutrition administration. We describe a case of IHPS complicated by incomplete pyloromyotomy and subsequently managed successfully by atropine sulphate therapy.

G389 Charting the rise of Gram negative organisms in Children with recurrent central line associated blood stream infections

Aims Long-term tunnelled central venous catheters deliver potentially toxic medications such as chemotherapy and parenteral nutrition. Recurrent central line associated bloodstream infections (CLASBI) are a potentially serious complication. Introduction of central line care bundles can dramatically reduce paediatric CLABSI rates (Wheeler et al., Paediatrics 2011), however despite these interventions some patients develop recurrent CLABSIs. This study reports the recurrent CLABSI rate and organisms found in two regional paediatric hospitals. Methods Paediatric patients diagnosed with a CLABSI between January 2012 and December 2012 were identified retrospectively in two regional paediatric institutions. All subsequent infection and line events were recorded for these patients. CLABSIs were classified according to the Centres for Disease Control and Prevention definition. Line event data was verified by comparing theatre records, clinic and discharge letters and radiology images. Results Eighty seven patients were included in the study (44 patients from centre 1, 43 patients from centre 2). 165 CLABSIs were diagnosed during the study period (87 first CLABSI and 78 subsequent CLABSIs). Forty three patients (50%) developed a second CLABSI. And 22 (25%) developed a third CLABSI. The median number of line days from 1st CLABSI per patient was 389 days in centre 1 and 188 days in centre 2. 112 CLABSIs were due to a Gram negative pathogen (68%). 44 CLABSIs were due to a Gram positive (27%) pathogen. 9 CLABSIs were due to fungi (5%). The overall recurrent CLABSI rate after one CLABSI was 4.2 per 1000 catheter days (3.3 per 1000 catheter days in centre 1, 5.1 per 1000 catheter days in centre 2). Repeat infections with identical pathogens occurred on 16 occasions. The most commonly identified organisms were Enterococcus faecalis (29), Escherischia coli (27), Klebsiella pneumoniae (23), Staphylococcus epidermidis (21), Staphylococcus aureus (12). Conclusion Patients who develop one CLABSI are at high risk of recurrent catheter associated sepsis. Gram negative organisms are the most frequently identified group of pathogens.