Surgical site infections in neonates are independently associated with longer hospitalizations.

OBJECTIVE: There is limited data characterizing the risk and impact of surgical site infection (SSI) in neonates; this makes it difficult to identify factors that increase neonatal SSI risk and to determine how SSI affects outcomes in this special population. STUDY DESIGN: The American College of Surgeons National Surgical Improvement Program Pediatric (NSQIP-P) collected data on children undergoing surgery at children's hospitals from 2012 to 2014. Neonates undergoing general surgical procedures were characterized with regard to demographic characteristics and comorbidities. Perioperative variables such as wound class, type of surgery and length of operation were also evaluated. RESULTS: Seven thousand three hundred and seventy-nine neonates were identified in the NSQIP-P participant user file. The overall SSI rate was 2.6%. Only wound class and length of surgery were significantly associated with SSI. Furthermore, SSI was independently associated with longer length of stay, even after adjusting for covariates. CONCLUSIONS: This is the largest study to date analyzing SSI in neonates. We found that perioperative variables have a more significant impact on SSI than patient factors, suggesting that operation-related characteristics are influencing SSI. Furthermore, neonates with SSI are more likely to have prolonged hospitalizations even after adjusting for patient comorbidities.

Functional outcomes of conservatively managed acute ruptures of the Achilles tendon.

AIMS: This prospective cohort study aims to determine if the size of the tendon gap following acute rupture of the Achilles tendon shows an association with the functional outcome following non-operative treatment. PATIENTS AND METHODS: All patients presenting within two weeks of an acute unilateral rupture of the Achilles tendon between July 2012 and July 2015 were considered for the study. In total, 38 patients (nine female, 29 male, mean age 52 years; 29 to 78) completed the study. Dynamic ultrasound examination was performed to confirm the diagnosis and measure the gap between ruptured tendon ends. Outcome was assessed using dynamometric testing of plantarflexion and the Achilles tendon Total Rupture score (ATRS) six months after the completion of a rehabilitation programme. RESULTS: Patients with a gap ≥ 10 mm with the ankle in the neutral position had significantly greater peak torque deficit than those with gaps < 10 mm (mean 23.3%; 7% to 52% vs 14.3%; 0% to 47%, p = 0.023). However, there was no difference in ATRS between the two groups (mean score 87.2; 74 to 100 vs 87.4; 68 to 97, p = 0.467). There was no significant correlation between gap size and torque deficit (τ = 0.103), suggesting a non-linear relationship. There was also no significant correlation between ATRS and peak torque deficit (τ = -0.305). CONCLUSION: This is the first study to identify an association between tendon gap and functional outcome in acute rupture of the Achilles tendon. We have identified 10 mm as a gap size at which deficits in plantarflexion strength become significantly greater, however, the precise relationship between gap size and plantarflexion strength remains unclear. Large, multicentre studies will be needed to clarify this relationship and identify population subgroups in whom deficits in peak torque are reflected in patient-reported outcome measures. Cite this article: Bone Joint J 2017;99-B:87-93.

Ultrasonographic findings after Achilles tenotomy during Ponseti treatment for clubfeet: Is ultrasound a reliable tool to assess tendon healing?

INTRODUCTION: Several studies have claimed ultrasound to be useful and accurate in assessing the healing phase of Achilles tendons after tenotomy during Ponseti treatment for clubfoot deformity. The purpose of our study was to assess the healing process of Achilles tendons ultrasonographically after tenotomy as part of Ponseti clubfoot management and to assess the effects of previously not considered ultrasound properties (anisotropy, partial volume effect), and whether these practical considerations affect accurate measurements which have been claimed possible in previous studies. MATERIALS AND METHODS: We monitored the post-tenotomy healing process in 15 patients (22 tendons) using high frequency ultrasound for a minimum of six months (range 6-14 months). The scanning was discontinued once a tendon looked normal or when the appearance remained unchanged between scans. We also studied nine patients (11 tendons) who had undergone Achilles tenotomies up to seven years previously (range 34-83 months). RESULTS: In the immediate postoperative period, ultrasound showed large variations in the distance of the tenotomy from the calcaneum as well as the obliquity and completeness of the surgical division. We encountered pitfalls in the use of ultrasound to define healing stages that were not described previously. Sonography was inaccurate and subjective in assessing both completeness of the surgical division and tendon measurements. Despite ultrasonographically proven incomplete tendon division in 63 % of cases, the clinical effect of an immediate increase of passive foot dorsiflexion from the pretenotomy position with an obvious palpable tendon gap was achieved in all patients. At the end of the study, 65 % of tendons did not achieve a normal appearance. CONCLUSIONS: We do not think that routine ultrasound studies are of any value as an adjunct to clinical assessment intra- and post-operatively. It can give misleading information regarding the need to complete the tenotomy, which may increase risks associated with a further pass of the scalpel blade.

Otolaryngologist-performed head and neck ultrasound: outcomes and challenges in learning the technique.

OBJECTIVE: To assess the feasibility and accuracy of otolaryngologist-performed ultrasound in evaluating head and neck pathology. METHOD: An ENT trainee, who had undergone basic training in neck ultrasonography, performed this on patients referred with suspected neck pathology. The trainee recorded the presence and nature of any abnormality. Findings were compared with those from a repeated scan performed by an experienced head and neck radiologist. RESULTS: The study included 250 patients. The absence or presence of lesion as reported by the trainee correlated with the radiologist's findings in 207 cases (83 per cent). There were 144 true positives, 63 true negatives, 32 false negatives and 11 false positives, yielding a sensitivity of 82 per cent, specificity of 85 per cent and accuracy of 83 per cent. Of the 144 true positive lesions, 81 per cent were interpreted concordantly with the radiologist. CONCLUSION: Neck ultrasonography performed by an otolaryngologist is less accurate than that performed by an experienced radiologist, but is still a useful adjunct to clinical assessment, facilitating assessment in a 'one-stop' clinical setting.

Percutaneous testicular biopsy for indeterminate testicular lesions.

Ultrasound forms an important part of the assessment of the testicle. Nevertheless, there are a number of situations in which clinical and radiological assessment is unable to provide a definitive diagnosis of a testicular lump. In these situations, historically, either open biopsy or orchidectomy has been performed. Ultrasound-guided percutaneous testicular biopsy is an alternative, less invasive method of obtaining histological diagnosis. Here we describe the rationale, technique and potential uses of the technique.

Ultrasound of the male anterior urethra.

Imaging of the anterior male urethra has traditionally been performed by fluoroscopic contrast urethrography. While providing easily interpretable images, this technique has a number of disadvantages associated with it. An alternative approach is to use ultrasound to assess the lumen of the urethra and the periurethral tissues. Here we describe the development of urethral ultrasound and the ascending and descending urethral ultrasound techniques employed in our institution with reference to commonly and uncommonly encountered pathologies. We also identify common pitfalls and how to avoid them.

Ultrasound-guided core-needle biopsy and magnetic resonance imaging in the accurate diagnosis of intramuscular haemangiomas of the head and neck.

INTRODUCTION: Intramuscular haemangiomas of the digastric muscle are often misdiagnosed due to their low incidence and non-specific manifestation. Only two out of six previously reported cases were diagnosed correctly before excision. Ultrasound may not reveal their vascularity, and fine-needle aspiration biopsy is unhelpful as it reveals only blood. METHODS: A case of intramuscular haemangioma of the posterior belly of the digastric muscle is described. Previously reported cases are reviewed. Investigations used to diagnose the lesions and reasons for their common failure are discussed. RESULTS: Core-needle biopsy led to the correct histological diagnosis, and magnetic resonance imaging precisely located the lesion within the digastric muscle. CONCLUSION: Core-needle biopsy was safely used in the diagnosis of an intramuscular haemangioma. The combination of core-needle biopsy and meticulous review of magnetic resonance imaging enables accurate diagnosis pre-operatively.

Optics Concept for a Pair of Undulator Beamlines for MX.

We describe a concept for x-ray optics to feed a pair of macromolecular crystallography (MX) beamlines which view canted undulator radiation sources in the same storage ring straight section. It can be deployed at NSLS-II and at other low-emittance third-generation synchrotron radiation sources where canted undulators are permitted, and makes the most of these sources and beamline floor space, even when the horizontal angle between the two canted undulator emissions is as little as 1-2 mrad. The concept adopts the beam-separation principles employed at the 23-ID (GM/CA-CAT) beamlines at the Advanced Photon Source (APS), wherein tandem horizontally-deflecting mirrors separate one undulator beam from the other, following monochromatization by a double-crystal monochromator. The scheme described here would, in contrast, deliver the two tunable monochromatic undulator beams to separate endstations that address rather different and somewhat complementary purposes, with further beam conditioning imposed as required. A downstream microfocusing beamline would employ dual-stage focusing for work at the micron scale and, unique to this design, switch to single stage focusing for larger beams. On the other hand, the upstream, more highly automated beamline would only employ single stage focusing.

[Association of the polymorphisms of the ERBB3 and SH2B3 genes with type 1 diabetes].

To study the association with diabetes mellitus type 1 we performed analysis of the distribution of frequencies of alleles and genotypes of polymorphic marker rs2292239 of ERBB3 gene, encoding epidermal growth factor receptor type 3 and polymorphic marker rs3184504 of SH2B3 gene, encoding adaptor protein LNK. The study included groups of T1DM patients and unrelated controls of Russian origin. Genotyping was performed using methods of RFLP and real-time amplification. For the polymorphic marker rs2292239 of ERBB3 gene was not found statistically significant associations with type 1 diabetes, while analysis of the distribution of frequencies of alleles and genotypes of the polymorphic marker rs3184504 of SH2B3 gene showed the presence of association with T1DM in Russian population.

Competencias transversales en la formación de especialistas en pediatría, Universidad de Chile / Transversal competencies for specialists training in the Pediatrics Residency Program, University of Chile

Introducción. El Programa de Formación de Especialistas en Pediatría (PFEP) debe responder a las necesidades futuras de la salud, políticas del país y, además, modernizarse acorde con las evidencias de la educación en ciencias de la salud, las que recomiendan la educación basada en competencias. Objetivo. El objetivo del estudio fue identificarlas competencias transversales (CT) que debe lograr el licenciado del PFEP de la Universidad de Chile y evaluar su adquisición. Sujetos y métodos. Estudio cualitativo, descriptivo. Entre noviembre de 2006 y enero de 2007 se seleccionaron informantes clave mediante entrevistas en profundidad: ocho líderes, seis residentes y seis licenciados del PFEP de la Universidad de Chile, y se les preguntó por la relevancia y el logro de seis CT. Resultados. Para enfrentarlos actuales desafíos laborales y epidemiológicos, se consideró fundamental la capacitación como médico de cabecera en pediatría ambulatoria y clínicas de continuidad, la adquisición de competencias de urgencia pediátrica y el manejo básico del niño hospitalizado. Se dio relevancia ala incorporación de CT carentes en el PFEP, como bioética, relación médico-paciente-familia, salud pública, trabajo en equipo y medicina basada en la evidencia (MBE). La docencia fue considerada como una actividad inherente al ejercicio médico, y se pudo ofrecer como un electivo al igual que la gestión. Conclusión. La adquisición de CT, más allá de las tradicionales competencias clínicas, es un desafío para la actual formación del pediatra y su adecuada preparación para el ejercicio profesional (AU)

Introduction. Teaching guidelines and the pediatrics exercise must adequate to the health requirements of the population needs and country politics, taking in consideration the new tendencies in medical education, with the introduction of competencies in the specialists training programs. Aim. To identify the competencies transversal to all specialties training programs (CT), that are important for the Pediatrics Residency Program (PFEP) at the Chile University. Subjects and methods. Qualitative and interpretive study, performed between November 2006 and January 2007. Key persons were interviewed (6 residents, 6 graduates and 8 opinion leaders)about the relevance and achievement of six CT. Results. The interviewed highlighted the necessity of trained pediatricians in ambulatory settings and continuity clinics, the acquisition of competencies in emergency units and basic skills in hospital training. They considered that the current training is lacking of important CT such as bioethics, physician-patient and family communication, public health, team work and evidence based medicine. Teaching skills and practice management are part of the medical profession; they could be introduced as an elective activity. Conclusion. The acquisition of CT during the PFEP transcend beyond the traditional clinical competencies, it is a challenge to introduce them in the PFEP (AU)

[Association of the C1858T polymorphism of the PTPN22 gene with type 1 diabetes].

To study the association with diabetes mellitus type 1 (T1DM) we performed TDT analysis and analysis of the distribution of frequencies of alleles and genotypes of polymorphic marker C1858T of the PTPN22 gene, encoding tyrosine phosphatase of non-receptor type (LYP). Groups of concordant (27 families) and discordant (62 families) sibpairs and groups of T1DM patients and unrelated controls of Russian origin were recruited in Endocrinology Research Center, Moscow and Center of Diabetes, Samara. For a given polymorphic marker was not found statistically significant associations with type 1 diabetes in the transmission disequilibrium test, while analysis of the distribution of frequencies of alleles and genotypes showed the association with T1DM. Thus, the polymorphic marker C1858T of the PTPN22 gene is associated with T1DM in Russian patients.

Ultrasound-guided core needle biopsy of parotid gland swellings.

OBJECTIVE: To determine whether ultrasound-guided core needle biopsy is a safe and reliable investigation in cases of parotid swelling in which fine needle aspiration cytology has failed to give a definitive diagnosis. DESIGN: Analysis of 66 ultrasound-guided core biopsy specimens of the parotid gland (the largest series reported thus far) sample number refers to histological samples throughout the paper. SUBJECTS: All the 184 cases of parotid surgery with a histological diagnosis were included. MAIN OUTCOME MEASURES: The sensitivity, positive predictive value and diagnostic accuracy of fine needle aspiration cytology and ultrasound-guided core needle biopsy, as compared with the final histological analysis. RESULTS: Of a total of 184 patients, 89.1 per cent (164/184) had benign parotid lesions excised. The sensitivity, positive predictive value and diagnostic accuracy of fine needle aspiration cytology for benign lesions were 76.2, 84.2 and 87.5 per cent, respectively, and those of ultrasound-guided core needle biopsy were 91.7, 98.2 and 96.4 per cent, respectively. Twenty of 184 patients (10.9 per cent) had malignant lesions. The sensitivity, positive predictive value and diagnostic accuracy of fine needle aspiration cytology for detection of malignant lesions were 60, 75 and 75 per cent, respectively, while those of ultrasound-guided core biopsy were 89, 100 and 100 per cent, respectively. Non-diagnostic rates were 25.8 per cent for fine needle aspiration cytology and 4.5 per cent for ultrasound-guided core biopsy. Only one case of complications (a sub-clinical haematoma) occurred in the ultrasound-guided core biopsy group. CONCLUSION: We propose ultrasound-guided core needle biopsy as a very safe and effective tool in cases of parotid swelling in which fine needle aspiration cytology has failed to give a definitive diagnosis.

[Association of the chromosomal region 2q35 with type 1 diabetes mellitus in the Russian patients from Moscow].

To map human chromosome 2 region associated with type 1 diabetes mellitus, 89 families with concordant and discordant sib pairs were analyzed. Linkage and association with type 1 diabetes were examined using polymorphic microsatellite markers spanning the region of about 4 Mb. The linkage plot was constructed, and association of the five microsatellite markers within the chromosomal region 2q35 was examined. Polymorphic marker D2S137 (Z' = 3.225, p(c) = 0.0048) demonstrated maximum linkage and association with type 1 diabetes.

Comparison of calculated brightness and flux of radiation from a long-period wiggler and a short-period undulator.

In this article the calculation of brightness and flux for two insertion devices of the 2.8 GeV X-ray storage ring at the NSLS is discussed. The radiation properties from the X25 linearly polarized wiggler and the new X25 short-period undulator are compared at a fixed photon energy (11.3 keV) corresponding to emission from the fifth harmonic of the short-period undulator. For this computation, three commonly available synchrotron radiation programs are used. The capabilities of each of these codes are briefly discussed, and their range of applicability are commented on. It is concluded that special care is needed when modeling the radiation of the classes of insertion devices considered here.

High-resolution imaging of an ancient Egyptian mummified head: new insights into the mummification process.

BACKGROUND AND PURPOSE: Systematic facial mutilations during mummification have never been described before. The purpose of this work was to study a wrapped mummified head using high-resolution CT scanning. MATERIALS AND METHODS: An isolated mummified head from the Egyptian Middle Kingdom was scanned at 200 mum isotropic resolution. A prototype flat panel CT scanner was used to generate 800 nonoverlapping CT sections at 120 kV and 50 mA. This dataset was analyzed to discern various surgical alterations during mummification. RESULTS: There were large defects in the cribriform plate and the posterior fossa. Systematic mutilations of the facial bones and mandible, involving the anterior and inferior walls of the maxillary sinuses, the floor of both orbits, and the zygomatic arches with contiguous segments of the zygomas, were demonstrated. The coronoid processes of both mandibles had been sharply excised and the articular tubercles of the temporomandibular joints fractured. CONCLUSION: Defects in the ethmoid and the posterior skull base are consistent with previous descriptions of excerebration. Mutilations of the facial skeleton and jaw, which are unrelated to the process of excerebration, have never been described previously. It is noteworthy that the osteotomies selectively include the insertions of the muscles of mastication. These mutilations apparently were designed for mobilization of lower jaw. The "Opening of the Mouth" ceremony, described in the ancient texts, would be difficult to perform in the presence of rigor mortis; it is probable that the observed osteotomies were performed to facilitate this ceremony. Our research suggests that by the Middle Kingdom, Egyptian embalmers had developed highly sophisticated surgical techniques that have not been appreciated previously.

Feasibility of percutaneous organ biopsy as part of a minimally invasive perinatal autopsy.

To determine the feasibility of percutaneous fetal organ biopsies in the context of a 'minimally invasive' perinatal autopsy after stillbirth and termination for abnormality is the aim of this study. We assessed successful biopsy rate and the proportion adequate for histological examination in 30 fetuses undergoing organ sampling before autopsy. The relationship between gestational age, body weight, death-biopsy interval, operator experience and successful biopsy rate was investigated. Significant findings from conventional block histology were compared with corresponding percutaneous biopsies. Of 210 organ biopsies attempted from seven target organs, 107 were obtained, of which 94 were adequate for pathological comment. The median delivery-autopsy interval was 4 (range 2-11) days. Adequate samples were obtained from the lung in 86% cases (95% CI 68, 96%), liver 76% (95% CI 56, 90%) and less frequently for the myocardium, kidney, adrenal, thymus and spleen. There was no relationship between biopsy success and time to biopsy, gestational age, body weight and user experience. No histological abnormalities found at autopsy were diagnosed from needle biopsies. Although targeted percutaneous biopsies appear feasible for some organs, fewer than 50% of all biopsies are adequate for histological examination. This technique cannot be considered to provide useful clinical information as part of a 'minimally invasive' perinatal autopsy.

Spatial mapping of the brachial plexus using three-dimensional ultrasound.

Imaging of the brachial plexus with MRI and standard two-dimensional (2D) ultrasound has been reported, and 2D ultrasound-guided regional anaesthetic block is an established technique. The aim of this study was to map the orientation of the brachial plexus in relation to the first rib, carotid and subclavian arteries, using three-dimensional (3D) ultrasound. A free-hand optically tracked 3D ultrasound system was used with a 12 MHz transducer. 10 healthy volunteers underwent 3D ultrasound of the neck. From the 3D ultrasound data sets, the outlines of the brachial plexus, subclavian artery and first rib were manually segmented. A surface was interpolated from the series of outlines to produce a spatially orientated 3D reconstruction of the brachial plexus. The brachial plexus could be mapped in all volunteers, although a variation in image resolution between individuals existed. Anatomical variations were demonstrated between the 10 volunteers; the most notable and clinically relevant was the alignment of the plexus divisions. 3D reconstructions illustrated the plexus, changing its orientation from a vertical alignment in the interscalene region to a more horizontal alignment in the supraclavicular fossa. Spatial mapping of the brachial plexus is possible with 3D ultrasound using the subclavian artery and first rib as landmarks. There is a deviation from the conventionally described anatomy and this may have implications for the administration of regional anaesthesia.

3D reconstruction of the skeletal anatomy of the normal neonatal foot using 3D ultrasound.

Currently imaging plays a limited role in the assessment of the neonate with a foot deformity. The aim of this study was to establish a technique for examining the neonatal foot with three-dimensional ultrasound (3D US). 3D US was attempted on the normal feet of 20 infants (9 male, 11 female) under 6 weeks old (range 35-41 days). The data sets were obtained whilst the infants were feeding or asleep to minimize movement artefact. A high-resolution optically tracked freehand 3D US system (Diasus, 16 MHz transducer) was used with Stradx software to acquire and analyse the data sets. Manual segmentation of the non-ossified tarsi from the data sets was performed. Five infants were too restless to be examined. 107 data sets were recorded from 22 feet of the remaining 15 infants. 21 of the data sets were discarded due to movement artefact. 86 were suitable for manual segmentation. Surface interpolation of the segmented data sets produced surface rendered reconstructions illustrating the complex 3D anatomy of the foot. This new technique may offer a method of examining the deformed foot, e.g. congenital talipes equinovarus.