The role of parenteral nutrition following surgery for duodenal atresia or stenosis.

PURPOSE: In our institution, some children routinely receive parenteral nutrition (PN) following surgery for duodenal atresia/stenosis, while others do not. Our aim was to compare growth and infection rate between these two treatment strategies. METHODS: This was a retrospective study of all children undergoing surgery for duodenal atresia/stenosis over 7 years. RESULTS: Of the 54 children, 19 commenced PN soon after surgery (the 'Initial PN' group). Of the remaining 35 children, 13 (37 %) subsequently required PN (the 'Delayed PN' group). The remaining 22 never received PN (the 'Never PN' group). The proportion of patients experiencing clinically suspected sepsis was higher in those receiving PN ('Initial' plus 'Delayed'; 41 %) compared with those who never received PN (14 %; p = 0.04). The 'Initial PN' and 'Never PN' groups did not show a significant change in weight Z score over time. However, the 'Delayed PN' group showed a significant decrease in weight Z scores from the time of operation to the time of achieving full enteral feeds, and failed to catch up by the time of last follow-up. CONCLUSION: Children with duodenal atresia/stenosis can be managed without PN. However, a third of these children subsequently require PN, lose weight centiles, and have a high rate of sepsis.

Septicaemia due to enteric organisms is a later event in surgical infants requiring parenteral nutrition.

INTRODUCTION: The purpose of this study was to determine whether, in surgical infants requiring parenteral nutrition (PN), septicaemia due to enterococci or Gram-negative bacilli occurs later than septicaemia due to coagulase-negative staphylococci (CNS). PATIENTS/MATERIAL AND METHODS: We retrospectively studied 112 consecutive surgical infants (corrected gestational age up to 3 months) receiving PN for at least 5 days for congenital or acquired intestinal anomalies over a 2-year period (July 2007-June 2009). Data collected included diagnosis, duration of PN, episodes of septicaemia (defined as growth of bacteria from blood culture), and organisms cultured. We compared the time to first occurrence of septicaemia due to CNS with the times to first occurrence of septicaemia due to enterococci, Gram-negative bacilli, or other micro-organisms, using Kruskal-Wallis nonparametric ANOVA test and Dunn's multiple comparisons test. Data are given as median (range). RESULTS: 31 patients (28%) had a total of 65 episodes of septicaemia. Septicaemia due to CNS was most common, occurring in 22% of patients, after 17 days (1-239) of PN. Septicaemia due to enteric organisms was less common and occurred significantly later, at 59 (24-103) days for enterococci (p<0.01), and at 55 (30-106) days for Gram-negative bacilli (p<0.05). CONCLUSIONS: Septicaemia due to enterococci or Gram-negative bacilli occurs later in the course of PN than septicaemia due to CNS, in surgical infants. This suggests that these infants become more vulnerable to the translocation of enteric micro-organisms after a longer period of parenteral nutrition.

Regulation of subcellular distribution and oncogenic potential of nucleophosmin by plakoglobin.

Nucleophosmin (NPM) is a nucleolar phosphoprotein that is involved in many cellular processes and has both oncogenic and growth suppressing activities. NPM is localized primarily in nucleoli but shuttles between the nucleus and the cytoplasm, and sustained cytoplasmic distribution contributes to its tumor promoting activities. Plakoglobin (PG, γ-catenin) is a homolog of ß-catenin with dual adhesive and signaling functions. These proteins interact with cadherins and mediate adhesion, while their signaling activities are regulated by association with various intracellular partners. Despite these similarities, ß-catenin has a well-defined oncogenic activity, whereas PG acts as a tumor/metastasis suppressor through unknown mechanisms. Comparison of the proteomic profiles of carcinoma cell lines with low- or no PG expression with their PG-expressing transfectants has identified NPM as being upregulated upon PG expression. Here, we examined NPM subcellular distribution and in vitro tumorigenesis/metastasis in the highly invasive and very low PG expressing MDA-MB-231 (MDA-231) breast cancer cells and their transfectants expressing increased PG (MDA-231-PG) or NPM shRNA (MDA-231-NPM-KD) or both (MDA-231-NPM-KD+PG). Increased PG expression increased the levels of nucleolar NPM and coimmunoprecipitation studies showed that NPM interacts with PG. PG expression or NPM knockdown decreased the growth rate of MDA-231 cells substantially and this reduction was decreased further in MDA-231-NPM-KD+PG cells. In in vitro tumorigenesis/metastasis assays, MDA-231-PG cells showed substantially lower and MDA-231-NPM-KD cells substantially higher invasiveness relative to the MDA-231 parental cells, and the co-expression of PG and NPM shRNA led to even further reduction of the invasiveness of MDA-231-PG cells. Furthermore, examination of the levels and localization of PG and NPM in primary biopsies of metastatic infiltrating ductal carcinomas revealed coordinated expression of PG and NPM. Together, the data suggest that PG may regulate NPM subcellular distribution, which may potentially change the function of the NPM protein from oncogenic to tumor suppression.

Morbidity after ganglioneuroma excision: is surgery necessary?

INTRODUCTION: Ganglioneuroma (GN), the benign form of peripheral neuroblastic tumour, is often asymptomatic and the diagnosis can be incidental. Our aim was to evaluate the incidence of complications after surgical treatment following diagnosis of this tumour. MATERIAL AND METHODS: 24 consecutive children were diagnosed with GN in our centre between January 1989 and December 2009. All patients had negative urinary catecholamines and/or biopsy confirming the diagnosis of GN. Data are reported as mean ± SD. RESULTS: Age at diagnosis was 73 ± 43 months. The most common presentation was respiratory symptoms and/or abdominal pain; 9 (38%) patients were asymptomatic. Tumour location was in the chest (n=14), abdomen (n=7), or pelvis (n=3). 23 children (9 asymptomatic) were operated on; 1 child with a thoracic mass did not undergo surgery because of severe neurological impairments from birth unrelated to GN. 13 children (4 asymptomatic) had a thoracotomy, 8 children (4 asymptomatic) had laparotomy, and 2 (1 asymptomatic) underwent perineal resection. A macroscopically complete surgical excision was performed in 17 cases (74%) and a macroscopically near-complete excision in 6 (26%). At histological examination, resection margins contained tumour in 10 patients (43%) and were free of tumour in the remaining 13 (57%). 7 children (30%) had complications after surgery including 3 patients with Horner's syndrome (which persisted in 2), 1 with chylothorax, 1 with pneumothorax, 1 with pain in the arm, and 1 who developed adhesive intestinal obstruction. 2 children received adjuvant chemotherapy. We re-evaluated the histology specimens according to the International Neuroblastoma Pathology Classification and found that the diagnosis of GN was confirmed in 20 cases (83%), while intermixed ganglioneuroblastoma (iGNB) was diagnosed in 4 patients (17%). At 33.5 ± 40 months (range 1-137) follow-up, all 24 patients, including the child not operated on and the children with incomplete resection or iGNB, are alive with no tumour progression or recurrence. CONCLUSIONS: GN excision is associated with postoperative complications which can be persistent and may affect the quality of life of survivors. In our series we did not observe tumour progression in spite of incomplete excision. The rationale for GN excision should be revisited.

Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures.

As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient-, injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis. The patients were reviewed until clinical and radiological evidence of union at a mean of 13.3 months (4 to 60). Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 2.38 times for highly comminuted fractures, by 3.14 times when nail dynamisation was applied, and by 1.65 times when the locking screws failed. In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was > or = 3 mm.

The efficacy of the A-V Impulse system in the treatment of posttraumatic swelling following ankle fracture: a prospective randomized controlled study.

OBJECTIVES: To determine whether the use of the A-V Impulse "in-cast" system conveyed any clinical benefit in the treatment of post-traumatic swelling following ankle fracture. DESIGN: A prospective randomised study comparing the effectiveness of the A-V Impulse "in-cast" system to that of elevation and plaster in the treatment of preoperative swelling. SETTING: Clinical management in a large level 2 trauma center. PATIENTS: Sixty-four adult patients were recruited to the study who had sustained closed unilateral ankle fractures requiring internal fixation, but for whom immediate surgery was not possible. INTERVENTION: All fractured ankles were treated with initial application of a plaster back-slab splint. Patients were randomized to either a control group of limb elevation or to a study group in whom an A-V Impulse bladder was fitted under the arch of the foot within the plaster back-slab and intermittent pneumatic pedal compression provided until surgery. MAIN OUTCOME MEASUREMENTS: Daily circumferential ankle girth measurements were performed. The time taken for swelling to resolve sufficiently to permit surgery, the development of skin complications, and the duration of hospitalisation were recorded. RESULTS: Ten patients were withdrawn from the study. Twenty-seven patients in each group were followed up until discharge from outpatient care. Statistical analysis revealed a significant reduction in time taken for ankle swelling to settle prior to surgery (P = 0.01) in the study group, together with a reduction in wound and skin complications (P < 0.01) and final preoperative ankle swelling (P = 0.03). CONCLUSION: The A-V Impulse "in-cast" system demonstrated significant benefit in the management of adults with isolated ankle fractures who could not undergo immediate open reduction and internal fixation.

Initial rotational stability of distal tibial fractures nailed without proximal locking: the importance of fracture type and degree of cortical contact.

Although distally locked (dynamic) nailing is generally recommended for fractures below the isthmus of the tibia in the presence of adequate proximal nail-bone contact, rotational stability in the above situation appears to be a major concern and can increase the risk of malunion. However, there is no published experimental evidence to quantify this mechanical parameter or to relate factors such as the fracture pattern with the final clinical outcome. This in-vitro biomechanical experimental study was set out to measure the initial rotational stability of dynamically nailed fractures of the distal tibial diaphysis. Using a composite tibial model, three non-comminuted types (spiral, oblique and transverse) and various comminuted patterns (comminution, 0-85%) of dynamically nailed fractures of the distal tibial diaphysis were tested. Using a special rig to simultaneously apply axial and torsional loading measurements of torsional stiffness and the previously described "spring-back angle" were carried out. Our results showed that in terms of torsional stiffness and the "spring-back" angle oblique fractures are the most stable followed by transverse and spiral fractures. Furthermore, when testing of the above parameters against the degree of comminution was carried out, a significant reduction of rotational stability was evident with comminution of 50% or above. It is concluded that oblique fractures of the distal tibial third that can be reduced with at least 50% cortical apposition present the optimal rotational stability following dynamic nailing.

Avascular necrosis and the Aberdeen splint in developmental dysplasia of the hip.

Between January 1987 and December 1988 there were 7575 births in the Swansea maternity unit. Of these 823 (10.9%) were considered to be at 'high risk' for developmental dysplasia of the hip (DDH). Static ultrasound examination was performed in each case and the results classified on the basis of the method of Graf. A total of 117 type III-IV hips in 83 infants was splinted using the Aberdeen splint. Radiographs of these hips were taken at six and 12 months. Hilgenreiner's measurements of the acetabular angle were made in all cases and the development of the femoral capital epiphysis was assessed by measuring the epiphyseal area. The effect of splintage on the acetabular angle and the epiphyseal area between the normal and abnormal splinted hips was compared. Radiographs of 16 normal infants (32 normal unsplinted hips) were used as a control group. This cohort has now been followed up for a minimum of nine years. There have been no complications as a result of splintage. The failure rate was 1.7% or 0.25 per 1000 live births. No statistical difference was found when comparing the effect of splintage on the acetabular angle and epiphyseal area between normal and abnormal splinted hips and normal unsplinted hips. Our study has shown that while the Aberdeen splint had a definite but small failure rate, it was safe in that it did not produce avascular necrosis. The current conventional view that a low rate of splintage is always best is therefore brought into question if the Aberdeen splint is chosen for the management of neonatal DDH.

Problems with the Rotaflex: a 10 year review of a rotating hinge prosthesis.

The results of the first 10-year review of the Rotaflex total knee prosthesis are presented. Loosening, fracture, implant failure, and damage to the extensor mechanism have been frequent findings. Of 25 implants reviewed, an arthrodesis has been performed in 4 patients and an amputation in 2. Surgery has been declined in a further 4 patients. A brace is required by 7 of 19 patients in whom the prosthesis has not been removed, and the results of surgery are considered poor in 13 of these 19 patients. With an overall complication rate of almost 80%, there would appear to be no place for this prosthesis despite its continued availability.

The results of external fixation of the radius in the treatment of comminuted intraarticular fractures of the distal end.

14 unstable comminuted intraarticular fractures of the distal radius were treated by the use of the A/O mini-external fixator. The distal pins were inserted in the distal fragment, thus leaving the wrist joint free to mobilize. Clinical results were assessed at 3 to 12 months using the Sarmiento demerit point system. Nine were male and five female, with a mean age of 37 years. Ten fractures were closed and four were open. 11 patients (78.5%) had an excellent functional score and three (21.5%) had a good score. All patients had normal wrist morphology with an average radial length of 11 mm, radial angle of 23 degrees and a mean volar angle of 12 degrees. 12 patients had anatomical radio-carpal and radio-ulnar joints and two patients had a step less than 2 mm at the radio-carpal surface. This method has proved in our experience to be reliable in maintaining the position as well as allowing early functional recovery.

Failure of the sliding hip screw in the treatment of femoral neck fractures: 'left-handed surgeons for left-sided hips'.

The pre-operative radiographs of 265 patients consecutively treated with sliding hip screws were reviewed. In 244 cases the fixation was for a basicervical or intertrochanteric fracture. The post-operative radiographs of these 244 patients were examined for technical failure of the device. Of the 15 failures analysed, one had occurred where insufficient sliding length had been available to the screw within the barrel, and one was due to jamming of the screw within the barrel. Of the remaining 13 fixations, 12 had occurred where the screw had been poorly positioned within the femoral head, and one device had failed for no obvious reason. Malpositioning of the failures occurred significantly more frequently on the left than on the right, in a Unit where all the surgeons were right-handed. We conclude that the majority of technical failures of the sliding hip screw occur because of poor positioning of the screw. This occurs more commonly on the left side when the surgeon is right-handed.

Assessment of hip abductor function in relation to peritrochanteric heterotopic ossification after closed femoral nailing.

The relationship between peritrochanteric heterotopic ossification and the strength of hip abduction after closed intramedullary nailing for femoral shaft fractures was investigated in 25 patients after a mean follow-up of 2 years (range 9 months to 4 years). The power of hip abduction was assessed and compared with the normal hip. Of the 21 patients with heterotopic ossification, 16 had measurable weakness of hip abduction. Grade III heterotopic ossification resulted in 8-20 per cent weakness of hip abduction, but this was not associated with any disability or symptoms. Clinically important abductor weakness is more likely to be due to ipsilateral fractures or a long nail rather than heterotopic ossification.

Conservative management of transverse fractures of the sacrum with neurological features. A report of four cases.

Transverse fractures of the sacrum with neurological complications have been studied in four patients illustrating the following features: diagnosis is often delayed, there are radiological difficulties in making the diagnosis, and the indications for surgery are not well defined. Specific radiographic views are recommended. All the cases presented in this report responded well to conservative management.