Visit-to-visit and 24-h blood pressure variability: association with endothelial and smooth muscle function in African Americans.

The purpose of this study was to investigate the association of visit-to-visit and 24-h blood pressure (BP) variability with markers of endothelial injury and vascular function. We recruited 72 African Americans who were non-diabetic, non-smoking and free of cardiovascular (CV) and renal disease. Office BP was measured at three visits and 24-h ambulatory BP monitoring was conducted to measure visit-to-visit and 24-h BP variability, respectively. The 5-min time-course of brachial artery flow-mediated dilation and nitroglycerin-mediated dilation were assessed as measures of endothelial and smooth muscle function. Fasted blood samples were analyzed for circulating endothelial microparticles (EMPs). Significantly lower CD31+CD42- EMPs were found in participants with high visit-to-visit systolic blood pressure (SBP) variability or high 24-h diastolic blood pressure (DBP) variability. Participants with high visit-to-visit DBP variability had significantly lower flow-mediated dilation and higher nitroglycerin-mediated dilation at multiple time-points. When analyzed as continuous variables, 24-h mean arterial pressure variability was inversely associated with CD62+ EMPs; visit-to-visit DBP variability was inversely associated with flow-mediated dilation normalized by smooth muscle function and was positively associated with nitroglycerin-mediated dilation; and 24-h DBP variability was positively associated with nitroglycerin-mediated dilation. All associations were independent of age, gender, body mass index and mean BP. In conclusion, in this cohort of African Americans visit-to-visit and 24-h BP variability were associated with measures of endothelial injury, endothelial function and smooth muscle function. These results suggest that BP variability may influence the pathogenesis of CV disease, in part, through influences on vascular health.

Roux-en-Y feeding jejunostomy in infants and children.

Roux-en-Y jejunostomy (RYJ) permits enteral feeding in children unable to tolerate oral or intragastric feeds. It avoids many of the complications of nasojejunal and gastrojejunal tubes. Here we report our experience of intubated RYJ. By retrospective review of patient notes from 1998 - 2003, thirty-five children were identified. The median age was seven months (1 month - 16 years) and median follow-up was twenty-five months (1 - 55 months). There were no early postoperative complications or deaths. There were eighteen (51 %) late complications: peristomal leak (6), peristomal infection (2), bilious vomiting (5), tube displacement (3), abscess (1) and jejuno-colic fistula (1). Five children progressed to full oral feeds and had the RYJ resected. Fourteen of the twenty-eight children still alive remain fed by RYJ. Nine infants subsequently underwent fundoplication and gastrostomy with RYJ resection. Seven children died during the study period. RYJ is a straightforward procedure which can be performed safely in the face of poor nutrition and significant comorbidity. We recommend RYJ as a medium-term measure for enteral feeding.

Audit of epidural analgesia in children undergoing thoracotomy for decortication of empyema.

BACKGROUND: Uncertainty remains over the risk of epidural space infection after neuraxial blockade in the presence of systemic sepsis. For many years, we have provided epidural analgesia to children undergoing thoracotomy for the decortication of parapneumonic empyemas. Following recent publications asserting that epidural analgesia is absolutely contraindicated in this situation, we audited our management. The purpose of this audit was to document the effectiveness and the incidence of complications after epidural insertion in children with active sepsis from empyemas. METHODS: This is a retrospective single-centre audit over a 10-yr period. RESULTS: Forty-six epidurals were performed in children with empyema, and three children were treated with systemic opioids. We found no infective complications of the epidural space or insertion sites. The epidurals provided excellent analgesia. The incidence of moderate-severe pain was 18%, and 2% for severe pain in the first 24 h after surgery. Minor complications of epidural analgesia were uncommon. Two children receiving systemic opioids for pain relief suffered respiratory complications, one of which resulted in a prolonged admission to the intensive care unit. CONCLUSIONS: Epidural analgesia provides excellent pain relief after thoracotomy in children with empyema, with a low complication rate. Until evidence to the contrary emerges, it remains our technique of choice for thoracotomy, even in the presence of empyema.

Ball valve obstruction of a bronchus causing lobar emphysema in a neonate.

Lobar emphysema in the neonate is usually congenital, resulting from cartilage deficiency causing bronchomalacia and distal air trapping. Acquired forms are usually associated with chronic lung disease or endobronchial obstruction such as mucus plugging. We report a pedunculated endobronchial polyp in a 2-month old ex-premature infant causing intermittent hyperinflation of the right middle lobe. The polyp was seen prolapsing in and out of the bronchus intermedius at bronchoscopy. Possible aetiological links with mechanical ventilation are discussed. We also emphasise the value of bronchoscopy prior to lobectomy in cases of congenital lobar emphysema (CLE).

Delayed diagnosis of appendicitis in children treated with antibiotics.

The diagnosis of appendicitis in children can be difficult. Misdiagnosis may result in empirical treatment with antibiotics. The aim of this study was to determine whether initial treatment with antibiotics hindered subsequent diagnosis of appendicitis. Retrospective review of 311 children treated for appendicitis between 1999 and 2004. Patients were divided into two groups: Group 1: (n = 45) received antibiotics prior to a definitive diagnosis of appendicitis. Group 2: (n = 266) did not receive antibiotics prior to a diagnosis of appendicitis. Group 1 patients were significantly younger and more likely to be female than in group 2. Abdominal tenderness was less marked and there was a greater reliance on radiological investigations in patients receiving antibiotics. C-reactive protein and pre-operative temperature were significantly higher in group 1 patients compared to group 2. The perforation rate and complication rate were significantly greater in group 1. The commonest misdiagnoses were urinary tract infection and respiratory infection. Initial misdiagnosis results in significant delay before appendicectomy. This study shows that the clinical signs of acute appendicitis can be masked by prior treatment with antibiotics. The diagnosis of acute appendicitis must be considered and, if necessary, excluded in all children seen with abdominal pain who have recently been treated with antibiotics.

Prediction of difficult laryngoscopy in a population of Nigerian obstetric patients.

Difficulty in the maintenance of the airway during obstetric anaesthesia is a major contributory factor in anaesthetic related morbidity and mortality. There is an eightfold increase in the incidence of failed intubation in obstetrics. This is attributable to the physiological changes in pregnancy. Eighty consecutive obstetric patients, over a one year period who required general anaesthesia for caesarian section were evaluated using five bedside tests viz: Mallampati test, Thyrometal distance, Sterno-mental distance, Horizontal length of the Mandible and Inter-incisor gap. Eight patients had difficult laryngoscopy (10%). Mallampati test had a sensitivity, specificity and positive predictive value of 87.1%, 99.6% and 70% respectively. The values obtained for the Thyro-mental distance were 62.5%, 93.1% and 50% respectively. The other tests were not able to predict intubation difficulty significantly. When all tests were combined, sensitivity, specificity and positive predictive were values 100%, 36.1% and 14.8%. The combination of Mallampati and Thyro-mental distance had values of 100%, 93.1% and 61.5%--sensitivity, specificity and positive predictive value. Mallampati can be used as the sole predictor of difficult intubation in Nigerian obstetric patients.

Congestive heart failure after myocardial infarction in the rat: cardiac force and spontaneous sarcomere activity.

The causes of reduced cardiac force development in congestive heart failure (CHF) are still uncertain. We explored the subcellular mechanisms leading to decreased force development in trabeculae from rats with a myocardial infarction. We defined CHF according to clinical and pathological criteria and compared properties of trabeculae from animals with CHF (cMI) to those of animals with a myocardial scar but without evidence of CHF (uMI), and sham-operated animals. The new findings of this study on properties of cMI trabeculae are that (1) maximal twitch force following post-extrasystolic potentiation is unchanged; (2) the sensitivity of cMI trabeculae to [Ca(2+)](o) is increased; (3) spontaneous diastolic sarcomere length (SL) fluctuations (SA) are increased in cMI at all levels of SR Ca(2+) loading; and (4) SA is accompanied by a proportional reduction of F(max). The results suggest that the probability of spontaneous diastolic opening of SR Ca(2+) channels is increased in CHF. These data provide the basis for a novel mechanism underlying systolic and diastolic dysfunction as well as arrhythmias in hearts in CHF. If SA proves to be a component of myocardial dysfunction in human CHF, our thinking about therapy of the patient with CHF may be profoundly changed.

Tracheomalacia.

Tracheomalacia is a rare condition characterised by collapse of the trachea during respiration. The condition is seen most often in infants and young children. Mild cases can be managed expectantly; however, severe cases can be associated with life-threatening cyanotic attacks and intervention to stabilise the airway is invariably necessary. Most commonly this involves an aortopexy to suspend the anterior wall of the trachea but other options include endoluminal or extraluminal stenting, long-term positive pressure ventilation and tracheostomy. Although tracheomalacia resolves spontaneously in most infants within the first few years of life, severe tracheomalacia is associated with significant morbidity and mortality that should not be underestimated.

Cost-effectiveness of population screening for Helicobacter pylori in preventing gastric cancer and peptic ulcer disease, using simulation.

OBJECTIVES: To evaluate the cost-effectiveness of population screening for Helicobacter pylori in preventing gastric cancer and peptic ulcer disease in England and Wales. METHODS: A discrete event simulation model used parameter estimates, derived from peer-reviewed literature, routine data and statistical modelling. Population screening was compared with no screening but with opportunistic eradication in patients presenting with dyspepsia. Costs included screening, eradication and costs averted to provide costs per life years saved (cost/LYS) for preventing gastric cancer and peptic ulcer disease. Sensitivity analyses were undertaken. RESULTS: The cost/LYS from screening at age 40 years was Uk pounds 5860 at discount rates of 6%. The outcomes were sensitive to H. pylori prevalence, the degree of opportunistic eradication, the discount rate, the efficacy of eradication on gastric cancer risk, the risk of complicated peptic ulcer disease and gastric cancer associated with H. pylori infection, and the duration of follow-up. In sensitivity analyses, the cost/LYS rarely exceeded UK pounds 20000 over an 80-year follow-up, but did for shorter periods. CONCLUSIONS: H. pylori screening may be cost-effective in the long term. However, before screening can be recommended further evidence is needed to resolve some of the uncertainties, particularly over the efficacy of eradication on risk of gastric cancer, the risk associated with complicated peptic ulcers, and the effect of more widespread opportunistic testing of patients with dyspepsia.

Effects of oestrogen deficiency on rat mandibular and tibial microarchitecture.

OBJECTIVES: To investigate the effects of oestrogen deficiency on the microarchitecture of trabecular bone in the mandible and the tibia and to test whether they are correlated. METHODS: Twenty-four age-matched Lewis-Brown-Norway female rats underwent surgical intervention either to remove ovaries (ovariectomy, n=12) or to create a complementary control group (sham-operated, n=12). Sixteen weeks later, the animals were sacrificed and the left side of the mandibles and the tibias were scanned with high resolution micro-CT (15 micro m). Multiple morphological measures including the ratio of bone volume/tissue volume, trabecular thickness, trabecular separation and structure model index were obtained from the experimental and control groups. RESULTS: Ovariectomy significantly decreased the ratio of bone volume/soft tissue volume and trabecular thickness, whilst significantly increasing trabecular separation and structure model index in the mandible (P<0.005) and the tibia (P<0.005). There were significant positive correlations between the mandible and the tibia for trabecular separation (r=0.68, P<0.01) and structure model index (r=0.60, P<0.01). CONCLUSIONS: Oestrogen deficiency results in microarchitectural alterations of trabecular bone in both the mandible and the tibia within 16 weeks. The size of marrow spaces and the shape of trabeculae in the mandible correlate with osteoporotic changes in the long bone.

Pectus deformities of the anterior chest wall.

Pectus deformities affect about 1% of the population. Despite a subjective reduction in exercise tolerance, objective physiological disturbance is very uncommon. However, there is no doubt that cultural changes have significantly altered perception and tolerance of these deformities and increasing numbers of children are actively seeking surgery. Pectus excavatum is readily amenable to correction using minimally invasive techniques and pectus carinatum can be corrected using safe established conventional techniques. Good or excellent results can be expected in over 90% of cases, and children should no longer be denied treatment.

Isolated tracheo-oesophageal fistula.

Congenital isolated tracheo-oesophageal fistula is a rare malformation that presents with a characteristic triad of symptoms: choking and cyanosis on feeding, recurrent lower respiratory tract infection and abdominal distension. Children are invariably symptomatic from birth, although the symptoms may be intermittent and may vary in severity. A high index of suspicion is required because the symptoms are not specific. Establishing the diagnosis can be difficult and neither radiology nor bronchoscopy is infallible. Surgical division of the fistula is curative.

Handlebar hernia masquerading as an inguinal haematoma.

We report a child who sustained a traumatic hernia of the lower abdominal wall after being thrown forward against the handlebar of his bicycle. This is a rare injury in children, and the clinical features mimic an inguinal haematoma. Suspicion should be raised by the immediate appearance of a mass above the inguinal canal following groin injury, particularly if the swelling then disappears with the patient supine.

Limitations and uses of gastrojejunal feeding tubes.

BACKGROUND: Gastrostomy feeding is a well established alternative method to long term nasogastric tube feeding. Many such patients have gastro-oesophageal reflux (GOR) and require a fundoplication. A transgastric jejunal tube is an alternative when antireflux surgery fails, or is hazardous or inappropriate. AIMS: To review experience of gastrojejunal (G-J) feeding over six years in two regional centres in the UK. METHODS: Retrospective review of all children who underwent insertion of a G-J feeding tube. RESULTS: There were 18 children, 12 of whom were neurologically impaired. G-J tubes were inserted at a median age of 3.1 years (range 0.6-14.7) because of persistent symptoms after Nissen fundoplication (n = 8) or symptomatic GOR where fundoplication was inappropriate. Four underwent primary endoscopic insertion of the G-J tube; the remainder had the tube inserted via a previous gastrostomy track. Seventeen showed good weight gain. There was one insertion related complication. During a median follow up of 10 months (range 1-60), four experienced recurrent aspiration, bilious aspirates, and/or diarrhoea. There were 65 tube related complications in 14 patients, necessitating change of the tube at a median of 74 days. Jejunal tube migration was the commonest problem. Five died from complications of their underlying disease. CONCLUSIONS: Although G-J feeding tubes were inserted safely and improved nutritional status, their use was associated with a high rate of morbidity. Surgical alternatives such as an Roux-en-Y jejunostomy may be preferable.

An unusual left-sided abdominal-wall defect.

Gastroschisis is a congenital abdominal-wall defect (AWD) that typically occurs to the right of the umbilicus. Rarely, a mirror variation of the above may occur with a defect to the left of the umbilical cord. This report concerns a neonate born with an unusual AWD in the left upper quadrant, distant from an intact umbilicus.

Is epidural analgesia associated with an improved outcome following open Nissen fundoplication?

Postoperative epidural analgesia is increasingly popular in paediatric practice, although evidence of its benefit is scarce. We performed a retrospective analysis of a series of 104 consecutive open Nissen fundoplications, to determine whether mode of analgesia, epidural (n=65) or opioid infusion (n=39), influenced certain outcome measures, including intensive care utilization, duration of hospital stay, morbidity and mortality. The two groups were similar in terms of demographic characteristics and associated pathologies. Overall, morbidity and mortality (2%) rates were low. Mean duration of hospital stay was significantly greater for the opioid group, compared to those receiving epidural analgesia (13 vs. 8 days, P < 0.05). The number of patients who remained in hospital for more than 7 days was also significantly greater in the opioid group. Accepting the limitations of a retrospective study, these data suggest that epidural analgesia might be associated with an improved outcome following Nissen fundoplication and this merits a prospective study.

Hirschsprung's disease: problems with transition-zone pull-through.

BACKGROUND/PURPOSE: It is generally accepted that if surgery for Hirschsprung's disease is to be successful, ganglionic bowel must be anastomosed to the lower rectum or anal canal. Above the aganglionic distal bowel lies a transition zone (TZ) where more subtle abnormalities of innervation are apparent. The significance of this transition zone in respect to the functional outcome of surgery has received little attention. The aim of this study was to identify the incidence of transition zone pull-through (TZPT) in a cohort of children who underwent surgery for Hirschsprung's disease, to identify the reasons why TZPTs occurred, and to identify the functional consequences. The authors report the long-term outcome of these children with emphasis on bowel function and the results of subsequent surgery. METHODS: A Retrospective study was conducted of children treated at a single institution from 1979 through 1994. TZPT patients were subject to detailed review of surgical records and histopathologic material. RESULTS: Thirteen children were identified with a TZPT. In 12 cases, histopathologic errors contributed to the TZPT: in 5 cases this was caused by single point biopsies missing an asymmetrical TZ, whereas in 7 cases the histopathologic features of the TZ were not recognized. In 1 case the TZPT was caused by surgical error. As a consequence of the TZPT 7 children underwent repeat pull-through. One child is fully continent, one has daytime fecal continence, and 2 others are incontinent. Two children have permanent stomas. One child is clean with antegrade colonic washouts. Repeat pull-throughs were not attempted in 6 children. Two children have achieved full continence, 2 have permanent stomas, 1 is clean with antegrade colonic washouts, and 1 child receives regular suppositories. CONCLUSIONS: Transition zone pull-throughs occurred because of a combination of surgical and histopathologic errors. The transition zone may follow an asymmetric course around the circumference of the bowel and may be missed if single-point extramucosal biopsy specimens are taken. Recognition of the subtle histologic features of the transition zone requires an experienced pathologist. The functional consequences of a TZPT are severe, with symptoms of constipation, diarrhea, and incontinence. The results of revisional pull-through were disappointing. Serious consideration should be given to alternative procedures such as the antegrade continence enema operation.