Repair of oesophageal atresia by consultants and supervised trainees results in similar outcomes.

INTRODUCTION: Consultants and trainees require exposure to complex cases for maintaining and gaining operative experience. Oesophageal atresia (OA) repair is a neonatal surgical procedure with indicative numbers for completion of training. A conflict of interest may exist between adequate training, maintaining consultant experience and achieving good outcomes. We aimed to review outcomes of procedures performed primarily by trainees and those performed by consultants. METHODS: We carried out a retrospective case note review of all consecutive infants who underwent surgical repair of OA with distal tracheooesophageal fistula (TOF) between January 1994 and December 2014 at our institution. Only cases that underwent primary oesophageal anastomosis were included. Surgical outcomes were compared between cases that had a trainee and those that had a consultant listed as the primary operator. RESULTS: One hundred and twenty-two cases were included. A total of 52 procedures were performed by trainees, and 68 by consultants. Two cases were undeterminable and excluded. Infant demographics, clinical characteristics and duration of follow-up were similar between groups. All infants survived to discharge. Procedures performed by trainees and those performed by consultants as primary operators had a similar incidence of postoperative pneumothorax (trainees 4, consultants 3; p=0.46), anastomotic leak (trainees 5, consultants 3; p=0.29) and recurrent TOF (trainees 0, consultants 2; p=0.5). Overall 52% of cases had an anastomotic dilatation during follow-up, with no difference between the trainee and consultant groups (50% vs 53%; p=0.85). CONCLUSIONS: Surgical outcomes for repair of OA/TOF are not adversely affected by trainee operating. Trainees with appropriate skills should perform supervised OA/TOF repair. These data are important for understanding the interrelationship between provision of training and surgical outcomes.

Implementing an early feeding pathway post gastrostomy insertion reduces inpatient stay.

BACKGROUND: There is no consensus regarding optimal postoperative feeding strategy following gastrostomy insertion in children. The aim of this study was to determine whether implementing an early postoperative feeding pathway reduces length of stay (LOS) without increasing complications. METHODS: A retrospective case note review of all children having a new gastrostomy inserted during a one-year period prior to (July 2016-July 2017) and following (July 2017-July 2018) pathway introduction was performed. Children unable to follow the pathway for coexisting medical or nutritional reasons were excluded. The pathway comprised feeding 50% of normal feed 2 hours postprocedure, followed by 100% of normal feed at 5 and 8 h. Previously, patients were fed postoperatively according to surgeon preference. RESULTS: 116 cases met inclusion criteria, 55 prior to and 61 after pathway implementation. Children following the early feeding pathway had a shorter postoperative LOS than the historical group (median 28 vs 33 h, p < 0.003), while immediate (<72 h) and early (<30 day) complication rates were similar (8.2 vs 7.3%, p = 1.00 and 12 vs 16%, p = 0.59, respectively). CONCLUSIONS: Early postoperative feeding after gastrostomy insertion is safe and reduces LOS. TYPE OF STUDY: Quality improvement. LEVEL OF EVIDENCE: III.

Esophageal replacement by gastric transposition: A single surgeon's experience from a tertiary pediatric surgical center.

BACKGROUND: Many pediatric surgeons have limited experience of esophageal replacement. This study reports outcomes of esophageal replacement by gastric transposition performed by a single UK-based pediatric surgeon. METHODS: Consecutive patients were identified who underwent esophageal replacement by gastric transposition over a 28 year period. Clinical and demographic data were collected. Weight-for-age Z-scores were calculated for esophageal atresia patients. RESULTS: Nineteen patients were identified. Indication in the majority was long-gap esophageal atresia (n = 17; 10 with tracheoesophageal fistula). At surgery, median age was 8.5 months (range 2-55); median weight was 7.4 kg (range 4.0-17.4 kg). A right-sided thoracotomy or transhiatal approach was used. Median postoperative length of stay was 17.5 days (range 7-130); median intensive care stay was three days (range 1-63). There were no deaths. Anastomotic leak rate at 30 days was 10.5% (n = 2). One patient required early stricture dilatation. Median weight-for-age Z-score increased from -2.17 at one year of age to -1.86, -1.70 and -1.93 at 5, 10 and 15 years. CONCLUSIONS: Esophageal replacement by gastric transposition offers a potentially life-changing treatment; however, it is associated with significant morbidity. The majority of patients eventually achieve full oral feeding and maintenance of weight gain trajectory. A right-sided approach to the esophagus is feasible. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: IV.

Histological assessment of intermediate- and long-term creatine monohydrate supplementation in mice and rats.

Creatine monohydrate (CrM) supplementation appears to be relatively safe based on data from short-term and intermediate-term human studies and results from several therapeutic trials. The purpose of the current study was to characterize pathological changes after intermediate-term and long-term CrM supplementation in mice [healthy control and SOD1 (G93A) transgenic] and rats (prednisolone and nonprednisolone treated). Histological assessment (18-20 organs/tissues) was performed on G93A mice after 159 days, and in Sprague-Dawley rats after 365 days, of CrM supplementation (2% wt/wt) compared with control feed. Liver histology was also evaluated in CD-1 mice after 300 days of low-dose CrM supplementation (0.025 and 0.05 g x kg-1x day-1) and in Sprague-Dawley rats after 52 days of CrM supplementation (2% wt/wt) with and without prednisolone. Areas of hepatitis were observed in the livers of the CrM-supplemented G93A mice (P < 0.05), with no significant inflammatory lesions in any of the other 18-20 tissues/organs that were evaluated. The CD-1 mice also showed significant hepatic inflammatory lesions (P < 0.05), yet there was no negative effect of CrM on liver histology in the Sprague-Dawley rats after intermediate-term or long-term supplementation nor was inflammation seen in any other tissues/organs (P = not significant). Dietary CrM supplementation can induce inflammatory changes in the liver of mice, but not rats. The observed inflammatory changes in the murine liver must be considered in the evaluation of hepatic metabolism in CrM-supplemented mice. Species differences must be considered in the evaluation of toxicological and physiological studies.

Antioxidant activity of retinol, glutathione, and taurine in bovine photoreceptor cell membranes.

The antioxidant activities of compounds endogenous to mammalian rod outer segments (ROS) were investigated in vitro by measuring the oxidative loss of polyunsaturated fatty acids (PUFA's) from the membranes of intact ROS and from liposomes made from ROS phospholipids (PL) to which lipid soluble compounds had been added. The membranes were exposed to the water-soluble oxidant 2, 2'-azobis(2-amidinopropane) dihydrochloride (AAPH). Retinol protected PUFA's in ROS liposome PL's, whereas retinaldehyde promoted lipid peroxidation. When isolated ROS were stimulated to produce endogenous retinol, PUFA loss was inhibited by up to 17%. These findings suggest an antioxidant function for the enzymatic reduction of retinaldehyde to retinol during the visual cycle. Water-soluble antioxidants, taurine and reduced glutathione (GSH), were investigated individually and in combination with retinol in ROS PL liposomes. GSH protected PUFA's in ROS PL liposomes. Taurine alone showed little antioxidant activity, but in combination with retinol it protected lipids twice as much as retinol alone. These results support previous findings that taurine protects ROS lipids during exposure to cyclic light.

Optimizing the roles of school mental health professionals.

Each mental health discipline offers unique contributions to the development and operation of school-based mental health programs. The collaboration of professionals from different disciplines with each other, as well as with health and educational staff, is essential for service delivery in school settings. Conversely, interprofessional conflicts and turf issues can impede the development of effective school-based mental health programs. The authors, who represent counseling, nursing, psychiatry, psychology, and social work, discuss the roles and competencies of each profession in providing school-based mental health services. Training requirements within each discipline that relate to school mental health are described. Barriers to effective interdisciplinary collaboration, and methods of overcoming them, are delineated.

Vaginal lever pessary in patients with multiple gestation, preterm labor and low fetal station. A report of three cases.

BACKGROUND: The vaginal pessary has been utilized previously in patients with cervical incompetence, resulting in improvement in pregnancy outcome. The mechanical advantages generated by the vaginal lever pessary could theoretically be applied to patients in preterm labor with low station of the presenting part to prevent cervical dilatation. CASES: One patient with twins and two with triplet pregnancies presented in preterm labor with advanced cervical dilatation and low fetal station. They were treated with tocolytic drugs, and a vaginal lever pessary was placed. The gestational age at delivery was delayed with the addition of the vaginal pessary. Based on previous experience with these difficult cases, it was judged that the use of the pessary achieved a delay in delivery that would not have occurred without the device. CONCLUSION: Vaginal pessaries can be used as mechanical adjuvants in the treatment of preterm labor. These devices work by altering the pressure dynamics on the cervix and lower uterine segment. They may also help limit cervical change by preventing engagement of the presenting part into the maternal pelvis. In these cases, a vaginal pessary appears to be beneficial in delaying delivery in multiple gestations presenting with advanced cervical dilatation and low station of the presenting part.

A model membrane system to investigate antioxidants in bovine rod outer segments.

The antioxidant activities of compounds endogenous to bovine rod outer segments (ROS) were investigated by measuring the loss of polyunsaturated fatty acids (PUFA's) from membranes exposed to the water-soluble oxidant 2,2'-azobis(2-amidinopropane) dihydrochloride (AAPH). Osmotically intact ROS, ROS membranes, and unilamellar liposomes prepared from ROS phospholipids (PL) were compared. Intact ROS were most resistant to oxidative loss of PUFA's, followed by ROS membranes and then PL liposomes. The development of a model membrane system allowed the investigation of putative antioxidants singly and in combination. These lipid-soluble compounds were incorporated into PL liposomes, and it was found that normal physiological concentrations of alpha-tocopherol (vitamin E) and free fatty acids (16:0, 18:0, 18:1, 22:6) significantly decreased oxidative loss of PUFA's. When all the major free fatty acids were added to PL liposomes at the same concentrations found when ROS phospholipase A is stimulated, the oxidative loss of PUFA's was reduced by 31%. The antioxidant effect of free fatty acids suggests that endogenous phospholipase A's may act to protect membranes by releasing esterified fatty acids in proportions and concentrations that afford protection to membrane lipids.

Coenzyme A independent acylation of phosphatidylethanolamine in isolated bovine rod cell outer segments.

The acylation of membrane phospholipids in isolated bovine rod outer segments (ROS) by exogenous, radiolabeled palmitic acid (16:0) was assayed, using [14C]palmitoyl-coenzyme A (16:0-CoA), [3H]16:0 alone and [3H]16:0 with added ATP and CoA. Both [14C]16:0-CoA and [3H]16:0 with added ATP and CoA are incorporated predominantly into phosphatidylcholine (PC), whereas [3H]16:0 without added ATP and CoA is incorporated almost exclusively into phosphatidylethanolamine (PE). Without added ATP and CoA in the incubation medium, [3H]16:0 is esterified predominantly to the 2 position of PE, but with added ATP and CoA, it is esterified to both the 1 and 2 positions; the rates of esterification of [3H]16:0 to the 2 position of PE under these two conditions are similar. These results suggest that 16:0 is esterified to the 2 position of PE of ROS membranes by an acyl transferase mechanism that does not utilize an acyl-CoA intermediate. The product of this reaction is likely to be a molecular species of PE with 16:0 at the 2 position and a polyunsaturated fatty acid at the 1 position.

Phospholipid molecular species from isolated bovine rod outer segments incorporate exogenous fatty acids at different rates.

The incorporation of radiolabeled palmitic (16:0), oleic (18:1), and docosahexaenoic (22:6) acids into different molecular species of membrane phospholipids was investigated in isolated bovine rod outer segments (ROS). Phosphatidylcholine (PC), phosphatidylethanolamine (PE), and phosphatidylserine (PS) were isolated, and their diacylglyceroacetate and diacylglycerobenzoate derivatives were prepared, separated by HPLC, quantified, and assayed for radioactivity. Maximal incorporation of fatty acids occurred within 15-30 min. The rate of incorporation of the fatty acids into PC was three to six times higher than it was into PS or PE. The rate of incorporation of 22:6 into the molecular species, 22:6-22:6, of PC was ten to 15 times higher than into that of PE or PS, and it was three to four times higher than the incorporation rates of 22:6 into the other 22:6-containing molecular species. Similarly, incorporation of 18:1 into 18:1-22:6 was ten to 30 times more rapid in PC than in PE and PS, but in both PE and PS, 18:1 was incorporated into 18:1-22:6 at a rate of 20 to 25 times higher than the incorporation into the other molecular species analysed. For PC, incorporation of 16:0 was most rapid into 16:0-16:0, but for PE and PS it was most rapid into 16:0-20:4; for all cases, incorporation of 16:0 into these molecular species was four to six times more rapid than into the other 16:0-containing molecular species. These results are further evidence for the presence within a membranous organelle, the ROS, of an active acylation-deacylation system that is selective with regard to phospholipid, molecular species of phospholipid, and fatty acid.

Effects of the antioxidants dithiothreitol and vitamin E on phospholipid metabolism in isolated rod outer segments.

Phospholipid peroxidation and the activities of phospholipase A, acyl Coenzyme A:lysophospholipid acyltransferase and lysophospholipase were measured in isolated bovine rod outer segments (ROS) that were incubated in the presence or absence of the added antioxidants, vitamin E and dithiothreitol (DTT), and additionally in light or dark. DTT and vitamin E significantly inhibit both lipid peroxidation and the enzyme activities. These results suggest that one function of the enzymes for molecular replacement of fatty acids in ROS, is removal of peroxidized fatty acids and thus protection of the membrane phospholipids and proteins from further oxidative damage.

Lysophospholipase and the metabolism of lysophosphatidylcholine in isolated bovine rod outer segments.

Incubation of bovine rod outer segments (ROS) with radiolabeled palmitic acid (16:0) and lysophosphatidylcholines (lysoPC) radiolabeled in either the fatty acid or the choline group indicated the presence of a lysophospholipase activity that is unaffected by Ca2+. In the presence of ATP, Mg2+ and CoA and acyl CoA:lysophospholipid acytransferase activity is evident, and free fatty acids, including those released by lysophospholipase activity, are esterified to membrane phospholipids. At low concentrations of lysoPC, 68% of it is acylated to form phosphatidylcholine (PC) and 24% is converted to glycerophosphocholine (GPC) and fatty acid per hour. As the concentration of lysoPC increases lysophospholipase activity increases, acyl-CoA:lysophospholipid acyltransferase activity decreases, and the proportion of lysoPC converted to PC decreases. The rate of production of lysophospholipids in vitro under phospholipase A-stimulatory conditions exceeds the rate at which it can be removed by 5-10-fold. This suggests the possibility that an early step in light, anoxia- or hypoxia-induced damage to photoreceptor cells may be activation of the phospholipase A endogenous to ROS.

Acylation and deacylation of phospholipids in isolated bovine rod outer segments.

Isolated bovine rod outer segments (ROS) were incubated under different conditions with radiolabeled fatty acid-Coenzyme A (CoA) compounds, fatty acids and phospholipids in order to further investigate the rates, mechanisms and function of phospholipid metabolism within that organelle. ROS contain acyl CoA synthetase, acyl transferase, acyl CoA hydrolase, and phospholipase A activities. Although different radiolabeled fatty acid CoAs were esterified to the major ROS phospholipids (phosphatidylcholine, phosphatidylethanolamine, phosphatidylserine) at the same rate, different free fatty acids were esterified at different rates. There was no correlation between these estimates of in vitro rates of incorporation of fatty acids and the fatty acid composition of ROS phospholipids. Both the deacylation of radiolabeled phospholipids (phospholipase A activity) and the acylation of endogenous phospholipids (acyl transferase activity) were maximally stimulated when ATP, CoA, Mg2+ and Ca2+ were present, and both processes were stimulated by pro-oxidizing conditions and exposure to light. Under phospholipase A-stimulatory conditions, there was preferential hydrolysis of polyenoic fatty acids from endogenous ROS phospholipids. Both the acylation and deacylation reactions were primarily at the sn-2 position of ROS phospholipids.

Acyl transferase and fatty acid coenzyme A synthetase activities within bovine rod outer segments.

Rod outer segments purified from bovine retinal homogenates were incubated with radiolabelled fatty acids (palmitic, docosahexaenoic) and palmitoyl Coenzyme A, and were found to contain enzyme activities that catalyze addition of these compounds to the major phospholipids of rod outer segment membranes. It is suggested that these phospholipid retailoring enzymes function to establish the unique fatty acid distribution and composition of the phospholipids of vertebrate rod outer segment membranes.