A standardized feeding regimen for hypertrophic pyloric stenosis decreases length of hospitalization and hospital costs.

BACKGROUND/PURPOSE: Before the institution of a standardized feeding regimen (SFR) for hypertrophic pyloric stenosis (HPS) at the authors' institution, the postoperative feeding regimen and, thus, the length of hospitalization for HPS patients was variable. The aim of this study was to evaluate whether a SFR would affect the length of hospitalization or hospital costs for HPS patients. METHODS: A 5-year retrospective analysis was performed on 242 patients who underwent pyloromyotomy via a standard right upper quadrant incision. The length of hospitalization and hospital costs were compared in these patients before and after the institution of a standardized postoperative feeding regimen. RESULTS: The SFR decreased total length of hospitalization by 19.4% (3.1 days v2.5 days, P = .002), postoperative length of stay by 21% (1.9 days v 1.5 days, P< .001), total costs by 11.9% (P= .05), direct costs by 7.7% (P= .22), and indirect costs by 18.6% (P= .003). This occurred despite a small increase in costs per day. The SFR did not change the complication rate (5.3% before SFR v6.1% after SFR, P = 1.0). CONCLUSION: A postoperative standardized feeding regimen for patients with HPS decreased length of hospitalization and hospital costs without adverse effects.

The umbilical fold approach to pyloromyotomy: is it a safe alternative to the right upper-quadrant approach?

BACKGROUND: Hypertrophic pyloric stenosis has been approached using two standard incisions for pyloromyotomy: the circumumbilical (UMB) and the right upper quadrant (RUQ). The UMB approach produces an almost undetectable scar but has been associated with more complications. STUDY DESIGN: A 5-year retrospective analysis was performed on 344 patients (90 UMB and 254 RUQ) to compare technical and wound complications. The effect of prophylactic antibiotics on wound infection was also evaluated. RESULTS: The intraoperative complication rate was 5.5% (13.3% UMB versus 2.8% RUQ; p = 0.001). The mucosal perforation rate was 3.5% (8.9% UMB versus 1.6% RUQ; p = 0.003). Mucosal perforations increased the mean +/- SD length of hospitalization in UMB patients (3.9 +/- 0.8 versus 2.4 +/- 1.1 days; p < 0.001). The serosal tear rate was 2.0% (4.4% UMB versus 1.2% RUQ; p=0.08). The postoperative complication rate was 5.8% (14.4% UMB versus 2.8% RUQ; p < 0.001), and the wound infection rate was 2.6% (6.7% UMB versus 1.2% RUQ; p = 0.01). Antibiotic prophylaxis decreased the rate of wound infection to 1.8% and eliminated the statistical difference between the groups (4.5% UMB versus 0% RUQ; p=0.16). The rate of other postoperative complications was 3.2% (7.8% UMB versus 1.6% RUQ; p = 0.009). Duration of hospital stay did not differ between the groups overall (2.6+/-1.12 days for UMB versus 2.7+/-1.5 days for RUQ; p = 0.35). CONCLUSIONS: The UMB approach to pyloromyotomy was cosmetically superior but increased complication rates. Technical complications were easily corrected and length of stay was not affected. Wound infections were decreased in both groups by the use of prophylactic antibiotics.

Conserved function of mSpry-2, a murine homolog of Drosophila sprouty, which negatively modulates respiratory organogenesis.

In Drosophila embryos, the loss of sprouty gene function enhances branching of the respiratory system. Three human sprouty homologues (h-Spry1-3) have been cloned recently, but their function is as yet unknown [1]. Here, we show that a murine sprouty gene (mSpry-2), the product of which shares 97% homology with the respective human protein, is expressed in the embryonic murine lung. We used an antisense oligonucleotide strategy to reduce expression of mSpry-2 by 96%, as measured by competitive reverse transcriptase PCR, in E11. 5 murine embryonic lungs cultured for 4 days [2]. Morphologically, the decrease in mSpry-2 expression resulted in a 72% increase in embryonic murine lung branching morphogenesis as well as a significant increase in expression of the lung epithelial marker genes SP-C, SP-B and SP-A. These results support a striking conservation of function between the Drosophila and mammalian sprouty gene families to negatively modulate respiratory organogenesis.

Chronic ethanol consumption exacerbates liver injury following hemorrhagic shock: role of sinusoidal perfusion failure.

Although the deleterious effect of chronic ethanol consumption on subsequent stressful events has long been recognized, the pathophysiological mechanisms are incompletely understood. This study tested whether chronic ethanol consumption in doses that increase sinusoidal contractility increases susceptibility to hepatic microvascular failure and liver injury after hemorrhagic shock. Liver microcirculation was assessed by in vivo microscopy during hemorrhage and up to 24 h after onset of resuscitation and was compared with liver histology and serum enzyme levels. Mean sinusoidal blood flow was neither impaired by chronic ethanol feeding at baseline nor during hemorrhage and early resuscitation. However, failure of individual sinusoids to conduct flow was observed more frequently after fluid resuscitation in ethanol-fed animals (e.g. at 1 h after onset of volume therapy: 26% of sinusoids) than in controls (11%), reflecting substantial flow heterogeneity. Failing sinusoids had substantially smaller diameters than sinusoids conducting flow with a more profound and sustained response in ethanol-fed rats. At 24 h marked pericentral necrosis and increase in serum alanine aminotransferase levels were observed in six of nine surviving ethanol-fed animals but only in 1 of 10 pair fed controls and correlated with microvascular failure. These data suggest that early as well as late microvascular failure in this model of hemorrhagic shock and resuscitation is primarily mediated at the level of individual sinusoids. Chronic ethanol feeding exacerbates microvascular and hepatocellular injury after shock/resuscitation, probably involving increased sinusoidal contractile responsiveness.

Pharmacodynamics of subconjunctival gentamicin after experimental cataract operations and traumatic lacerations.

We addressed the concern whether retinal toxicity could occur with subconjunctival gentamicin injections after cataract operations or traumatic corneoscleral lacerations. The lacerations were created along the superior limbus of rabbit eyes and the lenses removed. We sutured the right eyes to mimic a cataract operation and the left eyes remained unsutured to mimic a traumatic corneoscleral laceration. Vitreous humor samples were obtained at 1, 2, 4, 8 and 12 hours after the subconjunctival injection, but in no case did vitreal concentration approach retinotoxic levels (> 133 micrograms/ml).

Topical and intravenous gentamicin in traumatically lacerated eyes.

Intravenous or topical gentamicin may be the initial mode of treatment for lacerated or ruptured eyes by emergency room physicians while awaiting ophthalmic consultation and surgical repair. The purpose of this study was to determine the possibility of having retinotoxic intravitreal gentamicin concentrations in experimentally lacerated rabbit eyes treated with either intravenous or topical gentamicin separately or in combination with each other. Nontoxic concentrations of gentamicin were found in the vitreous bodies by all routes of drug administration. After 3 h intravitreal concentrations of gentamicin were: 0.20-0.30 microgram/ml when treated intravenously, 0-2.9 micrograms/ml when treated topically, and 0.20-0.51 microgram/ml when treated both intravenously and topically. While the upper range of topically applied gentamicin concentrations (2.9 micrograms/ml) is therapeutic for some pathogens, the wide range of intravitreal concentrations (0-2.9 micrograms/ml) achieved does not indicate that topically applied gentamicin with or without intravenously administered gentamicin can reliably achieve therapeutic concentrations.

Experimental transscleral iontophoresis of ciprofloxacin.

Ciprofloxacin was administered into the aqueous humor and vitreous body of the rabbit eye by transscleral iontophoresis. Positively and negatively charged forms of the drug molecule were tested. Therapeutic concentrations of ciprofloxacin were achieved in the aqueous body only when the negatively charged drug molecule was used. Ciprofloxacin did not reach the vitreous body in therapeutic concentrations in either the positively or negatively charged form, but higher concentrations were achieved when the drug was negatively charged. Peak levels were obtained in the aqueous and vitreous bodies (0.62 micrograms/ml and 0.19 micrograms/ml, respectively) one hour after transscleral iontophoresis of negatively charged ciprofloxacin at 5 mA for 15 minutes.