Factors associated with the development of paediatric chronic otitis media by age nine: a prospective longitudinal cohort study of 6560 children.

OBJECTIVE: This study aimed to analyse social, health and environmental factors associated with the development of chronic otitis media by age nine. METHOD: This was a prospective, longitudinal, birth cohort study of 6560 children, reviewed at age nine. Chronic otitis media defined as previous surgical history or video-otoscopic changes of tympanic membrane retraction, perforation or cholesteatoma. Non-affected children were used as the control group. RESULTS: Univariate analysis demonstrated an association between chronic otitis media and otorrhoea, snoring, grommet insertion, adenoidectomy, tonsillectomy, hearing loss, abnormal tympanograms and preterm birth. Multivariate analysis suggests many of these factors may be interrelated. CONCLUSION: The association between chronic otitis media and otorrhoea, abnormal tympanograms and grommets supports the role of the Eustachian tube and otitis media (with effusion or acute) in the pathogenesis of chronic otitis media. The role of snoring, adenoidectomy and tonsillectomy is unclear. Associations suggested by previous studies (sex, socioeconomic group, parental smoking, maternal education, childcare, crowding and siblings) were not found to be significant predictors in this analysis.

Meta-analysis of the demographic and prognostic significance of right-sided versus left-sided acute diverticulitis.

AIM: The aim of this work was to compare demographic factors, outcomes and prognosis for right-sided versus left-sided acute colonic diverticulitis. METHOD: We searched MEDLINE, CINAHL, EMBASE, CENTRAL, Scopus and unpublished literature to identify all observational studies comparing demographic factors and outcomes of right-sided versus left-sided acute colonic diverticulitis (PROSPERO registration number CRD42020180075). We used the QUIPS tool to assess the risk of bias of included studies. Random effects modelling was applied to calculate pooled outcome data. RESULTS: Analysis of 2933 patients from nine studies suggests that right-sided diverticulitis affects younger patients [mean difference (MD) -14.16 (-17.19, -11.14), P < 0.00001] and more male patients [odds ratio (OR) 1.33 (1.04, 1.71), P = 0.02] compared with left-sided diverticulitis. Smoking [OR 2.23 (1.50, 3.32), P < 0.0001], alcohol consumption [OR 1.85 (1.26, 2.71), P = 0.002] and comorbidity [OR 0.21 (0.15, 0.30), P < 0.00001] were more common in patients with right-sided diverticulitis. The risk of complicated diverticulitis was lower in the right-sided group [OR 0.21 (0.08, 0.55), P = 0.001]. More patients in the right-sided diverticulitis group had modified Hinchey Stage I disease [OR 10.21 (3.34, 31.22), P < 0.0001] while more patients in the left-sided group had Stage II [OR 0.19 (0.10, 0.38), P < 0.00001], Stage III [OR 0.08 (0.01, 0.54), P = 0.009] or Stage IV disease [OR 0.02 (0.00, 0.08), P < 0.00001]. Right-sided diverticulitis was associated with a lower risk of recurrence [OR 0.49 (0.25, 0.98), P = 0.04], failure of conservative management [OR 0.14 (0.04, 0.43), P = 0.0006], the need for emergency surgery [OR 0.13 (0.05, 0.36), P < 0.00001] and a shorter length of hospital stay [MD -1.70 (-3.08, -0.33), P = 0.02]. CONCLUSION: Right-sided acute diverticulitis predominantly affects younger male patients compared with left-sided disease and is associated with favourable outcomes as indicated by the lower risk of complications, failure of conservative management, need for emergency surgery, recurrence and shorter length of hospital stay. More studies are required to compare the postoperative outcomes in patients with right-sided and left-sided diverticulitis undergoing emergency surgery.

Comparison of extended right hemicolectomy, left hemicolectomy and segmental colectomy for splenic flexure colon cancer: a systematic review and meta-analysis.

AIM: The aim of this work was to compare the outcomes of extended right hemicolectomy (ERH), left hemicolectomy (LH) and segmental colectomy (SC) for the surgical management of splenic flexure tumours. METHOD: In compliance with PRISMA statement standards, a systematic review was performed to identify all studies comparing outcomes of ERH, LH and SC for the surgical management of splenic flexure tumours. Primary outcomes included anastomotic leakage and all postoperative complications. The secondary outcomes included operative time, R0 resection, number of harvested lymph nodes, > 12 harvested lymph nodes, severe complications, postoperative mortality, paralytic ileus, wound infection, pancreatic fistula, intra-abdominal abscess, need for reoperation, length of hospital stay, 5-year overall survival and 5-year disease-free survival. The ROBINS-I tool and GRADE system were used to assess the risk of bias and certainty of evidence, respectively. RESULTS: Analysis of 956 patients from seven observational studies showed that ERH was associated with more paralytic ileus than LH (OR 2.74, P = 0.002) and SC (OR 6.67, P < 0.0001) and the operative time was shorter in SC than in ERH (mean difference 25.48, P < 0.0001) and LH (mean difference -17.94, P = 0.0002). There were no differences between ERH, LH and SC in terms of anastomotic leakage, postoperative complications, R0 resection, severe complications, postoperative mortality, wound infection, pancreatic fistula, intra-abdominal abscess, need for reoperation, length of hospital stay, > 12 harvested lymph nodes, 5-year overall survival and 5-year disease-free survival. CONCLUSIONS: The available evidence, limited to observational studies, suggests that there is no difference between ERH, LH and SC in terms of postoperative morbidity and mortality, lymph node yield and cancer survival. Randomized controlled trials are required for definite conclusions.

Appendiceal Duplication: A Comprehensive Review of Published Cases and Clinical Recommendations.

BACKGROUND: Duplex appendix is very rare (incidence 0.004%) but has clinical relevance given the frequency of appendicectomies performed. Failure to recognise duplication can result in failure of treatment and medico-legal consequences. A review of published cases was undertaken to identify factors that may help in managing this rare condition. METHODS: All English and non-English publications were identified in PubMed, Embase and Cochrane databases. Patient demographics, intraoperative findings, anatomical details and histopathology were analysed. RESULTS: A total of 141 cases were identified [male/female ratio 1.4:1, median age 20 years (range foetus to 69 years)]. Duplication of the appendix ranges from branching of the appendix trunk to a fully matured appendix located elsewhere along the colon. Most can be categorised by the Cave-Wallbridge classification. There were 22 Type A, 8 Type B1, 46 Type B2 and 10 Type C cases (Cave-Wallbridge). There were six cases of horseshoe and two cases of triple appendix. Six reports gave anatomical descriptions that could not be classified by Cave-Wallbridge categories and in 11 cases there were no anatomical descriptions. CONCLUSIONS: An anteriorly placed appendix, away from the convergence of the taenia, or a normal appendix in the presence of convincing clinical or radiological signs of appendicitis should instigate a careful examination of the caecal pole and possible exploration of the retrocaecal space for appendiceal duplication. If the patient had previous surgery for congenital abnormalities, Type B1 or Type C duplication should be considered.

The nitroxide 4-methoxy TEMPO inhibits neutrophil-stimulated kinase activation in H9c2 cardiomyocytes.

After acute myocardial infarction (AMI), neutrophils are recruited to the affected myocardium. Hypochlorous acid (HOCl) produced by neutrophil myeloperoxidase (MPO) damages cardiomyocytes and potentially expands the primary infarct. Rat cardiomyocyte-like cells were incubated with isolated human neutrophils treated with chemical activators in the absence or presence of nitroxide 4-methoxy-Tempo (MetT; 25 µM) for 4, 6 or 24 h; studies with reagent HOCl served as positive control. Treating cardiomyocytes with activated neutrophils or reagent HOCl resulted in a marked increase in protein tyrosine chlorination and a decline in protein tyrosine phosphatase (PTP) activity. On balance our data also supported an increase in phosphorylation of MAPK p38 and ERK1/2 suggestive of an intracellular hyperphosphorylation status and this was accompanied by decreases in cell viability, as judged by assessing caspases-3/7 activity. For cells exposed to activated neutrophils receptor-mediated uptake of transferrin decreased although total matrix metalloproteinase (MMP) activity was unaffected. Addition of MetT ameliorated protein tyrosine chlorination, decreased MAPK activity and restored receptor-mediated transferrin uptake and PTP activity in cardiomyocytes. Overall, adverse effects of neutrophil-derived HOCl on cultured cardiomyocytes were ameliorated by MetT suggesting that nitroxides may be beneficial to inflammatory pathologies, where neutrophil recruitment/activation is a prominent and early feature.

Genetic diversity and population structure in native chicken populations from myanmar, Thailand and laos by using 102 indels markers.

The genetic diversity of native chicken populations from Myanmar, Thailand, and Laos was examined by using 102 insertion and/or deletion (indels) markers. Most of the indels loci were polymorphic (71% to 96%), and the genetic variability was similar in all populations. The average observed heterozygosities (H O ) and expected heterozygosities (H E ) ranged from 0.205 to 0.263 and 0.239 to 0.381, respectively. The coefficients of genetic differentiation (Gst) for all cumulated populations was 0.125, and the Thai native chickens showed higher Gst (0.088) than Myanmar (0.041) and Laotian (0.024) populations. The pairwise Fst distances ranged from 0.144 to 0.308 among populations. A neighbor-joining (NJ) tree, using Nei's genetic distance, revealed that Thai and Laotian native chicken populations were genetically close, while Myanmar native chickens were distant from the others. The native chickens from these three countries were thought to be descended from three different origins (K = 3) from STRUCTURE analysis. Genetic admixture was observed in Thai and Laotian native chickens, while admixture was absent in Myanmar native chickens.

The prevalence of tympanic membrane and related middle ear pathology in children: a large longitudinal cohort study followed from birth to age ten.

OBJECTIVE: To record with video-otoscopy the appearance of the tympanic membranes of a cross section of children aged 9 to 10 years. STUDY DESIGN: Cross-sectional study nested within an established longitudinal study of childhood development, the Avon Longitudinal Study of Parents and Children. SETTING: South West England, U.K. PARTICIPANTS: Approximately 6908 of 7261 children with ages ranging from 105 to 140 months born between April 1, 1991, and December 31, 1992, were examined by trained technicians with video-otoscopy. MAIN OUTCOME MEASURES: Two photographs were taken of each child's tympanic membranes to show the features of the pars tensa and the pars flaccida. RESULTS: In just less than three quarters of the children, both ears were normal. Retraction of the pars flaccida was present in 9.6% of children, and that of the pars tensa was present in 7.9%. Most of these changes were mild with few severe retractions. There were 15 cases of overt or suspected cholesteatoma. CONCLUSION: The tympanic membrane changes reflect most of the middle ear disease seen in 9- to 10-year-old children. The prevalence is low, and few children have serious disease at this stage.

Decisions to operate: the ASA grade 5 dilemma.

INTRODUCTION: Deciding to operate on high risk patients suffering catastrophic surgical emergencies can be problematic. Patients are frequently classed as American Society of Anesthesiologists (ASA) grade 5 and, as a result, aggressive but potentially lifesaving intervention is withheld. The aim of our study was to review the short-term outcomes in patients who were classed as ASA grade 5 but subsequently underwent surgery despite this and to compare the ASA scoring model to other predictors of surgical outcome. METHODS: All patients undergoing emergency surgery with an ASA grade of 5 were identified. Patient demographics, indications for surgery, intraoperative findings and outcomes were recorded. In addition to the ASA scores, retrospective Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P POSSUM) and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were calculated and compared to the observed outcomes. RESULTS: Nine patients (39%) survived to discharge. ASA grade was a poor predictor of outcome. P POSSUM and APACHE II scores correlated significantly with each other and with observed outcomes when predicting surgical mortality. The median stay for survivors in the intensive care unit was nine days. CONCLUSIONS: In times of an ageing population, the number of patients suffering catastrophic surgical events will increase. Intervention, with little hope of a cure, a return to independent living or an acceptable quality of life, leads to unnecessary end-of-life suffering for patients and their relatives, and consumes sparse resources. The accuracy and reliability of ASA grade 5 as an outcome predictor has been questioned. P POSSUM and APACHE II scoring systems are significantly better predictors of outcome and should be used more frequently to aid surgical decision-making in high risk patients.

Use of a patient consultation questionnaire and weighted numerical scoring system for the prediction of colorectal cancer and other colorectal pathology in symptomatic patients: a prospective cohort validation study of a Welsh population.

OBJECTIVE: There is currently no system in widespread use that accurately prioritizes colorectal referrals in symptomatic patients with an acceptable degree of sensitivity and specificity. We have validated a weighted numerical scoring system for the prioritization of such colorectal referrals in an attempt to rectify this, with detection of colorectal cancer (CRC) the primary outcome. METHOD: We conducted a prospective study of symptomatic patients referred by primary care to the colorectal service in a district general hospital. A computer-generated weighted numerical score (WNS) was derived from the primary symptoms and symptom combinations. Patients underwent colorectal investigations and a final diagnosis was established. Sensitivity, specificity and accuracy of CRC detection as determined by the WNS, Department of Health (DOH) and National Institute for Health and Clinical Excellence guidelines was determined. Primary Care compliance with guidelines was analysed. RESULTS: A definitive diagnosis was established in 3457 patients. One hundred and eighty-six (5.4%) had CRC. The mean score for the cancer patients (76.9, 95%CI 72-81) was significantly higher than that of non-cancer patients (52, 95%CI 52-53) P < 0.001. Receiver Operator Curve analysis demonstrates a high discriminatory power for the Patient Consultation Questionnaire (PCQ) with an area under curve of 0.76. Compliance by primary care with the nationally recommended referral guidelines was poor with only 55% and 58% compliance with DOH and National Institute for Clinical Excellence referral guidelines for suspected cancer respectively. CONCLUSION: The PCQ and the WNS is an efficient, objective system that allows the accurate prioritization of colorectal referrals with a high sensitivity for cancer and other serious colorectal pathologies.

Developmental outcomes in early compared with delayed surgery for glue ear up to age 7 years: a randomised controlled trial.

OBJECTIVES: To investigate whether early versus delayed surgery for children severely affected by otitis media with effusion (OME) results in improved performance on developmental tests up to age 7 years. DESIGN: Follow-up of a randomised controlled trial. SETTING: University of Bristol. PARTICIPANTS: One hundred and eighty-two children (mean age 35 months) with persistent OME, hearing loss and speech, language or behaviour problems who were originally eligible and randomised to either early surgery or delayed surgery after a period of watchful waiting were followed-up as part of the Avon Longitudinal Study of Parents and Children (ALSPAC) at age 4 1/2 and 7-8 years. MAIN OUTCOME MEASURES: Measures included behaviour, language, educational attainment tests, hearing, reading, cognition and coordination. RESULTS: Of the original randomised trial, 88 of 92 of the early surgery and 74 of 90 of the watchful waiting group were still participating in ALSPAC. Analysis was by intention to treat. At age 4 1/2 years there were significant differences in teacher assessment of language (adj OR 3.45, 95% CI: 1.42-8.39) and writing (adj OR 3.74, 95% CI: 1.51-9.27), in favour of early surgery. At age 7-8 years, there was a significant difference on teacher report of emotional problems (adj OR 4.11, 95% CI: 1.15-14.64) in favour of early surgery. There were no other significant differences. CONCLUSIONS: Early surgery for the child severely affected by OME may be associated with subtle benefits at age 4 1/2 years. This may continue to 7-8 years but the small study size makes it difficult to distinguish these effects from chance. A larger study is recommended.