Reduced Presentation of Biliary Atresia During the COVID-19 Lockdown: A Population Based Observational Study.

OBJECTIVE: The aim of this study was to assess whether there has been a change in presentations of biliary atresia (BA) in England and Wales during the first and second coronavirus disease 2019 (COVID-19) lockdowns (January-June 2020 and 2021). DESIGN: This population study assessed all confirmed cases of BA, from January 2020 to December 2021 across the 3 UK pediatric liver centers originating from England and Wales. Data was then compared to the incidence of confirmed BA cases from January to December 2017, 2018, and 2019. RESULTS: During January-June 2020 and 2021, there were only 8 and 12 presenting cases of BA in England and Wales, compared to 16, 13, and 18 for the same time periods in 2017, 2018, and 2019, respectively. This difference was significant in a two-sided t test for 2020 ( P = 0.035) but not for 2021 ( P = 0.385). There was no difference in the mean days to Kasai procedure in January-June 2020 and 2021 compared to 2017-2019; however average time to Kasai after the lockdown periods was significantly higher. CONCLUSIONS: There was a significant reduction in the presenting cases of BA during the first COVID-19 lockdown, with an increased time for BA referrals after the pandemic lockdowns were lifted in England and Wales.

The flexibility and convenience of using a standard orthopaedic table in peri-articular knee fractures: Allowing ligamentotaxis and improving imaging accessibility.

Tibial plateau and distal femoral fractures are common injuries presenting a significant operative challenge. Complexity of the fracture often needs multi-planar surgical access. A combined two-staged procedure is frequently suggested both in supine and prone position to address this issue. However, this will significantly increase the operative time and eventually impact the outcome, in addition to the complications associated with prone positioning. In this study we used a standard orthopaedic table to position these patients in order to grant access to the postro-medial and a postro-lateral structures while the patient stays in supine setup, at the same time, giving the flexibility to change the alignment from valgus to varus and vice versa. This facilitates fracture reduction while addressing the anatomical structure of the knee. A further advantage is the unobstructed imaging access throughout the surgical fixation. This facilitates the reduction in operative time hence leading to a better outcome in these difficult fractures. We tested this positioning technique in more than 40 patients over a 4-year period at two different centres in the United Kingdome. We found that this approach is safe, reproducible and relatively easy to set up in the two centres.

Similarities and Differences in Allocation Policies for Pediatric Liver Transplantation Across the World.

OBJECTIVES: We aimed to investigate national allocation policies for pediatric liver transplantation (LT). METHOD: A survey was prepared by the European Society for Paediatric Gastroenterology Hepatology and Nutrition Hepatology Committee in collaboration with the North American Studies of Pediatric Liver Transplantation consortium. The survey was sent to pediatric hepatologists and transplant surgeons worldwide. National data were obtained from centrally based registries. RESULTS: Replies were obtained from 15 countries from 5 of the world continents. Overall donation rate varied between 9 and 35 per million inhabitants. The number of pediatric LTs was 4 to 9 per million inhabitants younger than 18 years for 13 of the 15 respondents. In children younger than 2 years mortality on the waiting list (WL) varied between 0 and 20%. In the same age group, there were large differences in the ratio of living donor LT to deceased donor LT and in the ratio of split liver segments to whole liver. These differences were associated with possible discrepancies in WL mortality. CONCLUSIONS: Similarities but also differences between countries were detected. The described data may be of importance when trying to reduce WL mortality in the youngest children.

Early and Late Factors Impacting Patient and Graft Outcome in Pediatric Liver Transplantation: Summary of an ESPGHAN Monothematic Conference.

As pediatric liver transplantation comes of age, experts gathered to discuss current paradigms and define gaps in knowledge warranting research to further improve patient and graft outcomes. Identified areas ripe for collaborative research include understanding the molecular and cellular mechanisms of tolerance and the role of donor-specific antibodies, considering ways to expand donor pool, minimizing long-term side effects of immunosuppression, and fine-tuning surgical techniques to minimize biliary and vascular complications.

Can an Inferior Calcar Stabilising Antirotation Screw Improve Stability in Unstable A2 Inter Trochanteric Fractures when Fixed with a Dynamic Hip Screw?

OBJECTIVE: To determine the effect of a calcar stabilising anti rotation screw on reducing the complication rate in intertrochanteric hip fractures. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Hinchingbrooke Hospital, Northwest Anglia Foundation Trust, Huntingdon, UK, from July 2019 to December 2020. METHODOLOGY: All A2 Intertrochanteric fractures according to the AO31 classification fixed with dynamic hip screw (DHS) were included. Exclusion criteria were A1 and A3 fractures, pathological, and per-prosthetic fractures. Fifty-four patients were divided into two groups. Group one (21) patients were managed with a DHS and a calcar stabilising screw. Group two (33) were managed with a dynamic hip screw (DHS) only. Both groups had a 12 months follow-up. Study variables were age, gender, ASA and preoperative mobility status, and tip-apex distance; while outcome measures were mechanical failures including cut-out needing revisions and medialisation associated with pain. RESULTS: No patients in the group one suffered mechanical failure compared to 27% in group two. CONCLUSION: A calcar stabilising screw reduces the failure rate of A2 unstable intertrochanteric fractures when used in conjunction with the DHS. KEY WORDS: Intertrochanteric fractures, Hip fracture, A2 unstable fracture, Dynamic hip screw, Calcar stabilising screw, Mechanical failure.

Treatment outcomes among tuberculosis patients in Jeddah, Saudi Arabia: Results of a community mobile outreach directly observed Treatment, Short-course (DOTS) project, compared to a standard facility-based DOTS: A randomized controlled trial.

INTRODUCTION: Tuberculosis (TB) remains a global public health threat affecting people in many developing countries, including the Kingdom of Saudi Arabia. Maintaining a long-term treatment regimen has always been the cornerstone of successful treatment outcomes among tuberculosis patients. In the Jeddah region, the National Tuberculosis Control and Prevention Program is now treating TB patients by means of a community mobile outreach team approach.The objective of this study was to compare the effectiveness of the community mobile outreach approach in improving treatment outcomes (success rate) among local tuberculosis patients with those being treated with a facility-based directly observed treatment, short-course (DOTS). STUDY DESIGN: Our study consisted of a two-sample, parallel design [1:1], statistician -blind randomized control trial with 200 newly diagnosed, TB patients as subjects. SETTING/PARTICIPANTS: The patients had all presented at the Madain Alfahd Primary Health Care Center, Jeddah. Between Nov 2017 and Nov 2018, a total of 221 TB patients were screened of whom 200 were randomly selected using randomly generated sequences. INTERVENTION: Patients in the intervention sample group were treated by means of mobile outreach teams with oral anti-TB treatment under the DOTS, and control group patients were given the traditional facility-based DOTS treatment according to the WHO recommendations and national guidelines. MAIN OUTCOME: The primary outcome was the level of overall treatment success rate. It was finally determined and compared in the two sample groups using chi-square analysis and relative risk assessment. RESULTS: In the analysis stage, 97 patients were in the intervention group, while the control group consisted of 76. The overall response rate was 86.5% (173/200). We found that the percentage of overall treatment success rate among the patients served by the mobile outreach team was 97%, compared to 76% in the non-mobile team treated patients. The relative risk of treatment success rate among the intervention group was 1.27 (95% CI = 1.13-1.43) times greater than that amongst the control group. Log-rank test (log-rank statistics = 18.91; p < 0.001) identified a significant difference in the default rate after six months of treatment. CONCLUSION: This study has shown that a mobile outreach DOTS approach is an effective and acceptable strategy for treating TB patients. It also provides important data on the efficacy of using mobile outreach teams to improve TB treatment outcomes in Jeddah. Our results provide evidence and highlight the positive and significant impact of mobile outreach teams in mitigating TB recurrence rates and in improving TB treatment outcomes.Clinical Trial Registration: Clinicaltrials.gov: NCT03787914.

Safe use of segmental liver grafts from donors after cardiac death (DCD) in children with acute liver failure.

Emergency liver transplantation is a life-saving procedure in selected subset of children with acute liver failure (ALF), when most recipients receive a segmental graft from a living or heart-beating deceased donor. The increased use of full-liver grafts from donors after cardiac death (DCD) has had a beneficial impact on elective liver transplantation in adults. These grafts however are more susceptible to poor initial function, and most centres are reluctant to consider their use as segmental grafts, let alone in the situation of ALF where good initial function is imperative. In this short article, we describe the use and successful outcome in two children aged 6 weeks and 6 years with acute liver failure who received reduced-size DCD liver grafts.

Hepatocellular carcinoma in children.

Liver tumors are relatively rare in childhood, but may be associated with a range of diagnostic, genetic, therapeutic, and surgical challenges sufficient to tax even the most experienced clinician. This article outlines the epidemiology, etiology, pathologic condition, initial workup, and management of hepatocellular carcinoma in children and adolescents.

What is the role of the orthopaedic surgeon in management of fragility fractures?

Fragility fractures are the most prevalent trauma condition that orthopaedic surgeons face today. Osteoporosis and susceptibility to falls are the key predisposing factors. Despite evidence supporting the impact of treating osteoporosis on reducing the incidence of fragility fractures, it is often left untreated. Orthopaedic surgeons are often the first physicians to assess and treat the patient after a fragility fracture. Their role therefore does not end in the skillful fixation of the fractures, but they have a unique opportunity to ensure that preventive measures are implemented. This includes falls prevention, investigation of possible causes underlying osteoporosis, attention to diet, exercise, calcium, and vitamin D supplementation as well as prescription of anti-resorptive and anabolic medication. The need for a dedicated multidisciplinary team needs to be emphasized and therefore effective communication between the different parties is of paramount importance.

Austin Moore hemiarthroplasty: technical aspects and their effects on outcome, in patients with fractures of the neck of femur.

In order to determine which technical aspects of the Austin Moore hemiarthroplasty procedure affect the outcome, we reviewed 243 patients with a non-pathological intracapsular femoral neck fracture who had, Austin Moore uncemented hemiarthroplasty. The immediate post-operative X-rays were assessed for alignment of the prosthetic stem, calcar seating, length of the neck remnant, leg length discrepancy and size of the head, compared with the contralateral femur. All patients were followed-up for 1 year. Significant pain at 1 year and/or revision of the prosthesis for loosening were considered as unfavourable outcomes. Inadequate calcar seating was significantly associated with pain and revision of the prosthesis (P = 0.04 and 0.01, respectively). Length of the neck remnant was also significantly associated with these two outcomes (P = 0.05 and 0.023, respectively). Difference in head size was associated with pain, but not with loosening (P = 0.01 and 0.08, respectively). The rest of the parameters were not significantly associated with the outcome. We recommend that when inserting an Austin Moore hemiarthroplasty, particular attention must be paid to the seating of the collar of the prosthesis on the calcar and correct choice of head size.