Critical Role of Pleural Wrap and Post-operative Neonatal Protocol in Long-gap Oesophageal Atresia: A Team Effort.

BACKGROUND: The objectives of this study were to bring out the results of application of pleural wrap in primary repair of tracheo - esophageal fistula (TEF) with long-gap oesophageal atresia (LGEA) and also define the role of neonatologists and paediatric intensivists in post-operative management in these patients by laying down standard neonatal management protocol. MATERIALS AND METHODS: This was a retrospective descriptive observational study conducted between March 2011 and April 2019 on 23 cases of LGEA with TEF. The study was conducted at two tertiary care paediatric surgery centres in Northern part of India wherein these newborn babies were operated by two paediatric surgeons with variable experience of 8-12 years. It also describes the neonatal management protocol used in post-operative period. RESULTS: Out of 23 patients, 15 were boys and 8 were girls, with a mean age of 32.25 weeks and a mean birth weight of 2.02 kg. The mean hospital stay was 23.5 ± 8 days. Eleven cases had gap between 3 and 3.5 cm, 8 cases between 3.5 and 4 cm and 4 cases had gap more than 4 cm. The incidence of associated anomalies was 52%. Anastomotic leak rate was 8.69%, and 3 (13.04%) patients died in the post-operative period. All the operated patients were managed postoperatively as per strict neonatal management protocol exclusively by the team of neonatologists and neonatal intensivists. CONCLUSION: Application of pleural wrap over anastomosis following primary repair of LGEA with TEF significantly reduced the incidence of anastomotic leak in our study. Apart from the pleural wrap, the key to successful outcome also is contributed by the little prolonged, controlled ventilation and patience and perseverance in post-operative feeds. This post-operative management protocol that has been followed by us in our study is easily reproducible and can be adopted by paediatric surgeons working alongside neonatologists as a team.

A Hospitalist-Led Team to Manage Patient Boarding in the Emergency Department: Impact on Hospital Length of Stay and Cost.

OBJECTIVES: Admitted patients boarding in the emergency department (ED) while awaiting inpatient beds represent a bottleneck in patient flow. We sought to examine the impact on patient flow and potential for cost savings by an active management of boarded ED medical admissions by a hospitalist-led team, which included a hospitalist, an advanced practitioner, and a case manager. METHODS: This was a retrospectively conducted analysis of a quality improvement pilot intervention implemented at a large tertiary center. We analyzed patients admitted under observation status between April 1, 2016 and June 30, 2016. We calculated the difference for length of stay (in hours) and direct cost between patients in the intervention group and a usual care group from a similar time period in the prior year matched on the all patients refined-diagnosis related groups (APR-DRG) and severity of illness (SOI) level. RESULTS: One hundred seventy-five observation patients were managed by the hospitalist team during the 3-month pilot period. This group had an average hospital stay of 26.0 hours compared with 29.7 hours in the usual care group. Direct costs resulted in the following results: average cost for the intervention patient group $1452 (±$775) versus $2524 (±$894) group, for an average savings of $1072 (P < 0.001), with a total estimated direct cost savings of $187,660. CONCLUSIONS: Active management of ED boarding patients by a hospitalist-led team is feasible and can lead to hospital cost savings and decrease in hospital stay. The findings from this pilot resulted in a decision to make the ED hospitalist-led team permanent in our institution. The evaluation of the program may help other hospitals to decide whether this intervention is worth pursuing in their own organization.

FMRP Interacts with C/D Box snoRNA in the Nucleus and Regulates Ribosomal RNA Methylation.

FMRP is an RNA-binding protein that is known to localize in the cytoplasm and in the nucleus. Here, we have identified an interaction of FMRP with a specific set of C/D box snoRNAs in the nucleus. C/D box snoRNAs guide 2'O methylations of ribosomal RNA (rRNA) on defined sites, and this modification regulates rRNA folding and assembly of ribosomes. 2'O methylation of rRNA is partial on several sites in human embryonic stem cells, which results in ribosomes with differential methylation patterns. FMRP-snoRNA interaction affects rRNA methylation on several of these sites, and in the absence of FMRP, differential methylation pattern of rRNA is significantly altered. We found that FMRP recognizes ribosomes carrying specific methylation patterns on rRNA and the recognition of methylation pattern by FMRP may potentially determine the translation status of its target mRNAs. Thus, FMRP integrates its function in the nucleus and in the cytoplasm.