The outcome of fundoplication in patients with GERD based on abnormal impedance testing.

INTRODUCTION: The role of impedance testing in selecting patients for antireflux surgery is poorly understood. The aim of this study was to compare the outcomes of patients that underwent antireflux surgery for GERD based on an abnormal pH/abnormal impedance test versus a normal pH/abnormal impedance test. METHODS: Records of patients who had an abnormal off-medication impedance test (≥ 48 total reflux events) who underwent antireflux surgery were reviewed and divided into two groups: normal [pH-] or abnormal [pH+] esophageal acid exposure (DeMeester score > 14.7). Symptom resolution was compared: scale 1 (no resolution) to 5 (complete resolution). RESULTS: Eighty-two patients met criteria: 44 [pH+] and 38 [pH-]. There were no differences in the demographics or indications for surgery. The frequencies of heartburn and regurgitation symptoms were significantly reduced by fundoplication in both groups. Complete resolution of heartburn was more common in the [pH+] group (90%) compared to the [pH-] group (67%) [p = 0.02]. Resolution of regurgitation was similar in both groups (90% in the [pH+] group vs 79% in the [pH-] group, p = 0.20). The mean dysphagia frequency score decreased for the [pH+] group, but increased in the [pH-] group. New-onset dysphagia was more common in [pH-] patients (23%) compared to [pH+] patients (5%), (p = 0.02). Continued use of PPI medications was significantly more likely in [pH-] group (42%) compared to the [pH+] group (21%). There was no difference in surgical satisfaction rates between groups. DISCUSSION: Patients with abnormal impedance and increased esophageal acid exposure had significantly better symptom resolution, less dysphagia, and less frequent PPI use with antireflux surgery versus those with normal pH. These findings urge caution in the use of abnormal impedance values with normal esophageal acid exposure for the selection of patients for an antireflux operation.

Esophagectomy for failed endoscopic therapy in patients with high-grade dysplasia or intramucosal carcinoma.

Endoscopic therapy (ablation +/- endoscopic resection) for high-grade dysplasia and/or intramucosal carcinoma (IMC) of the esophagus has demonstrated promising results. However, there is a concern that a curable, local disease may progress to systemic disease with repeated endotherapy. We performed a retrospective review of patients who underwent esophagectomy after endotherapy at three tertiary care esophageal centers from 2006 to 2012. Our objective was to document the clinical and pathologic outcomes of patients who undergo esophagectomy after failed endotherapy. Fifteen patients underwent esophagectomy after a mean of 13 months and 4.1 sessions of endotherapy for progression of disease (53%), failure to clear disease (33%), or recurrence (13%). Initially, all had Barrett's, 73% had ≥3-cm segments, 93% had a nodule or ulcer, and 91% had multifocal disease upon presentation. High-grade dysplasia was present at index endoscopy in 80% and IMC in 33%, and some patients had both. Final pathology at esophagectomy was T0 (13%), T1a (60%), T1b (20%), and T2 (7%). Positive lymph nodes were found in 20%: one patient was T2N1 and two were T1bN1. Patients with T1b, T2, or N1 disease had more IMC on index endoscopy (75% vs. 18%) and more endotherapy sessions (median 6.5 vs. 3). There have been no recurrences a mean of 20 months after esophagectomy. Clinical outcomes were comparable to other series, but submucosal invasion (27%) and node-positive disease (20%) were encountered in some patients who initially presented with a locally curable disease and eventually required esophagectomy after failed endotherapy. An initial pathology of IMC or failure to clear disease after three treatments should raise concern for loco-regional progression and prompt earlier consideration of esophagectomy.

Family resources for families of children with cerebral palsy in Jordan: psychometric properties of the Arabic-family resources scale.

BACKGROUND: Resource-based, family-centred practices are associated with better health, emotional, and social well-being of children with disabilities. The adequacy of resources available for families of children with disabilities in Middle Eastern countries has not been described adequately in part because of lack of measures that are culturally adapted to be used in Arabic countries. Therefore, this study aims to (1) to evaluate the psychometric properties of the Arabic-Family Resource Scale (A-FRS) on a sample of families of children cerebral palsy (CP); (2) examine the adequacy of family resources as perceived by parents of children with CP in Jordan; and (3) examine the influence of child and family demographic variables on how parents report resources available to their families. METHOD: A cross-section design was applied. One-hundred fifteen parents of children with CP with mean age 4.6 years (SD = 4.4) and their parents participated in the study. Research assistants interviewed the participants to complete the A-FRS, and family and child demographic questionnaire, and determined the Gross Motor Function Classification System level of children. RESULTS: The principal axis factoring of the A-FRS yielded a six-factor solution that accounted for 67.39% of the variance and that is different than the factor structure reported by the developers of the FRS. Cronbach's coefficient alpha of the total score of family resources was 0.86 indicating a good internal consistency and the test­retest reliability for the total scale score was r = 0.92 (P = 0.000) indicating excellent test­retest reliability. Child health and family income were significantly associated with the total score of the A-FRS. CONCLUSIONS: The A-FRS is a valid and reliable measure of family resources for Jordanian families of children with CP. Service providers are encouraged to use A-FRS with families to plan resource-based interventions in which family resources are mobilized to meet family needs.

Wait only to resuscitate: early surgery for acutely presenting paraesophageal hernias yields better outcomes.

INTRODUCTION: Incarceration and obstruction of an intrathoracic stomach are potentially devastating complications of paraesophageal hernias (PEH). Gastric decompression and resuscitation are important elements of preoperative management of acutely presenting PEH. The optimal time for surgical repair after decompression is unknown. We hypothesized that in obstructed PEH, early surgery may improve outcomes. METHODS: From the 2005-2010 National Surgical Quality Improvement Project database, we selected PEH repairs with a diagnosis of obstruction. Patients were divided by time to surgery: ≤1 day of admission (early) or >1 day (interval). Outcomes were mortality and morbidity. Multivariable regression controlled for age and cardiopulmonary comorbidities. RESULTS: Of 224 patients, 149 (67%) were early and 75 (33%) were interval, with mean 3.6 days. Repairs were 89% transabdominal, 9% included fundoplication, and 18% gastrostomy. Early and interval groups experienced similar morbidity 23 versus 31% (p = 0.2) and mortality 5.4 versus 4% (p = 0.7). Pulmonary, wound, or VTE complications were equivalent. Sepsis was less (2.7 vs. 13%, p = 0.002) and length of stay was shorter (5 vs. 11 days, p < 0.001) for early vs. interval patients. On adjusted analysis, the early group had an 80% reduction in sepsis (95% confidence interval (CI), 0.05-0.6, p = 0.005). Odds of overall or other morbidity or mortality were statistically similar between groups. CONCLUSIONS: Patients who required emergency surgery for PEH have disease complicated by strangulation, perforation, bleeding, or sepsis. Emergency surgery for PEH repair is inherently high-risk and preoperative resuscitation and decompression is critical. In our analysis, patients with an obstructed PEH had less postoperative sepsis and fewer days in the hospital if surgery was performed within the first hospital day. However, there was no difference in mortality between early and delayed treatment. Deferring surgery for resuscitation permits optimization, but prolonged delay may worsen patient outcomes.

Diagnosis of Type-I hiatal hernia: a comparison of high-resolution manometry and endoscopy.

Sliding Type-I hiatal hernia is commonly diagnosed using upper endoscopy, barium swallow or less commonly, esophageal manometry. Current data suggest that endoscopy is superior to barium swallow or esophageal manometry. Recently, high-resolution manometry has become available for the assessment of esophageal motility. This novel technology is capable of displaying spatial and topographic pressure profiles of gastroesophageal junction and crural diaphragm in real time. The objective of the current study was to compare the specificity and sensitivity of high-resolution manometry and endoscopy in the diagnosis of sliding hiatal hernia in patients with gastroesophageal reflux disease. Data were analyzed retrospectively for 83 consecutive patients (61% females, mean age 52 ± 13.2 years) with objective gastroesophageal reflux disease who were considered for laparoscopic antireflux surgery between January 2006 and January 2009 and had preoperative high-resolution manometry and endoscopy. Manometrically, hiatal hernia was defined as separation of the gastroesophageal junction >2.0 cm from the crural diaphragm. Intraoperative diagnosis of hiatal hernia was used as the gold standard. Sensitivity, specificity and likelihood ratios of a positive test and a negative test were used to compare the performance of the two diagnostic modalities. Forty-two patients were found to have a Type-I sliding hiatal hernia (>2 cm) during surgery. Twenty-two patients had manometric criteria for a hiatal hernia by high-resolution manometry, and 36 patients were described as having a hiatal hernia by preoperative endoscopy. False positive results were significantly fewer (higher specificity) with high-resolution manometry as compared with endoscopy (4.88% vs. 31.71%, P= 0.01). There were no significant differences in the false negative results (sensitivity) between the two diagnostic modalities (47.62% vs. 45.24%, P= 0.62). Analysis of likelihood ratios of a positive and negative test demonstrated that high-resolution manometry is better than endoscopy both to rule out and rule in a hiatal hernia. A significant discordance was also observed between the two tests (P= 0.033). High-resolution manometry has better specificity and ability to rule out an overt Type-I sliding hiatal hernia (greater likelihood ratio of a positive test) in patients with GERD. Because of high false negative results, both high-resolution manometry and endoscopy are unreliable for ruling in a hiatal hernia. Negative result for a hiatal hernia by either modality mandates additional testing.

Endoscopic suture fixation of gastrointestinal stents: proof of biomechanical principles and early clinical experience.

BACKGROUND AND STUDY AIMS: Gastrointestinal stents have become an important therapeutic option for several indications. However, migration in up to 40 % of cases represents a significant drawback, especially when covered prostheses are used. We hypothesized that a novel endoscopic suturing device could enable endoluminal stent fixation, which might increase attachment and thereby potentially reduce migration. PATIENTS AND METHODS: In an initial ex vivo porcine model, stents were attached to the esophageal wall with either endoscopic hemoclips or by endoscopic suture stent fixation (ESSF). The distal tension force required to induce dislocation was measured in Newtons (N) by a digital force gauge and was compared with conventional stent placement. ESSF was then performed clinically in five patients, in whom self-expanding metal stents were sutured in place for endoscopic treatment of gastrointestinal fistulas or strictures. RESULTS: Esophageal ESSF was achieved in all experiments and significantly increased the force needed to displace the stent (n = 12; mean force 20.4 N; 95 % confidence interval [CI]: 15.4 - 25.4; P < 0.01) compared with clip fixation (n = 8; mean 6.1 N; 95 %CI 4.7 - 7.6) or stent placement without fixation (n = 16; mean 4.8 N; 95 %CI 4.0 - 5.6). All clinical cases of ESSF were performed successfully (5 /5) and took a median of 15 minutes. Elective stent removal was achieved without complications. One stent migration (1 /5) due to sutures being placed too superficially was observed. More loosely tied sutures remained intact, with the stent attached in place. CONCLUSION: Endoscopic suture fixation of gastrointestinal stents provided significantly enhanced migration resistance in an ex vivo setting. In addition, early clinical experience found ESSF to be technically feasible and easy to accomplish.

Profiles of family needs of children and youth with cerebral palsy.

BACKGROUND: To identify profiles of family needs of families of children and youth with cerebral palsy (CP), and determine whether profile membership is related to child, family and service characteristics. METHODS: Participants were mostly mothers (80%) of 579 children and youth with CP. A family member completed modified version of the Family Needs Survey and questionnaires about their child, family and services. Research assistants determined the Gross Motor Function Classification System levels. K-means cluster analysis identified profiles of needs. Cluster membership was analysed to examine differences in clusters based on selected characteristics. RESULTS: Four profiles of needs were identified: Low needs, Needs related to community and financial resources, Needs related to child health condition and High needs. Profile membership was differentiated based on child/youth gross motor function, adaptive behaviour, family relationships, family income, access and effort to co-ordinate services. CONCLUSION: Despite heterogeneity among individuals with CP and their families, four profiles of family needs were identified. In total, 51% of families had low needs suggesting that they are effectively managing their children's health conditions while 11% of families had high needs that may require high levels of services and supports. Service providers are encouraged to partner with families, provide anticipatory guidance and co-ordinate services.

Mediastinal surgery in connective tissue tunnels using flexible endoscopy.

BACKGROUND: Mediastinal surgery most often is performed via a transthoracic or transabdominal approach; however, the pre- and paratracheal mediastinum can be readily accessed with a transcervical approach. The purpose of this study was to evaluate the feasibility, safety, and success rate of using a transcervical approach and flexible endoscopes to perform mediastinal surgery also in the retro- and paraesophageal mediastinum. METHODS: Mediastinal operations on four live pigs and one human cadaver were performed using standard endoscopes through a small cervical incision. The procedure involved marking of four mediastinal lymph nodes using endoscopic ultrasound (EUS). The esophagus was dissected to the phrenoesophageal junction by creating connective tissue tunnels with balloon dilatation and low-pressure CO(2) insufflation. Heller myotomy was performed followed by sequential identification and removal of the marked nodes. Success rate of esophageal dissection to the diaphragm, Heller myotomy, directed mediastinal lymph node harvest, and complication rates were evaluated. RESULTS: Dissection of the esophagus to the diaphragm was achieved in 100% of attempts. Distal esophageal myotomy was performed in all cases. Harvest of marked lymph nodes (ln) was successful in 100% of animals (16/16 ln) and cadavers (2/2 ln). One major complication was recorded in the pig group (tension pneumomediastinum). CONCLUSIONS: The entire visceral mediastinum can be successfully accessed through a transcervical incision using flexible endoscopes. Directed lymph node harvest and esophageal myotomy is feasible with a high success rate. Connective tissue tunnels are safe, atraumatic, and a promising concept for targeted mediastinal exploration. With refinement in technology, this approach may be useful for a variety of mediastinal surgeries.

Contact palm burns in toddlers from glass enclosed fireplaces.

We have seen an alarming increase in the incidence of pediatric palm burns associated with gas fireplaces. The increasing popularity of these units places more children at risk. Medical records of patients under the age of 5 years who sustained hand burns from contact with the glass enclosure of gas fireplaces from 1996 through 2002 were reviewed. Thirty-nine patients were identified, with a mean age of 12.8 months. A 15-fold increase in incidence was observed. Thirty-three patients suffered superficial second-degree burns that were treated conservatively. Twenty-one percent of children developed significant wound complications requiring intensive therapy including extension splinting or surgery. Pediatric burns resulting from palmar contact with the glass enclosures of gas fireplaces have emerged as an avoidable new danger within the home. Although most of these injuries heal with conservative treatment alone, many require surgery or other intensive management to regain acceptable function.

Family-oriented early intervention policies and practices: family-centered or not?

This article includes a multimethod, multisource analysis and synthesis of the degree to which contemporary family-oriented early intervention policies and practices are family centered. Federal laws and legislation, state-level policy positions, and the viewpoints of service providers and consumers were analyzed as part of the study. The findings, taken together, indicate a movement toward adoption of family-centered early intervention policies and practices at the different levels of analysis. There are, however, discrepancies between what state-level policymakers and "street-level" providers and consumers see as current beliefs and practices within states.

The effect of social support on adolescent mothers' styles of parent-child interaction as measured on three separate occasions.

The purpose of this study was to determine the effect of social support on parent-child interaction in a group of 19 adolescent mothers. The subjects participated in a 20-week model demonstration program in which they worked in a preschool classroom with skilled caregivers who modeled facilitative styles of interacting with young children. Each subject was videotaped while interacting with a 1- to 2-year-old child upon entering the program, midway through the program, and at the end. Results showed that girls who were 16 years or older significantly increased their frequency of using responsive, engaging, and elaborative styles of behavior. Those under age 16 did not show significant changes in these three behaviors. Overall, subjects significantly increased the duration of time they spent observing the child's play behavior.

Empowerment, effective helpgiving practices and family-centered care.

Improving practices with families of pediatric patients is most likely to occur when nurses and other health care professionals more fully understand the characteristics and consequences of different approaches to their work. A review of relevant literature in the empowerment, helpgiving, and family-centered care fields suggests the kinds of beliefs, attitudes, and behaviors that will optimize benefits to families in different domains of functioning. Family-centered care is a special case of effective helpgiving, and effective helpgiving is a special case of an empowerment approach to working with people seeking professional advice and expertise.

Test settings and the sensorimotor performance of infants with Down's syndrome.

The effects of test setting (home vs classroom) on the sensorimotor performance of 7 Down's syndrome infants were examined. The 7 Uzgiris-Hunt scales were administered on 10 occasions over a 4-mo. period, yielding 5 home-classroom comparisons for each subject. Analyses of mean performance scores, intersetting test-retest reliability, and intrasetting stability indicated that test performance was minimally affected by test setting, but that intrasetting interindividual invariance in performance was less stable when the subjects were tested in a classroom environment.

Biomesh placement in laparoscopic repair of paraesophageal hernias.

The placement of mesh in the crural closure of paraesophageal hiatal hernia repairs has been shown to decrease hernia recurrence rates. Typical synthetic mesh are easy to use but have high rate of erosion into the esophagus. Alternatively, biologic mesh decrease the risk of erosion, but are more difficult to manipulate, and there is currently no well-described method for securing them. Current fixation techniques of mesh are difficult, cumbersome, incur extra expense, and are not without complications. A method that requires no additional sutures or staples and achieves excellent contact and reinforcement of the crural closure is presented.

Stage transitioning in the sensorimotor development of Down's syndrome infants.

The relative amount of time necessary to move from stage-to-stage during the sensorimotor period was examined among a group of 30 Down's syndrome and 12 non-retarded infants. Stage transitioning was examined for the four transitional points between Stages II and VI for the seven branches of sensorimotor development on the Uzgiris-Hunt scales. The findings showed that the Down's syndrome infants generally took longer to move from one stage to the next even after their slower pace of development was taken into consideration.

Measuring the adequacy of resources in households with young children.

Both the reliability and validity of the Family Resource Scale (FRS) are described. The FRS is a 30-item rating scale for measuring the adequacy of resources in households with young children. The ordinality of the items, rank ordered from the most to least basic, was established in a study of 28 professionals. Both the reliability and validity of the scale was established in a second study of 45 mothers of preschool-aged children. The utility of the FRS for assessment and intervention purposes is discussed.

Fostering the object construct: large-scale intervention with handicapped infants.

Parents provided their developmentally delayed infants with sequential experiences intended to foster the development of the object construct. The participants were enrolled in a multidisciplinary early intervention program serving a wide spectrum of impaired infants from a large, rural geographic area. In comparison with infants who were not exposed to object-construct intervention, infants who received training performed moderately but significantly higher on Scale I of the Uzgiris-Hung Ordinal Scales of Psychological Development.