Source, fate and management of recreational fishing marine debris.

Marine debris, directly and indirectly, threatens marine habitat and biota. Fishing activity is generally recognised as a contributor to marine debris, but the relative input from recreational fishing remains unassessed. Here we provide the first comprehensive literature review of recreational fishing marine debris (RFMD) on a global scale. A systematic literature review identified 70 studies related to RFMD, and plastic and metal respectively were the dominant debris materials found. Nearshore coastal areas and reefs, acted as both sources and sinks of RFMD and a diverse suite of potential impacts such as ghost fishing and entanglement were identified at local scales. Overall, research of RFMD is lacking globally, however, its role in marine debris input is likely underestimated. We recommend more research on the volumes and risks, using a standardised classification approach. Where intervention is required, we suggest cooperative approaches between the sector and authorities.

Worldwide variation of dialysis-associated peritonitis in children.

Peritonitis is the most common cause of dialysis failure in children on chronic peritoneal dialysis. We performed a prospective study of 501 peritonitis episodes in 44 pediatric dialysis centers located in 14 countries that examined peritonitis etiology, efficiency of opinion-based management guidelines, and final outcomes. Culture-negative incidence varied significantly from 11% in North America to 67% in Mexico. Argentina and North America had the highest rate of Gram-negative episodes. Pseudomonas-based peritonitis was eightfold more common in the United States than in Europe, and correlated with the frequency of exit site cleansing and topical mupirocin administration. Significant regional variation in antibiotic susceptibility was noted for the first generation cephalosporins and aminoglycosides. Initial response rates to standardized empiric antibiotic treatment did not differ between regions; however, final outcomes were significantly less favorable in Eastern Europe. The wide regional variation in culture-negative peritonitis, and the distribution and antibiotic susceptibilities of causative bacteria needs to be taken into consideration when the guidelines for empiric therapy of pediatric dialysis-associated peritonitis are revised.

Unilateral multicystic dysplastic kidney: long term outcomes.

AIMS: To report the long term follow up of children with antenatally detected unilateral multicystic dysplastic kidney (MCDK) with documentation of complications, involution rate with time, and renal function at 10 years. METHODS: Data were retrieved from a prospective regional registry of patients with MCDK between 1985 and 2004. Children were followed using a common protocol of investigation with follow up ultrasound scans (USS) at 2 (165 patients), 5 (117 patients), and 10 years (43 patients). RESULTS: Serial USS showed that 33% of the MCDK kidneys had completely involuted at 2 years of age, 47% at 5 years, and 59% at 10 years. No patients developed hypertension, significant proteinuria, or malignancy, but two developed pelviureteric junction obstruction in the contralateral kidney. Twenty seven of 143 children (19%) had vesicoureteric reflux (VUR) (96% mild to moderate VUR) into the contralateral kidney with no difference in the incidence of urinary tract infections or renal scarring between those with or without VUR. The mean estimated glomerular filtration rate (GFR) was 86.4 ml/min/1.73 m2 (range 48-125) in 31 of 43 patients followed to 10 years. CONCLUSIONS: Conservative management of unilateral MCDK is justified with clinical review and infrequent USS but longer term follow up continues in the 41% still with renal remnants at 10 years and those with impaired GFR. It is suggested that the initial micturating cystogram is deferred unless abnormal USS features are present in the contralateral kidney or ureter.

The impact of laparoscopic bariatric workshops on the practice patterns of surgeons.

BACKGROUND: This study was designed to evaluate the impact of a 2-day laparoscopic bariatric workshop on the practice patterns of participating surgeons. METHODS: From October 1998 to June 2002, 18 laparoscopic bariatric workshops were attended by 300 surgeons. Questionnaires were mailed to all participants. RESULTS: Responses were received from 124 surgeons (41%), among whom were 56 bariatric surgeons (open) (45%), 30 advanced laparoscopic surgeons (24%), and 38 surgeons who performed neither bariatric nor advanced laparoscopic surgery (31%). The questionnaire responses showed that 46 surgeons (37%) currently are performing laparoscopic gastric bypass (LGB), 38 (31%) are performing open gastric bypass, and 39 (32%) are not performing bariatric surgery. Since completion of the course, 46 surgeons have performed 8,893 LGBs (mean, 193 cases/surgeon). Overall, 87 of the surgeons (70%) thought that a limited preceptorship was necessary before performance of LGB, yet only 25% underwent this additional training. According to a poll, the respondents thought that, on the average, 50 cases (range, 10-150 cases) are needed for a claim of proficiency. CONCLUSION: Laparoscopic bariatric workshops are effective educational tools for surgeons wishing to adopt bariatric surgery. Open bariatric surgeons have the highest rates of adopting laparoscopic techniques and tend to participate in more adjunctive training before performing LGB. There was consensus that the learning curve is steep, and that additional training often is necessary. The authors propose a mechanism for post-residency skill acquisition for advanced laparoscopic surgery.

Ethics support in clinical practice.

Ethical considerations have long been a part of clinical decision making. However, just as doctors and healthcare professionals are being increasingly challenged about the evidence base for their practice, there is increasing focus on the ethical dimension of clinical care.

Clinical agreement between automated and calculated ultrasound measurements of bladder volume.

Non-invasive urine volume measurement is an important tool in the management of dysfunctional and neuropathic bladders in children. Ultrasound imaging devices have been used for many years for this purpose. An automated scanner (Bladderscan) is now available and has been recommended by a number of authors, but there is conflicting evidence in the literature regarding the accuracy and appropriate clinical application of the device. We aimed to assess the level of clinical agreement between the two methods. 36 urine volume measurements were made on 11 children using both instruments. Although there was a good correlation between the methods (r=0.97), the clinical agreement was poor (limits of agreement +/-77 ml). 13 voided volumes were directly measured and compared with the difference between pre- and post-void ultrasound measurements. The systematic errors were small but the mean absolute errors were 54 ml and 23 ml, respectively, for the automated and ultrasound imaging methods. If used correctly, ultrasound imaging provides more accurate results and can compete with the cost, convenience and ease of use of the automated method. Low cost, highly portable ultrasound imaging devices are now available and should be used in preference to the Bladderscan.

Do gastrostomies close spontaneously? A review of the fate of gastrostomies following successful renal transplantation in children.

Previous published data have shown the benefit of nutritional support delivered via a gastrostomy button (GB) for children on chronic dialysis. The use of the GB is suspended following renal transplantation (RT) in most children and it is usually removed 2-3 months later together with the chronic dialysis catheter when the child is on alternate-day steroids. We reviewed the outcome of gastrostomies following successful RT in children. The gastrostomies were created by an open technique (Stamm) with the child under general anaesthesia, usually at the time of insertion of a chronic dialysis catheter. Growth data and complications of the GB were collected in a prospective registry. Following RT, the GB was removed with the expectation that the tract would close spontaneously. Those in whom a gastrocutaneous fistula persisted underwent formal surgical closure. A total of 18 children have had gastrostomy buttons removed: 11 gastrostomies (61%) closed spontaneously, but 7 (39%) required operative closure at a median of 2 months (range 3 weeks-4 years) post-removal. The need for formal closure was significantly related to the duration that the gastrostomy had been in situ pre-transplant (non-parametric statistics, 0.05 > p > 0.01). Although nearly two-thirds of gastrostomies in this study closed spontaneously following RT, less than one-half of those that had been in situ for more than 1 year did so. We thus recommend formal closure of all gastrostomies that have been in situ for more than 1 year. This can be done at the same operation as the removal of the chronic dialysis catheter.

Snapshots of five clinical ethics committees in the UK.

Each of the following papers gives an account of a different UK clinical ethics committee. The committees vary in the length of time they have been established, and also in the main focus of their work. The accounts discuss the development of the committees and some of the ethical problems that have been brought to them. The issues raised will be relevant for other National Health Service (NHS) trusts in the UK that wish to set up such a committee.

Congenital midureteric stricture.

Congenital midureteric obstruction is a rare entity which can be caused by either ureteric valves or strictures. We report our experience with four patients with midureteric obstruction due to stricture over a six-year period. The condition needs to be differentiated from obstruction of the pelviureteric and vesicoureteric junctions. Obstruction can be initially screened by ultrasound and confirmed by a radionuclide scan with furosemide challenge. Retrograde ureteropyelography and/or intravenous urography may be required to define the level of the stricture.

Gastrostomy buttons for nutritional support in children with cystinosis.

Poor growth in children with cystinosis may be a combination of sub-optimal nutritional intake, gastrointestinal dysfunction and polypharmacy. We report our experience with gastrostomy buttons (GBs) in five children (4 male) with cystinosis treated at a median age of 3 years (range 1.4-8.8 years). All children received overnight GB feeding for a mean duration of 27 months (range 7-42 months). During 135 patient-months of observation, the mean life of the GB was 5.7 months (range 3-7.7 months), with a mean of 3.4 GB changes (range 1-6) per patient. An average of five (range 3-7) medications were administered daily via the button. The mean energy intake achieved was 118% of the estimated average requirement (range 86%-183%), with 58% of total energy and 55% of protein intake being delivered via the GB during the study period. Mean height standard deviation score (SDS) was -3.79 at the start of GB feeding and -3.08 at the end of the study period, with mean weight SDS of -3.79 and -2.17 (P=0.042), respectively. The buttons have been welcomed by the families and should be considered as a treatment option for providing the nutritional prescription and administering medications.

Unilateral multicystic dysplastic kidney disease: defining the natural history. Anglia Paediatric Nephrourology Group.

Controversy exists as to what is the optimal management of antenatally detected multicystic dysplastic kidney disease (MCDK): conservative or operative. We report 70 (31M, 39F) children with unilateral MCDK in whom the initial micturating cystourethrography revealed vesicoureteric reflux into the contralateral kidney in 16/63 (25%). Involution of the MCDK kidney was noted at birth in 4 and occurred by 2 y of age in 11/46 (24%), with 16/46 (35%) showing a significant reduction in size. Of 21 children followed to 5 y, the MCDK had disappeared in 3 (14%) and 8 (38%) had shown a further reduction in size. No child has developed hypertension or proteinuria. Four children had urinary tract infections with lower tract symptoms, but no scarring of the normal hypertrophied kidney. We conclude that conservative management of unilateral MCDK is justified with long-term follow-up consisting of annual clinical review and ultrasound evaluation at 2, 5 and 10 y.

Non-compliance and transfer from paediatric to adult transplant unit.

Adolescents and young adults appear to be a particularly high-risk group for problems of non-compliance and associated graft loss. We reviewed the progress of 20 young adults (9 female) who had been transferred to three different adult centres at a mean age of 17.9 years (range 15.7-20.9 years) having been transplanted at a mean age of 14.3 years (range 9.6-18.1 years) in the paediatric unit. Eight transplants failed within 36 months of transfer, and in 7 of 20 (35%) the transplant failure was unexpected (3 < 12 months, 3 12-24 months, 1 31 months post transfer). Although many of the patients had recognised problems in family dynamics, only 1 had had a major rejection episode prior to transfer due to admitted non-compliance. In 3 others low cyclosporin levels had been noted. Two young men had been transplanted preemptively in the paediatric unit at 15.3 and 16.7 years, and 3 patients had been transferred to the adult unit via the recently established transition clinic. The results suggest that close attention needs to be paid to this group of patients who require ongoing education and support. Improved dialogue between staff of the paediatric and adult units about transition issues is also essential.