Association of Exclusive Breast Milk Intake and Outcomes in Infants With Uncomplicated Gastroschisis: A National Cohort Study.

BACKGROUND: Enteral feeding is an essential part of the management of infants with gastroschisis. We hypothesized that exclusive breast milk is associated with improved neonatal outcomes. METHODS: We conducted a retrospective review of infants with uncomplicated gastroschisis through the Canadian Pediatric Surgery Network (CAPSNet) and Canadian Neonatal Network (CNN). The primary outcome was time to full enteral feeds. RESULTS: We identified 411 infants with gastroschisis treated at CAPSNet centres from 2014 to 2022. 144 patients were excluded due to gestational age <32 weeks, birth weight <1500 g, other congenital anomalies, or complicated gastroschisis. Of the remaining 267 participants, 78% (n = 209) received exclusive breast milk diet in the first 28 days of life, whereas 22% (n = 58) received supplemental or exclusive formula. Infants who received exclusive breast milk experienced higher time to reach full enteral feeding (median 24 vs 22 days, p = 0.047) but were more likely to have undergone delayed abdominal closure (32% vs 17%, p = 0.03). After adjustment, there were no significant differences between groups in time to reach full enteral feeds, duration of parenteral nutrition, or length of stay. Infants who received supplemental or exclusive formula had a similar risk of necrotizing enterocolitis (4% vs 3%) but were less likely to transition to exclusive breast milk at discharge (73% vs 11%, p < 0.001). CONCLUSION: Early use of exclusive breast milk in infants with uncomplicated gastroschisis is associated with similar outcomes compared to supplemental or exclusive formula. Patients who received supplemental or exclusive formula were unlikely to transition to exclusive breastfeeding by discharge. LEVEL OF EVIDENCE: Level IIb (Individual Cohort Study).

Intravenous acetaminophen for postoperative pain in the neonatal intensive care unit: A protocol for a pilot randomized controlled trial (IVA POP).

BACKGROUND: In neonates, uncontrolled pain and opioid exposure are both correlated with short- and long-term adverse events. Therefore, managing pain using opioid-sparing approaches is critical in neonatal populations. Multimodal pain control offers the opportunity to manage pain while reducing short- and long-term opioid-related adverse events. Intravenous (IV) acetaminophen may represent an appropriate adjunct to opioid-based postoperative pain control regimes. However, no trials assess this drug in patients less than 36 weeks post-conceptual age or weighing less than 1500 g. OBJECTIVE: The proposed study aims to determine the feasibility of conducting a randomized control trial to compare IV acetaminophen and fentanyl to a saline placebo and fentanyl for patients admitted to the neonatal intensive care unit (NICU) undergoing major abdominal or thoracic surgery. METHODS AND DESIGN: This protocol is for a single-centre, external pilot randomized controlled trial (RCT). Infants in the NICU who have undergone major thoracic or abdominal surgery will be enrolled. Sixty participants will undergo 1:1 randomization to receive intravenous acetaminophen and fentanyl or saline placebo and fentanyl. After surgery, IV acetaminophen or placebo will be given routinely for eight days (192 hours). Appropriate dosing will be determined based on the participant's gestational age. Patients will be followed for eight days after surgery and will undergo a chart review at 90 days. Primarily feasibility outcomes include recruitment rate, follow-up rate, compliance, and blinding index. Secondary clinical outcomes will be collected as well. CONCLUSION: This external pilot RCT will assess the feasibility of performing a multicenter RCT comparing IV acetaminophen and fentanyl to a saline placebo and fentanyl in NICU patients following major abdominal and thoracic surgery. The results will inform the design of a multicenter RCT, which will have the appropriate power to determine the efficacy of this treatment. TRIAL REGISTRATION: ClinicalTrials.gov NCT05678244, Registered December 6, 2022.

Intravenous acetaminophen for postoperative pain control after open abdominal and thoracic surgery in pediatric patients: a systematic review and meta-analysis.

Pediatric opioid exposure increases short- and long-term adverse events (AE). The addition of intravenous acetaminophen (IVA) to pediatric pain regimes to may reduce opioids but is not well studied postoperatively. Our objective was to quantify the impact of IVA on postoperative pain, opioid use, and AEs in pediatric patients after major abdominal and thoracic surgery. Medline, Embase, CINAHL, Web of Science, and Cochrane Library were searched systematically for randomized controlled trials (RCTs) comparing IVA to other modalities. Five RCTs enrolling 443 patients with an average age of 2.12 years (± 2.81) were included. Trials comparing IVA with opioids to opioids alone were meta-analyzed. Low to very low-quality evidence demonstrated equivalent pain scores between the groups (-0.23, 95% CI -0.88 to 0.40, p 0.47) and a reduction in opioid consumption (-1.95 morphine equivalents/kg/48 h, 95% CI -3.95 to 0.05, p 0.06) and minor AEs (relative risk 0.39, 95% CI 0.11 to 1.43, p 0.15). We conclude that the addition of IVA to opioid-based regimes in pediatric patients may reduce opioid use and minor AEs without increasing postoperative pain. Given the certainty of evidence, further research featuring patient-important outcomes and prolonged follow-up is necessary to confirm these findings.

Glycerin Suppositories and Enemas in Premature Infants: A Meta-analysis.

BACKGROUND AND OBJECTIVES: Premature infants are often given glycerin suppositories or enemas to facilitate meconium evacuation and the transition to enteral feeds. We reviewed the best-available evidence for the use of glycerin suppositories and enemas in premature infants. METHODS: We searched MEDLINE, Embase, and Cochrane Central for randomized controlled trials (RCTs) of premature infants treated with glycerin suppositories or enemas through January 2022. Studies were screened and data extracted independently and in duplicate. We included RCTs of premature infants <32 weeks gestation and/or birth weight <1500 g who were treated with glycerin suppositories or enemas. Meta-analysis was performed using random effects and reported as relative risk or mean difference. RESULTS: We identified 6 single-center, RCTs of 389 premature infants treated with glycerin suppositories (n = 207) or enemas (n = 182). Mortality rates ranged from 0% to 17%, and the meta-analysis revealed no differences between treatment groups (P = .86). Active treatment was associated with earlier meconium evacuation (mean, 1.5 days; 95% confidence interval, 3.0 to 0.01; P = .05) but not a faster time to enteral feeds (mean, 0.5 days; P = .48). We identified 1 ongoing trial with a target recruitment of 220 premature infants. The quality of evidence was very low to moderate because of inadequate statistical power and other methodologic issues. CONCLUSIONS: The use of glycerin suppositories and enemas in premature infants is associated with earlier meconium evacuation, but the clinical significance of this finding is uncertain. Treatment has no definitive effects on mortality, necrotizing enterocolitis, or enteral feeds.

Use of breast milk in infants with uncomplicated gastroschisis: A retrospective cohort study.

BACKGROUND: Infants with gastroschisis often experience slow return of bowel function following closure. The purpose of this study was to determine whether exclusive breast milk is associated with decreased time to enteral autonomy. METHODS: We conducted a retrospective cohort study of infants with uncomplicated gastroschisis from a tertiary pediatric hospital. The primary outcome was enteral autonomy, defined as days from initiating enteral feeds to stopping parenteral nutrition. Secondary outcomes included days of parenteral nutrition, length of stay, positive culture, necrotizing enterocolitis, cholestasis, additional surgery, readmission, and mortality. RESULTS: We identified 100 infants with gastroschisis treated from 2005 to 2019. Twenty-five were excluded due to gestational age <32 weeks, birth weight <1500 g, or gastroschisis-associated complications (e.g., intestinal atresia). Seventy-five were included in the analysis. Mean gestational age was 36 weeks, 48% were female, and all were diagnosed antenatally. Sixty-five infants (87%) received exclusive maternal (n = 64) or donor (n = 1) breast milk, while 10 others (13%) were fed formula for 1-16 days (mean 7 days). Two infants received formula only. Demographics and gastroschisis prognostic scores were similar between groups. Infants who were given breast milk exclusively demonstrated decreased time to enteral autonomy (median 18 versus 25 days, p = 0.023) and shorter duration of parenteral nutrition (median 20 versus 26 days, p = 0.037). CONCLUSION: Exclusive breast milk may be associated with improved outcomes among infants with gastroschisis. Further research is needed to evaluate the economic impact of this association and explore possible confounders. These efforts may expand the role of donor breast milk for these patients.

Postoperative management of pediatric patients undergoing minimally invasive repair of pectus excavatum: Where are we now?

PURPOSE: Minimally invasive repair of pectus excavatum (MIRPE) often leads to a painful and challenging recovery period. This study aims to describe the postoperative management of pediatric patients undergoing MIRPE and compare postoperative outcomes between patients using different routes of postoperative analgesia. METHODS: Retrospective chart review of pediatric patients who underwent MIRPE from July 2003 to September 2019 at a single pediatric tertiary care center. Data on pain management and course of hospital stay were ascertained. Descriptive statistics, Mann-Whitney U and Pearson Chi-Square tests were used to analyze data. A p-value <0.05 was considered significant. RESULTS: Of the 115 patients identified, 58 (50.4%) managed pain postoperatively using thoracic epidural and 57 (49.6%) used intravenous patient-controlled analgesia (IVPCA). The transition from the predominant use of epidural to IVPCA for MIRPE occurred between 2012 and 2013. Higher pain scores were reported by the IVPCA group at 6 h (p<0.001) and 12 h (p<0.001) postoperative. Patients using IVPCA had lower postoperative opioid consumption (p<0.001) and switched to oral opioids sooner than the epidural group (p<0.001). Fewer patients in the IVPCA group required urinary catheterization (p<0.001). Patients using IVPCA had a shorter hospital stay (4 days [IQR 4-5]) compared to the epidural group (5.5 [IQR 5-6]; p<0.001). Readmission was comparable at 3.48% in the total sample. CONCLUSION: Patients using intravenous patient-controlled analgesia reported higher pain scores however, this route of analgesia was associated with shorter hospital stay. Prospective studies designed to address moderator variables are required to confirm findings and develop standardized recovery protocols.

Generalised urticaria following ingestion of a nickel-plated coin in a 4-year-old girl.

We report the case of a 4-year-old girl who presented to the emergency department after ingestion of a nickel-plated coin. Abdominal radiographs confirmed the presence of a coin in her stomach but she was otherwise asymptomatic. She was discharged with assurances that the foreign body would pass spontaneously. The patient developed significant generalised urticaria the next day, which became progressively more severe. Her symptoms prompted endoscopic removal of the nickel-plated coin and a postoperative course of corticosteroids and antihistamine therapy. This is the first reported case of generalised urticaria secondary to ingestion of a coin with nickel plating only (2% nickel content overall). A review of similar cases is provided.

Mechanical Thrombectomy for Acute Ischemic Stroke in the Cardiac Catheterization Laboratory.

OBJECTIVES: The aim of this study was to determine the feasibility of establishing a mechanical thrombectomy (MT) program for acute ischemic stroke in a community hospital using interventional cardiologists working closely with neurologists. BACKGROUND: American Heart Association/American Stroke Association 2018 guidelines give a Class I (Level of Evidence: A) recommendation for MT in eligible patients with large vessel occlusion stroke. Improvement in neurological outcomes with MT is highly time sensitive. Most hospitals do not have trained neurointerventionalists to perform MT, leading to treatment delays that reduce the benefit of reperfusion therapy. METHODS: An MT program based in the cardiac catheterization laboratory was developed using interventional cardiologists with ST-segment elevation myocardial infarction teams. RESULTS: Forty patients underwent attempted MT for acute ischemic stroke. An additional 5 patients who underwent angiography did not undergo attempted thrombectomy, because of absence of target thrombus (n = 4) or unsuitable anatomy (n = 1). Median National Institutes of Health Stroke Scale score prior to MT was 19 and at discharge was 7. TICI (Thrombolysis In Cerebral Infarction) grade 2b or 3 flow was restored in 80% of patients (32 of 40). At 90 days, 55% of patients (22 of 40) were functionally independent (modified Rankin score ≤2). In-hospital mortality was 13% (5 of 40). Symptomatic intracranial hemorrhage occurred in 15% of patients (6 of 40). Major vascular complications occurred in 5% of patients (2 of 40). CONCLUSIONS: MT can be successfully performed by interventional cardiologists with carotid stenting experience working closely with neurologists in hospitals lacking formally trained neurointerventionists. This model has the potential to increase access to timely care for patients with acute ischemic stroke.

Colonic microbiota is associated with inflammation and host epigenomic alterations in inflammatory bowel disease.

Studies of inflammatory bowel disease (IBD) have been inconclusive in relating microbiota with distribution of inflammation. We report microbiota, host transcriptomics, epigenomics and genetics from matched inflamed and non-inflamed colonic mucosa [50 Crohn's disease (CD); 80 ulcerative colitis (UC); 31 controls]. Changes in community-wide and within-patient microbiota are linked with inflammation, but we find no evidence for a distinct microbial diagnostic signature, probably due to heterogeneous host-microbe interactions, and show only marginal microbiota associations with habitual diet. Epithelial DNA methylation improves disease classification and is associated with both inflammation and microbiota composition. Microbiota sub-groups are driven by dominant Enterbacteriaceae and Bacteroides species, representative strains of which are pro-inflammatory in vitro, are also associated with immune-related epigenetic markers. In conclusion, inflamed and non-inflamed colonic segments in both CD and UC differ in microbiota composition and epigenetic profiles.

Room temperature "optical nanodiamond hyperpolarizer": Physics, design, and operation.

Dynamic Nuclear Polarization (DNP) is a powerful suite of techniques that deliver multifold signal enhancements in nuclear magnetic resonance (NMR) and MRI. The generated athermal spin states can also be exploited for quantum sensing and as probes for many-body physics. Typical DNP methods require the use of cryogens, large magnetic fields, and high power microwave excitation, which are expensive and unwieldy. Nanodiamond particles, rich in Nitrogen-Vacancy (NV) centers, have attracted attention as alternative DNP agents because they can potentially be optically hyperpolarized at room temperature. Here, unraveling new physics underlying an optical DNP mechanism first introduced by Ajoy et al. [Sci. Adv. 4, eaar5492 (2018)], we report the realization of a miniature "optical nanodiamond hyperpolarizer," where 13C nuclei within the diamond particles are hyperpolarized via the NV centers. The device occupies a compact footprint and operates at room temperature. Instrumental requirements are very modest: low polarizing fields, low optical and microwave irradiation powers, and convenient frequency ranges that enable miniaturization. We obtain the best reported optical 13C hyperpolarization in diamond particles exceeding 720 times of the thermal 7 T value (0.86% bulk polarization), corresponding to a ten-million-fold gain in averaging time to detect them by NMR. In addition, the hyperpolarization signal can be background-suppressed by over two-orders of magnitude, retained for multiple-minute long periods at low fields, and deployed efficiently even to 13C enriched particles. Besides applications in quantum sensing and bright-contrast MRI imaging, this work opens possibilities for low-cost room-temperature DNP platforms that relay the 13C polarization to liquids in contact with the high surface-area particles.

Glycerin suppositories used prophylactically in premature infants (supp): A pilot randomized controlled trial.

BACKGROUND: Glycerin suppositories are often used to facilitate meconium evacuation in premature infants. The evidence for this practice is inconclusive. The purpose of this study was to assess the feasibility of a multicenter randomized controlled trial on the effectiveness of this treatment strategy. STUDY DESIGN: We conducted an external pilot study for a multicenter randomized controlled trial of premature infants randomized to glycerin suppositories or placebo procedure. Participants were included if they were gestational age of 24 weeks 0 days to 31 weeks 6 days and/or birthweight of 500 to 1500 grams. We excluded infants with life-threatening congenital anomalies, contraindications to receiving suppositories, or signs of clinical instability. Outcomes included cost, recruitment, and treatment-related adverse events. RESULT: A total of 109 were screened, 79 were initially eligible, and 34 consented to participate. Four of these infants were excluded prior to randomization due to thrombocytopenia, 30 were randomized, and 26 reached full enteral feeds. Three infants (10%) experienced rectal bleeding 5 to 43 days after completing study treatments. An anal fissure was noted in two of these patients. There were no cases of rectal perforation but one infant assigned to active treatment developed necrotizing enterocolitis. CONCLUSIONS: Conducting a multicenter randomized controlled trial on the use of glycerin suppositories in premature infants is feasible. Minor modifications to the study protocol are needed to increase participant recruitment and simplify the administration of study treatments.

Postoperative pain control following minimally invasive correction of pectus excavatum in pediatric patients: A systematic review.

PURPOSE: Surgery for pectus excavatum is associated with significant postoperative pain. The aim of this study was to summarize the current literature regarding postoperative pain control for pediatric patients undergoing minimally invasive repair of pectus excavatum (MIRPE). METHODS: A systematic search of Medline, Embase, PubMed, CINAHL, Web of Science, and the Cochrane Library for randomized controlled trials (RCT) comparing methods of pain control in pediatric patients undergoing MIRPE was conducted. Studies were restricted to the English language. RESULTS: After screening 1304 references, 9 randomized control trials (RCTs) enrolling 485 patients were included. The average age was 11.9 years (±3.1). Pain scores were decreased with ropivacaine compared to bupivacaine-based epidurals. In studies comparing ketamine to opioid based patient-controlled anesthesia (PCA) pumps, the results were variable. Intercostal and paravertebral nerve blocks had decreased pain scores in 75% of the studies compared to opioid-based PCA. Opioid consumption was decreased in 50% of the trials assessing ketamine-based infusions and 75% of the studies comparing intercostal and paravertebral nerve blocks. Nausea was decreased in several of the ketamine-based infusion and intercostal and paravertebral nerve block studies. CONCLUSION: Ketamine-including infusions or paravertebral and intercostal nerve blocks may represent superior methods of postoperative pain control for MIRPE. Further work is needed to confirm results. LEVEL OF EVIDENCE: 2A [1].

Effectiveness of Intrapleural Tissue Plasminogen Activator and Dornase Alfa vs Tissue Plasminogen Activator Alone in Children with Pleural Empyema: A Randomized Clinical Trial.

Importance: Clinical guidelines recommend that children with pleural empyema be treated with chest tube insertion and intrapleural fibrinolytics. The addition of dornase alfa (DNase) has been reported to improve outcomes in adults but remains unproven in children. Objective: To determine if intrapleural tissue plasminogen activator (tPA) and DNase is more effective than tPA and placebo at reducing hospital length of stay in children with pleural empyema. Design, Setting, and Participants: This multicenter, parallel-group, placebo-controlled, superiority randomized clinical trial included children diagnosed as having pleural empyema requiring drainage aged 6 months to 18 years treated at 6 tertiary Canadian children's hospitals. A total of 379 children were assessed for eligibility; 281 were excluded and 98 were randomized. One child was excluded after randomization for not meeting the inclusion criteria. Data were collected from March 4, 2013, to December 13, 2017. Interventions: Participants underwent chest tube insertion and 3 daily administrations of intrapleural tPA, 4 mg, followed by DNase, 5 mg (intervention group), or 5 mL of normal saline (placebo; control group). Participants, families, clinical staff, and members of the study team were blinded to allocation. Main Outcomes and Measures: The primary outcome was hospital length of stay from chest tube insertion to discharge. Secondary outcomes included time to meeting discharge criteria, time to chest tube removal, mean fever duration, additional pleural drainage procedures, hospital readmissions, and total health care cost. Results: Of the 97 analyzed children with pleural empyema, 52 (54%) were male, and the mean (SD) age was 5.1 (3.6) years. A total of 49 children were randomized to tPA and DNase and 48 were randomized to tPA and placebo. Treatment with tPA and DNase was not associated with decreased hospital length of stay compared with tPA and placebo (mean [SD] length of stay, 9.0 [4.9] vs 9.1 [5.3] days; mean difference, -0.1 days; 95% CI, -2.0 to 2.1; P = .96). Similarly, no significant differences were observed for any of the secondary outcomes. Of the 14 adverse events in the tPA and DNase group, 6 (43%) were serious; of the 21 adverse events in the tPA and placebo group, 8 (38%) were serious. There were no deaths. Conclusions and Relevance: The addition of DNase to intrapleural tPA for children with pleural empyema had no effect on hospital length of stay or other outcomes compared with tPA with placebo. Clinical practice guidelines should continue to support the use of chest tube insertion and intrapleural fibrinolytics alone as first-line treatment for pediatric empyema. Trial Registration: ClinicalTrials.gov identifier: NCT01717742.

Habitual protein intake, protein distribution patterns and dietary sources in Irish adults with stratification by sex and age.

BACKGROUND: Given the importance of habitual dietary protein intake, distribution patterns and dietary sources in the aetiology of age-related declines of muscle mass and function, the present study examined these factors as a function of sex and age in Irish adults aged 18-90 years comprising The National Adult Nutrition Survey (NANS). METHODS: In total, 1051 (males, n = 523; females, n = 528) undertook a 4-day semi-weighed food diary. Total, body mass relative intake and percentage contribution to total energy intake of dietary protein were determined in addition to protein distribution scores (PDS), as well as the contribution of food groups, animal- and plant-based foods to total protein intake. RESULTS: Total and relative protein intake [mean (SD)] were highest in those aged 18-35 years [96 (3) g day-1 , 1.32 (0.40) g kg-1  day-1 ], with lower protein intakes with increasing age (i.e. in adults aged ≥65 years [82 (22) g, 1.15 (0.34) g kg-1  day-1 , P < 0.001 for both]. Differences in protein intake between age groups were more pronounced in males compared to females. Protein distribution followed a skewed pattern for all age groups [breakfast, 15 (10) g; lunch, 30 (15) g; dinner, 44 (17) g]. Animal-based foods were the dominant protein source within the diet [63% (11%) versus 37% (11%) plant protein, P < 0.001]. CONCLUSIONS: Protein intake and the number of meals reaching the purported threshold for maximising post-prandial anabolism were highest in young adults, and lower with increasing age. For main meals, breakfast provided the lowest quantity of protein across all age categories and may represent an opportunity for improving protein distribution, whereas, in older adults, increasing the number of meals reaching the anabolic threshold regardless of distribution pattern may be more appropriate.

Developing Residents as Medical Educators via the McMaster Multidisciplinary Academic Day Planning Committee.

Background Residents are being asked to perform educator roles such as curriculum design and learner assessment with minimal professional development in leadership or medical education. The Multidisciplinary Academic Day (MAD) planning committee is a resident-led initiative responsible for delivering combined educational half-day sessions and workshops for all residents at McMaster University. Objective We sought to determine the impact participation in MAD planning committee had on residents' professional development and career goals.  Methods We conducted a program evaluation survey of 19 of 30 (63.3%) current and former committee members to determine how the MAD planning committee's alumni perceived its usefulness, and how participation affected their professional development.  Results Residents cited a desire to gain medical education experience, learn about event planning and management, and improve resident education as reasons for joining the committee; 89.5% of respondents felt they had met these goals. Experience on the committee included skills related to curriculum design, developing needs assessments and programmatic evaluation. Many residents felt it helped them acquire leadership skills such as decision-making, idea generation, delegation, and public speaking. Several noted that it had sparked an interest in medical education as part of an academic career, and one former member subsequently pursued a Master's of Education. The majority of the respondents (78.9%) felt it was helpful for their careers and 94.7% would recommend this experience to others interested in leadership and medical education.  Conclusion Involvement in the MAD planning committee is a highly useful way for residents to acquire leadership skills, develop an interest in medical education and work in a multidisciplinary team.

Safety of mucous fistula refeeding in neonates with functional short bowel syndrome: A retrospective review.

PURPOSE: Mucous fistula (MF) refeeding of proximal stoma effluent in neonates after small bowel resection can promote nutrient absorption and prevent atrophy of the unused distal bowel. This study aimed to assess the safety of this practice in neonates. METHODS: A retrospective chart review of all patients admitted to the neonatal intensive care unit (NICU) between 2009 and 2015 who underwent a laparotomy with creation of an enterostomy and mucous fistula was performed. Patients were included if they were refed proximal stoma effluent into the MF. RESULTS: Thirty-one patients were identified that were refed. There were no major complications (perforation, stricture, death) related to refeeding. Patients were refed for an average of 41 days (± 22), with patients gaining an average of 25.7 g/day (± 10.1) while being refed. Total parental nutrition (TPN) was administered for an average of 55 days (± 31.4) between resection and reanastomosis, with only 7 (23%) developing cholestasis and 15 (48%) reaching full feeds in this time. Mean time to full feeds after reanastomosis was 36 days (± 58.6) with two patients having anastomotic leaks. CONCLUSION: MF refeeding is a safe technique that has the potential to contribute to significant weight gain and a decreased dependence on total parenteral nutrition. LEVEL OF EVIDENCE: II.