Paediatric abdominal pain in the time of COVID-19: a new diagnostic dilemma.

The diagnostic uncertainty for children with abdominal pain has increased during the COVID-19 pandemic with the additional consideration of both COVID-19 and paediatric inflammatory multisystem syndrome-temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (PIMS-TS) alongside appendicitis, mesenteric adenitis and other less common causes of abdominal pain. We describe the cases of two children who presented with severe abdominal pain, non-bilious vomiting and high temperatures during the UK's first peak of the COVID-19 pandemic. Laboratory and abdominal ultrasound features were similar for both children but symptom progression in combination with cross-sectional abdominal imaging enabled differentiation between PIMS-TS and appendicitis with concurrent COVID-19. These cases highlight the importance of regular clinical review, multidisciplinary working and the utility of early cross-sectional imaging to determine the underlying condition.

ImERSE (Improving Experience through Regular Shadowing Events).

Systematic operational quality improvement strategies within the NHS are hard to find, although there are numerous published reports of sporadic departmental models and methods resulting in improvements in clinical care. We describe the experience of devising a tool to provide large data collection of patient care experiences by using medical students to shadow patient journeys. This combines patient and family centred care (PFCC) and quality improvement approaches to create a systematic organisational strategy for improving care. The ImERSE (improving experience through regular shadowing events) approach could be applied to any area of health care to generate population specific improvement priorities. It can be used to promote patient and family centred care and provide a unique medical education experience. We describe its evolution in its first year of use and suggest that using the ImERSE approach delivers beneficial characteristics to patients and their families, those undergoing a shadowing experience, and provider organisations.

Chemical stability of heparin, isopropanol, and ethanol line lock solutions.

BACKGROUND: Ethanol line locks are used in the US to prevent catheter associated bloodstream infections. Heparin precipitates in solution with ethanol. However, isopropanol may reduce precipitate formation. We aimed to determine the chemical stability of heparin, isopropanol, and ethanol line lock for a 10 day period at 2-8°C and 25°C. METHODS: Forty samples were prepared for analysis. Each sample was prepared identically using a 5 ml syringe capped with a Combi-stopper: 1 ml 70% isopropanol, 1 ml 70% ethanol, and 1 ml heparin sodium 10 IU/ml. Twenty syringes were stored at 2-8°C and 20 at 25°C. Analysis was carried out on days 1, 3, 6, 8, and 10 with a single syringe from each condition being tested in duplicate. Samples were assessed visually. Sub-visible particle count analysis was carried out using a CLIMET particle counting system. Heparin concentration was analysed using an anti-Xa assay. Ethanol and isopropanol concentrations were analysed by gas chromatography. RESULTS: Samples remained clear and colourless throughout the study. Sub-visible particle counts remained within limits specified in British Pharmacopoeia 2013 when stored at 2-8°C and 25°C, 60% humidity for up to 10 days. There was no significant change in ethanol or isopropanol concentration during the study. However, heparin activity fell by >10% after 1 day storage and to 65% of original activity after 10 days. CONCLUSIONS: This study shows that addition of isopropanol to heparin and ethanol prevents precipitation. However, this solution shows a progressive decline in heparin activity over time making it unsuitable for extended shelf life.

Potential benefits of fast-track concepts in paediatric colorectal surgery.

BACKGROUND: Structured care pathways optimising peri-operative care have been shown to significantly enhance post-operative recovery. We aim to determine if enhanced recovery after surgery (ERAS) principles could provide benefit for paediatric patients undergoing major colorectal resection for inflammatory bowel disease (IBD). METHODS: Children undergoing elective bowel resection for IBD at a regional paediatric unit using standard methods of peri-operative care were matched to adult cases from an associated tertiary referral university hospital already using an ERAS program. Cases were matched for disease type, gender, operative procedure, and ASA grade. RESULTS: Forty-four children undergoing fifty procedures were identified. Thirty-four were matched to adult cases. Total length of stay in the paediatric group was significantly longer than in the adult group (6 vs. 9 days; P=0.001). Paediatric patients were slower to start solid diet (1 vs. 4 days; P<0.0001) and were slower to mobilize post-operatively (1 vs. 4 days; P<0.0001). No difference was seen in time to restoration of bowel function (2 vs. 3 days; P=0.49). Thirty day readmissions and total in-hospital morbidity were not significantly different between the groups. CONCLUSION: Potentially, application of ERAS in paediatric surgery could accelerate recovery and reduce length of post-operative stay thereby improving quality and efficiency of care.

Laparostomy closure in stage 4S neuroblastoma.

Laparostomy in children is a rare procedure, and there is little in the literature as to the best method for closure in children with an open abdomen. We describe 2 cases with stage 4S neuroblastoma that required emergency decompressive laparostomy. Both cases highlight advantages and disadvantages with known techniques for achieving skin and fascia closure. We believe this to be the first report of a combination of extracellular matrix mesh and vacuum therapy for successful fascial and skin closure in stage 4S neuroblastoma.

Multiple jejunoileal atresia and colonic atresia managed by multiple primary anastomosis with a single gastroperineal transanastomotic tube without stomas.

Multiple jejunoileal atresia is a challenge to the pediatric surgeon. The aim of the study is to preserve bowel length and prevent the long-term complications of short bowel syndrome. The authors present a rare case of combined multiple jejunoileal atresia and colonic atresia managed by 9 primary anastomoses over a gastroperineal transanastomotic tube. This technique avoided the use of stomas and their attendant complications.