Umbilical hernia following gastroschisis closure: a common event?

PURPOSE: To assess incidence and natural history of umbilical hernia following sutured and sutureless gastroschisis closure. METHODS: With audit approval, we undertook a retrospective clinical record review of all gastroschisis closures in our institution (2007-2013). Patient demographics, gastroschisis closure method and umbilical hernia occurrence were recorded. Data, presented as median (range), underwent appropriate statistical analysis. RESULTS: Fifty-three patients were identified, gestation 36 weeks (31-38), birth weight 2.39 kg (1-3.52) and 23 (43 %) were male. Fourteen patients (26 %) underwent sutureless closure: 12 primary, 2 staged; and 39 (74 %) sutured closure: 19 primary, 20 staged. Sutured closure was interrupted sutures in 24 patients, 11 pursestring and 4 not specified. Fifty patients were followed-up over 53 months (10-101) and 22 (44 %) developed umbilical hernias. There was a significantly greater hernia incidence following sutureless closure (p = 0.0002). In sutured closure, pursestring technique had the highest hernia rate (64 %). Seven patients underwent operative hernia closure; three secondary to another procedure. Seven patients had their hernias resolve. One patient was lost to follow-up and seven remain under observation with no reported complications. CONCLUSIONS: There is a significant umbilical hernia incidence following sutureless and pursestring sutured gastroschisis closure. This has not led to complications and the majority have not undergone repair.

The role of parenteral nutrition following surgery for duodenal atresia or stenosis.

PURPOSE: In our institution, some children routinely receive parenteral nutrition (PN) following surgery for duodenal atresia/stenosis, while others do not. Our aim was to compare growth and infection rate between these two treatment strategies. METHODS: This was a retrospective study of all children undergoing surgery for duodenal atresia/stenosis over 7 years. RESULTS: Of the 54 children, 19 commenced PN soon after surgery (the 'Initial PN' group). Of the remaining 35 children, 13 (37 %) subsequently required PN (the 'Delayed PN' group). The remaining 22 never received PN (the 'Never PN' group). The proportion of patients experiencing clinically suspected sepsis was higher in those receiving PN ('Initial' plus 'Delayed'; 41 %) compared with those who never received PN (14 %; p = 0.04). The 'Initial PN' and 'Never PN' groups did not show a significant change in weight Z score over time. However, the 'Delayed PN' group showed a significant decrease in weight Z scores from the time of operation to the time of achieving full enteral feeds, and failed to catch up by the time of last follow-up. CONCLUSION: Children with duodenal atresia/stenosis can be managed without PN. However, a third of these children subsequently require PN, lose weight centiles, and have a high rate of sepsis.

Clinical utilization of near-infrared spectroscopy devices for burn depth assessment.

The diagnosis of burn depth is based on a visual assessment and can be subjective. Near-infrared (NIR) spectroscopic devices were used preclinically with positive results. The purpose of this study was to test the devices in a clinical setting using easily identifiable burn wounds. Adult patients with acute superficial and full-thickness burns were enrolled. NIR point spectroscopy and imaging devices were used to collect hemodynamic data from the burn site and an adjacent unburned control site. Oxy-hemoglobin and deoxy-hemoglobin concentrations were extracted from spectroscopic data and reported as oxygen saturation and total hemoglobin. Sixteen patients (n=16) were included in the study with equal numbers in both burn wound groups. Point spectroscopy data showed an increase in oxygen saturation (p<0.0095) and total hemoglobin (<0.0001) in comparison with the respective control areas for superficial burn wounds. The opposite was true for full-thickness burns, which showed a decrease in oxygenation (p<0.0001) and total hemoglobin (p<0.0147) in comparison with control areas. NIR imaging technology provides an estimate of hemodynamic parameters and could easily distinguish superficial and full-thickness burn wounds. These results confirm that NIR devices can successfully distinguish superficial and full-thickness burn injuries.

Simultaneous measures of contraction and intracellular calcium in single, cultured smooth muscle cells.

Simple methods are presented for quantitating contraction and intracellular calcium simultaneously in single, cultured smooth muscle cells. These methods are the first to demonstrate that reliable velocities of cell shortening can be measured in cultured smooth muscle cells and that cells in vitro exhibit shortening velocities comparable to those measured in the fastest phasic muscles in situ. Temporal relationships between changes in intracellular calcium and shortening within single cells were determined with a resolution of 100 ms and were consistent with measures in more "classical" preparations. Intracellular calcium rose quickly and transiently 10-fold above the basal level of 80-90 nM in response to the muscarinic agonist, carbachol. Shortening of the cells occurred 200 ms after intracellular calcium began to rise. The sensitivity and reliability of these methods allowed the effects of different stimuli to be easily resolved. The present report demonstrates that genuine contractility need not be ignored in cultured smooth muscle cells and that the temporal relations between shortening and intracellular calcium mobilization can be quantitatively assessed in controlled in vitro environments.

Effects of a static stretching program on the incidence of lower extremity musculotendinous strains.

OBJECTIVE: Musculotendinous strains are among the most prevalent injuries for which health care professionals provide treatment and rehabilitation interventions. Flexibility has been identified as one of the primary etiologic factors associated with musculotendinous strains, but limited research exists on the effect of a preventive stretching program on musculotendinous strains. Therefore, the purpose of our study was to compare the number of musculotendinous strains for the hamstrings, quadriceps, hip adductors, and gastrocnemius-soleus muscle groups before and after the incorporation of a static stretching program for each muscle group. DESIGN AND SETTING: We analyzed the incidence of musculotendinous strains among the players of a Division III collegiate football team between 1994 and 1995. All variables were consistent between the 2 seasons except for the incorporation of a lower extremity stretching program in 1995. SUBJECTS: One hundred and ninety-five Division III college football players. MEASUREMENTS: We calculated the number of musculotendinous strains that required a minimum absence of 1 day from practices or games in 1994 and 1995. RESULTS: A x(2) analysis revealed a significant reduction in the number of lower extremity musculotendinous strains in 1995 as opposed to 1994. CONCLUSIONS: Our statistical analysis indicates an association between the incorporation of a static stretching program and a decreased incidence of musculotendinous strains in Division III college football players.

Functional performance following an ice immersion to the lower extremity.

Cryotherapy is a widely accepted component of treatment for acute injuries. It has recently re-entered the later stages of rehabilitation as a contributing modality. Cryotherapy's depressive effects on the body's physiological systems have generated concern among many health care practitioners about its effect on motor activity. This study examined the effects of an ice immersion on three functional performance tests: the shuttle run, the 6-m hop test, and the single-leg vertical jump. Twenty volunteers from Division III soccer and football teams who had not sustained an injury to the lower extremity within the past 6 months were randomly assigned to either an experimental or control group. Subjects in the experimental group performed three trials of each functional performance test before and after the application of a 20-minute ice immersion (13 degrees C) to the lower leg. Subjects in the comparison group followed the same procedure except that a 20-minute resting period replaced the cold treatment. A mixed design analysis of variance was used to analyze the data. Vertical jump scores decreased in the experimental group (41.4 +/- 6.8 cm to 39.3 +/- 6.1 cm) but not in the control group (45.2 +/- 5.5 cm to 45.7 +/- 5.9 cm) as a result of the treatment. Shuttle run times decreased in the experimental group (6.5 +/- 0.3 seconds to 6.7 +/- 0.4 seconds) but not in the control group (6.8 +/- 0.4 seconds to 6.8 +/- 0.4 seconds). Six-meter hop test values were not affected. We suggest that clinicians should carefully consider the immediate effects, potentially, of cold on motor activity.

Activation of nicotinic acetylcholine receptors expressed in quail fibroblasts: effects on intracellular calcium.

1. The aim of these experiments was to determine the ability of the muscle-type nicotinic acetylcholine receptor (AChR) stably expressed in quail fibroblasts (QF18 cells) to elevate intracellular calcium ([Ca2+]i) upon activation. Ratiometric confocal microscopy, with the calcium-sensitive fluorescent dye Indo-1 was used. 2. Application of the nicotine agonist, suberyldicholine (SDC), to the transfected QF18 cells caused an increase in [Ca2+]i. Control [Ca2+]i levels in QF18 cells were found to be 164 +/- 22 nM (mean +/- s.e. mean; n = 40 cells) rising to 600 +/- 81 nM on addition of SDC (10 microM; n = 15 cells), whereas no increase in [Ca2+]i was seen in non-transfected control QT6 fibroblasts (before: 128 +/- 9 nM, n = 40; after; 113 +/- 13 nM, n = 15). 3. The increase in [Ca2+]i caused by application of SDC was dose-dependent, with an EC50 value of 12.7 +/- 5.9 microM (n = 14). 4. The responses to SDC in QF18 cells were blocked by prior application of alpha-bungarotoxin (200 nM), by the addition of Ca2+ (100 microM), by removal of Na+ ions from the extracellular solution, or by the voltage-sensitive calcium channel blockers nifedipine and omega-conotoxin, which act with IC50 values of 100 nM and 100 pM respectively. 5. We conclude that activation of the nicotinic AChRs leads to a Na(+)-dependent depolarization and hence activation of endogenous voltage-sensitive Ca2+ channels in the plasma membrane and an increase in [Ca2+]i. There is no significant entry of Ca2+ through the nicotinic receptor itself.

Enhancement by 5-hydroxytryptamine and analogues of desensitization of neuronal and muscle nicotinic receptors expressed in Xenopus oocytes.

1. The action of 5-hydroxytryptamine (5-HT) on neuronal and muscle nicotinic acetylcholine receptors (nicotinic AChR) expressed in Xenopus oocytes was studied. 2. 5-HT enhanced the rate of desensitization of the acetylcholine (ACh) current response in all receptor subtypes investigated (muscle, alpha beta 2 gamma delta and alpha 4 beta 2), acting in a dose-dependent manner. 3. 5-HT also reduced the peak current elicited by ACh in a dose-dependent manner. The IC50 value for the muscle type receptor was 227 +/- 0.44 microM, and 166 +/- 0.47 microM and 283 +/- 0.28 microM for the combinations alpha beta 2 gamma delta and alpha 4 beta 2 respectively. 4. The effect of 5-HT on the responses to ACh (10 microM) was found to be independent of membrane voltage over the range tested (-80 to -10 mV), and to be readily reversed by washout. 5. The action of 5-HT could be mimicked by structurally similar molecules. The homologue tryptamine was less potent than 5-HT in blocking the ACh current, with an IC50 of 1.0 +/- 0.02 mM. Ketanserin, a 5-HT2 receptor antagonist, was more potent than 5-HT, the IC50 being 49.0 +/- 1.4 microM. 6. We postulate that a highly conserved portion of the tertiary structure of nicotinic AChRs, which includes some part of the ACh binding site, has affinity for 5-HT and structural analogues.

Membrane clustering and bungarotoxin binding by the nicotinic acetylcholine receptor: role of the beta subunit.

Nicotinic acetylcholine receptors (nAChRs) are localised at morphologically distinct regions of the post-synaptic membrane by interactions between the receptor subunits and cytoskeletal proteins, such as the 43-kDa protein. We have used Xenopus oocytes to examine the localisation and pharmacological properties of muscle nAChRs associated with 43-kDa protein and to compare them with hybrid muscle nAChRs containing a beta subunit derived from a neuronal source. Receptors expressed on the oocyte outer membrane were visualised using confocal scanning laser microscopy. Coexpression of mouse muscle subunit alpha 1 beta 1 gamma delta and 43-kDa protein transcripts produced discrete receptor aggregates with a diameter of 1-5 microns whose function was partially blocked by application of neuronal bungarotoxin (NBT) at 100 nM. Substitution of the beta 1 subunit by the neuronal beta 2 protein produced a functioning receptor that did not aggregate in the presence of 43-kDa protein and was substantially blocked by the same concentration of NBT. Hybrid alpha 1 beta 4 gamma delta receptors exhibited a combination of characteristics in that they clustered like normal muscle subunits in the presence of 43-kDa protein, but showed a sensitivity to NBT intermediate between that of muscle receptors and that of hybrids containing beta 2. These results suggest that the beta subunit is an important determinant in receptor localisation and sensitivity to NBT.

Phorbol esters impair endothelium-dependent and independent relaxation in rat aortic rings.

1. This study examined the ability of various nitro-vasodilators, 8-bromo cyclic guanosine 3':5' monophosphate (8-BrcGMP) and forskolin to relax rings of rat thoracic aorta pre-contracted with either noradrenaline (0.1 microM) or the protein kinase C activators, phorbol 12,13-dibutyrate (PDB, 0.1 microM) or phorbol 12-myristate 13-acetate (PMA, 0.5 microM). 2. In noradrenaline pre-contracted rings, acetylcholine (10 nM-10 microM), sodium nitroprusside (1 nM-0.5 microM), the calcium ionophore A23187 (10 nM-10 microM) and 8-BrcGMP (10 mM) totally reversed the smooth muscle contraction. In PDB-contracted aortic rings acetylcholine, sodium nitroprusside and 8-BrcGMP-induced relaxation was reduced compared to that in noradrenaline-contracted aortic rings, but A23187 and forskolin-induced relaxations were unaffected. Both acetylcholine and A23187-induced relaxations in PDB-contracted rings were abolished in the presence of the nitric oxide synthesis inhibitor N omega-nitro-L-arginine (NOLA, 100 microM). 3. Acetylcholine and sodium nitroprusside were even less potent in their ability to relax PMA-contracted aortic rings compared with noradrenaline and PDB-contracted rings. A23187-induced relaxation was also inhibited in PMA-contracted rings. 4. These results show that protein kinase C activation reduces the ability of agents which liberate nitric oxide to induce smooth muscle relaxation, and also inhibits the biochemical pathways which are subsequently activated by nitric oxide and lead to vascular smooth muscle relaxation.