Intrarater and interrater reliability of the modified Thomas Test.

INTRODUCTION: The modified Thomas Test (MTT) is a method of assessing flexibility of the iliopsoas, rectus femoris and tensor fascia Latae. The aim of this study is to identify the intra and inter-rater reliability of the pass/fail scoring for the Modified Thomas Test (MTT) using digital photographs. METHODS: Six raters varying between 1 and 13years of clinical experience were used to review digital photographs of 20 semi-professional rugby players performing the /MTT. Raters were asked to score each muscle of the MTT either with 0 (fail) or 1 (pass). Digital photographs were allocated in a randomized order. Each rater reviewed each photograph three times at two week intervals. RESULTS: Cronbach's alpha (Cα) revealed a mean result of high reliability for both iliopsoas (Cα = 0.95) and rectus femoris (Cα = 1.00) flexibility. TFL flexibility values ranged from 0.64 to 0.95, demonstrating some inconsistencies within some of the 6 raters. Fleiss kappa (Fк) revealed a high mean reliability result across the 3 testing sessions for both iliopsoas (Fк = 0.78) and rectus femoris (Fк = 0.80) flexibility, along with a moderate reliability mean result for TFL (Fк = 0.56). CONCLUSION: High intra and inter rater reliability was found for iliopsoas and rectus femoris flexibility with those for TFL found to be moderately reliable.

Cross-Canada differences in early-stage breast cancer treatment and acute-care use.

Background: Chemotherapy has improved outcomes in early-stage breast cancer, but treatment practices vary, and use of acute care is common. We conducted a pan-Canadian study to describe treatment differences and the incidence of emergency department visits (edvs), edvs leading to hospitalization (edvhs), and direct hospitalizations (hs) during adjuvant chemotherapy. Methods: The cohort consisted of women diagnosed with early-stage breast cancer (stages i-iii) during 2007-2012 in British Columbia, Manitoba, Ontario, or Nova Scotia who underwent curative surgery. Parallel provincial analyses were undertaken using linked clinical, registry, and administrative databases. The incidences of edvs, edvhs, and hs in the 6 months after treatment initiation were examined for patients treated with adjuvant chemotherapy. Results: The cohort consisted of 50,224 patients. The proportion of patients who received chemotherapy varied by province, with Ontario having the highest proportion (46.4%), and Nova Scotia, the lowest proportion (38.0%). Age, stage, receptor status, comorbidities, and geographic location were associated with receipt of chemotherapy in all provinces. Ontario had the highest proportion of patients experiencing an edv (36.1%), but the lowest proportion experiencing h (6.4%). Conversely, British Columbia had the lowest proportion of patients experiencing an edv (16.0%), but the highest proportion experiencing h (26.7%). The proportion of patients having an edvh was similar across provinces (13.9%-16.8%). Geographic location was associated with edvs, edvhs, and hs in all provinces. Conclusions: Intra- and inter-provincial differences in the use of chemotherapy and acute care were observed. Understanding variations in care can help to identify gaps and opportunities for improvement and shared learnings.

Factors associated with imaging in patients with early breast cancer after initial treatment.

Background: Overuse of surveillance imaging in patients after curative treatment for early breast cancer (ebc) was recently identified as one of the Choosing Wisely Canada initiatives to improve the quality of cancer care. We undertook a population-level examination of imaging practices in Ontario as they existed before the launch of that initiative. Methods: Patients diagnosed with ebc between 2006 and 2010 in Ontario were identified from the Ontario Cancer Registry. Records were linked deterministically to provincial health care databases to obtain comprehensive follow-up. We identified all advanced imaging exams [aies: computed tomography (ct), bone scan, positron-emission tomography] and basic imaging exams (bies: ultrasonography, chest radiography) occurring within the first 2 years after curative treatment. Poisson regression was used to assess associations between patient or provider characteristics and the rate of aies. Results: Of 30,006 women with ebc, 58.6% received at least 1 bie, and 30.6% received at least 1 aie in year 1 after treatment. In year 2, 52.7% received at least 1 bie, and 25.7% received at least 1 aie. The most common aies were chest cts and bone scans. The rate of aies increased with older age, higher disease stage, comorbidity, chemotherapy exposure, and prior staging investigations (p < 0.001). Imaging was ordered mainly by medical oncologists (38%), followed by primary care physicians (23%), surgeons (13%), and emergency room physicians (7%). Conclusions: Despite recommendations against its use, imaging is common in ebc survivors. Understanding the factors associated with aie use helps to identify areas for further research and is required to lower imaging rates and to improve survivorship care.

Risk factors for local recurrence in Wilms tumour and the potential influence of biopsy - the United Kingdom experience.

RATIONALE: The UKW3 trial compared biopsy/pre-operative chemotherapy versus immediate nephrectomy and afforded the opportunity to examine the influence of percutaneous retroperitoneal biopsy and other factors on local and distant relapse of Wilms tumour (WT). METHODS: Patients with unilateral WT (stages I-IV) excluding metachronous relapse or early progressive disease were eligible. Metastatic and 'inoperable' tumours were biopsied electively. 'Local' was defined as relapse within the abdomen, except for liver metastases considered as 'distant' relapse, together with other haematogenous routes. Uni- and multivariable analyses estimated the risk factors for relapse. RESULTS: Overall, 285/635 (44.9%) patients had a biopsy. With a median follow-up of 10.1 years, 35 (5.5%) patients experienced a 'local', 15 a combined (2.4%) and 60 (9.4%) a 'distant' relapse. On univariate analysis, biopsy, anaplasia and tumour size were associated with an increased risk of local relapse. On multivariable analysis, anaplasia and tumour size remained significant for local relapse whereas the elevated risk of biopsy (hazards ratio (HR) = 1.80: 95% confidence interval (CI) 0.97-3.32, p = 0.060) was marginal. Age, anaplasia, tumour size, lymph nodes metastases and stage, but not biopsy, were individually associated with increased risk of distant relapse but only age and anaplasia remained significant following multivariable analysis. CONCLUSIONS: The UKW3 trial provides some reassurance that biopsy should not automatically lead to 'upstaging' of WT. Further assessment of this controversial area is required. Comparison of local relapse rates in a multinational trial in which the United Kingdom (UK) continued the practice of routinely biopsying all patients in contrast to the standard European approach will afford this opportunity and is planned.

Treatment and outcome of Wilms' tumour patients: an analysis of all cases registered in the UKW3 trial.

BACKGROUND: The randomised findings of the UKW3 trial were that preoperative chemotherapy was associated with a more advantageous stage distribution and reduction in therapy burden versus immediate nephrectomy without compromising outcome in localised Wilms' tumour (WT). We analysed outcome in all WT registered in UKW3. PATIENTS AND METHODS: Seven hundred and eighteen WT cases (7% anaplastic) were registered in UKW3. We assigned a treatment stage and conducted survival analysis. RESULTS: Five-year event-free survival (EFS) and overall survival (OS) were 77.2% [95% confidence interval (CI) 73.9-80.2] and 87.5% (95% CI 84.8-89.7) after median follow-up of 9.5 years and 10.0 years, respectively. Five-year OS in localised non-anaplastic cases was 92.9% (95% CI 90.2-94.9). Anaplasia was associated with adverse outcome compared with non-anaplastic cases: 5-year EFS of 42.0% (95% CI 28.3-55.1) versus 79.8% (95% CI 76.5-82.7) and 5-year OS of 60% (95% CI 45.1-72.0) versus 89.6% (95% CI 87.0-91.7), respectively. Outcomes were similar for non-anaplastic stage I or II but significantly poorer in stage III cases than stage I. Five-year OS after relapse was 54.1% (95% CI 44.5-62.8). Forty-seven percent of non-anaplastic WT received anthracycline; 27% were treated with radiotherapy first line. CONCLUSION: These outcomes provide a baseline for future comparisons of WT treatment approach, burden and patient outcome.

Splenogonadal fusion: a rare cause of testicular enlargement.

Splenogonadal fusion is a rare congenital abnormality found in boys and girls. There is fusion of the developing splenic anlage and the gonadal mesoderm at approximately week 5 of intrauterine life. It commonly presents as a testicular mass treated with an unnecessary orchidectomy. We report two cases of the discontinuous type presenting with testicular swelling and review the literature.

Segmental infarction of the omentum: a difficult diagnosis.

Segmental infarction of the greater omentum is a rare diagnosis. This report describes a case of omental torsion in an eight-year-old boy. The report assesses the predisposing factors, the classification and the place of ultrasonography.

Energy metabolism of infants and children with systemic inflammatory response syndrome and sepsis.

OBJECTIVE: To evaluate whether critically ill children with systemic inflammatory response syndrome (SIRS) or sepsis have altered resting energy expenditure (REE) and substrate utilization. SUMMARY BACKGROUND DATA: Studies in adults with sepsis have shown increased energy expenditure and mobilization of endogenous fat. In infants and children, energy metabolism and substrate utilization during sepsis have not been characterized. METHODS: Metabolic studies were performed in 21 critically ill children with SIRS or sepsis. Twenty-one stable control children, matched for weight, were also studied. Seven patients required inotropic support and 17 received mechanical ventilation. Fifteen patients with SIRS had evidence of bacterial, fungal, or viral infection and were considered septic. Respiratory gas exchange was measured by computerized indirect calorimetry for 1 to 2 hours continuously. RESULTS: The REE of patients with SIRS or sepsis was not different from that of controls. Similarly, there were no differences in carbon dioxide production and oxygen consumption. Resting energy metabolism was not different between patients with SIRS and patients with sepsis. In addition, the presence of low platelet count or inotropic support did not affect resting energy metabolism. The median respiratory quotient of patients with SIRS or sepsis was 0.88 (range 0.75-1.12), indicating mixed utilization of fat and carbohydrate; this was not significantly different from that of controls. The Pediatric Risk of Mortality Score was not significantly correlated with REE or respiratory quotient. CONCLUSIONS: The energy requirements of children with SIRS or sepsis are not increased. Their resting metabolism is based on both carbohydrate and fat utilization. The authors speculate that these children divert the energy for growth into recovery processes.

Endoscopic ultrasound in the clinical staging and management of pancreatic cancer: its impact on cost of treatment.

BACKGROUND: Surgical resection for pancreatic cancer carries a 5% 5-year survival rate. Most conventional methods of imaging do not detect small pancreatic tumors and do not accurately stage pancreatic neoplasms. There is a significant impact on medical resources despite the relatively small number of patients affected. For these reasons, careful selection of patients for surgical resection is necessary. METHODS: Endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) have been developed to overcome limitations of conventional staging. We address the issues of how EUS may provide cost-effective treatment in the patient with pancreatic cancer. RESULTS: EUS produces high-resolution images of the pancreas, which can detect small pancreatic tumors and accurately stage pancreatic neoplasms. Evaluation with EUS-guided FNA selects patients who would benefit most from surgical resection. EUS also can be used to deliver palliative treatment for pain at the initial time of staging. EUS with FNA identifies patients most likely to benefit from surgical resection and thus channels health care resources more appropriately. CONCLUSIONS: Defining this patient population helps to reduce direct medical care costs in pancreatic cancer. However, prospective data are lacking in this regard and will need to be addressed in the future. When palliative care is the goal for patients, EUS-guided fine-needle injection techniques can be used for celiac neurolysis and possibly in the future use of antitumor agents.

Endoscopic placement of Sengstaken-Blakemore tube.

A Sengstaken-Blakemore (SB) tube, when used approximately, still has a place in the management of acute variceal bleeding. Due to a number of reported complications from the misplacement of this tube, an x-ray localization before full inflation of the gastric balloon is recommended as the standard of care. Here, we report a new technique of SB tube placement with endoscopic confirmation in three patients. This technique is easy, accurate, and can be performed in any unit where a patient with variceal bleeding can be managed. Because it cuts down on the need for an x-ray or ultrasound confirmation, this technique may well become the "standard of care" among the practicing gastroenterologists.

Differential energy metabolism in conjoined twins.

BACKGROUND/PURPOSE: Conjoined twins often have different body composition and growth rate before separation. This may be because of differences in energy metabolism. The aim of this study was to investigate the energy expenditure, body composition, and calorie intake of thoracopagus conjoined twins with shared hepatic circulation but separate gastrointestinal tracts. METHODS: The twins were studied at two periods: (1) before separation (age, 73 days) and (2) after separation (age, 97 days). Calorie intake over the study periods was carefully documented. Respiratory gas exchange was measured by computerized indirect calorimetry. The postseparation weight ratio of twin A to twin B was used to approximate the preseparation weights. Body composition (total body fat) was calculated from skinfold thickness and anthropometric measurements. RESULTS: The body composition of the twins was different: body weight and total body fat were higher in twin B. Resting energy expenditure and calorie intake were markedly different between the conjoined twins before separation. In both twins, the energy expenditure increased after separation. After separation, the resting energy expenditure of the twins was similar. CONCLUSIONS: This study illustrates the difference in energy metabolism in a set of thoracopagus conjoined twins. The authors speculate that twin A was supplying nutrients to twin B resulting in increased energy expenditure before separation. This would explain the lower calorie intake and higher fat mass of twin B.

Characteristics of protein and energy metabolism in neonates with necrotizing enterocolitis--a pilot study.

BACKGROUND/PURPOSE: It is assumed that neonates with necrotizing enterocolitis (NEC) are hypermetabolic. However, the dynamics of protein and energy metabolism in neonates with NEC have not been characterized. The purpose of this study was to test the hypothesis that protein turnover and energy expenditure are increased during the acute stage of NEC and later return to normal values. METHODS: A pilot study was performed on six neonates with proven NEC (Bell's stage II or III). Patients were studied in two phases: (1) in the acute stage of their disease and (2) when their clinical condition had stabilized. Whole-body protein turnover was calculated using an intravenous infusion of [1-13C] leucine and by measuring the isotopic enrichment of plasma [13C]alpha-ketoisocaproic acid and 13CO2. Respiratory gas exchange was measured simultaneously by computerized indirect calorimetry. RESULTS: Median gestational age was 36 weeks (range, 28 to 40) with a median postnatal age of 21 days (range, 6 to 47). All patients recovered from the acute episode, although three patients died after recovering from the acute disease from other conditions. The patients studied showed marked variability in protein metabolism kinetics. However, there was no difference in whole-body protein flux between the acute phase (7.6 g/kg/d; range, 5.6 to 18.2) and the recovery phase (7.0 g/kg/d; range, 6.9 to 12.2; P = .89). Furthermore, there was no difference in any of the component parts of wholebody protein turnover. Resting energy expenditure did not change between the acute phase (42.8 kcal/kg/d; range, 34.4 to 52.5) and the recovery phase (51.0 kcal/kg/d; range, 34.9 to 55.3; P = .18). CONCLUSIONS: This pilot study shows that the rates of protein and energy metabolism in neonates with NEC are comparable with reported values in stable neonates. There was no difference in protein or energy dynamics between study phases. The authors speculate that neonates with NEC may divert the products of protein synthesis from growth to tissue repair.

Fentanyl analgesia increases the incidence of postoperative hypothermia in neonates.

Postoperative hypothermia remains a clinical problem in neonates undergoing surgery. Intraoperative analgesia can blunt the metabolic and hormonal response to operative stress in neonates. However, its effects on heat production and thermoregulation are not known. The aim of this review was to characterise the effects of intraoperative analgesia on body temperature in neonates undergoing surgery. The case notes of 25 consecutive neonates who underwent major operations were retrospectively reviewed. Axillary temperature was measured before the operation, and postoperatively after returning to the neonatal intensive care unit (NICU). Patients were divided into groups based on the intraoperative analgesic used: (1) 9 neonates received fentanyl; (2) 5 received morphine; and (3) 11 received epidural bupivacaine. All groups were comparable in terms of conceptional age, postnatal age, body weight, duration of operation, and operative stress score. In all groups the body temperature was significantly lower at the time of returning to the NICU than preoperatively. Three patients (33%) who received fentanyl became hypothermic during the operation, whereas none of those who received either morphine or bupivacaine had hypothermia. The drop in temperature between preoperative and initial postoperative values was significantly greater in patients who received fentanyl intraoperatively (median drop 0.8 degreesC, range 0.6 - 2.4) when compared with patients who received morphine (P = 0.02) or epidural bupivacaine (P = 0.01). These data suggest that intraoperative fentanyl modulates the postoperative body temperature in neonates. We hypothesise that fentanyl blocks metabolic heat production, which results in a reduction in postoperative body temperature.

Preputial intussusception or acquired megaprepuce.

Preputial intussusception, or acquired megaprepuce, is a clinical condition whose incidence is increasing. It results from infolding of the outer preputial skin, obstruction of urinary flow, and the development of a phimosis. With time the process continues, resulting in a distinctive clinical picture. Treatment by early circumcision cures the problem and allows resolution of the sequelae.

Effect of major abdominal operations on energy and protein metabolism in infants and children.

PURPOSE: The authors attempted to test the hypothesis that infants and children increase whole-body protein flux and energy metabolism during the early postoperative period. METHODS: Ten infants and children (age range, 2 days to 3 years; weight range, 1.5 to 14.2 kg) who had undergone a major operation were studied. Anaesthesia was standardised, and operative stress score (OSS) recorded. Patients were studied for 4 hours preoperatively and for the first 6 hours after surgery. Respiratory gas exchange was measured by computerised indirect calorimetry. The components of whole-body protein turnover were estimated by giving an intravenous infusion of [1-13C]leucine, and by measuring the isotopic enrichment of plasma [13C]alpha-ketoisocaproic acid by gas chromatograph mass spectrometry and 13CO2 enrichment by isotope ratio mass spectrometry. RESULTS: Median duration of the operation was 73.5 minutes (range, 28 to 285 minutes) with a OSS of 8 (range, 7-17). There were no significant differences in oxygen consumption and resting energy expenditure between the two study phases. The respiratory quotient (RQ) fell from a preoperative value of 0.92 (range, 0.81 to 1.08) to 0.89 (range, 0.79 to 0.95) postoperatively (P = .04). The authors found no significant differences in the rates of whole body protein flux, protein synthesis, amino acid oxidation, and protein degradation between the study phases. CONCLUSIONS: Infants and children do not increase their whole-body protein turnover and metabolic rate after major operations. The observed decrease in RQ reflects mobilisation of endogenous fat. We speculate that the lack of catabolism observed in children is caused by a diversion of protein synthesis from growth to tissue repair.

The effect of complete excision on stage III neuroblastoma: a report of the European Neuroblastoma Study Group.

UNLABELLED: Current opinion is divided about the value of excisional surgery in Evans stage III neuroblastoma. AIMS: To evaluate and correlate the survival of patients with stage III neuroblastoma with the effectiveness of the surgical excision, as assessed by (1) the surgeon (resection data) at the time of operation and (2) the pathologist (excision data). METHODS: The ENSG (European Neuroblastoma Study Group) database of 202 patients from 29 centres with proven stage III were analysed. The data include all patients with neuroblastoma diagnosed between 1982 and 1992 and their subsequent follow-up. RESULTS: Patients were grouped according to the extent of resection (100%, 75% to 99%, and < 75%) and the completeness of excision (complete, microscopic residual, macroscopic residual). There were 123 with resection data, a subgroup of 104 with excision data, and 27 with no excision. There was no statistically significant difference (log rank test) in overall survival (p = 0.11) or event-free survival between the resection subgroups, even when the data from patients without resection were included. Complete excision was associated with a highly significant survival advantage, in terms of overall survival (P = .007) and event-free survival (P = .006). This effect is most obvious among patients with the worst prognosis: older children and those with an abdominal tumour. CONCLUSION: Histological confirmation of complete excision confers a significant survival advantage for patients with stage III neuroblastoma and justifies a painstaking attempt at complete resection.