Screening for malnutrition in emergency laparotomy patients: a comparison of three tools.

INTRODUCTION: Malnourished patients undergoing emergency laparotomy are at risk of significant morbidity. The optimum screening tool to identify such patients in practice and research is yet to be determined. This study aims to compare the performance of three nutrition risk tools in predicting time without enteral nutrition in this population. METHODS: A prospective cohort study (NCT04696367) was conducted across two sites, recruiting patients undergoing National Emergency Laparotomy Audit eligible procedures. Data collected included demographics, diagnosis, procedure and outcomes. Nutrition risk was assessed using three tools: Malnutrition Universal Screening Tool (MUST) score, Nutritional Risk Index (NRI) and Nutritional Risk Score 2002 (NRS-2002). Complications were assessed with the Comprehensive Complication Index. Quality of life was measured at baseline and 5 days postsurgery using EQ-5D-5L. RESULTS: A total of 59 patients were recruited. Median age was 69 years. Of the 59 participants, 23 were judged high risk using MUST score, 13 using NRS and 8 using NRI. Median time to restart enteral intake was 7 days (interquartile range 7-14). Time without intake was correlated with increasing score using MUST (r=0.463, p<0.001) and NRS-2002 (r=0.296, p=0.03) but not NRI (r=-0.121, p=0.38). High-risk nutritional groups also had increased length of hospital stay, but not complication scores. CONCLUSIONS: Patients undergoing emergency laparotomy spend a prolonged time without enteral nutrition. Although all nutritional tools demonstrated some propensity to identify patients at higher risk of needing nutritional support, their performance was variable. Nevertheless, some may be useful in future clinical studies.

Paediatric acute mastoiditis, then and now: is it more of a problem now?

BACKGROUND: Acute mastoiditis is a significant cause of morbidity in the paediatric population. This paper reviews our experience with this condition over the last 10 years and compares it with historical data from Alder Hey Children's Hospital, Liverpool, UK. METHOD: A retrospective case note review of patients who presented between 2003 and 2012 was performed. RESULTS: Forty-six patients with acute mastoiditis were identified. Imaging with computed tomography and magnetic resonance imaging was carried out in 14 cases (30.4 per cent). Intracranial complications were identified in six patients (13.0 per cent), one of whom required neurosurgical intervention. In 27 cases (58.7 per cent), a surgical procedure was performed. Data from 1995 to 2000 revealed similar rates of imaging (30.0 per cent), but significantly lower rates of surgical intervention (23 per cent). A lower rate of intracranial complications (4.8 per cent) in the historical cohort did not prove to be statistically significant (p = 0.419). CONCLUSION: The numbers of paediatric patients presenting with acute mastoiditis appears essentially unchanged. Improvement in imaging technology and aids to interpretation may explain the apparent increase of intracranial complications.

Tracheocutaneous fistula following paediatric tracheostomy--a 14-year experience at Alder Hey Children's Hospital.

OBJECTIVE: To assess the rate of tracheocutaneous fistula requiring surgical repair and the complications and outcomes following it in the ENT department of a tertiary referral university paediatric hospital. METHODS: A retrospective review of all children requiring airway support with a tracheostomy between 1995 and 2009 and subsequently requiring closure of tracheocutaneous fistula. RESULTS: One hundred and ninety-three children underwent 196 tracheostomies. Seventy-three children were successfully decannulated until now. Twenty-three children (11.9%) required subsequent surgical closure of their tracheocutaneous fistula. In all these children the age at tracheostomy was less than 1 year old, and the median age at decannulation was 4 years old, (range 2-9 yo). Surgical repair was undertaken 6-12 months after decannulation. There were 4 minor complications in the postoperative period (wound infection, haemorrhage and early recurrence) and no major complications. None of the patients have experienced any degree of significant airway stenosis and there was no need for a repeat tracheotomy in any of the tracheocutaneous fistula closure patients. The cosmetic results were deemed to be good. CONCLUSIONS: Our rate of tracheocutaneous fistula compares well with the reported rates in the literature (13-43%). There appears to be a significant relation to age at tracheostomy and duration of tracheostomy.

Recurrent respiratory papillomatosis.

Recurrent respiratory papillomatosis (RRP) is a benign, often multi-focal neoplasm. A potentially fatal manifestation of human papilloma virus infection, the condition is characterised by multiple warty excrescences on the mucosal surface of the respiratory tract. RRP is rare--incidence is estimated at 3.5 per million person-years, with a prevalence of 4 in 100,000 children. Affected children usually require multiple interventions; the impact on patients, their families, and the healthcare system is considerable. Treatment of RRP accounts for an estimated dollar 109 million annual expenditure in the USA.

Passive smoking, allergic rhinitis and nasal obstruction in children.

Allergic rhinitis is a common cause of nasal obstruction in childhood. This prospective study looked at the effect of passive smoking on nasal obstruction in children with and without allergic rhinitis. Eighty-one children took part. Each child was asked to score his or her degree of nasal obstruction on a visual analogue scale. Exposure to passive smoking was determined subjectively using a parental questionnaire, and objectively by measuring the urinary cotinine/creatinine ratio. Results were tabulated using Microsoft Excel and analysed with SPSS statistical software. Nasal obstruction was significantly worse in children with a positive history of allergic rhinitis (p < 0.05). There was also a trend towards a higher nasal obstruction score in children without allergic rhinitis exposed to passive smoking compared to those who were not so exposed. As would be expected, nasal obstruction is worse in children with allergic rhinitis than in those without. Passive smoking tends to increase the symptom of nasal obstruction in children without allergic rhinitis.

Aryepiglottoplasty for laryngomalacia: the Alder Hey experience.

Laryngomalacia is the most common cause of stridor in infants. Severely affected children are at risk of feeding difficulties, apnoeic episodes and cor pulmonale secondary to upper airway obstruction. The aim of this study was to assess the outcome of aryepiglottoplasty. This is a simple surgical procedure that relieves the obstruction by dividing the aryepiglottic folds. Thirty children had an aryepiglottoplasty at the Royal Liverpool Children's Hospital between January 1995 and June 2001. The case notes of all 30 children were reviewed for age, sex, age at operation, indications, operative technique, complications and long-term outcomes. Complete resolution of stridor was obtained in 83 per cent of patients, with an improvement in a further 7 per cent. Post-operative complications included lower respiratory tract infections (13 per cent) and vomiting (7 per cent). In conclusion, simple endoscopic aryepiglottoplasty remains an effective way of treating upper airway obstruction in children. Its high resolution and low complication rate make it a safe, first choice procedure for treatment of moderate to severe laryngomalacia.

Otitis media in children.

Otitis media is the term used for a group of conditions characterized by inflammation of the middle-ear cleft. These conditions are particularly common in children where they present important diagnostic and therapeutic dilemmas.

Paediatric otolaryngology services in the UK: a postal questionnaire survey of ENT consultants.

Approximately half a million children in England and Wales receive in-patient or day-case surgical treatment annually. Otolaryngology is the surgical specialty that provides the greatest number of episodes of such care. As 30-50 per cent of our total volume of work is paediatric, we feel it is important to assess current attitudes to paediatric otolaryngological practice. In its year 2000 document Children's Surgery: a First Class Service, The Royal College of Surgeons (RCS) of England sets out recommendations on how children's surgical services should be delivered in the UK. A postal questionnaire was sent to all UK-based ENT consultant members of the British Association of Otorhinolaryngologists-Head and Neck Surgeons (BAO-HNS). The questionnaire was designed to assess the current practice of paediatric otolaryngology in the UK with an emphasis on the RCS recommendations. Wide variations were found, and they are discussed with reference to the recommendations.

Endoscopy: a must in neonatal respiratory distress.

Respiratory distress in a newborn presents both diagnostic and therapeutic dilemmas. Definitive treatment must be preceded by an accurate diagnosis other than in extremes. Complete tracheal rings are a very rare congenital cause of airway obstruction. Unlike other causes of upper airway obstruction, this cannot be relieved by tracheostomy, which may be counterproductive. We report the case of an 8-day-old female baby who presented with respiratory distress and was found to have complete tracheal rings and right pulmonary agenesis. The value of tracheo-bronchoscopy in this case cannot be overstressed.

Complete tracheal rings: lower airway symptoms can delay diagnosis.

Bronchial asthma is a very common condition seen in children diagnosed by clinical examination. While treating these children, all the other possible causes of breathlessness including complete tracheal rings should be considered. Further investigations in the form of endoscopy may need to be carried out in doubtful cases.

Advances in genetic manipulations in the treatment of hearing disorders.

Gene transfer into the inner ear is an attractive technology for clinical applications. It offers the hope of preventing, arresting, reversing or curing vestibular or hearing disorders caused by hereditary diseases or environmental insults. There are currently very few treatment options for vestibular disorders and sensorineural hearing loss, and therefore, it is important to investigate and develop new technologies for inner ear disease. In utero gene transfer may indeed be an option, but this technology will have many technical and ethical issues that remain to be overcome.

Glutamate and tachykinin receptors in central sensitization of withdrawal reflexes in the decerebrated rabbit.

This study assessed the involvement of NMDA and group I metabotropic glutamate receptors, and tachykinin NK1 and NK3 receptors, in central sensitization of withdrawal reflexes in the decerebrated rabbit. Reflexes evoked in the ankle flexor tibialis anterior and the knee flexor semitendinosus by electrical stimulation at the base of the toes were enhanced for 29-63 min after application of 20% mustard oil to the tips of the toes. Selective antagonists of mGlu1, mGlu5, NMDA and NR2B-subunit-containing NMDA glutamate receptors, as well as NK1, and NK3 receptors, and a non-selective blocker of all tachykinin receptors, were assessed for their effects on the magnitude and duration of the increase in reflexes induced by mustard oil. Dizocilpine, an antagonist of all NMDA receptors (1 mg intrathecal) abolished facilitation of tibialis anterior reflexes and significantly reduced the magnitude and duration of increase of the semitendinosus response. The NR2B-subtype selective antagonist CP-101,606 decreased the magnitude of facilitation of both reflexes but had no effect on duration of enhancement. Selective antagonists for the mGlu1 (CPCCOEt, 1-3 mg intrathecal), mGlu5 (MPEP, 0.2-1 mg intrathecal), NK1 (L-733,060, 0.3 mg intrathecal) or NK3 (SR 142,801, 1 mg kg(-1) i.v.) receptors had no effect on the amplitude or duration of sensitization. However, the non-selective tachykinin receptor blocker ZD-6021 (0.3 mg intrathecal) reduced the amplitude but not the duration of sensitization in the flexor reflexes. Combination of ZD-6021 with CP-101,606 (doses as above) decreased both aspects of the sensitization response. Dizocilpine reduced reflexes evoked from the heel per se, and dizocilpine, CP-101,606 and ZD-6021 reduced arterial blood pressure. Otherwise the drugs used had no effects on baseline variables. The present data confirm the importance of NMDA receptors as a critical part of the process of central sensitization, provide no evidence for a role of metabotropic glutamate receptors, and show that simultaneous blockade of all tachykinin receptors is required to reveal their role in hyperalgesia. The data further indicate that a combined pharmacological approach offers a potential way forward for the development of new antihyperalgesic agents.

A sinonasal primary Ewing's sarcoma.

Nasal fractures are a common complaint familiar to all otolaryngologists. Sinonasal primary Ewing's sarcomas are extremely rare. The case of a 9-year-old boy is presented whose nasal fracture and subsequent lateral nasal wall hematoma revealed an underlying Ewing's sarcoma. There are several unusual features in the history and clinical course of this patient. Following biopsies, immunohistochemistry proved essential in distinguishing a Ewing's sarcoma from other small cell tumours. It is important that a seemingly common condition can be the first presentation of a less common, more sinister pathology.

Direct lung delivery of para-aminosalicylic acid by aerosol particles.

Para-aminosalicylic acid (PAS), a tuberculostatic agent, was formulated into large porous particles for direct delivery into the lungs via inhalation. These particles possess optimized physical properties for deposition throughout the respiratory tract, a drug loading of 95% by weight and physical stability over 4 weeks at elevated temperatures. Upon insufflation in rats, PAS concentrations were measured in plasma, lung lining fluid and homogenized whole lung tissue. Systemic drug concentrations peaked at 15 min, with a maximum plasma concentration of 11+/-1 microg/ml. The concentration in the lung lining fluid was 148+/-62 microg/ml at 15 min. Tissue concentrations were 65+/-20 microg/ml at 15 min and 3.2+/-0.2 microg/ml at 3h. PAS was cleared within 3 h from the lung lining fluid and plasma but was still present at therapeutic concentrations in the lung tissue. These results suggest that inhalation delivery of PAS can potentially allow for a reduction in total dose delivered while providing for higher local and similar peak systemic drug concentrations as compared to those obtained upon oral PAS dosing. Similar particles could potentially be used for the delivery of additional anti-tuberculosis agents such as rifampicin, aminoglucosides or fluoroquinolones.

Tetrodotoxin block of A-fibre conduction and its effect on reflex responses evoked by electrical stimulation of the sural nerve in the decerebrated rabbit.

In the present study, we have investigated the viability of using tetrodotoxin (TTX) to induce selective blockade of myelinated fibre conduction in rabbit sural nerve, and explored some aspects of reflexes evoked by non-myelinated sural nerve afferents before and after application of TTX. In rabbits decerebrated under halothane-nitrous oxide anaesthesia, application of 30 nM TTX to the desheathed sural nerve completely blocked Abeta and Adelta waves of the compound action potential evoked by electrical stimulation of the nerve at 95 times threshold. The amplitude of C-fibre volleys evoked by these stimuli was reduced to a mean of 60 % of pre-treatment values. Reflexes evoked in medial gastrocnemius motoneurones by sural nerve stimulation showed corresponding changes after TTX treatment, with activation latency increasing from 5-7 ms in the control state to > 100 ms after TTX application. Temporal summation (wind up) in long latency reflexes (> 100 ms) was significantly enhanced after application of TTX. These data show that low concentrations of TTX can selectively block conduction in rabbit sural nerve A-fibres, providing a method for studying the central actions of non-myelinated C-fibres in isolation.

Paediatric acute mastoiditis: the Alder Hey experience.

Acute mastoiditis was a common condition in the pre-antibiotic era, but has become rare now with the widespread use of antibiotics. A retrospective study was carried out of patients with acute mastoiditis who were seen at Alder Hey Children's Hospital, Liverpool over a five-year period. Their case records were identified and details of gender, age at presentation, symptoms, signs and clinical management were noted and analysed. Twenty-one patients who presented with acute mastoiditis were identified. The patients' age at presentation ranged from three months to 14 years. Five cases out of 21 (23.8 per cent) were under one year of age. Eighteen cases (85.7 per cent) presented with post-aural swelling while 12 (57.1 per cent) had aural discharge. All patients were treated with intravenous antibiotics and only five patients (23.8 per cent) required surgical intervention in the form of a cortical mastoidectomy with, or without, myringotomy. A significant number of cases can be treated conservatively with intravenous antibiotics. Surgery in the form of cortical mastoidectomy can be reserved for complicated cases and in those in whom conservative treatment has failed.