The Association of Weight With Surgical Morbidity in Infants Undergoing Enterostomy Reversal: A Study of the NSQIP-Pediatrics Database.

INTRODUCTION: Optimal criteria and timing for enterostomy closure (EC) in neonates is largely based on clinical progression and adequate weight, with most institutions using 2.0-2.5 kg as the minimum acceptable weight. It is unclear how the current weight cutoff affects post-operative morbidity. AIM: To determine how infant weight at the time of EC influences 30-day complications. METHODS: Infants weighing ≤4000 g who underwent EC were identified in the 2012-2019 ACS NSQIP-P database. Demographics, comorbidities, and 30-day outcomes were assessed using univariate analysis. Multivariable logistic regression controlling for ASA score, nutritional support, and ventilator support was used to estimate the independent association of weight on risk of 30-day complications. RESULTS: A total of 1692 neonates from the NSQIP-P database during the years 2012-2019 met inclusion criteria. Neonates weighing <2.5 kg were significantly more likely to have a younger gestational age, require ventilator support, and have concurrent comorbidities. Major morbidity, a composite outcome of the individual postoperative complications, was observed in 283 (16.7%) infants. ASA classifications 4 and 5, dependence on nutritional support, and ventilator support were independently associated with increased risk of 30-day complications. With respect to weight, we found no significant difference in major morbidity between infants weighing <2.5 kg and infants weighing ≥2.5 kg. CONCLUSION: Despite using a robust, national dataset, we could find no evidence that a defined weight cut-off was associated with a reduction in major morbidity, indicating that weight should not be a priority factor when determining eligibility for neonatal EC. LEVEL OF EVIDENCE: III.

Effects of tall man lettering on the visual behaviour of critical care nurses while identifying syringe drug labels: a randomised in situ simulation.

BACKGROUND: Patients in intensive care units are prone to the occurrence of medication errors. Look-alike, sound-alike drugs with similar drug names can lead to medication errors and therefore endanger patient safety. Capitalisation of distinct text parts in drug names might facilitate differentiation of medication labels. The aim of this study was to test whether the use of such 'tall man' lettering (TML) reduces the error rate and to examine effects on the visual attention of critical care nurses while identifying syringe labels. METHODS: This was a prospective, randomised in situ simulation conducted at the University Hospital Zurich, Zurich, Switzerland. Under observation by eye tracking, 30 nurses were given 10 successive tasks involving the presentation of a drug name and its selection from a dedicated set of 10 labelled syringes that included look-alike and sound-alike drug names, half of which had TML-coded labels.Error rate as well as dwell time, fixation count, fixation duration and revisits were analysed using a linear mixed-effects model analysis to compare TML-coded with non-TML-coded labels. RESULTS: TML coding of syringe labels led to a significant decrease in the error rate (from 5.3% (8 of 150 in non-TML-coded sets) to 0.7% (1 of 150 in TML-coded sets), p<0.05). Eye tracking further showed that TML affects visual attention, resulting in longer dwell time (p<0.01), more and longer fixations (p<0.05 and p<0.01, respectively) on the drug name as well as more frequent revisits (p<0.01) compared with non-TML-coded labels. Detailed analysis revealed that these effects were stronger for labels using TML in the mid-to-end position of the drug name. CONCLUSIONS: TML in drug names changes visual attention while identifying syringe labels and supports critical care nurses in preventing medication errors.

Magnetic Appendix: An Uncommon Indication for Appendectomy.

Foreign object ingestions are a common occurrence in pediatrics, often necessitating endoscopic or surgical intervention. The ingestion of multiple magnets poses an increased risk for serious complications. Our article presents a case of a five-year-old boy who swallowed two pennies and four magnets. The latter failed to pass spontaneously and were lodged in the appendiceal orifice resulting in a challenging and unsuccessful endoscopic retrieval and hence required laparoscopic exploration, appendectomy, and partial cecal resection.

Superior Mesenteric Artery Stenosis Due to Disseminated Tuberculosis in a Pediatric Patient.

Disseminated tuberculosis (TB) associated with mesenteric arteritis has not been established in children. We present the case of an 8-year-old woman who presented with TB and superior mesenteric artery stenosis. Although rare, large vessel involvement from Takayasu arteritis can occur in TB. Evaluation for mesenteric vessel involvement should be considered in pediatric patients presenting with widely disseminated TB and abdominal pain.

Bilateral lower extremity ischemia due to a retained umbilical artery catheter in a preterm neonate.

The use of umbilical artery catheters is common in Neonatal Intensive Care Units, especially in low and very low birth weight neonates. Rarely, these can break or fracture, leading to a retained fragment, which can embolize or cause thrombosis. We pre sent a case of a very low birth weight, premature neonate, 940 grams, with a retained umbilical artery catheter that led to bilateral lower extremity ischemia. A laparotomy with aortotomy was per formed for retrieval of the catheter. Chronic occlusion of the aorta with collateralization is a long-term complication associated with this case.

Sacroiliac Pain: Structural Causes of Pain Referring to the SI Joint Region.

BACKGROUND: The currently reported incidence of primary sacroiliac joint (SIj) pathology ranges from 15% to 30%. The differential diagnosis of SIj region pain includes pain generated from the lumbar spine, the SIj, and the hip joint. The origins of SIj dysfunctions are controversial and pain generation from this joint has been questioned. PURPOSE: Retrospectively analyze the relative incidence of lumbar spine, SIj, and hip joint etiologies in patients complaining of ≥50% SIj region pain. STUDY DESIGN: This is a retrospective cohort case series. METHODS: Inclusion criteria: chief complaint SIj pain (≥50% of overall complaint). In total, 124 patients charts were reviewed from a single spine surgeon's clinic. All patients were evaluated by the same 2 practitioners and all cases were reviewed for clinical examination findings, diagnostic tests performed, final diagnosis, treatment, and clinical follow-up. RESULTS: After complete diagnostic workup, 112 (90%) had lumbar spine pain, 5 (4%) had hip pain, 4 (3%) had primary SIj pain, and 3 (3%) had an undetermined source of pain upon initial diagnosis. SIj pain generation was confirmed via fluoroscopy-guided diagnostic injections. Following designated treatment, 11 (9%) patients returned to clinic at an average of 2.4 years complaining of continued/recurrent SIj region pain. Further investigation revealed 6 patients had confirmed pain generation from the lumbar spine, 3 patients had confirmed pain generation from the SIj, and 2 patients had undetermined sources of pain. CONCLUSIONS: The SIj is a rare pain generator (3%-6%) in patients complaining of ≥50% SIj region pain and is a common site of referral pain from the lumbar spine (88%-90%). Clinicians ought to quantify areas of pain (via percent of overall complaint) when interviewing their patients complaining of low back pain to distinguish potential pain generators. Recommended breakdown of areas of interest include axial low back, SIj region, buttock/leg, groin/anterior thigh.

Navigation accuracy comparing non-covered frame and use of plastic sterile drapes to cover the reference frame in 3D acquisition.

BACKGROUND: Advancements in surgical navigation technology coupled with 3-dimensional (3D) radiographic data have significantly enhanced the accuracy and efficiency of spinal fusion implant placement. Increased usage of such technology has led to rising concerns regarding maintenance of the sterile field, as makeshift drape systems are fraught with breaches thus presenting increased risk of surgical site infections (SSIs). A clinical need exists for a sterile draping solution with these techniques. Our objective was to quantify expected accuracy error associated with 2MM and 4MM thickness Sterile-Z Patient Drape® using Medtronic O-Arm® Surgical Imaging with StealthStation® S7® Navigation System. Camera distance to reference frame was investigated for contribution to accuracy error. METHODS: A testing jig was placed on the radiolucent table and the Medtronic passive reference frame was attached to jig. The StealthStation® S7® navigation camera was placed at various distances from testing jig and the geometry error of reference frame was captured for three different drape configurations: no drape, 2MM drape and 4MM drape. The O-Arm® gantry location and StealthStation® S7® camera position was maintained and seven 3D acquisitions for each of drape configurations were measured. Data was analyzed by a two-factor analysis of variance (ANOVA) and Bonferroni comparisons were used to assess the independent effects of camera angle and drape on accuracy error. RESULTS: Median (and maximum) measurement accuracy error was higher for the 2MM than for the 4MM drape for each camera distance. The most extreme error observed (4.6 mm) occurred when using the 2MM and the 'far' camera distance. The 4MM drape was found to induce an accuracy error of 0.11 mm (95% confidence interval, 0.06-0.15; P<0.001) relative to the no drape testing, regardless of camera distance. Medium camera distance produced lower accuracy error than either the close (additional 0.08 mm error; 95% CI, 0-0.15; P=0.035) or far (additional 0.21mm error; 95% CI, 0.13-0.28; P<0.001) camera distances, regardless of whether a drape was used. CONCLUSIONS: In comparison to the 'no drape' condition, the accuracy error of 0.11 mm when using a 4MM film drape is minimal and clinically insignificant.

Postnatal MRI for CDH: A pictorial review of late-presenting and recurrent diaphragmatic defects.

Late-presenting or recurrent diaphragmatic defects can pose a diagnostic challenge due to varying clinical presentations. Current diagnostic approaches include plain film radiograph for initial assessment, with other imaging modalities such as fluoroscopy, ultrasound, CT and MRI mainly utilized for troubleshooting. As a radiation-free modality, MRI can provide a more definitive diagnosis in particular cases due to its ability to visualize discontinuity of the diaphragm, distinguishing it from eventration. MRI can also accurately characterize hernia contents, defect location and size. We present our MRI technique and review cases of different hernia types with relevant discussion of the imaging findings and correlation with intraoperative findings. MRI can be a useful diagnostic tool in the assessment of late presenting or recurrent diaphragmatic hernias.

Intraductal papillary mucinous neoplasm in a neonate with congenital hyperinsulinism and a de novo germline SKIL gene mutation.

A 3 day old infant with persistent severe hypoglycemia was found to have a cystic pancreatic tumor. Cessation of glucose infusion led to severe hypoglycemia. Pancreaticoduodenectomy was performed and revealed an intraductal papillary mucinous neoplasm (IPMN) with high-grade dysplasia. Sequencing of the IPMN revealed a KRAS gene mutation not present in surrounding normal tissues. Deep sequencing of the patient's blood for KRAS mutations showed no evidence of mosaicism. Whole exome sequencing of the blood of the patient and both parents revealed a de novo germline SKIL mutation in the child that was not present in either parent. This suggests a possible role for SKIL in the pathogenesis of pancreatic tumors.

Intraoperative monitoring may prevent neurologic injury in non-myelopathic patients undergoing ACDF.

The efficacy of spinal cord monitoring for patients undergoing anterior cervical discectomy and fusion (ACDF) as indicated for radiculopathy without myelopathy is debated in the literature. The reported rate of complications is low for this procedure. Previous studies have shown both improvements in outcome as well as no change in monitored vs. unmonitored patients. We report two cases where intraoperative spinal cord monitoring using somatosensory and transcranial motor evoked potentials detected impending iatrogenic injury to the spinal cord. In both cases, changes in the electrophysiological data prompted intervention and prevented a permanent neurological deficit. Based on these observations we recommend spinal cord monitoring using sensory and motor evoked potentials to prevent new deficits in non-myelopathic patients undergoing ACDF surgery.

Recombinant human bone morphogenetic protein-2-augmented transforaminal lumbar interbody fusion for the treatment of chronic low back pain secondary to the homogeneous diagnosis of discogenic pain syndrome: two-year outcomes.

STUDY DESIGN: A retrospective observational study. OBJECTIVE: To assess clinical outcomes, perioperative complications, revision surgery rates, and recombinant human bone morphogenetic protein-2 (BMP-2)-related osteolysis, heterotopic bone, and unexplained postoperative radiculitis (BMPP) in a group of patients treated with BMP-2-augmented transforaminal lumbar interbody fusion (bTLIF) for the homogeneous diagnosis of discogenic pain syndrome (DPS) and to put forth the algorithm used to make the diagnosis. SUMMARY OF BACKGROUND DATA: There is a paucity of literature describing outcomes of TLIF for the homogeneous diagnosis of DPS, an old but controversial member of the lumbar degenerative disease family. METHODS: The registry from a single surgeon was queried for patients who had undergone bTLIF for the homogeneous diagnosis of DPS, which was made via specific diagnostic algorithm. Clinical outcomes were determined by analyzing point improvement from typical outcome questionnaires and the data from Patient Satisfaction and Return to Work questionnaires. Independent record review was used to assess all outcomes. RESULTS: Eighty percent of the cohort (36/45) completed preoperative and postoperative outcome questionnaires at an average follow-up of 41.9 ± 11.9 months, which demonstrated significant clinical improvement: Oswestry Disability Index = 16.4 (P < 0.0001), 12-Item Short Form Health Survey physical component summary score = 10.0 (P < 0.0001), and a Numeric Rating Scale for back pain = 2.3 (P < 0.0001). The median patient satisfaction score was 9.0 (10 = complete satisfaction), and 84.4% (27/32) of the cohort were able to return to their preoperative job, with or without modification. There were 3 perioperative complications, 4 revision surgical procedures, and 11 cases of benign BMPP. There were no incidents of the intraoperative dural tears or nerve root injury, and litigation involvement (11/36, P > 0.17), preoperative depression (15/36, P > 0.19) or prior discectomy/decompression (14/36, P < 0.37) was not a predictor of outcomes. CONCLUSION: Although limited by retrospective design and small cohort, the results of this investigation suggest that bTLIF is a reasonable treatment option for patients who experience DPS and affords high patient satisfaction. A larger study is needed to confirm these findings. LEVEL OF EVIDENCE: 4.

Bile salts increase epithelial cell proliferation through HuR-induced c-Myc expression.

BACKGROUND: Bile salts increase intestinal mucosal proliferation through an increase in c-Myc, a transcription factor that controls the expression of numerous translation regulatory proteins. HuR is an RNA-binding protein that regulates translation of target mRNAs. RNA-binding proteins can control mRNA stability by binding to AU- and U-rich elements located in the 3'-untranslated regions (3'-UTRs) of target mRNAs. AIM: To determine how bile salt-induced c-Myc stimulates enterocyte proliferation. METHODS: Enterocyte proliferation was measured both in vivo using C57Bl6 mice and in vitro using IEC-6 cells after taurodeoxycholate (TDCA) supplementation. HuR and c-Myc protein expression was determined by immunoblot. c-Myc mRNA expression was determined by PCR. HuR expression was inhibited using specific small interfering RNA. HuR binding to c-Myc mRNA was determined by immunoprecipitation. RESULTS: TDCA increased enterocyte proliferation in vivo and in vitro. TDCA stimulates translocation of HuR from the nucleus to the cytoplasm. Cytoplasmic HuR regulates c-Myc translation by HuR binding to the 3'-UTR of c-Myc mRNA. Increased TDCA-induced c-Myc increases enterocyte proliferation. CONCLUSIONS: Bile salts have beneficial effects on the intestinal epithelial mucosa, which are important in maintaining intestinal mucosal integrity and function. These data further support an important beneficial role of bile salts in regulation of mucosal growth and repair. Decreased enterocyte exposure to luminal bile salts, as occurs during critical illness, liver failure, starvation, and intestinal injury, may have a detrimental effect on mucosal integrity.

Bile salt supplementation acts via the farnesoid X receptor to alleviate lipopolysaccharide-induced intestinal injury.

BACKGROUND: Intestinal barrier integrity may be disrupted in many conditions allowing for bacterial invasion and ensuing systemic illness. We investigated the efficacy and mechanism of bile salts in protecting the intestinal mucosa integrity after injury through stimulation of cell proliferation and an increased resistance to apoptosis. METHODS: Over 7 days, wild-type C57Bl/6J and Nr1h4(tm1Gonz)/J (farnesoid X receptor [FXR] knockout) male mice received either liquid rodent chow alone (for control animals) or with added 50 mg/kg per day of taurodeoxycholic acid (TDCA; for experimental animals). On day 6, all mice received 10 mL/kg of lipopolysaccharide intraperitoneally. On day 7, small intestines were harvested. After immunohistochemistry with hematoxylin and eosin, activated caspase-3, and 5-bromo2'-deoxy-uridine (BrdU), mean proliferating and apoptotic cells were determined with light microscopy. In vitro, FXR proteins were immunoblotted from cultured cells after exposure to TDCA. FXR expression was then inhibited in the presence and absence of TDCA. Intestinal epithelial proliferation along with c-Myc and FXR protein expressions were determined. RESULTS: C57Bl/6J mice exhibited significant mucosal enterocyte proliferation and decreased mucosal enterocyte apoptosis when provided with supplemental TDCA in their diet. Inhibition of FXR, both in vivo and in vitro, prevented the bile salt-induced enterocyte proliferation and resistance to apoptosis. TDCA exposure stimulated nuclear translocation of FXR resulting in increased expression of c-Myc. CONCLUSION: A diet supplemented with bile salts, especially in patients who have decreased luminal bile salt, may prove beneficial and therapeutic in critical illness where intestinal injury is part of the spectrum.

Deoxycholic acid causes DNA damage while inducing apoptotic resistance through NF-κB activation in benign Barrett's epithelial cells.

Gastroesophageal reflux is associated with adenocarcinoma in Barrett's esophagus, but the incidence of this tumor is rising, despite widespread use of acid-suppressing medications. This suggests that refluxed material other than acid might contribute to carcinogenesis. We looked for potentially carcinogenetic effects of two bile acids, deoxycholic acid (DCA) and ursodeoxycholic acid (UDCA), on Barrett's epithelial cells in vitro and in vivo. We exposed Barrett's (BAR-T) cells to DCA or UDCA and studied the generation of reactive oxygen/nitrogen species (ROS/RNS); expression of phosphorylated H2AX (a marker of DNA damage), phosphorylated IkBα, and phosphorylated p65 (activated NF-κB pathway proteins); and apoptosis. During endoscopy in patients, we took biopsy specimens of Barrett's mucosa before and after esophageal perfusion with DCA or UDCA and assessed DNA damage and NF-κB activation. Exposure to DCA, but not UDCA, resulted in ROS/RNS production, DNA damage, and NF-κB activation but did not increase the rate of apoptosis in BAR-T cells. Pretreatment with N-acetyl-l-cysteine (a ROS scavenger) prevented DNA damage after DCA exposure, and DCA did induce apoptosis in cells treated with NF-κB inhibitors (BAY 11-7085 or AdIκB superrepressor). DNA damage and NF-κB activation were detected in biopsy specimens of Barrett's mucosa taken after esophageal perfusion with DCA, but not UDCA. These data show that, in Barrett's epithelial cells, DCA induces ROS/RNS production, which causes genotoxic injury, and simultaneously induces activation of the NF-κB pathway, which enables cells with DNA damage to resist apoptosis. We have demonstrated molecular mechanisms whereby bile reflux might contribute to carcinogenesis in Barrett's esophagus.

Sphingosine-1-phosphate regulates the expression of adherens junction protein E-cadherin and enhances intestinal epithelial cell barrier function.

BACKGROUND: The regulation of intestinal barrier permeability is important in the maintenance of normal intestinal physiology. Sphingosine-1-phosphate (S1P) has been shown to play a pivotal role in enhancing barrier function in several non-intestinal tissues. The current study determined whether S1P regulated function of the intestinal epithelial barrier by altering expression of E-cadherin, an important protein in adherens junctions. METHODS: Studies were performed upon cultured differentiated IECs (IEC-Cdx2L1 line) using standard techniques. RESULTS: S1P treatment significantly increased levels of E-cadherin protein and mRNA in intestinal epithelial cells (IECs) and also led to E-cadherin localizing strongly to the cell-cell border. S1P also improved the barrier function as indicated by a decrease in 14C-mannitol paracellular permeability and an increase in transepithelial electrical resistance (TEER) in vitro. CONCLUSIONS: These results indicate that S1P increases levels of E-cadherin, both in cellular amounts and at the cell-cell junctions, and leads to improved barrier integrity in cultured intestinal epithelial cells.

Dietary bile acid supplementation improves intestinal integrity and survival in a murine model.

PURPOSE: In vitro supplementation of the bile salt, taurodeoxycholic acid (TDCA), has been shown to stimulate proliferation and prevent intestinal apoptosis in IEC-6 cells. We hypothesize that addition of TDCA to a rodent liquid diet will be protective against induced intestinal injury. METHODS: C57Bl6 mice were fed a liquid diet with or without 50-mg/(kg d) TDCA supplementation. After 6 days, the mice were injected with lipopolysaccharide (LPS) (10 mg/kg) to induce intestinal injury. Specimens were obtained 24 hours later and evaluated for intestinal apoptosis, crypt proliferation, and villus length. A separate cohort of animals was injected with LPS (25 mg/kg) and followed 7 days for survival. RESULTS: Mice whose diet was supplemented with TDCA had significantly increased survival. After LPS-induced injury, mice supplemented with TDCA showed decreased intestinal apoptosis by both H&E and caspase-3. They also had increased intestinal proliferation by 5-bromo-2'deoxyuridine staining and increased villus length. CONCLUSIONS: Dietary TDCA supplementation alleviates mucosal damage and improves survival after LPS-induced intestinal injury. Taurodeoxycholic acid is protective of the intestinal mucosa by increasing resistance to injury-induced apoptosis, stimulating enterocyte proliferation, and increasing villus length. Taurodeoxycholic acid supplementation also results in an increased survival benefit. Therefore, bile acid supplementation may potentially protect the intestine from injury or infection.

Cutaneous ciliated cyst: a case report with focus on mullerian heterotopia and comparison with eccrine sweat glands.

Cutaneous ciliated cyst is an exceedingly rare, benign lesion most commonly found in the dermis or subcutis of the lower extremities of young female patients in their second and third decades. The pathogenesis of the cyst is unknown. We report a cutaneous ciliated cyst in the lower extremity of a 13-year-old female patient. On histologic examination, clusters of eccrine sweat glands were observed adjacent to the cyst. Upon comparison of the immunohistochemical profile of the cutaneous ciliated cyst and the eccrine sweat glands, they appeared almost completely unrelated. The histologic, immunohistochemical, and ultrastructural findings of this case and the literature provide evidence in favor of the Mullerian heterotopia theory.

Acid and bile salt-induced CDX2 expression differs in esophageal squamous cells from patients with and without Barrett's esophagus.

BACKGROUND & AIMS: It is not clear why only a minority of patients with gastroesophageal reflux disease (GERD) develop Barrett's esophagus. We hypothesized that differences among individuals in molecular pathways activated when esophageal squamous epithelium is exposed to reflux underlie the development of Barrett's metaplasia. METHODS: We used esophageal squamous cell lines from patients who had GERD with Barrett's esophagus (normal esophageal squamous [NES]-B3T and NES-B10T) and without Barrett's esophagus (NES-G2T and NES-G4T) to study effects of acid and bile salts on expression of the CDX2 gene. Bay 11-705, Ad5 inhibitor kappaB(IkappaB)alpha-SR, and site-directed mutagenesis were used to explore effects of nuclear factor-kappaB (NF-kappaB) inhibition on CDX2 promoter activity; DNA binding of the NF-kappaB subunits p50 and p65 was assessed by chromatin immune-precipitation. RESULTS: Acid and bile salts increased CDX2 messenger RNA (mRNA), protein, and promoter activity in NES-B3T and NES-B10T cells, but not in NES-G2T or NES-G4T cells. Inhibition of NF-kappaB abolished the increase in CDX2 promoter activity. Increased CDX2 promoter activity was associated with nuclear translocation of p50, which bound to the promoter. We found CDX2 mRNA in 7 of 10 esophageal squamous biopsy specimens from patients with Barrett's esophagus, but in only 1 of 10 such specimens from patients who had GERD without Barrett's esophagus. CONCLUSIONS: Acid and bile salts induce CDX2 mRNA and protein expression in esophageal squamous cells from patients with Barrett's esophagus, but not from GERD patients without Barrett's esophagus. We speculate that these differences in acid- and bile salt-induced activation of molecular pathways may underlie the development of Barrett's metaplasia.

Intraabdominal pulmonary sequestration presenting with elevated urinary normetanephrine levels.

Carrying a prenatal diagnosis of a left-sided intraabdominal mass, a term female newborn underwent postnatal imaging that confirmed a left suprarenal mass. Urinary normetanephrine levels were elevated. Given a preoperative diagnosis of neuroblastoma, the baby underwent an uneventful resection of the mass en bloc with the left adrenal gland. The pathologic examination returned pulmonary sequestration and a normal adrenal gland. Postoperative urinary catecholamines were normal. To the best of our knowledge, this is the first description of a newborn with an intraabdominal pulmonary sequestration presenting with elevated urinary catecholamines.