Introduction of paediatric laparoscopic cholecystectomy in Scotland: a national review of incidence, outcomes and training implications.

BACKGROUND: We present a national data series to determine the incidence, outcomes and training opportunities for laparoscopic cholecystectomy among children <16yrs in Scotland as performed by paediatric surgeons. METHODS: A retrospective cohort study was performed reviewing laparoscopic cholecystectomy performed at the three children's hospitals in Scotland. Using the National Records Scotland Database mid-year population estimates; age and sex specific annual incidence rates of laparoscopic cholecystectomy were calculated between 1998-2015. Trends in the observed case mix were tested using univariate linear regression and students t-test. RESULTS: Between 1998-2015; 141 paediatric laparoscopic cholecystectomies were performed. The annual rate of cholecystectomy increased from 0.10/100,000 to 0.88/100,000 (p = 0.069). Sex specific incidences were identified; 0.00-0.90/100,000 (p = 0.098) in girls and 0.20-0.86/100,000 in boys (p = 0.28). Cholecystectomy was more frequent in girls (63%; p = 0.04). No major complications, defined as common bile duct injury or mortality were identified. Overall; 75% of cases were performed by consultants (n = 17 consultants, median = 5 cases, p < 0.05) and 25% by trainees. CONCLUSION: We have demonstrated that despite a low national case load (8 laparoscopic cholecystectomies per year) paediatric surgeons have been able to perform laparoscopic cholecystectomy safely without major morbidity.

Measurement of Typhi Vi antibodies can be used to assess adaptive immunity in patients with immunodeficiency.

Vaccine-specific antibody responses are essential in the diagnosis of antibody deficiencies. Responses to Pneumovax II are used to assess the response to polysaccharide antigens, but interpretation may be complicated. Typhim Vi® , a polysaccharide vaccine for Salmonella typhoid fever, may be an additional option for assessing humoral responses in patients suspected of having an immunodeficiency. Here we report a UK multi-centre study describing the analytical and clinical performance of a Typhi Vi immunoglobulin (Ig)G enzyme-linked immunosorbent assay (ELISA) calibrated to an affinity-purified Typhi Vi IgG preparation. Intra- and interassay imprecision was low and the assay was linear, between 7·4 and 574 U/ml (slope = 0·99-1·00; R2  > 0·99); 71% of blood donors had undetectable Typhi Vi IgG antibody concentrations. Of those with antibody concentrations  > 7·4 U/ml, the concentration range was 7·7-167 U/ml. In antibody-deficient patients receiving antibody replacement therapy the median Typhi Vi IgG antibody concentrations were  < 25 U/ml. In vaccinated normal healthy volunteers, the median concentration post-vaccination was 107 U/ml (range 31-542 U/ml). Eight of eight patients (100%) had post-vaccination concentration increases of at least threefold and six of eight (75%) of at least 10-fold. In an antibody-deficient population (n = 23), only 30% had post-vaccination concentration increases of at least threefold and 10% of at least 10-fold. The antibody responses to Pneumovax II and Typhim Vi® correlated. We conclude that IgG responses to Typhim Vi® vaccination can be measured using the VaccZyme Salmonella typhi Vi IgG ELISA, and that measurement of these antibodies maybe a useful additional test to accompany Pneumovax II responses for the assessment of antibody deficiencies.

Validity of an ultra-wideband local positioning system to measure locomotion in indoor sports.

The validity of an Ultra-wideband (UWB) positioning system was investigated during linear and change-of-direction (COD) running drills. Six recreationally-active men performed ten repetitions of four activities (walking, jogging, maximal acceleration, and 45º COD) on an indoor court. Activities were repeated twice, in the centre of the court and on the side. Participants wore a receiver tag (Clearsky T6, Catapult Sports) and two reflective markers placed on the tag to allow for comparisons with the criterion system (Vicon). Distance, mean and peak velocity, acceleration, and deceleration were assessed. Validity was assessed via percentage least-square means difference (Clearsky-Vicon) with 90% confidence interval and magnitude-based inference; typical error was expressed as within-subject standard deviation. The mean differences for distance, mean/peak speed, and mean/peak accelerations in the linear drills were in the range of 0.2-12%, with typical errors between 1.2 and 9.3%. Mean and peak deceleration had larger differences and errors between systems. In the COD drill, moderate-to-large differences were detected for the activity performed in the centre of the court, increasing to large/very large on the side. When filtered and smoothed following a similar process, the UWB-based positioning system had acceptable validity, compared to Vicon, to assess movements representative of indoor sports.

Vitamin E homologues α- and γ-tocopherol are not associated with bone turnover markers or bone mineral density in peri-menopausal and post-menopausal women.

UNLABELLED: In a large cohort of older women, we investigated the relationships that different forms of vitamin E may have with bone turnover markers and bone mineral density (BMD). We found a suggestive positive association between serum alpha-tocopherol and BMD at the femoral neck, but no other clinically relevant observations. INTRODUCTION: Vitamin E has anti-oxidant and anti-inflammatory properties hypothesized to benefit bone, but limited studies exist regarding its homologues. We examined circulating and dietary α- and γ-tocopherols with bone turnover markers (BTMs) and bone mineral density (BMD), and the role of inflammation in this relationship. METHODS: We performed two cross-sectional analyses from two visits (V2, 1997-1999, n = 3883; V3, 2007-2011, n = 2130) of the Aberdeen Prospective Osteoporosis Screening Study. Dietary and supplement intakes by food frequency questionnaire were assessed at both visits. V2 BTMs (urinary free pyridinoline and deoxypyridinoline, serum N-terminal propeptide of type 1 collagen) and V3 serum α- and γ-tocopherols, inflammatory markers (interleukin-6 [IL-6], serum amyloid A [SAA], high-sensitivity C-reactive protein [hs-CRP], E-selectin) and dual X-ray absorptiometry BMD at the femoral neck and lumbar spine were collected. Food sources of tocopherol homologues and diet-serum correlations were determined. The relationships between dietary tocopherols and BTMs (V2), and dietary and serum tocopherols with BMD (V3) were examined by multivariable regression (adjusting for age, cholesterol, inflammatory markers, carotenoids, body mass index, physical activity level, alcohol intake, smoking status and national deprivation category). RESULTS: Serum γ-tocopherol was associated with increasing concentrations of hs-CRP, SAA and E-selectin (P-trend all <0.0001), while α-tocopherol was associated with decreasing concentrations of IL-6 and hs-CRP (P-trend all <0.001). Controlling for covariates, serum α-tocopherol was positively associated with BMD at the femoral neck (ß = 0.002, P = 0.04) among those not reporting vitamin E supplementation. CONCLUSION: We did not find biologically meaningful results between dietary and tocopherol homologues with BTMs or BMD.

Phytochemical profile of commercially available food plant powders: their potential role in healthier food reformulations.

Reformulation of existing processed food or formulation of new foods using natural products (plant-based) will inherently confer to new products with less calories, fat, salt, phosphates and other synthetic components, and higher amounts of fibre, antioxidants, vitamins and other beneficial components. Plant ingredients, such as food plant powders, are currently being used in food manufacturing, predominantly for flavouring and colouring purposes. To expand their use as a food ingredient, freeze-dried powders representing major vegetable groups were characterised by targeted LC-MS/MS analysis of their phytochemicals. All the plant powders were found to be rich in flavonoids, phenolic acids and derivatives; total content in these compounds varied from around 130 mg kg(-1) (green pea) to around 930 mg kg(-1) (spinach). The food plant powders' phytochemical content represents valuable information for the food industry in the development of healthier novel foods and for the reformulation of existing food products in relation to antioxidants, food preservatives and alternatives to nitrite use.

Traditional measures of normal anal sphincter function using high-resolution anorectal manometry (HRAM) in 115 healthy volunteers.

BACKGROUND: High-resolution anorectal manometry (HRAM) is a relatively new method for collection and interpretation of data relevant to sphincteric function, and for the first time allows a global appreciation of the anorectum as a functional unit. Historically, traditional anal manometry has been plagued by lack of standardization and healthy volunteer data of variable quality. The aims of this study were: (i) to obtain normative data sets for traditional measures of anorectal function using HRAM in healthy subjects and; (ii) to qualitatively describe novel physiological phenomena, which may be of future relevance when this method is applied to patients. METHODS: 115 healthy subjects (96 female) underwent HRAM using a 10 channel, 12F solid-state catheter. Measurements were performed during rest, squeeze, cough, and simulated defecation (push). Data were displayed as color contour plots and analysed using a commercially available manometric system (Solar GI HRM v9.1, Medical Measurement Systems). Associations between age, gender and parity were subsequently explored. KEY RESULTS: HRAM color contour plots provided clear delineation of the high-pressure zone within the anal canal and showed recruitment during maneuvers that altered intra-anal pressures. Automated analysis produced quantitative data, which have been presented on the basis of gender and parity due to the effect of these covariates on some sphincter functions. In line with traditional manometry, some age and gender differences were seen. Males had a greater functional anal canal length and anal pressures during the cough maneuver. Parity in females was associated with reduced squeeze increments. CONCLUSIONS & INFERENCES: The study provides a large healthy volunteer dataset and parameters of traditional measures of anorectal function. A number of novel phenomena are appreciated, the significance of which will require further analysis and comparisons with patient populations.

Bound phytophenols from ready-to-eat cereals: comparison with other plant-based foods.

Whole-grain diets are linked to reduced risk of several chronic diseases (heart disease, cancer, diabetes, metabolic syndrome) and all-cause mortality. There is increasing evidence that these benefits are associated with the gut microbiota and that release of fibre-related phenolic metabolites in the gut is a contributing factor. Additional sources of these metabolites include fruits and vegetables, but the evidence for their protective effects is less well established. With respect to the availability of bound phytophenols, ready-to-eat cereals are compared with soft fruits (considered rich in antioxidants) and other commonly consumed fruits and vegetables. The results demonstrated that when compared with an equivalent serving of fruits or vegetables, a recommended portion of whole-grain cereals deliver substantially higher amounts of bound phytophenols, which are available for metabolism in the colon. The increased amount of these phenolic metabolites may, in part, explain the evidence for the protective effects of whole-grain cereals.

Human O-sulfated metabolites of (-)-epicatechin and methyl-(-)-epicatechin are poor substrates for commercial aryl-sulfatases: implications for studies concerned with quantifying epicatechin bioavailability.

Epicatechin is a widely consumed dietary flavonoid and there is substantial evidence that it contributes to the health benefits reported for flavanol-rich cocoa products including dark chocolate. Numerous reports have described the appearance of epicatechin and epicatechin phase-2 conjugates (sulfates and glucuronides of epicatechin and methylepicatechin) in blood and urine samples of subjects following ingestion of epicatechin. The most widely reported method of quantifying total epicatechin in plasma and urine samples involves hydrolysis with a mixture of ß-glucuronidase and sulfatase to convert the conjugates to epicatechin aglycone which is subsequently quantified. We observed a lack of hydrolysis of epicatechin sulfates and methylepicatechin sulfates using commercial sulfatases and investigated this further. Samples of urine or plasma from subjects who had consumed epicatechin were subjected to enzyme hydrolysis and then analysed using LC-MS/MS, or analysed without enzyme hydrolysis. Attempts to increase the extent of hydrolysis of epicatechin conjugates were made by increasing the amount of enzyme, hydrolysis pH and length of incubations, and using alternative sources of enzyme. The standard hydrolysis conditions failed to hydrolyse the majority of epicatechin sulfates and methylepicatechin sulfates. Even when the quantity of enzyme and incubation period was increased, the pH optimised, or alternative sources of sulfatases were used, epicatechin monosulfates and methylepicatechin monosulfates remained as major peaks in the chromatograms of the samples. An assessment of literature data strongly suggested that the majority of reports where enzyme hydrolysis was used had significantly underestimated epicatechin bioavailability in humans. Methods for quantifying epicatechin concentrations in blood and urine need to take account of the lack of hydrolysis of (methyl)epicatechin-sulfates, for example by quantifying these directly using LC-MS/MS.

Temporary gastric neuromodulation for intractable nausea and vomiting.

INTRODUCTION: Gastric neuromodulation (GNM) has been advocated for the treatment of drug refractory gastroparesis or persistent nausea and vomiting in the absence of a mechanical bowel obstruction. There is, however, little in the way of objective data to support its use, particularly with regards to its effects on gastric emptying. METHODS: Six patients (male-to-female ratio: 4:2, mean age: 49 years, range: 44-57 years) underwent the GNM between April and August 2010. Three patients had confirmed slow gastrointestinal transit. Aetiology included previous gastric surgery in two, diabetes in one and idiopathic nausea and vomiting in three patients. GNM pacing wires were placed endoscopically and left in situ for seven days. Patients underwent gastric scintigraphy before and 24 hours after the commencement of GNM. Total gastroparesis symptom scores (TSS), weekly vomiting frequency scores (VFS), health-related quality of life (using the SF-12(®) questionnaire), gastric emptying, nutritional status and weight were compared before and after GNM. RESULTS: TSS improved after GNM in comparison with baseline data. VFS improved in three of four symptomatic patients. The SF-12(®) physical composite score improved in four patients (27.5 vs 34.3) and the mental composite score improved in five patients (34.9 vs 35.9). All patients reported an improvement in oral intake. A significant weight gain (mean: 1kg, range: 0.3-2.4kg) was observed over seven days. Gastric emptying half-time improved in four patients. CONCLUSIONS: GNM improved upper gastrointestinal symptoms, quality of life and nutritional status in patients with intractable nausea and vomiting. GNM merits further investigation.

Injectable anal bulking agent for the management of faecal incontinence.

This study was conducted to determine the safety and efficacy of injectable bulking agents. A total of 13 procedures were performed on 11 patients with faecal incontinence during 2002 to 2007. Patients with internal anal sphincter defect and low incontinence score (Cleveland score < 10) revealed improvement. Patients with higher incontinence score and external sphincter defect secondary to obstetric damage required further intervention. At a median follow-up of 43 months, 7 (63%) patients showed improvement in incontinence score and 4 (32%) showed marked improvement in their symptoms. Fifty six percent of the patients described this as an effective procedure, though the level of effectiveness varied from person to person. Anal injectable collagen was found safe and effective in the management of faecal incontinence. Long-term follow-ups are required to re assess and consider definitive procedure in failed cases.

Are we following the guiding SIGN when managing paediatric head injury?

BACKGROUND AND AIMS: The Scottish Intercollegiate Guidelines Network (SIGN) has published guidelines for the management of children with head injuries. The management of children with head injuries admitted to our local unit under the Paediatric Surgeons has been audited to determine whether or not current practice follows SIGN recommendations. METHODS: Data were collected retrospectively from the case records of patients admitted between January and December 2007. The SIGN guideline 'Early Management of Patients with a Head Injury' (Guideline 46) was published in 2000 and updated in 2009 (Guideline 110). Head injury admission practices were audited against both guidelines. RESULTS: The case records of 200 patients were analysed. According to SIGN Guideline 46 (2000), 146 Computed Tomography (CT) scans were indicated but only 24 were performed (16%). The updated Guideline 110 (2009) suggests a CT scan was indicated in 24 patients and should have been considered in a further 87. However, only 12 (50%) and 18 (21%) patients were imaged in these respective groups. Both guidelines indicated neurosurgical review in 13 patients but sought in only 4 (31%). 50 patients were deemed to have suffered a significant head injury warranting follow-up, but this was arranged in only 14 (28%). CONCLUSIONS: Our study has identified that management of paediatric head injuries in our unit is reliant on clinical acumen rather than the SIGN guidelines when making decisions regarding the need for imaging, neurosurgical review and follow-up. We suggest further investigation is required to determine whether greater awareness and closer adherence with the guidelines would alter clinical outcomes.

Randomized controlled trial of patient-controlled sedation for colonoscopy: Entonox vs modified patient-maintained target-controlled propofol.

AIM: Propofol sedation is often associated with deep sedation and decreased manoeuvrability. Patient-maintained sedation has been used in such patients with minimal side-effects. We aimed to compare novel modified patient-maintained target-controlled infusion (TCI) of propofol with patient-controlled Entonox inhalation for colonoscopy in terms of analgesic efficacy (primary outcome), depth of sedation, manoeuvrability and patient and endoscopist satisfaction (secondary outcomes). METHOD: One hundred patients undergoing elective colonoscopy were randomized to receive either TCI propofol or Entonox. Patients in the propofol group were administered propofol initially to achieve a target concentration of 1.2 µg/ml and then allowed to self-administer a bolus of propofol (200 µg/kg/ml) using a patient-controlled analgesia pump with a handset. Entonox group patients inhaled the gas through a mouthpiece until caecum was reached and then as required. Sedation was initially given by an anaesthetist to achieve a score of 4 (Modified Observer's Assessment of Alertness and Sedation Scale), and colonoscopy was then started. Patients completed an anxiety score (Hospital Anxiety and Depression questionnaire), a baseline letter cancellation test and a pain score on a 100-mm visual analogue scale before and after the procedure. All patients completed a satisfaction survey at discharge and 24 h postprocedure. RESULTS: The median dose of propofol was 174 mg, and the median number of propofol boluses was four. There was no difference between the two groups in terms of pain recorded (95% confidence interval of the difference -0.809, 5.02) and patient/endoscopist satisfaction. There was no difference between the two groups in either depth of sedation or manoeuvrability. CONCLUSION: Both Entonox and the modified TCI propofol provide equally effective sedation and pain relief, simultaneously allowing patients to be easily manoeuvred during the procedures.

Sacral neuromodulation for the treatment of faecal incontinence in a patient with organophosphate poisoning.

Faecal incontinence is a debilitating condition. Sacral neuromodulation may have a role in the treatment of faecal incontinence. We report a case of faecal incontinence secondary to chronic organophosphate poisoning, which was successfully treated with sacral neuromodulation. The patient's faecal incontinence and quality of life improved significantly.

Quality assurance in colonoscopy: role of endomucosal clips.

OBJECTIVE: Quality assurance in colonoscopy is important, and subjective assessment of completion based on endoscopic signs can be inaccurate leading to missed lesions. We aimed to determine the technique of endomucosal clips with follow-up X-rays in objectively documenting completion and correlation with pathology miss rates. METHOD: A total of 82 patients undergoing colonoscopy by trained colonoscopists had an endomucosal clip applied to the most proximal bowel reached. A plain abdominal X-ray was performed while there was still a pneumocolon, and the clip position was assessed by a blinded radiologist to determine objective completion rates. Repeat colonoscopies were performed in patients with incomplete procedures. Pathology and endoscopy database were also reviewed to identify missed lesions at a median follow-up of 6 years. These were correlated with colonoscopy completions. RESULTS: The clip was found in caecum of 76 (93%), ascending-colon in three (3.6%), hepatic flexure in one (1.2%) and splenic flexure in two (2.4%) patients. The endoscopist opinion was incorrect in six incomplete colonoscopies. A total of 33 patients underwent repeat colonoscopies over the median 6-year follow-up. Three adenomas and one carcinoma were missed in the incomplete group and were subsequently picked up in repeat endoscopies. Only one adenoma was truly missed in complete colonoscopies, providing an overall miss rate of 1.3%. CONCLUSION: Use of endomucosal clips with follow-on abdominal X-ray is a safe and effective method of determining completion of colonoscopy. This technique is also an excellent objective measure of quality assurance of completion and miss rates in colonoscopy, especially when combined with an audit to determine the missed lesions at two years postprocedure.

Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists.

AIM: Assessment of patient satisfaction with lower gastrointestinal endoscopy (LGE) comprising colonoscopy and flexible sigmoidoscopy is gaining increasing importance. We have now trained non healthcare professionals such as nonmedical endoscopists (NMEs) to perform LGE to overcome shortage of trained endoscopists. The aim of this study was to prospectively determine patient satisfaction, factors affecting satisfaction with LGE and to compare with nurses, NME and medical endoscopists, in terms of patient satisfaction. METHOD: Consecutive patients undergoing LGE answered specially developed patient satisfaction questionnaire at discharge and 24 h thereafter. This questionnaire was a modification of m-Group Health Association of America questionnaire. Construct and face validity of questionnaire were tested by an expert group. Demographic and clinical data was prospectively collected. Multivariate regression analysis was performed to determine factors influencing patient satisfaction. RESULTS: Some 503 patients were surveyed after LGE. Examinations were performed by nurse (n = 105), doctor (n = 191), or NMEs (n = 155). There were no differences between three groups in terms of completion rates/complications. No differences were detected between endoscopists in patient rating for overall satisfaction (P = 0.6), technical skills (P = 0.58), communication skills (P = 0.61) or interpersonal skills (0.59). Multivariate regression analysis showed that higher preprocedure anxiety, history of pelvic operations/hysterectomy and higher pain scores were associated with adverse patient satisfaction and preprocedure anxiety, history of hysterectomy and female gender were associated with higher pain scores. CONCLUSION: This study has shown that there are no differences in patient satisfaction with LGE performed by nurse, doctor or NME. The most important factor affecting patient satisfaction is degree of discomfort/pain experienced by patient.

Artificial neural networks to predict presence of significant pathology in patients presenting to routine colorectal clinics.

AIM: Artificial neural networks (ANNs) are computer programs used to identify complex relations within data. Routine predictions of presence of colorectal pathology based on population statistics have little meaning for individual patient. This results in large number of unnecessary lower gastrointestinal endoscopies (LGEs - colonoscopies and flexible sigmoidoscopies). We aimed to develop a neural network algorithm that can accurately predict presence of significant pathology in patients attending routine outpatient clinics for gastrointestinal symptoms. METHOD: Ethics approval was obtained and the study was monitored according to International Committee on Harmonisation - Good Clinical Practice (ICH-GCP) standards. Three-hundred patients undergoing LGE prospectively completed a specifically developed questionnaire, which included 40 variables based on clinical symptoms, signs, past- and family history. Complete data sets of 100 patients were used to train the ANN; the remaining data was used for internal validation. The primary output used was positive finding on LGE, including polyps, cancer, diverticular disease or colitis. For external validation, the ANN was applied to data from 50 patients in primary care and also compared with the predictions of four clinicians. RESULTS: Clear correlation between actual data value and ANN predictions were found (r = 0.931; P = 0.0001). The predictive accuracy of ANN was 95% in training group and 90% (95% CI 84-96) in the internal validation set and this was significantly higher than the clinical accuracy (75%). ANN also showed high accuracy in the external validation group (89%). CONCLUSION: Artificial neural networks offer the possibility of personal prediction of outcome for individual patients presenting in clinics with colorectal symptoms, making it possible to make more appropriate requests for lower gastrointestinal endoscopy.

Extradural haematomas in children: a 10-year review.

Extradural haematomas are a significant consequence of head injuries in children. The aim of this study was to evaluate the demographics, symptoms and signs, management and outcome of patients less than 18 years of age with extradural haematomas in our unit. We also specifically looked at repeat imaging performed, indications for this and its effect on further management. No previous reviews have included this. Fifty-six patients were identified from 01/01/1997 to 01/01/2007 for inclusion in this study. Their imaging was then reviewed as were the case notes. Of the patients studied, 70% were male. The average age was 10 years and 2 months with an average length of stay of one week. The commonest mechanisms of injury were a fall from height and an accident involving a bike. Presenting symptoms were documented in 40% of cases. 32% of patients had associated skull fractures. Six patients had other injuries, including long bone fractures and maxillofacial injuries. Glasgow Coma Scale was generally better on admission than pre-operatively and post-operatively was generally better than prior to surgery. Eight patients had neurological signs on admission, 11 had pre-operatively, and nine had post-operatively. 71% underwent a craniotomy with evacuation of the haematoma. Complications were reported in 16% with no mortality. 66% were seen in a neurosurgical clinic, with 46% seen in a Paediatric Head Injury Clinic after discharge. 66% had further imaging after their initial scan of which 52% had no clinical indication. Eight patients were operated on following re-imaging. Most extradural haematomas in children are caused by falls or vehicle accidents. The majority are treated surgically and do well. Indications for further scanning are often not present and in most, management is unchanged. The follow up of these patients also appears to be suboptimal.