Necrotising enterocolitis-A 15-year outcome report from a UK specialist centre.

AIMS: Necrotising enterocolitis (NEC) is a disease associated with high mortality and morbidity, low birthweight and prematurity are risk factors. This study reports outcomes of babies having emergency laparotomy for NEC, examining institutional trends and exploring impact of multiple variables on mortality at 30 days and 1 year post-operatively. METHODS: Case records of babies with ICD coding for NEC were examined from 2000 to 2015. After exclusions, 243 cases were identified-confirmed by operative findings and histology. Cohort demographics and trends in mortality were investigated, and the relationship of common variables to mortality was modelled with univariate and multivariate logistic regression to generate a mortality prediction tool. RESULTS: Mean gestational age was 28 + 4 weeks. A 30-day mortality was 18.9%. Gestation, birthweight and area of bowel affected were significant of outcome (mortality), and the presence of pre-operative pneumoperitoneum was strongly correlated. Year of surgery and congenital cardiac pathology requiring intervention were not significant. Using multivariate regression modelling, a mortality outcome prediction tool has been developed. CONCLUSION: Good survival following operation for NEC (>70%) is feasible, even in those babies born extremely premature (<28 weeks) and post-operatively re-located to tertiary NICUs. With increasing gestational age (>32 weeks), mortality is uncommon.

Simple fundoplication versus additional vagotomy and pyloroplasty in neurologically impaired children--a single centre experience.

BACKGROUND AND AIMS: Gastrooesophageal reflux disease (GERD) is a significant problem in children with neurological impairment (NI) with high failure rates for fundoplication. Fundoplication with vagotomy and pyloroplasty (FVP) can improve the outcome by altering the sensory or motor dysfunction associated with the reflux. We report our comparative outcomes for simple fundoplication (SF) and FVP in NI children. METHODS: Case records of all patients having fundoplication under a single consultant at a tertiary UK paediatric surgical centre between January 1997 and December 2012 were retrospectively assessed for recurrent symptoms and redo surgery. The data were collected using a Microsoft Excel database and analysed on Graphpad prism software program. Data are median (range). P value<0.05 was considered significant. RESULTS: Data were available for 244 out of 275 patients who underwent fundoplication during this period (157 SF and 87 FVP). Neurological disease or known syndromes were recorded in 158 patients. Thirty-five children had congenital anatomical abnormalities. Laparoscopic fundoplication was done in 37 cases. Revisional surgery for recurrent symptoms was performed in 22 patients. In the neurologically normal children, all of whom had SF, the revision rate was 6.5%. In the NI children the revision rates were 18.5% for SF and 3.9% for FVP, respectively (Fisher's exact, P<0.05). The median time to redo surgery was 10 (1-63) months, and the median time to follow up was 19.5 (2-177) months. CONCLUSIONS: There appears to be a significantly lower need for redo surgery following FVP than SF in children with NI.

ImERSE (Improving Experience through Regular Shadowing Events).

Systematic operational quality improvement strategies within the NHS are hard to find, although there are numerous published reports of sporadic departmental models and methods resulting in improvements in clinical care. We describe the experience of devising a tool to provide large data collection of patient care experiences by using medical students to shadow patient journeys. This combines patient and family centred care (PFCC) and quality improvement approaches to create a systematic organisational strategy for improving care. The ImERSE (improving experience through regular shadowing events) approach could be applied to any area of health care to generate population specific improvement priorities. It can be used to promote patient and family centred care and provide a unique medical education experience. We describe its evolution in its first year of use and suggest that using the ImERSE approach delivers beneficial characteristics to patients and their families, those undergoing a shadowing experience, and provider organisations.

Publicized sobriety checkpoint programs: a community guide systematic review.

CONTEXT: Publicized sobriety checkpoint programs deter alcohol-impaired driving by stopping drivers systematically to assess their alcohol impairment. Sobriety checkpoints were recommended in 2001 by the Community Preventive Services Task Force for reducing alcohol-impaired driving, based on strong evidence of effectiveness. Since the 2001 review, attention to alcohol-impaired driving as a U.S. public health problem has decreased. This systematic review was conducted to determine if available evidence supports the effectiveness of publicized sobriety checkpoint programs in reducing alcohol-impaired driving, given the current context. The economic costs and benefits of the intervention were also assessed. EVIDENCE ACQUISITION: This review focused on studies that evaluated the effects of publicized sobriety checkpoint programs on alcohol-involved crash fatalities. Using Community Guide methods, a systematic search was conducted for studies published between July 2000 and March 2012 that assessed the effectiveness of publicized sobriety checkpoint programs. EVIDENCE SYNTHESIS: Fourteen evaluations of selective breath testing and one of random breath testing checkpoints met the inclusion criteria for the systematic review, conducted in 2012. Ten evaluations assessed the effects of publicized sobriety checkpoint programs on alcohol-involved crash fatalities, finding a median reduction of 8.9% in this crash type (interquartile interval=-16.5%, -3.5%). Five economic evaluations showed benefit-cost ratios ranging from 2:1 to 57:1. CONCLUSIONS: The number of studies, magnitude of effect, and consistency of findings indicate strong evidence of the effectiveness of publicized sobriety checkpoint programs in reducing alcohol-involved crash fatalities. Economic evidence shows that these programs also have the potential for substantial cost savings.

Novel therapeutic use of Versajet for intestinal mucormycosis.

We describe the case of a 17-year-old boy who developed intestinal mucormycosis from Rhizophus oryzae (order Mucorales) following chemotherapy for the management of acute myeloid leukaemia. He underwent a hemicolectomy and further surgery utilising the pressure washing of Versajet to debride colonised fungal collections from the psoas muscle limiting the amount of surgical debridement needed.

Symptomatic ureteric triplex in a child.

We describe a case of a triplex system in a 4-year-old girl that was associated with a ureterocele and vesicoureteric reflux and causing symptomatic culture-proven urinary tract infections. Undetected on preoperative ultrasound imaging and micturating cystourethrogram, this was discovered at the time of a planned left heminephrectomy. The redundant system having been removed the patient is now asymptomatic.

Effects of intraperitoneal lipopolysaccharide on Morris maze performance in year-old and 2-month-old female C57BL/6J mice.

Several studies have shown that systemic lipopolysaccharide (LPS) or interleukin-1beta (IL-1beta) may affect performance in various learning tasks, including the Morris water maze. In the current study, female C57BL/6J mice, either 2 months or 1 year of age, were given 5 days of testing followed by 3 days of rest, and then three additional days of testing. Mice either received a single LPS injection on day 1 and saline on days 2-5, LPS injections on days 1-5, or saline injections on days 1-5. Daily LPS administration significantly prolonged latency for the animals to find the platform, and decreased their swimming speed. Year-old mice treated with LPS each day also exhibited significantly higher levels of thigmotaxis in the maze. Despite effects on latency and swim speed, no effect of LPS treatment was observed for distance traveled to the platform or other measures that clearly indicate disruption of learning in the maze. On the other hand, age was a significant factor affecting both latency and distance, with older animals swimming greater distances to find the platform. Additionally, older animals were more adversely affected by daily LPS treatment. In this study, although LPS-induced performance impairments in the Morris water maze were noted, particularly in older animals, these effects were not clearly indicative of learning impairment per se.

Moving toward the eradication of syphilis.

This study analyzed syphilis incidence among active duty U.S. Sailors and Marines and explored opportunities and strategies for the Department of the Navy to contribute to the achievement of the National Syphilis Elimination Plan. From 1987 through 1999, there were 1,886 cases of syphilis among active duty members reported to the Navy Environmental Health Center. Most were male (90%), younger than 30 years (81%), and black (64%). Most were diagnosed within the continental United States (79%). Incidence rates of primary and secondary syphilis per 100,000 among the active duty force declined steadily, from 37 in 1990 to 3 in 1999. Strategies suggested to further reduce syphilis among active duty members include the following: (1) Navy Medicine adoption and tracking of the national target of < 0.4 cases per 100,000 by 2005; (2) expand training of medical professionals in client-centered prevention counseling; (3) include affected populations in the design of interventions; (4) conduct outcome evaluations of educational interventions; (5) examine condom access policies; and (6) evaluate the current syphilis surveillance system.

FORAGING DYNAMICS OF BIRD PREDATORS ON OVERWINTERING MONARCH BUTTERFLIES IN MEXICO.

By suspending nets within and adjacent to a 2.25 hectare overwintering colony of monarch butterflies in Mexico, we estimated that black-backed orioles and black-headed grosbeaks killed 4,550 to 34,300 and an average of 15,067 butterflies per day. A conservative calculation of mortality through the 135 day overwintering season was 2.034 million butterflies, or about 9% of the colony. The birds preyed selectively upon male butterflies, possibly because of a difference in fat content, or possibly because females contain higher concentrations and larger amounts of cardenolide or other defensive chemicals. The risk to individual monarchs of being killed was much greater on the colony periphery and in thinned areas of the forest. Bird predation thus is sufficient to have played a major role in shaping the evolution of the monarch's overwintering and aggregation behavior. Substantial daily variation in predation intensity occurred, 26% of which was attributable to the birds eating more butterflies on colder days, and 30% of which was attributable to a 7.85 day predation cycle. The hypothesis is put forward that the birds feed cyclically because they build up toxic levels of cardenolides or other defensive chemicals contained in the butterflies. The cyclic predation may reduce total predation on the colony by as much as 50%. Such chemical-based group protection is interpreted as a fortuitous by-product of the evolution of unpalatability through selective processes acting on other phases of the monarch's life history.