Implementing a standardized gastroschisis protocol significantly increases the rate of primary sutureless closure without compromising closure success or early clinical outcomes.

PURPOSE: Standardized protocols have been shown to improve outcomes in several pediatric surgical conditions. We implemented a multi-disciplinary gastroschisis practice bundle at our institution in 2013. We sought to evaluate its impact on closure type and early clinical outcomes. METHODS: We performed a retrospective review of uncomplicated gastroschisis patients treated at our institution between 2008-2019. Patients were divided into two groups: pre- and post-protocol implementation. Multivariate logistic regression was used to compare closure location, method, and success. RESULTS: Neonates (pre-implementation n = 53, post-implementation n = 43) were similar across baseline variables. Successful immediate closure rates were comparable (75.5% vs. 72.1%, p = 0.71). The proportion of bedside closures increased significantly after protocol implementation (35.3% vs. 95.4%, p < 0.01), as did the proportion of sutureless closures (32.5% vs. 71.0%, p < 0.01). Median postoperative mechanical ventilation decreased significantly (4 days IQR [3, 5] vs. 2 days IQR [1, 3], p < 0.01). Postoperative complications and duration of parenteral nutrition were equivalent. After controlling for potential confounding, infants in the post-implementation group had a 44.0 times higher odds of undergoing bedside closure (95% CI: 9.0, 215.2, p < 0.01) and a 7.7 times higher odds of undergoing sutureless closure (95% CI: 2.3, 25.1, p < 0.01). CONCLUSIONS: Implementing a standardized gastroschisis protocol significantly increased the proportion of immediate bedside sutureless closures and decreased the duration of mechanical ventilation, without increasing postoperative complications. Level of Evidence III Type of Study Retrospective comparative study.

Parenteral nutrition-associated liver disease: a retrospective study of ursodeoxycholic Acid use in neonates.

OBJECTIVES: To verify the effect of ursodeoxycholic acid (UDCA) on the duration of neonatal parenteral nutrition-associated liver disease. METHODS: Retrospective cohort study of neonates in intensive care between 2004 and 2007 presenting with parenteral nutrition-associated liver disease. RESULTS: Of 118 eligible infants, 64 received UDCA. Cholestasis lasted longer in the UDCA group (79 vs. 50 days, p=0.001). However, treatment was delayed for a median of 24 days after cholestasis onset. Multivariate Cox regression analysis showed no association between UDCA and cholestasis duration. The rate of decline of conjugated bilirubin was greater in treated patients (median 0.084 mg/dL/day vs. 0.60 mg/dL/day; p=0.009) and weight gain was greater (22.8 vs. 17.7 g/kg/day, p=0.010). CONCLUSIONS: UDCA therapy was not associated with the duration of parenteral nutrition-associated liver disease. A delay in treatment initiation might explain this result. UDCA therapy was associated with a faster decline of conjugated bilirubin and greater weight gain.

Cohort study of probiotics in a North American neonatal intensive care unit.

OBJECTIVE: To determine whether routine probiotic administration to very preterm infants would reduce the incidence of necrotizing enterocolitis (NEC) without adverse consequences. STUDY DESIGN: Since the end of July 2011, we have administered a probiotic mixture to all admitted infants of <32 weeks' gestation. We give 0.5 g of a mixture of 4 bifidobacteria (Bifidobacterium breve, bifidum, infantis, and longum) and Lactobacillus rhamnosus HA-111 [corrected] (2 × 10(9) colony-forming units) per day, starting with the first feed, until the infant reaches 34 weeks. We compared complications among infants admitted during the first 17 months of routine use with those admitted during the previous 17 months. RESULTS: Two hundred ninety-four infants received probiotics, and 317 infants formed the comparison group. Introduction of probiotics was associated with a reduction in NEC (from 9.8% to 5.4%, P < .02), a nonsignificant decrease in death (9.8% to 6.8%), and a significant reduction in the combined outcome of death or NEC (from 17% to 10.5%, P < .05). After adjustment for gestational age, intrauterine growth restriction, and sex, the improvements remained significant (OR for NEC, 0.51; 95% CI, 0.26-0.98; OR for death or NEC, 0.56; 95% CI, 0.33-0.93). There was no effect of probiotics on health care-associated infection. DISCUSSION: A product that is readily available in North America, that has excellent quality control, and that contains strains similar to those that have been shown effective in randomized controlled trials substantially reduced the frequency of NEC in our neonatal intensive care unit.

Comparison between standard heparin and tinzaparin for haemodialysis catheter lock.

Tinzaparin offers some advantages over unfractionated heparin (UFH) for hemodialysis circuit anticoagulation. No study has compared these two molecules as hemodialysis catheter locks. This study aimed to compare the efficacy of tinzaparin and UFH as locks for hemodialysis tunnelled central venous catheter in patients with end-stage renal disease (ESRD). A randomized, prospective, single-blinded, controlled study was undertaken. Patients were randomly assigned to receive UFH and tinzaparin for two 7-week periods in a crossover fashion. The doses used were 5,000 U of UFH and 2,000 U of tinzaparin per catheter line. The primary outcome was the need for thrombolytic catheter lock use defined with the Hemodialysis Unit alteplase protocol. Forty-two patients with ESRD were enrolled, totalling 815 UFH lock sessions and 729 tinzaparin lock sessions. A 47.4% reduction in the incidence of alteplase lock use was observed with tinzaparin lock (3.16% vs. 6.01%, chi-square, p = 0.0078). There was no significant difference in the time to first alteplase use between the two locks by Kaplan-Meier survival analysis (logrank, p = 0.0900). Our results suggest that tinzaparin could be an appropriate alternative for a hemodialysis tunnelled central venous catheter lock, but these results should be confirmed with a larger trial.