Decade of the dangers of multiple magnet ingestion in children: A retrospective review.

AIM: Magnet ingestion has become more frequent in children as magnetic toys and jewellery have been popularised, with the potential to cause significant morbidity. Our aim was to describe our experience at a tertiary paediatric surgical centre. METHODS: Retrospective review of patients admitted with multiple magnet ingestion (January 2011-December 2020). Division into an intervention group and conservative group. Comparisons included demographics, number of magnets and clinical outcomes. Data analysis with a Student's t-test and ROC Curve, P value of <0.05 was significant. RESULTS: A total of 23 patients were identified with a total of 150 magnets ingested. The majority required an intervention for magnets retrieval (15/23, 65.2%), 11/15 (73.3%) surgical and 4/15 (26.7%) endoscopic. In the surgery group, 6/11 (54%) presented with an initial perforation and 1/11 (9.1%) an entero-enteric fistula. One patient (9.1%) had a multi-site anastomotic leak post-operatively. The conservative group had a significantly lower median number of ingested magnets (2 (2-6) vs. 7 (2-40), P = 0.03) and median length of stay (1 (1-4) vs. 7 (1-24), P = 0.03). ROC curve analysis revealed ingestion of >3 magnets had a sensitivity of 86.7% (95% CI: 62.1-97.6%) and specificity of 87.5% (95% CI: 53.0-99.4%) for requiring an intervention. CONCLUSION: This series highlights a significant morbidity in children with a higher incidence of intervention following ingestion of more than three magnets. There is a strong requirement for the creation and adherence to new legislature involving industry standards.

Presence of viable germ cells in testicular regression syndrome remnants: Is routine excision indicated? A systematic review.

There is no consensus in the literature about the necessity for excision of testicular remnants in the context of surgery for an impalpable testis and testicular regression syndrome (TRS). The incidence of germ cells (GCs) within these nubbins varies between 0 and 16% in previously published series. There is a hypothetical potential future malignancy risk, although there has been only one previously described isolated report of intratubular germ-cell neoplasia. Our aim was to ascertain an accurate incidence of GCs and seminiferous tubules (SNTs) within excised nubbins and hence guide evidence-based practice. The systematic review protocol was designed according to the PRISMA guidelines, and subsequently published by the PROSPERO database after review (CRD42013006034). The primary outcome measure was the incidence of GCs and the secondary outcome was the incidence of SNTs. The comprehensive systematic review included articles published between 1980 and 2016 in all the relevant databases using specific search parameters and terms. Strict inclusion and exclusion criteria were ultilised to identify articles relevant to the review questions. Twenty-nine paediatric studies with a total of 1455 specimens were included in the systematic review. The mean age of the patients undergoing nubbin resection was 33 months and the TRS specimen was more commonly excised from the left (68%). The incidence of SNTs was 10.7% (156/1455) and the incidence of GCs, 5.3% (77/1455). Histological analysis excluding the presence of either SNTs or GCs was consistent with TRS, fibrosis, calcification or haemosiderin deposits. There is limited evidence on subset analysis that GCs and SNTs may persist with increasing patient age. This systematic review has identified that 1 in 20 of resected testicular remnants has viable GCs and 1 in 10 has SNTs present. There is insufficiently strong evidence for the persistence of GCs and SNTs with time or future malignant potential. Intra-abdominal TRS specimens may contain more elements and, therefore, require excision, although this is based on limited evidence. However, there is no available strong evidence to determine that a TRS specimen requires routine excision in an inguinal or scrotal position.

Endoscopic Removal of a Fecalith or Fecomucolith in a Rectal Stump or Pouch.

Fecaliths or fecomucoliths can form in rectal stumps after a Hartmann procedure or in a coloneovaginal conduit. They can cause significant distress to the patient by causing symptoms such as discharge and odor. We describe a novel and effective method of endoscopic obliteration and removal where other techniques such as removal during examination under anesthesia or serial enemas have failed. By using a combination of hydrodissection with a saline injector gun and biopsy forceps and a polypectomy snare to break down the fecomucolith or fecalith, this troublesome problem can be resolved endoscopically. Successful removal of the fecalith/fecomucolith and resolution of the symptoms for the patients were achieved. No complications are reported. We describe an effective and novel method for endoscopic removal of fecaliths and fecomucoliths.

Preoperative anaemia and thrombocytopenia are associated with venous thromboembolism complications after colorectal resection.

BACKGROUND: Earlier studies have shown that abnormal levels of haemoglobin and platelets may be associated with worse post-operative outcomes. We aim to compare the rates of venous thromboembolism (VTE), anastomotic leak and other complications in patients post-colorectal resection with normal and abnormal levels of haemoglobin and platelets. METHODS: We performed a retrospective review of 1610 patients from July 2010 to June 2015 in a single colorectal unit. Our primary outcome was the rate of VTE and anastomotic leak in anaemic and thrombocytopenic patients. Secondary outcomes included length of stay, 30-day mortality, return to theatre, transfusion rates and Clavien-Dindo classification complications. RESULTS: VTE complications were more common in anaemic patients, and this difference became more pronounced with the severity of anaemia. Other complications such as length of stay >2 weeks occurred more frequently in anaemic and thrombocytopenic patients. A trend towards higher rates of 30-day mortality and anastomotic leak was noted in patients with anaemia and thrombocytopenia. CONCLUSION: Anaemia and thrombocytopenia are associated with worse outcomes including length of stay, anastomotic leak, VTE and 30-day mortality.

Inguinal hernias in children.

BACKGROUND: An inguinal hernia is one of the most common paediatric surgical presentations in a primary care setting. Hernias can present in multiple ways, ranging from an emergency such as a strangulated hernia to a less urgent reducible hernia. OBJECTIVE: The aim of this article is to aid in appropriate diagnosis and management of hernias in children. The article also provides useful tips for hernia reduction that are especially beneficial in the primary care setting and assist with the identification of hernias that require urgent referral. DISCUSSION: Recognising the signs of a hernia containing compromised contents is essential to prevent serious complications such as intestinal perforation, testicular atrophy and ovarian damage. Other common conditions such as hydrocoele and undescended testis are sometimes confused with an inguinal hernia. Young patients under the age of three months and patients with concern for compromised contents require urgent referral. Recent evidence regarding controversial issues in inguinal hernia repair such as the role of laparoscopy and the relevance of a contralateral patent internal inguinal ring will be discussed.

Undescended testes: What general practitioners need to know

BACKGROUND: Undescended testis (UDT) is a common condition, and parents often primarily present to general practitioners. Management in a timely fashion may reduce the risk of malignancy and infertility OBJECTIVES: The aim of this article is to summarise the key points of assessment and management of UDT in the primary care setting. By reviewing key definitions, such as undescended, retractile, ectopic and ascending testes, we aim to provide updated information for the ongoing management of these conditions. DISCUSSION: The exact pathophysiology of UDT is still an area of ongoing research, and there remains much controversy regarding the exact mechanisms leading to congenital and acquired UDT. Current evidence does not support the use of ultrasonography prior to referral. Hormone therapy has shown no significant benefit, and surgery remains the treatment of choice.

Factors Affecting Outcome Following Video-Assisted Thoracoscopic Surgery for Empyema in Children: Experience from a Large Tertiary Referring Centre.

Introduction: We report the results of video-assisted thoracoscopic surgery (VATS) in a large population of children with empyema, focusing on the factors affecting the postoperative length of stay (LOS). Materials and Methods: After ethical approval (RES-18-0000-071Q), a retrospective review was performed (2013-2018). Results are reported as number of cases (%) and median (range) and analyzed by Mann-Whitney U and Kruskal-Wallis tests. Correlation analysis was conducted. Results: We identified 159 children with empyema; 75 [42 (56%) males] underwent VATS. Median age was 3.6 (0.4-14.5) years. Presentation was: autumn 15 (20%), winter 26 (35%), spring 18 (24%), summer 16 (21%) with no difference in LOS (P = .6). Preoperative symptoms duration was 7 (2-28) days. Postoperatively, chest drain was on suction in 30 (40%) patients, in situ for 3 (2-13) days. Six (8%) children required further procedures. LOS was 8 (3-47) days. Pleural fluid revealed: Streptococcus species. 41 (55%), other species 8 (11%), no bacteria 26 (34%); LOS was longer with positive pleural fluid: 9 (4-47) versus 6.5 (3-16) days (P = .02). There was no correlation between the LOS and preoperative symptoms duration (r = -0.03 [95% CI -0.3 to 0.2]; P = .7), empyema size (r = 0.2 [95% CI -0.07 to 0.5]; P = .1) and chest drain size (r = 0.09 [95% CI -0.14 to 0.3]; P = .4). Discussion: In our experience, >90% of children with empyema will be treated with a single VATS with an average LOS of 8 days. Positive microbiology culture significantly affects the LOS.

The angiotensin receptor blocker, Losartan, inhibits mammary tumor development and progression to invasive carcinoma.

Drugs that target the Renin-Angiotensin System (RAS) have recently come into focus for their potential utility as cancer treatments. The use of Angiotensin Receptor Blockers (ARBs) and Angiotensin-Converting Enzyme (ACE) Inhibitors (ACEIs) to manage hypertension in cancer patients is correlated with improved survival outcomes for renal, prostate, breast and small cell lung cancer. Previous studies demonstrate that the Angiotensin Receptor Type I (AT1R) is linked to breast cancer pathogenesis, with unbiased analysis of gene-expression studies identifying significant up-regulation of AGTR1, the gene encoding AT1R in ER+ve/HER2-ve tumors correlating with poor prognosis. However, there is no evidence, so far, of the functional contribution of AT1R to breast tumorigenesis. We explored the potential therapeutic benefit of ARB in a carcinogen-induced mouse model of breast cancer and clarified the mechanisms associated with its success.Mammary tumors were induced with 7,12-dimethylbenz[α]antracene (DMBA) and medroxyprogesterone acetate (MPA) in female wild type mice and the effects of the ARB, Losartan treatment assessed in a preventative setting (n = 15 per group). Tumor histopathology was characterised by immunohistochemistry, real-time qPCR to detect gene expression signatures, and tumor cytokine levels measured with quantitative bioplex assays. AT1R was detected with radiolabelled ligand binding assays in fresh frozen tumor samples.We showed that therapeutic inhibition of AT1R, with Losartan, resulted in a significant reduction in tumor burden; and no mammary tumor incidence in 20% of animals. We observed a significant reduction in tumor progression from DCIS to invasive cancer with Losartan treatment. This was associated with reduced tumor cell proliferation and a significant reduction in IL-6, pSTAT3 and TNFα levels. Analysis of tumor immune cell infiltrates, however, demonstrated no significant differences in the recruitment of lymphocytes or tumour-associated macrophages in Losartan or vehicle-treated mammary tumors.Analysis of AT1R expression with radiolabelled ligand binding assays in human breast cancer biopsies showed high AT1R levels in 30% of invasive ductal carcinomas analysed. Furthermore, analysis of the TCGA database identified that high AT1R expression to be associated with luminal breast cancer subtype.Our in vivo data and analysis of human invasive ductal carcinoma samples identify the AT1R is a potential therapeutic target in breast cancer, with the availability of a range of well-tolerated inhibitors currently used in clinics. We describe a novel signalling pathway critical in breast tumorigenesis, that may provide new therapeutic avenues to complement current treatments.