Antioxidant enzymes, presbycusis, and ethnic variability

Objective

A proposed mechanism for presbycusis is a significant increase in oxidative stress in the cochlea. The enzymes glutathione S-transferase (GST) and N-acetyltransferase (NAT) are two classes of antioxidant enzymes active in the cochlea. In this work, we sought to investigate the association of different polymorphisms of GSTM1, GSTT1, and NAT2 and presbycusis and analyze whether ethnicity has an effect in the genotype-phenotype associations.

Study Design

Case-control study of 134 DNA samples.

Setting

University-based tertiary care center.

Subjects and Methods

Clinical, audiometric, and DNA testing of 55 adults with presbycusis and 79 control patients with normal hearing.

Results

The GSTM1 null genotype was present in 77 percent of white Hispanics and 51 percent of white non-Hispanics (Fisher's exact test, 2-tail, P = 0.0262). The GSTT1 null genotype was present in 34 percent of control patients and in 60 percent of white presbycusis subjects (P = 0.0067, odds ratio [OR] = 2.843, 95% confidence interval [95% CI] = 1.379-5.860). The GSTM1 null genotype was more frequent in presbycusis subjects, i.e., 48 percent of control patients and 69 percent of white subjects carried this deletion (P = 0.0198, OR = 2.43, 95% CI = 1.163-5.067). The NAT2*6A mutant genotype was more frequent among subjects with presbycusis (60%) than in control patients (34%; P = 0.0086, OR = 2.88, 95% CI = 1.355-6.141).

Conclusion

We showed an increased risk of presbycusis among white subjects carrying the GSTM1 and the GSTT1 null genotype and the NAT*6A mutant allele. Subjects with the GSTT1 null genotypes are almost three times more likely to develop presbycusis than those with the wild type. The GSTM1 null genotype was more prevalent in white Hispanics than in white non-Hispanics, but the GSTT1 and NAT2 polymorphisms were equally represented in the two groups.     

Crashes involving motorised rickshaws in urban India: characteristics and injury patterns

Introduction

Motorised three-wheeled vehicles (motorised rickshaw) are popular in Asian countries including India. This study aims to describe the crash characteristics and injury patterns for motorised rickshaw occupants and the road users hit-by-motorised rickshaw in urban India.

Methods

Consecutive cases of road traffic crashes involving motorised rickshaw, irrespective of injury severity, whether alive or dead, presenting to the emergency departments of two large government hospitals and three branches of a private hospital in Hyderabad city were recruited. Crash characteristics, details of injuries, injury severity parameters and outcome were documented in detailed interviews.

Results

A total of 139 (18%) of the 781 participants recruited were injured as a motorised rickshaw occupant (11%) or were hit by a motorised rickshaw (7%) in 114 crashes involving motorised rickshaw. Amongst motorised rickshaw occupants, single-vehicle collisions (54%) were more frequent than multi-vehicle collisions (46%), with overturning of motorised rickshaw in 73% of the single-vehicle collisions. Mortality (12%), the mean Injury Severity Score (5.8) and rate of multiple injured (60%) indicated a substantial trauma load. No significant differences in injury pattern were found between motorised rickshaw occupants and hit-by-motorised rickshaw subjects, with the pattern being similar to that of the pedestrians and two-wheeled vehicle users. With bivariate analysis for motorised rickshaw occupants, the risk of fatal outcome (odds ratio (OR) 2.60, 95% confidence interval (CI): 0.64-10.54), upper limb injury (OR 2.25, 95% CI: 0.94-5.37) and multiple injuries (OR 2.03, 95% CI 0.85-4.83) was high, although not statistically significant in multi-motorised-vehicle collisions as compared with the single-vehicle collisions or overturning. The risk of having multiple injuries (OR 4.55, 95% CI: 1.15-17.95) was significantly higher in motorised rickshaw occupants involved in front collisions. Being a front-seat motorised rickshaw passenger in a vehicle collision increased the risk of having a fatal outcome (OR 7.37, 95% CI: 0.83-65.66) and a Glasgow coma score ≤ 12 (OR 2.21, 95% CI: 0.49-9.89), although not significantly when compared to the back-seat passengers.

Conclusion

These findings can assist with planning to deal with the consequences and prevention of road traffic injuries due to crashes involving motorised rickshaw, given the high use of these and substantial morbidity of related injuries in India. The need for improved understanding of the risk characteristics of motorised rickshaw is highlighted.     

Maternal tobacco smoking, obesity, and low socioeconomic status during early pregnancy in the etiology of esophageal atresia

Background

The etiology of the congenital malformation esophageal atresia (EA) is essentially unknown. We hypothesized that maternal tobacco smoking, obesity, and low socioeconomic status (SES) during early pregnancy might increase the risk of the fetus developing EA.

Methods

A nationwide, population-based, case-control study was nested in a cohort of children born in Sweden in 1982 to 2004. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using logistic regression. Matching, stratification, and multivariable regression were used to control for confounding.

Results

Among 2,305,858 newborn children constituting the study cohort, 722 cases of EA and 3610 controls were included. For women smoking 10 cigarettes or more daily, the adjusted OR was 0.88 (95% CI, 0.62-1.25) compared to nonsmokers. For obese women (body mass index, >30), OR was 0.99 (95% CI, 0.64-1.55) compared to lean women (body mass index, <20). Women with more than 12 years of formal education, representing SES, had an OR of 0.94 (95% CI, 0.69-1.29) compared to those with less than 10 years of education. The lack of association remained in stratified analyses of isolated EA and EA accompanied by associated malformations.

Conclusion

This study provides evidence refuting the hypotheses of an increased risk of EA among children of women who smoke, are obese, or have a low SES during early pregnancy.     

Objective measures of renal mass anatomic complexity predict rates of major complications following partial nephrectomy

Background

The association between tumor complexity and postoperative complications after partial nephrectomy (PN) has not been well characterized.

Objective

We evaluated whether increasing renal tumor complexity, quantitated by nephrometry score (NS), is associated with increased complication rates following PN using the Clavien-Dindo classification system (CCS).

Design, setting, and participants

We queried our prospectively maintained kidney cancer database for patients undergoing PN from 2007 to 2010 for whom NS was available.

Interventions

All patients underwent PN.

Measurements

Tumors were categorized into low- (NS: 4-6), moderate- (NS: 7-9), and high-complexity (NS: 10-12) lesions. Complication rates within 30 d were graded (CCS: I-5), stratified as minor (CCS: I or 2) or major (CCS: 3-5), and compared between groups.

Results and limitations

A total of 390 patients (mean age: 58.0 ± 11.9 yr; 66.9% male) undergoing PN (44.6% open, 55.4% robotic) for low- (28%), moderate- (55.6%), and high-complexity (16.4%) tumors (mean tumor size: 3.74 ± 2.4 cm; median: 3.2 cm) from 2007 to 2010 were identified. Tumor size, estimated blood loss, and ischemia time all significantly differed (p < 0.0001) between groups; patient age, body mass index (BMI), and operative time were comparable. When stratified by CCS, minor and major complication rates for all patients were 26.7% and 11.5%, respectively. Minor complication rates were comparable (26.6 vs 24.9 vs 32.8%; p = 0.45), whereas major complication rates differed (6.4 vs 11.1 vs 21.9%; p = 0.009) among tumor complexity groups. Controlling for age, gender, BMI, type of surgical approach, operative duration, and tumor complexity, prolonged operative time (odds ratio [OR]: 1.01; confidence interval [CI], 1.0-1.02) and high tumor complexity (OR: 5.4; CI, 1.2-24.2) were associated with the postoperative development of a major complication. Lack of external validation is a limitation of this study.

Conclusions

Increasing tumor complexity is associated with the development of major complications after PN. This association should be validated externally and integrated into the decision-making process when counseling patients with complex renal tumors.     

Knowledge, attitudes and commitment toward organ donation among nursing students in Hong Kong

Background

Organ donation is the major component for transplant programs; however, the rate of organ donation is relatively low in Asia. Therefore, understanding the attitude and knowledge of individuals that affect their willingness to commit as an organ donor is crucial to develop effective educational programs that raise public awareness and commitment toward organ donation. The current study aims to identify the knowledge level, attitude, and commitment toward organ donation among nursing students in a local university.

Methods

A questionnaire was developed and distributed to all full-time nursing students of undergraduate and master programs in a university at Hong Kong.

Results

A total of 362 students completed the questionnaire, including 87 males and 257 females. The mean age of the students was 22.6 years. A total of 147 students (40.6%) had registered for organ donation. Students on average could correctly answer 23.7 out of 33 questions (71.8%) regarding their knowledge on organ donation and transplantation. With regard to attitude toward organ donation, students obtained a mean score of 70.2. Univariate analysis revealed that year of study, religion, and attitude were significantly associated with commitment toward organ donation. In logistic regression analysis, year of study (odds ratio [OR] for year 2, 1.961, 95% confidence interval [CI], 1.006-3.824; OR for year 3, 6.915, 95% CI, 2.835-16.868; and OR for year 4, 4.845, 95% CI, 2.071-11.334) and attitude (OR, 1.087, 95% CI, 1.049-1.126) were significantly associated with commitment toward donation after adjusting the age, gender, and study program.

Conclusion

Attitude and year of study were strongly correlated with commitment toward organ donation; therefore, educational or promotional materials should be provided to improve the attitude of students toward organ donation.     

Incidence and risk factors of non-fatal injuries in Chinese children aged 0-6 years: A case-control study

Aim

To identify the incidence and related risk factors of injuries in pre-school children aged 0-6 years in China.

Methods

Children with non-fatal injuries (n = 122) were matched to healthy controls by sex, age, community of residency and history of injury. Conditional multiple logistic regression analysis was performed to estimate the odds ratios (ORs) and 95% confidence intervals (CIs).

Results

The overall incidence of injuries was 3.3%. After adjustment for all selected variables, the risk factors for childhood injuries included father's occupation as a self-employed person (OR: 5.7, 95% CI: 1.8-18.5), child's active temperament type (OR: 2.8, 95% CI: 1.5-5.3), inappropriate storage of medicines (OR: 3.1, 95% CI: 1.3-6.9) and inappropriate placement of heating equipments (OR: 2.1, 95% CI: 1.0-4.4). The protective factors included children's acquirements of safety education from their teachers at school (OR: 0.03, 95% CI: 0.01-0.2), and from their parents (OR: 0.08, 95% CI: 0.02-0.3).

Conclusions

Interventions targeting the risk factors specifically may help prevent and reduce the occurrence of injuries in young children.     

Disparity in limb-salvage surgery among sarcoma patients

Background

Recent studies have shown that aggressive preoperative radiation increases the likelihood of limb salvage in sarcoma patients.

Method

The Surveillance, Epidemiology and End Results database was used to run an adjusted logistic regression for the receipt of cancer-directed treatment modalities.

Results

Of patients with specific surgical procedures recorded (n = 2,104), 86.0% had undergone a limb-sparing procedure. On bivariate analysis, African American patients were less likely to receive a limb-sparing procedure than white patients (80.4% vs 86.9%; P = .02). On multivariate analysis, African Americans were significantly more likely to receive preoperative radiation (odds ratio [OR], 2.31; 95% confidence interval [CI], 1.22-4.40; P = .011), yet this did not translate into an increase in limb salvage (OR, .67; 95% CI, .42-1.08; P = .10). Limb salvage significantly increased for all groups in 2001 and after (OR, 2.75; 95% CI, 1.55-4.88; P = .001) without a decrease in survival. For those with tumors greater than 4 cm, there was a trend away from limb salvage for African Americans (OR, .59; 95% CI, .32-1.07; P = .08).

Conclusions

Our results of an increase in limb-salvage surgeries after 2001 without a decrease in survival support previous studies. The trend away from limb salvage for African Americans cannot be answered by this study.     

Impact of maternal substance abuse and smoking on children with gastroschisis

Background/Purpose

Conflicting information exists regarding the effects of maternal substance abuse on gastroschisis. The objectives of this study are to determine if maternal smoking is associated with an increased risk of gastroschisis and whether substance abuse is associated with the severity of gastroschisis.

Methods

The Canadian Pediatric Surgery Network (CAPSNET) database was evaluated for associations between maternal substance abuse and the severity of the gastroschisis. We also compared smoking rates from this group to overall Canadian maternal smoking rates.

Results

One hundred fourteen cases of gastroschisis acquired over 18 months were evaluated. After adjusting for covariates, illicit drug use was associated with bowel necrosis (OR, 9.4; 95% CI,1.3-70) and marijuana use with matting of the intestines (OR, 4.0; 95% CI, 1.0-16). Functional outcomes assessment revealed that slower initiation of enteral feeds was associated with maternal smoking (OR, 3.8; 95% CI, 1.4-10). The overall maternal smoking rate in this cohort (30.7%) was significantly higher than the known Canadian rate (13.4%). This may be accounted for by the considerably higher smoking rate of mothers 20 to 24 years of age in our cohort (48.9%).

Conclusions

Substance abuse and smoking are associated with a greater severity of gastroschisis in terms of both the degree of intestinal injury and functional outcomes. High smoking rates among young mothers may be putting children with gastroschisis at risk for poor outcomes.     

The outcome of patients treated with sunitinib prior to planned nephrectomy in metastatic clear cell renal cancer

Background

The role of cytoreductive nephrectomy in metastatic clear cell renal cell carcinoma (ccRCC) is controversial.

Objective

To determine the outcome of patients with metastatic ccRCC who receive sunitinib prior to planned nephrectomy.

Design, setting, and participants

The study combined the data from two prospective phase 2 studies that assessed upfront sunitinib (12-16 wk) prior to nephrectomy in previously untreated patients with metastatic renal cell carcinoma (RCC). Sunitinib was discontinued during the perioperative period (median: 29 d).

Intervention

Sunitinib 50 mg in six weekly cycles (4 wk on, 2 wk off).

Measurements

Progression-free (PFS) and overall survival (OS) using the Kaplan-Meier method.

Results and limitations

Twenty-one patients (32%) had Memorial Sloan-Kettering Cancer Centre (MSKCC) poor-risk disease; 45 (68%) had intermediate-risk disease. Nephrectomy was not performed in 19 (29%), most commonly due to disease progression (n = 12). The PFS for the cohort was 6.3 mo (95% confidence interval [CI], 5.1-8.5). Seventeen (36%) patients progressed during the treatment break, 13 (76%) of whom stabilised upon reinitiating of sunitinib. The OS for the cohort was 15.2 mo (95% CI, 10.3-NA). The OS for the intermediate MSKCC risk group was significantly longer than that for the poor-risk group (26.0 mo [95% CI, 13.6-NA] and 9.0 mo [95% CI, 5.8-20.5], respectively; p < 0.01). In multivariate analysis, progression of disease prior to planned nephrectomy (hazard ratio [HR]: 5.34; 95% CI, 3.17-13.27), high Fuhrman grade (HR 3.27; 95% CI, 1.38-7.72), and MSKCC poor risk at diagnosis (HR 4.75; 95% CI, 2.05-11.02) were associated with short survival (p < 0.01). However, in the absence of randomised studies it is not possible to determine if this approach is beneficial.

Conclusions

Upfront sunitinib prior to planned nephrectomy in intermediate-risk disease is associated with a median survival of >2 yr despite frequent progression during treatment break. Progression in metastatic sites prior to planned surgery and MSKCC poor-risk disease was associated with a poor outcome.     

Tinnitus in the elderly: Profile, correlates, and impact in the Nigerian Study of Ageing

Objective

To determine the prevalence and correlates of tinnitus among community elderly and its impact on their quality of life.

Study Design

Longitudinal cohort.

Setting

Yoruba-speaking communities in Nigeria.

Subjects and Methods

Face-to-face interviews of 1302 subjects 65 years or older selected by the use of a multistage stratified sampling of households. Subjects were assessed for subjective tinnitus, chronic health conditions, functional impairment, and quality of life by use of the brief version of the World Health Organization quality of life instrument.

Results

Tinnitus was reported in 184 (110 female and 74 male subjects), giving a prevalence of 14.1 percent (SE = 0.49). Gender, age, economic status, educational level, residence, smoking, and alcohol consumption were not significantly associated with tinnitus. Univariate analysis revealed a history of recurrent otitis media (odds ratio [OR] = 4.5, 95% confidence interval [95% CI] 3.1-6.6, P = 0.01), head injury (OR 3.4, 95% CI 2.1-5.6, P = 0.01), rhinosinusitis (OR 2.4, 95% CI 1.5-4.0, P = 0.01), dizziness (OR 2.1, 95% CI 1.4-3.1, P = 0.01), and hypertension (OR 1.7, 95% CI 1.0-2.7, P = 0.05) as significant correlates. However, in multivariate analysis, only a history of otitis media and of head injury remained significant. Compared with those without, persons with tinnitus had a more negative perception of their overall health and a poorer quality of life as well as twofold likelihood to experience impairment in both activities of daily living and instrumental activities of daily living.

Conclusion

Tinnitus is common among elderly Nigerians and is associated with treatable health conditions, such as otitis media, rhinosinusitis, head injury, and hypertension. Its association with functional impairment and reduced quality of life highlights the need for inclusion in any comprehensive health care for the elderly.     

The contrast enema for Hirschsprung disease: predictors of a false-positive result

Purpose

To examine predictors of a false-positive (FP) result on contrast enema (CE) for the diagnosis of Hirschsprung disease (HD).

Methods

Retrospective analysis, over a 5-year period (1999-2004), of infants (<6 months of age) with suspected HD undergoing rectal biopsy following abnormalities identified on CE (transition zone [TZ], abnormal rectosigmoid ratio, microcolon, retained contrast, or mucosal irregularity).

Results

One hundred twenty-nine patients underwent rectal biopsy following an abnormal CE. The FP rate was 48.5% (66 with HD). Age below 30 days (OR, 3.4; 95% CI, 1.1-10.3), female sex (OR, 3.4; 95% CI, 1.6-7.3), and absence of TZ (OR, 6.3; 95% CI, 2.6-15.3) were independently associated with an increased risk for FP on multiple variable logistic regression. A history of bilious emesis decreased the probability of FP (OR, 0.2; 95% CI, 0.06-0.5).

Conclusions

Transition zone, sex, age, and bilious emesis are important predictors of FP in those with suspected HD and CE abnormalities. With 100% incidence of FP, infants younger than 30 days with neither bilious emesis nor a TZ and female infants younger than 30 days with these features may represent a subpopulation in whom rectal biopsy can be avoided.     

Risk factors for recurrent gastroesophageal reflux disease after fundoplication in pediatric patients: a case-control study

Background/Purpose

Recurrent gastroesophageal reflux disease (rGERD) is a common problem after fundoplication. Previous studies attempting to identify risk factors for rGERD have failed to control for confounding variables. The purpose of this study was to identify significant risk factors for rGERD after controlling for potential confounding variables.

Methods

A retrospective, matched case-control study was conducted at a tertiary children's hospital. Cases (n = 116) met 1 of these criteria: reoperation for rGERD, symptomatic rGERD (confirmed by upper gastrointestinal series, esophagogastroduodenoscopy, or pH monitoring), or postoperative reinstitution of antireflux medication for more than 8 weeks. Controls (n = 209) were matched for surgeon, approach (laparoscopic/open), technique (partial/complete), and approximate operative date. Univariate and multivariable associations were analyzed by conditional logistic regression.

Results

Significant risk factors for rGERD were age of less than 6 years (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.7-7.5), preoperative hiatal hernia (OR, 3.2; 95% CI, 1.4-7.3), postoperative retching (OR, 5.1; 95% CI, 2.6-10.0), and postoperative esophageal dilatation (OR, 10.8; 95% CI, 1.8-65.4). Interestingly, significant association was not found between neurologic impairment and rGERD after controlling for potential confounding variables.

Conclusion

Age of less than 6 years, preoperative hiatal hernia, postoperative retching, and postoperative esophageal dilatation are independently associated with increased risk of rGERD. Neurologic impairment alone does not increase the risk of developing rGERD.     

Infants with repaired esophageal atresia and distal tracheoesophageal fistula with severe respiratory distress: is it tracheomalacia, reflux, or both?

Aim of Study

Infants with repaired esophageal atresia and distal tracheoesophageal fistula (EA/TEF) are at risk for severe respiratory distress, which is related to tracheomalacia (TM), gastroesophageal reflux, or both. This usually mandates an operation for TM and/or a fundoplication procedure (FP).

Methods

We retrospectively performed a 26-year review of 288 patients with repaired EA/TEF. Research Ethic Board approval was obtained.

Results

Postoperatively, 22 (7.6%) infants with EA/TEF developed severe respiratory distress. Thirteen infants had an initial TM procedure and symptoms improved in 7 (54%). The 6 (46%) remaining patients with ongoing respiratory symptoms required an FP. Nine infants had an initial FP and the symptoms improved in 6 (67%). The remaining 3 (33%) patients with ongoing respiratory symptoms required a TM procedure. All patients improved with the second procedure. Several clinical parameters were assessed among the 4 patient groups (FP only, FP followed by TM procedure, TM procedure only, and TM procedure followed by FP); there were no significant differences noted.

Conclusions

Whereas 54% to 67% of infants improved with a TM procedure or FP, 33% to 46% required both surgical procedures. No clinical parameters were identified that could predict which procedure should be performed first.     

Tumours in End-Stage Kidney

Objective

Patients with end-stage kidney disease (ESKD) show a greater risk for renal cell carcinoma (RCC), which tends to be multifocal and bilateral. The malignant potential is unclear. The question is whether to remove both kidneys in patients with a tumor on one side only diagnosed by computed tomography (CT).

Materials and Methods

Kidney tumors were found in 14 patients with ESKD from January 2002 to December 2006. One was unfit for surgery. Thirteen patients underwent nephrectomy and 6 a bilateral procedure of whom only 2 had bilateral tumors on CT, 3 multiple tumors on the contralateral side, and 1 uncontrollable hypertension with tumors as an incidental finding. Tumors were found in all 19 specimens.

Results

In 13 kidneys (68.4%), the tumors were multiple; in 6 (31.6%), solitary. The types of tumor were: 13 (68.4%) papillary RCCs (PRCC), 9 (47.4%) clear RCCs (CRCC), a combination of PRCC and CRCC in 4 (21.0%), and myxoid liposarcoma (with solitary PRCC contralaterally). The mean follow-up was short (19 ± 15 months; maximum, 54 months). Only 1 patient died due to a tumor at 16 months after operation.

Conclusions

There is a high risk for bilateral involvement. Patients who undergo unilateral nephrectomy must be regularly followed and contralateral nephrectomy carefully considered, mainly in transplanted patients on immunosuppression. Further studies are needed to give a definitive answer about the indications for surgery and the indications for contralateral nephrectomy as well. To date, prophylactic contralateral nephrectomy should not be a therapeutic standard.     

Inflammation, metalloproteinases, and growth factors in the development of carotid atherosclerosis in renal transplant patients

Background

Cardiovascular disease is the leading cause of death in renal transplant (RT) patients. Both traditional and emerging risk factors, some of which are controversial, have been described in the pathogenesis of cardiovascular disease. Carotid ultrasound (CUS) is considered to be an excellent diagnostic tool for subclinical atherosclerosis.

Objective

To evaluate the relationship between biomarkers of inflammation, growth factors, metalloproteinases, and the development of subclinical atherosclerosis diagnosed by using CUS.

Methods

We studied 93 RT patients (aged 54 ± 12 years; 67.9% men; 13.5% with pre-RT diabetes mellitus). The following biomarkers were determined in the patients' blood hours before RT: C-reactive protein (CRP) and serum amyloid A using nephelometry; interleukin (IL) 2, 6, 8, and 10 and soluble IL-2 receptor, tumor necrosis factor (TNF) α, vascular endothelial growth factor (VEGF), epidermal growth factor, and monocyte chemotactic peptide using chemoluminescence; and pregnancy-associated plasma protein (PAPP)A using ELISA. A CUS was carried out during the first month after RT.

Results

Carotid intima-media thickness (IMT) was elevated in 51% of the patients, and 50.5% of the patients had atherosclerotic plaque. Both plaque (P = .004) and IMT (P = .001) correlated with age, and the increase of IMT was progressive, on both the left and the right side. Pre-RT CRP, IL-8, TNF-α, VEGF, MCP-1, and PAPP-A were significantly more elevated in patients with plaque. In the multivariate analysis adjusted for clinical variables, age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.01-1.10; P = .04), CRP (OR, 7.5; 95% CI, 2.05-27.3; P = .002), IL-8 (OR, 4.73; 95% CI, 1.27-17.6; P = .02), and PAPP-A (OR, 4.45; 95% CI, 1.22-16.2; P = .023) were independent markers of the presence of plaque.

Conclusions

Age, CRP, IL-8, and PAPP-A, and not growth factors, are markers of carotid atheromatous plaque in RT patients.     

Treatment of ingrown toenails in the pediatric population

Background/Purpose

Nail avulsion plus chemical matrixectomy (CM) using NaOH as an alternative to surgical matrixectomy (SM) has recently been used in the treatment of ingrown toenails (IGTNs) in adults. No studies exist to dictate the most effective and safe treatment method in the pediatric population.

Methods

A retrospective review of pediatric IGTNs treated at 2 institutions for 6 years was done, looking at presentation, treatment modality, SM vs CM, and outcomes.

Results

Eight hundred forty-eight IGTNs in 518 patients were reviewed with an average age of 12.5 years. Twenty-three percent were felt to be infected at the time of presentation, and 34% were being treated with antibiotics within the preceding week of surgery. Seventy-nine percent of toenails underwent surgical management with the most common procedure being avulsion plus SM (65%), followed by avulsion plus CM (17%), and avulsion alone (14%). The overall recurrence rate after initial surgery was 19.5%. After adjusting for covariates, recurrence was associated with treatment by avulsion alone (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.5-4.7), avulsion plus CM (OR, 0.3; 95% CI, 0.1-0.7), and treatment with antibiotics within the week before surgery (OR, 0.5; 95% CI, 0.3-0.9; P = .017). The overall postoperative infection rate was 6% and was unrelated to presence of preoperative infection, use of antibiotics, or surgical treatment method.

Conclusions

Ingrown toenails present a significant problem to youth and should be addressed in a diligent fashion. Chemical matrixectomy using NaOH is a safe and effective alternative to SM and maybe associated with a lower rate of recurrence, especially when use in conjunction with preoperative antibiotics.     

Development of a score to predict the need for coronary artery bypass graft surgery in patients with non-ST segment elevation acute coronary syndromes

Background

Our ability to identify surgical candidates before angiography is limited. Early identification of surgical patients would improve preoperative management and ultimately postoperative outcomes. The objective of this study was to determine whether surgical candidates could be identified before coronary angiography using simple clinical variables.

Methods

The study population was comprised of 688 patients admitted to a tertiary hospital because of non-ST segment elevation acute coronary syndromes. Stepwise logistic regression analysis was performed to identify predictors of surgery. A test cohort (50.2%) was used to generate the model and a validation cohort (49.8%) was used for independent validation of the proposed score.

Results

Three variables independently predicted the indication for bypass surgery: the absolute thrombolysis in myocardial infarction (TIMI) risk score (odds ratio [OR] = 2.34 for each unit increase in the score, 95% confidence interval [CI] = 1.89-2.89, p < 0.001), the presence of peripheral vascular disease (PVD) (OR = 4.08, CI = 1.48-11.24, p = 0.006), and the presence of congestive heart failure (CHF) on admission (OR = 2.57, CI = 1.08-6.81, p = 0.03). A simplified score that spans from 0-10 was developed based on the logistic regression model. The score adds two points to the TIMI score if PVD is present and one point if CHF is present. The area under the receiver-operating-characteristic (ROC) curve of the proposed score for predicting surgery was 0.80 ± 0.02.

Conclusions

The score we have proposed and validated can be used to predict the likelihood of bypass surgery before coronary angiography and may assist the clinician to tailor preoperative medical therapy.     

Determination of risk factors for deep venous thrombosis in hospitalized children

Purpose

Our objective was to determine the time trend and risk factors for deep venous thrombosis (DVT) of the lower extremities among pediatric inpatients.

Methods

This cross-sectional study used the data from the Health Care Cost and Utilization Project Kids' Inpatient Database for the years of 1997, 2000, and 2003 to estimate the DVT prevalence and crude and adjusted prevalence ratios. Patients between the ages of 1 and 17 years and who were hospitalized for at least 4 days were included.

Results

The weighted prevalence of DVT was 4.2 per 1000 hospital discharges (95% confidence interval [CI], 3.4-3.7). Independent of age, the prevalence of DVT was significantly greater in 2000 and 2003 compared to 1997, prevalence ratio (PR) of 1.2 and 1.4 (95% CI, 1.1-1.3 and 1.2-1.4). Using only the 2003 database, adjusted analysis revealed that patients at highest risk were those in the age range of 15 to 17 years (PR, 2.0; 95% CI, 1.6-2.4) and with the following comorbid conditions: obesity (PR, 2.1; 95% CI, 1.5-2.8), inflammatory bowel disease (PR, 1.8; 95% CI, 1.2-2.7), hematologic malignancy (PR, 2.5; 95% CI, 2.0-3.1), and thoracoabdominal (PR, 1.8; 95% CI, 1.6-2.2) or orthopedic (PR, 2.2; 95% CI, 1.7-2.8) operations. Predictors not associated with DVT included sex and diagnosis of trauma.

Conclusions

The discharge diagnosis of DVT of the lower extremities has significantly increased since 1997. In addition, teenagers with underlying disorders are at highest risk for DVT.     

Use of transanastomotic feeding tubes during esophageal atresia repair

Purpose

Esophageal atresia (EA) with tracheoesophageal fistula (TEF) type C accounts for 85% of all EA. In our center, patients were previously started on total parenteral nutrition (TPN) postoperatively and oral feedings initiated only after a contrast esophagogram. Our aim is to assess the benefit of intraoperatively placed transanastomotic feeding tubes (TAFTs).

Methods

A 7-year retrospective review analyzed the outcomes of children with EATEF type C as they relate to the use of TAFT. Demographics, associated anomalies, operative findings, complications, duration of TPN, resumption of oral feeding, length of stay, and follow-up were examined.

Results

Twenty-one patients had EATEF type C. Eleven (55%) and 9 (45%) patients were identified as nonfeeding tube (NFT) and TAFT groups, respectively. There were no differences in gestational age, birth weight, associated anomalies, and interval to operative intervention or operative time. Excluding one patient with a severe cardiac malformation in the NFT group, there were no significant differences in anastomotic leak (8% vs 22%), stenosis (36% vs 22%), TPN duration (20 days vs 12 days), and cholestasis (36% vs 11%).

Conclusion

Transanastomotic feeding tube may lead to shorter TPN duration and decreased cholestasis, but a larger prospective study would be required to prove these benefits and ensure that it does not increase anastomotic leaks. This could be done through an expanded Canadian Pediatric Surgery Network study.     

Analgesic efficacy of ultrasound-guided regional anesthesia: a meta-analysis

Study Objective

To determine if the use of ultrasound guidance (vs non-ultrasound techniques) improves the success rate of nerve blocks.

Design

Meta-analysis of randomized controlled trials (RCTs) in the published literature.

Setting

University medical center.

Measurements

16 RCTs of patients undergoing elective surgical procedures were studied. Patients underwent ultrasound-guided or non-ultrasound techniques (nerve stimulation, surface landmark) for peripheral nerve blocks. Success rates were measured.

Main Results

Ultrasound guidance (vs all non-ultrasound techniques) was associated with a significant increase in the success rate of nerve blocks [relative risk (RR) = 1.11 (95% confidence interval [CI]: 1.06 to 1.17, P < 0.0001]). When compared with nerve stimulator techniques only, ultrasound guidance was still associated with an increase in the success rate (RR = 1.11 [95% CI: 1.05 to 1.17, P = 0.0001]). For specific blocks, ultrasound guidance (vs all non-ultrasound) was associated with a significant increase in successful brachial plexus (all) nerve blocks (RR = 1.11 [95% CI: 1.05 to 1.20, P = 0.0001]), sciatic popliteal nerve block (RR = 1.22 [95% CI: 1.08 to 1.39, P = 0.002]) and brachial plexus axillary nerve block (RR = 1.13 [95% CI: 1.00 to 1.26, P = 0.05]) but not brachial plexus infraclavicular nerve block (RR = 1.25 [95% CI: 0.88 to 1.76, P = 0.22]).

Conclusions

Ultrasound-guided peripheral nerve block is associated with an increased overall success rate when compared with nerve stimulation or other methods. Ultrasound-guided techniques also increase the success rate of some specific blocks.