To trach or not to trach,that is the question

Progressive neuromuscular disease requires increasing degrees of respiratory support to sustain life. Each step from intermittent to continuous—and noninvasive to invasive—ventilation requires thoughtful consideration based on the goals of the patient and family, and the inherent benefits and burdens of the treatment. Tracheostomy, in particular, should not be viewed as an inevitable next step when less permanent or invasive methods prove insufficient. Like other modes of respiratory support, tracheostomy may represent a bridge to recovery of pulmonary function, or a stabilizing action in the hope that novel therapies may prove beneficial. In other situations, tracheostomy represents a destination therapy, necessitating consideration of the implications of chronic mechanical ventilation. Institutional, social, and financial considerations may affect decisions related to tracheostomy, as may implicit bias regarding quality of life. The complexity of such care and decisions highlight the need for optimal palliative care throughout the patient’s life.     

Editorial commentary: To DMSA or not,that is the question.

Pediatric Radiology -     

The distal pouch in esophageal atresia -- to dissect or not to dissect, that is the question.

Long-gap esophageal atresia remains a difficult problem for the pediatric surgeon and reconstruction using the native esophagus is considered to be superior to any interposition procedure. Because of esophageal segmental blood supply and vascular vulnerability of the distal esophageal pouch in the short term and its motility disorder in the long term, surgeons are reluctant to perform extensive esophageal dissection. However, ascending and descending branches of esophageal vessels converge along the anterolateral and posterolateral aspects of the esophagus.This arrangement allows for dissection and mobilization of the distal pouch without necessarily causing vascular impairment. Extensive dissection of the distal pouch was advocated by Robert Gross over fifty years ago. More recently, circular myotomy of the distal pouch has been performed. However, manometric studies showed that prior to surgical repair, peristalsis of the upper and lower esophageal pouch was synchronized, while after surgery this coordination was clearly defective. Furthermore, in the adriamycin-induced rat model, inherent abnormalities in the course and branching pattern of the vagus nerves in the lower esophagus have been demonstrated. Significant abnormalities of the intramural nervous components involving both the excitatory and inhibitory nerves, and elevated levels of S100 and galanin in the lower esophageal pouch could explain an inborn motility disorder. The selective injury of minor vagal branches in experimental animals also alters esophageal peristalsis. In conclusion, given that the native esophagus is still considered the best alternative for reconstruction of esophageal atresia, when indicated, gentle but extensive dissection of the lower esophageal pouch seems to be preferable, keeping in mind the possibility of vascular compromise and the inevitability of motility disfunction.     

To drain or not to drain: an analysis of abscess drains in the treatment of appendicitis with abscess

Background/purpose

Perforated appendicitis is associated with abscess formation before or after appendectomy. Many abscesses are not amenable to drainage due to size or location. In this study, we compare patients who had a drain placed for an abscess to those who were treated without a drain.

Methods

Data were retrospectively collected from January 2000 to March 2011. Abscess before or after appendectomy was assessed. CT scans were reviewed and abscess size was estimated using the product of the greatest anteroposterior and lateral dimensions from an axial image. Patients with abscess smaller than 5 cm² were excluded. Patients treated with a drain were compared to those without using t test for continuous variables and Fisher’s exact for categorical variables.

Results

Of 217 patients, those with drains had significantly more CT scans, total healthcare visits and larger abscess size. When match controlled for size, drain patients accrued more CT scans and healthcare visits. In a subset analysis of aspiration versus antibiotics only, there were more CT scans but no difference between length of stay, total healthcare visits, abscess size, recurrence, or complications.

Conclusions

Appendicitis-associated abscesses may be treated with antibiotics alone based on size, which improves resource utilization with fewer CT scans and healthcare visits.     

ARA or no ARA in infant formulae,that is the question

Recently, the European Commission issued a Delegated Regulation updating the compositional and information requirements for infant and follow-on formulae that are to be applied at the latest in February 2021. This new regulation changes the status of docosahexaenoic acid (DHA) from an optional ingredient to a mandatory nutrient in these formulae at levels between 20 and 50 mg/100 kcal (0.5–1% of fatty acids). By contrast, arachidonic acid (ARA) becomes an optional nutrient. Following publication of the new regulation, global scientific experts have expressed concerns regarding the potential health risks of new infant formulae containing only DHA, especially at levels higher than those in breast milk and infant formulae marketed to date. Both DHA and ARA play a crucial role in infant development. First, breast milk, the gold standard for infant feeding, contains both DHA and ARA. Second, during development, the conversion of linoleic acid into ARA through desaturation steps is not sufficient to meet nutritional needs, especially in carriers of newly identified genetic variants in fatty acid desaturases, which weaken the biosynthetic production of ARA. Third, circulating levels of DHA and ARA in breastfed infants can only be matched with the addition of both fatty acids to formulae. And fourth, most studies performed to date have demonstrated that important physiological and developmental endpoints are sensitive to the ratio of dietary ARA:DHA. The precautionary principle applies when implementing the new EU regulation for infant and follow-on formulae. As a consequence, given the vulnerability of developing infants as well as the absence of conclusive evidence that formulae with at least 20 mg DHA/100 kcal, but no ARA, are safe and suitable to support the growth and development of infants similar to their breastfed peers, it remains necessary to still market formulas containing both ARA and DHA until proved otherwise.     

Perforated appendicitis in children: to drain or not to drain?

We studied 66 children with perforated appendicitis at the University of New Mexico to determine whether or not transperitoneal drainage has any advantage in the management of these children. Patients were assigned to one or the other treatment group on the basis of the call schedule of the attending surgeons, two of whom preferred drainage and two of whom did not. Other aspects of appendicitis management (e. g., supportive care, antibiotics) were the same for both groups. Thirty-two other children who had an abscess at the time of appendectomy were excluded from the analysis. The two study groups were similar in age and severity of illness. Postoperative complications (wound infection, abdominal abscess, small-bowel obstruction) had a similar incidence in the two groups: 6/32 (18.8%) for the drained group and 7/34 (20.6%) for the undrained group. The hospital stay was significantly longer for the drained group (mean 10.1 days, median 9 days) versus the undrained group (mean 7.0 days, median 7 days). The power of our study was 0.52; twice our sample size would have been required to achieve a power of 0.80. The evidence suggests that, unless an abscess is present, drainage may be abandoned for children with perforated appendicitis.