Endosonographic Imaging of Anal Sphincter Injury

PURPOSE: This study was designed to test the hypothesis that the extent of anal sphincter muscle injury as graded at endosonography correlates with the degree of functional impairment. METHODS: Three hundred and thirty adults presenting for evaluation of fecal incontinence were recruited. Ultrasound was performed with a 7.5-MHz radial rotating axial endoprobe in the left lateral position. Anal sphincter muscle tears were graded on the basis of the degree of circumferential involvement (< or >25 percent) and by an assessment of the superoinferior longitudinal extent of an external anal sphincter tear. Muscles that demonstrated multiple tears, poor visualization, or fragmentation were classed as fragmented. Sphincter injuries were correlated with basal and squeeze pressures at manometry, pudendal nerve terminal latencies, and the severity of symptoms using the Parks-Browning clinical score. RESULTS: Patients with an intact external anal sphincter had a higher squeeze pressure (mean, 162.6 cm H(2)O) than those with a partial- (mean, 125.7 cm H(2)O) or full-length tear (mean, 124.9 cm H(2)O; P < 0.0001). There was no significant difference in squeeze pressure between those with partial- vs. full-length external anal sphincter tears nor between circumference tears < or >25 percent. Basal pressure was significantly lower in those with a full-length external anal sphincter tear (47.8 cm H(2)O) vs. an intact external anal sphincter (65.7 cm H(2)O; P < 0.001). The basal pressure in those with an intact internal anal sphincter was not significantly different from those with clearly defined internal anal sphincter tears, and the degree of circumferential involvement was also not important in this regard. However, those with a fragmented internal anal sphincter had a significantly lower basal pressure than other subgroups of internal anal sphincter injuries (P < 0.001). There was no association between external or internal anal sphincter status and the mean pudendal nerve terminal motor latency, suggesting the patient groups were neurologically similar. There was no significant association between external or internal anal sphincter status and the severity of reported symptoms. CONCLUSION: Correlations between the presence or absence of muscle tears and reduced manometric function have been identified. Further grading of tears was of less importance. No relationship between muscle injuries and the severity of clinical symptoms could be elicited.     

Predicting the growth response to growth hormone in patients with intrauterine growth retardation

OBJECTIVE Human GH treatment of short children who had intrauterine growth retardation (IUGR) results in a highly variable growth response. The object of this study was to test the hypothesis that differences in responsiveness to exogenously administered GH might reflect differences in endogenous GH secretion or sensitivity. DESIGN Prospective study evaluating the growth response to GH therapy in short individuals with prior IUGR. PATIENTS Ten short, prepubertal children with prior IUGR were studied. Mean age was 6 years (3.39–8.61). Mean bone age was 4.6 years (2.3–8.3). Mean body mass index was 13.2 kg/m² (9.9–14.0; normal 13.5–19.0). MEASUREMENTS Overnight spontaneous GH release was measured using a constant withdrawal pump and stimulated GH release was measured following clonidine (0.15 mg/m²) administration. IGF-I concentrations were measured at baseline and 12, 24, 36 and 48 hours after sequential doses of GH (0.05 and 0.2 mg/kg/dose) given 48 hour apart. Patients were treated with GH (0.125 mg/kg three times a week) and growth response was assessed. In the second and third year, attempts were made to improve the growth rate by nutritional supplementation and increasing the dose of GH to 0.25 mg/kg three times a week. RESULTS All patients had normal integrated nocturnal GH secretion (>3 μg/l, 6mU/l) and normal peak GH secretion in response to clonidine (>7 μg/l). In the first year of the trial, mean growth velocity (GV) increased from 5.39 cm/year ± 0.29 to 7.32 cm/year ± 0.39 (P = 0.004). Changes in GV correlated inversely with integrated GH (r = ? 0.69; P = 0038), baseline IGF-I concentration (r = ? 0.88; P = 0.002) and baseline GV-SDS (r = ? 0.68; P = 0.043). There was no correlation between change in GV and GH binding protein, baseline height SDS or age. The effect of GH waned in the second year, but tended to remain greater than the pretreatment growth rate (6.54 ± 0.49 vs 5.53 cm/year ± 0.29; P = 0.09). No significant advancement of bone age over chronological age was observed over the first 2 years. Increasing nutritional intake by 17% did not result in significant weight gain nor increase in height velocity. Doubling the dose of GH in the second or third year did not result in a significant increase in GV. CONCLUSION The variable response to GH therapy in short children with a history of intrauterine growth retardation may partly reflect relative sufficiency or insufficiency of GH. Baseline IGF-I levels and baseline growth velocity appear to be useful and practical predictors of response to GH.     

Clinical Characteristics and Outpatient Mental Health Service Use of Transition-Age Youth in the USA

This study examines diagnostic and service utilization patterns of transition-age youth in outpatient care derived from the 2007 nationally representative Client/Patient Sample Survey. Comparisons between 16–17, 18–21, and 22–25 year olds are highlighted. Among transition-age outpatients, the oldest youth had the highest rates of depression and bipolar disorder and co-occurring medical and substance use problems. Controlling for sociodemographic and clinical characteristics, 18–21 year olds were less likely to receive individual therapy than 16–17 year olds, but there were no age group differences in receipt of specialized therapy or psychotropic medication. Female gender and Hispanic ethnicity were positively associated with the number of services received and specialized service use, respectively; youth with private insurance were more likely than those with public insurance to receive psychotropic medication. Implications are discussed regarding access to and adequacy of services provided for young people in the critical transition to adulthood, especially with the implementation of the 2010 Affordable Care Act.     

Understanding Perinatal Death: A Systematic Analysis of New York City Fetal and Neonatal Death Vital Record Data and Implications for Improvement, 2007–2011

We aimed to compare demographic, medical, and cause-of-death information reported for third-trimester fetal and neonatal death vital records collected in New York City (NYC) before and after implementation of the revised fetal death certificate to identify: (1) the limitations of combining fetal and neonatal death records for the purpose of perinatal death prevention; and (2) improvement opportunities for fetal death vital records registration. Using Chi squared tests, we compared data completeness and cause-of-death information between third-trimester NYC fetal (n = 1,930) and neonatal deaths (n = 735) from 2007 to 2011. We also compared fetal death data before and after the 2011 implementation of the 2003 United States (US) Standard Report of Fetal Death and an electronic reporting system. Compared with neonatal deaths, fetal death data were generally less complete (P < 0.0001). Fetal death data much more frequently reported an ill-defined cause of death (67 vs. 5 %). Most ill-defined reported causes of fetal death (73 %) were attributed to stillbirth synonyms (e.g., “fetal demise”). Ill-defined causes of fetal death decreased from 68 to 61 % (P < 0.01) after 2011. Both data completeness and ill-defined causes of death varied widely by hospital. In NYC, fetal deaths lack demographic, medical, and cause-of-death information compared with neonatal deaths, with implications for research that uses combined perinatal mortality data sets. Electronic implementation of the US Standard Report of Fetal Death minimally improved cause-of-death information. Substantial variability by hospital suggests opportunities for improvement exist.     

Prospective Associations between Bilingualism and Executive Function in Latino Children: Sustained Effects While Controlling for Biculturalism

The study purpose was to test 1-year prospective associations between English–Spanish bilingualism and executive function in 5th to 6th grade students while controlling for biculturalism. Participants included 182 US Latino students (50 % female). Self-report surveys assessed biculturalism, bilingualism, and executive function (i.e., working memory, organizational skills, inhibitory control, and emotional control, as well as a summary executive function score). General linear model regressions demonstrated that bilingualism significantly predicted the summary executive function score as well as working memory such that bilingual proficiency was positively related to executive function. Results are the first to demonstrate (a) prospective associations between bilingualism to executive function while controlling for the potential third variable of biculturalism, and (b) a principal role for working memory in this relationship. Since executive function is associated with a host of health outcomes, one implication of study findings is that bilingualism may have an indirect protective influence on youth development.     

HIV Testing Histories and Risk Factors Among Migrants and Recent Immigrants Who Received Rapid HIV Testing from Three Community-Based Organizations

Migrants and recent immigrants in the US constitute a large population that is vulnerable to HIV. From March 2005 to February 2007, three community-based organizations conducted rapid HIV testing among migrants in five states. Participants were asked to complete a survey on sociodemographics, HIV-risk behaviors, and HIV-testing histories with the aim of understanding factors associated with HIV testing. Among 5,247 persons tested, 6 (0.1 %) were HIV-positive. Among 3,135 persons who completed surveys, more than half had never been tested for HIV previously (59 %). Participants reported high levels of HIV-risk behaviors in the past year, including 2 or more sex partners (45 %), sex while high/drunk (30 %), and transactional sex (29 %). Multivariate analysis identified several factors independently associated with decreased likelihood of prior HIV testing, including poor spoken English. Continued efforts are needed to ensure that migrant populations have improved access to HIV testing and prevention services. Understanding factors associated with migrants’ lack of previous HIV testing may help focus these efforts.     

Long-term Results of Comprehensive Clubfoot Release Versus the Ponseti Method: Which Is Better?

Background

Clubfoot can be treated nonoperatively, most commonly using a Ponseti approach, or surgically, most often with a comprehensive clubfoot release. Little is known about how these approaches compare with one another at longer term, or how patients treated with these approaches differ in terms of foot function, foot biomechanics, or quality-of-life from individuals who did not have clubfoot as a child.

Questions/purposes

We compared (1) focused physical and radiographic examinations, (2) gait analysis, and (3) quality-of-life measures at long-term followup between groups of adult patients with clubfoot treated either with the Ponseti method of nonsurgical management or a comprehensive surgical release through a Cincinnati incision, and compared these two groups with a control group without clubfoot.

Methods

This was a case control study of individuals treated for clubfoot at two separate institutions with different methods of treatment between 1983 to 1987. One hospital used only the Ponseti method and the other mainly used a comprehensive clubfoot release. There were 42 adults (24 treated surgically, 18 treated with Ponseti method) with isolated clubfoot along with 48 healthy control subjects who agreed to participate in a detailed analysis of physical function, foot biomechanics, and quality-of-life metrics.

Results

Both treatment groups had diminished strength and motion compared with the control subjects on physical examination measures; however, the Ponseti group had significantly greater ankle plantar flexion ROM (p < 0.001), greater ankle plantar flexor (p = 0.031) and evertor (p = 0.012) strength, and a decreased incidence of osteoarthritis in the ankle and foot compared with the surgical group. During gait the surgical group had reduced peak ankle plantar flexion (p = 0.002), and reduced sagittal plane hindfoot (p = 0.009) and forefoot (p = 0.008) ROM during the preswing phase compared with the Ponseti group. The surgical group had the lowest overall ankle power generation during push off compared with the control subjects (p = 0.002). Outcome tools revealed elevated pain levels in the surgical group compared with the Ponseti group (p = 0.008) and lower scores for physical function and quality-of-life for both clubfoot groups compared with age-range matched control subjects (p = 0.01).

Conclusions

Although individuals in each treatment group experienced pain, weakness, and reduced ROM, they were highly functional into early adulthood. As adults the Ponseti group fared better than the surgically treated group because of advantages including increased ROM observed at the physical examination and during gait, greater strength, and less arthritis. This study supports efforts to correct clubfoot with Ponseti casting and minimizing surgery to the joints, and highlights the need to improve methods that promote ROM and strength which are important for adult function.

Level of Evidence

Level III, prognostic study.     

A survey-based assessment of the Canadian pediatric surgery workforce

Background

There is significant lack of information regarding the Canadian pediatric surgery workforce.

Methods

An IRB-approved survey aimed at assessing workforce issues was administered to pediatric surgeons and pediatric surgery chiefs in Canada in 2012.

Results

The survey was completed by 98% of practicing surgeons and 13 of the 18 division chiefs. Only 6% of surgeons are older than 60 years, and only a fifth anticipate retirement over the next decade. The workforce is stable, with 82% of surgeons unlikely to change current positions. Surgical volume showed essentially no growth during the 5-year period 2006–2010. The majority of surgeons felt they were performing the right number or too few cases and anticipated minimal or no future growth in their individual practices or that of their group. Based on anticipated vacancies, the best estimate is a need for 20 new pediatric surgeons over the next decade. This need is significantly surpassed by the current output from the Canadian training programs.

Conclusions

The Canadian pediatric surgery workforce is currently saturated. The mismatch between the number of graduating trainees and the available positions over the next decade has significant repercussions for current surgery and pediatric surgery residents wishing to practice in Canada.