Institutional practice and outcome variation in the management of congenital diaphragmatic hernia and gastroschisis in Canada: a report from the Canadian Pediatric Surgery Network

Background

Perinatal management of congenital diaphragmatic hernia (CDH) and gastroschisis (GS) remains nonstandardized and institution specific. This analysis describes practice and outcome variation across a national network.

Methods

A national, prospective, disease-specific database for CDH and GS was evaluated over 4 years. Centers were evaluated individually and defined as low (low-volume center [LVC]) or high (high-volume center [HVC]) volume based on case mean.

Results

Congenital diaphragmatic hernia. Two hundred fifteen liveborn cases were studied (mean, 14.3 cases/center) across 15 centers (8 LVCs and 7 HVCs). Significant interinstitutional practice variation was noted in rates of termination (0%-40%) and cesarean delivery (0%-61%). Centers demonstrated marked variation in ventilation strategies, vasodilator and paralytic use, timing of surgery, and rates of primary closure. Overall survival was 81.4% (LVC, 76.9%; HVC, 82.4%; P = .43).Gastroschisis. Four hundred sixteen cases were investigated (mean, 26 cases/center; range, 6-72) across 16 centers (10 LVCs and 6 HVCs). Cesarean delivery rates varied widely between centers (0%-86%) as did timing of closure (early vs delayed, 1%-100%). There was no difference in length of stay, days on total parenteral nutrition, and overall survival (94.3% vs 97.2%; P = .17) between LVCs and HVCs.

Conclusions

The existence of perinatal practice and outcome variation for GS and CDH suggests targets for improved delivery of care and justifies efforts to standardize treatment on a national basis.     

Is Brown Adipose Tissue Visualization Reliable on 99mTc-Methoxyisobutylisonitrile Diagnostic SPECT Scintigraphy?

The ^99mTc-MIBI has been used with great value as a diagnostic technique in patients with primary hyperparathyroidism. False-positive scans may occur due to misinterpretation of the physiologic distribution of the ^99mTc-MIBI. Reviewing consecutive SPECT scans, we evaluated this possibility and assessed how frequently brown adipose tissue (BAT) is seen on ^99mTc-MIBI scintigraphy.Here, we retrospectively reviewed scans of consecutive patients who were evaluated for parathyroid adenomas from March 2015 to June 2015, using dual-phase (early and delayed) planar imaging and SPECT. We identified 60 patients (48 female and 12 male; mean age, 52.25 ± 15.20 years; range, 22–86 years).We detected the presence of ^99mTc-MIBI uptake in BAT in 20 of 60 patients (33.33%) in the neck. Although the patients with ^99mTc-MIBI uptake in BAT were younger (mean age, 48.85 ± 15.27 years, range, 26–73 years) than the patients with no ^99mTc-MIBI uptake (mean age, 53.95 ± 15.07 years, range, 22–86 years), this difference was not statistically significant (P = 0.224). The percentage of female patients with BAT detection was higher (17/48 patients; 37.5%) than that of the male population (3/12 patients; 25%), this difference was not also statistically significant (P = 0.85).In patient population referred to ^99mTc MIBI scintigraphy of the parathyroid glands, uptake of ^99mTc-MIBI in BAT should not be misinterpreted with ^99mTc-MIBI-avid-tumors. Fused SPECT/CT images (not SPECT-only) are necessary to distinguish BAT from bone, muscle, thyroid, myocardium, parathyroids, and other structures in the neck and chest.     

Adherence of enamel matrix derivatives on root-end filling materials

It was recently shown that application of enamel matrix derivatives (EMDs) on denuded root dentin promotes periodontal regeneration. EMD is shown to adhere to the etched dentin, but its adherence to root-end filling materials is not known. The purpose of this study was to evaluate the adherence of a commercially available EMD product to root-end filling materials. Dentin sections were embedded in blocks made of acrylic resin. Cavities were prepared in similar acrylic resin blocks and were filled with amalgam, IRM, or composite resin. EMD was labeled with radioactive iodine and applied to the surfaces of the dentin sections, freshly made fillings, or acrylic resin controls. The specimens were rinsed, and the amount of radioactive iodine was determined in a gamma counter. Substantial amounts of EMD adhered to dentin sections. EMD adherence to amalgam and IRM was significantly less than to dentin or composite resin.     

Menopause-related quality of life in chronically mentally ill women

OBJECTIVE: Menopause is an important life event that has not yet been well characterized among women with severe mental illness. Our goal was to evaluate menopause-related quality of life among severely mentally ill women. METHOD: We conducted a cross-sectional assessment of perimenopausal and postmenopausal women, ages 45-55, diagnosed with schizophrenia/schizoaffective disorder, bipolar disorder, or major depression, who were receiving inpatient or outpatient psychiatric care. Women were compared regarding menopausal symptoms and quality of life using the Menopause Specific Quality of Life Scale (MENQOL). RESULTS: Women with severe mental illnesses who were peri- and post-menopausal experienced considerable vasomotor, physical, sexual, and psychosocial symptoms related to menopause. On seven of 29 MENQOL items, women with major depression reported problems significantly more often than women with other serious mental illnesses. CONCLUSIONS: This preliminary study indicates that psychiatrists and other physicians should consider the frequency and overlap of menopausal and psychiatric symptoms among women with serious mental illness in this age group.     

Association between intraoperative opioid administration and 30-day readmission: a pre-specified analysis of registry data from a healthcare network in New England

Background

The use of intraoperative opioids may influence the rate of postoperative complications. This study evaluated the association between intraoperative opioid dose and the risk of 30-day hospital readmission.

Anorectal surgery in the HIV+ patient: Update

Anorectal surgery in HIV ⁺ patients historicially has been viewed with a great deal of nihilism. Advances in medical therapy and better understanding of unique pathophysiologic processes have afforded the colorectal surgeon the ability to treat better and sometimes cure the anorectal complications of AIDS. We present a series of 75 consecutive surgical procedures (1-year accrual) on HIV ⁺ (40) and CDC AIDS (22) patients. Surgical procedures, perioperative T cell counts, and outcome will be presented; 53 percent of procedures resulted in complete healing of anal wounds; 30 percent resulted in partial healing with symptomatic relief; 17 percent resulted in symptomatic relief or tissue diagnosis without appreciable wound healing. The healing rate was significantly higher in the HIV ⁺ group (69 percent) compared to the AIDS group (26 percent). Perioperative T cell counts did not have predictive value on outcome. No patients suffered significant unexpected morbidity, mortality, or incontinence. Pathophysiologic mechanisms of several disease processes unique to HIV ⁺ patients and data from our ongoing investigation using RNA hybridization are presented.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Microbial Analysis in Primary and Persistent Endodontic Infections by Using Pyrosequencing

Introduction

The aim of this study was to investigate the bacterial community profile of intracanal microbiota in primary and persistent endodontic infections associated with asymptomatic chronic apical periodontitis by using GS-FLX Titanium pyrosequencing. The null hypothesis was that there is no difference in diversity of overall bacterial community profiles between primary and persistent infections.

Methods

Pyrosequencing analysis from 10 untreated and 8 root-filled samples was conducted.

Results

Analysis from 18 samples yielded total of 124,767 16S rRNA gene sequences (with a mean of 6932 reads per sample) that were taxonomically assigned into 803 operational taxonomic units (3% distinction), 148 genera, and 10 phyla including unclassified. Bacteroidetes was the most abundant phylum in both primary and persistent infections. There were no significant differences in bacterial diversity between the 2 infection groups (P > .05). The bacterial community profile that was based on dendrogram showed that bacterial population in both infections was not significantly different in their structure and composition (P > .05).

Conclusions

The present pyrosequencing study demonstrates that persistent infections have as diverse bacterial community as primary infections.