Peritoneal drainage versus laparotomy as an initial treatment in complicated necrotizing enterocolitis: a single institution experience

Objective To determine whether initial peritoneal drainage (PD) or primary laparotomy is the most effective intervention in very-low-birth-weight and extremely lowbirth- weight infants who are diagnosed with necrotizing enterocolitis (NEC, Bell’s stage II and stage III).Patients and methods It is a retrospective chart review study. Demographic data, clinical characteristics, and outcome were reviewed from records of neonates with severe NEC requiring surgical intervention (Bell’s stage II and stage III) at our institution from 2003 to 2009.Results Thirty-two patients were included in our study. Seventeen patients (53.1%) underwent PD and 15 patients (46.8%) underwent laparotomy. Out of 17 patients in the drainage group, 11 patients (64.7%) underwent laparotomy and six patients (35.2%) did not undergo laparotomy because they were sick and died within few days. Difference in gestational age, sex, and birth weights between two groups was not statistically significant. Similarly, difference in variables as mode of delivery and days of enteral feeding was not statistically significant. Mean age at diagnosis was 31.5 days for the laparotomy group and 18.4 days for the drainage group. P value was 0.026 in the univariate analysis, but P value in the final model of analysis was found to be statistically not significant. It was found from our study that patients with many associated diseases were more in the PD group (P value was 0.008). Almost all patients were mechanically ventilated. Mean pH was 7.29 in the laparotomy group and 7.25 in the drainage group, which was statistically not significant. In the PD group, 13 patients required vasopressors; however, only four patients in the laparotomy group were on vasopressors (P value was 0.017). Difference in variables such as indomethacin, white blood cell count, and platelet count was found to be statistically not significant between the two groups. Six patients were on steroids in the PD group and only one patient was on steroid in the laparotomy group (P value is 0.007). In addition, outcome at 90 days was analyzed; nine patients died in the PD group, whereas four patients died in the laparotomy group (P value is 0.081). Data were also analyzed for complications such as stricture, short bowel syndrome, and cholestasis and the difference was not significant. Finally, total parenteral nutrition dependency difference was found to be statistically not significant between two groups.Conclusion Patients were very sick in the PD group and they were on vasopressors and steroids. Moreover, it was found that diagnosis of NEC early in life signifies a higher mortality. Insertion of a PD is still useful in resuscitating small critically ill infants with NEC; however, the majority of these infants will require subsequent laparotomy. Early diagnosis and early intervention are necessary to decrease the inflammatory insults to the body systems and this reflects on survival.Keywords: drainage versus laparotomy, less than 1500 g, necrotizing enterocoliti

Persistent hyperinsulinemic hypoglycemia of infancy: long-term follow-up after surgical treatment

Aim The aim of this study was to investigate the long-term outcome of six children with persistent hyperinsulinemic hypoglycemia of infancy (PHHI) after pancreatectomy who have been followed since 1990 at the Riyadh Military Hospital, Riyadh, Kingdom of Saudi Arabia.Patients and methods Data from six patients were retrospectively analyzed from chart review. PHHI was diagnosed on the basis of having high-insulin levels and low-glucose levels and a high insulin-to-glucose ratio. Lactate, pyruvate, ammonia, and urinary organic acid levels were recorded and tandem mass spectrometry screening was performed. The patients were assessed radiologically by MRI of the brain and by ultrasound examination of the abdomen. Patients who failed medical therapy underwent near-total pancreatectomy.Results Hypoglycemic convulsion was the most common presenting complaint. None of the patients responded to medical treatment and thus underwent surgery. Two patients still had hypoglycemic episodes after surgery, requiring medical treatment. However, they underwent subsequent surgery because of unresponsiveness to medical therapy. Three patients developed diabetes. None of them had malabsorption, and two patients later developed epilepsy.Conclusion The earlier the age at diagnosis, the better the neurological outcome. Delayed surgery might be associated with higher risk of development of diabetes. Near-total (90–95%) pancreatectomy is the treatment of choice for PHHI not responsive to medical treatment.Keywords: Near-total pancreatectomy, outcome, persistent hyperinsulinemic hypoglycemia of infanc

Infantile hypertrophic pyloric stenosis: a single institution’s experience

Background/purpose Infantile hypertrophic pyloric stenosis (IHPS) is said to be relatively common in the western world, but its incidence in the Kingdom of Saudi Arabia is unknown. We set out to study the incidence of IHPS in children presenting at our hospital and review the clinical presentation and treatment outcomes of such patients.Patients and methods A retrospective chart review of all cases with IHPS admitted to a tertiary hospital, Riyadh Military Hospital, over 18 years (1990–2008) was conducted. Diagnosis was confirmed by ultrasonography according to the length of the pyloric channel and thickness of the pyloric muscles. An analysis of demographic data, clinical presentation, diagnostic modality, and associated congenital anomalies was carried out. Operative technique, postoperative course, and complication rates were identified.Results The review of the medical records showed 22 patients with a diagnosis of IHPS. The incidence rate of IHPS was 1.4/10 000 live births. Demographically, most cases presented in the first month of life. It is more common in boys. In all, 55% of infants were first borns. Clinically, nonbilious projectile vomiting was the main symptom. Mild dehydration was found in half of the cases with alkalotic changes. Ultrasonography was the main diagnostic modality in 82% of cases. Others were diagnosed by contrast study. Open Ramstedt pyloromyotomy was the surgical approach in 20 (91%) cases and the laparoscopic approach in 2 cases (9%). Fourteen (14%) patients had an associated congenital inguinal hernia. The mean length of hospital stay was 5.5 days. The most common postoperative complication was wound infection in 4.5% of patients. Incidence of IHPS had obvious seasonal association.Conclusion Incidence of IHPS at our hospital (the biggest hospital in the Kingdom of Saudi Arabia with an annual birth record of 14 000) is far less common than international incidences reported in North America and Europe. More reports from Saudi Arabia, the Middle East, and Asia are recommended to support the rarity of IHPS in this region of the world. Seasonal variation suggests a possible etiological role for environmental factors. It is of practical use for both epidemiologists and clinicians for future comparability.Keywords: incidence, infantile pyloric stenosis, risk factor

Bacillus thuringiensis Cry5B Protein Is Highly Efficacious as a Single-Dose Therapy against an Intestinal Roundworm Infection in Mice

Intestinal parasitic nematode diseases infect over one billion people and cause significant disease burden in children (growth and cognitive stunting, malnutrition), in pregnant women, and via their dampening of the immune system in infected individuals. In over thirty years, no new classes of anti-roundworm drugs (anthelmintics) for treating humans have been developed. Because of limitations of the current drugs and the threat of parasite resistance, new anthelmintics are needed. The soil bacterium Bacillus thuringiensis (Bt) produces crystal (Cry) proteins that specifically target and kill insects and nematodes and is used around the world as a safe insecticide. Here we test the effects of the Bt Cry protein Cry5B on a chronic, natural intestinal roundworm infection in mice, namely the helminth parasite Heligmosomoides bakeri. We find that a single dose of Cry5B can eliminate 70% of the parasites and can almost completely block the ability of the parasites to produce progeny. Comparisons of Cry5B's efficacy with known anthelmintics suggest its activity is as good as or perhaps even better than those currently used. Furthermore, this protein is rapidly digested by simulated stomach juices, suggesting that protecting it from these juices would reveal a superior anthelmintic

``Agro-meteorological indices and climate model uncertainty over the UK''

Five stakeholder-relevant indices of agro-meteorological change were analysed for the UK, over past (1961--1990) and future (2061--2090) periods. Accumulated Frosts, Dry Days, Growing Season Length, Plant Heat Stress and Start of Field Operations were calculated from the E-Obs (European Observational) and HadRM3 (Hadley Regional Climate Model) PPE (perturbed physics ensemble) data sets. Indices were compared directly and examined for current and future uncertainty. Biases are quantified in terms of ensemble member climate sensitivity and regional aggregation. Maps of spatial change then provide an appropriate metric for end-users both in terms of their requirements and statistical robustness. A future UK is described with fewer frosts, fewer years with a large number of frosts, an earlier start to field operations (e.g., tillage), fewer occurrences of sporadic rainfall, more instances of high temperatures (in both the mean and upper range), and a much longer growing season

A high-resolution radiation hybrid map of the proximal region of rat Chromosome 4

Radiation hybrid (RH) mapping has been used to produce genome maps in the human and mouse, but as yet the technique has been applied little to other species. We describe the use of RH mapping in the rat, using a newly available rat/hamster RH panel, to construct an RH map of the proximal part of rat Chromosome (Chr) 4. This region is of interest because quantitative trait loci (QTLs) for defective insulin and catecholamine action, hypertension, and dyslipidemia map to this region. The RH map includes 23 rat genes or microsatellites previously mapped to this part of Chr 4, one rat gene not previously mapped in the rat, and markers for four new genes, homologs of which map to the syntenic region of the mouse genome. The RH map integrates genetic markers previously mapped on several rat crosses, increases the resolution of existing maps, and may provide a suitable basis for physical map construction and gene identification in this chromosomal region. Our results demonstrate the utility of RH mapping in the rat genome and show that RH mapping can be used to localize, in the rat genome, the homologs of genes from other species such as the mouse. This will facilitate identification of candidate genes underlying QTLs on this chromosomal segment