Search

Constraining the primary growth channel of supermassive black holes (SMBHs) remains one the most actively debated questions in the context of cosmological structure formation. Owing to the expected connection between SMBH spin parameter evolution and the accretion and merger history of individual black holes, population spin measurements offer a rare observational window into the cosmic growth of SMBHs. As of today, the most common method for estimating SMBH spin relies on modeling the relativistically broaden atomic profiles in the reflection spectrum observed in X-rays. In this paper, we study the observational requirements needed to confidently distinguish between the primary SMBH growth channels based on their distinct spin-mass distributions predicted by the Horizon-AGN cosmological simulation. Indoing so, we characterize outstanding limitations associated with the existing measurements and discuss the landscape of future observational campaigns which could be planned and executed with future X-ray observatories. We focus our attention on the High-Energy X-ray Probe (HEX-P), a proposed probe-class mission designed to serve the high- energy community in the 2030s. [ABSTRACT FROM AUTHOR]

Objective: To develop a core set of prenatal and neonatal outcomes for clinical studies evaluating perinatal interventions for congenital diaphragmatic hernia, using a validated consensus‐building method. Methods: An international steering group comprising 13 leading maternal–fetal medicine specialists, neonatologists, pediatric surgeons, patient representatives, researchers and methodologists guided the development of this core outcome set. Potential outcomes were collected through a systematic review of the literature and entered into a two‐round online Delphi survey. A call was made for stakeholders with experience of congenital diaphragmatic hernia to review the list and score outcomes based on their perceived relevance. Outcomes that fulfilled the consensus criteria defined a priori were discussed subsequently in online breakout meetings. Results were reviewed in a consensus meeting, during which the core outcome set was defined. Finally, the definitions, measurement methods and aspirational outcomes were defined in online and in‐person definition meetings by a selection of 45 stakeholders. Results: Overall, 221 stakeholders participated in the Delphi survey and 198 completed both rounds. Fifty outcomes met the consensus criteria and were discussed and rescored by 78 stakeholders in the breakout meetings. During the consensus meeting, 93 stakeholders agreed eventually on eight outcomes, which constituted the core outcome set. Maternal and obstetric outcomes included maternal morbidity related to the intervention and gestational age at delivery. Fetal outcomes included intrauterine demise, interval between intervention and delivery and change in lung size in utero around the time of the intervention. Neonatal outcomes included neonatal mortality, pulmonary hypertension and use of extracorporeal membrane oxygenation. Definitions and measurement methods were formulated by 45 stakeholders, who also added three aspirational outcomes: duration of invasive ventilation, duration of oxygen supplementation and use of pulmonary vasodilators at discharge. Conclusions: We developed with relevant stakeholders a core outcome set for studies evaluating perinatal interventions in congenital diaphragmatic hernia. Its implementation should facilitate the comparison and combination of trial results, enabling future research to better guide clinical practice. © 2023 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objectives: A contributing factor to unsuccessful prenatal spina bifida aperta (SBA) repair via an open approach may be incomplete neurosurgical repair causing persistent in‐utero leakage of cerebrospinal fluid (CSF) and exposure of the fetal spinal cord to amniotic fluid. We aimed to investigate the neurostructural and neurofunctional efficacy of watertight prenatal SBA repair in a validated SBA fetal lamb model. Methods: A well‐powered superiority study was conducted in the validated SBA fetal lamb model (n = 7 per group). The outcomes of lambs which underwent watertight or non‐watertight multilayer repair through an open approach were compared to those of unrepaired SBA lambs (historical controls) at delivery (term = 145 days). At ∼75 days, fetal lambs underwent standardized induction of lumbar SBA. At ∼100 days, they were assigned to an either watertight or non‐watertight layered repair group based on an intraoperative watertightness test using subcutaneous fluorescein injection. At 1–2 days postnatally, as primary outcome, we assessed reversal of hindbrain herniation using magnetic resonance imaging (MRI). Secondary proxies of neuroprotection were: absence of CSF leakage at the repair site; hindlimb motor function based on joint‐movement score, locomotor grade and Motor Evoked Potential (MEP); four‐score neuroprotection scale, encompassing live birth, complete hindbrain herniation reversal, absence of CSF leakage and joint‐movement score ≥ 9/15; and brain and spinal cord histology and immunohistochemistry. As the watertightness test cannot be used clinically due to its invasiveness, we developed a potential surrogate intraoperative three‐score skin‐repair‐quality scale based on visual assessment of the quality of the skin repair (suture inter‐run distance ≤ 3 mm, absence of tear and absence of ischemia), with high quality defined by a score ≥ 2/3 and low quality by a score < 2/3, and assessed its relationship with improved outcome. Results: Compared with unrepaired lambs, lambs with watertight repair achieved a high level of neuroprotection (neuroprotection score of 4/4 in 5/7 vs 0/7 lambs) as evidenced by: a significant 100% (vs 14%) reversal of hindbrain herniation on MRI; low CSF leakage (14% vs 100%); better hindlimb motor function, with higher joint‐movement score, locomotor grade and MEP area under the curve and peak‐to‐peak amplitude; higher neuronal density in the hippocampus and corpus callosum; and higher reactive astrogliosis at the SBA lesion epicenter. Conversely, lambs with non‐watertight SBA repair did not achieve the same level of neuroprotection (score of 4/4 in 1/7 lambs) compared with unrepaired lambs, with: a non‐significant 86% (vs 14%) reversal of hindbrain herniation; high CSF leakage (43% vs 100%); no improvement in motor function; low brain neuron count in both the hippocampus and corpus callosum; and small spinal astroglial cell area at the epicenter. Both watertight layered repair and high (≥ 2/3) intraoperative skin‐repair‐quality score were associated with improved outcome, but the watertightness test and skin‐repair‐quality scale could not be used interchangeably due to result discrepancies. Conclusions: Watertight layered fetal SBA repair is neuroprotective since it improves brain and spinal‐cord structure and function in the fetal lamb model. This translational research has important clinical implications. A neurosurgical technique that achieves watertightness should be adopted in all fetal centers to improve neuroprotection. Future clinical studies could assess whether a high skin‐repair‐quality score (≥ 2/3) correlates with neuroprotection. © 2022 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Background: Pregnant women have been identified as a potentially at-risk group concerning COVID-19 infection, but little is known regarding the susceptibility of the fetus to infection. Co-expression of ACE2 and TMPRSS2 has been identified as a prerequisite for infection, and expression across different tissues is known to vary between children and adults. However, the expression of these proteins in the fetus is unknown.Methods: We performed a retrospective analysis of a single cell data repository. The data were then validated at both gene and protein level by performing RT-qPCR and two-colour immunohistochemistry on a library of second-trimester human fetal tissues.Findings: TMPRSS2 is present at both gene and protein level in the predominantly epithelial fetal tissues analysed. ACE2 is present at significant levels only in the fetal intestine and kidney, and is not expressed in the fetal lung. The placenta also does not co-express the two proteins across the second trimester or at term.Interpretation: This dataset indicates that the lungs are unlikely to be a viable route of SARS-CoV2 fetal infection. The fetal kidney, despite presenting both the proteins required for the infection, is anatomically protected from the exposure to the virus. However, the gastrointestinal tract is likely to be susceptible to infection due to its high co-expression of both proteins, as well as its exposure to potentially infected amniotic fluid.Tweetable Abstract: This work provides detailed mechanistic insight into the relative protection & vulnerabilities of the fetus & placenta to SARS-CoV-2 infection by scRNAseq & protein expression analysis for ACE2 & TMPRSS2. The findings help to explain the low rate of vertical transmission. [ABSTRACT FROM AUTHOR]

Flat-spectrum radio quasars (FSRQs) are the most luminous blazars at GeV energies but only rarely emit detectable fluxes of TeV gamma rays, typically during bright GeV flares. We explore the gamma-ray variability and spectral characteristics of three FSRQs that have been observed at GeV and TeV energies by Fermi-LAT and VERITAS, making use of almost 100 hr of VERITAS observations spread over 10 yr: 3C 279, PKS 1222+216, and Ton 599. We explain the GeV flux distributions of the sources in terms of a model derived from a stochastic differential equation describing fluctuations in the magnetic field in the accretion disk and estimate the timescales of magnetic flux accumulation and stochastic instabilities in their accretion disks. We identify distinct flares using a procedure based on Bayesian blocks and analyze their daily and subdaily variability and gamma-ray energy spectra. Using observations from VERITAS, as well as Fermi, Swift, and the Steward Observatory, we model the broadband spectral energy distributions of PKS 1222+216 and Ton 599 during very high energy (VHE)–detected flares in 2014 and 2017, respectively, strongly constraining the jet Doppler factors and gamma-ray emission region locations during these events. Finally, we place theoretical constraints on the potential production of PeV-scale neutrinos during these VHE flares. [ABSTRACT FROM AUTHOR]

Gastroschisis (GS) is a congenital abdominal wall defect, in which the bowel eviscerates from the abdominal cavity. It is a non-lethal isolated anomaly and its pathogenesis is hypothesized to occur as a result of two hits: primary rupture of the 'physiological' umbilical hernia (congenital anomaly) followed by progressive damage of the eviscerated bowel (secondary injury). The second hit is thought to be caused by a combination of mesenteric ischemia from constriction in the abdominal wall defect and prolonged amniotic fluid exposure with resultant inflammatory damage, which eventually leads to bowel dysfunction and complications. GS can be classified as either simple or complex, with the latter being complicated by a combination of intestinal atresia, stenosis, perforation, volvulus and/or necrosis. Complex GS requires multiple neonatal surgeries and is associated with significantly greater postnatal morbidity and mortality than is simple GS. The intrauterine reduction of the eviscerated bowel before irreversible damage occurs and subsequent defect closure may diminish or potentially prevent the bowel damage and other fetal and neonatal complications associated with this condition. Serial prenatal amnioexchange has been studied in cases with GS as a potential intervention but never adopted because of its unproven benefit in terms of survival and bowel and lung function. We believe that recent advances in prenatal diagnosis and fetoscopic surgery justify reconsideration of the antenatal management of complex GS under the rubric of the criteria for fetal surgery established by the International Fetal Medicine and Surgery Society (IFMSS). Herein, we discuss how conditions for fetoscopic repair of complex GS might be favorable according to the IFMSS criteria, including an established natural history, an accurate prenatal diagnosis, absence of fully effective perinatal treatment due to prolonged need for neonatal intensive care, experimental evidence for fetoscopic repair and maternal and fetal safety of fetoscopy in expert fetal centers. Finally, we propose a research agenda that will help overcome barriers to progress and provide a pathway toward clinical implementation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Decade-long monitoring of blazars at optical and infrared (OIR) wavelengths with the Small and Moderate Aperture Research Telescope System (SMARTS) in Chile and in γ- rays with the Fermi -Large Area Telescope (LAT) has enabled the systematic study of their multiwavelength long-term variability. In this work, we investigate, from a theoretical perspective, the long-term variability properties of blazar emission by introducing an observationally motivated time-dependence to four main parameters of the one-zone leptonic model: injection luminosity of relativistic electrons, strength of magnetic field, Doppler factor, and external photon field luminosity. For the first time, we use both the probability density function and the power spectral density of the 10-yr-long Fermi -LAT light curves to create variation patterns for the model parameters. Using as test beds two bright blazars from the SMARTS sample (PKS 2155−304 and 3C 273), we compute 10-yr-long OIR, X-ray, and γ- ray model light curves for different varying parameters. We compare the findings of our theoretical investigation with multiwavelength observations using various measures of variability. While no single-varying parameter simulation can explain all multiwavelength variability properties, changes in the electron luminosity and external radiation field in PKS 2155−304 and 3C 273, respectively, can account for most of them. Our results motivate future time-dependent studies with coupling between two or more physical parameters to describe the multiwavelength long-term blazar variability. [ABSTRACT FROM AUTHOR]

Background: Abnormal intracranial findings are often detected at mid-trimester ultrasound (US) in fetuses with myelomeningocele (MMC). It is unclear whether these findings constitute a spectrum of the disease or are an independent finding, which should contraindicate fetal surgery.Objective: To ascertain the spectrum and frequency of US-detected cranial findings in fetuses with MMC.Search Strategy: MEDLINE, Embase, Web of Science and CENTRAL were searched from January 2000 to June 2020.Selection Criteria: Study reporting incidence of cranial US findings in consecutive cases of second-trimester fetuses with MMC.Data Collection and Analysis: Publication quality was assessed by Newcastle-Ottawa Scale (NOS) and modified NOS. Meta-analysis could not be performed as a result of high clinical diversity and study heterogeneity.Main Results: Fourteen cranial US findings were reported in 15 studies. Findings in classic Chiari II malformation (CIIM) spectrum included posterior fossa funnelling (96%), small transcerebellar diameter (82-96%), 'banana' sign (50-100%), beaked tectum (65%) and 'lemon' sign (53-100%). Additional cranial findings were small biparietal diameter (BPD) and head circumference (HC) (<5th centile; 53 and 71%, respectively), ventriculomegaly (45-89%), abnormal pointed shape of the occipital horn (77-78%), thinning of the posterior cerebrum, perinodular heterotopia (11%), abnormal gyration (3%), corpus callosum disorders (60%) and midline interhemispheric cyst (42%).Conclusions: We identified 14 cranial findings by second-trimester US in fetuses with MMC. The relatively high incidence of these findings and their unclear prognostic significance might not contraindicate fetal surgery in the case of normal fetal genetic testing. Some cranial findings may independently affect postnatal outcome, however. Long-term detailed follow-up is required to investigate this.Tweetable Abstract: A high rate of cranial abnormalities found on second-trimester ultrasound in fetuses with myelomeningocele. [ABSTRACT FROM AUTHOR]

Polarimetric measurements, especially if extended at high energy, are expected to provide important insights into the mechanisms underlying the acceleration of relativistic particles in jets. In a previous work, we have shown that the polarization of the synchrotron X-ray emission produced by highly energetic electrons accelerated by a mildly relativistic shock carries essential imprints of the geometry and the structure of the magnetic fields in the downstream region. Here, we present the extension of our analysis to the non-stationary case, especially suitable to model the highly variable emission of high-energy emitting BL Lacs. We anticipate a large (⁠|$\Pi \approx 40{{\ \rm per\ cent}}$|⁠), almost time-independent degree of polarization in the hard/medium X-ray band, a prediction soon testable with the upcoming mission IXPE. The situation in other bands, in particular in the optical, is more complex. A monotonic decrease of the optical degree of polarization is observed during the development of a flare. At later stages, Π reaches zero and then it starts to increase, recovering large values at late times. The instant at which Π = 0 is marked by a rotation of the polarization angle by 90°. However, at optical frequencies, it is likely that more than one region contribute to the observed emission, potentially making it difficult to detect the predicted behaviour. [ABSTRACT FROM AUTHOR]

Objective: The Management of Myelomeningocele Study (MOMS) trial demonstrated the safety and efficacy of open fetal surgery for spina bifida aperta (SBA). Recently developed alternative techniques may reduce maternal risks without compromising the fetal neuroprotective effects. The aim of this systematic review was to assess the learning curve (LC) of different fetal SBA closure techniques.Methods: MEDLINE, Web of Science, EMBASE, Scopus and Cochrane databases and the gray literature were searched to identify relevant articles on fetal surgery for SBA, without language restriction, published between January 1980 and October 2018. Identified studies were reviewed systematically and those reporting all consecutive procedures and with postnatal follow-up ≥ 12 months were selected. Studies were included only if they reported outcome variables necessary to measure the LC, as defined by fetal safety and efficacy. Two authors independently retrieved data, assessed the quality of the studies and categorized observations into blocks of 30 patients. For meta-analysis, data were pooled using a random-effects model when heterogeneous. To measure the LC, we used two complementary methods. In the group-splitting method, competency was defined when the procedure provided results comparable to those in the MOMS trial for 12 outcome variables representing the immediate surgical outcome, short-term neonatal neuroprotection and long-term neuroprotection at ≥ 12 months of age. Then, when raw patient data were available, we performed cumulative sum analysis based on a composite binary outcome defining successful surgery. The composite outcome combined four clinically relevant variables for safety (absence of extreme preterm delivery < 30 weeks, absence of fetal death ≤ 7 days after surgery) and efficacy (reversal of hindbrain herniation and absence of any neonatal treatment of dehiscence or cerebrospinal fluid leakage at the closure site).Results: Of 6024 search results, 17 (0.3%) studies were included, all of which had low, moderate or unclear risk of bias. Fetal SBA closure was performed using standard hysterotomy (11 studies), mini-hysterotomy (one study) or fetoscopy by either exteriorized-uterus single-layer closure (one study), percutaneous single-layer closure (three studies) or percutaneous two-layer closure (one study). Only outcomes for standard hysterotomy could be meta-analyzed. Overall, outcomes improved significantly with experience. Competency was reached after 35 consecutive cases for standard hysterotomy and was predicted to be achieved after ≥ 57 cases for mini-hysterotomy and ≥ 56 for percutaneous two-layer fetoscopy. For percutaneous and exteriorized-uterus single-layer fetoscopy, competency was not reached in the 81 and 28 cases available for analysis, respectively, and LC prediction analysis could not be performed.Conclusions: The number of cases operated is correlated with the outcome of fetal SBA closure, and the number of operated cases required to reach competency ranges from 35 for standard hysterotomy to ≥ 56-57 for minimally invasive modifications. Our observations provide important information for institutions looking to establish a new fetal center, develop a new fetal surgery technique or train their team, and inform referring clinicians, potential patients and third parties. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Purpose: Macrolide antibiotics, erythromycin, in particular, have been linked to the development of infantile hypertrophic pyloric stenosis (IHPS). Our aim was to conduct a systematic review of the evidence of whether post-natal erythromycin exposure is associated with subsequent development of IHPS.Methods: A systematic review of postnatal erythromycin administration and IHPS was performed. Papers were included if data were available on development (yes/no) of IHPS in infants exposed/unexposed to erythromycin. Data were meta-analysed using Review Manager 5.3. A random effects model was decided on a priori due to heterogeneity of study design; data are odds ratio (OR) with 95 % CI.Results: Nine papers reported data suitable for analysis; two randomised controlled trials and seven retrospective studies. Overall, erythromycin exposure was significantly associated with development of IHPS [OR 2.45 (1.12-5.35), p = 0.02]. However, significant heterogeneity existed between the studies (I 2 = 84 %, p < 0.0001). Data on erythromycin exposure in the first 14 days of life was extracted from 4/9 studies and identified a strong association between erythromycin exposure and subsequent development IHPS [OR 12.89 (7.67-2167), p < 0.00001].Conclusion: This study demonstrates a significant association between post-natal erythromycin exposure and development of IHPS, which seems stronger when exposure occurs in the first 2 weeks of life. [ABSTRACT FROM AUTHOR]

Aim Of the Study: Complex tracheo-oesophageal fistulae (TOF) are rare congenital or acquired conditions in children. We discuss here a multidisciplinary (MDT) approach adopted over the past 5 years.Methods: We retrospectively collected data on all patients with recurrent or acquired TOF managed at a single institution. All cases were investigated with neck and thorax CT scan. Other investigations included flexible bronchoscopy and bronchogram (B&B), microlaryngobronchoscopy (MLB) and oesophagoscopy. All cases were subsequently discussed in an MDT meeting on an emergent basis if necessary.Main Results: 14 patients were referred during this study period of which half had a congenital aetiology and the other half were acquired. The latter included button battery ingestions (5/7) and iatrogenic injuries during oesophageal atresia (OA) repair. Surgical repair was performed on cardiac bypass in 3/7 cases of recurrent congenital fistulae and all cases of acquired fistulae. Post-operatively, 9/14 (64%) patients suffered complications including anastomotic leak (1), bilateral vocal cord paresis (1), further recurrence (1), and mortality (1). Ten patients continue to receive surgical input encompassing tracheal/oesophageal stents and dilatations.Conclusions: MDT approach to complex cases is becoming increasingly common across all specialties and is important in making decisions in these difficult cases. The benefits include shared experience of rare cases and full access to multidisciplinary expertise. [ABSTRACT FROM AUTHOR]

The dissipation of energy flux in blazar jets plays a key role in the acceleration of relativistic particles. Two possibilities are commonly considered for the dissipation processes, magnetic reconnection – possibly triggered by instabilities in magnetically dominated jets – or shocks – for weakly magnetized flows. We consider the polarimetric features expected for the two scenarios analyzing the results of state-of-the-art simulations. For the magnetic reconnection scenario we conclude, using results from global relativistic MHD simulations, that the emission likely occurs in turbulent regions with unstructured magnetic fields, although the simulations do not allow us to draw firm conclusions. On the other hand, with local particle-in-cell simulations we show that, for shocks with a magnetic field geometry suitable for particle acceleration, the self-generated magnetic field at the shock front is predominantly orthogonal to the shock normal and becomes quasi-parallel downstream. Based on this result we develop a simplified model to calculate the frequency-dependent degree of polarization, assuming that high-energy particles are injected at the shock and cool downstream. We apply our results to HBLs, blazars with the maximum of their synchrotron output at UV-soft X-ray energies. While in the optical band the predicted degree of polarization is low, in the X-ray emission it can ideally reach 50 per cent, especially during active/flaring states. The comparison between measurements in the optical and in the X-ray band made during active states (feasible with the planned IXPE satellite) is expected to provide valuable constraints on the dissipation and acceleration processes. [ABSTRACT FROM AUTHOR]

Purpose: To assess incidence and natural history of umbilical hernia following sutured and sutureless gastroschisis closure.Methods: With audit approval, we undertook a retrospective clinical record review of all gastroschisis closures in our institution (2007-2013). Patient demographics, gastroschisis closure method and umbilical hernia occurrence were recorded. Data, presented as median (range), underwent appropriate statistical analysis.Results: Fifty-three patients were identified, gestation 36 weeks (31-38), birth weight 2.39 kg (1-3.52) and 23 (43 %) were male. Fourteen patients (26 %) underwent sutureless closure: 12 primary, 2 staged; and 39 (74 %) sutured closure: 19 primary, 20 staged. Sutured closure was interrupted sutures in 24 patients, 11 pursestring and 4 not specified. Fifty patients were followed-up over 53 months (10-101) and 22 (44 %) developed umbilical hernias. There was a significantly greater hernia incidence following sutureless closure (p = 0.0002). In sutured closure, pursestring technique had the highest hernia rate (64 %). Seven patients underwent operative hernia closure; three secondary to another procedure. Seven patients had their hernias resolve. One patient was lost to follow-up and seven remain under observation with no reported complications.Conclusions: There is a significant umbilical hernia incidence following sutureless and pursestring sutured gastroschisis closure. This has not led to complications and the majority have not undergone repair. [ABSTRACT FROM AUTHOR]

Background The aim of this RCT was to determine whether radiologically inserted gastrostomy (RIG) in children is associated with more complications than percutaneous endoscopic gastrostomy (PEG). Methods Children at a single tertiary children's hospital requiring a primary gastrostomy were randomized to PEG or RIG. Patients were followed by assessors blinded to the insertion method. Complications were recorded, assigned a severity score, and analysed by zero-inflated Poisson regression analysis on an intention-to-treat basis, adjusting for length of follow-up. Results Over a 3-year period, 214 children were randomized (PEG, 107; RIG, 107), of whom 100 received PEG and 96 RIG. There was no significant difference in the number of complications between PEG and RIG groups ( P = 0·875), or in the complication score: patients undergoing RIG had a 1·04 (95 per cent c.i. 0·89 to 1·21) times higher complication score than those who underwent PEG ( P = 0·597). Only age had an independent significant effect on complication score, with older patients having a 0·97 (0·95 to 1·00) times lower complication score per year. Conclusion PEG and RIG are both safe methods of gastrostomy insertion with a low rate of major complications. Registration number: NCT01920438 ( ). [ABSTRACT FROM AUTHOR]

The corona, a hot cloud of electrons close to the centre of the accretion disc, produces the hard X-ray power-law continuum commonly seen in luminous active galactic nuclei. The continuum has a high-energy turnover, typically in the range of one to several 100 keV and is suggestive of Comptonization by thermal electrons. We are studying hard X-ray spectra of AGN obtained with NuSTAR after correction for X-ray reflection and under the assumption that coronae are compact, being only a few gravitational radii in size as indicated by reflection and reverberation modelling. Compact coronae raise the possibility that the temperature is limited and indeed controlled by electron-positron pair production, as explored earlier (Paper I). Here, we examine hybrid plasmas in which a mixture of thermal and non-thermal particles is present. Pair production from the non-thermal component reduces the temperature leading to a wider temperature range more consistent with observations. [ABSTRACT FROM AUTHOR]

Introduction: The purpose of this study was to determine whether, in surgical infants requiring parenteral nutrition (PN), septicaemia due to enterococci or Gram-negative bacilli occurs later than septicaemia due to coagulase-negative staphylococci (CNS).Patients/material and Methods: We retrospectively studied 112 consecutive surgical infants (corrected gestational age up to 3 months) receiving PN for at least 5 days for congenital or acquired intestinal anomalies over a 2-year period (July 2007-June 2009). Data collected included diagnosis, duration of PN, episodes of septicaemia (defined as growth of bacteria from blood culture), and organisms cultured. We compared the time to first occurrence of septicaemia due to CNS with the times to first occurrence of septicaemia due to enterococci, Gram-negative bacilli, or other micro-organisms, using Kruskal-Wallis nonparametric ANOVA test and Dunn's multiple comparisons test. Data are given as median (range).Results: 31 patients (28%) had a total of 65 episodes of septicaemia. Septicaemia due to CNS was most common, occurring in 22% of patients, after 17 days (1-239) of PN. Septicaemia due to enteric organisms was less common and occurred significantly later, at 59 (24-103) days for enterococci (p<0.01), and at 55 (30-106) days for Gram-negative bacilli (p<0.05).Conclusions: Septicaemia due to enterococci or Gram-negative bacilli occurs later in the course of PN than septicaemia due to CNS, in surgical infants. This suggests that these infants become more vulnerable to the translocation of enteric micro-organisms after a longer period of parenteral nutrition. [ABSTRACT FROM AUTHOR]

Introduction: Bone marrow-derived circulating granulocyte and macrophage progenitor cells can contribute to the regeneration of ischemic tissue. Mobilization after heart or brain ischemia is well established, but it is unclear if this occurs after intestinal ischemia-reperfusion injury. Our aim was to evaluate bone marrow granulocyte-macrophage proliferation and the possible beneficial effect of recombinant human granulocyte-colony stimulating factor (rhG-CSF) in a model of intestinal ischemia-reperfusion.Material and Methods: After animal committee approval, anesthetized adult rats were divided into groups (n=4 per group) as follows: (i) control [C], (ii) 60 min intestinal ischemia [I], (iii) 60 min intestinal ischemia+360 min reperfusion [IR], (iv) 420 min sham operation [SH]. At sacrifice, bone marrow was removed, erythrocytes lysed and 1 50 000 nucleated cells plated in triplicate in 35 mm Petri dishes containing methylcellulose (MethoCult). After 11 days, granulocyte-macrophage colony-forming units (CFU-GM) were counted. In addition, to determine whether rhG-CSF injection stimulates progenitor cell activation, two further groups were studied: (v) 60 min intestinal ischemia+360 min reperfusion with injection of 50 microg/kg rhG-CSF at reperfusion [IR-G]; (vi) 420 min sham with rhG-CSF injected at 60 min [SH-G]. Data are expressed as median, range and IQR and compared using one-way ANOVA with Tukey's post-hoc test.Results: Neither sham operation nor ischemia alone influenced the activation of bone marrow. However, IR caused a significant increase in bone marrow activation compared to control animals (p<0.01), ischemic animals (p<0.01) and sham operated animals (p<0.05). Administered at a dose of 50 microg/kg, which is commonly used in animal studies, rhG-CSF had no effect on bone marrow activation, and did not augment the effects of ischemia-reperfusion. At a higher dose (100 microg/kg), however, rhG-CSF resulted in the mortality of IR animals.Conclusions: Intestinal ischemia-reperfusion injury causes proliferation of bone marrow granulocyte-macrophage progenitors which contribute to long-term repair. This phenomenon is not augmented by the administration of exogenous rhG-CSF. [ABSTRACT FROM AUTHOR]

We present multi-epoch optical observations of the blazar 3C 454.3 (z = 0.859) from 2008 August through 2011 December, using the Small and Medium Aperture Research Telescope System Consortium 1.5 m + RCSpectrograph and 1.3 m + ANDICAM in Cerro Tololo, Chile. The spectra reveal that the broad emission lines Mg II, Hβ, and Hγ are far less variable than the optical or γ-ray continuum. Although the γ-rays varied by a factor of 100 above the EGRET era flux, the lines generally vary by a factor of two or less. Smaller variations in the γ-ray flux did not produce significant variation in any of the observed emission lines. Therefore, to first order, the ionizing flux from the disk changes only slowly during large variations of the jet. However, two exceptions in the response of the broad emission lines are reported during the largest γ-ray flares in 2009 December and 2010 November, when significant deviations from the mean line flux in Hγ and Mg II were observed. Hγ showed a maximum 3σ and 4σ deviation in each flare, respectively, corresponding to a factor of 1.7 and 2.5 increase in flux. Mg II showed a 2σ deviation in both flares; no variation was detected in Hβ during either flare. These significant deviations from the mean line flux also coincide with 7 mm core ejections reported previously (Jorstad et al.). The correlation of the increased emission line flux with millimeter core ejections and γ-ray, optical, and ultraviolet flares suggests that the broad-line region extends beyond the γ-emitting region during the 2009 and 2010 flares. [ABSTRACT FROM AUTHOR]

Aim: To review our practice of Meckel's Tc-99m pertechnetate scans over 18 years with regard to indications for the test, sensitivity and specificity in our particular referral patients' population. Materials and methods: This is a retrospective review of Meckel's scans performed in two paediatric tertiary care teaching hospitals from April 1993 to March 2011 and followed up till October 2011. The scan was performed according to published international guidelines. 183 patients were included in this study. We classified the patients into two groups: group 1, which included 77 patients (42 %) presenting with painless per rectum bleeding, and group 2, which included 106 patients (58 %) presenting with other non-specific symptoms (e.g. abdominal pain, possibly associated with nausea and/or vomiting, failure to thrive). Data were analysed using Chi square test, considering P value less than 0.05 as significant. The age of the patients ranged from 4 days to 16.5 years (median 3 years). Results: 161 of the total 183 children on the study (88 %) had a negative Meckel's scan, and 22 children (12 %) had a positive scan. In the group with a positive Meckel's scan (22 children), all patients underwent surgical exploration and ectopic gastric mucosa was found in 17 cases (77 %, true positives). In the remaining 5 cases (23 %), there was no evidence of ectopic gastric mucosa (false positives). Within the group with a negative scan, 8 children (5 %) underwent surgery; only 1 child had a ectopic gastric mucosa detected following surgery (false negative). In other 52 children (32 %) of the group with a negative Meckel's scan, an endoscopy was done, which showed a normal result in 21 children and was abnormal in 31 children. Of the remaining 101 (63 %) children with a negative Meckel's scan, 74 children (46 %) improved without any further intervention. In 13 cases (8 %), other pathologies were identified. The sensitivity and specificity of the Meckel's scan for ectopic gastric mucosa were 94 and 97 %, respectively. The Meckel's scan was positive in 26 % of the patients of group 1 and in only 2 % patients of group 2. The difference between the two groups was highly significant [ P < 0.0001 (Yates-corrected Chi square); odds ratio 18 (Woolf-logit method 95 % CI)]. Conclusion: The Meckel's scan retains a high diagnostic accuracy in children for detecting a Meckel's diverticulum with ectopic gastric mucosa within it, when performed according to the recommended guidelines. The test yields its highest positive result in children presenting with significant per rectum bleeding. [ABSTRACT FROM AUTHOR]

We present the results of multi-year gamma-ray observations by the AGILE satellite of the black hole binary system Cygnus X-1. In a previous investigation we focused on gamma-ray observations of Cygnus X-1 in the hard state during the period mid-2007/2009. Here we present the results of the gamma-ray monitoring of Cygnus X-1 during the period 2010/mid-2012 which includes a remarkably prolonged "soft state" phase (2010 June-2011 May). Previous 1-10 MeV observations of Cyg X-1 in this state hinted at a possible existence of a nonthermal particle component with substantial modifications of the Comptonized emission from the inner accretion disk. Our AGILE data, averaged over the mid-2010/mid-2011 soft state of Cygnus X-1, provide a significant upper limit for gamma-ray emission above 100 MeV of Fsoft < 20 × 10-8 photons cm-2 s-1 , excluding the existence of prominent non-thermal emission above 100 MeV during the soft state of Cygnus X-1. We discuss theoretical implications of our findings in the context of high-energy emission models of black hole accretion. We also discuss possible gamma-ray flares detected by AGILE. In addition to a previously reported episode observed by AGILE in 2009 October during the hard state, we report a weak but important candidate for enhanced emission which occurred at the end of 2010 June (2010 June 30 10:00-2010 July 2 10:00 UT) exactly coinciding with a hard-to-soft state transition and before an anomalous radio flare. An appendix summarizes all previous high-energy observations and possible detections of Cygnus X-1 above 1 MeV. [ABSTRACT FROM AUTHOR]

Purpose In our institution, some children routinely receive parenteral nutrition (PN) following surgery for duodenal atresia/stenosis, while others do not. Our aim was to compare growth and infection rate between these two treatment strategies. Methods This was a retrospective study of all children undergoing surgery for duodenal atresia/stenosis over 7 years. Results Of the 54 children, 19 commenced PN soon after surgery (the ‘Initial PN’ group). Of the remaining 35 children, 13 (37 %) subsequently required PN (the ‘Delayed PN’ group). The remaining 22 never received PN (the ‘Never PN’ group). The proportion of patients experiencing clinically suspected sepsis was higher in those receiving PN (‘Initial’ plus ‘Delayed’; 41 %) compared with those who never received PN (14 %; p = 0.04). The ‘Initial PN’ and ‘Never PN’ groups did not show a significant change in weight Z score over time. However, the ‘Delayed PN’ group showed a significant decrease in weight Z scores from the time of operation to the time of achieving full enteral feeds, and failed to catch up by the time of last follow-up. Conclusion Children with duodenal atresia/stenosis can be managed without PN. However, a third of these children subsequently require PN, lose weight centiles, and have a high rate of sepsis. [ABSTRACT FROM AUTHOR]

We report on the discovery of high-energy (HE; E > 0.1 GeV) and very high energy (VHE; E > 100 GeV) γ-ray emission from the high-frequency-peaked BL Lac object RBS 0413. VERITAS, a ground-based γ-ray observatory detected VHE γ rays from RBS 0413 with a statistical significance of 5.5 standard deviations (σ) and a γ-ray flux of (1.5 ± 0.6stat ± 0.7syst) x 10-18 photonsm-2s-1 (~1% of the Crab Nebula flux) above 250 GeV. The observed spectrum can be described by a power law with a photon index of 3.18 ± 0.68stat ± 0.30syst. Contemporaneou observations with the Large Area Telescope (LAT) on the Fermi Gamma-ray Space Telescope detected HE γ ray from RBS 0413 with a statistical significance of more than 9σ, a power-law photon index of 1.57 ± 0.12+0.11stat-0.12sys and a γ-ray flux between 300 MeV and 300 GeV of (1.64 ± 0.43+0.31stat-0.22sys) x 10-5 photons m-2 s-1. We present the results from Fermi-LAT and VERITAS, including a spectral energy distribution modeling of the γ-ray, quasi-simultaneous X-ray (Swift-XRT), ultraviolet (Swift-UVOT), and R-band optical (MDM) data. We find that, if conditions close to equipartition are required, both the combined synchrotron self-Compton/external-Compton and the lepto-hadronic models are preferred over a pure synchrotron self-Compton model. [ABSTRACT FROM AUTHOR]

We present the time variability properties of a sample of six blazars, AO0235+164, 3C 273, 3C 279, PKS 1510-089, PKS 2155-304, and 3C 454.3, at optical-IR frequencies as well as γ-ray energies. These observations were carried out as a part of the Yale/SMARTS program during 2008-2010 that has followed the variations in emission of the bright Fermi Large Area Telescope monitored blazars in the southern sky with closely spaced observations at BVRJK bands. We find that the optical-near IR variability properties are remarkably similar to those at the γ-ray energies. The discrete auto-correlation functions of the variability of these six blazars at optical-IR and γ-ray energies do not show any periodicity or characteristic timescale. The power spectral density (PSD) functions of the R-band variability of all six blazars are fit well by simple power-law functions with negative slopes such that there is higher amplitude variability on longer timescales. No clear break is identified in the PSD of any of the sources. The average slope of the PSD of R-band variability of these blazars is similar to what was found by the Fermi team for the γ-ray variability of a larger sample of bright blazars. This is consistent with leptonic models where the optical-IR and γ-ray emission is generated by the same population of electrons through synchrotron and inverse Compton processes, respectively. The prominent flares present in the optical-IR as well as the γ-ray light curves of these blazars are predominantly symmetric, i.e., have similar rise and decay timescales, indicating that the long-term variability is dominated by the crossing time of radiation or a disturbance through the emission region rather than by the acceleration or energy-loss timescales of the radiating electrons. For the blazar 3C 454.3, which has the highest-quality light curves, the total energy output, the ratio of γ-ray to optical energy output, and the γ-ray versus optical flux relation differ in the six individual flares observed between 2009 August and December. The results are consistent with the location of a large γ-ray outburst in 3C 454.3 during 2009 December being in the jet at ~18 pc from the central engine. This poses strong constraints on the models of high-energy emission in the jets of blazars. [ABSTRACT FROM AUTHOR]

Introduction The purpose of this study was to determine whether, in surgical infants requiring parenteral nutrition (PN), septicaemia due to enterococci or Gram-negative bacilli occurs later than septicaemia due to coagulase-negative staphylococci (CNS).Patients/Material and Methods We retrospectively studied 112 consecutive surgical infants (corrected gestational age up to 3 months) receiving PN for at least 5 days for congenital or acquired intestinal anomalies over a 2-year period (July 2007-June 2009). Data collected included diagnosis, duration of PN, episodes of septicaemia (defined as growth of bacteria from blood culture), and organisms cultured. We compared the time to first occurrence of septicaemia due to CNS with the times to first occurrence of septicaemia due to enterococci, Gram-negative bacilli, or other micro-organisms, using Kruskal-Wallis nonparametric ANOVA test and Dunn's multiple comparisons test. Data are given as median (range).Results 31 patients (28%) had a total of 65 episodes of septicaemia. Septicaemia due to CNS was most common, occurring in 22% of patients, after 17 days (1-239) of PN. Septicaemia due to enteric organisms was less common and occurred significantly later, at 59 (24-103) days for enterococci (p<0.01), and at 55 (30-106) days for Gram-negative bacilli (p<0.05).Conclusions Septicaemia due to enterococci or Gram-negative bacilli occurs later in the course of PN than septicaemia due to CNS, in surgical infants. This suggests that these infants become more vulnerable to the translocation of enteric micro-organisms after a longer period of parenteral nutrition. [ABSTRACT FROM AUTHOR]

Aim of the study Intraoperative hypothermia may have a detrimental clinical effect. Preterm infants undergoing laparotomy for necrotizing enterocolitis (NEC) are particularly at risk. We investigated the relationship between intraoperative temperature and morbidity and outcome in infants with NEC.Methods A review of all laparotomies for NEC (n = 82, 69 infants) performed between Jan 2008 and Jan 2011 in our institution was done. Relationships between intraoperative temperature and intra- and postoperative fluid and blood product requirements, postoperative clinical status (sequential organ failure assessment [SOFA] score) and outcome were determined. Data (mean [range]) were compared using paired t-test and regression analysis.Results Data were available for 52 laparotomies (49 infants). The lowest intraoperative core temperature was significantly lower than the preoperative temperature (peri-op 34.9°C [31.5-37.0] vs. pre-op 37.0° C [35.8-38.0]; p < 0.0001). There was a statistically significant inverse relationship between mean intraoperative temperature and intraoperative blood transfusion requirement (p = 0.01). There were no statistically significant relationships between intraoperative temperature and other blood product or volume requirements, postoperative infective complications, change in SOFA score following surgery, length of stay, or mortality.Conclusions During laparotomy for NEC, there is a significant and profound drop in core temperature. The effect of this on short-term morbidity and long-term outcome (e.g., neurodevelopment) warrants further investigation. [ABSTRACT FROM AUTHOR]

Aim of the Study The aim of this study was to report incidence and clinical outcomes of recurrent necrotizing enterocolitis (NEC).Methods Review of infants treated for recurrent episode(s) of NEC at a tertiary Neonatal Surgical Intensive Care Unit over 8 years (January 2002 to February 2011). Demographic, clinical, radiological, and operative data were analyzed and compared using Mann-Whitney or Fisher's exact tests. Data are reported as median (range).Results A total of 212 consecutive infants were referred for surgical evaluation and treatment of NEC (Bell stage II or III). Of these patients, 22 (10%) had suspected recurrent NEC: in 11 of these the primary episode was Bell stage I successfully treated before coming to our institution (suspected recurrent NEC); in the remaining 11, the primary episode was confirmed (Bell stage II or III) NEC successfully treated in our hospital. Birth weight, gestational age at birth, corrected gestational age, weight on admission, gender, need for surgery, stricture, and mortality rates were similar between infants with recurrent NEC and those with a single episode. Long-term parenteral nutrition (PN) dependency (>28 days) was significantly more common following recurrent NEC compared with a single episode. Among the infants with recurrent NEC, medical therapy alone was not successful in the majority (82%) of cases during the first episode and all required surgery during the recurrent episode.Conclusion Infants (10%) referred for surgical treatment of NEC develop recurrence of the disease. Surprisingly, these infants have similar mortality and stricture rates to those with a single episode. However, the incidence of long-term PN dependency was significantly increased in those with recurrent episodes of NEC. [ABSTRACT FROM AUTHOR]

Aim of the Study The aim of this study was to investigate the factors associated with mortality in infants referred for the surgical treatment of advanced necrotizing enterocolitis (NEC).Methods Retrospective review of all infants with confirmed (Bell stage II or III) NEC treated in our unit during the past 8 years (January 2002 to December 2010). Data for survivors and nonsurvivors were compared using Mann-Whitney test and Fisher's exact test and are reported as median (range).Results Of the 205 infants with NEC, 35 (17%) were medically managed; 170 (83%) had surgery; 66 (32%) infants died; all had received surgery. Survivors and nonsurvivors were comparable for gestational age, birth weight, and gender distribution. Overall mortality was 32%, the highest mortality was in infants with pan-intestinal disease (86%) but remained significant in those with less severe disease (multifocal 39%; focal disease 21%). The commonest cause of mortality was multiple organ dysfunction syndrome and nearly half of the nonsurvivors had care withdrawn.Conclusion Despite improvement in neonatal care, overall mortality (32%) for advanced NEC has not changed in 10 years. Mortality is significant even with minimal bowel involvement. [ABSTRACT FROM AUTHOR]

Aim In ventilator-dependent infants with complex comorbidities, severe gastro-oesophageal reflux (GOR) may contribute to prolonging the period of ventilation. It is often difficult to predict whether antireflux surgery will improve the respiratory status of an infant and assist with weaning off the ventilator. The aim of this study was to review the outcomes in a cohort of ventilator-dependent infants who underwent fundoplication to help wean them off ventilation.Methods Between January 2006 and December 2010, out of 596 infants who underwent fundoplication for symptoms of GOR, 26 were ventilator dependent before surgery; 13 patients had an emergency fundoplication following an acute life-threatening event (n = 5, 19%) or an acute deterioration of respiratory status (n = 8, 31%). Fundoplication was planned in the rest of the group (n = 13, 50%) with the aim of improving respiratory status and weaning from ventilation. The median age at surgery was 5.8 months (range: 0.8 to 19.4 months). The median weight at surgery was 6.3 kg (range: 4 to 15.1 kg). Data were collected for each infant on comorbidities, pre- and postoperative ventilation status, pre- and postoperative GOR symptoms, and survival.Results All infants underwent a Nissen fundoplication with no intraoperative morbidity or mortality. Of these, 12 infants had a laparoscopic fundoplication; 14 infants had an open fundoplication. Postoperatively, all infants received invasive positive pressure ventilation in the intensive care unit (ICU). All infants were successfully weaned from ventilation. The median time to extubation was 4 days (range: 2 to 18 days). The median postoperative ICU stay was 9 days (range: 3 to 52 days). Of the patients, 9 (34%) had a recurrence of symptoms following fundoplication; 5 (19%) subsequently underwent revision of fundoplication and 1 (3.8%) underwent oesophago-gastric dissociation; and 10 (38%) died within the study period.Conclusion In infants with severe GOR, ventilator dependence, and complex comorbidities, fundoplication may be a useful procedure to assist weaning off ventilator dependence. Rates of symptom recurrence, of revision of fundoplication, and of mortality within this cohort were higher than expected. These data reflect the challenges of patient selection in high-risk groups. [ABSTRACT FROM AUTHOR]

Purpose: The management of Incarcerated Inguinal Hernia (IIH) in children is challenging and may be associated with complications. We aimed to compare the outcomes of laparoscopic vs. open repair of IIH. Methods: With institutional ethical approval (09SG13), we reviewed the notes of 63 consecutive children who were admitted to a single hospital with the diagnosis of IIH between 2000 and 2008. Data are reported as median (range). Groups were compared by chi-squared or t-tests as appropriate. Results: • Open repair (n = 35): There were 21 children with right and 14 with left IIH. 2 patients also had contralateral reducible inguinal hernia. Small bowel resection was required in 2 children. • Laparoscopic repair (n = 28): All children had unilateral IIH (19 right sided, 9 left sided). 15 children (54 % ) with no clinical evidence of contralateral hernia, had contralateral patent processus vaginalis at laparoscopy, which was also repaired. The groups were similar with regard to gender, age at surgery, history of prematurity, interval between admission and surgery, and proportion of patients with successful preoperative manual reduction. However, the duration of operation was longer in the laparoscopy group (p = 0.01). Time to full feeds and length of hospital stay were similar in both groups. Postoperative follow-up was 3.5 months (1-36), which was similar in both groups. 5 patients in the group undergoing open repair had serious complications: 1 vas transaction, 1 acquired undescended testis, 2 testicular atrophy and 1 recurrence. The laparoscopic group had a single recurrence. Conclusion: Open repair of incarcerated inguinal hernia is associated with serious complications. The laparoscopic technique appears safe, avoids the difficult dissection of an oedematous sac in the groin, allows inspection of the reduced hernia content and permits the repair of a contralateral patent processus vaginalis if present. [ABSTRACT FROM AUTHOR]

Introduction: Ganglioneuroma (GN), the benign form of peripheral neuroblastic tumour, is often asymptomatic and the diagnosis can be incidental. Our aim was to evaluate the incidence of complications after surgical treatment following diagnosis of this tumour. Material and Methods: 24 consecutive children were diagnosed with GN in our centre between January 1989 and December 2009. All patients had negative urinary catecholamines and/or biopsy confirming the diagnosis of GN. Data are reported as mean±SD. Results: Age at diagnosis was 73±43 months. The most common presentation was respiratory symptoms and/or abdominal pain; 9 (38 % ) patients were asymptomatic. Tumour location was in the chest (n = 14), abdomen (n = 7), or pelvis (n = 3). 23 children (9 asymptomatic) were operated on; 1 child with a thoracic mass did not undergo surgery because of severe neurological impairments from birth unrelated to GN. 13 children (4 asymptomatic) had a thoracotomy, 8 children (4 asymptomatic) had laparotomy, and 2 (1 asymptomatic) underwent perineal resection. A macroscopically complete surgical excision was performed in 17 cases (74 % ) and a macroscopically near-complete excision in 6 (26 %). At histological examination, resection margins contained tumour in 10 patients (43 %) and were free of tumour in the remaining 13 (57 %). 7 children (30 % ) had complications after surgery including 3 patients with Horner ' s syndrome (which persisted in 2), 1 with chylothorax, 1 with pneumothorax, 1 with pain in the arm, and 1 who developed adhesive intestinal obstruction. 2 children received adjuvant chemotherapy. We re-evaluated the histology specimens according to the International Neuroblastoma Pathology Classification and found that the diagnosis of GN was confirmed in 20 cases (83 %), while intermixed ganglioneuroblastoma (iGNB) was diagnosed in 4 patients (17 % ). At 33.5±40 months (range 1-137) follow-up, all 24 patients, including the child not operated on and the children with incomplete resection or iGNB, are alive with no tumour progression or recurrence. Conclusions: GN excision is associated with postoperative complications which can be persistent and may affect the quality of life of survivors. In our series we did not observe tumour progression in spite of incomplete excision. The rationale for GN excision should be revisited. [ABSTRACT FROM AUTHOR]

Introduction: Ganglioneuroma (GN), the benign form of peripheral neuroblastic tumour, is often asymptomatic and the diagnosis can be incidental. Our aim was to evaluate the incidence of complications after surgical treatment following diagnosis of this tumour. Material and Methods: 24 consecutive children were diagnosed with GN in our centre between January 1989 and December 2009. All patients had negative urinary catecholamines and/or biopsy confirming the diagnosis of GN. Data are reported as mean�SD. Results: Age at diagnosis was 73�43 months. The most common presentation was respiratory symptoms and/or abdominal pain; 9 (38%) patients were asymptomatic. Tumour location was in the chest (n=14), abdomen (n=7), or pelvis (n=3). 23 children (9 asymptomatic) were operated on; 1 child with a thoracic mass did not undergo surgery because of severe neurological impairments from birth unrelated to GN. 13 children (4 asymptomatic) had a thoracotomy, 8 children (4 asymptomatic) had laparotomy, and 2 (1 asymptomatic) underwent perineal resection. A macroscopically complete surgical excision was performed in 17 cases (74%) and a macroscopically near-complete excision in 6 (26%). At histological examination, resection margins contained tumour in 10 patients (43%) and were free of tumour in the remaining 13 (57%). 7 children (30%) had complications after surgery including 3 patients with Horner's syndrome (which persisted in 2), 1 with chylothorax, 1 with pneumothorax, 1 with pain in the arm, and 1 who developed adhesive intestinal obstruction. 2 children received adjuvant chemotherapy. We re-evaluated the histology specimens according to the International Neuroblastoma Pathology Classification and found that the diagnosis of GN was confirmed in 20 cases (83%), while intermixed ganglioneuroblastoma (iGNB) was diagnosed in 4 patients (17%). At 33.5�40 months (range 1–137) follow-up, all 24 patients, including the child not operated on and the children with incomplete resection or iGNB, are alive with no tumour progression or recurrence. Conclusions: GN excision is associated with postoperative complications which can be persistent and may affect the quality of life of survivors. In our series we did not observe tumour progression in spite of incomplete excision. The rationale for GN excision should be revisited. [ABSTRACT FROM AUTHOR]

Purpose: The management of Incarcerated Inguinal Hernia (IIH) in children is challenging and may be associated with complications. We aimed to compare the outcomes of laparoscopic vs. open repair of IIH. Methods: With institutional ethical approval (09SG13), we reviewed the notes of 63 consecutive children who were admitted to a single hospital with the diagnosis of IIH between 2000 and 2008. Data are reported as median (range). Groups were compared by chi-squared or t-tests as appropriate. Results: � Open repair (n=35): There were 21 children with right and 14 with left IIH. 2 patients also had contralateral reducible inguinal hernia. Small bowel resection was required in 2 children. � Laparoscopic repair (n=28): All children had unilateral IIH (19 right sided, 9 left sided). 15 children (54%) with no clinical evidence of contralateral hernia, had contralateral patent processus vaginalis at laparoscopy, which was also repaired. The groups were similar with regard to gender, age at surgery, history of prematurity, interval between admission and surgery, and proportion of patients with successful preoperative manual reduction. However, the duration of operation was longer in the laparoscopy group (p=0.01). Time to full feeds and length of hospital stay were similar in both groups. Postoperative follow-up was 3.5 months (1–36), which was similar in both groups. 5 patients in the group undergoing open repair had serious complications: 1 vas transaction, 1 acquired undescended testis, 2 testicular atrophy and 1 recurrence. The laparoscopic group had a single recurrence. Conclusion: Open repair of incarcerated inguinal hernia is associated with serious complications. The laparoscopic technique appears safe, avoids the difficult dissection of an oedematous sac in the groin, allows inspection of the reduced hernia content and permits the repair of a contralateral patent processus vaginalis if present. [ABSTRACT FROM AUTHOR]