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Dimethyl sulfoxide (DMSO) was introduced to the medical community in the mid-1960s as a powerful anti-inflammatory agent. Clinical studies and subjective claims abounded about its healing effects on a variety of musculoskeletal injuries. Unfortunately, soon after the incorporation of DMSO into rehabilitation routines, the American Medical Association (AMA) denounced many of the studies of DMSO as being unscientific in nature, and the possibility of toxic effects on the optical lens was noted in an experiment using primates as subjects. As a result, the use of DMSO in the medical community was halted. The exact mechanisms by which DMSO affects the healing process are unknown; however, several studies from the 1980s noted specific effects during various phases of the inflammatory process, such as monocyte and fibroblast activity. Presently, DMSO is considered an investigational drug and has not been approved by the Food and Drug Administration for use with musculoskeletal disorders. [ABSTRACT FROM AUTHOR]

Objective: Musculotendinous strains are among the most prevalent injuries for which health care professionals provide treatment and rehabilitation interventions. Flexibility has been identified as one of the primary etiologic factors associated with musculotendinous strains, but limited research exists on the effect of a preventive stretching program on musculotendinous strains. Therefore, the purpose of our study was to compare the number of musculotendinous strains for the hamstrings, quadriceps, hip adductors, and gastrocnemius-soleus muscle groups before and after the incorporation of a static stretching program for each muscle group. Design and Setting: We analyzed the incidence of musculotendinous strains among the players of a Division III collegiate football team between 1994 and 1995. All variables were consistent between the 2 seasons except for the incorporation of a lower extremity stretching program in 1995. Subjects: One hundred and ninety-five Division III college football players. Measurements: We calculated the number of musculotendinous strains that required a minimum absence of 1 day from practices or games in 1994 and 1995. Results: A chi square analysis revealed a significant reduction in the number of lower extremity musculotendinous strains in 1995 as opposed to 1994. Conclusions: Our statistical analysis indicates an association between the incorporation of a static stretching program and a decreased incidence of musculotendinous strains in Division III college football players. [ABSTRACT FROM AUTHOR]

Context: An arthrogenic muscle response (AMR) of the soleus and peroneal muscles has been previously demonstrated in individuals with chronic ankle instability (CAI), but the presence of AMR in muscles acting on joints proximal to unstable ankles has not been previously explored. Objective: To determine if AMR is present in the quadriceps and hamstrings muscles of those with and without unilateral CAI. Design: Case control. Setting: University research laboratory. Patients or Other Participants: Twenty subjects with unilateral CAI (12 males, 8 females: age = 19.9 ± 3.7 years; height = 170.3 ± 15.6 cm; mass = 78.0 ± 23.1 kg) and 21 controls (16 males, 5 females: age = 23.2 ± 5.4 years; height = 173.9 ± 12.7 cm; mass = 87.2 ± 24.6 kg) with no previous ankle injuries. Main Outcome Measure(s): The central activation ratio (CAR), a measure of motoneuron pool excitability during maximal voluntary isometric contraction, for the hamstrings and quadriceps muscles was measured in both limbs using the superimposed burst technique. Results: The CAI group demonstrated quadriceps CARs that were significantly larger in their involved limbs (.87 ± .09), as compared with their uninvolved limbs (.84 ± .08), whereas no significant side-to-side difference was seen in the control group (sham involved = .80 ± .11, sham uninvolved = .81 ± .11). When values from both the involved and uninvolved limbs were averaged, the hamstrings CAR was significantly lower for the CAI group (.94 ± .03) than for the control group (.96 ± .03). Conclusions: Arthrogenic inhibition of the hamstrings muscles bilaterally and facilitation of the quadriceps muscle ipsilateral to the involved limb were noted in subjects with unilateral CAI. Motoneuron pool excitability appears to be altered in muscles that act on joints proximal to the ankle in those with unilateral CAI. [ABSTRACT FROM AUTHOR]

Background: Evidence as to how patient thigh muscle strength and limb loading (LL) during a squatting task recovers throughout rehabilitation after anterior cruciate ligament reconstruction (ACLR) is lacking., Hypothesis: Patients will improve LL and strength throughout rehabilitation. Changes in LL and strength over time will be positively correlated., Study Design: Prospective cohort study., Level of Evidence: Level 3., Methods: A total of 60 participants (28 male/32 female; age, 22.5 ± 9.35 years) participated in 2 visits post-ACLR, assessing LL and strength. Using an instrumented pressure mat, patients completed 3 sets of 3 repetitions of bodyweight squats. Peak force (N), unilateral cumulative load (%), and quadriceps and hamstring isokinetic peak torque (N·m) were calculated and recorded bilaterally. LL and peak torque were compared over time and between limbs., Results: A significant limb-by-time interaction was observed for LL peak force (N), where patients underloaded the ACLR limb at visit 1 compared with the contralateral limb ( P < 0.01). Patients increased their ACLR LL across visits ( P = 0.04). A limb-by-time interaction for quadriceps peak torque (N·m) was observed where the ACLR limb increased peak torque across visits ( P < 0.01); however, strength deficits persisted at visit 2 ( P < 0.01) when compared with the nonoperative limb. Weak correlations were observed between all change scores metrics ( r , 0.20-0.25)., Conclusion: Patients recovering from ACLR exhibited more symmetric loading during a squatting task and improved their lower extremity strength over time. Changes in strength were not related to changes in LL during a squatting task over time., Clinical Relevance: Squatting tasks are safe and easily implemented throughout ACLR recovery. As changes in functional LL and strength recovery are not related, both should be considered in serial postoperative testing for more comprehensive function and strength assessments., Competing Interests: The following authors declared potential conflicts of interest: B.W. has received consulting fees from Arthrex and Zimmer Biomet, speaking fees from Zimmer Biomet, and research funding from Zimmer Biomet, Pacira, Exactech, and Lifenet. J.H. is cofounder and holds stock and stock options from Springbok Inc. R.Q. holds board positions with the Orthopaedic Research Society and the American Society of Biomechanics.The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: funding from the Innovative, Developmental Exploratory Award (IDEA) research and development fund from the School of Education and Human Development at the University of Virginia; funding from the graduate student summer research fellowship from the American College of Sports Medicine Biomechanics Interest Group (BIG).

Context: The purpose of this study was to compare short-term clinical outcomes between meniscus procedures performed with anterior cruciate ligament reconstruction (ACLR), ACLR (ACLR-only), ACLR with meniscectomy/resection (ACLR-resect), and ACLR with meniscal repair (ACLR-repair) for bone patellar tendon bone grafts (BPTB) and hamstring tendon grafts, separately., Design: This was a cross-sectional study conducted in a controlled laboratory setting as part of a large point-of-care collaborative research program., Methods: This study included 314 participants (168 females; mean [SD]: age, 19.7 [4.8]) with primary unilateral ACLR with a BPTB or hamstring tendon. Patients were divided into 3 groups depending on meniscal procedure (ACLR-only, ACLR-resect, and ACLR-repair). Postsurgical testing included: isokinetic assessment of knee extension and flexion, single-leg hop tests, and patient-reported outcomes. Multivariate analysis of covariance compared differences between meniscal procedures on the battery of tests, and for each statistically significant variable an analysis of covariance assessed the effect of meniscal procedure within each graft type. Chi-square analysis assessed the influence of meniscal procedure on tests' pass rates defined as 90% of limb symmetry index., Results: BPTB: ACLR-only had greater hamstring strength than ACLR-resect (P = .05) and ACLR-repair (P = .005). ACLR-only had the highest proportion of participants to pass the hamstring strength test (P = .02). Hamstring tendon: ACLR-only (P = .03) and ACLR-resect (P = .003) had higher International Knee Documentation Committee scale scores than ACLR-repair. There was a significant difference in the proportion of participants who scored >90% limb symmetry index on the timed hop test (P = .05)., Conclusions: The influence of meniscal repair on clinical outcomes is dependent on the graft choice. Following an ACLR with BPTB and a meniscal procedure, hamstring function should be more closely monitored for optimal short-term recovery.

Purpose: Melatonin, a natural hormone mainly synthesized by the pineal gland, is regulated by circadian rhythm. Synthetic melatonin is not approved by the US Food and Drug Administration for any indication. However, melatonin receptor agonists such as ramelteon and tasimelteon are US Food and Drug Administration approved and are considered by the American Academy of Family Physicians for the treatment of insomnia. Due to the availability of over-the-counter products in some countries and the increasing use of melatonin, it is interesting to highlight knowledge regarding the potential benefits of melatonin outside sleep disorders., Methods: This narrative review included published reports in EMBASE and MEDLINE databases between 1975 and 2021 relating to the therapeutic applications of melatonin., Findings: Based on the quality of the evidence published to date, the most promising non-insomnia indications are for treating ischemia/reperfusion injury, primary headache disorders, fibromyalgia, glucose control, and blood pressure control., Implications: Most of the studies were preclinical and in in vivo and in vitro phases. More clinical trials are needed before recommending melatonin as a treatment in clinical practice., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Aim: No widely agreed consensus protocols exist for the management of benign ovarian tumors (BOT) in children. This presents a substantial risk for suboptimal management. We aimed to generate multispecialty consensus guidance to standardize surgical management and provide a clear follow-up protocol for children with BOTs., Methods: Prospective two-round confidential e-Delphi consensus survey distributed among multispecialty expert panel; concluded by two semistructured videoconferences., Main Results: Consensus was generated on these core outcome sets: preoperative/intraoperative management; follow-up; adolescent gynecology referral. (1) Children with BOTs should receive the same management as other patients with potentially neoplastic lesions: Preoperative discussion at a pediatric oncology multidisciplinary meeting to risk stratify tumors, and management by health professionals with expertise in ovarian-sparing surgery and laparoscopy. (2) Ovarian-sparing surgery for BOTs should be performed wherever possible to maximize fertility preservation. (3) Ovarian masses detected during emergency laparoscopy/laparotomy should be left in situ wherever feasible and investigated appropriately (imaging/tumor markers) before resection. (4) Follow-up should be undertaken for all patients after BOT resection. Patients should be offered referral to adolescent gynecology to discuss fertility implications., Conclusion: This best practice Delphi consensus statement emphasizes the importance of managing children with BOTs through a well-defined oncological MDT strategy, in order to optimize risk stratification and allow fertility preservation by ovarian-sparing surgery wherever possible., (© 2022 Wiley Periodicals LLC.)

Objective: To create the first structured surgical report form for NBL with international consensus, to permit standardized documentation of all NBL-related surgical procedures and their outcomes., Summary of Background Data: NBL, the most common extracranial solid malignant tumor in children, covers a wide spectrum of tumors with significant differences in anatomical localization, organ or vessel involvement, and tumor biology. Complete surgical resection of the primary tumor is an important part of NBL treatment, but maybe hazardous, prone to complications and its role in high-risk disease remains debated. Various surgical guidelines exist within the protocols of the different cooperative groups, although there is no standardized operative report form to document the surgical treatment of NBL., Methods: After analyzing the treatment protocols of the SIOP Europe International Neuroblastoma Study Group, Children's Oncology Group, and Gesellschaft fuer Paediatrische Onkologie und Haematologie - German Association of Pediatric Oncology and Haematology pediatric cooperative groups, important variables were defined to completely describe surgical biopsy and resection of NBL and their outcomes. All variables were discussed within the Surgical Committees of SIOP Europe International Neuroblastoma Study Group, Children's Oncology Group, and Gesellschaft fuer Paediatrische Onkologie und Haematologie - German Association of Pediatric Oncology and Haematology. Thereafter, joint meetings were organized to obtain intercontinental consensus., Results: The "International Neuroblastoma Surgical Report Form" provides a structured reporting tool for all NBL surgery, in every anatomical region, documenting all Image Defined Risk Factors and structures involved, with obligatory reporting of intraoperative and 30 day-postoperative complications., Conclusion: The International Neuroblastoma Surgical Report Form is the first universal form for the structured and uniform reporting of NBL-related surgical procedures and their outcomes, aiming to facilitate the postoperative communication, treatment planning and analysis of surgical treatment of NBL., Competing Interests: The authors declare no conflicts of interest and received no funding., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To discuss the use of melatonin as an early treatment option on the first day of diagnosis for COVID-19., Methods: Medical Subject Headings terms "COVID-19" and "viral diseases" were manually searched on PubMed, and relevant articles were included., Results: The results showed that melatonin acts to reduce reactive oxygen species-mediated damage, cytokine-induced inflammation, and lymphopenia in viral diseases similar to COVID-19., Conclusion: These conclusions provide evidence for potential benefits in melatonin use for COVID-19 treatment as early as the day of diagnosis., (Copyright © 2021 AACE. Published by Elsevier Inc. All rights reserved.)

Patient-reported outcome measures (PROMs) for chronic wounds mainly focus on specific types of wounds. Our team developed the WOUND-Q for use with all types of wounds in any anatomic location. We conducted 60 concept elicitation interviews with patients in Canada, Denmark, the Netherlands, and the United States. Analysis identified concepts of interest to patients and scales were formed and refined through cognitive interviews with 20 patients and input from 26 wound care experts. Scales were translated into Danish and Dutch. An international field-test study collected data from 881 patients (1020 assessments) with chronic wounds. Rasch measurement theory (RMT) analysis was used to refine the scales and examine psychometric properties. RMT analysis supported the reliability and validity of 13 WOUND-Q scales that measure wound characteristics (assessment, discharge, and smell), health-related quality of life (life impact, psychological, sleep impact, and social), experience of care (information, home care nurses, medical team, and office staff), and wound treatment (dressing and suction device). The WOUND-Q can be used to measure outcomes in research and clinical practice from the perspective of patients with any type of wound., (© 2021 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

Introduction:  Evidence supporting best practice for long-gap esophageal atresia is limited. The European Reference Network for Rare Inherited Congenital Anomalies (ERNICA) organized a consensus conference on the management of patients with long-gap esophageal atresia based on expert opinion referring to the latest literature aiming to provide clear and uniform statements in this respect., Materials and Methods:  Twenty-four ERNICA representatives from nine European countries participated. The conference was prepared by item generation, item prioritization by online survey, formulation of a final list containing items on perioperative, surgical, and long-term management, and literature review. The 2-day conference was held in Berlin in November 2019. Anonymous voting was conducted via an internet-based system using a 1 to 9 scale. Consensus was defined as ≥75% of those voting scoring 6 to 9., Results:  Ninety-seven items were generated. Complete consensus (100%) was achieved on 56 items (58%), e.g., avoidance of a cervical esophagostomy, promotion of sham feeding, details of delayed anastomosis, thoracoscopic pouch mobilization and placement of traction sutures as novel technique, replacement techniques, and follow-up. Consensus ≥75% was achieved on 90 items (93%), e.g., definition of long gap, routine pyloroplasty in gastric transposition, and avoidance of preoperative bougienage to enable delayed anastomosis. Nineteen items (20%), e.g., methods of gap measurement were discussed controversially (range 1-9)., Conclusion:  This is the first consensus conference on the perioperative, surgical, and long-term management of patients with long-gap esophageal atresia. Substantial statements regarding esophageal reconstruction or replacement and follow-up were formulated which may contribute to improve patient care., Competing Interests: None declared., (Thieme. All rights reserved.)

Introduction:  Improvements in care of patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF) have shifted the focus from mortality to morbidity and quality-of-life. Long-term follow-up is essential, but evidence is limited and standardized protocols are scarce. Nineteen representatives of the European Reference Network for Rare Inherited Congenital Anomalies (ERNICA) from nine European countries conducted a consensus conference on the surgical management of EA/TEF., Materials and Methods:  The conference was prepared by item generation (including items of surgical relevance from the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)-The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) guidelines on follow-up after EA repair), item prioritization, formulation of a final list containing the domains Follow-up and Framework, and literature review. Anonymous voting was conducted via an internet-based system. Consensus was defined as ≥75% of those voting with scores of 6 to 9., Results:  Twenty-five items were generated in the domain Follow-up of which 17 (68%) matched with corresponding ESPGHAN-NASPGHAN statements. Complete consensus (100%) was achieved on seven items (28%), such as the necessity of an interdisciplinary follow-up program. Consensus ≥75% was achieved on 18 items (72%), such as potential indications for fundoplication. There was an 82% concordance with the ESPGHAN-NASPGHAN recommendations. Four items were generated in the domain Framework, and complete consensus was achieved on all these items., Conclusion:  Participants of the first ERNICA conference reached significant consensus on the follow-up of patients with EA/TEF who undergo primary anastomosis. Fundamental statements regarding centralization, multidisciplinary approach, and involvement of patient organizations were formulated. These consensus statements will provide the cornerstone for uniform treatment protocols and resultant optimized patient care., Competing Interests: None declared., (Thieme. All rights reserved.)

With the rise in physical inactivity and its related diseases, it is necessary to understand the mechanisms involved in physical activity regulation. Biological factors regulating physical activity are studied to establish a possible target for improving the physical activity level. However, little is known about the role metabolism plays in physical activity regulation. Therefore, we studied protein fractional synthesis rate (FSR) of multiple organ tissues of 12-week-old male mice that were previously established as inherently low-active (n = 15, C3H/HeJ strain) and high-active (n = 15, C57L/J strain). Total body water of each mouse was enriched to 5% deuterium oxide (D2O) via intraperitoneal injection and maintained with D2O enriched drinking water for about 24 h. Blood samples from the jugular vein and tissues (kidney, heart, lung, muscle, fat, jejunum, ileum, liver, brain, skin, and bone) were collected for enrichment analysis of alanine by LC-MS/MS. Protein FSR was calculated as -ln(1-enrichment). Data are mean±SE as fraction/day (unpaired t-test). Kidney protein FSR in the low-active mice was 7.82% higher than in high-active mice (low-active: 0.1863±0.0018, high-active: 0.1754±0.0028, p = 0.0030). No differences were found in any of the other measured organ tissues. However, all tissues resulted in a generally higher protein FSR in the low-activity mice compared to the high-activity mice (e.g. lung LA: 0.0711±0.0015, HA: 0.0643±0.0020, heart LA: 0.0649± 0.0013 HA: 0.0712±0.0073). Our observations suggest that high-active mice in most organ tissues are no more inherently equipped for metabolic adaptation than low-active mice, but there may be a connection between protein metabolism of kidney tissue and physical activity level. In addition, low-active mice have higher organ-specific baseline protein FSR possibly contributing to the inability to achieve higher physical activity levels., Competing Interests: The authors have declared no competing interests exist.

Background: Recent research has focused on the epidemiology of shoulder and elbow injuries among high school and professional baseball players. Shoulder and elbow injury data has not been comprehensively reported among college baseball student-athletes., Purpose: The purpose of this study is to describe shoulder and elbow injury rates and their characteristics among collegiate baseball student-athletes in order to improve injury prevention., Study Design: Descriptive Epidemiology Study., Methods: Shoulder and elbow injury data were obtained from the NCAA Injury Surveillance System for baseball from 2004-2014. Incidence rate ratios and descriptive analyses described injury characteristics for the shoulder and elbow, separately., Results: The injury rate for the shoulder was 4.02/10,000 athlete-exposures and for the elbow was 2.44/10,000 athlete-exposures. During the ten-year period, the injury rate of the shoulder has approximately decreased by 75% and of the elbow by approximately 50%. Injury rates were higher during competitions compared to practice for the shoulder (rate ratio, 1.81;95% CI, 1.51, 2.18) and elbow (rate ratio, 2.19;95% CI, 1.73, 2.78). Freshmen and juniors were most likely to sustain shoulder (F=40.6%, J = 29%) and elbow (F=33%, J=33.7%) injuries. Regarding shoulder injuries, surgery was required for 7.1%, and the outcome was season ending for 14.5%. More elbow injuries (17.5%) ended in surgery, and a greater proportion (28.9%) had season-ending injuries., Conclusion: In collegiate baseball, shoulder and elbow injury rates have decreased but still result in high morbidity. More granular analyses, especially during Division 1 competitions, are necessary for more specific interventions. While shoulder injuries are more common, elbow injuries result in a longer time to return to play and a higher proportion of surgical interventions., Level of Evidence: Level 3., (© 2020 by the Sports Physical Therapy Section.)

Introduction:  Many aspects of the management of esophageal atresia (EA) and tracheoesophageal fistula (TEF) are controversial and the evidence for decision making is limited. Members of the European Reference Network for Rare Inherited Congenital Anomalies (ERNICA) conducted a consensus conference on the surgical management of EA/TEF based on expert opinions referring to the latest literature., Materials and Methods:  Nineteen ERNICA representatives from nine European countries participated in the conference. The conference was prepared by item generation, item prioritization by online survey, formulation of a final list containing the domains diagnostics, preoperative, operative, and postoperative management, and literature review. The 2-day conference was held in Berlin in October 2018. Anonymous voting was conducted via an internet-based system. Consensus was defined when 75% of the votes scored 6 to 9., Results:  Fifty-two items were generated with 116 relevant articles of which five studies (4.3%) were assigned as level-1evidence. Complete consensus (100%) was achieved on 20 items (38%), such as TEF closure by transfixing suture, esophageal anastomosis by interrupted sutures, and initiation of feeding 24 hours postoperatively. Consensus ≥75% was achieved on 37 items (71%), such as routine insertion of transanastomotic tube or maximum duration of thoracoscopy of 3 hours. Thirteen items (25%) were controversial (range of scores, 1-9). Eight of these (62%) did not reach consensus., Conclusion:  Participants of the conference reached significant consensus on the management of patients with EA/TEF. The consensus may facilitate standardization and development of generally accepted guidelines. The conference methodology may serve as a blueprint for further conferences on the management of congenital malformations in pediatric surgery., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Aim: Minimally invasive repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) and congenital diaphragmatic hernia (CDH) is feasible and confers benefits compared to thoracotomy or laparotomy. However, carbon dioxide (CO 2 ) insufflation can lead to hypercapnia and acidosis. We sought to determine the effect of lower insufflation pressures on patients' surrogate markers for CO 2 absorption - arterial partial pressure of CO 2 (PaCO 2 ), end tidal CO 2 (EtCO 2 ) and pH., Methods: Single center retrospective review, including neonates without major cardiac anomaly. Selected patients formed 2 groups: Historical pressure (HP) group and low pressure (LP) group. We reported on the patients' preoperative characteristics that potentially confound the degree of CO 2 absorption or elimination. Outcome measures were perioperative PaCO 2 , EtCO 2 , arterial pH and anesthetic time., Results: 30 patients underwent minimally invasive surgery for CDH and 24 patients for EA/TEF with similar distribution within the HP and LP group. For CDH patients as well as for EA/TEF patients, there were no significant differences in their preoperative characteristics or surgery duration comparing HP and LP groups. With a decrease in insufflation pressure in CDH patients, there were a significant decrease (p = 0.002) in peak PaCO 2 and an improvement in nadir pH (p = 0.01). For the EA/TEF patients, the decrease in insufflation pressure was associated with a significant decrease (p = 0.03) in peak EtCO 2 . Considering all 54 patients, we found EtCO 2 to be highly significantly inversely correlated with pH and positively correlated with intraoperative PaCO 2 (p < 0.001). Baseline Hb was inversely correlated with mean EtCO 2 (p < 0.001)., Conclusion: With lower insufflation pressures, CDH patients had significantly improved hypercapnia and acidosis, while EA/TEF patients had significantly reduced EtCO 2 . EtCO 2 was correlated with acidosis and hypercapnia., Type of Study: Retrospective case control study., Level of Evidence: Level III., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction:  The diagnosis of anorectal malformations (ARMs) is made at birth by perineal examination of the newborn, yet small series reported late diagnosis in almost 13%. No large series to date have looked into the magnitude of missed ARM cases in the neonatal period across Europe. This study aimed to define the rate of missed ARM at birth across four United Kingdom and European Union centers., Materials and Methods:  All ARM cases treated at two United Kingdom tertiary centers in the past 15 years were compared with two tertiary European centers. Demographic and relevant clinical data were collected. Late diagnosis was defined as any diagnosis made after discharge from the birth unit. Factors associated with late diagnosis were explored with descriptive statistics., Results:  Across the four centers, 117/1,350, 8.7% were sent home from the birth unit without recognizing the anorectal anomaly. Missed cases showed a slight female predominance (1.3:1), and the majority (113/117, 96.5%) were of the low anomaly with a fistula to the perineum. The rate of missed ARM cases was significantly higher in the United Kingdom centers combined (74/415, 17.8%) compared with those in the European Union (43/935, 4.6%) ( p  < 0.00001), and this was independent of individual center and year of birth., Conclusion:  Significant variation exists between the United Kingdom and other European countries in the detection of ARM at birth. We recommend raising the awareness of accurate perineal examination at the time of newborn physical examination. We feel this highlights an urgent need for a national initiative to assess and address the timely diagnosis of ARM in the United Kingdom., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: The ability to reliably measure real-world vaping behavior is critical to understand exposures to potential toxins. Commercially available mobile topography devices were originally designed to measure cigarette puffing behavior. Information regarding how applicable these devices are to the measurement of electronic cigarette (e-cigarette) vaping topography is needed., Methods: Clinical Research Support System (CReSS; Pocket) and Smoking Puff Analyzer Mobile (SPA-M) topography devices were tested against the calibrated laboratory-based smoking puff analyzer duplicator (SPA-D) device combined with an analytical smoking machine that generates programmable puffs with high precision. Puff topography of e-cigarettes was measured over a range of puff volumes (10-130 mL) at 2 and 5 s puff durations (using bell- and square-shaped puffs). "Real-world" topography data collected from 10 participants during 1 week of at-home vaping were also analyzed. Recording anomalies and limitations of the devices, such as accuracy of detection of the puff end, flow rate dropouts, unreported puffs, and abandoned vaping sessions for the CReSS, and multi-peak puffs for the SPA-M were defined., Results: The accuracy of puff volumes and durations was determined for both devices. The error for SPA-M was generally within ±10%, whereas that for the CReSS varied more widely. The CReSS consistently underestimated puff duration at higher flow rates., Conclusions: CReSS and SPA-M topography devices can be used for real-world e-cigarette topography measurements, but researchers have to be aware of the limitations. Both devices can provide accurate measurements only under certain puff parameter ranges. The SPA-M provided more accurate measurements under a wider range of puffing parameters than the CReSS. Summary data reported by both devices require thorough analysis of the raw data to avoid misleading data interpretation., Implications: Results of this study provide researchers with valuable information about the capability of commercially available cigarette topography devices to measure real-world vaping behaviors. The differing measurement ranges of the two devices and puff recording limitations and anomalies should be taken into account during analysis and interpretation of real-world data., (© The Author(s) 2018. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: Congenital intrathoracic stomach (CIS) is an uncommon pediatric surgical diagnosis where > 2/3rd of the stomach lies within the chest through a hiatus defect. We reviewed our recent experience with this condition., Methods: A retrospective single-center review of children with a diagnosis of CIS (2007-2018) was performed. Patient demographics, presentation, imaging and management were assessed. Results are expressed as median (range)., Results: Eleven patients (6 girls) were identified with onset of symptoms at 2 (0-26) months of age. Presenting symptoms were vomiting (8/11), respiratory symptoms (4/11) and failure to thrive (2/11). Two patients had Marfan's syndrome. An upper gastrointestinal contrast study demonstrated gastric herniation in all. All were corrected laparoscopically with hiatus repair and fundoplication [age at surgery 10.5 (1.5-34.5) months]. A concurrent gastrostomy was done in children ≤ 6 months (n = 5). Enteral feeds were commenced on post-operative day one in 9 and second post-operative day in 2. At 7 (0-95) months follow-up, all were on full enteral feeds. One patient had a recurrence 6 months post-operatively, which was re-operated laparoscopically without any further recurrence., Conclusion: This is the largest reported series of children with CIS. All could be managed laparoscopically with no conversions and a low recurrence.

Introduction:  Congenital duodenal obstruction (CDO) repair can be performed open or laparoscopically. We aimed to determine the potential benefit of laparoscopic repair regarding tolerance of enteral feeding, postoperative pain, hospital stay, and complication rate., Materials and Methods:  In a single-center retrospective cohort study, we compared neonates with isolated CDO operated open versus laparoscopically from 2010 to 2019. No transanastomotic tubes were used, and anastomoses were created in a side-to-side fashion in all cases. An early feeding policy is applied for all cases operated at our institution. Statistical comparison was performed using the Mann-Whitney's test or Fisher's exact test where appropriate., Results:  Forty-one patients analyzed were similar regarding body weight, gestational age, and proportion of patients with trisomy 21. Median follow-up was 21 months. Four (20%) out of 20 laparoscopic procedures started laparoscopically were converted to open. Comparing the 21 open with the 16 laparoscopically completed patients, median anesthetic duration was shorter by 18% in the open versus laparoscopic completed group (218 vs. 179 minutes, respectively; p  = 0.025). Median postoperative time to full enteral feeds was shorter by 4 days in the first group (7 vs. 11 days, respectively; p  = 0.028). In accordance, the median duration of parenteral nutrition (PN) was less than half in the laparoscopic completed compared with the open group (5 vs. 11.5 days, respectively; p  = 0.031). Postoperative opioids were required for only half the duration in the laparoscopically completed group compared with open (2 vs. 4 days, respectively; p  = 0.026). Outcomes such as length of stay, the occurrence of strictures or adhesions requiring reintervention, or line sepsis were similar in both groups., Conclusion:  Patients undergoing laparoscopic CDO repair at our institution benefited from shorter time to full enteral feeds, and reduced the need for PN as well as postoperative pain medication., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Open Ladd's procedure is the gold standard for the correction of intestinal malrotation and laparoscopic approach remains controversial. This study aimed to evaluate our experience in laparoscopic management of malrotation., Methods: Single center retrospective study including patients who underwent a laparoscopic assessment of intestinal malrotation with correction if appropriate between 2007 and 2017., Results: Sixty-five patients (median age 7 months) had a laparoscopic assessment with and without correction of malrotation. Forty-five (69%) were symptomatic, including 16 (25%) with a midgut volvulus. The procedure was completed laparoscopically in 55 (86%) patients in 110 min (30-190). Conversions happened more frequently at the beginning of the experience. With a follow-up of 12.5 months (8 days-5.3 years), morbidity rate was 15% and 4 (6%) patients underwent a redo surgery, all in the first 5 months after surgery, compared with 3/53 (6%) in a contemporaneous group undergoing open Ladd's., Conclusion: This is the largest series reported so far of the laparoscopic management of malrotation. Laparoscopic Ladd's procedure is reliable but still exposes to open conversion which may be in part owing to a learning curve. A low conversion threshold is important in cases with volvulus. The redo rate is similar to that of the open procedure., Level of Evidence: Level III retrospective comparative treatment study., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Aim:  Regular anal dilatations are commonly recommended in the postoperative management following posterior sagittal anorectoplasty (PSARP) in anorectal malformations (ARM). We hypothesized that routine postoperative dilatations may not affect surgical outcomes following PSARP. We compare surgical outcomes of routine postoperative dilatations versus no routine postoperative dilatations from two United Kingdom tertiary pediatric surgical centers., Materials and Methods:  This is retrospective records review of patients undergoing definitive surgery for ARM in two tertiary surgical centers in the UK over 5 years. Center A used a protocol of routine postoperative dilatations, and center B used a protocol, which used dilatations only for clinical indications of stricture. Data collected included ARM type, operative procedures, and postoperative interventions. All post-operative interventions under general anesthesia (GA) were compared between groups., Results:  From 2011 to 2015, 49 procedures (46 PSARPs) were performed in center A and 54 (52 PSARPs) in center B. Median follow up period was 31 months (interquartile range [IQR] 18-48). The first postoperative anal calibration under GA was documented for 43 (86%) patients in center A and for 42 (78%) patients in center B. Following this, center A followed routine postoperative dilatation (RPD) at home, and center B reserved further dilatations for specific indications. RPD was performed for 100% of patients in center A versus 8% in center B. Further anal dilatations under GA were performed in 19 (38%) children in center A and in 17 (34%) children in center B ( p  = 0.68). In center A, 10 patients (22%) needed further surgery versus 14 (28%) in center B ( p  = 0.48)., Conclusion:  The use of routine postoperative dilatations does not significantly improve surgical outcomes following PSARP in ARM., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Complications of the diabetic lower extremity (such as diabetic foot ulcers, DFUs) occur when monitoring is infrequent, and often result in serious sequelae like amputation or even death., Objective: To evaluate the potential application of mobile health (mHealth) to diabetic foot monitoring. We surveyed the self-management routines of a group of diabetic patients, as well as patient and clinician opinions on the use of mHealth in this context., Methods: Patients with DFUs in Toronto, Ontario, Canada completed a 25-item questionnaire addressing their foot care practices, mobile phone use, and views on mHealth. Wound care clinicians across Canada were also surveyed using a 9-item questionnaire., Results: Of the patients surveyed, 59/115 (51.3%) spend less than a minute checking their feet, and 17/115 (15%) of patients find it difficult to see their doctor or get to the hospital regularly. Mobile phone use was widespread in our patient cohort (93/115, 80.9%). Of mobile phone users, 68/93 (73.1%) would use a device on their mobile phone to help them check their feet. Of the clinicians who completed the questionnaire, only 7/202 (3.5%) were familiar with mHealth; however, 181/202 (92%) of clinicians expressed interest in using mHealth to monitor their patients between visits., Conclusions: Patient education or motivation and clinician training were identified as the major barriers to mHealth use in the diabetic lower extremity, which may be a viable mechanism to improve DFU monitoring practices., (©David Wallace, Julie Perry, Janelle Yu, Joshua Mehta, Paul Hunter, Karen Michelle Cross. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 16.04.2019.)

Background: One of the most common (and costly) complications of diabetes are diabetic foot ulcers, which often result in lower-extremity amputation. Regular foot care can reduce complications; however, roughly half of Canadians with diabetes do not participate in screening. We sought to evaluate the economic effects of using telemonitoring for diabetic foot ulcer prevention using mathematical modelling., Methods: We used Markov modelling to compare current screening standards (standard care) to population-wide and targeted (high-risk) telemonitoring programs in a hypothetical cohort of Canadian patients aged 60 years. We varied the effectiveness (or outcome), defined as the proportion of diabetic foot ulcers prevented, to explore cost-effectiveness using model parameters from published literature and clinical experts., Results: At 20%-40% effectiveness, population-based prevention resulted in 0.00399-0.00790 quality-adjusted life years (QALYs) gained per person over 5 years and an incremental cost of $479-$402 compared to standard care. At 15%-40% effectiveness, high-risk prevention resulted in a cost decrease per person over 5 years ($1.26-$25.55), with health benefits of 0.000207-0.00058 QALYs gained., Interpretation: The use of telemonitoring in the diabetic lower extremity can offer patients better quality of life and can be cost-effective compared to current Canadian screening practices. Future work should focus on developing and validating technologies based on objective outcome measures for remote monitoring of the diabetic foot., Competing Interests: Competing interests: General Leung and Karen Cross have an equity interest in a company developing a diabetic foot ulcer telemonitoring device. No other competing interests were declared., (Copyright 2018, Joule Inc. or its licensors.)

Background/purpose: Morgagni diaphragmatic hernia (MH) is rare. We report our experience based on routine patch use in MH repair to curb recurrence. A systematic review and meta-analysis were performed to study the recurrence and complications associated with minimally invasive surgery and the use of patch., Methods: We retrospectively reviewed all cases of MH who underwent first-time repair in 2012-2017 in our institution to determine recurrence and complication rate. A MEDLINE search related to minimally invasive surgery (MIS) and patch repair of MH was conducted for systematic review. Eligible articles published from 1997-2017 with follow-up data available were included. Primary outcomes measured were recurrence and complication. Meta-analysis to compare open versus MIS and primary versus patch repair in the MIS group were performed in comparative cohorts. Continuous data were presented as median (range), and statistical significance was P<0.05., Results: In our institution, 12 consecutive patients aged 17-month-old (22 days-7 years), underwent laparoscopic patch repair of MH, with one conversion to laparotomy. No recurrence or significant complication occurred over a follow-up period of 8 months (1-48 months). Thirty-six articles were included from literature review and were combined with the current series. All were retrospective case reports or series, of which 6 were comparative cohorts with both MIS and open repairs. A total of 296 patients from 37 series were ultimately used for analysis: 80 had open repair (4 patch) and 216 had MIS repair (32 patch), with a patch rate of 12%. There were 13 recurrences (4%): no difference between open and MIS repairs (4/80 vs 9/216, p=0.75); recurrence rate following primary repair was 13/260 (5%), but no recurrence occurred with 36 patch repairs. Meta-analysis showed no difference in recurrence between open and MIS repair (p=0.83), whereas patch repair was associated with 14% less recurrence compared with primary repair, although it did not reach statistical significance (p=0.12). There were 13 complications (5%): no difference between open and MIS repairs (5/80 vs 8/216, p=0.35). One small bowel obstruction occurred in a patient who had laparoscopic patch repair., Conclusion: In MH, recurrence and complication rates are comparable between MIS and open repairs. Use of patch appeared to confer additional benefit in reducing recurrence., Type of Study: Systematic review LEVEL OF EVIDENCE: 3A., (Copyright © 2018. Published by Elsevier Inc.)

Context: Thigh muscle strains are among the most common injuries in high school soccer for both males and females. Similar results have been reported among college soccer players, specifically for hamstring strains. In college soccer, males have a higher injury rate than women, although they share common injury characteristics. Currently, no studies exist comparing the injury rate or injury characteristics of thigh muscle strains between sexes playing high school soccer., Objective: To compare thigh muscle strain injury rates and injury event characteristics among sexes participating in high school soccer., Design: Descriptive epidemiology study., Setting: A total of 100 nationally representative high schools that participated in the High School Sports-Related Injury Surveillance System, Reporting Information Online., Participants: High school soccer athletes who had a thigh muscle strain., Main Outcome Measures: Injury rates of thigh muscle strains were calculated between sexes. The occurrence of the following variables during a thigh muscle injury was compared between sexes: grade level, age, level of play, event type, time of practice, time of competition, basic injury mechanism, soccer activity, player position, field location, practice type, and time of season., Results: Males had a lower injury rate of thigh muscle strains during competition than females (rate ratio = 0.66; 95% confidence interval, 0.47-0.93). No differences between sexes existed in the distribution of first-time or recurrent event characteristics. When combining sexes, recurrent strains (93%) occurred more frequently on the offensive side of the field than first-time strains (59%), P < .001. The majority of strains occurred among the varsity players (71%), during running activities (60%) and practices (58%)., Conclusions: Males were less likely to sustain a thigh muscle strain during competitions, but no other differences existed between sexes. The events surrounding all thigh muscle strains may be described with some common properties. Consideration of these characteristics may assist in the development of preventive and rehabilitative programs as well as direct future research on thigh muscle strains among high school soccer players.

The objective of this article is to convey the importance of nutrition in plastic surgery, to offer possible outpatient nutritional interventions within the surgical care setting, and to guide the plastic surgeon in integrating nutrition as a key practice enhancement strategy for the care of wound patients and beyond. The impact of nutritional status on surgical outcomes is well recognized. Malnutrition is very frequent among the hospitalized patient population and up to 1 in 4 plastic surgery outpatient is at risk for malnutrition. Micro- and macronutrients are both essential for optimal wound healing and although specific patient populations within the field of plastic surgery are more at risk of malnutrition, universal screening, and actions should be implemented. Outpatient interventions to promote adequate nutritional intake and address barriers to the access of fruits and vegetables have included both exposure and incentive interventions. In the clinical setting, universal screening using validated and rapid tools such as the Canadian Nutritional Screening Tool are encouraged. Such screening should be complemented by appropriate blood work, body mass index measurements, and prompt referral to a dietician when appropriate. The notion of prehabilitation has also emerged with impetus in surgery and encompasses the nutritional optimization of patients by promoting the enhancement of functional capacity preoperatively.

Plastic surgeons routinely see patients with complex or chronic wounds of all etiology. In a previous study, we found that up to 1 in 4 of these patients is at risk for malnutrition, which may be influencing their ability to heal. The goal of this study was to develop and validate a universal screening protocol that would be fast and accurate and allow for effective intervention and optimization of nutrition before plastic surgery., Methods: To accomplish these goals, we adopted a 2-part screening algorithm using the Canadian Nutritional Screening Tool (CNST) to triage patients in our outpatient clinics and then further screened those identified as being at risk using the Subjective Global Assessment (SGA) tool and blood work., Results: We screened 111 patients with diagnoses related to breast cancer (n = 10; 9.01%), elective surgery (n = 38; 34.23%), emergency surgery (n = 8; 7.21%), fractures (n = 15; 13.51%), and wounds (n = 40; 36.04%). Of the screened subjects, 15.32% (n = 17) were found to be at nutritional risk using the CNST, and 13 were confirmed to be moderately or severely malnourished using the SGA. Importantly, there were no positive correlations between nutritional status and smoking, diabetes, body mass index, or age, indicating that a universal screening protocol is needed to effectively screen a diverse plastic surgery population for malnutrition., Conclusions: Screening patients with both the CNST and the SGA is an effective way to identify patients before surgery to improve outcomes., Competing Interests: Disclosure: Supported by a research grant from the AFP Innovation Fund (Ontario, Canada). The Article Processing Charge was paid for by the authors.

Background and Purpose: Muscle dysfunction is very common following musculoskeletal injury. There is very little evidence to suggest that muscle function may be positively impacted by soft tissue interventions, such as dry needling. The purpose of this case report is to describe the immediate effect of dry needling on muscle thickness in a subject after shoulder surgery., Case Description: A 22 year-old competitive gymnast presented seven months post shoulder surgery with significant impairments and functional limitations. Previous physical therapy focused on restoration of range of motion and strength using general exercise interventions, but the subject had persistent tightness and weakness of musculature of the shoulder complex. A subject-specific physical therapy program including manual physical therapy resulted in significant initial improvement, but lack of flexibility and weakness of the rotator cuff limited progress. Dry needling was used to address persistent myofascial trigger points., Outcomes: Immediately after dry needling the infraspinatus, the muscle's thickness was significantly improved as measured by rehabilitative ultrasound imaging. There was a corresponding increase in force production of external rotation at 90 degrees of abduction., Discussion: Minimal research exists that validates the potential of dry needling on muscle function, as assessed by muscle thickness measured using rehabilitative ultrasound imaging. The results of this case report suggest that dry needling contributed to improvement in muscle thickness and strength in a subject with muscle dysfunction following an injury., Level of Evidence: 4.

Diabetic foot ulcers (DFUs) are a significant problem in an aging population. Fifteen percent of diabetics develop a DFU over their lifetime, which can lead to potential amputation. The 5-year survival rate after amputation is 31%, which is greater than the lifetime risk of mortality from cancer. Topical oxygen is a promising technique for the adjunctive therapy of chronic wounds including DFUs, but few controlled studies exist to support its clinical adoption. The aim of this study was to compare a portable topical oxygen delivery system in patients with nonhealing DFUs to standard best practice. Twenty patients were randomized into a topical oxygen group (n = 10), and a nonplacebo control group with regular dressings and standard care (n = 10), and attended the diabetic foot clinic once weekly for 8 weeks. Ulcer surface area over time was analyzed using standardized digital imaging software. DFUs were present without healing for a mean duration of 76 weeks prior to the study. They found a significant difference in healing rate between patients receiving topical oxygen and those receiving standard care. Topical oxygen, therefore, represents a potentially exciting new technology to shorten healing time in patients with nonhealing DFUs. More prospective randomized and powered studies are needed to determine the benefits of topical oxygen, but our current results are very promising., (© 2016 by the Wound Healing Society.)

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.

Context: Among US collegiate soccer players, the incidence rate and the event characteristics of hamstrings strains differ between sexes, but comparisons in the return-to-participation (RTP) time have not been reported., Objective: To compare the RTP time between male and female collegiate soccer players and analyze the influence of event characteristics on the RTP time for each sex., Design: Descriptive epidemiology study., Setting: Data were collected from collegiate teams that voluntarily participated in the National Collegiate Athletic Association Injury Surveillance System., Patients or Other Participants: Collegiate soccer athletes who sustained 507 hamstrings strains (306 men, 201 women) during the 2004 through 2009 fall seasons., Main Outcome Measure(s): Nonparametric statistics were used to evaluate RTP time differences between sexes and among categories of each event characteristic (ie, time of season, practice or competition, player position). Negative binomial regression was used to model the RTP time for each sex. All analyses were performed separately for first-time and recurrent strains., Results: We found no differences in the RTP time between sexes for first-time (median: men = 7.0 days, women = 6.0 days; P = .07) or recurrent (median: men = 11 days, women = 5.5 days; P = .06) hamstrings strains. For male players with first-time strains, RTP time was increased when the strain occurred during competition or the in-season/postseason and varied depending on the division of play. Among female players with first-time strains, we found no differences in RTP time within characteristics. For male players with recurrent hamstrings strains, the RTP time was longer when the injury occurred during the in-season/postseason. Among female players with recurrent strains, RTP time was longer for forwards than for midfielders or defenders., Conclusions: Although we found no differences in the RTP time after hamstrings strains in male and female collegiate soccer players, each sex had unique event characteristics that influenced RTP time.

Purpose: To evaluate outcomes in critically ill neonates with necrotising enterocolitis (NEC) undergoing a laparotomy in the neonatal intensive care unit (NICU)., Methods: This is a retrospective review of neonates diagnosed with NEC who underwent a laparotomy on NICU between 2001 and 2011. Demographic, diagnostic, operative and outcome data were analysed. Nonparametric comparison was used. Data are reported as median (range)., Results: 221 infants with NEC were referred for surgical evaluation; 182 (82%) underwent surgery; 15 (8%) required a laparotomy on NICU. Five had NEC totalis, 4 multifocal disease and 6 focal disease. Five had an open and close laparotomy, 8 stoma with/without bowel resection and 2 bowel resection and primary anastomosis. Ten (67%) died at a median of 6.5-hours (2-72) postoperatively; 2 died at 72 and 264-days. The 30-day mortality rate was higher (p=0.01) among infants undergoing a laparotomy on NICU (10/15; 67%) than in theatre (54/167; 32%). There was no significant difference in mean Paediatric Index of Mortality 2 Scores between survivors and nonsurvivors (p=0.55). Three (20%) infants remain alive with no or minimal disability at 1.4 (0.5-7.5) years., Conclusion: Laparotomy for NEC on NICU is a treatment option for neonates who are too unstable to transfer to theatre. However, with 67% dying within 6.5-hours and a further 13% after months in hospital, we must consider whether surgery is always in their best interests. Development of a prediction model to help distinguish those at highest risk of long-term morbidity and mortality could help with decision making in this difficult situation., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: Gastroschisis neonates have delayed time to full enteral feeds (ENT), possibly due to bowel exposure to amniotic fluid. We investigated whether delivery at <37weeks improves neonatal outcomes of gastroschisis and impact of intra/extra-abdominal bowel dilatation (IABD/EABD)., Methods: A retrospective review of gastroschisis (1992-2012) linked fetal/neonatal data at 2 tertiary referral centers was performed. Primary outcomes were ENT and length of hospital stay (LOS). Data (median [range]) were analyzed using parametric/non-parametric tests, positive/negative predictive values, and regression analysis., Results: Two hundred forty-six patients were included. Thirty-two were complex (atresia/necrosis/perforation/stenosis). ENT (p<0.0001) and LOS (p<0.0001) were reduced with increasing gestational age. IABD persisted to last scan in 92 patients, 68 (74%) simple (intact/uncompromised bowel), 24 (26%) complex. IABD or EABD diameter in complex patients was not significantly greater than simple gastroschisis. Combined IABD/EABD was present in 22 patients (14 simple, 8 complex). When present at <30weeks, the positive predictive value for complex gastroschisis was 75%. Two patients with necrosis and one atresia had IABD and collapsed extra-abdominal bowel from <30weeks., Conclusion: Early delivery is associated with prolonged ENT/LOS, suggesting elective delivery at <37weeks is not beneficial. Combined IABD/EABD or IABD/collapsed extra-abdominal bowel is suggestive of complex gastroschisis., (Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine whether fluoroscopic balloon dilation (FBD) is a safe and effective method of treating esophageal anastomotic stricture after surgical repair in an unselected patient population., Materials and Methods: With ethics committee approval, records for 103 consecutive patients who underwent FBD with our interventional radiology service (1999-2011) were reviewed retrospectively. Patients underwent diagnostic contrast material-enhanced study prior to the first dilation. Dilations were performed by using general anesthesia. Outcomes were number and/or frequency of dilations, clinical effectiveness and response to dilations, esophageal perforation, requirement for surgery, and mortality. Data were expressed as mean ± standard deviation (with range). Comparisons were conducted by using the Fisher exact test and log-rank test. The significance level was set at P < .05., Results: One hundred three patients (61 male patients, 59%) underwent 378 FBD sessions (median, two dilations per patient; range, 1-40 dilations). The median age at first FBD was 2.2 years (range, 0.1-19.5 years). The balloon catheter diameters ranged from 4 to 20 mm. FBD was successful in 93 patients (90%): 44 (47%) after single dilation and 49 (53%) after multiple dilations. There was no difference in the proportion of patients who required one dilation and were younger than 1 year versus those who were 1 year of age and older (P > .99; odds ratio, 1.07 [range, 0.43-2.66]). Ten patients (10%) required further procedures: Three underwent stent placement, three underwent esophageal stricture resection, and four underwent esophageal reconstruction. Four esophageal perforations (1%) developed after FBD. Antireflux surgery was performed in 18 patients (17%). There were no deaths., Conclusion: FBD for anastomotic strictures after esophageal atresia repair is feasible and acceptably safe and provides relief of symptoms in most patients (90%); however, about half require more than one dilation, and surgery is best predicted if more than 10 dilations are required.

Objective: We aimed to evaluate the effect of thoracoscopy in neonates on intraoperative arterial blood gases, compared with open surgery., Background: Congenital diaphragmatic hernia (CDH) and esophageal atresia with tracheoesophageal fistula (EA/TEF) can be repaired thoracoscopically, but this may cause hypercapnia and acidosis, which are potentially harmful., Methods: This was a pilot randomized controlled trial. The target number of 20 neonates (weight > 1.6 kg) were randomized to either open (5 CDH, 5 EA/TEF) or thoracoscopic (5 CDH, 5 EA/TEF) repair. Arterial blood gases were measured every 30 minutes intraoperatively, and compared by multilevel modeling, presented as mean and difference (95% confidence interval) from these predictions., Results: Overall, the intraoperative PaCO2 was 61 mm Hg in open and 83 mm Hg [difference 22 mm Hg (2 to 42); P = 0.036] in thoracoscopy and the pH was 7.24 in open and 7.13 [difference -0.11 (-0.20 to -0.01); P = 0.025] in thoracoscopy. The duration of hypercapnia and acidosis was longer in thoracoscopy compared with that in open. For patients with CDH, thoracoscopy was associated with a significant increase in intraoperative hypercapnia [open 68 mm Hg; thoracoscopy 96 mm Hg; difference 28 mm Hg (8 to 48); P = 0.008] and severe acidosis [open 7.21; thoracoscopy 7.08; difference -0.13 (-0.24 to -0.02); P = 0.018]. No significant difference in PaCO2, pH, or PaO2 was observed in patients undergoing thoracoscopic repair of EA/TEF., Conclusions: This pilot randomized controlled trial shows that thoracoscopic repair of CDH is associated with prolonged and severe intraoperative hypercapnia and acidosis, compared with open surgery. These findings do not support the use of thoracoscopy with CO2 insufflation and conventional ventilation for the repair of CDH, calling into question the safety of this practice. The effect of thoracoscopy on blood gases during repair of EA/TEF in neonates requires further evaluation. (ClinicalTrials.gov Identifier: NCT01467245).

Background: Hamstring strains are common among soccer athletes, and they have a high incidence of recurrence. Among American collegiate soccer players, men have an overall higher incidence rate of hamstring strains than women., Purpose: This research compares the hamstring strain injury rates in event and athlete characteristics between male and female college soccer athletes., Study Design: Descriptive epidemiology study., Methods: Data describing partial and complete hamstring strains were obtained from the National Collegiate Athletic Association (NCAA) Injury Surveillance System (ISS) for men's and women's soccer from 2004 to 2009. Incidence rate ratios (IRRs) comparing the incidence of hamstring strains between the sexes as well as during games versus practices and the preseason versus the in-season were calculated. χ(2) tests were used to compare the occurrence of hamstring strains across different event and athlete characteristics., Results: Men were 64% more likely than women to sustain a hamstring strain (IRR, 1.64; 95% CI, 1.37-1.96). Men had significantly higher rates of hamstring strains than women during both games (IRR, 2.42; 95% CI, 1.82-3.23) and practices (IRR, 1.34; 95% CI, 1.06-1.68). There were no differences between men and women in injury rates during the preseason, but men were significantly more likely to sustain a hamstring strain during the in-season (IRR, 1.98; 95% CI, 1.56-2.52). Men had a significantly higher proportion of recurrent hamstring strains compared with women (men, 22%; women, 12%; P = .003). There were no significant differences in the distribution of strains in event or athlete characteristics between men and women for first-time or recurrent hamstring strains., Conclusion: In collegiate soccer, men have significantly higher rates of hamstring strains than women, and regardless of the recurrence status, the event and athlete characteristics were similar for both sexes. Identifying common characteristics may assist in the targeted development of preventive and rehabilitative programs as well as continued research on hamstring strains among collegiate soccer players.

Purpose: Morgagni diaphragmatic hernia can be repaired laparoscopically. The aim of this study is to evaluate the outcome of this minimally invasive approach., Methods: A retrospective review was conducted on all consecutive children who underwent repair of Morgagni hernia from January 2002 to December 2011 in our hospital. Data are expressed as median (range)., Results: There were 12 children with Morgagni hernia. Age at surgery was 7.5 months (2-125). Associated malformations were present in 7 children (58 %). All children underwent initial laparoscopic approach. Two children (16 %) underwent conversion to open surgery. The hernia was closed primarily in 11 children (92 %), using a polyester patch in 1 (8 %). There were no intraoperative or immediate postoperative complications. Five children (42 %), all repaired initially without a patch, had a recurrence of the Morgagni hernia. The repair of the recurrent hernia was performed laparoscopically in four out of the five children, and a patch was used in two patients with no further recurrences or complications., Conclusions: There is a high rate of recurrence after laparoscopic Morgagni hernia repair. This is exclusively associated with laparoscopic repair without patch, and it is in contrast with the low recurrence rate reported previously. More frequent use of patch may be beneficial.

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.

Aim: "Buried bumper" is a complication of percutaneous gastrostomy related to the internal flange getting buried into the wall of the stomach. The aim of this study is to evaluate the management of this complication., Methods: The surgical and interventional radiology database in our hospital from August 1999 to May 2011 was analyzed. There were 2,007 patients who underwent percutaneous gastrostomy insertion. Notes for patients with buried bumper were reviewed. A telephonic interview with the parents of these children was performed with focused assessment of the care of the gastrostomy tube before the episode of buried bumper. Continuous data are reported as median (range)., Results: Twenty children developed buried bumper after gastrostomy insertion. They had a primary diagnosis of neurological (n = 14), metabolic (n = 3), or endocrine (n = 3) disorders. The age at presentation was 5.7 years (2 to 18 years); 2.5 years (1 month to 5 years) after gastrostomy insertion. Ten children (50%) presented with symptoms related to buried bumper which included leakage around the gastrostomy (n = 4), pus, discharge or bleeding from the site (n = 5), stiffness on feeding (n = 3), and unable to push the flange (n = 1) (three children had more than one symptom). Ten children (50%) were asymptomatic and underwent routine change or removal of gastrostomy. In nine children, there was an attempt to remove the flange by interventional radiology but this was successful only in one. In the remaining 19 children, 4 had endoscopic removal while 15 children developed an inflammatory mass and required a laparotomy (n = 12) or laparoscopic-assisted excision (n = 3)., Conclusion: Buried bumper is a rare complication of percutaneous gastrostomy. Inadequate postoperative care without appropriate mobilization is a factor leading to this preventable complication. Endoscopic removal is possible, failing which laparoscopic surgery should be considered., (Georg Thieme Verlag KG Stuttgart · New York.)

Histological diagnosis of burn depth lacks consensus. The purpose of this study was to determine whether Ki-67, a cell proliferation marker, provides an index of integument viability after burn injury. Induction of thermal burn injuries (3, 12, 20, 30, 75, 90, and 120 seconds) were made with a brass rod heated to 100°C on the dorsal trunk of the swine. Controls were created with a brass rod heated to 37.5°C. Four 6-mm biopsies were obtained from each site for histological analysis of Ki-67. Biopsies were taken at the following times postinjury: 1, 12, 24, 36, 48, 72, and 96 hours. The results illustrate a characteristic Ki-67 nuclear staining in the basal layer of the epidermis and in the hair follicle. With increasing thermal injury, the nuclei of the cells changed morphology: condensing, fragmenting, and elongating. The uniqueness of the labeling index was to include only morphologically intact nuclei as having capacity to proliferation. Quantitative analysis showed a reduction in the mean number of Ki-67-positive cells, suggesting a reduced regenerative capacity. This study supports using this index as a means of performing histology for burn depth analysis. In future studies, determining viability of partial-thickness burns will require multiple histological markers such as Ki-67 in addition to hematoxylin and eosin staining.

Study Design: Systematic review., Background: Neck pain is a common diagnosis in the physical therapy setting, yet there is no gold standard for treatment. This study is part of a growing body of literature on the use of thoracic spine thrust manipulation for the treatment of individuals with mechanical neck pain., Objective: The purpose of this systematic review was to determine the effects of thoracic spine thrust manipulation on pain, range of motion, and self-reported function in patients with mechanical neck pain., Methods: Six online databases were comprehensively searched from their respective inception to October 2010. The primary search terms included "thoracic mobilization," "thoracic spine mobilization," "thoracic manipulation," and "thoracic spine manipulation." Of the 44 studies assessed for inclusion, 6 randomized controlled trials were retained. Between-group mean differences and effect sizes for pretreatment-to-posttreatment change scores, using Cohen's d formula, were calculated for pain, range of motion, and subjective function at all stated time intervals., Results: Effect size point estimates for the pain change scores were significant for global assessment across all studies (range, 0.38-4.03) but not conclusively significant at the end range of active rotation (range, 0.02-1.79). Effect size point estimates were large among all range-of-motion change measures (range, 1.40-3.52), and the effect size point estimates of the change scores among the functional questionnaires (range, 0.47-3.64) also indicated a significant treatment effect., Conclusions: Thoracic spine thrust manipulation may provide short-term improvement in patients with acute or subacute mechanical neck pain. However, the body of literature is weak, and these results may not be generalizable., Level of Evidence: Therapy, level 1b-.