Royal Alexandra Hospital

Hereditary spherocytosis is an inherited red cell membrane disorder resulting in haemolytic anaemia. Recognised clinical manifestations include anaemia, jaundice, splenomegaly and gallstones. Here we describe the case of a 40‐year‐old male with hereditary spherocytosis presenting with severe hyperbilirubinaemia. Liver biopsy demonstrated features consistent with acute severe cholestasis. Despite extensive investigations for gallstone disease and other causes of liver pathology, no aetiology was identified. There are very few reports in the literature describing cases of profound unexplained jaundice in hereditary spherocytosis. Hereditary spherocytosis may be associated with idiopathic acute cholestasis. We report that the case was managed conservatively and spontaneously resolved.

Barrett's esophagus (BE) is a metaplastic, premalignant condition that can develop following sleeve gastrectomy (SG). While various treatment modalities exist for management of post-SG BE, conversion to Roux-en-Y gastric bypass (RYGB) can be an effective option which can also improve gastroesophageal reflux disease (GERD). However, the effectiveness of RYGB for resolving BE has not been rigorously studied. This systematic review evaluates the outcomes of BE in patients converted from SG to RYGB. A comprehensive literature search was conducted in Ovid MEDLINE, Ovid Embase, PubMed, and Cochrane Library. Studies reporting BE onset following SG and subsequent RYGB conversion were included. Data extracted included patient demographics, Prague classification, dysplasia status, time from SG to BE diagnosis and time to RYGB conversion, and resolution of BE post-RYGB. The validated MINORS tool was used to assess the quality and risk of bias of reviewed studies. A total of 4 studies were included, comprising 21 patients who underwent conversion from SG to RYGB with BE. The weighted mean age at RYGB was 46.7 ± 13.8years, with an initial BMI of 44.7 ± 2.7kg/m2 and post-SG BMI of 32.5 ± 6.9kg/m2. The time for conversion between SG and RYGB occurred at an average of 58 ± 19.31months. BE resolution was observed in 81% of patients, while dysplasia resolved in n = 1/1 patients. No significant perioperative complications were noted. Based on these results, SG to RYGB conversion appears to be an effective intervention for BE, with the majority of patients achieving histological regression and resolution of symptoms. While preliminary findings indicate favorable outcomes, further studies with bigger sample sizes, longer follow-ups and more diverse patient pools are needed.

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Background: Current neonatal resuscitation guidelines recommend epinephrine preferably be given via intravenous (IV) or intraosseous (IO) routes during cardiac arrest. Vasopressin might be an alternative during asphyxial cardiac arrest; however, whether it remains effective when administered via IO is unclear. Objective: We aimed to compare IO with IV vasopressin or epinephrine on incidence and time to return of spontaneous circulation (ROSC) in asphyxiated newborn piglets. Design/Methods: Thirty-two newborn piglets ( n =8/group) were anesthetized, intubated, instrumented, and exposed to 45 minutes of normocapnic hypoxia, followed by asphyxiation till asystolic cardiac arrest. Piglets were randomized to 0.4IU/kg IV or IO vasopressin, or 0.02mg/kg IV or IO epinephrine. Drug was administered via IV or IO 1 minute after the start of chest compressions (CCs) and administered every 3 minutes as needed if no return of spontaneous circulation (ROSC) was observed, to a maximum of three doses. Results: Rates of ROSC were not different between IV or IO vasopressin, 5/8(63%) vs 3/8(38%), respectively ( p =0.619), or between IV or IO epinephrine, 2/8(25%) vs 6/8(75%), respectively ( p =0.132). Rates of ROSC were similar between all four groups ( p =0.233). Median (IQR) time to ROSC was 254 (220-473)sec and 215 (200-240)sec for IV and IO vasopressin, respectively ( p =0.143), and 272 (265-278)sec and 233 (203-266)sec for IV and IO epinephrine, respectively ( p =0.286). Time to ROSC was similar amongst all groups ( p =0.312). Conclusions: In a neonatal piglet model of asystolic cardiac arrest, administration of IO vasopressin or epinephrine resulted in similar resuscitative outcomes to IV vasopressin or epinephrine. Our findings suggest that IO vasopressor administration is effective during neonatal resuscitation, and that IO vasopressin is a feasible alternative to IV vasopressin.

Background: Neonatal resuscitation guidelines recommend the use of the vasopressor epinephrine during neonatal cardiopulmonary resuscitation (CPR); however, vasopressin may be a potential alternative. Successful neonatal CPR requires rapid vasopressor administration, but the current guideline-recommended routes can take several minutes to establish and require substantial skill and/or training. The intramuscular (IM) route provides rapid drug administration and does not require special skills, training, or equipment. Objective: We aimed to compare two doses of IM vasopressin to intravenous (IV) vasopressin in a healthy neonatal piglet model to examine the hemodynamic and pharmacokinetic effects. Methods: Fifteen neonatal piglets (n = 5/group; 1–3 days of age) were anesthetized, intubated via a tracheostomy, and randomized to 4 IU/kg IM vasopressin, 8 IU/kg IM vasopressin, or 0.4 IU/kg IV vasopressin. Various hemodynamic and cardiac function parameters were continuously recorded throughout the experiment. Blood was collected prior to drug administration and throughout the experiment for pharmacokinetic and pharmacodynamic analysis. Results: The 4 IU/kg IM vasopressin dose was ineffective in producing systemic changes in hemodynamics or cardiac function as it was poorly absorbed. The 8 IU/kg IM vasopressin dose had comparable results to IV vasopressin and was rapidly distributed to systemic circulation. Conclusions: The higher IM vasopressin dose of 8 IU/kg is effective in increasing systolic and diastolic blood pressure.

Abstract Background Over 60% UK adults are overweight or obese. Obesity is not only associated with increased risk of developing colorectal cancer, but can lead to longer operative time, increase risk of perioperative mortality and subsequently prolong hospital stay. We assessed impact of patient body mass index (BMI) on operating time, post-operative complications and length-of-stay, and oncological resection margins for patients undergoing robotic-assisted surgery (RAS) for colorectal cancer. Methods Retrospective review of a prospectively maintained database for patients undergoing elective RAS for colorectal cancer between 1/7/2021-31/12/2024 at one NHS National Wait Times Hospital. Patients were categorised into subgroups as per BMI: normal (18-24.9); overweight (25-29.9) and obese (>30). Outcomes including surgical operating time, post-operative complications and length-of-stay, and resection margin status were assessed in relation to BMI category. Chi-squared and ANOVA statistical analysis were performed. Results 182 patients underwent RAS-resection for colorectal malignancy. Two patients with BMI <18 were excluded from analysis. 39 patients (21.4%) had a normal BMI; 74 patients (40.7%) were overweight, and 67 patients (36.8%) were obese. BMI did not significantly impact operative time (F(27,27) = 1.032, p=0.468), risk of post-operative complications (x2(2) = 3.849, p=0.146), post-operative length-of-stay (F(27,161) = 0.906, p=0.568) or resection margin (x2(2) = 1.374, p=0.503). Subgroup analysis of right-sided (n=55, 30.5%) and left-sided/rectal malignancies (n=125, 69.5%) demonstrated similar outcomes. Conclusions RAS-assisted surgery is a safe and efficient method for colorectal cancer resection in overweight and obese patients. Further health-cost analysis would be beneficial to understand impact on NHS efficiency.

Neonatal cerebral hemodynamics represents a complex process affected by dynamic circulatory changes. Understanding the pathophysiology and factors that may affect cerebral blood flow in neonates is crucial to addressing the circulatory mechanism for neonatal brain injury. Studies have described multiple tools for monitoring cerebral blood flow; however, these are limited by the impracticality of using invasive tools. In this review, we explain the physiology of neonatal cerebral autoregulation with a focus on the transitional period and summarize the currently available methods for monitoring.

Epinephrine is currently the only vasopressor recommended for use during neonatal resuscitation. Epinephrine can be administered via intravenous, intraosseous, or endotracheal tube (ETT) route during cardiopulmonary resuscitation (CPR). Supraglottic airway (SGA) may be a novel route of epinephrine administration. This study aimed to compare the pharmacokinetics and pharmacodynamics of 0.1 mg/kg epinephrine administered via ETT, SGA top end, and SGA bottom end. Newborn piglets (n = 5/group) were anesthetized, randomized to SGA or tracheostomy, then surgically instrumented. Piglets randomized to SGA underwent another round of randomization following stabilization to receive epinephrine at the top or bottom of the SGA. Heart rate (HR), arterial blood pressure, carotid blood flow, and cardiac function (e.g., stroke volume and ejection fraction) were continuously recorded throughout the experiment. Blood was collected prior to drug administration and throughout the observation period for pharmacodynamics and pharmacokinetic analysis. Significant changes in hemodynamic parameters of HR, carotid blood flow, and cardiac function were only observed following ETT administration of epinephrine, while pharmacokinetic parameters were not different between ETT, SGA top, or SGA bottom. There were no differences in pharmacokinetic parameters between ETT, SGA top, or SGA bottom routes of epinephrine administration in neonatal piglets. Endotracheal tube (ETT) epinephrine results in significant hemodynamic parameters changes, whereas supraglottic airway (SGA) epinephrine did not produce the same hemodynamic effects, despite similar pharmacokinetic profiles. Systematic comparison of pharmacokinetics and pharmacodynamics of epinephrine via SGA versus ETT identifying potential limitations of SGA for epinephrine administration. The study raises important questions about the effectiveness of SGA for epinephrine administration during neonatal resuscitation. This research could influence future resuscitation guidelines and drive further studies to explore alternative dosing strategies or methods to improve the efficacy of SGA epinephrine. Further experiments examining SGA epinephrine during neonatal cardiopulmonary resuscitation are warranted.