Keep Calm: Does parental preoperative anxiety affect post-tonsillectomy pain scores in children?

PURPOSE: To understand if high parental anxiety leads to increased post-tonsillectomy pain in children. METHODS: Prospective study including parents of children aged 3-10 years old submitted to tonsillectomy with or without adenoidectomy. To evaluate anxiety, parents were asked to fill the State-Trait Anxiety Inventory form-Y, with postoperative pain being evaluated with the Wong-Baker FACES pain scale at postoperative days 1, 3 and 7. Parents were also asked to register the number of days during which children took analgesic and the number of analgesic intakes needed. RESULTS: 41 parents were enrolled, of which 95.1% (n = 39) were female with a mean age of 35.64 years (SD 5.751), with 41 children also being enrolled, of which 85.4% of children (n = 35) underwent tonsillectomy and adenoidectomy. 43.9% (n = 18) of parents presented State anxiety scores above the cut-off level and 53.7% (n = 22) above the Trait anxiety scores above the cut-off. Children of parents with high State anxiety presented statistically higher pain scores in both the third (p = 0.035) and the seventh postoperative days (p = 0.006), with significantly longer use of analgesic medication (p = 0.043) being found, as well as a statistically higher number of analgesic intakes (p = 0.045) (Table 4). CONCLUSION: The present study establishes an association between preoperative parental anxiety, postoperative pain scores and the need for longer analgesic use in children undergoing tonsillectomy. This reinforces the importance of reducing parental anxiety and opens the door for further strategies to better post-tonsillectomy outcomes.

Preservation Rhinoplasty by the Ones Who Do It: A Worldwide Survey.

Dorsal preservation (DP) rhinoplasty techniques, including surface techniques (STs) and foundation techniques (FTs) have garnered significant attention internationally over the past few years. The practice patterns and opinions from 117 of these surgeons were surveyed from a cohort of these surgeons who participate in an online Evidence-Based Rhinoplasty Research Group. The findings of the survey are merely a snapshot of the international rhinoplasty community's practices, yet did capture data from surgeons from a diverse geographic, years of experience, and training background. STs were most used for the bone changes, and the high-strip technique was preferred for the cartilaginous septal surgery. STs are mostly performed by younger surgeons (<10 years of experience), whereas FTs were more common in older surgeons (10-30 years of experience). STs were considered more stable (p < 0.001), more predictable (p < 0.001), and associate with a shorter learning curve (p = 0.015). Revision surgery rates were not different. Regarding why many surgeons using DP still perform structural rhinoplasty, the most cited concern was hump persistence/recurrence. In summary, among surgeons using DP rhinoplasty techniques, the majority perform DP in over half of their primary rhinoplasty surgeries, highlighting the importance of updating educational programs in medical training, conferences, and courses.

A utilização de recursos de suporte nas famílias que integram pessoas dependentes no autocuidado / The use of support resources in families that integrate dependent people in self-care

Problemática: O aumento do envelhecimento e da esperança média de vida irá acentuar-se no futuro, sendo expectável que o número de pessoas dependentes no autocuidado a necessitar de cuidados de saúde aumente (Petronilho, 2014; Rodrigues, 2017; Rodrigues, 2018). Na maioria dos casos estes cuidados de que falamos são efetuados por cuidadores informais pertencentes ao seio familiar, permanecendo este cuidado e os recursos utilizados desconhecido em muitas das suas vertentes (Gonçalves, 2013) e sem estatísticas oficiais existentes. Têm-se realizado estudos de investigação focados no estudo da dependência no autocuidado, do processo de tomar conta por um familiar e dos recursos a que estes recorrem. O projeto que nos propomos a realizar é a replicação desses estudos na freguesia de São Martinho do Bispo. Objetivo: Caracterizar e descrever os recursos de suporte utilizados pelas famílias clássicas para tomar conta do familiar dependente no autocuidado. Material e métodos: Estudo quantitativo, transversal e descritivo. O método de recolha de dados e os instrumentos a serem utilizados passarão pela aplicação de dois questionários e posterior análise das respostas obtidas. Resultados: De uma amostra de 387, apenas 42 corresponderam aos critérios do estudo, aceitaram participar e tinham familiares dependentes. Os recursos mais utilizados correspondem aos autocuidados ?tomar a medicação? (80,5%), ?andar? (78,1%) e ?uso do sanitário? (62,8%). Os recursos menos utilizados correspondem aos autocuidados ?elevar-se? (15,8%), ?virar-se? (27,5%) e ?transferir-se? (32%), obtendo-se uma taxa global de recursos não utilizados de 44%. O maior motivo da razão de não utilização prende-se em 34,9% com o desconhecimento da forma como os recursos funcionam. Conclusão: Estamos perante uma população de idosos a cuidar de idosos, pouco mais de metade dos recursos necessários são utilizados, obtendo-se um valor significativo de recursos não utilizados, sendo que quase metade das famílias em estudo não utiliza os recursos de suporte por desconhecimento.

Impact of adenotonsillectomy in pediatric respiratory function / Impacto de la cirugía adenoamigdalar sobre la función respiratoria pediátrica

Introduction: Adenotonsillar hypertrophy (ATH) is an important health condition that leads to upper airway obstruction and constitutes the main cause of obstructive sleep disordered breathing (OSDB) in children. The aim of this study was to analyze the effect of surgical intervention on spirometrical parameters of children with ATH/OSDB and upper airway recurrent infections (URTIs). Material and methods The study covered children treated surgically in a Pediatric Ambulatory Unit in a tertiary hospital. Spirometric tests were performed before and three months after surgery and results were compared. Results A total of 78 children were enrolled with a mean age of 6.95 ± 2,81 years. There was a significant improvement in forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), peak expiratory flow (PEF) and forced expiratory flow rate at 25% (F25) values after surgery in children suffering from OSDB (FVC pre: 1.52 ± 0.47 L vs FVC post: 1.85 ± 0.63 L, p < 0.001; FEV1 pre: 1.24 ± 0.38 L vs FEV1 post: 1.39 ± 0.40 L, p = 0.014; PEF pre: 2.04 ± 0.85 L/s vs PEF post: 2.33 ± 0.76 L/s, p = 0.014; F25 pre: 1.77 ± 0.77 L/s vs F25 post: 2.02 ± 0.73 L/s, p = 0.030). On a multivariate analysis model, preoperative tonsil size and performing tonsillectomy were the most significant determinants of improvement in spirometric values (p < 0.05). Children with isolated adenoid hypertrophy without tonsillar obstruction and those with URTIs alone did not show relevant differences in spirometric values after surgery (p > 0.05). No significant differences were found concerning pre-operative and post-operative forced expiratory flow rate at 75% (F75) and forced expiratory flow between 25 and 75% of the pulmonary volume (FEF25–75%) in any group (p > 0.05). Conclusions Surgery seems effective in ameliorating spirometry values in patients with OSDB and ATH, namely FVC, FEV1, PEF and F25. ... (AU)

Introducción: La hipertrofia adenoamigdalar (HAA) es una importante condición de salud que conduce a la obstrucción de las vías respiratorias superiores y constituye la principal causa de trastornos respiratorios obstructivos del sueño (TROS) en los niños. El objetivo de este estudio fue analizar el efecto de la intervención quirúrgica sobre los parámetros espirométricos de niños con HAA/TROS e infecciones recurrentes de las vías respiratorias superiores (IrVAS). Material y Métodos El estudio abarcó a niños operados en una Unidad Ambulatoria Pediátrica de un hospital de tercer nivel. Se realizaron espirometrías antes y tres meses después de la cirugía y se compararon los resultados. Resultados Se incluyeron un total de 78 niños con una edad media de 6,95 ± 2,81 años. Hubo una mejora significativa en los valores de capacidad vital forzada (FVC), volumen espiratorio forzado en el primer segundo (FEV1), flujo espiratorio máximo (PEF) y tasa de flujo espiratorio forzado al 25 % (F25) después de la cirugía en niños que sufrían de TROS (FVC pre: 1.52 ± 0.47 L vs FVC post: 1.85 ± 0.63 L, p < 0.001; FEV1 pre: 1.24 ± 0.38 L vs FEV1 post: 1.39 ± 0.40 L, p = 0.014; PEF pre: 2.04 ± 0.85 L/s vs PEF post: 2.33 ± 0.76 L/s, p = 0.014; F25 pre: 1.77 ± 0.77 L/s vs F25 post: 2.02 ± 0.73 L/s, p = 0.030). En un modelo de análisis multivariado, el tamaño preoperatorio de las amígdalas y la amigdalectomía fueron los determinantes más significativos de la mejora en los valores espirométricos (p < 0.005). Los niños con hipertrofia adenoidea aislada sin obstrucción amigdalina y aquellos con IrVAS sin TROS no mostraron diferencias relevantes en los valores espirométricos tras la cirugía (p > 0,05). ... (AU)

Labyrinthine Fistula in Chronic Otitis Media Surgery: Management and Outcomes.

The objective of this retrospective study was to present the experience on the management of labyrinthine fistula secondary to chronic otitis media in a tertiary center. 263 patients, who underwent tympanomastoidecomy, in Centro Hospitalar Universitário do Porto, between 2015 and 2020 were reviewed, to select only those with labyrinthine fistulas. 26 patients (9.89%) had cholesteatoma complicated by fistula of the lateral semicircular canal. Most frequent symptoms were unspecific, such as otorrhea, hearing loss and dizziness. Preoperative high-resolution computed tomography predicted fistula in 54%. Using the Dornhoffer and Milewski classification, 10 cases (38.46%) were identified as stage I, 15 (57.69%) at stage II, and 1 (3.85%) as stage III. The choice between open or closed surgical procedure was independent of the type of fistulae. The cholesteatoma matrix was completely removed from the fistula and immediately covered by autogenous material. In one patient matrix was left over the fistula. After surgery, hearing (bone conduction) was preserved or improved in 73% of the patients. There was no statistically significant relationship between the extent of the labyrinthine fistula, type of material used in fistula repair and the hearing outcome. Also, we didn't find a statistically significant relationship between extent of the labyrinthine fistula and the presence of facial nerve canal dehiscence, tegmen timpani erosion, sigmoid sinus exposure or ossicular bone erosions. In conclusion, a complete and nontraumatic removal of cholesteatoma matrix over the fistula in a single-staged procedure, is a safe and effective procedure, which achieves a hearing preservation or improvement in most cases.

Unilateral Vocal Fold Paralysis and Voice Therapy: Predictors of Long-Term Quality of Life.

To date, little is known about the long-term predictors of quality of life (QoL) in unilateral vocal fold paralysis (UVFP). The main objective of this study was to evaluate the predictors of long-term QoL in UVFP patients submitted to voice therapy (VT) exclusively. Data from patients diagnosed with UVFP who followed a VT program between 2013 and 2019 were reviewed. Video laryngoscopy (VL) records were obtained at the beginning and at the end of VT. To assess QoL, Voice Handicap Index 30 (VHI-30) score was assessed in three temporal frames: before voice therapy (pre-VT), at the last VT session (post-VT), and in the present (cur-VHI). A longitudinal analysis was performed regarding the evolution of QoL and the factors influencing QoL through time were analyzed. Seventy-eight percent of patients had iatrogenic UVFP. The mean time of follow-up after VT was 3.942 years (range 6 months-7 years). There was a significant improvement in QoL through all time points (F (2,88)=72.179, p<0.001), with VHI-30 decrease from the baseline pre-VT to post-VT(p<0.001) and from post-VT to cur-VT (p=0.0013). In the iatrogenic UVFP population, patients starting VT earlier showed better long-term QoL (p=0.023). UVFP patients with dysphagia at presentation showed significantly worse QoL in the late follow-up (p=0.016). Hence, iatrogenic UVFP patients beginning VT rapidly may show better QoL in the future. Also, our results suggest that dysphagia at UVFP onset may predict higher morbidity later in life.

Nasopharyngeal Approach to a Cholesterol Granuloma of the Petrous Apex.

Cholesterol granulomas are rare cystic inflammatory lesions characterized by the formation of cholesterol crystals. They are the most prevalent lesions of the petrous apex and when symptomatic, hearing loss, vertigo, tinnitus, headache, and facial pathology can be present. Surgical management is recommended in symptomatic patients. There are different surgical approaches to cholesterol granulomas. The aim of this article is to present and describe an endoscopic endonasal nasopharyngeal approach to a cholesterol granuloma and explain the advantages and disadvantages.

Validation of the Portuguese Version of the Voice Handicap Index-10.

INTRODUCTION: The aim of this study is to validate the Voice Handicap Index 10, to be implemented on the Portuguese population. MATERIAL AND METHODS: Fourty-five subjects were included on the study with vocal complaints and 45 subjects with no vocal complaints, followed on Otorhinolaryngology external appointment at Centro Hospitalar Universitário of Porto. The Voice Handicap Index 30 (VHI-30) and The Voice Handicap Index 10 (VHI-10) questionnaires were applied to the subjects by phone call. Posteriorly, VHI-10 was again applied in the next two to seven days after the first call. These procedures helped validating VHI-10 according to its reproducibility, internal consistency and correlation between questionnaires. RESULTS: In the group with vocal complaints, we verified a significant statistical correlation and a strong linear correlation between VHI-30 and VHI-10 (r = 0.915; P< 0.001). The group without vocal complaints has shown a significant statistical correlation and a moderate linear correlation between VHI-30 and VHI-10 (r = 0.647; P< 0.001). Regarding VHI-10, It was detected a significant statistical difference between patients with and without vocal complaints. DISCUSSION: VHI-10 in Portuguese of Portugal was applied to a sample that included, not only subjects with different ages, but also subjects with and without vocal complaints. Among patients with vocal complaints, it was included subjects with different diagnosis (organic and functional pathology). Thus, the sample was representative, and VHI-10 was reliable and reproducible. CONCLUSION: VHI-10 is a valid representation of VHI-30 that helps evaluate the impact of vocal complaints on life quality, with proven psychometric properties to be implemented on the Portuguese population.

Presbylarynx: Is it Possible to Predict Glottal Gap by Cut-Off Points in Auto-Assessment Questionnaires?

PURPOSE: To determine cut-off points in auto-assessment questionnaires to predict the presence and extent of presbylarynx signs. METHOD: This case control, prospective, observational, and cross-sectional study was carried out on consecutive subjects observed by Otorhinolaryngology, in a tertiary center, in 2020. Each subject underwent fiberoptic videolaryngoscopy with stroboscopy, and presbylarynx was considered when it was identified two or more of the following endoscopic findings: vocal fold bowing, prominence of vocal processes in abduction, and a spindle-shaped glottal gap. Each subject completed three questionnaires: the Voice Handicap Index (VHI), with 30 and 10 questions, and the "Screening for voice disorders in older adults questionnaire" (RAVI). RESULTS: The studied population included 174 Caucasian subjects (60 males; 114 females), with a mean age of 73.99 years (standard deviation = 6.37; range 65-95 years). Presbylarynx was identified in 71 patients (41%). Among patients with presbylarynx, a glottal gap was identified in 22 patients (31%). The mean score of VHI-30 between "no presbylarynx" and "presbylarynx" groups was statistically different (P < 0.001), with a higher score for subjects with signs of presbylarynx. The presence of glottal gap was associated to a higher mean score of VHI-30 (41.64 ± 11.87) (P < 0.001). The mean score of VHI-10 between "no presbylarynx" and "presbylarynx" groups was statistically different (P < 0.001), with a higher score for subjects with signs of presbylarynx. Among patients with presbylarynx, the presence of glottal gap was associated to higher mean score of VHI-10 (14.04 ± 3.91) (P < 0.001). There was a strong positive correlation between VHI-30 and VHI-10 (rs = 0.969; P < 0.001). The mean score of RAVI between "no presbylarynx" and "presbylarynx" groups was statistically different (P < 0.001), with a higher score for subjects with signs of presbylarynx. Among patients with presbylarynx, the presence of glottal gap was associated to a higher mean score of RAVI (11.68 ± 1.61) (P < 0.001). There was a strong positive correlation not only between RAVI and VHI-30 (rs = 0.922; P < 0.001), but also between RAVI and VHI-10 (rs = 0.906; P < 0.001). The optimal cut-off points to discriminate "no presbylarynx" from "presbylarynx", obtained by the Youden' index, were 3.5 for RAVI, 4.5 for VHI-30 and 1.5 for VHI-10. RAVI had the highest sensitivity and specificity. The optimal cut-off points to predict glottal gap, obtained by the Youden' index, were 9.5 for RAVI, 21 for VHI-30 and 7.5 for VHI-10. CONCLUSION: The optimal cut-off points do discriminate "no presbylarynx" from "presbylarynx" were 3.5 for RAVI, 4.5 for VHI-30 and 1.5 for VHI-10. RAVI had the highest sensitivity and specificity, probably because it was designed specifically for vocal complaints of the elderly. Among patients with presbylarynx, cut-off points of 9.5 for RAVI, 21 for VHI-30 and 7.5 for VHI-10 were determined to predict patients with and without glottal gap. It was found a strong positive correlation between RAVI, VHI-30 and VHI-10. Thus, VHI-10 can be preferred to VHI-30 to assess voice impairment in clinical practice, because for elderly patients it is easier to answer. However, to predict endoscopic signs of presbylarynx, RAVI should be preferred.

Presbylarynx: Is It a Sign of the Health Status of the Elderly?

PURPOSE: Only a full understanding of how different diseases affect the same or different anatomical/functional entities, may provide a clue on how comorbidity should be taken into consideration. The aim of this study was to evaluate the chronic medical illnesses of an elderly population, in order to analyze potential correlation of specific comorbidities with presbylarynx. METHODS: This case-control, prospective, observational, and cross-sectional study was carried out on consecutive subjects observed by otorhinolaryngology, in a tertiary center, from January to September 2020. The inclusion criteria were ability to report an accurate medical history and ≥65 years of age. The exclusion criteria were neurologic diagnoses, autoimmune disease, history of thoracic or head and neck surgery, cancer, radiotherapy, thyroid pathology, vocal fold mass lesions, acute laryngitis, or vocal fold paralysis. Based on videostroboscopy of the larynx, the patients were subdivided into two main groups: presbylarynx versus no presbylarynx. Health status was assessed by evaluation of chronic medical illnesses (individual diagnoses of chronic conditions plus Charlson comorbidity index [CCI]), functional status (Katz index of independence in activities of daily living and functional Ambulation ambulation classification), and emotional status (Geriatric Depression Scale). RESULTS: A total of 174 subjects (60 males; 114 females) were included (mean age = 73.99 years; range 65-95 years). Presbylarynx was identified in 71 patients (41%). A statistically significant difference was found concerning diabetes mellitus type 2 (T2DM); P< 0.001), asthma or chronic obstructive pulmonary disease (COPD; P< 0.001), and psychiatric disorder (P< 0.001). The mean score of CCI between "presbylarynx" and "no presbylarynx" groups was statistically different (P= 0.021). Results showed an association between some functional dependence (P< 0.001), and mild or severe depression (P< 0.001) and the presence of presbylarynx. CONCLUSIONS: Presbylarynx may be considered a sign of the health status of the elderly. Based on CCI, It was found that patients with higher probability of 10-year mortality exhibit more endoscopic signs of presbylarynx. It was also found that patients with better scores in functionality scales exhibited less endoscopic findings compatible with presbylarynx. Among chronic medical illnesses, T2DM, asthma, or COPD may be considered risk factors for noticeable endoscopic signs of presbylarynx.

Impact of adenotonsillectomy in pediatric respiratory function.

INTRODUCTION: Adenotonsillar hypertrophy (ATH) is an important health condition that leads to upper airway obstruction and constitutes the main cause of obstructive sleep disordered breathing (OSDB) in children. The aim of this study was to analyze the effect of surgical intervention on spirometrical parameters of children with ATH/OSDB and upper airway recurrent infections (URTIs). MATERIAL AND METHODS: The study covered children treated surgically in a Pediatric Ambulatory Unit in a tertiary hospital. Spirometric tests were performed before and three months after surgery and results were compared. RESULTS: A total of 78 children were enrolled with a mean age of 6.95 ±â€¯2,81 years. There was a significant improvement in forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), peak expiratory flow (PEF) and forced expiratory flow rate at 25% (F25) values after surgery in children suffering from OSDB (FVC pre: 1.52 ±â€¯0.47 L vs FVC post: 1.85 ±â€¯0.63 L, p < 0.001; FEV1 pre: 1.24 ±â€¯0.38 L vs FEV1 post: 1.39 ±â€¯0.40 L, p = 0.014; PEF pre: 2.04 ±â€¯0.85 L/s vs PEF post: 2.33 ±â€¯0.76 L/s, p = 0.014; F25 pre: 1.77 ±â€¯0.77 L/s vs F25 post: 2.02 ±â€¯0.73 L/s, p = 0.030). On a multivariate analysis model, preoperative tonsil size and performing tonsillectomy were the most significant determinants of improvement in spirometric values (p < 0.05). Children with isolated adenoid hypertrophy without tonsillar obstruction and those with URTIs alone did not show relevant differences in spirometric values after surgery (p > 0.05). No significant differences were found concerning pre-operative and post-operative forced expiratory flow rate at 75% (F75) and forced expiratory flow between 25 and 75% of the pulmonary volume (FEF25-75%) in any group (p > 0.05). CONCLUSIONS: Surgery seems effective in ameliorating spirometry values in patients with OSDB and ATH, namely FVC, FEV1, PEF and F25. Spirometry may give a clue on the importance of adequate surgical resolution of pediatric lymphoid hypertrophy obstruction. No significant differences exist on spirometric parameters of children with isolated adenoid hypertrophy and URTIs without ATH. Further studies are needed in order to evaluate the potential benefit of spirometry utilization in the daily clinical setting.

Battery Ingestion in Children, an Ongoing Challenge: Recent Experience of a Tertiary Center.

Introduction: Morbidity related to childhood battery ingestions (BI) has increased recently due to the expanding use of larger lithium cells. A prompt endoscopic removal is vital to prevent severe complications in cases of esophageal batteries (EB). Materials and Methods: A retrospective, descriptive study of admissions for BI requiring endoscopic removal in a tertiary hospital's pediatric emergency department (Jan. 2011/Dec. 2020). Results: We had 35 cases, with an increasing incidence in the last 6 years; median age, 26 m (8 m-10 years), witnessed ingestion in 86%. On the X-ray: 14 (40%) had an EB, 21 (60%), a gastric battery (GB). Symptoms were present in 57% (100% EB/24% GB), and vomiting was the most frequent (50%). Endoscopy revealed: EB, 13 (37%); GB, 17 (49%); duodenal battery, 1 (3%); no battery, 4 (11%). Median time to removal: EB, 7 h (2 h-21days); GB, 12 h (2 h-3 days). All the patients with EB on the X-ray (14) had severe mucosal injury (Zargar classification): Grade IIIa, 7 (50%); IIIb, 5 (36%); IV, 2 (14%). CT-scan showed perforation in 2 patients (total, 4; 29% of EB). In patients with GB (21), 14 (67%) had mucosal damage; 13 (93%), mild (< Grade III, two esophageal erosions); 1 (7%) IIIa (esophageal ulceration). A statistically significant association between exposure time, younger age or battery size and severity of endoscopic lesions was found in EB location. There were no mortality cases. Acute complications occurred in 57% of EB: infection, 50%; perforation, 29%; pneumomediastinum/stridor, 14%; pneumothorax/subglottic stenosis/hemodynamic instability, 7 vs. 0% GB. Stenosis subsequently developed in 6 (43%) of EB: mild, 4 cases (29%); severe, 2 cases (14%, one resolved after endoscopic dilation; one needed a gastrostomy and esophagocoloplasty). Conclusion: We verified recent increase in admissions due to battery ingestions and associated complications, despite the availability of an emergency pediatric endoscopy team. The patients with EB had more severe mucosal injury and poorer short/long-term outcomes. Children with GB had milder lesions, although the presence of a GB did not exclude esophageal injury. The availability of actual data from national referral centers will support advocacy efforts among stakeholders, including industry representatives and policy makers, in preventing worldwide button battery injury.

Emergency endoscopy in pediatrics during the SARS-CoV-2 pandemic in a tertiary center - A changing pattern?

A retrospective analysis of admissions to the pediatric emergency department that required emergency endoscopy was performed, to evaluate if changes in the lifestyle and hospital practices imposed by the pandemic had an impact on the frequency and profile of the emergency endoscopy. The first 6 months of the pandemic (Group A) were compared with the homologous period of the previous year (Group B). Eight-nine cases were analyzed. Most emergency endoscopies occurred in children under the age of two (28%) and most of these were in Group A (p = 0.009). More foreign bodies were removed in Group A (p = 0.026). There were no statistically significant differences in the time to reach the emergency department (p = 0.934) or in the time delay since emergency room admission until the endoscopic procedure (p = 0.266). Overall, the pandemic did not seem to affect the quality of healthcare practice regarding emergency endoscopic procedures.

Efficacy of Exclusive Enteral Nutrition in Pediatric Crohn’s Disease

Introduction: Exclusive enteral nutrition (EEN) is recommended as first line therapy for mild to moderate Crohn’s disease (CD) to induce remission in pediatric patients. It involves the use of a whole protein formula given exclusively for six to eight weeks. Aims: To report the preliminary experience of a tertiary care center in Portugal, concerning the efficacy and tolerance of EEN in pediatric patients with CD. Materials and methods: Retrospective descriptive study of pediatric CD patients who received EEN as induction of remission therapy between January/2014 and June/2019. Clinical and laboratory parameters were assessed, including clinical disease activity and nutritional status before and immediately after treatment. Results: In the study period, 37 patients were diagnosed with CD; 19 were included in the study, 17/19 (89.5%) completed the EEN therapy and 16/17 (94%) achieved clinical remission. Ten patients were male, with a median (IQR) age of 14.2 years (11.8; 16.7 years). The majority of the patients had ileocolonic disease (47.4%) or ileocecal disease (42.1%) and an inflammatory behavior (78.9%). None of the patients had growth delay at diagnosis. All patients received EEN orally for six to eight weeks, 18 used polymeric formulas and one used an elemental formula. Comparing data at baseline and after treatment, significant improvements were observed in BMI Z-score (p=0.002), PCDAI score (p<0.001), erythrocyte sedimentation rate (p=0.002), C-reactive protein (p=0.003), faecal calprotectin concentration (p=0.036), and serum albumin (p=0.020). No side effects were noticed. Discussion/Conclusion: In this series, EEN therapy was associated to significant improvement of disease activity index, nutritional status, weight gain and decreased markers of inflammation in most patients. Our data are in accordance with previous observations that EEN is an effective and well tolerated treatment for the induction of remission in pediatric patients with CD. (AU)

Portuguese Consensus on Diagnosis, Treatment, and Management of Anemia in Pediatric Inflammatory Bowel Disease.

Anemia is a common extraintestinal manifestation of inflammatory bowel disease (IBD), both in pediatric and in adult patients. Iron deficiency is the main cause of anemia in patients with IBD. Anemia is a clinically relevant comorbidity, with impact on patients' quality of life and it should be timely diagnosed and adequately treated. Currently, an active treatment approach is the recommended strategy, with evidence showing efficacy and safety of intravenous iron formulations. However, evidence in pediatric age remains scarce and no clinical recommendations exist for the diagnosis and treatment of this particular age group. The present document represents the first national consensus on the management of anemia in pediatric IBD and is therefore particularly relevant. The authors anticipate that the proposed recommendations will be useful in daily clinical practice for diagnosing and managing iron deficiency and iron-deficiency anemia in the pediatric population with IBD.

A anemia é uma manifestação extra-digestiva frequente associada à doença inflamatória intestinal, tanto na população pediátrica como adulta, sendo a anemia por défice de ferro a sua forma mais frequente. Constitui uma comorbilidade clinicamente relevante, com repercussão na qualidade de vida. Deve ser atempadamente diagnosticada e adequadamente tratada. A estratégia terapêutica atualmente aceite preconiza uma atitude interventiva. Neste contexto, a evidência científica atual tem demonstrado a eficácia e segurança da utilização das formulações de ferro endovenoso. Contudo, em idade pediátrica a evidência ainda é insuficiente, não existindo orientações de abordagem diagnóstica ou terapêutica especificamente dirigidas a este grupo etário. Este é o primeiro consenso nacional sobre a abordagem da anemia na doença inflamatória intestinal pediátrica, revestindo-se por isso de particular relevância. Pretendese que este documento tenha utilidade e aplicabilidade na prática clínica na avaliação e seguimento do défice de ferro e anemia por défice de ferro em doentes pediátricos com doença inflamatória intestinal.

Adhesive free-standing multilayer films containing sulfated levan for biomedical applications.

This work is the first reporting the use of layer-by-layer to produce adhesive free-standing (FS) films fully produced using natural-based macromolecules: chitosan (CHI), alginate (ALG) and sulfated levan (L-S). The deposition conditions of the natural polymers were studied through zeta potential measurements and quartz crystal microbalance with dissipation monitoring analysis. The properties of the FS films were evaluated and compared with the control ones composed of only CHI and ALG in order to assess the influence of levan polysaccharide introduced in the multilayers. Tensile tests, dynamic mechanical analysis and single lap shear strength tests were performed to evaluate the mechanical properties of the prepared FS films. The presence of L-S conferred both higher tensile strength and shear strength to the developed FS membranes. The results showed an adhesion strength 4 times higher than the control (CHI/ALG) FS films demonstrating the adhesive character of the FS films containing L-S. Morphological and topography studies were carried out revealing that the crosslinking reaction granted the L-S based FS film with a higher roughness and surface homogeneity. Preliminary biological assays were performed by cultivating myoblasts cells on the surface of the produced FS films. Both crosslinked and uncrosslinked FS films containing L-S were cytocompatible and myoconductive. STATEMENT OF SIGNIFICANCE: Sutures remain as the "gold standard" for wound closure and bleeding control; however they still have limitations such as, high infection rate, inconvenience in handling, and concern over possible transmission of blood-borne disease through the use of needles. One of the challenges of tissue engineering consist on the design and development of biocompatible tissue adhesives and sealants with high adhesion properties to repair or attach devices to tissues. In this work, the introduction of sulfated levan (L-S) on multilayered free-standing membranes was proposed to confer adhesive properties. Moreover, the films were myoconductive even in the absence of crosslinking just by the presence of L-S. This study provides a promising strategy to develop biological adhesives and for cardiac tissue engineering applications.

Bioinspired Ultratough Hydrogel with Fast Recovery, Self-Healing, Injectability and Cytocompatibility.

Inspired by the mussel byssus adhesiveness, a highly hydrated polymeric structure is designed to combine, for the first time, a set of interesting features for load-bearing purposes. These characteristics include: i) a compressive strength and stiffness in the MPa range, ii) toughness and the ability to recover it upon successive cyclic loading, iii) the ability to quickly self-heal upon rupture, iv) the possibility of administration through minimally invasive techniques, such as by injection, v) the swelling ratio being adjusted to space-filling applications, and vi) cytocompatibility. Owing to these characteristics and the mild conditions employed, the encapsulation of very unstable and sensitive cargoes is possible, highlighting their potential to researchers in the biomedical field for the repair of load-bearing soft tissues, or to be used as an encapsulation platform for a variety of biological applications such as disease models for drug screening and therapies in a more realistic mechanical environment. Moreover, given the simplicity of this methodology and the enhanced mechanical performance, this strategy can be expanded to applications in other fields, such as agriculture and electronics. As such, it is anticipated that the proposed strategy will constitute a new, versatile, and cost-effective tool to produce engineered polymeric structures for both science and technology.

Pediatric Crohn's disease, iron deficiency anemia and intravenous iron treatment: a follow-up study.

BACKGROUND AND AIMS: Increasing evidence in adults demonstrates efficacy and safety of IV iron in inflammatory Bowel disease (IBD) associated iron deficiency anemia; however, evidence in pediatric patients is yet scarce and no previous study has included a long follow-up. This study aimed to evaluate safety and efficacy of IV iron (primary end point), and the need of re-treatment (secondary end point), in this setting. METHODS: Prospective recruitment (40 months); PCDAI determined before and after treatment; anemia defined according to WHO criteria; IV iron treatment included iron sucrose and ferric carboxymaltose. Primary and secondary endpoints included hemoglobin, serum ferritin, transferrin saturation at baseline and 4-6 weeks after treatment; and the need of re-treatment during the median follow-up period (18 months), respectively. RESULTS: Nineteen patients (median age: 15.5 years) with remissive/mild disease were included. At recruitment, the median hemoglobin was 10.5 g/dl, (median s-ferritin: 20.1 ug/l, median transferrin saturation; 6%) and 4-6 weeks after treatment was 12.7 g/dl. Median hemoglobin according to age groups before vs. after treatment: <12 years:11 vs. 12.0 g/dl; females ≥12 years:9.9 vs. 12.6 g/dl; and males ≥12 years:11.1 vs. 13.3 g/dl. Patients with remissive vs. mild disease had median Hb of 10.5 g/dl vs. 10.6 g/dl, and median s-ferritin: 6.8 ug/dl vs. 43.3 ug/dl, respectively). Nine patients were treated with iron sucrose (median dose 672.6 mg/dl) and 10 patients with ferric carboxymaltose (median dose 811.5 mg/dl). No major adverse reactions occurred. Six patients needed re-treatment after a median 15.5 months period. CONCLUSIONS: Our prospective study, concerning pediatric IBD anemia patients with remission/mild disease and a significant follow-up, emphasizes efficacy and safety of IV-iron and the importance of long-term follow-up of iron status. SUMMARY: In pediatric IBD iron anemia, the evidence supporting the efficacy and safety of IV-iron is scare. This prospective study aims to evaluate the safety and efficacy (short and long term) of IV-iron in these patients. Nineteen pediatric CD patients were evaluated before and after IV iron treatment (40-month period).The median Hb before and after IV iron was 10.5 and 12.7 g/dl, respectively. No major adverse reactions were documented. Six patients needed re-treatment (median period of 15.5 months). This study further demonstrates the efficacy and safety of IV iron. It reinforces the importance of long-term follow-up of the iron status in pediatric CD patients.

Surgery in Pediatric Crohn Disease: Case Series from a Single Tertiary Referral Center.

INTRODUCTION: There is a recognized increase of lifelong surgery risk in Crohn disease (CD). Outcome data concerning surgery in children, particularly in the biological era, are limited. AIM: To characterize the clinical profile and the clinical outcome in children and adolescents with CD who underwent surgical intervention, in a single tertiary referral center. METHODS: Retrospective, cross-sectional study, including pediatric patients with CD undergoing intra-abdominal surgery in the last 11 years. RESULTS: Included eight of 50 CD total patients (16%); six female; median age at CD diagnosis of 12.0 years; Paris classification: (a) location: ileocolonic (5), colonic (1), upper disease (1), ileocolonic/upper disease (1); (b) behavior: stricturing (4), nonstricturing nonpenetrating (2), penetrating (1), both penetrating and stricturing disease (1); growth delay (2). Six children received thiopurines, five mesalazine, three corticosteroids and four anti-TNF therapy, preoperatively. Surgery followed diagnosis by a median of 2.9 years. Median PCDAI at the time of surgery was 35.0. Elective surgery was performed in six patients and emergency surgery in two, without major complications. Five children received anti-TNF and three thiopurines post-operatively. Within the follow-up period (median 1.7 years), relapse occurred in one child (3.2 years after intervention); the remaining seven patients persist in clinical remission. Median PCDAI in the last evaluation was 6.3. Weight and height recovery was observed in seven patients, at last follow-up. CONCLUSION: Surgical treatment of CD is a valid alternative in selected cases, contributing to the resolution of acute complications and maintenance of remission, allowing disease-free interval and nutritional recovery.

INTRODUÇÃO: É reconhecido o risco aumentado de cirurgia ao longo da vida na população com doença de Crohn (DC). Contudo os estudos publicados em idade pediátrica são ainda escassos, particularmente na era dos biológicos. OBJETIVOS: Caraterizar o perfil evolutivo da população pediátrica com DC submetida a cirurgia num centro de referência. MÉTODOS: Estudo retrospetivo, transversal, doentes pediátricos com DC submetidos a cirurgia intra-abdominal no período de 11 anos. RESULTADOS: 8/50 doentes com DC (16%); seis raparigas; idade mediana ao diagnóstico 12,0 anos; Classificação de Paris: a) localização: ileocólica (5), cólica (1), proximal (1); ileocólica e proximal (1); b) comportamento: estenosante (4), não estenosante não penetrante (2), penetrante (1), estenosante e penetrante (1); atraso de crescimento (2); terapêutica pré-cirurgia: tiopurinas (6), mesalazina (5), corticóides (3) e agentes biológicos (4). Mediana do PCDAI à data da cirurgia 35,0. O timing cirúrgico mediano foi 2,9 anos após o diagnóstico. Foram efetuadas cirurgias eletivas em seis doentes e de emergência em dois, sem complicações. No período após cirurgia, a terapêutica de manutenção incluiu: biológicos (5) e tiopurinas (3). No período de seguimento (mediana 1,7 anos), ocorreu recidiva numa criança (3,2 anos após a intervenção); as restantes persistiram em remissão clínica; PCDAI mediano na última avaliação 6,3. Observou-se recuperação ponderal e estatural em sete doentes, na última avaliação. CONCLUSÃO: O tratamento cirúrgico da DC representa uma alternativa válida em casos selecionados, contribuindo para a resolução de complicações agudas e manutenção da remissão, permitindo um intervalo livre de doença e recuperação nutricional.