Pediatric spinal anesthesia at a tertiary care hospital: Eleven years after.

BACKGROUND: Pediatric spinal anesthesia is an old technique whose use is not widespread, in spite of reducing the risk of cardiorespiratory events (hypoxemia, bradycardia, and hypotension) associated with general anesthesia, especially in neonates and infants. This retrospective cohort study aimed to assess the safety and effectiveness of the pediatric spinal anesthesia program at our tertiary care hospital over 11 years. METHODS: Two hundred children, between 8 days and 13 years of age, who underwent lower body surgery under spinal anesthesia from May 2010 to July 2021 were included. Demographic and procedural data were collected, and success, failure, and complication rates calculated. RESULTS: The success rate was 97.5% (n = 195). The incidence of complications was 2% (n = 4). They were 2 cases of intraoperative hypoxemia and 2 cases of postoperative postdural puncture headache , and they quickly resolved with no sequelae. CONCLUSION: Pediatric spinal anesthesia is a safe and effective technique with good acceptance among anesthesiologists. Thus, the implementation of a pediatric spinal anesthesia program at a tertiary care hospital is feasible and affordable.

Strengths-Weaknesses-Opportunities-Threats Analysis for a Pediatric Anesthesia Program.

Risk management in healthcare institutions begins by first identifying the potential risks within a certain organization or specific area and then goes on to develop further strategies to reduce harm. The most common tool for this type of analysis is Strengths-Weaknesses-Opportunities-Threats (SWOT). METHODS: We conducted a SWOT analysis in our pediatric anesthesia program: key factors were identified in a matrix, prioritized in a score table, represented in a graph, and finally analyzed. RESULTS: Items obtained partial scores from 20 to 120. The item "lack of clinical protocols" was given greater weight (60) and received a lower value (1), resulting in the highest partial score (60) among the negative key factors and indicating a need for greater efforts to improve this specific aspect. CONCLUSION: The SWOT tool proved effective in identifying safety and quality key factors, and it provided information for initiating an improvement program.

La epigenética como herramienta diagnóstica y pronóstica en la estenosis pieloureteral / Epigenetics as a diagnostic and prognostic tool for pyeloureteral stenosis

Objetivo: En los últimos años, numerosos estudios se han centrado en la genética del sistema renal. Betchel et al. en 2010, demostraron como la metilación, fenómeno epigenético, estaría implicado en la perpetuación de la fibrosis. En nuestro estudio queremos demostrar si la epigenética tiene relación con la estenosis pieloureteral y en caso de ser así, si podría ser utilizada como material pronóstico y diagnóstico. Material y métodos: Se ha realizado un estudio descriptivo observacional o transversal en el que se analizó la metilación en el ADN extraído de las muestras de unión pieloureteral en pacientes pediátricos obtenidas durante la cirugía entre 1999 y 2015, resultando un total de 20 pacientes. Los datos clínicos-radiológicos se analizaron según correlación y agrupación de los mismos mediante un paquete software filogenético/estadístico denominado PHYLIP de acceso libre gratuito. Los genes seleccionados sobre los que se realizó la PCR específica de metilación (MSP) fueron: p16, RASSF1A, MGMT, Ciclina D-2, HIN-1, E-Cadherina y RASAL-1. Resultados: Los datos clínico-radiológicos analizados filogenéticamente mediante el programa PHYLIP establecieron 7 grupos de pacientes. Los resultados con respecto a la metilación mostraron una proporción considerable de metilación aberrante en la región del promotor de los genes p16 (25%), MGMT (15%), E-Cadherina (25%),HIN-1 (25%) y RASAL-1 (35%). Se analizó la asociación de los grupos clínico-radiológicos con los estados de metilación/no metilación de cada gen. Conclusiones: Se demuestra que la metilación sí tiene un papel en la fibrosis desarrollada en la estenosis pieloureteral destacando dos patrones clínicos de mal pronóstico asociados a dos clusters epigenéticos de metilación. RASAL-1, E-Cadherina, HIN-1 y p16 serían los candidatos para desarrollar estudios futuros sobre sus implicaciones pronósticas en la estenosis pieloureteral

Objective: In the last few years, numerous studies have focused on the genetics of the renal system. Betchel et al in 2010 demonstrated that methylation, as a epigenetic phenomenon, would be involved in the perpetuation of fibrosis. In our study, we want to demonstrate whether epigenetics is related to pyeloureteral stenosis and, if that is the case, if it could be used as prognostic and diagnostic biomarker. Methods: This is a descriptive observational and cross-sectional study that analyzed the methylation in DNA extracted from pyeloureteral junction samples obtained from surgery in pediatric patients in the period from 1999 to 2015, resulting in a total of 20 patients. Clinical data were analyzed using correlation tests and they were grouped with a free access software statistical phylogenetic package called PHYLIP. The selected genes for methylation-specific PCR (MSP) were the following: p16, RASSF1A, MGMT, Cyclin D-2, HIN-1, E-Cadherin and RASAL-1. Results: The clinical-radiological data analyzed phylogenetically by the PHYLIP program established 7 groups of patients. The results of methylation showed a considerable proportion of aberrant methylation in the promotor region of the genes p16 (25%), MGMT (15%), E-Cadherin (25%), HIN-1 (25%) and RASAL-1 (35%). The association of the clinical-radiological groups with methylation/non-methylation states of each gene was also analyzed. Conclusions: This study demonstrates that methylation does have a role in fibrosis developed in pyeloureteral stenosis. Two clinical patterns of poor prognosis associated with two epigenetic methylation cluster. RASAL-1, E-Cadherin, HIN-1 and p16 would be candidates for future studies on their prognostic implications in pyeloureteral stenosis

[Epigenetics as a diagnostic and prognostic tool for pyeloureteral stenosis.] / La epigenética como herramienta diagnóstica y pronóstica en la estenosis pieloureteral.

OBJECTIVE: In the last few years, numerous studies have focused on the genetics of the renal system. Betchel et al in 2010 demonstrated that methylation, as a epigenetic phenomenon, would be involved in the perpetuation of fibrosis. In our study, we want to demonstrate whether epigenetics is related to pyeloureteral stenosis and, if that is the case, if it could be used as prognostic and diagnostic biomarker. METHODS: This is a descriptive observational and cross-sectional study that analyzed the methylation in DNA extracted from pyeloureteral junction samples obtained from surgery in pediatric patients in the period from 1999 to 2015, resulting in a total of 20 patients. Clinical data were analyzed using correlation tests and they were grouped with a free access software statistical phylogenetic package called PHYLIP. The selected genes for methylation-specific PCR (MSP) were the following: p16, RASSF1A, MGMT, Cyclin D-2, HIN-1, E-Cadherin and RASAL-1. RESULTS: The clinical-radiological data analyzed phylogenetically by the PHYLIP program established 7 groups of patients. The results of methylation showed a considerable proportion of aberrant methylation in the promotor region of the genes p16 (25%), MGMT (15%), E-Cadherin (25%), HIN-1 (25%) and RASAL-1 (35%). The association of the clinical-radiological groups with methylation/non-methylation states of each gene was also analyzed. CONCLUSIONS: This study demonstrates that methylation does have a role in fibrosis developed in pyeloureteral stenosis. Two clinical patterns of poor prognosis associated with two epigenetic methylation cluster. RASAL- 1, E-Cadherin, HIN-1 and p16 would be candidates for future studies on their prognostic implications in pyeloureteral stenosis.

OBJETIVO: En los últimos años, numerosos estudios se han centrado en la genética del sistema renal. Betchel et al. en 2010, demostraron como la metilación, fenómeno epigenético, estaría implicado en la perpetuación de la fibrosis. En nuestro estudio queremos demostrar si la epigenética tiene relación con la estenosis pieloureteral y en caso de ser así, si podría ser utilizada como material pronóstico y diagnóstico. MATERIAL Y MÉTODOS: Se ha realizado un estudio descriptivo observacional o transversal en el que se analizó la metilación en el ADN extraído de las muestras de unión pieloureteral en pacientes pediátricos obtenidas durante la cirugía entre 1999 y 2015, resultando un total de 20 pacientes. Los datos clínicos-radiológicos se analizaron según correlación y agrupación de los mismos mediante un paquete software filogenético/estadístico denominado PHYLIP de acceso libre gratuito. Los genes seleccionados sobre los que se realizó la PCR específica de metilación (MSP) fueron: p16, RASSF1A, MGMT, Ciclina D-2, HIN-1, E-Cadherina y RASAL-1. RESULTADOS: Los datos clínico-radiológicos analizados filogenéticamente mediante el programa PHYLIP establecieron 7 grupos de pacientes. Los resultados con respecto a la metilación mostraron una proporción considerable de metilación aberrante en la región del promotor de los genes p16 (25%), MGMT (15%), E-Cadherina (25%),HIN-1 (25%) y RASAL-1 (35%). Se analizó la asociación de los grupos clínico-radiológicos con los estados de metilación/no metilación de cada gen. CONCLUSIONES: Se demuestra que la metilación sí tiene un papel en la fibrosis desarrollada en la estenosis pieloureteral destacando dos patrones clínicos de mal pronóstico asociados a dos clusters epigenéticos de metilación. RASAL-1, E-Cadherina, HIN-1 y p16 serían los candidatos para desarrollar estudios futuros sobre sus implicaciones pronósticas en la estenosis pieloureteral.

ANGPTL-4 is Associated with Obesity and Lipid Profile in Children and Adolescents.

Angiopoietin-like protein 4 (ANGPTL-4) regulates lipidic metabolism and affects energy homeostasis. However, its function in children with obesity remains unknown. We investigated plasma ANGPTL-4 levels in children and its relationship with body mass index (BMI) and different lipidic parameters such as free fatty acids (FFA). Plasma ANGPTL-4 levels were analyzed in two different cohorts. In the first cohort (n = 150, age 3-17 years), which included children with normal weight or obesity, we performed a cross-sectional study. In the second cohort, which included only children with obesity (n = 20, age 5-18 years) followed up for two years after an intervention for weight loss, in which we performed a longitudinal study measuring ANGPTL-4 before and after BMI-loss. In the cross-sectional study, circulating ANGPTL-4 levels were lower in children with obesity than in those with normal weight. Moreover, ANGPTL-4 presented a negative correlation with BMI, waist circumference, weight, insulin, homeostasis model assessment of insulin resistance index (HOMA index), triglycerides, and leptin, and a positive correlation with FFA and vitamin-D. In the longitudinal study, the percent change in plasma ANGPTL-4 was correlated with the percent change in FFA, total-cholesterol and high-density lipoprotein cholesterol. This study reveals a significant association of ANGPTL-4 with pediatric obesity and plasma lipid profile.

Uroguanylin Improves Leptin Responsiveness in Diet-Induced Obese Mice.

The gastrointestinal-brain axis is a key mediator of the body weight and energy homeostasis regulation. Uroguanylin (UGN) has been recently proposed to be a part of this gut-brain axis regulating food intake, body weight and energy expenditure. Expression of UGN is regulated by the nutritional status and dependent on leptin levels. However, the exact molecular mechanisms underlying this UGN-leptin metabolic regulation at a hypothalamic level still remains unclear. Using leptin resistant diet-induced obese (DIO) mice, we aimed to determine whether UGN could improve hypothalamic leptin sensitivity. The present work demonstrates that the central co-administration of UGN and leptin potentiates leptin's ability to decrease the food intake and body weight in DIO mice, and that UGN activates the hypothalamic signal transducer and activator of transcription 3 (STAT3) and phosphatidylinositide 3-kinases (PI3K) pathways. At a functional level, the blockade of PI3K, but not STAT3, blunted UGN-mediated leptin responsiveness in DIO mice. Overall, these findings indicate that UGN improves leptin sensitivity in DIO mice.

How to Manage Kidney Transplant Recipients: Deciding Between Glomerular Filtration Rate-Estimating Equations, Creatinine Clearance and Albumin-Creatinine Ratio, or Albumin Excretion.

OBJECTIVES: Management of renal transplant recipients involves measuring glomerular filtration rate and albuminuria; however, data are conflicting on the use of estimating equations or creatinine clearance and albumin-creatinine ratio in early morning urine or albumin excretion in 24-hour urine. We aimed to determine the performance of creatinine clearance and 3 estimated creatinine-based formulas and compare the usefulness of albumin-creatinine ratio related to albumin excretion in kidney transplant patients. MATERIALS AND METHODS: This cross-sectional study examined 300 consecutive kidney transplant patients. Serum creatinine was measured with Cobas-8000 and albumin-creatinine ratio, and albumin excretion was measured with Cobas-C311 (Roche Diagnostics, Hitachi, Tokyo, Japan). We quantified bias and percent bias, Bland-Altman results, and concordances in the classification of chronic kidney disease between formulas and creatinine clearance. We also conducted linear regression analyses of all parameters and for cutoffs of 30 and 300 mg/24 hours and determined the ability of albumin-creatinine ratio to predict abnormal albumin excretion (receiver operator characteristic curve analysis). RESULTS: Bias (mL/min/1.73 m2), percent bias, and concordances between creatinine clearance and Cockcroft-Gault, Modification of Diet in Renal Disease, and Chronic Kidney Disease Epidemiology Colla-boration formulas in the classification of chronic kidney disease were as follows: 15.89, 20.91%, and 0.35; 20.52, 27.89%, and 0.21; and 18.24, 25.39%, and 0.27, respectively. Regression analyses showed a weak but significantly linear relationship for the cutoff values (P < .001). Receiver operator characteristic curve analyses showed areas under the curve of 0.957 and 0.997 at cutoffs of 30 and 300 mg/24 hours. In our patients, the cutoffs were 27 mg/g (88.38% sensitivity, 92.16% specificity) and 238 mg/g (80.00% sensitivity, 97.45% specificity). CONCLUSIONS: We suggest using estimating equations and albumin-creatinine ratio with caution. In routine management of patients with successive stable revisions, we recommended using the Cockcroft-Gault or Chronic Kidney Disease Epidemiology Collaboration formulas and albumin-creatinine ratio.

Spinal Anesthesia for Pediatric Laparoscopic Hernia Repair: A Case Report.

Spinal anesthesia is practical and safe in infants and toddlers and prevents perioperative complications including cardiorespiratory instability and apnea. Other perioperative advantages include reduced time from surgery completion to operating room exit and first feed. This article presents the case of an ex-premature infant who underwent laparoscopic inguinal hernia repair under spinal anesthesia. The infant remained calm and stable throughout the uneventful procedure and postoperative period. Spinal anesthesia may be feasible for laparoscopic herniotomy when pneumoperitoneum pressure and operative time are restricted to 8 mm Hg and 60 minutes, respectively, with sensory level at T10 or higher.

Perineal groove in female infants: A case series and literature review.

BACKGROUND: Perineal groove is a rare congenital malformation that is unknown to many clinicians and is often misdiagnosed. Although it may be self-resolving during childhood, this nonepithelized mucous membrane can pose the risk of local irritation and infection, particularly urinary tract infection. METHODS: A retrospective study of female infants diagnosed with a perineal groove was performed, demographic characteristics and clinical features were analyzed, and a photographic review was conducted. RESULTS: Five patients with perineal groove were observed in our clinic in 2015-16. The mean age was 14 months. None had symptoms, and no treatment was required. During follow-up of 1 year, all remained asymptomatic. CONCLUSIONS: Our retrospective review suggests that perineal groove may be an underdiagnosed condition. Most cases resolve spontaneously, but confusion in diagnosis may lead to misdiagnosis or misinterpretation of sexual abuse and unnecessary treatments.

Neurotoxicity versus Neuroprotection of Anesthetics: Young Children on the Ropes?

Normal brain development in young children depends on a balance between excitation and inhibition of neurons, and alterations to this balance may cause apoptosis. During the perioperative period, both surgical stimuli and anesthetics can induce neurotoxicity. This article attempts to expand the perspective of a topical issue-anesthetic-induced neurotoxicity-by also considering the protective effect of general anesthetics against surgery-induced neurotoxicity, all of which may generate some controversy in the current literature. The "new" major factor influencing neurotoxicity-nociceptive stimulus-is discussed together with other factors to develop clinical and research strategies to obtain a balance between neurotoxicity and neuroprotection.

Unfavorable cytokine and adhesion molecule profiles during and after pregnancy, in women with gestational diabetes mellitus.

BACKGROUND: Gestational diabetes mellitus is a significant risk factor for metabolic syndrome and cardiovascular disease. AIMS: To assess the relationships between components of the metabolic syndrome and cytokine and adhesion molecule levels in women with GDM during pregnancy and after delivery. PATIENTS AND METHODS: A prospective case-control study on a sample of 126 pregnant women (63 with and 63 without gestational diabetes mellitus). In an intra-subject analysis, 41 women with history of gestational diabetes mellitus and 21 controls were re-assessed in the postpartum period. Clinical data and levels of cytokines and adhesion molecules were recorded during weeks 24-29 of pregnancy and 12 months after delivery. RESULTS: In the postpartum period, there were significantly higher levels of tumor necrosis factor alpha in both cases and controls, and of adiponectin in controls. Cases showed higher leptin levels, with no significant differences during and after pregnancy. No significant differences were seen in adhesion molecules and interleukin-6 between cases and controls during pregnancy and in the postpartum period, but levels of both were higher in cases. During pregnancy and after delivery, adiponectin decreased in cases and increased in controls. Significant positive correlations were seen between adiponectin and fasting blood glucose levels and vascular cell adhesion molecule-1, and also between leptin and tumor necrosis factor alpha levels. CONCLUSIONS: The results suggest that increased inflammation and transient hyperglycemia during pregnancy would represent a latent form of metabolic syndrome, with an increased risk for type 2 diabetes mellitus and future cardiovascular disease.

Magnesium sulfate in pediatric anesthesia: the Super Adjuvant.

Magnesium is an essential chemical element in all organisms, intervening in most cellular enzymatic reactions; thus, its importance in homeostasis and as a therapeutic tool in highly challenging patients such as pediatrics. The primary purpose of this paper was to review the role of magnesium sulfate as an adjuvant drug in pediatric anesthesia. This compound already has the scientific backing in certain aspects such as analgesia or muscle relaxation, but only theoretical or empirical backing in others such as organ protection or inflammation, where it seems to be promising. The multitude of potential applications in pediatric anesthesia, its high safety, and low cost make magnesium sulfate could be considered a Super Adjuvant.

A simple dressing for hypospadias surgery in children.

One of the most controversial aspects of hypospadias surgery is the election of an appropriate wound dressing. In fact, there may be as many different types of dressing as there are types of surgical repair. Here, we describe a new, simple method for hypospadias dressing in children that minimizes painful removal.

Unfavorable cytokine and adhesion molecule profiles during and after pregnancy, in women with gestational diabetes mellitus / Perfiles de citocinas y moléculas de adhesión desfavorables durante y después del embarazo en mujeres con diabetes mellitus gestacional

Background: Gestational diabetes mellitus is a significant risk factor for metabolic syndrome and cardiovascular disease. Aims: To assess the relationships between components of the metabolic syndrome and cytokine and adhesion molecule levels in women with GDM during pregnancy and after delivery. Patients and methods: A prospective case-control study on a sample of 126 pregnant women (63 with and 63 without gestational diabetes mellitus). In an intra-subject analysis, 41 women with history of gestational diabetes mellitus and 21 controls were re-assessed in the postpartum period. Clinical data and levels of cytokines and adhesion molecules were recorded during weeks 24-29 of pregnancy and 12 months after delivery. Results: In the postpartum period, there were significantly higher levels of tumor necrosis factor alpha in both cases and controls, and of adiponectin in controls. Cases showed higher leptin levels, with no significant differences during and after pregnancy. No significant differences were seen in adhesion molecules and interleukin-6 between cases and controls during pregnancy and in the postpartum period, but levels of both were higher in cases. During pregnancy and after delivery, adiponectin decreased in cases and increased in controls. Significant positive correlations were seen between adiponectin and fasting blood glucose levels and vascular cell adhesion molecule-1, and also between leptin and tumor necrosis factor alpha levels. Conclusions: The results suggest that increased inflammation and transient hyperglycemia during pregnancy would represent a latent form of metabolic syndrome, with an increased risk for type 2 diabetes mellitus and future cardiovascular disease (AU)

Antecedentes: La diabetes mellitus gestacional es un factor de riesgo importante para el síndrome metabólico y la enfermedad cardiovascular. Objetivos: Se evaluaron las relaciones entre los componentes del síndrome metabólico, los niveles de citocinas y moléculas de adhesión en mujeres con diabetes gestacional durante el embarazo y en el posparto. Pacientes y métodos: Estudio prospectivo de casos y controles. Se analizaron 126 mujeres gestantes (63 con diabetes mellitus gestacional y 63 controles). En el periodo posparto, se reevaluaron 41 casos y 21 controles. Se analizaron variables clínicas, niveles de citocinas y moléculas de adhesión durante las semanas 24-29 de la gestación y 12 meses después del parto. Resultados: En el periodo posparto, el factor de necrosis tumoral alfa en casos y controles, y la adiponectina en controles fueron significativamente más altos. Los casos mostraron mayores niveles de leptina, sin diferencias significativas durante el embarazo y después del parto. No se observaron diferencias significativas en las moléculas de adhesión y la interleucina 6 entre casos y controles durante el periodo de embarazo y el posparto, pero ambos fueron mayores en los casos. Durante el embarazo y posparto, la adiponectina disminuyó en los casos y aumentó en los controles. Observamos correlaciones positivas significativas entre adiponectina con glucemia en ayunas y moléculas de adhesión celular vascular-1, y entre leptina y factor de necrosis tumoral alfa. Conclusiones: Los resultados indican que el aumento de la inflamación y la hiperglucemia transitoria durante el embarazo representarían una forma latente de síndrome metabólico, con un mayor riesgo de diabetes mellitus tipo 2 y de enfermedad cardiovascular en el futuro (AU)

Nocturnal blood pressure is associated with the progression of microvascular complications and hypertension in patients with type 1 diabetes mellitus.

AIMS: To evaluate relationships between early alterations in blood pressure and the progression of microvascular complications of diabetes in clinically-normotensive patients with type 1 diabetes (T1DM). METHODS: In a prospective observational study of 85 normotensive T1DM patients without microalbuminuria, blood pressure (BP) was monitored over 24h using the ambulatory blood pressure monitoring (ABPM) system at baseline and 7years later. Development or progression of microalbuminuria, retinopathy and hypertension was evaluated. RESULTS: Initially, 20 patients (24%) were diagnosed with masked hypertension and 31 (37%) with non-dipper pattern as the only pathological findings. At 7years: 1) twenty-seven patients (32%) had progression of retinopathy related to the nocturnal diastolic blood pressure (BPD) (OR:1.122; p=0.034) and final non-dipper pattern (OR:5.857; p=0.005); 2) seven patients (10%) developed microalbuminuria for which nocturnal systolic blood pressure (BPS) was a risk factor (OR:1.129; p=0.007); 3) five of the normotensive patients (9%) progressed to hypertension; historic HbA1c (OR:2.767; p=0.046) and nocturnal BPD (OR:1.243; p=0.046) being the related risk factors. BPD level ≥65mmHg was associated with an increase in progression of retinopathy and hypertension. CONCLUSIONS: In T1DM patients there is an elevated prevalence of BP alterations, detected using ABPM. Alterations in nocturnal BP predispose to development/progression of microvascular complications and overt hypertension.

Lipid rescue in children: The prompt decision.

We report the case of a 17-month-old child who underwent laparotomy under general anesthesia and caudal block. Electrocardiogram ST-T changes were observed after local anesthetic injection. The prompt use of Intralipid 30% was successful in normalizing ECG alterations. Our experience is consistent with previous literature, mainly carried out in adults. Thereby, we conduct a brief review of the subject in pediatrics. As a major conclusion, we strongly recommend the "fast-track" lipid rescue as soon as this severe complication is detected.