[Unusual presentation of juvenile idiopathic arthritis and autoimmune hepatitis]. / Infrecuente presentación de artritis idiopática juvenil y hepatitis autoinmune.

The coexistence of autoimmune hepatitis and juvenile idiopathic arthritis is very rare. This is the case of an 18 month old female patient whose first sign of disease was torticollis due to an underlying atlanto-axial subluxation. Three months later, bilateral knee arthritis developed and she was diagnosed with Juvenile Idiopathic Arthritis. Throughout the disease a persistent elevation of liver enzymes was noted, combined with positive antinuclear antibodies and hypergammaglobulinemia, reaching the diagnosis of concomitant autoimmune hepatitis.

Hormonal response to surgical stress in schoolchildren.

PURPOSE: To determine hormone concentrations (ACTH, cortisol, beta-endorphin) in children before and after surgery, to assess the correlation between any hormonal changes and to study the influence exercised on them by the severity of surgical stress and the elective/emergency nature of the surgery. PATIENTS AND METHODS: Prospective cohort of 78 children (age= 10+/-2.6 years, range 6-13 years) undergoing elective or emergency surgery. Preoperative and postoperative (1 and 24 hours postoperation) plasma concentrations of ACTH, cortisol and beta-endorphin were determined in all children. The severity of surgical stress was evaluated as low (< 6) or high (> 6) according to the Oxford scale. Student's t-test was used to analyse hormonal changes and the influence of degree of surgical stress and elective/emergency character of the surgery, and Pearson's coefficient for correlations between hormonal values. p < 0.05 was regarded as significant. RESULTS: We observed a significant increase in hormonal concentrations one hour after surgery. ACTH and cortisol values normalised 24 hours after surgery, but beta-endorphin concentrations remained increased. There was a correlation between ACTH and beta-endorphin values both before surgery and one hour after. Operations with high surgical stress significantly increased cortisol concentrations one hour after surgery and beta-endorphin concentrations 24 hours after surgery. Patients selected for emergency surgery showed significantly higher concentrations of cortisol and ACTH both before and after surgery. CONCLUSIONS: Postoperative hormonal response among children of school age is characterised by increases in ACTH, cortisol and beta-endorphin one hour after surgery, and by high concentrations of beta-endorphin 24 hours after surgery. Cortisol is an index of surgical stress. Emergency surgery is associated with significant increases in ACTH and cortisol.

Estrés quirúrgico y activación hipófiso-suprarrenal en edad pediátrica / Surgical stress and hipophysal-suprarrenal, activation in the paediatric age

Introducción. El estudio de las alteraciones fisiológicas secundarias a la agresión quirúrgica (estrés quirúrgico), ampliamente desarrollado en pacientes adultos, se halla aún por delimitar con precisión en la edad pediátrica. El objetivo del presente trabajo de investigación es la cuantificación del estrés quirúrgico en niños (evaluado según la escala de Oxford en bajolalto en valores inferiores o superiores a 6) mediante las modificaciones de los niveles plasmáticos de hormona adrenocorticotropa (ACTH),13-endorfina y cortisol en niños. Pacientes y métodos. Estudio observaeional analítico tipo cohorte prospectiva con comparación interna de grupos expuestos. Treinta y tres pacientes sometidos a intervención quirúrgica (edad 10 ñ 2,6; rango 514). Variables resultado: concentraciones plasmáticas de ACTH,13-endorfina y cortisol determinadas pre y postoperatoriamente (1 y 24 horas tras la intervención), mediante técnicas de radioinmunoanálisis. Resultados. Elevación significativa (p < 0,05) a la hora de la intervención de las tres hormonas consideradas con descenso a valores preoperatorios a las 24 horas de la intervención. Relación significativa de la concentración de la beta-endorrma (a la hora 24 postoperación) y del cortisol (una hora postoperación), con el grado de estrés quirúrgico. Conclusiones. La cirugía en el niño activa el eje hipófiso-suprarrenal, recuperando la normalidad precozmente a las 24 horas de la intervención. Existe un patrón específico de comportamiento de la f3-endorfina, pudiéndose afirmar que ésta es una 'hormona de estrés' en cuanto que refleja el impacto de la agresión quirúrgica. El cortisol se muestra como índice fiable de la cuantía del estrés quirúrgico (AU)

[Surgical stress and hypophyseal-adrenal activation in childhood]. / Estrés quirúrgico y activación hipófiso-suprarrenal en edad pediátrica.

INTRODUCTION: The study on the physiological alterations due to surgical aggression (surgical stress), widely investigated in adults, is less known in paediatric age. THE OBJECTIVE: Of this work is to quantify surgical stress (evaluated by means of Oxford Scale as high or low depending on its value bigger or lower than 6), after determining changes of plasmatic concentrations of ACTH, beta-endorphin and cortisol in operated children. PATIENTS AND METHODS: Observational analytic design of a prospective cohort with internal comparison of the groups. SAMPLE SIZE: 33 (age 10 +/- 2.6 years; range 5 to 14 years). DEPENDENT VARIABLES: plasmatic concentrations of ACTH, beta-endorphin and cortisol determined before and after the intervention (1 and 24 hours after surgery), by radio-immune-analysis. RESULTS: Significative increase of the three considered hormones one hour after surgery, with decrease of them until preoperative levels 24 hours later. Significative correlation between beta-endorphin (24 hours after surgery), cortisol (1 hour after surgery) and surgical stress levels. CONCLUSIONS: Surgery in children provokes the activation of hipophysal-suprarrenal system. These levels early came back to normal ones, 24 hours after surgery. There is a specific change in beta-endorphin, that is why it is possible to assure that beta-endorphin is a "stress-hormone", since it is affected by surgical aggression. Cortisol seems to be a good index of level of surgical stress.

[Hormonal response and two special techniques of postoperative analgesia in pediatric surgery]. / Respuesta hormonal con dos técnicas distintas de analgesia postoperatoria en cirugía pediátrica.

AIMS: We studied neuroendocrine response in the postoperative pain relief in pediatric patients treated with two analgesic techniques (conventional intravenous analgesia and patient controlled analgesia). MATERIAL AND METHODS: A double blind study was made in 30 patients, 6-14 year-old children, under total intravenous anesthesia for programmed surgery. An intravenous analgesia dose of 0.5 mg/Kg was given 10 minutes before operation was finished. Postoperative analgesia was achieved by two techniques: A. Patient controlled analgesia (PCA), and B. Conventional intravenous analgesia every 6 hours. Hormones measurements were made (catecholamines, cortisol, ACTH and beta-endorphin), hemodynamic monitoring (blood pressure and heart rate), and pain measurement (Hannallah's score) in both pre and postoperative times (1, 6 and 24 hours after operation). RESULTS: Pain score was low and without significant differences in both groups (p > 0.05). beta-endorphin level decreased in both groups, and a cortisol and catecholamine level increase was noticed at 6 hours after operation; these changes were less significant in PCA group (p < 0.001). ACTH level did not change significantly in both groups. Hemodynamic monitoring measurements were not significantly different. CONCLUSIONS: Both analgesic techniques were appropriate to postoperative pain relief in pediatric patients. Low pain score shows better conditions to attend these patients. We suggest PCA technique is better to treat postoperative stress response following pediatric surgery.