Oxigenoterapia de alto flujo frente a ventilación no invasiva en niños con estatus asmático: estudio observacional de cohortes / High-flow oxygen therapy versus non-invasive ventilation in children with asthmatic status: observational cohort study

Introducción El objetivo de este estudio es comparar nuestra experiencia con el uso de oxigenoterapia de alto flujo (OAF) frente a la ventilación no invasiva (NIV) en niños con estatus asmático (EA). Métodos Estudio observacional de una cohorte retrospectiva de 42 niños con EA ingresados en nuestra Unidad de Cuidados Intensivos Pediátricos (UCIP) con soporte respiratorio no invasivo. El objetivo principal del estudio fue valorar el éxito/fracaso del soporte respiratorio inicial (necesidad o no de escalar a un soporte respiratorio superior). El objetivo secundario fue comparar la duración del soporte respiratorio y del ingreso en la UCIP. Resultados Cuarenta y dos niños cumplieron con los criterios de inclusión. Veinte (47,6 por ciento) fueron tratados con OAF y 22 (52,3 por ciento) con VNI como soporte respiratorio inicial. No hubo fracaso terapéutico en el grupo VNI, si bien 8 niños (40 por ciento) del grupo OAF fueron cambiados a VNI. La duración de la estancia en la UCIP y en el hospital fue similar en ambos grupos NIV y HFNC. Sin embargo, en el subgrupo de fracaso de OAF, la duración del soporte respiratorio (el triple, 63h) y la estancia en la UCIP fueron mucho mayores en comparación con los sujetos que tuvieron éxito en el tratamiento. Conclusiones Este estudio observacional, con sus evidentes limitaciones, podría sugerir que el uso de HFNC en algunos sujetos con EA puede retrasar el inicio de la VNI y potencialmente causar un soporte respiratorio más prolongado y una mayor estancia en la UCIP.

Glomeruloesclerosis nodular en un tabaquista hipertenso no-diabético con dislipidemia / Nodular glomerulosclerosis in a non-diabetic hypertensive smoker with dyslipidemia

Nodular glomerulosclerosis may be idiopathic ordevelop associated with diabetes mellitus, membranoprolipherativeglomerulonephritis, light or heavy chaindeposits, amyloidosis, fibrillary or immunotactoide disease,and Takayasu’s arteritis. Histological features ofidiopathic nodular glomerulosclerosis are similar to theKimmelstiel-Wilson changes. Recent evidence points tothe role of hyperglycemia, hyperlipidemia, hypertensionand smoking in the mechanisms of this uncommoncondition.The case study of a 65-year-old male presentingrecent arterial hypertension and nodular non-diabeticglomerulosclerosis is described, and the possible roleof heavy smoking in the pathogenesis of this conditionis emphasized (AU)

La glomeruloesclerosis nodular puede ser idiopáticao desarrollarse asociada con diabetes mellitus,glomerulonefritis membranoproliferativa, depósitosde cadenas leves o pesadas, amiloidosis, enfermedadfibrilar o inmmunotactoide, y arteritis de Takayasu. Losaspectos histológicos de la glomeruloesclerosis nodularidiopática son similares a las alteraciones de Kimmelstiel-Wilson. Recientes evidencias indican el papelde la hiperglicemia, la hiperlipidemia, la hipertensión yel tabaquismo en los mecanismos de esta entidad rara.Se presenta el estudio del caso de un hombre con65 años que presentó hipertensión arterial reciente yglomeruloesclerosis nodular no diabética, y se da énfasisal posible papel de excesivo tabaquismo en la patogénesisde esta condición (AU)

[Clinical assessment of peritoneal drainages for necrotizing enterocolitis. A Bayesian approach]. / Evaluación del drenaje peritoneal en la enterocolitis necrosante mediante metodología bayesiana.

AIM: To assess effectiveness of peritoneal drainages for necrotizing enterocolitis. MATERIAL AND METHODS: Retrospective cohort study (years 2000 to 2006). Laparotomy or patient's death were considered as failure. STUDY VARIABLES: sex, gestational age, weight at delivery, Apgar score at minutes 1 and 5, modified Bell score, radiology and ventilatory status. RESULTS: 25 patients were diagnosed with necrotizing enterocolitis and treated with peritoneal drainages. Sample's Bell score was: 13(52%) Ia, 6 (24%) IIa, 5 (20%) IIb, and 1 (4%) IIIa. Mean gestational age was 31.8 (+/- 4.2) weeks, and mean weight 1,564 (+/- 810) g. Patients classified as Bell I presented statistically significat differences compared with Bell II-III as for radiology (unspecific), delivery weight (lower) and ventilatory status (higher mechanical ventilation rates). For the 12 patients with Bell scores II-III, peritoneal drains were enough for 5 cases (41.7%) and failed in 7 (58.3%), who were operated on. Multivariate analysis (logistic regression) was not able to show any conection with collected variables. However, a bayesian analysis using data from similar studies showed that the probability for drainage success rate to be higher than 50% is 99%. CONCLUSIONS: In our centre, 52% of peritoneal drainages were used in patinets with low clinical suspect for necrotizing enetrocolitis, maybe in relation with their lower body weight and need for ventilatory support. In patients affected with necrotizing enterocolitis, drainages were effective in 41.7%. Although limited for its retrospective nature, our study suggests that peritoneal drainages can be curative in, at least, 50% of patients with necrotizing enterocolitis without pneumoperitoneum and clinical signs of peritonitis.

Evaluación del drenaje peritoneal en la enterocolitisnecrosante mediante metodología bayesiana / Clinical assessment of peritoneal drainages for necrotizing enterocolitis. A bayesian approach

Introducción: El objetivo del presente estudio es evaluar la eficacia del drenaje peritoneal para la enterocolitis necrosante en la prácticaclínica. Material y métodos: Estudio de cohorte retrospectiva (periodo2000-2006). Se consideró como fracaso del tratamiento la indicación de laparotomía o el exitus del paciente. Variables del estudio: sexo, edad gestacional, peso al nacimiento, Apgar 1 y 5, estadio de Bell modificado, patrón radiológico y tipo de ventilación. Resultados: 25 pacientes fueron diagnosticados de enterocolitisy tratados inicialmente mediante drenaje peritoneal. La distribución según estadios de Bell fue: 13 (52%) Ia, 6 (24%) IIa, 5 (20%) IIb, y 1(4%) IIIa. La media de la edad gestacional fue de 31,8 (±4,2) semanas, y la del peso 1.564 (±810) g. Los pacientes con estadio I presentaron diferencias estadísticamente significativas en cuanto al patrón radiológico (más inespecífico), peso al nacimiento (menor peso) y tipo de ventilación (mayor necesidad de soporte ventilatorio), que los pacientes con estadios II-III. En los 12 casos restantes el drenaje fue efectivo (..) (AU)

Aim: To assess effectiveness of peritoneal drainages for necrotizing enterocolitis. Material and methods: Retrospective cohort study (years 2000 to2006). Laparotomy or patient’s death were considered as failure. Study variables: sex, gestational age, weight at delivery, Apgar score at minutes 1 and 5, modified Bell score, radiology and ventilatory status. Results: 25 patients were diagnosed with necrotizing enterocolitis and treated with peritoneal drainages. Sample’s Bell score was: 13(52%)Ia, 6 (24%) IIa, 5 (20%) IIb, y 1 (4%) IIIa. Mean gestational age was31,8 (±4,2) weeks, and mean weight 1,564 (±810) g. Patients classified as Bell I presented statistically significat differences compared with BellII-III as for radiology (unspecific), delivery weight (lower) and ventilatory status (higher mechanical ventilation rates). For the 12 patients with Bell scores II-III, peritoneal drains were enough for 5 cases (41,7%)and failed in 7 (58,3%), who were operated on. Multivariate analysis(logistic regression) was not able to show any conection with collected variables. However, a bayesian analysis using data from similar studies showed that the probability for drainage success rate to be higher than 50% is 99%. Conclusions: In our centre, 52% of peritoneal drainages were used in patinets with low clinical suspect for necrotizing enetrocolitis, maybe (..) (AU)

[Evidence-based medicine in Spanish pediatric surgery reports]. / Nivel de evidencia científica en la cirugía pediátrica española.

INTRODUCTION: Pediatric surgical literature is characterized by a high prevalence of observational studies and a paucity of randomized controlled trial, comparing mainly medical therapies. AIMS: To asses scientific evidence level produced by spanish pediatric surgeons. MATERIAL AND METHODS: Articles reported in Cirugía Pediátrica, surgical reports in Anales Españoles de Pediatría, and reports from spanish authors published in the Journal of Pediatric Surgery, Pediatric Surgery International and European Journal of Pediatric Surgery, from 1997 to 2002. Internal validity was assessed through the critial guides from Sackett, and evidence level was classified through the Oxford Centre for Evidence Based Medicine classification. RESULTS: 94.5% on therapy reports, 61.5% on diagnosis, 83.3% on prognosis and 52.2% on risk factors or etiology, were classified as level 4 (descriptive studies). Only four randomized controlled trials were found, all of them comparing medical therapies (analgesia, antibiotics and surgical stress control). CONCLUSIONS: Our results are similar to those offered by previous reviews, showing up a low level of scientific evidence in most articles. Diffusion of guides on reporting descriptive studies may improve the evidence level of our reports.

Nivel de evidencia científica en la cirugía pediátrica española / Evidence-Based medicine in spanish pediatric surgery reports

Introducción. El cuerpo de la literatura en cirugía pediátrica se caracteriza por un predominio de estudios observacionales y una escasez de ensayos clínicos aleatorizados que estudian principalmente terapias médicas. Objetivo. Evaluar el nivel de evidencia científica producido en nuestro medio. Material y métodos. Artículos publicados en la revista Cirugía Pediátrica, artículos sobre cirugía publicados en Anales Españoles de Pediatría, así como los publicados por autores españoles en Journal of Pediatric Surgery, Pediatric Surgery International y European Journal of Pediatric Surgery en el período entre 1997 y 2002. Se utilizaron las guías de lectura crítica de Sackett para evaluar la validez interna y la clasificación de niveles de evidencia del Centro de Medicina Basada en la Evidencia de la Universidad de Oxford. Resultados. El 94,5% de los artículos sobre terapia, el 61,5% sobre pruebas diagnósticas, el 83,3% sobre pronóstico y el 52,2% sobre factores de riesgo o etiología presentaron un nivel de evidencia 4, equivalente a estudios descriptivos. Se hallaron únicamente 4 ensayos clínicos aleatorizados, todos comparando terapias médicas (antibioterapia, analgesia y control del estrés quirúrgico). Conclusión. Los resultados son similares a los ofrecidos por revisiones sobre revistas anglosajonas, destacando el bajo nivel de evidencia científica de la mayoría de los artículos. La difusión de guías para la comunicación de estudios descriptivos puede mejorar el nivel de evidencia de los mismos (AU)

Introduction. Pediatric surgical literature is characterized by a high prevalence of observational studies and a paucity of randomized controlled trial, comparing mainly medical therapies. Aims. To asses scientific evidence level produced by spanish pediatric surgeons. Material and methods. Articles reported in Cirugía Pediátrica, surgical reports in Anales Españoles de Pediatría, and reports from spanish authors published in the Journal of Pediatric Surgery, Pediatric Surgery International and European Journal of Pediatric Surgery, from 1997 to 2002. Internal validity was assessed through the critial guides from Sackett, and evidence level was classified through the Oxford Centre for Evidence Based Medicine classification. Results. 94.5% on therapy reports, 61.5% on diagnosis, 83.3% on prognosis and 52.2% on risk factors or etiology, were classified as level 4 (descriptive studies). Only four randomized controlled trials were found, all of them comparing medical therapies (analgesia, antibiotics and surgical stress control). Conclusions. Our results are similar to those offered by previous reviews , showing up a low level of scientific evidence in most articles. Diffusion of guides on reporting descriptive studies may improve the evidence level of our reports (AU)

Avoiding hypothermia in trauma: use of the flameless heater pack, meal ready to eat, as a field-expedient means of warming crystalloid fluid.

Forward-deployed medical units do not have the capability to warm intravenous (i.v.) fluids before their administration. We intend to demonstrate a field-expedient means of warming i.v. fluids and preventing hypothermia using the flameless heater available in the Meal, Ready to Eat (MRE). Room-temperature and refrigerated lactated Ringer's solution were organized into three data collection groups using either one or two MRE heaters. The temperature change of the fluid was recorded. Average temperature increases ranged from 15.8 to 31.2 degrees C in times ranging from 8 to 20 minutes. Therefore, we conclude that the flameless MRE heater provides a simple, field-expedient means of warming i.v. fluids before their administration.

Isolated splenic metastasis from colorectal carcinoma: report of a case and review of the literature.

In general, surgical resection for metastatic colorectal adenocarcinoma rarely benefits more than a small percentage of patients long term. In the case of isolated splenic metastasis without evidence of other metastatic disease, splenectomy may increase survival times in patients with previously resected colorectal adenocarcinoma. Currently there are only five case reports involving isolated splenic metastases in the English-language literature. This article presents a sixth case and a review of the previous five cases in the literature, with a discussion on the possible diagnostic and therapeutic approaches to these rare but important cases and the apparently significant survival advantage of early diagnosis and treatment.

Surgical debridement and intralesional steroid injection in the treatment of idiopathic AIDS-related anal ulcerations.

BACKGROUND: The treatment of idiopathic anal ulcerations in AIDS patients is still evolving. These patients suffer with severe incapacitating anal pain. PATIENTS AND METHODS: Relief of pain was achieved with the use of intralesional steroid injections. Twenty-one patients from 1990 to 1993 presented with severe anal pain of 4.5 months average durations (range 3 weeks to 2 years). The average CD4 count was 52.1 (range 0 to 150). Fourteen (67%) patients had a solitary ulcer, while 7 (33%) had complex ulcerations. RESULTS: All patients were treated by debridement of the ulcer, biopsy, and intralesional injection of steroids. Microscopic evaluation revealed nonspecific inflammatory changes, without histopathologic evidence of viral infection or malignancy. Viral tissue cultures were negative. Fifty-seven percent of patients required only one injection to achieve dramatic relief of pain. Forty-three percent necessitated additional injections at 2-week intervals. The average patient was injected 1.9 times (range 1 to 7), with 20 of 21 patients (95%) reporting good to excellent pain relief. CONCLUSION: AIDS anal ulcerations should be treated aggressively with surgical debridement, biopsy and intralesional steroids. The efficacy of this therapy suggests that symptoms are partially due to inflammatory mediators.

[Acute epiglottitis caused by Haemophilus influenzae type b in children: presentation of 21 cases]. / Epiglotitis aguda por Haemophilus influenzae tipo b en niños: presentación de 21 casos.

BACKGROUND: The aim of this paper is to review the epidemiological, clinical and therapeutical characteristics of Haemophilus influenzae type b (Hib) epiglottitis in children at a time when an efficient and safe vaccination is available. METHODS: The clinical histories of 21 children admitted to Children's Hospital La Fe (1971-1996) with a clinical diagnosis of epiglottitis and isolation of the microorganism in blood cultures (20 cases) and surface culture of the epiglotis (one case) are reviewed. RESULTS: The annual average was 4/100,000 children under 5 years of age. Evolution prior to diagnosis was > 12 hours in 52.4% of the cases. More males were affected (52.4% vs 47.6%). All the children except one (95.2%) were under 5 years of age; 81% were under 3 years of age and 1 child was 6 years and 8 months old. Respiratory distress (100%) and fever > or = 38 degrees C (85.7%) were the most common clinical manifestations. General health was affected in 71.4% of the cases and 66.7% had leucocytosis on admission. The clinical diagnosis was confirmed by direct visualization of the epiglotis in 76.1% of the cases. Hib was isolated in blood culture in 20 cases (95.2%). The strains produced beta-lactamases and were ampicillin-resistant in 57.1%. 19 children (90.5%) required endotracheal intubation. Initial empiric antibiotic therapy was third generation cephalosporins (cefotaxime or ceftriaxone) alone or combined with ampicillin. One child died (4.8%). CONCLUSIONS: Pediatricians must still be aware of this serious infection in order to diagnosis and treat it as early as possible.

The crochet hook method of stab avulsion phlebectomy for varicose veins.

Excision of varicose veins through ministab incisions is currently the choice for the removal of varicose vein clusters. The crochet hook technique of stab avulsion phlebectomy is described in this paper. This surgical method for the treatment of varicose veins has been widely utilized in a residency training environment during the last twelve years and has been used by the senior author for more than 20 years. The technique is easily mastered, cost effective, and has excellent therapeutic and cosmetic results.

Sexually transmitted diseases and anal manifestations of AIDS.

During the past 20 years, there has been an increased use of the anorectum for erotic pleasure. Consequently, this has led to an overwhelming rise in sexually transmitted diseases (STDs) of the anus and rectum. It is important that surgeons involved with the care of colon and rectal disorders be familiar with each of these diseases. The recent AIDS epidemic has been a challenge to the medical community. Equally as challenging is the management of common anorectal disorders in the AIDS patient. AIDS not only influences the manner in which STDs present but is associated with its own spectrum of anorectal disorders. Discussion and management of STDs and anorectal disorders of AIDS patients are presented.

Laparoscopic gastrostomy using four-point fixation.

Percutaneous endoscopic gastrostomy (PEG) has become an effective alternative to surgical gastrostomy in patients who require enteral access or gastric decompression. Technical considerations, however, limit the application of PEG in selected patients and those who have contraindications to PEG. Laparoscopic gastrostomy tube placement has been introduced as an alternative to PEG. A technique for laparoscopic gastrostomy tube placement that emphasizes four-point fixation of the anterior gastric wall is presented.

A mass casualty while in garrison during Operation Desert Storm.

In the theater of operations, rear echelon hospitals by doctrine receive patients who have been stabilized by forward hospitals. Occasionally, mass casualties will occur in the rear area, but rarely from combat causes. This report documents a mass casualty occurring in garrison from an anti-tank weapon misfiring. All rear echelon hospitals, regardless of their mission, must be prepared for the acute care of combat mass casualties.