Frostbite in the Pediatric Population: A Comprehensive Review and a Prospective Canadian Survey

INTRODUCTION

Frostbite in the pediatric population, where skeletal maturity has not been achieved, can have important repercussions on subsequent growth. Yet, the optimal management of frostbite injuries in children remains vague. This review aims to summarize the current evidence for frostbite management in children and understand Canadian practice trends on this topic.

METHODS

A review using Medline, Scopus, Web of Science, and gray literature was performed to identify relevant literature on the clinical manifestations, diagnostic methods, and treatment options in pediatric frostbite. An online survey was sent to plastic surgeons through the Canadian Society of Plastic Surgeons (CSPS) mailing list to further identify national practices and trends for pediatric frostbite management.

RESULTS

A total of 109 articles were reviewed. No article provided a specific algorithm for pediatric frostbite, with existing recommendations suggesting the use of adult guidelines for treating children. Our survey yielded 9 responses and highlighted the rarity of pediatric frostbite cases, with no responder treating more than 10 cases per year. Most (55.6%) do not use a pediatric-specific treatment algorithm, whereas 30% apply adult guidelines. A conservative approach focusing on rewarming (55.6%), limb elevation (50%), and tetanus status verification (66.7%) was predominant. Imaging and surgical interventions seem to be reserved for severe cases.

CONCLUSIONS

The current literature for pediatric frostbite management lacks specificity. Canadian practices vary, with a trend toward a conservative approach. The limited evidence and rarity of experience highlight the need for further research, ideally in a collaborative multicentric manner, to create a consensus for pediatric frostbite care.

Multi-Modality Imaging of Atheromatous Plaques in Peripheral Arterial Disease: Integrating Molecular and Imaging Markers

Peripheral artery disease (PAD) is a common and debilitating condition characterized by the narrowing of the limb arteries, primarily due to atherosclerosis. Non-invasive multi-modality imaging approaches using computed tomography (CT), magnetic resonance imaging (MRI), and nuclear imaging have emerged as valuable tools for assessing PAD atheromatous plaques and vessel walls. This review provides an overview of these different imaging techniques, their advantages, limitations, and recent advancements. In addition, this review highlights the importance of molecular markers, including those related to inflammation, endothelial dysfunction, and oxidative stress, in PAD pathophysiology. The potential of integrating molecular and imaging markers for an improved understanding of PAD is also discussed. Despite the promise of this integrative approach, there remain several challenges, including technical limitations in imaging modalities and the need for novel molecular marker discovery and validation. Addressing these challenges and embracing future directions in the field will be essential for maximizing the potential of molecular and imaging markers for improving PAD patient outcomes.

Incidence of contrast-induced nephropathy after a computed tomography scan

BACKGROUND AND AIMS

The term contrast-induced nephropathy is used to describe acute deterioration of renal function after the intravenous administration of iodinated contrast material. We aimed to estimate the incidence of contrast-induced nephropathy and to analyze the evolution of different biomarkers of renal function in patients who underwent computed tomography with intravenous contrast administration after premedication with oral hydration and N-acetylcysteine.

MATERIAL AND METHODS

This prospective observational study included 112 patients with chronic renal failure (glomerular filtration rate (GFR) 30ml-60ml/min/1.73m²) scheduled for computed tomography with intravenous iodinated contrast material. We recorded demographic variables, dose of contrast material, diabetes mellitus, hypertension, and serum hemoglobin. We measured serum creatinine and GFR after premedication and after the CT examination. We summarized variables as means, standard deviations, and percentages. We used the Wilcoxon and Mann-Whitney tests to compare pre- and post-CT values and Pearson's r to analyze correlations.

RESULTS

Incidence acute kidney injury: 0.9%; 95%CI: 0.36-1.4. Mean difference between pre- and post-CT creatinine: 0.04; 95%CI: 0.002-0.09, p<0.004. Mean difference between pre- and post-CT GFR: -3.06; 95%CI: -4.66 to -1.47), p<0.001.

CONCLUSIONS

The incidence of contrast-induced nephropathy in patients with chronic renal failure and GFR 30ml-60ml/min/1.73m² is low. The biomarkers of renal function analyzed improve in patients who receive premedication and the minimum dose of contrast material.

Are patients with mild to moderate renal impairment on metformin or other oral anti-hyperglycaemic agents at increased risk of contrast-induced nephropathy and metabolic acidosis after radiocontrast exposure?

AIM

To investigate whether the use of metformin during computed tomography (CT) with radiocontrast agents increases the risk of contrast-induced nephropathy (CIN) and metabolic acidosis after CT in type 2 diabetes patients with mild to moderate renal failure.

MATERIALS AND METHODS

Patient records from January 2015 to December 2017 were reviewed retrospectively. A total of 374 patients were included in the final analysis. Of them, 157 patients received metformin, and 217 patients were taking other oral hypoglycaemic agents (OHAs) during radiocontrast administration.

RESULTS

No significant difference in CIN incidence was observed between the metformin use group and the other OHAs group (p=0.085). Metabolic acidosis after CT was seen in 91 (58%) patients who used metformin and 141 (65%) patients who were taking other OHAs. There was no relationship between metabolic acidosis after CT and the use of metformin (p=0.195). Metabolic acidosis after radiocontrast agent exposure was associated with malignant disease, low serum albumin level, and low serum total CO₂ level at baseline.

CONCLUSION

These data show that other factors, but not metformin use, are associated with metabolic acidosis after radiocontrast agent exposure in patients with reduced renal function. These data support current recommendations that there is no need to discontinue metformin before CT using radiocontrast agents in patients with mild to moderate renal failure.

Acute effects of Iodixanol on renal function after intra-arterial administration in patients with end-stage kidney disease

BACKGROUND

Contrast-induced acute kidney injury (CI-AKI), a potentially life-threatening complication of iodinated contrast media in patients with impaired renal function, has attracted increasing attention in recent years. There is overwhelming evidence that the most important pre-disposing factor for a contrast-medium induced nephropathy is the pre-existence of a renal impairment.

METHODS

The registry was performed as a part of a quality management project in the Dresden-Friedrichstadt heart catheter laboratory. In compliance with the Declaration of Helsinki/Somerset West, 9,026 patients were included between 2010 and 2015. 100 patients of these were participants in a chronic dialysis program. All patients were dialyzed on the day before angiography. In all patients a coronary angiography, in 28 patients a stent implantation and in 12 patients a surgical reconstruction had to be performed. Prior to the intervention and one, two and three days thereafter the serum creatinine was measured.

RESULTS

Up to the third day after application of the iodinated contrast medium no significant changes of the serum creatinine (baseline value: 423.3±42.6μmol/l) occurred (ANOVA for repeated measures: p = 0.507). On average, a slight decrease of the serum creatinine was found.All patients remained in their routine dialysis-program. 18 out of 100 died during the next three months after the procedure.

CONCLUSION

The study revealed that the coronary angiography using Iodixanol as iodinated contrast medium did not result in an increase of serum creatinine, which was drastically elevated in these patients before application of the iodinated contrast medium.

Comparative Efficacy of Statins for Prevention of Contrast-Induced Acute Kidney Injury in Patients With Chronic Kidney Disease: A Network Meta-Analysis

Contrast-induced acute kidney injury (CI-AKI) is a common complication of iodinated contrast medium administration during cardiac catheterization. Statin treatment has been shown to be associated with reduced risk of CI-AKI; however, the results are inconsistent, especially for patients with chronic kidney disease (CKD). Thus, we conducted a network meta-analysis to evaluate the effects of statins in the prevention of CI-AKI. We systematically searched several databases (including, Embase, PubMed, the Cochrane Library, and ClinicalTrials.gov ) from inception to January 31, 2018. The primary outcome was occurrence of CI-AKI in patients with CKD undergoing cardiac catheterization. Both pairwise and network meta-analysis were performed. Finally, 21 randomized controlled trials with a total of 6385 patients were included. Results showed that statin loading before contrast administration was associated with a significantly reduced risk of CI-AKI in patients with CKD undergoing cardiac catheterization (odds ratio: 0.46; P < .05). Atorvastatin and rosuvastatin administered at high dose may be the most effective treatments to reduce incidence of CI-AKI, with no difference between these 2 agents.