Working status of Spanish pediatric surgeons

OBJECTIVE

To analyze work, demographic, and social parameters in order to learn about the working status of pediatric surgeons in Spain.

MATERIAL AND METHODS

A survey inspired in job satisfaction models and designed by the authors was performed. It was an observational, descriptive, cross-border online survey intended for pediatric surgeons from the Spanish Society of Pediatric Surgery (SECIPE).

RESULTS

Of the 290 SECIPE pediatric surgeons, 133 responded to the survey (45.8% response rate), of whom 49.6% were 30-39 years old. The number of male and female respondents was virtually the same. 69% of respondents devoted 75-100% of their working hours to healthcare, 89.4% devoted 0-25% to research, and 80% devoted 0-25% to teaching. The survey demonstrated job satisfaction in terms of colleagues, healthcare role, professional development expectations, and social consideration. However, respondents showed disconformity with their pay, the time devoted to research and teaching, and their relationship with the executive board.

CONCLUSION

This study sheds light on the Spanish professionals' working status, which can help identify measures for improvement. The survey shows widespread disconformity with the short time devoted to research, and little satisfaction with teaching. Most of the working hours are devoted to clinical practice, with poor pay satisfaction, which can contribute to dissatisfaction in the development of healthcare activity.

Buccal dental-microwear and feeding ecology of Early Pleistocene Theropithecus oswaldi from Cueva Victoria (Spain)

Despite the scarcity of fossil specimens of Theropithecus oswaldi in Eurasia, its presence out of Africa attests to the great dispersal of this Papionini genus during the Early Pleistocene. In the present study, we analyze the buccal dental microwear of T. oswaldi (T. o. leakeyi) fossil specimens from Cueva Victoria (Southeastern Spain). This analysis is the first characterization of the feeding ecology of T. oswaldi in Europe. The buccal microwear pattern of the molar and premolar teeth of T. oswaldi from Cueva Victoria shows great similarities to that observed for the extant frugivorous forest-dwelling Mandrillus sphinx and mangabeys (Cercocebus sp.)-both species adapted to durophagous dietary habits-while significantly different from that observed for the gramnivorous Theropithecus gelada. These results suggest that T. oswaldi from Cueva Victoria could have exploited both hard-shelled fruits or seeds and succulent fruits from open and forested Mediterranean ecosystems.

Efficacy of endoscopic removal in the treatment of subglottic ductal cysts

INTRODUCTION

Subglottic cyst is a rare cause of airway obstruction, and there is a lack of evidence about the best treatment in the literature. This report describes our experience with endoscopic removal.

MATERIAL AND METHODS

A retrospective study of all patients undergoing endoscopic removal of subglottic cyst at our healthcare facility between 2014 and 2019 was performed. Clinic and demographic data regarding gestational age, intubation, comorbidities, surgical procedures, first symptoms, endoscopic findings, treatment, and follow-up were collected.

RESULTS

Four patients were identified. Two out of four (50%) were preterm, and all patients were intubated during their neonatal period. Median age and weight at diagnosis were 6.5 months (6-8) and 5.9 kg (3.6-7). Median time between last intubation and diagnosis was 119.5 days (71-171). Biphasic stridor and progressive respiratory distress were the most common clinical symptoms. Airway obstruction of at least 50% was found during upper airway endoscopy in all patients. Endoscopic removal was performed as a first-line treatment in 3 patients, and as a second-line treatment in 1 patient. Median intubation time after treatment and hospital stay were 13.5 hours (0-48) and 7 days (6-9). All four patients are free of disease, with a median follow-up of 17.5 months (6-42).

CONCLUSION

Subglottic cyst is a rare cause of post-extubation stridor. Endoscopic removal seems to be a feasible and effective treatment with a low recurrence rate.

[Neutrophil-to-lymphocyte ratio as a predictor of peritonitis in acute appendicitis in children]

AIM OF THE STUDY

The neutrophil-to-lymphocyte ratio (NLR) has been postulated as an inflammatory marker in several abdominal pathologies such as acute appendicitis (AA). However, there are few studies that determine its association with the degree of severity of AA. This is the first study that analyzes the usefulness of NLR as a predictor of peritonitis in children with AA.

METHODS

Retrospective observational study in patients treated of AA during the years 2017 and 2018. They were divided into two groups according to the intraoperative diagnosis (uncomplicated AA and AA with peritonitis). Demographic and analytical variables were analyzed. The NLR was defined as the quotient between the absolute values of neutrophils and lymphocytes. The sensitivity and specificity for the diagnosis of peritonitis of different analytical parameters were determined by ROC curves.

RESULTS

A total of 398 patients were included (uncomplicated AA n=342 and AA with peritonitis n=56), with a mean age of 10.5±2.9 years. The NLR had an area under the curve (AUC) of 0.78, significantly higher than the determination of leukocytes (AUC 0.71, p=0.002) and of neutrophils (AUC 0.74, p=0.009). No differences were observed when compared to the determination of C-reactive protein (AUC 0.79, p=0.598). A cut-off point of NLR>8.75 was estimated with a sensitivity and specificity of 75.0 and 72.2% respectively.

CONCLUSIONS

The NLR is a useful tool to predict the presence of peritonitis in AA, and could be considered an alternative to other higher cost determinations such as C-reactive protein.

[Inferior vena cava compression in children with pectus excavatum]

INTRODUCTION

In severe cases of pectus excavatum (PE) the sternal depression may cause distortion of the cardiac chambers and great vessels. The aim of our study was to determine if the sternal impingement causes significant inferior vena cava (IVC) compression.

METHODS

Retrospective study of patients with severe PE assessed between 2015-2017. The antero-posterior (AP) and transverse diameters of the suprahepatic IVC were measured on a cardiac-MRI at the level of the diaphragmatic hiatus. Results were compared with patients that had a thoracic image study performed for other causes, adjusting for age and sex.

RESULTS

Among the 81 patients, 28 cases and 53 controls, 63% were males and had a mean age of 12.9±0.5 yrs. Significant differences were found between groups in both AP and transverse diameter of the IVC: 13.3±0.75 mm vs. 15.8±0.76 mm (p=0.001) and 28.8±1.34 mm vs. 27.1±0.89mm (p=0.045) respectively. After adjusting for age and sex, these differences were only statistically significant for AP IVC diameter in males 12.7±0.5 mm (95% CI 11.66-13.79 mm) vs. 16.6±0.5 mm (95% CI 15.69-17.56 mm) (p=0.000). The Pearson correlation coefficient for the Haller index was r=0.471 (p=0.01).

CONCLUSION

Male patients with severe sternal depression show changes in the IVC diameter that may correspond to compression. These changes are correlated with the severity of the deformity and can justify certain clinical symptoms and cardiac function abnormalities in patients with severe PE.

[Intranodal lymphangiography in pediatric chylothorax, a diagnostic and therapeutic tool]

INTRODUCTION

High morbidity has been described in secondary chylothorax. Thoracic duct embolization (TDE) after intranodal lymphangiography (IL) is one of the treatments in adults but there is poor experience in children. We aim to describe our experience with this technique for refractory pediatric chylothorax.

METHODS

A retrospective study of patients with refractory chylothorax treated with thoracic duct embolization at our Institution in the last 4 years was performed. Lymphatic vessels visualization was obtained by intranodal lymphangiography with ethiodized oil. Demographic and clinical data as well as imaging findings were collected.

RESULTS

A total of 4 patients were treated during the study period with a median of age and weight of 2.5 months (1-16) and 4.25 kg (2.8-10) respectively. Chylothorax was secondary to cardiothoracic surgery in 3 patients and to venous thrombosis in the other one. Medical treatment was provided during a median of 47 days (13-56) without benefit in thoracic output [median: 46 ml/kg/day (19-64)]. After IL, thoracic duct catheterization was achieved in one patient however embolization was not possible. Chylothorax stopped in the 3 post-surgical patients regardless of how much lymphatic visualization was achieved in IL. In the venous thrombosis patient surgical treatment was performed 6 days after the study.

CONCLUSION

IL can be a diagnostic and therapeutic tool in children. Ethiodized oil seems to seal lymphatic leak in postsurgical chylothorax. IL could be an option for chylothorax in patients too sick for surgical treatment or in whom thoracic duct embolization is not feasible.

[Study of pulmonary hypertension and long-term respiratory clinic in children with congenital diaphragmatic hernia]

INTRODUCTION AND OBJECTIVES

The aim of this study is to identify respiratory clinic and pulmonary arterial hypertension (PAH) in congenital diaphragmatic hernia (CDH) and whether these could be predicted by prenatal measures.

MATERIAL AND METHODS

We studied fetal ultrasound: Observed/expected Lung to Head Ratio (O/E LHR) and classified patients according to their outcome (group 1: O/E LHR <25%, group 2: 26-35%, group 3: 36-45%, group 4: >55%) as well as the severity of PAH (group 0: non-PAH, group 1: mild, group 2: moderate, group 3: severe) in echocardiograms at birth, 1st, 6th, 12th and 24 months of life. We also evaluated gestational age, weight, bronchodilator treatment and number of hospital admissions.

RESULTS

58 patients with CDH, 13 without prenatal diagnosis. 36 patients out of 45 had O/E LHR calculated at 22.4 ± 5.8 weeks. O/E LHR had significant association with the severity of PAH at birth and in the 1st, 6th, 12th and 24th months (p <0.05). At 6 months, only 30.4% had PAH without any association with a higher risk of hospital admission [OR 1.07 (0.11-10.1)] and only three patients (5.1%) required bronchodilator treatment.

CONCLUSION

In CDH, PAH and the respiratory clinic improve over time, being uncommon the need for treatment as of the 6th month. O/E LHR predicts the presence and severity of PAH in short and long term.

[Perinatal factors for necrotizing enterocolitis (NEC). A case-control study]

AIM OF THE STUDY

The aim of this study is to identify potential perinatal risk or protective factors associated with NEC.

MATERIALS AND METHODS

Single-center, retrospective case-control study of newborns admitted to the neonatal intensive care unit with NEC from 2014 to 2015. Clinical charts were reviewed recording maternal factors (fever, positive recto-vaginal swab and signs of corioamnionitis or fetal distress), and neonatal factors analyzed were: birth-weight and weeks gestation, umbilical vessel catheterization, time of enteral feedings and the use of probiotics, antibiotics and antifungal agents. Cases and controls were matched for all of these factors. Parametric tests were used for statistical analysis and p < 0.05 deemed significant.

RESULTS

We analyzed 500 newborns of which 44 developed NEC (cases) and 456 controls. Univariate analysis did not identify any maternal risk factors for NEC. We did not found statistical differences between patients either time of enteral feedings or probiotics. Nevertheless, patients with signs of fetal distress and early sepsis had a higher risk of NEC (p < 0.0001).

CONCLUSIONS

Infants with history of fetal distress and signs of early sepsis are at a higher risk of NEC. The use of prophylactic catheter infection or orotracheal intubation with antifungal treatment seemed to elevate the incidence of NEC. However, antibiotic treatment couldn´t be demonstrated to increase the risk of NEC.

[Pulmonary lobectomy in children: the sooner the better?]

AIM OF THE STUDY

Recommendation of early pulmonary resection in asymptomatic congenital pulmonary airway malformations (CPAMs) is based on the presumed compensatory lung growth during the first months of life. Our aim is to analyze the long-term pulmonary function after lobectomy before and after one year of age using spirometry.

METHODS

We performed a retrospective review of children who underwent pulmonary lobectomy for CPAM between 2001 and 2016. Patients who were old enough (>5 years) to carry out a spirometry were included in the study and were divided into 2 groups (surgery before or after 12 months of age). Pulmonary function testing values were considered normal if they were >80% of predicted.

MAIN RESULTS

Forty-seven patients underwent pulmonary lobectomy for CPAM, 23 of them met the inclusion criteria and prospectively performed a spirometry. Among them, 7 had surgery before and 16 after one year of age (0.1 vs. 2); being both groups comparable in terms of sex, type of CPAM and surgical approach. Time from surgery until pulmonary function testing was longer in patients who had surgery before one year of age (9.1 vs. 4.6 years, p = 0.003). After correcting results by time from surgery until spirometry, a better FEV1/FVC was found in patients who had surgery after one year of age (90% vs. 77%, p = 0.043).

CONCLUSION

Although spirometry may be influenced by many other variables, these preliminary results do not support the current recommendation of performing early lobectomy in CPAMs. Further studies are required in order to resolve the best age to perform pulmonary lobectomy.

[Risk factors associated with the development of enterocolitis in Hirschsprung's disease]

OBJECTIVES

Hirschsprung's-associated enterocolitis (HAEC) is a live-threatening complication that remains badly understood. Our objective is to identify the risk factors related to the development of HAEC in the cohort of patients with Hirschsprung's disease (HD) treated in our center.

METHODS

We reviewed the patients treated for HD between 2000 and 2016. Ninety four patients were included, and the clinical details related to the disease were evaluated. Our primary outcome measure was the development of HAEC. Relative risks are presented with 95% confidence intervals.

RESULTS

Twenty seven patients out of the ninety four (28.7%) suffered HAEC. None of them died from this complication. The extended aganglionosis, the need of a preoperative stoma, a transabdominal surgery and the diagnosis before the age of 7.2 months were related to a higher risk of suffering HAEC.

CONCLUSIONS

HAEC remains a common complication in patients suffering from HD, especially those with complex forms. The identification of the risk factors could result in a better control of the HAEC, which lead to a faster diagnosis and treatment, reducing the morbi-mortality related to HAEC.

[Mesenteric edema as a prenatal ultrasound sign of poor prognosis in gastroschisis]

INTRODUCTION/AIM OF THE STUDY

Gastroschisis is a congenital malformation with an easy and early prenatal diagnosis, however, it has a variable post-natal outcome. Our aim was to determine if certain ultrasound markers or early delivery were related with a worse postnatal outcome.

PATIENTS AND METHODS

Retrospective study of a cohort of patients with gastroschisis diagnosed between 2005-2014, with emphasis on prenatal ultrasounds, gestational age at delivery and post-natal outcome. Oligohydramnios, peel, mesenteric edema, fixed and dilated bowel with loss of peristalsis and small wall defect were considered ultrasonographic markers associated with poor prognosis. Outcome variables included: length-of-stay, complications, nutritional and respiratory factors. Non-parametric statistical analysis were used with p < 0,05 regarded as significant.

RESULTS

Clinical charts of 30 patients with gastroschisis were reviewed (17M/13F). Gestational age at diagnosis was 20 (12-31) and at delivery 36 (31-39) weeks (33% of the patients over 36+3 weeks). A 73% of the patients presented at least one ultrasonographic marker factor during follow-up. Univariate analysis showed that mesenteric edema was associated with poor outcome variables: short-bowel syndrome (p= 0,000), PN-dependence (p= 0,007) and intestinal atresia (p= 0,02). The remaining risk factors analysed, including late delivery (> 36+3 weeks) were not associated with length-of-stay, ventilatory support, digestive autonomy, complications or mortality.

CONCLUSIONS

Neither the presence of ultrasonographic markers classically associated with unfavorable outcomes, nor early delivery (< 36 weeks) resulted in worse postnatal outcome. Mesenteric edema was the only alarming ultrasound marker and that may suggest the need of closer follow-up.

[Benefits of magnetic resonance for the study of pectus excavatum in children: initial experience]

INTRODUCTION/AIM OF THE STUDY

In patients with PE, cardiovascular alterations ensue as a result of the mediastinum compression caused by sternum impingement and is responsible of many of the symptoms. Anatomical and functional assessment is of the utmost importance for a comprehensive understanding of the disease and an adequate treatment plan. Our aim was to describe the use of magnetic resonance image (MRI) in the study of PE and whether it is comparable to imaging techniques.

PATIENTS AND METHODS

A retrospective study of the first 10 patients in which an MRI was performed as part of PE assessment within august 2015-2016. PE indexes were evaluated: Haller, correction, asymmetry, as well as sternal rotation. An analysis of right ventricular function was carried out comparing echocardiogram and MRI.

RESULTS

MRI scan on 10 patients showed the following findings: Haller index: inspiration: 3.75 (3.5-7.3) and expiration 4,9 (3.9-10.8), correction index of 24% (5-37%) and a sternal rotation of 12º (0-31º). The cardiovascular study showed a median ejection fraction of the right ventricle (EFRV) of 50% (38-64%), with 9 of the 10 patients under the normal value of 61% (54-71%). Echocardiographic findings underestimated functional alterations in all of the patients.

CONCLUSION

This initial study suggests that the use of MRI as a test of choice in the evaluation of PE subject to surgical correction is feasible. Absence of radiation offers the capacity of a complete and dynamic anatomical as well as cardiovascular study.

[Negative pressure system in the treatment of enterocutaneous fistulas in the pediatric population]

AIM OF THE STUDY

The management of children with enterocutaneous fistulas (EF) along with large abdominal wall defects secondary to multiple surgical interventions can be difficult and sometimes lead to intestinal failure (IF). The aim of this study is to present the results of negative pressure systems and their properties (edema reduction angiogenesis promotion and granulation tissue formation) in children with enterocutaneous fistulas (EF) and their prognosis.

MATERIALS AND METHODS

A retrospective analysis of children with refractory, high output EF treated with NPS between 2008-2014. Outcome variables were duration and effectiveness of treatment as well as complications associated with NPS.

RESULTS

Eight patients met inclusion criteria and were treated with NPS during a median of 25 days (range 5-50). The aetiologies were volvulus (2), necrotizing enterocolitis (2), gastroschisis (2), Blue Rubber Bleb Nevus (1) and duodenopancreatic anastomosis fistula following hepatopancreatic transplantation (1). Most patients (n=7) had large abdominal wall defects that closed during treatment, though two patients required further laparotomies due to evisceration. Two patients developed a second EF that was also successfully treated with NPS. No complications were identified arising from the use of NPS. After a 5-yr follow up 3 patients had a multivisceral transplantation and survive, and 4 died due to encephalopathy (1), hemolytic anemia (1), catheter-related sepsis (1) and one while waiting for a multivisceral graft for transplantation.

CONCLUSIONS

Despite of a limited series of patients we recommend NPS as a useful tool in the management of EF and/ or abdominal wall defects.

[Growth in children with choledochal cyst]

AIM

In patients with a choledochal cyst, the malformation and subsequent biliodigestive reconstruction lead to a non-physiological state in the digestive tract and biliary excretion that could affect the child's growth. The effect of this malformation and its surgical treatment are reviewed here in a large patient cohort.

MATERIAL AND METHODS

Retrospective review of patients undergoing surgery for choledochal cyst in the last 20 years. Nutrition and liver function parameters, weight and height data were collected from medical records. Patients presenting other serious diseases affecting growth were excluded.

RESULTS

From 1994-2014 forty-five patients were diagnosed for choledochal cyst (75% female). All underwent cyst resection followed by Roux-en-Y hepaticojejunostomy. Eight patients were excluded for comorbidities and 37 selected for the study, with a median age at diagnosis and surgery of 16 (0-120) and 24 (1-149) months, respectively. The median follow-up was 76 (1-215) months. At diagnosis, 10.8% of patients had low weight, which was entirely resolved within 6 months after surgery (p< 0.05).

CONCLUSIONS

The choledochal cyst induces a situation of moderate malnutrition in around 10% of the patients. Surgical correction quickly reverses this situation, despite the decreased absorption surface and deviation of biliary secretion to the jejunum instead of the duodenum.

[Intussusception: hospital admission for risk of recurrence or early discharge?]

INTRODUCTION/PURPOSE

There is current debate about the need of hospitalization of patients with enema-reduced intussusception. The purpose of this study is to describe intussusception recurrence in a tertiary care children's hospital in order to evaluate the feasibility of ambulatory treatment.

PATIENTS AND METHODS

Retrospective review of children diagnosed with intussusception from January 2009 to December 2013, identifying early recurrences as those that occurred between 12-72 hours after successful enema reduction and comparing the results with current literature.

RESULTS

A total of 121 children (77 male - 44 female), with a mean age of 18,9±2,7 months and weight of 10,77±0,57 kg (CI 95%) were treated for intussusception. Enema reduction was attempted in 90,7% (n= 88) of the cases, with a success rate of 76,1% (n= 67). Early recurrence rate was 6% (n= 4), without associated complications, which is similar to recent meta-analysis results (5,4%); however, three patients required surgical exploration. Mean length of stay was 2 days for enema-reduced intussusception, which resulted in a total cost of 2,076.67 euro per patient.

CONCLUSION

The low recurrence rate and scarce risk of complications suggests that an 8 to 12 hour observation is a feasible alternative to hospital admission, which results in social advantages including family welfare as well as management costs. These results are a starting point for prospective randomized controlled trials comparing both treatment modalities.

[Gynecological abnormalities in patients with rectovestibular fistula]

Patients with recto vestibular fistula may have gynecological malformations that could be unnoticed at the initial examination. The aim of this paper is to demonstrate the incidence of these malformations and propose a study method to help diagnose these malformations, avoiding unnecessary surgeries. We reviewed the records of patients treated with rectovaginal fistula (RVF) in the last 18 years and studied their gynecological malformations, time at diagnosis and treatment received. Of the 39 patients treated, 5 of them (13.1%) demonstrated 9 gynecological malformations: Hemivaginas (2), hemiuteros (2), uterine agenesis (2), vaginal agenesis (2) and vaginal septum (1). The diagnosis was made after the posterior sagittal approach (PSA) in two patients (acute abdomen and hydrometrocolpos), during the PSA in 2 patients and only one of them was diagnosed before the PSA. The 2 patients with hemivaginas and hemiuterus underwent a hemihysterosalpinguectomy and a vaginoplasty later in adolescence. The patient with vaginal and uterine agenesis diagnosed prior to PSA underwent a posterior sagittal anorectoplasty and a vaginoplasty with colon in the same procedure. The patient with vaginal and uterine agenesis (age 13 months) is waiting for vaginal replacement. The patient with vaginal septum (intraoperative finding) underwent a septum resection during the PSA. Gynecological defects are part of RVF spectrum. Girls with RVF require a complete gynecological examination prior to the definitive repair. Preoperative examinations assist in the timing and type of repair, and ultimately avoids complications and unnecessary interventions.

[Primary versus secondary closure: ventilatory and nutritional differences in patients with gastrosquisis]

AIM OF THE STUDY

Optimal surgical treatment of patients with gastroschisis remains controversial. Recent studies suggest better outcomes with secondary closure techniques (surgical or preformed silo). The purpose of the study is to identify differences in outcome of infants treated with traditional primary closure (PC) versus surgical silo (SS).

PATIENTS AND METHODS

Retrospective study of patients primarily treated of gastroschisis between 2004 and 2014. Patients were divided in PC and SS according to abdominal wall closure. Non-parametric statistical analysis was used with p< 0.05 regarded as significant.

RESULTS

Twenty-seven patients were included (14M/13F). Primary closure was performed on 17 and 10 underwent surgical silo placement with a median of 6 (5-26) days till secondary closure. Prenatal diagnosis was available in most patients (74%) by the 20th week of gestation. There were no significant differences regarding sex, gestational age or birthweight between groups. Fewer ventilation days were required in PC group compared to SS (4 vs 13, p< 0,05), however, there was no difference in type of ventilation or oxygen needs. Sedation and parenteral nutrition requirements were also lower in PC patients 4 vs 10 and 12 vs 20 days respectively (p< 0,05). Post-operative complications (5vs6) and median length of stay (36vs43 days) were also similar in PC and SS patients. One patient ultimately died due to catheter-related sepsis. Mean length of stay in hospital was 42 days (20-195).

CONCLUSION

Patients with gastroschisis who underwent primary closure showed shorter ventilator support and PN dependency than those treated with surgical silo. However, SS is as safe and effective technique as PC and led to similar outcome regarding digestive autonomy and hospital length of stay.

[Participatory design guide for mental health promotion in prisons]

OBJECTIVE

[corrected] The main aim was to describe the issues and the participatory process required to design a Guide to promotemental health in prison through group activities.

MATERIAL AND METHOD

We reviewed the bibliography, the mental health policies, the workshops about healthy mental habits, and a video about protection and risk factors. We identified the stakeholders and sought their points of view about the topics included in the Guide. We decided on the contents of the Guide and the incorporation of the health assets model and the perspectives provided by gender and cultural diversity. After the initial design of the modules and sessions, we started a pilot in the Prison of Valencia and the Prison of Zaragoza with women and men from different cultures, incorporating the suggested improvements, unifying contents and the discursive style.

RESULTS

The guide is formed by: a preface, introduction, description, modules, sessions and evaluation. It has 6 modules and 19 sessions on: health and motivation; self-esteem; health and emotions; more assets to improve health: relax, positive thinking, keeping calm, communication and problem resolution; progress is possible: resiliency and starring in my own change. Each session consists of: activities (objectives, material, allocated time and development), theoretical material and tabbed sheets for activities. The guide is available in print and online versions.

CONCLUSIONS

A guide has been elaborated with involved stakeholders and the opinion of the prison population.

Mortality in patients with dementia treated with atypical antipsychotics (olanzapine, quetiapine and ziprasidone)

INTRODUCTION

The atypical antipsychotics (AA) quetiapine, olanzapine and ziprasidone are used to treat behavioural disorders associated with dementia. This indication does not appear on their technical sheet. The object of this study is to analyse the relationship of these treatments with mortality and other factors.

METHOD

Retrospective study from March 2005 to July 2007 of AA treatments requested as compassionate use. We collected information on mortality, age, history of heart disease or cerebrovascular disease, and duration and number of concomitant treatments per patient.

RESULTS

289 patients were studied. Mortality was 31.1%. A higher mortality rate was shown for patients with a history of heart disease and in those who used olanzapine. Quetiapine was the most commonly prescribed antipsychotic drug.

CONCLUSIONS

The use of AA in the elderly could have risks that outweigh the benefits. When prescribing these drugs for at-risk patients, one should consider their safety warnings and the individual case of each patient. According to our data, olanzapine seems to be associated with a higher risk than quetiapine and ziprasidone.

A geometric morphometric analysis of hominin upper first molar shape

Recent studies have revealed interesting differences in upper first molar morphology across the hominin fossil record, particularly significant between H. sapiens and H. neanderthalensis. Usually these analyses have been performed by means of classic morphometric methods, including the measurement of relative cusp areas or the angles defined between cusps. Although these studies have provided valuable information for the morphological characterization of some hominin species, we believe that the analysis of this particular tooth could be more conclusive for taxonomic assignment. In this study, we have applied geometric morphometric methods to explore the morphological variability of the upper first molar (M(1)) across the human fossil record. Our emphasis focuses on the study of the phenetic relationships among the European middle Pleistocene populations (designated as H. heidelbergensis) with H. neanderthalensis and H. sapiens, but the inclusion of Australopithecus and early Homo specimens has helped us to assess the polarity of the observed traits. H. neanderthalensis presents a unique morphology characterized by a relatively distal displacement of the lingual cusps and protrusion in the external outline of a large and bulging hypocone. This morphology can be found in a less pronounced degree in the European early and middle Pleistocene populations, and reaches its maximum expression with the H. neanderthalensis lineage. In contrast, modern humans retain the primitive morphology with a square occlusal polygon associated with a round external outline.

Error rates in buccal-dental microwear quantification using scanning electron microscopy

Dental microwear, usually analyzed using scanning electron microscopy (SEM) techniques, is a good indicator of the abrasive potential of past human population diets. Scanning electron microscopy secondary electrons provide excellent images of dental enamel relief for characterizing striation density, average length, and orientation. However, methodological standardization is required for interobserver comparisons since semiautomatic counting procedures are still used for micrograph characterization. The analysis of normally distributed variables allows the characterization of small interpopulation differences. However, the interobserver error rates associated with SEM experience and the degree of expertise in measuring striations are critical to population dietary interpretation. The interobserver comparisons made here clearly indicate that the precision of SEM buccal microwear measurements depends heavily on variable definition and the researcher's expertise. Moreover, error rates are not the only concern for dental microwear research. Low error rates do not guarantee that all researchers are measuring the same magnitudes of the variables considered. The results obtained show that researchers tend to maintain high intrapopulation homogeneity and low measurement error rates, whereas significant interobserver differences appear. Such differences are due to a differential interpretation of SEM microwear features and variable definitions that require detailed and precise agreement among researchers. The substitution of semiautomatic with fully automated procedures will completely avoid interobserver error rate differences.

[In vitro activity of azithromycin against clinical isolates of Acinetobacter baumannii]

The activity of azithromycin against 225 clinical strains of Acinetobacter baumannii isolated consecutively from 26 Spanish hospitals in November 2000 was studied. The MICs of azithromycin were determined by microdilution, according to the NCCLS guidelines. The bactericidal activity of azithromycin against 15 clonally unrelated A. baumannii strains with different antimicrobial susceptibility patterns was tested using the subculture method. The killing-curves method was also performed against five strains with different susceptibility to azithromycin. The MIC(50) and MIC(90) of azithromycin were 32 and 64 mg/l, respectively. Moderate bactericidal activity was observed in 14 out of the 15 strains evaluated by the subculture method (MBCs from 1 to 4 dilution steps higher than the MICs) and by the killing-curve method. For three strains the number of CFU/ml was reduced 1 to 1.4 log by concentrations of azithromycin equivalent to 1 and 4 times their MICs. lt is concluded that azithromycin has moderate bactericidal activity against the strains of A. baumannii evaluated.

[Heterogenicity of Gorham-Stout syndrome: association with lymphatic and venous malformations]

INTRODUCTION

Gorham-Stout syndrome is a rare disorder of unknown etiology characterized by osteolysis and microscopic proliferation of abnormal vessels. We report two cases of this syndrome associated with lymphatic and venous malformations.

CASE REPORTS

The first case is a 5-year-old boy with disseminated lymphangiomatosis of poor prognosis, with significant pleural involvement and osteolytic lesions. The second case is a 5-year-old girl with a diagnosis of Klippel-Trenaunay syndrome with significant skeletal involvement of the lower extremities and secondary pathological fracture.

CONCLUSIONS

Gorham-Stout syndrome may occasionally be associated with various lymphatic and venous malformations. Osteolysis and bone resorption may be induced by lymphatic bone involvement.

[Scientific evidence in the endoscopic treatment of the vesico-ureteral reflux]

The way used by physicians to obtain information from scientific research may have low-quality, with effects on assistance. Evidence-based medicine became necessary due to the exponential growing produced in the published research.

OBJECTIVES

1. To establish the scientific goodness of published papers on endoscopic treatment of vesicoureteral reflux. 2. To quantify the quality level of the papers by means of a series of explicit criteria.

MATERIAL AND METHODS

Work type: Bibliometric revision. Databases: Revision of the electronic bases: Medline, ACP Journal Bandolier, Cochrane Collaboration and Pediatric Evidence Based Medicine.

INCLUSION CRITERIA

Papers on endoscopic treatment of primary reflux in children. Evaluation criteria: 1. Scientific level: Evidence classification proposed by Goodman, describing 10 levels from 1 (high) to 10 (low) and the Agency of Evaluation of Technology (AET) describing 9 levels. 2. Quality level: Dichotomic characters referred to the presence or absence of: experimental design, objectives, result measurement and concordance of methods and conclusion with the objectives.

RESULTS

114 papers were found and analyzed 1. Evidence level: 86.9% of papers showed a low level of evidence by Goodman score (level 9) whereas 90.4% presented level 8 of AET. 79.5% of papers were consecutive series of clinical cases, 9% were non-critical bibliographic revisions, 1.7% were cohorts works, 5.3% non-randomized clinical trials and only 1 paper was a randomized clinical trial. 2. Quality level: 61.4% did not explicit the objectives and 57% did not expose the design. The population was not defined in 68.4% of papers and the way to appreciate the results in 73.7%. The experimental design, in 57.9% of works, and the conclusions, in 64.9%, did not concordate with the objectives.

CONCLUSIONS

Endoscopic treatment of vesicoureteral reflux is becoming more popular. However, its effectiveness has to be proved by means of solid scientific bases, for works referring to it have low methodological level and low quality.

[Bladder augmentation in reconstruction of the urinary tract (1985-1997)]

Bladder augmentation with intestinal or urinary segments has virtually replaced other treatments in the management of both neuropathic and no neuropathic bladder dysfunction that has not responded to pharmacotherapy nor other intervention. We present herein our experience in 55 patients who underwent augmentation cystoplasty. Their mean age were 12.2 years (range 2.5-22.8) and the mean follow-up time was 4 years (1-13.1). They were divided in three groups according to the diagnosis: vesical or cloacal exstrophy (14 patients), neuropathic bladder (36) and posterior urethral valves (5 patients). Indications were: 1) to get a low pressure, high volume reservoir and avoid upper urinary tract damage in low-compliance bladders (41 patients); 2) as an undiversion (8 patients), and 3) prior to renal transplantation. Cystoplasty was performed with bowel segments in 47 cases and ureter in 8, adding some other urological procedures in 22 patients. Mean bladder capacity after 1 year was 400 ml versus 112 as previous value. 52 out of the 55 patients are continent after augmentation. There was no impairment of the renal function in the 5 patients with prior renal failure who underwent cystoplasty. Vesicoureteral reflux disappeared in 78.6% of the patients after cystoplasty. The complications were urinary stones in 5 cases, upper urinary tract infections in 3, and spontaneous bladder perforation in 1 patient. Augmentation cystoplasty is the best choice to achieve a low pressure reservoir, to assure contingency and to avoid progressive damage of the upper urinary tract in neuropathic or no neuropathic pediatric bladder dysfunctions.

Characterization of a maize heat-shock protein 101 gene, HSP101, encoding a ClpB/Hsp100 protein homologue

Heat shock protein 101 (HSP101) cDNA and genomic clones from maize have been isolated. The structure of maize HSP101 reveals the presence of six exons interrupted by five introns. Maize HSP101 contains a predicted open reading frame that translates into a 912-aa sequence with a mass of 101kDa. Initiation of transcription was mapped 146 bases upstream of the AUG codon. Five heat shock element (HSE) boxes were found within the proximal 289 bases of the promoter region. Southern blot analysis of genomic DNA indicates that the maize genome contains only one copy of HSP101. A protein sequence comparison showed that maize Hsp101 belongs to the heat shock 100kDa and caseino-lytic protease B protein family (Hsp100/ClpB) that plays important roles in bacteria and yeast in the survival to extremely high temperatures and the control of proteolysis. Accumulation of HSP101 mRNA was strong under heat shock conditions, but not detectable after cold or osmotic stress treatments or by exogenous application of ABA. The analysis of the predicted supersecondary structure of maize Hsp101 showed that a coiled-coil located in the middle region of the protein is evolutionarily conserved in all members of the Clp A, B and C subfamilies. It is proposed that these supersecondary structures may have important roles in Clp function.

[Diagnosis and therapeutic options in chronic idiopathic intestinal pseudo-obstruction: review of 16 cases]

Chronic idiopathic intestinal pseudo-obstruction (CIPS) is a rare condition in which there is a defective motility of the gastrointestinal tract of unknown cause leading to repeated bouts of intestinal obstruction without organic explanation. This syndrome groups several ill-defined varieties of motor disorders that can sometimes be classified according to the presence of familial incidence and to the presence of muscular or nervous lesions. Nevertheless, a considerable proportion of cases cannot be ascribed to either type. CIPS is a very difficult challenge for pediatric surgeons because our role is never curative and because when we are involved in it is usually as a result of a false diagnosis. We present herein the experience of 2 Pediatric Surgery Departments in this entity. In the last 30 years we have been involved in the management of 16 children with CIPS. Male-to-female ratio was 5:11 and all but 3 patients had symptoms before 6 months of life. Thirteen had abdominal distension, 10 maldevelopment, 9 recurrent bouts of intestinal obstruction, 8 chronic diarrhea, 7 vomiting, 2 dysphagia and 2 constipation. Seven out of the 16 had urinary tract involvement and in three prenatal diagnosis of megacysts was made. The mean delayed time for diagnosis was 3.08 years. Esophageal or antroduodenal manometry was performed in 8 patients and it was abnormal in 7. Histologic and histochemical samples were available in 8 patients, but only in 4 was enough to make a diagnosis of myopathy. Twelve patients underwent 41 surgical procedures. Three are currently included in a program of home parenteral nutrition. Only three have died, and the mean age of the survivors is 13.9 years. In most of the patients with CIPS surgery is only useful for nutritional purposes, for diversion procedures or for intestinal transplantation in extreme cases. Every effort should be made to avoid unnecessary explorations, misdiagnosis and delay in the identification of the syndrome.

[Neutropenic enterocolitis in children with cancer]

OBJECTIVES

Neuropenic enterocolitis (NEC) is a destructive lesion of the ileocecal region occurring in cancer patients treated with chemotherapy. Its clinical picture is one of febrile acute abdominal extension with bloody diarrhea and low neutrophil counts. Our aim was to determine the incidence of NEC in children with cancer and to review the indications of surgery in these cases.

MATERIAL AND METHODS

The records of children with cancer treated with chemotherapy in the last 6 years at Hospital Infantile La Paz were reviewed. We selected those patients who had abdominal pain and neutropenia and whose physical examination and radiological findings were consistent with NEC.

RESULTS

Twelve cases of NEC were diagnosed during this period among 432 malignancies. The symptoms most frequently seen were abdominal pain and distension, nausea and vomiting. The neutrophil count was consistently below 500/ml. All patients were receiving chemotherapy before the onset of the clinical picture. Five children were operated upon. In three of these we found various ileocecal perforations, in one a gastric perforation and in the remaining one a diffuse inflammation of the ileocecal area. Two non-operated patients died from NEC. The remaining children recovered without problems with medical therapy.

CONCLUSION

Pediatric surgeons treating neutropenic cancer patients should be familiar with this condition, that must be suspected early in granulocytopenic patients with acute abdominal extension. Aggressive surgical management is indicated in cases with severe peritonitis, bowel perforation or massive lower gastrointestinal bleeding, irrespective of the degree of neutropenia. Medical support should aim at reestablishing normal neutrophil counts.

Regulation of ammonium ion assimilation enzymes in Neurospora crassa nit-2 and ms-5 mutant strains

In Neurospora crassa the nit-2 and nmr-1 (ms-5) loci represent the major control genes encoding regulatory proteins that allow the coordinated expression of various systems involved with the utilization of a secondary nitrogen source. In this paper we examined the effect of the nit-2 and ms-5 (nmr-1 locus) mutations on the regulation of the ammonium assimilation enzymes, glutamine synthetase and glutamate dehydrogenase, which are regulated by the products of these genes; however, glutamate synthase is not so regulated. Glutamine synthetase and glutamate dehydrogenase levels are also regulated by the amino nitrogen content. We present evidence that the ms-5 and glnr strains, which behave very similarly in their resistance to glutamine repression, are different and map in different loci.

Effect of polyurethane catheters and bacterial biofilms on the in-vitro activity of antimicrobials against Staphylococcus epidermidis

The effect of two polyurethane ['Cavafix Certo' (CAV); 'Viacath' (VIA)] catheters on the in-vitro activity of amikacin (AN), clindamycin (CM), cloxacillin (CX), ciprofloxacin (CIP), vancomycin (VA), teicoplanin (TEI) and daptomycin (DAP) against slime producing and non-producing Staphylococcus epidermidis strains was determined using a microdilution assay. None of the antimicrobial agents was significantly affected in the presence of the catheters. The susceptibility of S. epidermidis attached to CAV and VIA catheters was also evaluated. Minimum inhibitory concentration (MIC) values were similar when planktonic and attached bacteria were compared. Minimum bactericidal concentrations (MBCs) markedly increased in the presence of 6 and 48 h bacterial biofilms. These increases in MBC values occurred when either slime producing or non-producing strains were used, and in most cases were higher for CAV catheters than for VIA catheters. This phenomenon was shown not to be due to differences in bacterial adherence. It is concluded that the in-vitro bactericidal activity of certain antimicrobials markedly decreased when bacteria adhered to plastic catheters, but this effect could have been dependent partially on the nature of the catheters.

[Surface microscopic patterns of an experimental model of surgically induced carcinogenesis]

An experimental model of carcinogenesis is developed by authors, using internal urinary diversion in Wistar rats. Results show the transformation of normal digestive pattern, discovering proliferative-inflammatory changes at the first time which after go to an histiotypical tumorous pattern. They conclude at the carcinogenicity of the presented surgical model and is described the evolution of the superficial morphological pattern during the tumorigenic process.

[Obstacle removal syndrome in the postoperative period of obstructive uropathy]

Eighty patients to operated upon secondary hidronephrosis to pieloureteral or ureterovesical stenosis are studied. Diary diuresis and excretion of sodium of the operated kidney and the healthy kidney are valorated. We analyse the differences between age groups, grade of parenquima afectation or kind of pathology that cause the obstruction. Results show that the desobstruction of the urinary tract is accompanied by a increase of diuresis (p less than 0.001) and by a lost of sodium (p less than 0.001) in the operated kidney. Poliury is bigger in neonatal period than in other age groups.

Effect of amoxycillin and clavulanic acid, alone and in combination, on human polymorphonuclear leukocyte function against Staphylococcus aureus

The effect of amoxycillin and clavulanic acid on the interaction in vitro of human polymorphonuclear leukocytes with Staphylococcus aureus was examined. The exposure of a non-penicillinase producing Staphylococcus aureus strain to one-fourth the MIC of amoxycillin or clavulanic acid alone significantly increased the uptake of both unopsonized and opsonized bacteria by human polymorphonuclear leukocytes. This effect was also observed when bacteria were exposed to one-fourth the MIC of different proportions of the combination of amoxycillin and clavulanic acid (4/1, 1/1, 1/8 and 1/32). When a penicillinase-producing Staphylococcus aureus strain was used, only clavulanic acid significantly increased the uptake of unopsonized bacteria. The production of superoxide radicals by human polymorphonuclear leukocytes was impaired only by the presence of high concentrations (100 mg/l) of both clavulanic acid or the combination amoxycillin/clavulanic acid (4/1). At this high concentration, however, amoxycillin/clavulanic acid (4/1) significantly increased the intracellular killing of Staphylococcus aureus.