Association of Multimodal Pain Control with Patient-Reported Outcomes in Children Undergoing Surgery

IntroductionOur aim was to describe practices in multimodal pain management at US children's hospitals and evaluate the association between non-opioid pain management strategies and pediatric patient-reported outcomes (PROs).MethodsData were collected as part of the 18-hospital ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) clinical trial. Non-opioid pain management strategies included use of preoperative and postoperative non-opioid analgesics, regional anesthetic blocks, and a biobehavioral intervention. PROs included perioperative nervousness, pain-related functional disability, health-related quality of life (HRQoL). Associations were analyzed using multinomial logistic regression models.ResultsAmong 186 patients, 62 (33%) received preoperative analgesics, 186 (100%) postoperative analgesics, 81 (44%) regional anesthetic block, and 135 (73%) used a biobehavioral intervention. Patients were less likely to report worsened as compared to stable nervousness following regional anesthetic block (relative risk ratio [RRR]:0.31, 95% confidence interval [CI]:0.11–0.85), use of a biobehavioral technique (RRR:0.26, 95% CI:0.10–0.70), and both in combination (RRR:0.08, 95% CI:0.02–0.34). There were no associations of non-opioid pain control modalities with pain-related functional disability or HRQoL.ConclusionUse of postoperative non-opioid analgesics have been largely adopted, while preoperative non-opioid analgesics and regional anesthetic blocks are used less frequently. Regional anesthetic blocks and biobehavioral interventions may mitigate postoperative nervousness in children.Level of evidenceIII.     

艾司氯胺酮复合麻醉在小儿瘢痕非插管全身麻醉患者超脉冲点阵二氧化碳激光治疗术中的应用及效果观察

目的探讨艾司氯胺酮+七氟烷+小儿布洛芬肛栓在小儿烧伤后增生性瘢痕非插管全身麻醉患者超脉冲二氧化碳点阵激光(UFCL)治疗术中的应用及效果观察。 方法选取2020年1月至2021年4月就诊于空军军医大学第一附属医院烧伤与皮肤外科门诊89例烧伤后增生性瘢痕患儿纳入本随机对照临床试验。将患儿采用随机数字表法分为氯胺酮+丙泊酚组[共42例，其中男22例，女20例，平均年龄为(44.33±14.87)个月]和复合麻醉镇痛组(艾司氯胺酮+七氟烷+小儿布洛芬肛栓)[共47例，男24例，女23例，平均年龄(44.47±14.65)个月]；在麻醉前和术中监测患儿血流动力学指标以及警觉/镇静(OAA/S)量表评分；在麻醉清醒时(T0)、麻醉清醒后1 h(T1)、麻醉清醒后2 h(T2)应用儿童疼痛行为量表(FLACC)对患儿疼痛程度进行评估；分别于术前和术后6个月应用温哥华瘢痕量表(VSS)对瘢痕进行评分。对数据行独立样本t检验和χ²检验。 结果(1)麻醉前氯胺酮+丙泊酚组血流动力学及OAA/S量表评分[平均动脉压(63.71±3.40)mmHg、心率(107.21±9.45)次/min、呼吸(25.29±2.34)次/min、血氧饱和度(99.00±0.80)%、OAA/S量表评分(4.64±0.49)分]与复合麻醉镇痛组[平均动脉压(63.87±3.57)mmHg、心率(109.34±12.21)次/min、呼吸(26.473.53)次/min、血氧饱和度(98.77±0.91)%、OAA/S量表评分(4.57±0.50)分]比较差异均无统计学意义(t＝-0.213、0.490、-1.840、1.280、0.204，P>0.05)；麻醉后手术中氯胺酮+丙泊酚组[平均动脉压(56.29±2.43)mmHg、心率(94.48±7.01)次/min、呼吸(21.07±3.03)次/min、血氧饱和度(96.12±1.64)%、OAA/S量表评分(2.07±0.71)分]与复合麻醉镇痛组[平均动脉压(62.87±3.56)mmHg、心率(108.791±1.93)次/min、呼吸(26.52±3.48)次/min、血氧饱和度(99.23±0.67)%、OAA/S量表评分(1.45±0.50)分]比较差异有统计学意义(t＝-10.068、-6.794、-7.824、-11.960、4.820，P<0.05)。(2)氯胺酮+丙泊酚组患儿麻醉清醒时[T0：(4.40±1.17)分]麻醉清醒后1 h[T1：(2.05±0.88)分]、麻醉清醒后2 h[T2：(0.43±0.63)分]FLACC评分比复合麻醉镇痛组[(1.32±0.96)、(0.43±0.62)、(0.13±0.34)分]评分高，说明患儿疼痛度高，且数据比较差异均有统计学意义(t＝10.139、13.669、2.794，P<0.05)。(3)术前及术后6个月瘢痕评分：氯胺酮+丙泊酚组[(9.33±1.60)、(4.48±1.11)分]与复合麻醉镇痛组[(8.43±2.04)、(4.26±1.04)分]相比差异均无统计学意义(t＝2.320、0.940, P>0.05)。 结论复合麻醉镇痛措施在小儿烧伤后增生性瘢痕非插管全身麻醉患者(UFCL)治疗术中应用效果较好，可使患儿术中血流动力学平稳，术中镇静良好，术后疼痛度较低，对于激光治疗效果无影响。     

儿童颌面部骨折诊疗研究进展

儿童处于生长发育特殊阶段，其颌面部解剖结构、牙列情况及心理状态与成年人有明显区别。颌面部骨折患儿常出现面部发育畸形、张口受限、咬合关系紊乱等，严重影响患儿的日常生活。因此，儿童颌面部骨折的诊疗一直是临床上的难题，也是国内外的研究热点。颌面部骨折好发于青少年，损伤原因多为意外跌倒、交通伤及运动伤。近年来，数字化外科技术为儿童颌面部骨折提供精确的诊断及微创的治疗。国内外学者对于儿童颌面部骨折治疗理念逐渐倾向于手术治疗，选择可吸收材料对儿童颌面部骨折进行固定，降低对儿童面部发育的影响。长期随访对于儿童颌面部骨折患儿具有重要意义，有助于监测患儿面部发育情况。此外，临床医生应注意患儿的心理状态。对于创伤较重或发现有心理问题的患儿，应尽早干预治疗。文章就近年儿童颌面部骨折流行病学特点、诊断、治疗原则及伴发的心理问题做一综述。     

SAA、hs-CRP、IL-6联合检测在儿童感染性疾病中的诊断价值

目的:分析SAA、hs-CRP、IL-6联合检测在儿童感染性疾病中的诊断价值。方法:选择2019年1月~2020年10月某院收治的72例感染性疾病患儿开展研究,根据患儿的病原体检测结果划分为病毒感染组和细菌感染组各36例,另选择同期体检的36名健康儿童作为研究的参照组,分别比较3组的SAA、hs-CRP、IL-6等指标水平的差异。结果:细菌感染组的SAA、hs-CRP、IL-6等指标水平及阳性率均高于病毒感染组、参照组,同时病毒感染组的SAA、hs-CRP、IL-6等指标水平及阳性率高于参照组(P<0.05);SAA、hs-CRP、IL-6联合诊断的敏感度、准确度、阳性预测值、阴性预测值均高于SAA、hs-CRP、IL-6三个指标单独检测的敏感度、准确度、阳性预测值、阴性预测值,差异有统计学意义(P<0.05);联合检测的特异度与单独检测特异度对比无统计学意义(P>0.05)。结论:SAA、hs-CRP、IL-6联合诊断在儿童感染性疾病中具备较高的诊断价值,临床可将SAA、hs-CRP、IL-6作为该病的诊断辅助指标,有效提高疾病的诊断准确性。     

注意缺陷多动障碍儿童执行功能的评估与干预

ADHD儿童认知障碍的主要特征之一是执行功能损害,涉及包括前额叶皮层在内的特定脑区域及多层级脑网络异常。执行功能按照功能性分为冷-热两方面:冷执行功能损害主要表现于反应抑制、工作记忆以及认知灵活性等;热执行功能损害通常涉及延迟满足、赏罚相关决策、自我调节及情绪调节等。ADHD儿童的执行功能评估应基于可信范式进行文化适应性调整。临床干预不能单一聚焦于冷执行功能,需关注儿童的身体发育以及热执行功能(情绪社会方面)的发展进程,结合其他共病与心理状况,进行全面的动态随访与干预,以达到最佳的长期疗效。     

Therapeutic plasma exchange in pediatric patients with acute demyelinating syndromes of the central nervous system: A single-center experience

BackgroundTherapeutic plasma exchange (TPE) is an extracorporeal treatment that can be used in adult and pediatric patients with acute demyelinating syndromes of the central nervous system. In this study, the efficacy and safety of TPE was evaluated in 10 pediatric patients who underwent TPE that were unresponsive to corticosteroid treatment.MethodsRecords of 10 pediatric patients who underwent TPE in our pediatric intensive care unit (PICU) between May 2017 and June 2020 were used. Expanded Disability Status Scale (EDSS), Gait Scale (GS), and Visual Outcome Scale (VOS) were applied to the patients before and after TPE.ResultsOf the 10 patients who underwent TPE, five were diagnosed with multiple sclerosis (MS), three with transverse myelitis (TM), and two with acute disseminated encephalomyelitis (ADEM). The median age of the patients was 13.3 years (IQR 8-15), and the median day from symptom onset to onset of TPE was 12.5 days (IQR 7-28). A total of 104 TPE sessions were performed successfully. While no complications were encountered in three patients during the sessions, the most common complication was hypofibrinogenemia. The decrease in EDSS and GS scores was found to be consistent with the clinical response of the patients. There was no statistically significant decrease in the VOS.ConclusionsWith this study, we can say that TPE is a feasible, effective, and safe treatment modality in children with acute demyelinating syndromes of the central nervous system.     

Left ventricular noncompaction associated with a pathogenic mutation in the MYH7 gene: Known mutation,different phenotype

Left ventricular noncompaction (LVNC) is a genetically heterogeneous cardiomyopathy, with familial and sporadic forms, but genetic testing only identifies a pathogenic mutation in a minority of cases. The main complications are heart failure, embolism and dysrhythmias. Herein we report a familial case of LVNC associated with a mutation in the MYH7 gene and review the literature regarding controversies in LVNC. A 50-year-old woman was referred to the cardiology clinic for palpitations. She underwent echocardiography and cardiac magnetic resonance imaging that revealed mild left ventricular systolic dysfunction and LVNC criteria. She had several episodes of non-sustained ventricular tachycardia and received an implantable cardioverter-defibrillator (ICD). Genetic testing revealed the c.1003G>C (p.Ala335Pro) mutation in the MYH7 gene. Familial screening showed clear genotype-phenotype cosegregation, which provided strong evidence for the pathogenic role of this mutation. To the best of our knowledge, this is the first report of LVNC associated with the p.Ala335Pro mutation in the MYH7 gene. This mutation has been described in hypertrophic cardiomyopathy, suggesting that the same pathogenic sarcomere mutation may be associated with different cardiomyopathies. This case also highlights the current difficulties regarding decisions on ICD implantation for primary prevention of sudden cardiac death in LVNC.     

‘It felt like there was always someone there for us’: Supporting children affected by domestic violence and abuse who are identified by general practice

One in five children in the UK are affected by domestic violence and abuse. However, primary care clinicians (GPs and nurses) struggle to effectively identify and support children and young people living in homes where it is present. The IRIS+ (Enhanced Identification and Referral to Improve Safety) training and advocacy support intervention aimed to improve how clinicians respond to children and young people affected by domestic violence and abuse. IRIS+ training was delivered as part of a feasibility study to four general practices in an urban area in England (UK). Our mixed method design included interviews and questionnaires about the IRIS+ intervention with general practice patients, including children and young people as well as with clinicians and advocacy service providers. We collected the number of identifications and referrals by clinicians of children experiencing domestic violence and abuse through a retrospective search of medical and agency records 10 months after the intervention. Forty-nine children exposed to domestic violence and abuse were recorded in medical records. Thirty-five children were referred to a specialist domestic violence and abuse support service over a period of 10 months. Of these, 22 received direct or indirect support. The qualitative findings indicated that children benefitted from being referred by clinicians to the service. However, several barriers at the patient and professional level prevented children and young people from being identified and supported. Some of these barriers can be addressed through modifications to professional training and guidance, but others require systematic and structural changes to the way health and social care services work with children affected by domestic violence and abuse.