Surgical Approaches to Epicardial Pacemaker Placement: Does Pocket Location Affect Lead Survival?

Permanent cardiac pacing in pediatric patients presents challenges related to small patient size, complex anatomy, electrophysiologic abnormalities, and limited access to cardiac chambers. Epicardial pacing currently remains the conventional technique for infants and patients with complex congenital heart disease. Pacemaker lead failure is the major source of failure for such epicardial systems. The authors hypothesized that a retrocostal surgical approach would reduce the rate of lead failure due to fracture compared with the more traditional subrectus and subxiphoid approaches. To evaluate this hypothesis, a retrospective chart review analyzed patients with epicardial pacemaker systems implanted or followed at Rady Children’s Hospital San Diego between January 1980 and May 2007. The study cohort consisted of 219 patients and a total of 620 leads with epicardial pacemakers. Among these patients, 84% had structural congenital heart disease, and 45% were younger than 3 years at time of the first implantation. The estimated lead survival was 93% at 2 years and 83% at 5 years. The majority of leads failed due to pacing problems (54%), followed by lead fracture (31%) and sensing problems (14%). When lead failure was adjusted for length of follow-up period, no significant differences in the rates of failure by pocket location were found.     

Clinical Improvement After Banding of a Pulmonary Branch Artery in a Symptomatic Patient with Osler–Rendu–Weber Syndrome

We report a symptomatic newborn with Osler–Rendu–Weber syndrome, multiple and diffuse pulmonary arteriovenous malformations, and right-to-left shunting in the left lung. Right-to-left shunting was significantly decreased by selectively banding the left pulmonary branch artery and clipping one large feeding vessel so that total resection of the left lung could be avoided.     

How to Treat Sepsis in the Background of Resistance?: Role of Pharmacodynamics / Pharmacokinetics in Treating Sepsis

Though a decline has been seen in child mortality and morbidity over the last decades, sepsis in neonates and infants remains a major cause of death. Optimal use of antibiotics in sepsis management is a key factor which can further reduce the number of poor clinical outcomes. Selecting the right antibiotic to which the offending bacteria is susceptible and administrating the antibiotic within the first hour can save many lives. However, the pharmacokinetic profile of an antibiotic is affected by developmental changes such as capacity of drug metabolizing enzymes and maturation of organ function. This can affect antibiotic exposure and response in neonates and infants. While suspecting sepsis, the primary focus of empiric treatment during the initial phase is to assure efficacy and it must be broad based to cover all suspected pathogens. Once the bacterial etiology is confirmed as a cause of sepsis and the in vitro antibiotic susceptibility is established, targeted treatment can be started which ensures optimal balance between efficacy and safety.     

What Is the Role for Magnesium to Treat Severe Pediatric Asthma Exacerbations?

In this review, we explore the role for intravenous magnesium sulfate (IVMg) to treat children with acute exacerbations of asthma. Children who receive care for severe acute asthma in emergency departments are often hospitalized after inadequate response to standard asthma treatment. IVMg may have a role to decrease hospitalization of children with severe acute asthma, but is in need of further research. Future exploration of IVMg should include larger randomized controlled trials of IVMg versus standard treatment, administration of IVMg with enough time to have effect on hospitalization, exploration of the pharmacology of IVMg so that the most effective dosage regimens can be selected, and use of measures and criteria to select research participants reflective of the children likely to benefit from more effective asthma treatment in clinical practice.     

Pediatric quality of life in transitioning to the insulin pump: does prior regimen make a difference?

A shift in conventional diabetes management has graduated to basal (glargine) and bolus (rapid-acting analogue) therapy via multiple daily injections or continuous subcutaneous insulin infusion (CSII). Continuous subcutaneous insulin infusion is considered the most intensive type of diabetes management, and before transitioning, consideration of regimen benefits should include lifestyle and quality-of-life issues in addition to medical benefits. Short-term and long-term changes in children's quality of life, as a function of their pre-CSII diabetes regimen, was assessed in 52 children before their transition to CSII from a conventional or multiple daily injection regimen. Results demonstrated significant improvement in quality of life only for those children transitioning to CSII from conventional vs multiple daily injection regimens; results were maintained at 6 months following pump initiation. Quality of life is an important consideration as children transition from more traditional to intensive regimens, and CSII devices may not necessarily improve satisfaction with diabetes control in all pediatric patients. Risks and benefits of both intensive regimens should be discussed before making the transition.     

Pediatric hepatocellular carcinoma in a developing country: Is the etiology changing?

HCC is the second most common malignant liver tumor of childhood. It typically affects children with a median age of 10–14 yr on background hepatitis B‐related liver disease and is often metastatic or locally advanced at diagnosis. Children below the age of five yr typically constitute <10% of all children with HCC. In these children, it occurs on a background of congenital or metabolic liver disease. The records of all children with HCC who presented to our department over a six‐yr study period were reviewed. Twelve patients with a median age of 5.9 yr (range 1.6–15.4) were diagnosed to have HCC. All patients underwent liver transplantation, and none were resected. Eleven patients had background congenital or metabolic liver disease. All five of those with hereditary tyrosinemia type 1 who presented to us were found to have HCC. No patient had hepatitis B‐related liver (HBV) disease. Eight (66.7%) patients had incidentally discovered HCC on examination of the explant. Incidentally discovered HCC were smaller, well differentiated, and did not show microvascular invasion compared to those diagnosed preoperatively. There was no recurrence with a median follow‐up of five months. The patient demographic for pediatric HCC is changing probably as a consequence of successful immunization against HBV. Younger patients with congenital and metabolic liver disease in whom liver transplantation is the ideal treatment are likely to constitute an ever‐increasing proportion of patients with pediatric HCC as HBV disease is controlled or eradicated.     

HFOV in Pediatric ARDS: Viable or Vestigial?

Indian Journal of Pediatrics -