The Effect of Roux-en-Y Gastric Bypass Surgery in Morbidly Obese Patients on Pharmacokinetics of (Acetyl)Salicylic Acid and Omeprazole: the ERY-PAO Study

Background

Data on the absorption of orally administered drugs following Roux-en-Y gastric bypass (RYGB) surgery in obese patients are limited and inconclusive. As it is difficult to predict changes in absorption, studies on frequently used drugs in this population are necessary. Acetylsalicylic acid (ASA) and omeprazole are two commonly prescribed drugs in obese patients.

Methods

In this repeated measures study, omeprazole and salicylic acid (SA) serum concentrations were measured before and after RYGB in 34 morbidly obese subjects. Time to maximum concentration (Tmax), lag time (Tlag), maximum concentration (Cmax), and area under the serum concentration versus time curve (AUC) were calculated for both drugs to determine possible differences in drug absorption after the procedure.

Results

For SA, Tmax significantly decreased after RYGB, while both Cmax and AUC_0–24 significantly increased. For omeprazole, both Tmax and Tlag significantly decreased after RYGB, while Cmax significantly increased. Mean AUC_0–12 significantly decreased post-surgery. The difference in AUC_0–12 before and after surgery varied between subjects.

Conclusions

Our study shows a faster absorption of both ASA and omeprazole after RYGB. The exposure to ASA is higher post-surgery, but the standard dose of 80 mg does not need to be modified, considering its range in effective dose. The exposure to omeprazole is, on average, decreased after surgery. Clinicians should be aware to increase the dose of omeprazole if symptoms suggest inadequate response.

     

Mizoribine therapy combined with steroids and mizoribine blood concentration monitoring for idiopathic membranous nephropathy with steroid-resistant nephrotic syndrome

Background

We designed a prospective and randomized trial of mizoribine (MZR) therapy combined with prednisolone (PSL) for idiopathic membranous nephropathy (IMN) with steroid-resistant nephrotic syndrome (SRNS).

Methods

Patients with IMN were divided into 2 groups, and MZR combined with PSL was administered for 2 years. PSL was initially prescribed at 40 mg/day and tapered. MZR was given once-a-day at 150 mg and 3-times-a-day at 50 mg each to groups 1 and 2. Serum MZR concentrations from 0 to 4 h after administration were examined within one month of treatment. The concentration curve and peak serum level (C _max) of MZR were estimated by the population pharmacokinetic (PPK) parameters of MZR.

Results

At 2 years, 10 of 19 patients (52.6 %) in group 1 and 7 of 18 patients (38.9 %) in group 2 achieved complete remission (CR). The time-to-remission curve using the Kaplan–Meier technique revealed an increase in the cumulative CR rate in group 1, but no significant difference between the groups. Meanwhile, there was a significant difference in C _max between groups 1 and 2 (mean ± SD: 1.20 ± 0.52 vs. 0.76 ± 0.39 μg/mL, p = 0.04), and C _max levels in CR cases were significantly higher than those in non-CR cases. Receiver operating characteristic analysis showed that C _max more than 1.1 µg/mL was necessary for CR in once-a-day administration.

Conclusion

Administration of MZR once a day is useful when combined with PSL for treatment of IMN with SRNS. In addition, it is important to assay the serum concentration of MZR and to determine C _max, and more than 1.1 µg/mL of C _max is necessary for CR.

     

The true distribution volume and bioavailability of mizoribine in children with chronic kidney disease

Background

Mizoribine (MZR) is used kidney transplant and various kidney diseases. However, few studies reported the association between pharmacokinetics and pharmacodynamics. The Pharmacokinetics Study Group for Pediatric Kidney Disease (PSPKD) used population pharmacokinetics (PPK) analysis and Bayesian analysis to investigate the usefulness of MZR. In this study, the fact that almost all MZR are excreted unchanged in urine was used to calculate its bioavailability (F) and true distribution volume (V _d), and analyzed these correlation with age.

Methods

Ishida et al. reported a PPK analysis by the PSPKD. In the present study, 71 samples extracted from their study population of 105 pediatric chronic kidney disease patients aged between 1 and 20 years were investigated. The bioavailability was calculated by measuring total excreted MZR in 24 h urine samples, and this was compared to the oral dosage. The apparent distribution volume (V _d/F) obtained from Bayesian analysis was then used to calculate true distribution volume (V _d), and the correlation of each parameter with age was investigated.

Results

The median dose of MZR per weight was 5.17 mg/kg/day. Median bioavailability was 32.02%. Median V _d per weight was 0.46 L/kg. There was a significant, weakly positive correlation between bioavailability and age (p = 0.026). There was also a significant, weakly negative correlation between V _d per weight and age (p = 0.003).

Conclusion

Bioavailability and V _d per weight tended to decrease depending on age. The younger patient required larger dose required to obtain the maximum effect from MZR, and this is important for immunosuppressive therapy.

     

Review of the enhanced recovery pathway for children: perioperative anesthetic considerations

Purpose

Enhanced recovery after surgery (ERAS) pathways have been used for two decades to improve perioperative recovery in adults. Nevertheless, little is known about their effectiveness in children. The purpose of this review was to consider pediatric ERAS pathways, review the literature concerned with their potential benefit, and compare them with adult ERAS pathways.

Source

A PubMed literature search was performed for articles that included the terms enhanced recovery and/or fast track in the pediatric perioperative period. Pediatric patients included those from the neonatal period through teenagers and/or youths.

Principal findings

The literature search revealed a paucity of articles about pediatric ERAS. This lack of academic investigation is likely due in part to the delayed acceptance of ERAS in the pediatric surgical arena. Several pediatric studies examined individual components of adult-based ERAS pathways, but the overall study of a comprehensive multidisciplinary ERAS protocol in pediatric patients is lacking.

Conclusion

Although adult ERAS pathways have been successful at reducing patient morbidity, the translation, creation, and utility of instituting pediatric ERAS pathways have yet to be realized.

     

Prevalence of acetabular labral tears in asymptomatic children

Purpose

Magnetic resonance imaging (MRI) is a sensitive, non-invasive modality to diagnose acetabular labral pathology, and the normal variants of the acetabular labrum have been characterized in adults. However, the prevalence of labral pathology in the asymptomatic pediatric population is unknown.

Methods

All pelvic MRIs performed at a large tertiary-care children’s hospital were reviewed during one calendar year (2014). Only patients aged between 2 and 18 years were included, and scans were excluded for hip pain/pathology or technical inadequacy. A blinded pediatric musculoskeletal radiologist read all eligible scans for the presence or absence of a labral tear.

Results

Three hundred and ninety-four pelvic MRIs were screened, and patients were excluded for hip pain/pathology (85 subjects), or technical inadequacy (190 subjects). One hundred and eight subjects (216 hips) met the inclusion criteria and were technically adequate for analysis. Labral tears were visualized in three of 216 (1.4 %) hips (two of the 110 subjects; 1.9 %).

Conclusions

There is a low rate of asymptomatic labral pathology by MRI in pediatric patients. The clinical history remains the means of differentiating real labral pathology from spurious imaging findings.

Level of evidence IV

Case series (prevalence).

     

Rahmenbedingungen für ein Kinderherztransplantationsprogramm

Background

Heart transplantations in the pediatric population pose specific technical and organizational challenges to the clinical team.

Material and methods

At the University Heart Center Freiburg-Bad Krozingen fixed organizational schemes, time management tracks and specific technical aspects of surgery were implemented. Between 1997 and 2016 a total of 46 patients under 18 years old underwent a heart transplantation at the center.

Results

Survival after 10 years was approximately 90%. The quality of life and physical activity were very satisfactory for the majority of children and adolescents.

Conclusion

Implementation of clinical planning schemes and time tracks for transplantation based on primary disease, type and number of previous surgeries, can help to achieve very satisfactory outcomes after heart transplantation in the pediatric population.

     

Incidence of contrast-induced acute kidney injury in a pediatric setting: a cohort study

Background

Contrast-induced acute kidney injury (CI-AKI) is a common pathology among adult patients, with an incidence ranging from 3–25 % depending on risk factors. Little information is available regarding CI-AKI incidence, risk factors, and prognostic impact in the pediatric population.

Methods

We performed a retrospective study of pediatric patients who underwent computed tomography (CT) scan with iodinated contrast media injection between 2005 and 2014 in five pediatric units of a university hospital. CI-AKI was defined according to Kidney Disease/Improving Global Outcomes (KDIGO) criteria.

Results

Of 346 identified patients, 233 had renal function follow-up and were included in our analyses. CI-AKI incidence was 10.3 % [95 % confidence interval (CI) 6.4–14.2 %]. CI-AKI was associated with 30-day unfavorable outcome before (45.8 % vs. 19.7 %, P?=?0.007) and after [odds ratio (OR) 3.6; 95 % CI 1.4–9.5] adjustment for confounders. No independent risk factors of CI-AKI were identified.

Conclusions

CI-AKI incidence was as high as 10.3 % following intravenous contrast media administration in the pediatric setting. As reported among adults, CI-AKI was associated with unfavorable outcome after adjustment for confounders. Although additional studies are needed in the pediatric setting, our data suggest that physicians should maintain a high degree of suspicion toward this complication among pediatric patients.

     

Effect of plasma NO<Subscript>x</Subscript> values on cardiac function in obese hypertensive and normotensive pediatric patients

Background

Hypertension (HT) is a major comorbidity of obesity that is associated with an increased risk of cardiovascular disease and higher mortality. The aim of our study was to evaluate cardiac function in obese hypertensive (OHT) and obese normotensive (ONT) pediatric patients and determine the effects of plasma nitric oxide (NO_x) values on cardiac function, while demonstrating the role of plasma NO_x in HT in obese pediatric patients.

Methods

The study population consisted of 62 patients (27 boys, 35 girls), aged 13–18 years and 21 age-matched healthy controls. All subjects enrolled in the study underwent echocardiography (Echo) evaluation and ambulatory blood pressure monitoring for HT. Plasma NO_x and biochemical values were studied in both patient groups separately.

Results

Plasma NO_x levels were found to be lower in the OHT group than in the ONT and control groups (p?<?0.001) and to be negatively correlated with left ventricular mass index values (p?<?0.05). Both the OHT and ONT groups had concentric hypertrophy of the heart.

Conclusions

Plasma NO_x plays an essential role in obesity-induced HT. Concentric hypertrophy of the left ventricle was found in both the OHT and ONT groups, indicating structural deformation of the heart.

     

Intra-cardiac extension of a Wilms’ tumor

Background

Wilms? tumor, or renal nephroblastoma, is the commonest malignant renal tumor in children and young adults. Intravascular and intracardiac extension of this tumor is a very rare and challenging clinical entity.

Case presentation

The case is reported of a 6-year-old boy diagnosed with nephroblastoma, in whom the tumor involved the inferior vena cava and the right atrium. The successful multimodal surgical management consisted of combined, synchronous surgical resection of both renal and intracardiac tumors. The boy had an uneventful postoperative course and recovery, followed by relapse-free living.

Conclusion

Intra-cardiac extension of Wilm’s tumor poses a surgical challenge where the favorable outcome is provided only by the combined and well-coordinated, skilled multidisciplinary care of pediatric surgeons and pediatric cardiac surgeons.

     

Pediatric Neuromyelitis Optica Spectrum Disorders

Purpose of review

Neuromyelitis optica spectrum disorders (NMOSDs) are a group of inflammatory and demyelinating disorders of the central nervous system that can occur in children and adults. The classic presentation of NMOSD is characterized by optic neuritis and transverse myelitis, but other presentations are also recognized, expanding the disease as NMO spectrum disorders. The purpose of this review is to discuss the clinical features, along with management and treatment options, including potential future therapeutic options, in pediatric NMOSD.

Recent findings

The aquaporin-4 antibody (AQP4 ab) is specific for NMOSD; however, recently another antibody, the myelin oligodendrocyte glycoprotein (MOG ab) has been found in a subset of AQP4 ab-negative patients including in children. Most treatment studies are reported in adults, but retrospective studies on efficacy and safety of mycophenolate mofetil, azathioprine, and rituximab in pediatric NMOSD are available.

Summary

While some pediatric NMOSD-specific treatment studies are available, more research is needed in the mechanisms of early onset and specific treatment options in children, including whether different treatment considerations are needed for AQP4 ab as opposed to MOG ab-positive disease.

     

Komplikationsmanagement im Internet Marketing

Background

New patients come more and more often over the internet; therefore internet marketing plays an increasingly important role.

Question

How can physicians build an effective internet marketing strategy and avoid complications?

Method

Selection and authorization of a reputable agency.

Results

New customer acquisition through high visibility in the internet, at the same time increasing the image and awareness.

Conclusions

In the overall “marketing mix” internet marketing has become indispensable to physicians who want to be successful. Those who are well positioned in Google are well known by their target audience and thus receive a higher response.

     

Pediatric out-of-hospital cardiopulmonary resuscitation by helicopter emergency medical service,does it has added value compared to regular emergency medical service?

Purpose

To determine the outcome of out-of-hospital (OOH) cardiopulmonary resuscitation (CPR) and the advanced life support (ALS) procedures provided in pediatrics by the Rotterdam Helicopter Emergency Medical Service (HEMS)

Methods

Retrospective evaluation of all pediatric (0–17 years) OOH cardiopulmonary arrests within a 6-year period and attended by the Rotterdam HEMS team.

Results

There were 201 OOH CPRs from October 2008 until October 2014. Endotracheal intubation was performed in 164 cases and done by HEMS in 104 patients (63%), intraosseous/intravenous cannulation 43/27 times, and additional medication given by HEMS in 70 patients (35%). The overall survival rate for OOH CPR was 15%, but in trauma was low. Twenty-seven of the 29 pediatric patients who survived until discharge are neurological well. Although the Dutch nationwide ambulance protocol states intubation, intravenous, or intraosseal excess and medication, in many patients, only HEMS provided additional ALS care.

Conclusion

The HEMS brings essential medical expertise in the field not provided by regular emergency medical service. HEMS provide a significant quantity of procedures, obviously needed by the OOH CPR of a pediatric patient.

     

The Met Needs for Pediatric Surgical Conditions in Sierra Leone: Estimating the Gap

Background

In low- and middle-income countries, there is a gap between the need for surgery and its equitable provision, and a lack of proxy indicators to estimate this gap. Sierra Leone is a West African country with close to three million children. It is unknown to what extent the surgical needs of these children are met.

Aim

To describe a nationwide provision of pediatric surgical procedures and to assess pediatric hernia repair as a proxy indicator for the shortage of surgical care in the pediatric population in Sierra Leone.

Methods

We analyzed results from a nationwide facility survey in Sierra Leone that collected data on surgical procedures from operation and anesthesia logbooks in all facilities performing surgery. We included data on all patients under the age of 16 years undergoing surgery. Primary outcomes were rate and volume of surgical procedures. We calculated the expected number of inguinal hernia in children and estimated the unmet need for hernia repair.

Results

In 2012, a total of 2381 pediatric surgical procedures were performed in Sierra Leone. The rate of pediatric surgical procedures was 84 per 100,000 children 0–15 years of age. The most common pediatric surgical procedure was hernia repair (18%), corresponding to a rate of 16 per 100,000 children 0–15 years of age. The estimated unmet need for inguinal hernia repair was 88%.

Conclusions

The rate of pediatric surgery in Sierra Leone was very low, and inguinal hernia was the single most common procedure noted among children in Sierra Leone.

     

Patellaformen

Background

Patella height is discussed as a possible factor in the development of osteoarthritis of the knee.

Methods

PubMed literature search

Results

Contradictory results are found in the literature.

Conclusion

According to the literature, there is currently no evidence that abnormal patella height can induce osteoarthritis of the knee.

     

Harnröhrenrekonstruktion bei vorausgegangener Hypospadieoperation

Background

The tasks involved in reconstructing the urethra after failed hypospadias repair range from correction of a trivial meatal stenosis to reconstruction of the entire anterior urethra.

Objectives

To describe pathological findings in the urethra after failed hypospadias repair and the respective surgical methods used for their correction.

Materials and methods

The various pathological findings after unsuccessful hypospadias surgery are classified according to their location and complexity.

Results

The general rules of reconstruction that should be applied in each particular situation are described.

Conclusions

Successful reconstruction of the urethra in patients with failed hypospadias surgery requires experience and good knowledge of the anatomy of the normal and hypospadic urethra and penis. Mastery of plastic surgical techniques and profound knowledge of the various surgical methods of hypospadias surgery are essential.

     

Challenge to pediatric anatomical variation : Can we draw the ideal line on the pediatric I-gel?

Objective

I-gel is a noncuff type of laryngeal airway mask. No horizontal line has yet been determined as an ideal position for pediatric sizes because of the variability in length of the oropharyngeal–laryngeal arch in children. We investigated whether there is a correlation between insertion length and patient body weight or height for the pediatric I-gel sizes from 1.5 to 2.5.

Methods

With parental informed consent, we planned to maintain the airway of 130 children aged from 7 months to 13 years by using the I-gel device under general anesthesia. The following two parameters were evaluated: (1) distance between the teeth and the connector wing; (2) insertion length (distance from the distal end of the gastric tube to the teeth). Size selection was determined on the basis of patients’ body weight. We identified the relationship between each parameter and height or weight.

Results

Average insertion length became gradually longer with increasing height and weight. Spearman’s R between insertion length and height or weight was 0.8. There was more correlation with height than with weight in pediatric size 2.5.

Conclusion

Results suggested that it is possible to draw an ideal line on the I-gel with sizes 1.5 and 2 only.

     

Performance on the Montreal Cognitive Assessment (MoCA) in Older Adults Presenting for Bariatric Surgery

Background

Bariatric surgery candidates exhibit cognitive impairment on neuropsychological testing and these deficits are associated with reduced post-operative weight loss. However, less is known about the prevalence of cognitive function in older adults that pursue surgery, despite being at higher risk for cognitive dysfunction.

Objective

To examine the prevalence and profile of cognitive impairment using the Montreal Cognitive Assessment (MoCA) in elderly bariatric patients. We hypothesized that increased body mass index (BMI) and higher number of medications would be linked to lower MoCA score, and that men would evidence poorer MoCA scores than women given past work showing that men presenting for bariatric surgery have more medical comorbidities.

Methods

Data was retrospectively extracted from electronic medical records. Patients 65 and older who completed pre-surgical MoCA assessment and bariatric surgery were included in the study (n?=?55).

Results

Twenty-two percent of patients scored below cutoff for impairment on the MoCA. MoCA total score was negatively correlated with BMI and number of medications pre-surgery. There was a significant effect for gender, with men outperforming women.

Conclusions

The current findings suggest that cognitive impairment is common in older adults presenting for bariatric surgery. Future studies are needed to determine the most appropriate methods for detecting cognitive dysfunction in this high-risk population.

     

Use of MR Urography in Pediatric Patients

Purpose of Review

In this article, we describe the basics of how magnetic resonance urography (MRU) is performed in the pediatric population as well as the common indications and relative performance compared to standard imaging modalities.

Recent Findings

Although MRU is still largely performed in major academic or specialty imaging centers, more and more applications in the pediatric setting have been described in the literature.

Summary

MRU is a comprehensive imaging modality for evaluating multiple pediatric urologic conditions combining excellent anatomic detail with functional information previously only available via renal scintigraphy. While generally still reserved for problem solving, MRU should be considered for some conditions as an early imaging technique.

     

Impaired longitudinal deformation measured by speckle-tracking echocardiography in children with end-stage renal disease

Background

Left ventricular dysfunction is an important co-morbidity of end-stage renal disease (ESRD) and is associated with a poor prognosis in the adult population. In pediatric ESRD, left ventricular function is generally well preserved, but limited information is available on early changes in myocardial function. The aim of this study was to investigate myocardial mechanics in pediatric patients with ESRD using speckle-tracking echocardiography (STE).

Methods

Echocardiographic studies, including M-mode, tissue Doppler imaging (TDI) and STE, were performed in 19 children on dialysis, 17 transplant patients and 33 age-matched controls. Strain measurements were performed from the apical four-chamber and the short axis view, respectively.

Results

The interventricular and left ventricular posterior wall thickness was significantly increased in dialysis and transplant patients compared to healthy controls. No significant differences were found in shortening fraction, ejection fraction and systolic tissue Doppler velocities. Dialysis and transplant patients had a decreased mean longitudinal strain compared to healthy controls, with a mean difference of 3.1 [95 % confidence interval (CI) 2.0–4.4] and 2.7 (95 % CI 1.2–4.2), respectively. No differences were found for radial and circumferential strain.

Conclusions

Speckle-tracking echocardiography may reveal early myocardial dysfunction in the absence of systolic dysfunction measured by conventional ultrasound or TDI in children with ESRD.

     

Advances and Challenges in Transitional Urology: Caring for Adolescents and Young Adults with Lifelong Complex Genitourinary Conditions

Purpose of Review

As long-term survival with complex congenital and pediatric diseases has improved, more patients with congenital genitourinary conditions are living into adulthood. These patients can continue to face lifelong issues related to their conditions, including urinary incontinence, recurrent urinary tract infections, chronic kidney disease, and difficulties with sexual health and function.

Recent Findings

The practice of transitional urology continues to grow nationwide and abroad, and it will be important to develop evidence-based practices for coordinated transition of these patients into the adult health care setting.

Summary

This review describes the broader attention to transitions of care in medicine and specifically evaluates spina bifida as a model disease system for implementation of transitional practices in urology.