Avaliação do comprometimento respiratório em pacientes com lúpus eritematoso sistêmico com o teste de caminhada de seis minutos

ObjectiveEvaluate SLE stable patients, without overt respiratory compromise, by means of 6 MWT.Casuistic and methodsForty‐five stable SLE patients were enrolled. The ATS/ERS protocol for 6 MWT, was used and two parameters with cut‐off points were chosen.ResultsForty‐two patients were women. The mean age was 39 ± 11.4 years; mean duration of disease, 121 ± 93.1 months; mean value of MRC, 2 ± 0; mean FVC, 85.9 ± 34.2%; meanFEV1, 67.5 ± 21.6%; mean MIP, 82 ± 58.4%; mean MEP, 78 ± 37.3%; mean heart rate at rest, 75 ± 12.8 bpm; mean respiratory rate at rest, 19 ± 5.3 bpm; mean 6 MWD, 478 ± 82 m; mean SpO2 at rest was 98 ± 0.8%; mean fall in SpO2, 4 ± 6 points. When the study population was divided according to the 400‐m walk distance cut‐off value, the heart rate immediately before the test was significant lower in those participants who walked less than 400 m (p = 0.0043), just like the value of Borg scale (p = 0.0036); according to the presence of saturation≥ 4, heart rate at the end of the test was significantly higher in those participants who were showing desaturation (p = 0.0170); MEP (p = 0.0282) and 6 MWD (p = 0.0291) were significantly lower, and MIP showed a tendency towards being smaller (p = 0.0504). FVC < normal inferior limit was significantly associated with the group with desaturation (p = 0.0274).ConclusionCompared to 6 MWD, desaturation was better suited to find the patients with the most compromised indexes in respiratory function tests.     

Adjuvant alpha adrenergic blockers: Are they equally efficient for renal and upper ureteral calculi disintegrated by shock wave lithotripsy?

ObjectivesTo evaluate the effects of tamsulosin on stone clearance and analgesic requirements after shock wave lithotripsy (SWL) for solitary renal and upper ureteral calculi.Patients and methodsA prospective randomized placebo controlled study was carried out on 126 patients who underwent SWL for solitary radio-opaque renal or upper ureteral calculi ≤20 mm. Patients were randomized into two groups receiving either 0.4 mg of tamsulosin (GT) or placebo (GP). SWL was performed 3-weekly until patients became stone-free or for a maximum of 3 months. Analgesics were used on demand and pain was evaluated by a visual pain scale.ResultsRenal stones represented 55.6% and 66.7% for GT and GP, respectively (p = 0.27). Mean renal and ureteral stone size were (12.3 ± 1.8 mm vs. 11.5 ± 2.3 mm, p = 0.14) and (9.7 ± 2.6 mm vs. 8.6 ± 1.7 mm, p = 0.1) for the GT and GP, respectively. GT required fewer SWL sessions for ureteral (1.2 vs. 1.6, p = 0.02) and renal stones (1.8 vs. 2.3, p = 0.08). Stone-free rate (SFR) was higher in GT for upper ureteral stones (96.4% vs. 66.7%, p = 0.01) and renal pelvis stones at a cutoff size >10 mm (p = 0.01). The mean time of stone clearance was significantly lower in GT (4.2 ± 1.9 weeks vs. 7.5 ± 2.3 weeks, p = 0.001) for ureteral stones. Attacks of renal colic were more frequent in GP (82.5% vs. 44.4%, p = 0.04) with increased demand for analgesia (p = 0.04). Steinstrasse was recorded in 3 and 7 patients of the GT and GP, respectively (p = 0.32).ConclusionTamsulosin facilitates clearance of upper ureteral stone fragments after SWL and decreases the analgesic requirements. These effects were not similarly evident for renal stones.     

Dynamic contrast-enhanced ultrasound (CEUS) after open and minimally invasive locked plating of proximal humerus fractures

IntroductionClosed reduction and locked plate fixation of proximal humerus fractures with the minimally invasive deltoid-splitting approach intends to minimize soft tissue damage although axillary nerve injury has been reported. The aim of this study was to assess the deltoid muscle perfusion with dynamic contrast-enhanced ultrasound (CEUS) as novel technique and evaluate its relation to the functional and neurologic outcome after open (ORIF) and minimally invasive (MIPO) fracture fixation.Patients and methods50 patients, 30 with deltopectoral ORIF and 20 with deltoid-splitting MIPO approach were examined 6–49 months after surgery. Only patients with a healthy, contralateral shoulder were selected. Shoulder function, satisfaction as well as psychosocial outcome were assessed with established scores (Constant, DASH, Simple Shoulder Test, ASES, SF-12). Electromyography (EMG) of the deltoid muscle was performed to determine axillary nerve damage. Ultrasound of both shoulders included CEUS and Power Doppler after deltoid muscle activation via active abduction for two minutes.ResultsNone of the examinations and scores showed significant differences between ORIF and MIPO patients, the psychosocial outcome was similar. The fracture types were equally distributed in both groups. The normalized Constant Score was 76.3 ± 18.6 in the ORIF and 81.6 ± 16.1 in the MIPO group (p = 0.373). Deltoid muscle perfusion in CEUS and Power Doppler revealed no differences between both approaches. EMG excluded functionally relevant axillary nerve injuries. Compared with the contralateral shoulder, Constant- and ASES-Scores (p ≤ 0.001 for both ORIF and MIPO) as well as the deltoid CEUS perfusion (ORIF p = 0.035; MIPO p = 0.030) were significantly worse for both approaches.ConclusionsConvincing consensus of functional, ultrasonographic and neurologic examinations demonstrated comparable outcomes after deltopectoral and deltoid-splitting approach. The quantification of the deltoid muscle perfusion with CEUS indicates that the proclaimed benefits of the MIPO approach on soft tissue might not be as great as expected.     

El entrenamiento preoperatorio induce cambios en la histomorfometría y función de los músculos del suelo pélvico en pacientes con indicación de prostatectomía radical

ObjectiveTo evaluate the efficacy of preoperative pelvic floor muscle training (PFMT) on histomorphometry, muscle function, urinary continence and quality of life of patients undergoing radical prostatectomy (RP).Material and methodsA prospective intervention clinical study was designed in 16 patients with indication of RP who were randomized into two groups. The Control Group received routine pre-surgical education (hygienic-dietary measures). The intervention group received a training session with supervised PFMT, three times a day, for four weeks, 30 days before the PR. Muscle function of the external urethral sphincter, contraction pressure of the levator ani, urinary continence and quality of life related to health (HRQoL) were evaluated before and after the intervention. At the end of the intervention and day of the surgery, samples of residual muscle tissue were obtained from the external sphincter muscle of the urethra for histomorphometric analysis.ResultsAfter the intervention, those participants who carried out PFMT showed an increase in the cross-sectional area of the muscle fibers of the external urethral sphincter (1,313 ± 1,075 μm² vs. 1,056 ±844 μm², P = .03) and higher pressure contraction of the levator ani (F = 9.188; P = .010). After catheter removal, 62% of patients in the experimental group and 37% in the control group showed no incontinence. After removal of the catheter, 75% of the experimental group did not require any pad compared to 25% in the control group (p=NS). There were no significant differences between the two groups in any of the HRQoL domains studied.ConclusionsPre-surgical PFMT in patients with RP indication induces changes in the histology and function of the pelvic floor muscles, without changes in urogenital function and HRQoL. These results provide new evidence regarding the benefit of PFMT in preventing RP associated complications.     

Different osteocalcin forms,markers of metabolic syndrome and anthropometric measures in children within the IDEFICS cohort

ObjectiveOsteocalcin (OC), an aboundant non-collagenous bone protein, is inversely associated with parameters of glucose metabolism. Interactions between bone tissue and energy metabolism have not been thoroughly investigated during childhood. This study investigated OC, metabolic parameters and anthropometric characteristics in normal weight and overweight/obese children.MethodsThis study comprised 108 (46 normal weight/62 overweight/obese) Swedish 2–9 year old children. Anthropometric data, insulin, glucose, glycosylated haemoglobin (HbA1c), HOMA index, vitamin D, adiponectin, total OC, carboxylated OC (cOC) and undercarboxylated OC (ucOC) were analysed.ResultsNo difference was found for total OC between the normal and overweight/obese groups, with a mean (± SD) value of 82.6 (± 2.8) ng/mL and 77.0 (± 2.4) ng/mL, (P = 0.11), respectively. Overweight children had lower cOC levels, mean 69.1 (± 2.2) ng/mL, vs. normal weight children, mean 75.6 (± 2.5) ng/mL (P = 0.03). The mean ucOC levels of 7.9 (± 0.4) ng/mL in overweight children did not differ vs. normal weight children, mean level 7.0 (± 0.4) ng/mL, (P = 0.067). None of the three OC forms correlated with any of the measured parameters.ConclusionsThe cOC levels were lower in overweight children. There was no correlation between the three OC forms and any of the measured anthropometric or metabolic parameters. OC has been suggested to have a possible metabolic role, but in general the current study in prepubertal children does not support the hypothesis of an association between OC and a positive metabolic profile.     

New methods for determination of the keyhole position in the lateral suboccipital approach to avoid transverse-sigmoid sinus injury: Proposition of the groove line as a new surgical landmark

PurposeThe asterion is frequently used as an anatomical landmark to determine the location of a keyhole in the lateral suboccipital approach used in craniotomies. However, the asterion may not be ideal because of large individual differences among patients. We examined a simple and safe method for determining an optimal keyhole position (KP) using the digastric groove as a new landmark in the lateral suboccipital approach.MethodsThirty-three patients with trigeminal neuralgia who underwent surgery in our institute between April 2014 and December 2018 were included. The groove line (GL) was designed accurately, extending the digastric groove on the surface of the occipital bone, as the x-axis. The y-axis was depicted from the posterior edge of the digastric groove (the groove point: GP) vertical to the GL. The x–y coordinates represented the distances from GP on each axis. The x–y coordinates of median edge of the transverse-sigmoid sinus (TSJ point), asterion, and the intersection of the GL and transverse sinus (the transverse point: TP) were investigated, based on intraoperative findings and recorded videos.ResultsThe x–y coordinated of the TSJ point were (23.9 ± 3.9, 7.2 ± 3.6). In all patients, the TSJ point was located superior to the GL. The x–y coordinates of the asterion were (27.3 ± 6.0, 8.9 ± 4.1), and in 28 of the 33 patients, their coordinates exceeded the TSJ points. The x-coordinate of the TP was 29.5 ± 4.5, and was located behind the TSJ point on the GL in all patients. The shortest distance between the TSJ points and TP was approximately 3 mm. According to these measurements, we decided that the optimal KP would be at 20 mm from the GP, subjacent to the GL.ConclusionsOur methods of using the GL as a new surgical landmark for setting the optimal KP is simple, safe, and useful.     

Evaluation of carotid intima media thickness in children with idiopathic nephrotic syndrome

AimAim of the study was to determine if carotid intima media thickness in children with idiopathic nephrotic syndrome is greater than in healthy subjects, and to assess whether carotid intima media thickness in children with nephrotic syndrome is associated with clinical (including disease duration, cumulative dose of steroids, number of relapses) and biochemical parameters.MethodsA cross-sectional study included 40 patients with nephrotic syndrome (mean age 11.7 ± 4.7 years). Steroid dependent nephrotic syndrome was established in 32 patients (80%), while 8 (20%) had steroid resistant nephrotic syndrome. Control group consisted of 20 age and gender matched healthy children. Blood pressure based on 24-h ambulatory blood pressure monitoring (ABPM), carotid intima media thickness, fasting glucose, insulin, HbA1c, lipid concentrations were measured in all children.ResultsA significant difference was detected in carotid intima media thickness values (P = 0.036). Children with nephrotic syndrome had significantly greater carotid intima media thickness compared with healthy children (0.42 ± 0.06 and 0.38 ± 0.03 mm). Carotid intima-media thickness was positively associated with duration of nephrotic syndrome (r = 0.45; P = 0.004), body mass index (r = 0.48; P = 0.002), daytime systolic blood pressure (r = 0.46; P = 0.003) and night-time systolic blood pressure (r = 0.52; P = 0.001). Multiple linear regression showed that duration of nephrotic syndrome was the only independent predictor of carotid intima media thickness in children with nephrotic syndrome (R² = 0.244; β=0.327; P = 0.037).ConclusionThe findings of the present study suggest subclinical vascular damage in patients with nephrotic syndrome. Duration of nephrotic syndrome was the only independent predictor of carotid intima media thickness.     

Preincisional peritonsillar vs. intravenous lornoxicam for posttonsillectomy analgesia: A clinical and platelet aggregometry comparative study

BackgroundLornoxicam is a fairly new short-half oxicam with an improved tolerability profile. Our objective was to investigate the safety and efficacy of intravenous and peritonsillar infiltration of 8 mg lornoxicam on pain relief in children undergoing tonsillectomy.MethodsIn a double-blinded, placebo-controlled trial, 60 children were randomized into three groups; intravenous group (n = 20), received lornoxicam 8 mg iv., infiltration group (n = 20) received lornoxicam 8 mg peritonsillar infiltration, and placebo controls (n = 20). The verbal rating pain scale, time to first postoperative analgesic request, total analgesic consumption during 1st 24 h postoperative, platelet aggregometry before, 15 min, 2 and 24 h after study drug administration, intraoperative blood loss, postoperative bleeding, and adverse effects were evaluated.ResultsThe time to first postoperative analgesic request was significantly prolonged in intravenous (318.75 ± 67.37 min) and infiltration (214.50 ± 43.06 min) groups compared with placebo group (66.75 ± 26.95 min). A significantly lower mean postoperative VRS scores and significantly reduced 1st day postoperative diclofenac consumption were recorded in iv. group (44.73 ± 9.31 mg), compared with infiltration (69.80 ± 38.71 mg) and placebo (87.8 ± 24.40 mg) groups. An increased intraoperative blood volume losses and intraoperative bleeding complains were observed in infiltration group (34.25 ± 11.93 ml), rather than in iv. (28.85 ± 10.01 ml) and placebo (24.75 ± 8.70 ml) groups. The (%) of platelet aggregation with ADP, collagen, and arachidonic acid was significantly reduced 15 min and 2 h after study drug administration with highest decreases in iv. group compared with infiltration and placebo groups. No patients reported postoperative bleeding or GIT adverse effects in the study.ConclusionIntraoperative preincisional intravenous lornoxicam enhanced postoperative analgesia after tonsillectomy in children. In comparison, the analgesic efficacy of locally applied lornoxicam was inferior to intravenous administration and was associated with increased incidence of intraoperative bleeding.     

Survival and health related quality of life after severe trauma − a 15 years follow up study

IntroductionAs the primary treatment of patients with severe trauma continues to improve, increasing interest has been directed towards long-term survival and Health Related Quality of Life (HRQoL). In trauma patients, there are few studies describing long-term outcome using tools specifically directed at HRQoL.HypothesisHRQoL measured with EQ-5D is significantly reduced compared to the Danish norm score 15 years after severe injury.Materials and methodsAll patients more than 18 years of age, admitted to a level 1 trauma center from March 1996 to September 1997 were prospectively included and scored with Injury Severity Score (ISS). Survival status was recorded in May 2012 and EQ-5D questionnaires were sent out.Results95 of the original 154 trauma patients were eligible for participation. The response rate was 66%. The average EQ-5D index score in the trauma population was significantly reduced compared to the index score in the Danish norm population (P = 0.00, one-sample t-test). In addition, ISS is associated with HRQoL and ISS ≥ 16 predicts poorer HRQoL.ConclusionEQ-5D is significantly reduced 15 years after severe trauma High ISS was associated with low HRQoL. Knowledge of the distribution and predictors of long-term disability can be used to develop more efficient prevention policies and to improve trauma care in general.     

Ultrasound guided transversus abdominis plane block versus local wound infiltration in children undergoing appendectomy: A randomized controlled trial

BackgroundThe transversus abdominis plane block (TAP) has been described for pain management following abdominal surgery in adults, but there are only few reports on its use in pediatrics. The aim of this study was to evaluate the analgesic effect of ultrasound guided TAP block in patients scheduled for open appendectomy versus an active comparator (wound infiltration).MethodsForty-four children aged 4–16 years (ASA 1–2) were enrolled. Patients were randomized into two groups (22 in each). Patients in group (T) were assigned to receive ultrasound guided TAP block using 0.4 ml/kg of bupivacaine 0.25%, and those in group (L) were assigned to receive local infiltration by the surgeon. Maximum pain scores, the time to the first analgesic requirement and the number of analgesic requirements were recorded over 48 h.ResultsThe ultrasound guided TAP block increased the mean time to the first analgesic requirement (10.4 ± 1.5 h) in comparison with the local infiltration group (5.4 ± 1.5). The cumulative number of doses of analgesic was significantly lower in TAP group than in local infiltration group (3.7 ± 1.1 versus 5.3 ± 2.1) and the Pain Scale score was significantly lower in the TAP group over the study period. Besides, there were no complications attributable to the ultrasound guided TAP block.ConclusionUltrasound-guided TAP block with (0.4 ml/kg) 0.25% bupivacaine provides prolonged postoperative analgesia and reduced analgesic use without any clinical side-effects after appendectomy in children.     

Quality of MRI pediatric sedation: Comparison between intramuscular and intravenous dexmedetomidine

ObjectiveThe study was designed to compare the efficacy of dexmedetomidine whether given intramuscular or intravenous for pediatric MRI sedation.Subjects and methodsNinety children between the ages of 2 and 8 years with ASA physical status I–II, scheduled for elective MRI, were enrolled in a double blind, comparative randomized study. Patients assigned into two equal groups. Group DV, sedation was performed using IV dexmedetomidine hydrochloride; a loading dose of 1 μg/kg administered over 10 min followed by a continuous infusion at 1 μg/kg/h. Group DM where the patient received IM dexmedetomidine 3 μg/kg. Primary endpoints included incidence of failed sedation and the requirement of midazolam supplementation. Secondary endpoints were time to sedation, duration of sedation, discharge time, and hemodynamic status.ResultsThe sedation failure rate was significantly higher in the DV group (40%) in comparison with the DM group (20%) (P = 0.04). Also, the use of rescue midazolam was significantly higher in the VD group (0.37 ± 0.47 mg) in comparison to the DM group (0.17 ± 0.35 mg) (P = 0.025). The onset of satisfactory sedation was significantly shorter in DV group in comparison to DM group (7.93 ± 0.884 vs. 16.87 ± 4.49). Also, the discharge time was significantly less in the DV group (32.27 ± 3.04 min) in comparison to DM group (41.87 ± 5.80 min). Patients in DV group had significantly lower MBP compared to patients in DM group after receiving dexmedetomidine (p < 0.05). Although the HR decreased in both groups during the MRI study, the decrease was statistically significant in the DV group compared to the DM group in the period extended from the 2nd to 35th min (p < 0.05).ConclusionIn pediatric MRI sedation, although IM dexmedetomidine does have a late sedation onset; it reduces the sedation failure rate, the need for supplement sedation and the incidence of hemodynamic instability associated with IV dexmedetomidine.     

Benefits of an abridged antibiotic protocol for treatment of gangrenous appendicitis

BackgroundWe previously reported a validated, objective definition of gangrenous, nonperforated appendicitis. In this study, we compared a cohort of children with gangrenous appendicitis treated with abridged antibiotics (AA) to another treated with prolonged antibiotics (PA).MethodsIn 2012, our service changed its standard of care for gangrenous appendicitis from PA to AA. In PA, patients received postoperative triple antibiotics until ileus resolved, they were afebrile (< 37.5 °C) for 24 hours, and achieved a normal WBC count. In AA, patients received two doses of postoperative triple antibiotics. A PA cohort during a 12-month period (February 2010–January 2011) was compared to an AA cohort during another 12-month period (April 2012–March 2013).ResultsTwenty patients were treated with AA and 38 patients with PA. AA patients had a significantly shorter overall length of stay (2.1 ± 1.58 vs. 3.18 ± 1.09 days, p = 0.003), as well as a significantly shorter postoperative stay (1.85 ± 1.42 vs. 2.95 ± 1.14 days, p = 0.002). There were no differences between the AA and PA cohorts in wound infections (0%), intraabdominal infections (0%), or appendicitis-related readmissions (0%).ConclusionsAbridged postoperative antibiotics for gangrenous appendicitis significantly shorten hospital stay without increasing complications.     

Joint debridement and microfracture for treatment late-stage Freiberg-Kohler’s disease: Long-term follow-up study

BackgroundFreiberg-Kohler’s disease is not a common disease and although various reports have been described since 1914, treatment methods are not completely established. The purpose of the present retrospective study was to evaluate the long-term outcomes following joint debridement and microfracture procedures for the treatment of Freiberg-Kohler’s disease.MethodsFifteen consecutive patients (16 feet) with Freiberg-Kohler’s disease (Smillie’s classification grade III–V) were operated between May 1996 to December 2011. All patients followed the same post-operative protocol. The objective and subjective evaluations were taken at the initial examination and at final follow-up.ResultsMean follow-up was 11 years ±5.5 (range 4.2–19.7 years). The AOFAS score, VAS score and ROM of the MTP joint improved significantly after surgery (p value <0.05).The AOFAS score improved from a preoperative value of 46.7 ± 15.5 points to 83.2 ± 9.4 points postoperative (p < 0.05). The mean preoperative joint ROM was 28° ± 8° and 49° ± 13° postoperative (p < 0.05). VAS score improved from a preoperative value of 5.5 ± 1.2 points to 1.2 ± 1 points at last follow-up (p < 0.05). At the end of follow-up 13 patients (81%) declared they were very satisfied, 3 patients (19%) satisfied and nobody unsatisfied.ConclusionsOur results suggest that joint debridement and microfracture procedure is an effective surgical treatment for late-stage Freiberg-Kohler’s disease with decrease of daily pain, improved ROM, and high patient satisfaction.     

Comparison of the efficacy of dexmedetomidine,ketamine, and a mixture of both for pediatric MRI sedation

AimTo compare the efficacy of intramuscular ketamine, dexmedetomidine, and a mixture of both for pediatric MRI sedation.Subjects and methodsOne-hundred and sixty-two children with ASA physical I–II were enrolled in a double-blind comparative study and assigned into three equal groups for sedation. Group D, patients received IM dexmedetomidine 3 μg/kg. Group K, patients received IM ketamine 4 mg/kg. Group DK, patients received a combination of IM dexmedetomidine 1.5 μg/kg and ketamine 2 mg/kg. Primary outcomes included incidence of failed sedation and the requirement of midazolam supplementation. Secondary outcomes were time to sedation, duration of sedation, and discharge time.ResultsThe onset of satisfactory sedation was significantly shorter in the DK group in comparison with the D group (4.8 ± 1.6 vs. 16.8 ± 4.5 min), while no significant difference between the DK group and K group. The duration of sedation was significantly less in the DK group in comparison with the K group, and the discharge time was significantly less in the DK group in comparison with the D and K groups. The sedation failure rate was significantly lower in the DK group (5.6%) in comparison with the K group (22.2%) and the D group (27.8%). The use of rescue midazolam was significantly less in the DK group (0.03 ± 0.12 mg) in comparison with the K and D groups (0.21 ± 0.41 mg, 0.24 ± 0.41 mg, respectively). None of the patients experienced episodes of hypotension or bradycardia in the DK and K groups while four patients (7.4%) experienced episodes of hypotension and five patients (9.3%) experienced episodes of bradycardia in the D group.ConclusionIn pediatric MRI sedation, the combination of IM dexmedetomidine and ketamine was superior to either IM dexmedetomidine or ketamine given individually with regard to the onset of sedation, the sedation failure rate, and hemodynamic stability.     

Children with nephrotic syndrome have greater bone area but similar volumetric bone mineral density to healthy controls

BackgroundGlucocorticoid use has been associated with an increased fracture risk and reduced bone mineral density (BMD), particularly in the trabecular compartment. However the contribution of the underlying inflammatory disease process to these outcomes is poorly understood. Childhood nephrotic syndrome (NS) typically follows a relapsing–remitting course often requiring recurrent courses of glucocorticoids, but with low systemic inflammation during remission. NS therefore represents a useful clinical model to investigate the effects of glucocorticoids on BMD and bone geometry in childhood.MethodsChildren with NS were compared to age and sex matched healthy controls. Body composition and areal BMD (whole body, lumbar spine and hip) were assessed by DXA. Peripheral quantitative computed tomography (pQCT) scans were obtained at metaphyseal (4%) and diaphyseal (66%) sites of the tibia to determine volumetric BMD and bone cross-sectional geometry. Lifetime cumulative glucocorticoid exposure was calculated from medical records.Results29 children with NS (55% male, age 10.7 ± 3.1 years) were compared to 29 healthy controls (55% male, age 11.0 ± 3.0 years). The children with NS were of similar height SDS to controls (p = 0.28), but were heavier (0.65 ± 1.28SDS vs − 0.04 ± 0.89SDS, p = 0.022) and had greater body fat percentage SDS (0.31 ± 1.01 vs − 0.52 ± 1.10, p = 0.008). Tibial trabecular and cortical vBMD were similar between the two groups but bone cross-sectional area (CSA) was significantly greater in children with NS at both the metaphysis (954 ± 234 mm² vs 817 ± 197 mm², p = 0.002) and diaphysis (534.9 ± 162.7 mm² vs 463.2 ± 155.5 mm², p = 0.014). Endosteal and periosteal circumferences were greater in children with NS than controls (both p < 0.01), resulting in reduced cortical thickness (2.4 ± 0.7 mm vs 2.8 ± 0.7 mm, p = 0.018), but similar cortical CSA (p = 0.22). The differences in cortical geometry were not statistically significant when weight was included as a confounding factor. There were no associations between cumulative steroid exposure, duration of NS or number of relapses and any bone parameter.ConclusionsTibial bone CSA is increased in children with NS. We speculate that this is a compensatory response to increased body weight. Defects in trabecular BMD were not identified in this cohort of children with NS.     

Bone status of Indian children and adolescents with type 1 diabetes mellitus

ObjectiveLow bone mineral density has been reported in children and adolescents with type 1 diabetes (T1DM). The aims of this cross-sectional study were to study growth, serum IGF1 concentrations and bone health parameters assessed by Dual Energy X-ray Absorptiometry (DXA).MethodsHeight was measured and converted to Z scores (HAZ). Serum IGF1 concentrations were measured (ELISA) in a subset. Bone mineral content for total body (less head) (TBBMC) and lumbar spine was measured (n = 170, 77 boys, 6–16 years old) and converted to Z scores using local normative data.ResultMean age was 11.1 ± 3.8 years, disease duration was 2.2 ± 2.5 years and HbA1C was 10.1 ± 1.8%. Diabetic children were shorter than reference population (HAZ − 0.6 ± 1.1); Z scores for height and total body bone area (TBBA) for height were <− 2SD in 12% & 6% respectively. Serum IGF1 Z scores were lower amongst group with longer disease duration (− 1.58 ± 1.3 vs − 2.63 ± 0.7; P = 0.037). Disease duration (β = − 0.180, P = 0.000) and metabolic control (HbA1C; β = − 0.096, P = 0.042) were negative predictors of HAZ and TBBA for height Z in younger children. Using the Molgaard approach, children with longer disease duration had lower HAZ (− 0.31 ± 0.92 vs − 1.28 ± 1.11; P = 0.000; “short bones”) and TBBA for height Z scores (0.12 ± 1.62 vs − 0.53 ± 0.94; P = 0.044; “slender bones”). Older children (tanner stages 4 and 5) had lower BMC and BA as compared to reference population possibly due to delayed growth spurt.ConclusionLonger duration of diabetes was associated with shorter and slender but appropriately mineralized bones. Small and slender bones in diabetic children may increase risk of fragility fractures in the future.This article is part of a Special Issue entitled “Bone and diabetes”.     

Development and evaluation of a low-cost part-task trainer for laparoscopic repair of inguinal hernia in boys and the acquisition of basic laparoscopy skills

PurposeTo examine the fidelity of our model of laparoscopic inguinal hernia repair (LIHR) in boys and evaluate its value in resident training programs and the learning of basic laparoscopy skills.MethodsWe created a simulation model with inexpensive, easy-to-obtain equipment. Study participants from 34 university hospital departments received a user manual and an evaluation questionnaire (11 items rated on a 5-point Likert scale). We considered that the evaluation was positive when the median overall score was 4 or over. We compared the results for residents (n = 26) vs. expert surgeons (n = 29) (t tests).ResultsThe duration of the procedure was significantly longer among the residents (30.0 ± 16.8 min) than among the expert surgeons (20.5 ± 11.7 min; p = 0.01). In both groups, the participants rated the model favorably with regard to the overall impression (median score: 4.0 ± 1.0), realism (4.0 ± 0.9), ease of access to the required equipment (5.0 ± 0.6), the quality of the user manual (5.0 ± 0.6), ease of assembly (5.0 ± 0.8), ease of the procedure (5.0 ± 0.8), value in resident training programs (4.0 ± 0.9), and value in learning basic laparoscopy skills (5.0 ± 0.8)). The evaluation was positive (4.0 ± 0.9).ConclusionOur low-cost model was an effective teaching and training tool for LIHR and basic laparoscopy skills.Level of EvidenceLevel IV.     

Progression of structural lung disease on CT scans in children with cystic fibrosis related diabetes

BackgroundDiabetes has a deleterious effect on clinical status in children with Cystic Fibrosis (CF). We hypothesized that children with CF Related Diabetes (CFRD) or Impaired Glucose Tolerance (IGT) would have more rapidly progressive lung disease based on chest computed tomography (CT) than those with normal glucose tolerance (NGT).MethodsIn a retrospective study we compared lung structure changes over time, as assessed by CT, in 34 CF children with CFRD, IGT or NGT. We then compared CT findings with changes in lung function.ResultsPercentage forced expiratory volume in 1 s (%FEV₁) remained stable over time with a mean (± SD) yearly change of ? 0.5% (± 3.9), ? 0.4% (± 2.3) and ? 0.85% (± 2.8) (p = 0.92) for the CFRD, IGT and NGT groups respectively. However, there was a mean (95%CI) increase in % CT score of 3.86%/year (1.77–5.95%), 1.59%/year (0.6–2.58%) and 1.09%/year (0.07–2.11%) (p = 0.023).ConclusionIn patients with CFRD, there was a more rapid progression of structural lung disease, compared to those who had NGT that was not reflected by change in lung function.     

Preemptive analgesia by peritonsillar ketamine versus ropivacaine for post-tonsillectomy pain in children

BackgroundPostoperative pain relief is a desired goal after tonsillectomy. Respiratory depression from opioid, bleeding from nonsteroidal antiinflammatory drugs, and airway edema all these factors make pain control is judges. Peritonsillar infiltration of a local anesthetic has been used for reduction of post-tonsillectomy pain.ObjectiveThis study aims to compare the postoperative analgesic efficacy and side-effects of preincisional peritonsillar infiltration of either ketamine or ropivacaine in children undergoing tonsillectomy.MethodsIn this prospective randomized double blind study, 60 children 7–12 years scheduled to tonsillectomy were divided into three groups: the tonsils were infiltrated by 0.2 ml kg⁻¹ ropivacaine, 0.75% in ropivacaine group R (=21), group 0.5 mg kg⁻¹ ketamine in the ketamine group K (n = 20), and 0.2 ml kg⁻¹ normal saline in the control group S (n = 19). All drugs were prepared in normal saline (3 ml per tonsil) infiltrated 3 min after induction of anesthesia and before surgical incision. Surgery was performed by a single otolaryngology fellow using the same dissection and snare technique. Postoperative pain was compared during 8-h period using a visual analog scale (VAS). The fast-tracking score was used to determine the post-anesthesia care unit discharge criteria. Patients were evaluated for: time of first request and the total analgesic requirement, time of first oral intake, nausea, vomiting, bleeding, and hallucination.ResultsIn the post-anesthesia care unit, groups K and R had comparable pain scores that were significantly lower than S group (P < 0.04). Pain scores in the postoperative ward at 2, 6, and 8 h were significantly higher in group S than in K and R groups (P < 0.05). The time of first analgesic demand was significantly longer in R group (5.52 ± 1.7) h than in K group (3.83 ± 0.16) h p = 0.003. It was the shortest in S group (2.57 ± 0.84) h p = 0.001. The time of first oral intake was significantly longer in S than in R and K groups (5 ± 1.72 versus 3.2 ± 1.97 and 3.65 ± 1.72 h) respectively = 0.006. Total analgesic consumption (mg) was significantly higher in S group than in R and K (12. ± 5.3 versus 8, 2 ± 2.3 and 8.6 ± 3.1) p = 0.004. There were no significant differences between groups regarding nausea, vomiting, or bleeding, and there was no other side-effect recorded.ConclusionPerincisional peritonsillar infiltration of both ropivacaine and ketamine was effective in reduction of post-tonsillectomy pain. Ropivacaine was superior to ketamine in reduction of time to first analgesic demand.     

Middle cerebral artery blood flow velocity during beach chair position for shoulder surgery under general anesthesia

ObjectivesThe goal of the present study was to examine changes of middle cerebral artery (V_MCA) blood flow velocity in patients scheduled for shoulder surgery in beach chair position.DesignProspective observational study.SettingOperating room, shoulder surgery.PatientsFifty-three consecutive patients scheduled for shoulder surgery in beach chair position.InterventionsTranscranial Doppler performed after induction of general anesthesia (baseline), after beach chair positioning (BC1), during surgery 20 minutes (BC2), and after back to supine position before stopping anesthesia (supine).MeasurementsMean arterial pressure (MAP), end-tidal CO₂, and volatile anesthetic concentration and V_MCA were recorded at baseline, BC1, BC2, and supine. Postoperative neurologic complications were searched.Main ResultsBeach chair position induced decrease in MAP (baseline: 73 ± 10 mm Hg vs lower MAP recorded: 61 ± 10 mm Hg; P < .0001) requiring vasopressors and fluid challenge in 44 patients (83%). There was a significant decrease in V_MCA after beach chair positioning (BC1: 33 ± 10 cm/s vs baseline: 39 ± 14 cm/s; P = .001). The V_MCA at baseline (39 ± 2 cm/s), BC2 (35 ± 14 cm/s), and supine (39 ± 14 cm/s) were not different. The minimal alveolar concentration of volatile anesthetics, end-tidal CO₂, SpO₂, and MAP were not different at baseline, BC1, BC2, and supine.ConclusionBeach chair position resulted in transient decrease in MAP requiring fluid challenge and vasopressors and a moderate decrease in V_MCA.