[Ibuprofen versus indomethacin in the preterm persistent patent ductus arteriosus therapy: review and meta-analysis]. / Ibuprofeno frente a indometacina para el tratamiento de la persistencia del conducto arterioso del prematuro: revisión sistemática y metaanálisis.

INTRODUCTION: Persistent patent ductus arteriosus (PDA) is a common pathology in the preterm whose traditional treatment has been indomethacin. Recently, ibuprofen has shown its effectiveness in closing the PDA with less hemodynamic effects. The objective of this paper is to review the current literature in order to determine if there is any benefit of ibuprofen versus indomethacin in the PDA therapy. MATERIAL AND METHODS: Eleven trials comparing intravenous ibuprofen versus indomethacin in the treatment of PDA confirmed by echocardiography in < 35 weeks preterm or < 1,500 g birth weight were included. A meta-analysis of the trials data was performed. RESULTS: No trial show statistically significant differences in the failure of closing PDA, neither the meta-analysis (RR 0.96 [CI 95 %: 0.74-1.26], with a power of 0.995). No differences were found in the rate of reopening and surgical ligation. Complications were similar, except for a significant lower incidence of oliguria in the ibuprofen group (RR 0.23 [CI 95 %: 0.10-0.51]). There were no differences in the respiratory outcomes (RR of bronchopulmonary dysplasia (BPD) at 28 days 1.32 [CI 95 %: 0.99-1.76]). CONCLUSIONS: In our revision ibuprofen was as effective as indomethacin in closing PDA. No significant differences were found in the incidence of complications except for less renal impairment with ibuprofen. A higher risk of BPD in the ibuprofen group is not confirmed, although more studies are needed.

[Prevalence of mechanical ventilation in pediatric intensive care units in Spain]. / Prevalencia de la ventilación mecánica en las unidades de cuidados intensivos pediátricos en España.

OBJECTIVE: To study the prevalence and characteristics of mechanical ventilation in children admitted to Spanish pediatric intensive care units (PICU). MATERIAL AND METHODS: A prospective, multicenter, observational study was performed using a written questionnaire sent to the 46 PICUs in Spain. Clinical data and mechanical ventilation settings in patients undergoing mechanical ventilation on 19th February 2002 were collected. RESULTS: Thirty-three PICUs participated in the study (27 had patients undergoing mechanical ventilation on the study day). The prevalence of mechanical ventilation was 86 patients (45.5 %). The mean age of patients undergoing mechanical ventilation was 36 months and the median was 8 months. Sixty percent of the patients were boys. The main indications for mechanical ventilation were acute respiratory failure (46.5 %), chronic respiratory failure (10.4 %), coma (11.6 %) and postoperative status (10.5 %). Endotracheal tubes were used in 73.2 % and a tracheostomy tube was used in 23.2 %. The most frequent mechanical ventilation modalities used were synchronized intermittent mandatory ventilation (SIMV) in 43 % and control or assisted-control ventilation in 36 %. In 30 % of the patients the duration of mechanical ventilation was longer than 1 month. From the initiation of mechanical ventilation to the study day, pneumothorax developed in 8.1 % of the patients, accidental extubation occurred in 10.5 % and ventilator-associated pneumonia developed in 17.4 %. CONCLUSIONS: A high percentage of children admitted to the PICU requires mechanical ventilation. The most frequent indication is respiratory failure. The most frequently used modality in children aged less than 1 month is pressure SIMV. In children older than 1 month volume-cycled or pressure-limited ventilation and volume-cycled SMIV are used in similar proportions. The prevalence of prolonged mechanical ventilation and the incidence of ventilator-associated complications are very high.

[Retrospective study of risk factors of vertical transmission of hepatitis C virus]. / Estudio retrospectivo de factores de riesgo de transmisión vertical de infección por virus hepatitis C.

INTRODUCTION: Despite the low prevalence of paediatric HCV infection and its initial mild clinical expressiveness, chronic infection could progress into cirrhosis and/or hepatocarcinoma. It is essential to control vertical transmission. Recent studies show that up to 50% of transmissions occur within the uterus. MATERIAL AND METHODS: [corrected] A retrospective study was conducted on 17 cases of (Hepatitis C virus) HCV infection registered over a period of 8 years. Vertical transmission risk factors were analysed, in order to introduce primary prevention. RESULTS: Only parenteral drug addiction significantly increased the rate of HCV transmission; HIV co-infection was not a confounding factor. HCV viremia, HIV co-infection, liver dysfunction and/or duration of the infection did not appear to affect the rate of transmission. Caesarean section, amniocentesis and internal monitoring may be risk factors (not statistically significant), but not prolonged vaginal delivery after amniotic membrane rupture. Breastfeeding showed protection. CONCLUSIONS: The effect of viremia on the risk of transmission is not clearly established, despite the importance usually attributed. Lack of viremia does not discount the risk of transmission, due to viral RNA detection can be intermittent, so it should be interpreted cautiously. Immunosuppression secondary to HIV co-infection implies a higher risk of transmission, but this effect decreases by improving immune competence by antiretroviral treatment. With regard to the birth characteristics, time after the rupture of membranes has not shown being a risk factor; being the caesarean not advisable as a good alternative to finish the pregnancy. Breastfeeding does not increase the risk, even it can be protective. This results would be justified by the low viral content of milk, its inactivation by gastric pH and its immunological benefits. Given that retrospective studies results are limited, prospective studies need to be carried out in order to improve the understanding of the role of possible risk factors and to provide a clear preventive guidelines. At the moment it is essential to control all the children born of mothers with HCV infection.

Pressure-regulated volume control versus volume control ventilation in severely obstructed patients / Control del volumen regulado por presión frente a ventilación con control del volumen en pacientes con obstrucción grave

No disponible

[Total plasma homocysteine levels. Relationship with plasmatic folic acid levels and 677C T polymorphism of 5,10-methylenetetrahydrofolate reductase]. / Concentración plasmática de homocisteína: relación con los niveles plasmáticos de ácido fólico y con el polimorfismo 677C T de la 5,10-metilenotetrahidrofolato reductasa.

BACKGROUND: Moderately increased plasma homocysteine (Hcy) in children has been associated with stroke and venous thrombosis and with a parental history of cardiovascular disease (CVD). Evaluation of Hcy concentrations during childhood and study of the factors determining its concentrations could play an important role in the primary prevention of CVD. Objective To detect cases of hyperhomocystinemia and to examine the association between Hcy levels and plasma folic acid levels and 677C T polymorphism of 5,10-methylenetetrahydrofolate reductase (MTHFR). METHODS: The relationship between plasma Hcy levels, plasma folic acid levels, and the three genotypes of 677C T MTHFR polymorphism was investigated in 127 children (aged 2-18 years) and in 105 parents by multiple linear regression. RESULTS: The median Hcy levels were 5.00 mol/l in the children and 8.00 mol/l in the parents. Plasma folic acid levels were normal in all of the patients. The prevalence of the three genotypes in the children was 32.3 % for the CC genotype, 42.5 % for the CT genotype and 15.7 % for the TT genotype. Hcy concentrations were significantly higher in children with the TT genotype (p 0.018). Multiple linear regression revealed a positive direct effect of age (b 0.029, p 0.002) and a negative effect of genotype TT (b 3.886, p 0.002) on Hcy concentration. Hcy concentration was inversely correlated with folic acid levels but this correlation did not reach statistical significance. CONCLUSIONS: No cases of hyperhomocystinemia were found. To evaluate Hcy, age and plasma folic acid levels have to be taken into account in case there is a 677C T mutation. Hcy concentrations should be determined in older children with a family history of atherothrombosis and other risk factors for premature CVD.

Estudio retrospectivo de factores de riesgo de transmisión vertical de infección por virus hepatitis C / Retrospective study of risk factors of vertical transmission of hepatitis C virus

Introducción: A pesar de la baja prevalencia infantil de infección por virus hepatitis C (VHC) y su leve clínica inicial, la infección crónica puede evolucionar a cirrosis y/o hepatocarcinoma. Es fundamental controlar su transmisión vertical. Los últimos estudios describen hasta 50% de transmisiones intraútero. Material y métodos: Estudiamos retrospectivamente 17 casos de infección por VHC en 8 años, analizando los factores de riesgo de transmisión vertical, para aplicar prevención primaria. Resultados: Solo la adicción a drogas vía parenteral muestra riesgo significativo, sin ser la coinfección VIH factor de confusión. La carga viral, la coinfección por VIH, la disfunción hepática y el tiempo de evolución de infección no muestran mayor riesgo. La cesárea, la amniocentesis y la monitorización interna pueden ser factores de riesgo (sin significación estadística), pero no las horas de amniorrexis. La lactancia materna muestra protección. Conclusiones: Pese a la importancia frecuentemente atribuida, el efecto de la carga viral sobre el riesgo de transmisión no está claramente establecido: la ausencia de viremia no descarta el riesgo de transmisión, ya que la detección de ARN viral puede ser intermitente, y por tanto, los datos al respecto deben interpretarse con cautela. La inmunosupresión secundaria a la coinfección por VIH supone mayor riesgo de transmisión, pero dicho efecto disminuye al mejorar la capacidad inmune gracias al tratamiento antirretroviral. Respecto a las características del parto, el tiempo transcurrido tras la rotura de membranas no ha mostrado ser factor de riesgo; y se desestima la cesárea como forma óptima y electiva de finalizar la gestación de estas mujeres. La lactancia materna, lejos de suponer mayor riesgo de transmisión, puede ser protectora. La escasa carga viral en la leche, su inactivación por el pH ácido gástrico y sus beneficios inmunológicos justificarían este resultado. Dadas las limitaciones de los estudios retrospectivos, es necesario plantear análisis prospectivos para conocer mejor el papel de los posibles factores de riesgo y establecer pautas claras de prevención; de momento, es fundamental el control evolutivo de todos los hijos de madres con infección por el VHC (AU)

Introduction: Despite the low prevalence of paediatric HCV infection and its initial mild clinical expressiveness, chronic infection could progress into cirrhosis and/or hepatocarcinoma. It is essential to control vertical transmission. Recent studies show that up to 50% of transmissions occur within the uterus. Material y methods: A retrospective study was conducted on 17 cases of (Hepatitis C virus) HCV infection registered over a period of 8 years. Vertical transmission risk factors were analysed, in order to introduce primary prevention. Results: Only parenteral drug addiction significantly increased the rate of HCV transmission; HIV co-infection was not a confounding factor. HCV viremia, HIV co-infection, liver dysfunction and/or duration of the infection did not appear to affect the rate of transmission. Caesarean section, amniocentesis and internal monitoring may be risk factors (not statistically significant), but not prolonged vaginal delivery after amniotic membrane rupture. Breastfeeding showed protection. Conclusions: The effect of viremia on the risk of transmission is not clearly established, despite the importance usually attributed. Lack of viremia does not discount the risk of transmission, due to viral RNA detection can be intermittent, so it should be interpreted cautiously. Immunosuppression secondary to HIV co-infection implies a higher risk of transmission, but this effect decreases by improving immune competence by antiretroviral treatment. With regard to the birth characteristics, time after the rupture of membranes has not shown being a risk factor; being the caesarean not advisable as a good alternative to finish the pregnancy. Breastfeeding does not increase the risk, even it can be protective. This results would be justified by the low viral content of milk, its inactivation by gastric pH and its immunological benefits. Given that retrospective studies results are limited, prospective studies need to be carried out in order to improve the understanding of the role of possible risk factors and to provide a clear preventive guidelines. At the moment it is essential to control all the children born of mothers with HCV infection (AU)

Neumonía adquirida en la comunidad. Factores que predisponen al desarrollo de derrame pleural / Community acquired pneumonia. Factors that predispose to pleural effusion

Objetivo: Describir nuestra experiencia en el diagnóstico y el tratamiento de niños que precisan ingreso por neumonía adquirida en la comunidad (NAC), y analizar los factores que predisponen al desarrollo de derrame pleural paraneumónico (DPP). Material y métodos: Estudio observacional de una cohorte prospectiva. Muestreo consecutivo de niños de 2-14 años de edad ingresados por NAC entre julio de 2007 y febrero de 2008.Variables independientes: edad, sexo, días de estancia, patología previa, antibioterapia previa, administración de vacuna antineumocócica conjugada heptavalente (VCN7v), sintomatología, recuento de leucocitos y neutrófilos, proteína C reactiva, antígeno de neumococo en orina, hemocultivo, serología para Mycoplasma, test de tuberculina, radiología al diagnóstico y antibioterapia. Variables de resultado principal: evolución a DPP y su tratamiento. Ajustamos un modelo de regresión logística (RL) multivariable. Resultados: Se estudió a un total de 102 pacientes con una mediana de edad de 4,8 años; un 13% tenía antecedentes de broncoespasmo; en 26 la vacunación con VCN7v era completa, en 29 incompleta, y 46 niños no habían sido vacunados; 23 pacientes desarrollaron un derrame pleural, 10 precisaron un drenaje pleural y urocinasa, y uno exclusivamente drenaje; en el resto se instauró tratamiento conservador. Describimos una incidencia de DPP con un intervalo de confianza del 95% de 13,95-31,15. Tras el análisis estadístico (RL), apreciamos que tanto la vacunación completa con VCN7v (p= 0,01) como la serología indicativa de infección aguda por Mycoplasma (p= 0,01) predicen independientemente la evolución a DPP. Conclusión: El tratamiento evacuador, asociado o no a fibrinolisis, fue eficaz en todos los casos. Nuestros datos permiten conjeturar un posible papel causal de la VCN7v y de la coinfección por Mycoplasma pneumoniae en el desarrollo de DPP (AU)

Objective: To describe our experience in the diagnosis and treatment of children with community-acquired pneumonia (CAP) that need hospitalization, and to analyze the factors that influence the development of parapneumonic pleural effusion(PPE). Material and methods: Observational study of a prospective cohort. Consecutive sample of children aged 2 to 14 years admitted with CAP between July 2007 and February 2008. Independent variables: age, sex, days of stay, previous pathology, previous antibiotic therapy, vaccination with heptavalent pneumococcal conjugated vaccine (PCV7), symptomatology, white blood cells and neutrophils, C reactive protein, pneumococcal antigen in urine, blood culture, serology of Mycoplasma, tuberculin test, chest radiology, antibiotic therapy. Primary outcomes: pleural effusion development and its treatment. We fit a multivariable logistic regression (LR) model. Results: 102 patients. Median age 4.8 years, 13% had a history of bronchospasm. In 26 vaccinations with PCV7 was complete, incomplete in 29, and 46 cases had not been vaccinated. 23 patients developed PPE, 10 needed pleural drainage and urokinase, 1 exclusively drainage, the rest of the patients conservative treatment. We report an incidence of PPE 95% (CI= 13.95-31.15). After the statistical analysis (LR) we see that both PCV7 complete vaccination (p= 0.01) and serology evidence of acute Mycoplasma infection (p= 0.01) independently predict the development of PPE. Conclusion: Treatment with drainage with or without effective fibrinolysis in all cases. Our data allows us to guess estimate a possible causal role of PCV7 and Mycoplasma pneumonia ecoinfection in PPE development (AU)

Tratamiento farmacológico con antifibrinolíticos del empiema secundario a derrame paraneumónicocomplicado / Drug treatment with antifibrinolytics of secondary empyema secondary to complicated parapneumonic effusion

En los últimos años se ha observado en nuestro país un incremento en las complicaciones asociadas a neumonía bacteriana, tales como derrame y empiema. El tratamiento inicial de este tipo de complicación es la asociación de antibióticos que cubran el posible germen implicado así como la colocación de un tubo de drenaje pleural para acelerarla resolución del proceso. La formación de septos dentro de la cavidad pleural requiere terapia adicional (tratamiento antifibrinolítico, videotoracoscopia), sin haberse demostrado cual de estas dos alternativas es mejor. Presentamos una revisión que abarca más de 15 años (1990-2006), del manejo del empiema en nuestro centro. La estrategia de manejo con instilación inicial de antifibrinolíticos intrapleurales, hace de nuestra serie la más larga de las revisadas en nuestro país en que se utiliza dicho tratamiento (30 pacientes de los 50 revisados (60%) fueron tratados con dicha técnica). El éxito inicial fue de 96% con esta modalidad, sin requerir cirugía de rescate. Se hace además un análisis descriptivo de varios parámetros clínicos, analíticos y radiológicos, destacando la estancia media hospitalaria y en unidad de cuidados intensivos. En el análisis comparativo se aprecia una disminución de la estancia en unidad de cuidados intensivos en aquellos pacientes a los que se administró antifibrinolíticos. Este resultado prueba la eficacia del tratamiento en ese aspecto, lo cual es bastante alentador (AU)

In recent years we have observed in our country an increase in complications associated with bacterial pneumonia, such as pleural effusion and empyema. The initial treatment is an association of antibiotics, covering the potential germ involved, and the placement of a pleural drainagetube, in order to accelerate the resolution process. Formation of septawith in the pleural cavity requires additional therapy (antifibrinolytictreatment, videothorascopy), but no one of these two alternatives is been demonstrated better than the other. We present a review that covers last15 years (1990-2006), related to management of empyema. The management strategy with initial instillation of antifibrinolytic intrapleural makes our series the longest in our country using such treatment(30 of 50 patients reviewed (60) were treated with this technique).Initial success was 96% with this modality, without rescuing surgery. There is also a descriptive analysis of several clinical, laboratory andradiological parameters. In comparative analysis, length of stay in intensive care unit decreases in those patients treated with antifibrinolytics. This result is a prove of the efficacy of this treatment, and quite encourageing (AU)

MBE en Cirugía Pediátrica. Lectura crítica de artículos. Etiología / EBM in pediatric surgery: critical reading of articles. Etiology

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MBE en Cirugía Pediátrica. Lectura crítica de artículos. Pronóstico / EBM in Pediatric Surgery. Critical appraisal of studies. Prognosis

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Ibuprofeno frente a indometacina para el tratamiento de la persistencia del conducto arterioso del prematuro: revisión sistemática y metaanálisis / Ibuprofen versus indomethacin in the preterm persistent patent ductu sarteriosus therapy: review and meta-analysis

Introducción El ductus arterioso persistente (DAP) es una patología frecuente en el recién nacido prematuro cuyo tratamiento tradicional ha sido la indometacina. Recientemente, el ibuprofeno ha mostrado ser eficaz en su cierre con menores efectos hemodinámicos. El objetivo de este trabajo es revisar la literatura disponible para determinar si existe alguna ventaja entre ambos fármacos en el tratamiento del DAP. Material y métodos Se incluyeron 11 ensayos que compararon ibuprofeno con indometacina en el tratamiento del DAP confirmado ecográficamente en prematuros de menos de 35 semanas o de menos de 1.500 g de peso al nacimiento. Se realizó un metaanálisis de los resultados aportados por los distintos estudios. Resultados Ningún estudio encontró diferencias significativas en el fracaso del cierre del DAP entre ambos fármacos, ni el metaanálisis tampoco (riesgo relativo [RR]: 0,96; intervalo de confianza [IC] del 95 %: 0,74 a 1,26], con un poder de 0,995). No hubo diferencias en la frecuencia de reaperturas ni de ligaduras quirúrgicas. Las complicaciones fueron similares, excepto una incidencia significativamente menor de oliguria en los tratados con ibuprofeno (RR: 0,23; IC 95 %: de 0,10 a 0,51). No se encontraron diferencias en la evolución respiratoria (RR de displasia broncopulmonar a los 28 días de 1,32; IC 95 %: de 0,99 a 1,76). Conclusiones En nuestra revisión, el ibuprofeno fue igual de eficaz que la indometacina en el cierre del DAP. No hubo diferencias en la incidencia de complicaciones excepto menores problemas renales con el ibuprofeno. No se confirma un mayor riesgo de displasia broncopulmonar en el grupo de ibuprofeno, aunque se necesitan más estudios al respecto

Introduction Persistent patent ductus arteriosus (PDA) is a common pathology in the preterm whose traditional treatment has been indomethacin. Recently, ibuprofen has shown its effectiveness in closing the PDA with less hemodynamic effects. The objective of this paper is to review the current literature in order to determine if there is any benefit of ibuprofen versus indomethacin in the PDA therapy. Material and methods Eleven trials comparing intravenous ibuprofen versus indomethacin in the treatment of PDA confirmed by echocardiography in < 35 weeks preterm or < 1,500 g birth weight were included. A meta-analysis of the trials data was performed. Results No trial show statistically significant differences in the failure of closing PDA, neither the meta-analysis (RR 0.96 [CI 95 %: 0.74-1.26], with a power of 0.995). No differences were found in the rate of reopening and surgical ligation. Complications were similar, except for a significant lower incidence of oliguria in the ibuprofen group (RR 0.23 [CI 95 %: 0.10-0.51]). There were no differences in the respiratory outcomes (RR of bronchopulmonary dysplasia (BPD) at 28 days 1.32 [CI 95 %: 0.99-1.76]). Conclusions In our revision ibuprofen was as effective as indomethacin in closing PDA. No significant differences were found in the incidence of complications except for less renal impairment with ibuprofen. A higher risk of BPD in the ibuprofen group is not confirmed, although more studies are needed