Adverse drug reactions in paediatric surgery: prospective study on frequency and risk related factors.

BACKGROUND: Paediatric patients are especially prone to experiencing adverse drug reactions (ADRs), and the surgical environment gathers many conditions for such reactions to occur. Additionally, little information exists in the literature on ADRs in the paediatric surgical population. We aimed to quantify the ADR frequency in this population, and to investigate the characteristics and risk factors associated with ADR development. METHODS: A prospective observational study was conducted in a cohort of 311 paediatric patients, aged 1-16 years, admitted for surgery at a tertiary referral hospital in Spain (2019-2021). Incidence rates were used to assess ADR frequency. Odds ratios (ORs) were calculated to evaluate the influence of potential risk factors on ADR development. RESULTS: Distinct ADRs (103) were detected in 80 patients (25.7%). The most frequent being hypotension (N = 32; 35%), nausea (N = 16; 15.5%), and emergence delirium (N = 16; 15.5%). Most ADRs occurred because of drug-drug interactions. The combination of sevoflurane and fentanyl was responsible for most of these events (N = 32; 31.1%). The variable most robustly associated to ADR development, was the number of off-label drugs prescribed per patient (OR = 2.99; 95% CI 1.73 to 5.16), followed by the number of drugs prescribed per patient (OR = 1.26, 95% CI 1.13 to 1.41), and older age (OR = 1.26, 95% CI 1.07 to 1.49). The severity of ADRs was assessed according to the criteria of Venulet and the Spanish Pharmacovigilance System. According to both methods, only four ADRs (3.9%) were considered serious. CONCLUSIONS: ADRs have a high incidence rate in the paediatric surgical population. The off-label use of drugs is a key risk factor for ADRs development.

[Complex regional pain syndrome and myoclonus: an uncommon combination]. / Distrofia simpático-refleja y mioclonías: una asociación infrecuente.

Complex regional pain syndrome (CRPS) is quite uncommon in paediatric patients. There is no identified organic aetiology. CRPS has a very significant psychosomatic component; therefore it is necessary to take a multidisciplinary approach to its treatment, which should include psychiatric assessment. CRPS is very difficult to diagnose, and can take months to control its symptoms. The association with myoclonus is rare, and since myoclonus is the clinical manifestation of a vast spectrum of different neurological disorders, some of which are degenerative, it is important to make a diagnosis as quickly as possible. We present the case of an adolescent male with an atypical presentation of CRPS. CRPS was located in the thorax, which is very unusual and was associated with myoclonus and dystonias. This made the diagnosis harder and widened the aetiological spectrum.

[Congenital xerocytosis]. / Xerocitosis congénita.

Hereditary xerocytosis is a genetic disease inherited as an autosomal dominant trait and is a rare cause of hemolytic anemia. It is caused by abnormal erythrocyte membrane permeability: monovalent cation pump activity is increased and the Na/K pump cannot compensate for the K lost. As a consequence, xerocytes dehydrate, becoming rigid and sensitive to metabolic stress and oxidation. Morbility depends on the severity of the hemolytic anemia. Periodic episodes of jaundice are common during mild infections; most patients remain asymptomatic but experience mild-to-moderate hemolytic anemia, which is generally well compensated. The diagnostic clues are a markedly increased flow through the Na/K pump with a decrease in total intracellular cation content and subsequent red cell dehydration. Treatment is based on monitoring for eventual complications and careful observation during infections, which may worsen the anemia. Splenectomy is not useful and for some authors may even be contraindicated. The prognosis is generally very good. We report the case of a patient with episodes of hemolytic anemia during intercurrent infections and positive diagnostic tests for hereditary xerocytosis.

[Serum transferrin receptor in healthy children. Diagnostic yield in ferropenic and infectious anemia]. / Receptor sérico de transferrina en niños sanos. Valor diagnóstico en la anemia infecciosa y en la ferropénica.

BACKGROUND: The serum transferrin receptor (TfR) presents certain advantages over other parameters of cellular iron status because it does not vary in acute or chronic diseases. OBJECTIVE: To establish reference ranges of TfR in healthy children for our laboratory, to define the distribution of this variable in children with acute illness and in those with iron deficiency, and to evaluate the diagnostic yield of TfR, the transferrin-receptor/ferritin ratio (TfR/F) and the transferrin-receptor-ferritin index (TfR-F) in distinguishing ferropenic from infectious anemia. PATIENTS AND METHODS: A descriptive, cross-sectional analysis was conducted in 132 children aged from 6 months to 16 years for a period of 18 months. The subjects were classified in three groups: healthy children, children with acute illness, and children with iron deficiency. The distribution of TfR and its diagnostic yield were evaluated. RESULTS: Of the 132 subjects, 30 were excluded because they lacked one or more of the parameters under analysis and 19 were excluded because they showed a thalassemic trait. In the 30 healthy children, the mean TfR concentration was 1.2 mg/l (SD 0.36) and the median was 1.02 (IQR 0.7-1.7). In the 32 children with acute illness, with or without anemia, TfR values were similar to those found in healthy children (p > 0.05). TfR values were higher in children with iron deficiency (21 patients; mean TfR value: 1.67 mg/l SD 0:98) than in healthy children but this difference was not statistically significant (p 0.08). The highest TfR values were found in the group with ferropenic anemia (mean TfR value: 2.13 mg/l SD 1.14) with a statistically significant difference between healthy children (p 0.04) and those with iron deficiency without anemia (p 0.01). The TfR/F ratio showed an optimal diagnostic yield in distinguishing ferropenic from acute disease anemia. If this ratio is higher than 80.7 ferropenia can be suspected as the cause of the anemia with a global value of the test of 100 % (95 % CI: 75.91-99.42). CONCLUSIONS: TfR could be useful in evaluating intracellular iron status in children. Acute disease does not alter TfR values and, in combination with ferritin, TfR offers an optimal diagnostical yield in distinguishing ferropenic from acute illness anemia.

[Pancreatitis: review of our casuistics in the last 10 years]. / Pancreatitis: revisión de nuestra casuística en los últimos 10 años.

OBJECTIVE: Pancreatitis is a rare cause of abdominal pain in childhood. Advances in imaging techniques for pancreatic disease have enabled earlier clinical and etiological diagnosis, thus improving treatment possibilities. The aim of this study was to analyze the etiology, diagnostic methods, and management in patients with pancreatitis diagnosed in our hospital in the last 10 years. MATERIAL AND METHODS: We reviewed the children aged 0-16 years with a diagnosis of pancreatitis admitted to our hospital between 1990 and 2000. Diagnostic criteria were symptoms suggestive of pancreatitis and hyperamylasemia. RESULTS: There were 8 females and 1 male. The median age was 11.5 years (range: 7-16 years). Laboratory findings were as follows: mean amylase level was 1601 U/l and mean lipase level was 506 U/l. Imaging tests: ultrasonography, abdominal computed tomography (CT), and endoscopic retrograde cholangiopancreatography (ERCP) were performed in 1 patient, and magnetic resonance cholangiopancreatography (MRCP) was performed in 2. Etiology was cholelithiasis (2 patients), secondary to anti-oncological therapy (3 patients), hypercholesterolemia (1 patient), and idiopathic (3 patients). Medical treatment consisted of diet, analgesia, and octreotide in 1 patient, and antioxidants in 1 patient. Surgery was required in 2 patients. Complications consisted of pancreatic pseudocyst in 2 patients. CONCLUSIONS: The incidence of childhood pancreatitis is low. In our series, mainly teenage girls were affected. The main causes were idiopathic and toxic. Diagnosis was given by elevated amylase and lipase levels in blood and by imaging tests (ultrasonography, abdominal CT, ERCP, MRCP, depending on the patient). Basic treatment consisted of support measures (fasting and analgesia) together with octreotide, antioxidants or surgical treatment, depending on etiology.

[Octreotide treatment of post surgical chylothorax]. / Tratamiento del quilotórax posquirúrgico con octreótido.

Chylothorax is an infrequent complication of cardiac surgery in children. Most patients respond to a low-fat diet or to parenteral nutrition, but pleuroperitoneal drainage or thoracic duct ligature is sometimes required. We present the case of a 3-year-old girl with Down syndrome and complex atrioventricular canal defect who presented chylothorax 22 days after the Glenn procedure with bidirectional pulmonary-cava fistula. Low-fat diet and parenteral nutrition produced no improvement and the patient was treated with octreotide 1-2 mcg/kg/min in intravenous continuous perfusion, which produced remission of chylothorax. Subsequently, 20 mcg/kg/day of octreotide was subcutaneously administered in three doses, allowing progressive dietary normalization, without recurrence of chylothorax or adverse effects. In conclusion, octreotide is well tolerated and produces few adverse effects. It could be used as a therapeutic alternative in chylothorax refractory to conservative treatment.

[Exhaled nitric oxide in healthy and asthmatic children]. / Oxido nítrico exhalado en niños sanos y asmáticos.

OBJECTIVES: One of the main findings in asthma is chronic inflammation of the airway. Exhaled nitric oxide may be a useful marker of airway inflammation in asthmatic children. To evaluate the concentration of nitric oxide (NO) in exhaled air in healthy and asthmatic children and to relate this variable with different treatments. MATERIAL AND METHODS: A cross-sectional study was performed in a tertiary hospital. The concentration of exhaled NO (in parts per billion) was analyzed by chemoluminescence using the T technique of exhaling against expiratory resistance with positive mouthpiece pressure in two different study groups: group A (control group) consisted of 105 healthy children aged 6-14 years old without a history of respiratory disease; group B (asthmatic group) consisted of 79 children aged 6-14 years old diagnosed with asthma and undergoing anti-asthmatic treatment for at least the previous two months, depending on the severity of their disease. Quantitative variables were analyzed using Student's t-test and the relationship between qualitative variables was analyzed using the chi-squared test. RESULTS: Expired NO concentrations were significantly higher in the asthma group (15.02 ppb) than in the control group (5.40 ppb) (p < 0.01). No significant differences were found among the asthmatic children in asthma severity. Expired NO was higher in asthmatic children treated with nedocromil (16.62 ppb) than in those treated with inhaled corticosteroids (11.8 ppb) but this difference was not significant (p 0.08). Children who presented signs of acute asthma (22.87 ppb) and those with a positive bronchial dilatation test (20.65) showed higher expired NO values (p < 0.05) than those without asthmatic crises and/or a negative bronchial dilatation test. Likewise, children with atopic dermatitis showed higher expired NO concentrations (23.07 ppb) than those without atopic dermatitis (11.68 ppb) (p < 0.001). CONCLUSIONS: Children with asthma of various degrees of severity have higher levels of expired NO than do healthy children. Measurement of expired NO concentrations can be used to monitor bronchial inflammation and to evaluate the efficacy of anti-inflammatory treatments.

[Childhood cholelithiasis. Analysis of 24 patients diagnosed in our department and review of 123 cases published in Spain]. / Colelitiasis en la infancia. Análisis de 24 pacientes y revisión de 123 casos publicados en España.

INTRODUCTION: Childhood cholelithiasis is being increasingly diagnosed worldwide, particularly in Spain. We retrospectively analyzed several epidemiological, clinical, diagnostic, etiologic and therapeutic aspects of this disease in 123 pediatric cases reported in Spain since 1971. PATIENTS AND METHODS: Twenty four patients with cholelithiasis were diagnosed in our department between 1981 and 1999. Data on sex, age at diagnosis, form of clinical presentation, imaging studies used in diagnosis, etiology and underlying associated diseases, complications and treatment were retrospectively analyzed. The data obtained on the patients in our study were compared with and added to those of a further 99 pediatric cases published in Spanish medical journals since 1971. Cases diagnosed during the neonatal period were not included. RESULTS AND CONCLUSIONS: The main findings were the following. The mean age at diagnosis was 7.8 years. The percentage of males was 51% and that of females was 49%. A total of 33.3% of the patients were asymptomatic and 66.6% were symptomatic. The most frequent symptoms were abdominal pain with or without vomiting (94%), jaundice (13.4%) and fever (9.7%). Etiology was idiopathic in 60.2% of patients and secondary in 39.8%. In the latter group the main causes of cholelithiasis were hemolytic anemia in 19 patients, obesity in 12, biliary tract malformations, hypercholesterolemia and liver disease in 4, and cystic fibrosis in 3. Diagnosis was based on abdominal ultrasonography in 89.4% of the patients and on Xray in 60.1%. Complications found were cholecystitis in five patients and pancreatitis in seven. One child with pancreatitis died from acute respiratory distress syndrome. Surgical treatment was given to 55.3% of the patients while 43.9% were treated conservatively. In one child cholelithotripsy was used.