Hemorrhagic shock due to ileal varices, a diagnostic challenge.

Gastrointestinal bleeding due to portal hypertension is a major complication in patients with cirrhosis, commonly attributed to esophagogastric varices. However, bleeding from ectopic varices accounts for 5% of variceal bleeding cases and it may occur at lower pressures than esophageal varices. Thus, ectopic varices should be considered in patients with portal hypertension that present with gastrointestinal bleeding lacking evidence of esophagogastric variceal bleeding on upper gastrointestinal endoscopy. We present the case of a patient with cirrhosis that had recurrent hemorrhagic shock due to small intestinal varices that were diagnosed via capsule endoscopy.

Association Between Unbalanced Solutions and Acute Kidney Injury During Fluid Resuscitation in Children With Sepsis.

OBJECTIVE: To evaluate the outcomes of patients with sepsis-associated organ dysfunction and septic shock who receive fluid resuscitation with balanced and unbalanced solutions in a middle-income country. DESIGN: An observational, analytical cohort study with propensity score matching (PSM) in children admitted to a pediatric intensive care unit (PICU). Patients from one month to 17 years old who required fluid boluses due to hemodynamic instability were included. The primary outcome was the presence of acute kidney injury and the secondary outcomes were the need to begin continuous renal replacement therapy (CRRT), metabolic acidosis, PICU length of stay and mortality. MEASUREMENTS AND MAIN RESULTS: Out of the 1,074 admissions to the PICU during the study period, 99 patients had sepsis-associated organ dysfunction and septic shock. Propensity score matching was performed including each patient´s baseline characteristics. The median age was 9.9 months (IQR 4.9-22.2) with 55.5% of the patients being male. Acute kidney injury was seen less frequently in children who received a balanced solution than in those who received an unbalanced solution (20.3% vs 25.7% P = 0.006 ORa, 0.75; 95% CI, 0.65-0.87), adjusted for disease severity. In addition, the group that received balanced solutions had less need for CRRT (3.3 % vs 6.5%; P = 0.02 ORa 0.48; 95% CI, 0.36-0.64) and a shorter PICU stay (6 days IQR 4.4-20.2 vs 10.2 days IQR 4.7-26; P < 0.001) than the group with unbalanced solutions. We found no difference in the frequency of metabolic acidosis (P = 0.37), hyperchloremia (P = 0.11) and mortality (P = 0.25) between the 2 groups. CONCLUSION: In children with sepsis-associated organ dysfunction and septic shock, the use of unbalanced solutions for fluid resuscitation is associated with a higher frequency of acute kidney injury, a greater need for continuous renal support and a longer PICU stay compared to the use of balanced solutions, in a middle-income country.

Venous-arterial CO2 difference in children with sepsis and its correlation with myocardial dysfunction.

Objective: This study aimed to determine the association between venous-arterial CO2 difference (Pv-aCO2) and clinical outcomes of interest in children with severe sepsis and septic shock. Design: An analytical observational study of a prospective cohort was conducted. Setting: The study was carried out from January 2015 to January 2018 in the pediatric intensive care unit of a referral hospital. Materials and methods: Of a total of 1159 patients who were admitted to pediatric critical care, 375 had severe sepsis and septic shock, of which 67 fulfilled the inclusion criteria. Arterial and venous gases were drawn simultaneously with a transthoracic echocardiogram, Pv-aCO2, and other measures of tissue perfusion such as arterial lactate, venous, and evolution to multiple organ failure. Measurements and main results: Half (53.7%) of the patients were under 24 months old, with a slight predominance of male patients. The main site of infection was the lungs in 56% of the cases, with a 91.2% survival rate. Patients who died had a higher venous lactate level (interquartile range 16.2-33.6, p = 0.02). However, there was no correlation between myocardial dysfunction seen on echocardiogram and a Pv-aCO2 greater than 6 mm Hg in children with severe sepsis and septic shock (r = 0.13). Pv-aCO2 and central venous saturation had low sensitivity to detect multiple organ failure and poor correlation with the number of compromised systems (r = 0.8). Conclusion: Pv-aCO2 was not associated with myocardial dysfunction, measured by echocardiogram, in children with severe sepsis and septic shock. It also did not correlate with the number of organs involved or mortality.

Association of Toll-like receptor 4 single-nucleotide polymorphisms Asp299Gly and Thr399Ile with the risk of primary open angle glaucoma.

PURPOSE: Toll-like receptor 4 (TLR4) is a transmembrane receptor that mediates immune responses to exogenous and endogenous ligands. Previously, non-coding single nucleotide polymorphisms (SNPs) in the TLR4 gene were related to primary open angle glaucoma (POAG). This study was undertaken to investigate whether coding TLR4 Asp299Gly (rs4986790 A/G) and Thr399Ile (rs4986791 C/T) are associated with POAG in a Mexican population. METHODS: One hundred and eighty-seven unrelated Mexican patients with POAG (94 men and 95 women; mean age 66.49 ± 14.3 years) and 109 control subjects (40 men and 69 women; age, 63.28 ± 7.93 years) were included. SNPs Asp299Gly (rs4986790 A/G) and Thr399Ile (rs4986791 C/T) were genotyped by a Taqman® Allelic Discrimination Assayand. Allelic, genotypic, haplotypic, and model-based (dominant, recessive, and codominant) associations of the SNPs with POAG were analyzed using Chi-squared tests or Fisher exact tests and logistic regression. RESULTS: Strong linkage disequilibrium was observed among the SNPs (D' = 0.8692), which were located in one haplotype block. With respect to allelic diversity, the minor allele of both SNPs generates a significantly increased risk of POAG. The minor allele of Asp299Gly conferred the highest increased risk of POAG (P = 0.0054, OR = 4.47, 95% CI = 1.46-13.70). With regard to genotypic diversity, individuals carrying the minor allele of Asp299Gly and Thr399Ile had a significant increased risk for POAG with OR of 4.47 (P = 0.054, 95% CI = 1.30-15.35) and 3.5, respectively (P = 0.012, 95% CI = 1.17-10.44). Haplotype analysis was non-significant. CONCLUSIONS: TLR4 coding SNPs Asp299Gly and Thr399Ile might be used as genetic susceptibility alleles for POAG in Mexican population. Our findings support the role of TLR4 in the pathophysiology of glaucoma.

Severity and mortality of acute respiratory failure in pediatrics: A prospective multicenter cohort in Bogotá, Colombia.

Background and Aims: Acute respiratory failure (ARF) is the most frequent cause of cardiorespiratory arrest and subsequent death in children worldwide. There have been limited studies regarding ARF in high altitude settings. The aim of this study was to calculate mortality and describe associated factors for severity and mortality in children with ARF. Methods: The study was conducted within a prospective multicentric cohort that evaluated the natural history of pediatric ARF. For this analysis three primary outcomes were studied: mortality, invasive mechanical ventilation, and pediatric intensive care unit (PICU) length of stay. Eligible patients were children older than 1 month and younger than 18 years of age with respiratory difficulty at the time of admission. Patients who developed ARF were followed at the time of ARF, 48 h later, at the time of discharge, and at 30 and 60 days after discharge. It was conducted in the pediatric emergency, in-hospital, and critical-care services in three hospitals in Bogotá, Colombia, from April 2020 to June 2021. Results: Out of a total of 685 eligible patients, 296 developed ARF for a calculated incidence of ARF of 43.2%. Of the ARF group, 90 patients (30.4%) needed orotracheal intubation, for a mean of 9.57 days of ventilation (interquartile range = 3.00-11.5). Incidence of mortality was 6.1% (n = 18). The associated factors for mortality in ARF were a history of a neurologic comorbidity and a higher fraction of inspired oxygen at ARF diagnosis. For PICU length of stay, the associated factors were age between 2 and 5 years of age, exposure to smokers, and respiratory comorbidity. Finally, for mechanical ventilation, the risk factors were obesity and being unstable at admission. Conclusions: ARF is a common cause of morbidity and mortality in children. Understanding the factors associated with greater mortality and severity of ARF might allow earlier recognition and initiation of prompt treatment strategies.

Use of high-flow cannula in pediatric patients with respiratory failure: A prospective cohort study in three high-altitude hospitals.

Background and Aims: Acute respiratory failure (ARF) is a common cause of morbimortality, and a frequent reason for admission to the pediatric intensive care unit (PICU). It requires a high-flow oxygen device as treatment. Our aim is to determine the frequency and main indications for the use of high-flow nasal cannula (HFNC), and the prevalence of HFNC failure and its main causes, in three hospitals. Methods: It is a multicenter prospective cohort study, developed in three hospitals in Bogota. Eligible patients were children older than 1 month and younger than 18 years who presented ARF and required management with an HFNC. The study was carried out between April 2020 and December 2021. The follow-up was carried out at 1, 6, and 48 h after starting the management. Results: Of 685 patients included in the study, 296 developed ARF. The prevalence of patients with ARF who required management with HFNC was 48%. The frequency of the pathologies that cause the ARF was: Bronchiolitis was the most frequent pathology (34.5%), followed by asthmatic crisis (15.5%) and pneumonia (12.7%). The average time of use of HFNC was 81.6 h. Regarding treatment failure with HFNC, 15 patients presented torpid evolution and required invasive mechanical ventilation, with a prevalence of therapeutic failure of the HFNC of 10.6%. Conclusion: The use of HFNC is more frequent in patients with bronchiolitis, in children under 2 years of age and in males, which is in line with what has been reported in the literature. In addition, the failure rate of HFNC is low (10.6%), and it may be useful in other pathologies besides bronchiolitis, such as asthma, pneumonia, among others. It opens the possibility to continue evaluating the role of HFNC in pediatric pathology in new studies.

COVID-19 in children and the influence on the employment activity of their female caregivers: A cross sectional gender perspective study.

Introduction: During the COVID-19 pandemic, women disproportionately assume more unpaid activities, affecting their employment. Objective: Describe the influence of COVID-19 on the employment of caregivers of children and adolescents from a gender perspective. Methods: Cross-sectional study in three high-complexity hospitals in Bogotá, Colombia from April 2020 to June 2021. A subsample of the FARA cohort was taken, including those patients with a positive test for SARS-COV2. We took as our analysis category children older than 8 years and younger than 18 years who had a positive SARS-COV2 test, as well as, caregivers of all children with a positive SARS-COV2 test. This subsample was drawn from the FARA cohort. A survey was applied to them. We carried out a descriptive and stratified analysis by age group, educational, and socioeconomic level. Results: We included 60 surveys of caregivers and 10 surveys of children. The main caregiver in 94.8% of the cases was a female. At the beginning of the pandemic, 63.3% of the caregivers were employed, and 78.9% of those lost their employment. The vast majority of these caregiver were women (96.6%, n = 29). A predominance of loss of work activity was documented in caregivers of children in early childhood 66.6% (n = 20), with lower education 66.6% (n = 20), and from lower strata 56.6% (n = 17). Conclusion: Caregivers of children with COVID-19 with low educational levels and lower socioeconomic conditions, as well as those with children under 5 years showed greater likelihood of employment loss between the interviewed subsample.

Incidence, etiology, sociodemographic and clinical characterization of acute respiratory failure in pediatric patients at a high-altitude city: A multicenter cohort study.

Background: Acute respiratory failure is a life-threatening medical condition, associated with a variety of conditions and risk factors, including acute respiratory diseases which are a frequent cause of pediatric morbidity and mortality worldwide. In Colombia, the literature related to ARF is scarce. Objective: To determine the incidence, causes, and sociodemographic and clinical characteristics of ARF in three hospitals in Bogota, a high-altitude city located in Colombia, during the COVID-19 pandemic. Methods: A multicenter prospective cohort study called the FARA cohort was developed between April 2020 - December 2021. Patients older than one month and younger than 18 years with respiratory distress who developed ARF were included. Results: 685 patients with respiratory distress were recruited in 21 months. The incidence density of ARF was found to be 41.7 cases per 100 person-year CI 95%, (37.3-47.7). The median age was 4.5 years.. Most of the patients consulted during the first 72 h after the onset of symptoms. Upon admission, 67.2% were potentially unstable. The most frequent pathologies were asthma, bronchiolitis, pneumonia, and sepsis. At admission, 75.6% of the patients required different oxygen delivery systems, 29,5% a low-flow oxygen system, 36,8% a high-flow oxygen system, and 9,28% invasive mechanical ventilation. SARS-COV-2, respiratory syncytial virus, rhinovirus/enterovirus, and adenovirus were the most frequently isolated viral agents. The coinfection cases were scarce. Conclusions: This multicenter study, the FARA cohort, developed at 2,600 meters above sea level, shows the first data on incidence, etiology, sociodemographic and clinical characterization in a pediatric population with ARF that also concurs with the COVID-19 pandemic. These results, not only have implications for public health but also contribute to the scientific and epidemiological literature on a disease developed at a high altitude.

Análisis de la continencia fecal en 83 pacientes operados de malformaciones anorrectales / Analysis of fecal incontinence in 83 patients operated on for anorrectal malformation

Se realiza un estudio retrospectivo de 83 pacientes operados de malformaciones anorrectales en el Hospital Pediátrico Universitario "William Soler" (46 varones y 37 hembras) en el período de enero de 1984 a diciembre de 1997, donde se analiza la continencia fecal según el método evaluativo de Kelly después de realizada la anorrectoplastia sagital posterior como técnica quirúrgica. Se relaciona la continencia fecal según variedad anatómica de la malformación y sexo, tiempo de seguimiento y relación con las alteraciones del hueso sacro, y se hallaron mejores resultados en las hembras con defectos bajos, con mayor tiempo de evolución y en aquellos niños donde el hueso sacro es normal

Cirugía de mínimo acceso / Minimally invasive surgery

Los avances en los procederes quirúrgicos no invasivos facilitan el tratamiento de patologías ginecológicas en edades tempranas

Irrigación total del intestino: nuestra experiencia en pacientes pediátricos / Total intestinal irrigation: our experience in pediatric patients

Se realiza irrigación total del intestino en 278 pacientes pediátricos en edades comprendidas entre 11 meses y 15 años, utilizando solución salina y manitol al 20 %. La irrigación se emplea en pacientes que iban a ser operados por distintas técnicas, para ser sometidos a diferentes estudios endoscópicos, con fines diagnósticos (manometría rectal, estudios radiológicos) y en el tratamiento de la constipación. Se emplea la solución salina en dosis de 200 ml por kg de peso y manitol al 20 % en dosis de 25 g. Se le realizó a los pacientes antes de la irrigación total y después ionograma, Hb, Hto, así como la toma de los signos vitales. No se usaron antibióticos profilácticos. La preparación fue satisfactoria en todos los casos y la infección posoperatoria se redujo al 3,7 %. La irrigación total del intestino en nuestros pacientes pediátricos resulto ser bién tolerada, fácil, rápida con excelentes resultados en la limpieza, exenta de complicaciones y con una significativa reducción en las infecciones en el posoperatorio

Tumores primarios del mediastino en la infancia / Primary mediastinal tumors in childhood

Sesenta y seis pacientes en edades comprendidas entre 16 horas y 15 años recibieron tratamiento en el Hospital Pediátrico Docente "William Soler" de 1967 a 1988. Las lesiones encontradas fueron las siguientes: neuroblastoma, 11; ganglioneuroma, 6; ganglioneuroblastoma, 5; quiste broncógeno, 6; quiste enterógeno, 5;higroma quístico, 3;teratoma, 3; lipoma, 2; timoma linfocítico, 1; timoma teratomatosa, 1; timoma granulomatoso, 1; carcinoma indiferenciado del timo, 1; timolipoma, 12; hiperplasia del timo, 5; enfermedad de Hodgkin, 9 y linfosarcoma, 6.Veinte y ocho (42,4 %) tenían de 0 a 2 años y 38 (57,7 %) entre 3 y 15 años. En 31 pacientes (47%) la lesión se localizó en el mediastino posterior; en 14 (21 %) en el medio: en 16 (25,7%) se localizó en el anterior y en 5 (6%) ocupó más de un comportamiento mediastínico. Veinte y cuatro pacientes (36%) se mostraron asintomáticos. En los pacientes sintomáticos predominaron los sintomas respiratorios, entre ellos disnea, tos, cianosis e infecciones respiratorias repetidas. Hubo 29 tumores benignos (44 %) y 37 lesiones malignas (56%). Entre la lesiones benignas sobrevivieron 26 (90%) y entre las malignas 23 (62%). El diagnóstico se comprobó por toracotomía en 53 pacientes, por biopsia ganglionar en 12 y por necropsia en uno. El tratamiento de elección fue la cirugía, excepto en los linfomas. En los tumores malignos se usó radioterapia y poliquimioterapia

Valor del ultrasonido abdominal en el diagnóstico y seguimiento de un absceso hepático en un adolescente / Value of abdominal ultrasound in the diagnosis and follow-up of hepatic abscess in an adolescent

Se presenta el caso de un adolescente del sexo masculino de 13 años de edad, de procedencia campesina, con un cuadro febril prolongado asociado con la afectación marcada del estado general, dolor en el hipocondrio derecho y hepatomegalia, por lo que fue diagnosticado como absceso hepático mediante las técnicas modernas de imagenología y gammagrafía. Se hace referencia a lo poco frecuente que es esta entidad en el niño cubano. El paciente fue atendido por un equipo multidisciplinario, el cual se apoyó en el dato de las imágenes seriadas tomadas por ultrasonido abdominal (USA), lo cual permitió aplicar un tratamiento médico conservador que tuvo un resultado exitoso. Otras técnicas más complejas y caras no aportaron más datos que el USA. Esta técnica no invasiva se encuentra prácticamente en todas las provincias de nuestro país

Irrigación total del intestino: usos en cirugía pediátrica; presentación de 60 casos / Complete intestinal irrigation: usen in pediatric surgery; report of 60 cases

Se describe el método de irrigación total del intestino con el empleo de tres soluciones, en la limpieza del mismo para procederes en cirugía pediátrica, se valoran los resultados obtenidos con relación a la rapidez, la cantidad de líquido irrigado, la disminución del costo con relación a métodos tradicionales así como las ventajas del método ya que no requiere la administración previa de antibióticos, ni provoca alteraciones en el equilibrio hidroelectrolítico, siendo los resultados que se muestran satisfactorios en los 60 pacientes

Esplenectomía parcial en esplenopatias hematológicas usando los rayos laser de CO2 / Partial splenectomy in hematologic splenopathies using CO2 laser rays

Se presentan 7 niños, que padecían de esplenopatías hematológicas necesitadas de esplenectomía, en edades comprendidas entre 15 meses y 15 años, con una media de 7,2 años. Se señala que las indicaciones de esplenectomía estuvieron dadas por: esplenomegalia gigante y marcados signos de hiperesplenismo. Dos niños presentaron enfermedad de Gaucher, 3 mostraron drepanocitemia, uno Sß talasanemia y otro, una leucemia mieloide crónica variedad infantil. Se informa que a todos se les practicó esplenectomía parcial, resecando de dos tercios a cuatro quintos del bazo , al que se le dejó solo un polo inferior, irrigado por arteria y vena polar. Un solo niño tuvo que ser reintervenido a las 2 horas de operado. A todos se les realizó gammagrafía con tecnetio 99m pre y posoperatorio. Se resume que hasta la fecha todos los niños se encuentran bien; se han normalizado las cifras de hematíes, leucocitos y plaquetas

Timectomía en la miastenia gravis en el niño: estudio preliminar / Thymectomy in the myasthenia gravis in the child: preliminary study

Se presentan 2 niñas con miastenia gravis, a las cuales se les realizó timectomía, y muestran desde el punto de vista histopatológico hiperplasia del órgano. Se analizan los distintos aspectos de la enfermedad con los casos publicados en la literatura médica mundial. En estos 2 casos se aprecia cómo los síntomas miasténicos regresaron completamente y las 2 niñas no reciben ningún medicamento desde que se operaron. Se considera que esos son los primeros casos informados en nuestro país de niños timectomizados por miastenia gravis. Se expresa que este trabajo se viene realizando en conjunto con el Instituto de Neurología y Neurocirugía, el Hospital Centro de Investigaciones Médico-Quirúrgicas (CIMEQ) y el Hospital Pediátrico Docente "William Soler"