Perfil de crianças e adolescentes dependentes de tecnologia em um hospital pediátrico do Sul do país / Perfil de niños e adolescentes dependientes de tecnología en un hospital pediátrico de referencia del sur del país / Profile of technology-dependent children and adolescents in a referral pediatric hospital in the south of the country

Resumo Objetivo identificar o perfil de crianças e adolescentes dependentes de tecnologia de um hospital de referência pediátrica do sul do país. Método estudo descritivo, com abordagem quantitativa. A coleta de dados ocorreu por meio da análise de prontuários, entre janeiro de 2016 e dezembro de 2019, armazenados em planilha Microsoft Excel para a análise estatística descritiva. Um projeto aprovado pelo Comitê de Ética sob o parecer 5.115.194. Resultados prevaleceu o sexo masculino (50,8%), em idade pré-escolar (30,8%), proveniente da Grande Florianópolis (60,1%). Os diagnósticos mais frequentes foram relacionados à prematuridade/período neonatal, anomalias congênitas/defeitos genéticos, doenças neurológicas e/ou neuromusculares, correspondendo a 37%, 33,2% e 18,5%. Os dispositivos tecnológicos mais utilizados foram gastrostomia (56,3%) e traqueostomia (36,6%). A utilização de medicamentos contínuos se deu em 93,4% e 49,2% utilizavam quatro ou mais medicamentos. As mães foram as principais cuidadoras (80,9%). Ocorreram 31 óbitos no período. Conclusão e implicação para a prática este grupo apresenta grande demanda de cuidados decorrentes do diagnóstico principal, dos dispositivos tecnológicos, das medicações e das possíveis complicações. A identificação do perfil das crianças e adolescentes dependentes de tecnologia contribuiu para ampliar a visibilidade de uma população que está em constante crescimento e, assim, prestar uma assistência integral, de acordo com suas especificidades e reais necessidades.

Resumen Objetivo identificar el perfil de niños y adolescentes dependientes de tecnología atendidos en un hospital de referência pediátrica del sur del país. Método estudio descriptivo con enfoque cuantitativo. La recolección de datos ocurrió através del análisis de las historias clínicas, desde enero de 2016 hasta diciembre de 2019, almacenadas en una hoja de cálculo de Microsoft Excel para el análisis estadístico descriptivo. El proyecto fue aprobado por el Comité de Ética bajo el parecer 5.115.194. Resultados predominaron varones (50,8%), en período de desarrollo preescolar (30,8%), la región más frecuentada de la Gran Florianópolis (60,1%). Los diagnósticos más frecuentes estuvieron relacionados con prematuridad/el período neonatal, anomalías congénitas/defectos genéticos, enfermedades neurológicas y/o neuromusculares, correspondiendo al 37%, 33,2% y 18,5%, respectivamente. Los dispositivos tecnológicos más utilizados fueron la gastrostomía (56,3%) y la traqueotomía (36,6%). El uso de medicación continua ocurrió en el 93,4% y el 49,2% utilizó cuatro o más medicamentos. Las madres fueron las principales cuidadoras en 80,9% de los casos, ocurriendo 31 óbitos en el período. Conclusión e implicación para la práctica este grupo tiene una alta demanda de atención debido al diagnóstico principal, dispositivos tecnológicos, medicamentos y posibles complicaciones. Identificar el perfil de niños y adolescentes dependientes de tecnología contribuye a aumentar la visibilidad de una población en constante crecimiento y, por lo tanto, calificar la asistencia, de acuerdo com sus especificidades y reales necesidades.

Abstract Objective to identify the profile of technology-dependent children and adolescents at a pediatric referral hospital in southern Brazil. Method a descriptive study with a quantitative approach. Data was collected by analyzing medical records between January 2016 and December 2019 and stored in a Microsoft Excel spreadsheet for descriptive statistical analysis. The project was approved by the Ethics Committee under protocol number 5.115.194. Results: The prevalence was male (50.8%), pre-school age (30.8%), from Greater Florianópolis (60.1%). The most frequent diagnoses were related to prematurity/neonatal period, congenital anomalies/genetic defects, and neurological and/or neuromuscular diseases, corresponding to 37%, 33.2%, and 18.5%. The most commonly used technological devices were gastrostomy (56.3%) and tracheostomy (36.6%). 93.4% used continuous medication and 49.2% used four or more medications. Mothers were the main caregivers (80.9%). There were 31 deaths during the period. Conclusion and implications for practice this group has a high demand for care due to the main diagnosis, technological devices, medications, and possible complications. Identifying the profile of technology-dependent children and adolescents has helped to increase the visibility of a population that is constantly growing and thus provides comprehensive care according to their specific needs.

Necrosis esofágica aguda (esófago negro) asociado a neoplasias digestivas / Acute esophageal necrosis (black esophagus) associated with digestive neoplasms

INTRODUCCIÓN. La necrosis esofágica aguda es un síndrome raro que se caracteriza endoscópicamente por una apariencia negra circunferencial irregular o difusa de la mucosa esofágica intratorácica, la afectación es generalmente del esófago distal y la transición abrupta de mucosa normal en la unión gastroesofágica, con extensión proximal variable. CASOS. Se presentan dos casos con diferentes comorbiliades, presentación de signos y síntomas, antecedentes y tratamiento, teniendo en común el diagnóstico a través de endoscopía digestiva alta. RESULTADOS. Caso clínico 1: tratamiento clínico basado en hidratación, suspensión de vía oral, omeprazol intravenoso y sucralfato; mala evolución clínica caracterizada por: disfagia, intolerancia oral y recurrencia del sangrado digestivo alto, se realiza colocación de gastrostomía endoscópica. Caso clínico 2: esófago con mucosa con fibrina y parches de necrosis extensa, se realiza compensación tanto de foco infeccioso pulmonar como hidratación y nutrición, en estudios complementarios se observa masa colónica, con estudio histopatológico confirmatorio de adenocarcinoma de colon en estado avanzado. DISCUSIÓN. La esofagitis necrotizante aguda es una entidad inusual, de baja prevalencia e incidencia, asociada con estados de hipoperfusión sistémica y múltiples comorbilidades que favorezcan un sustrato isquémico. Al revisar los reportes de casos que hay en la literatura médica, los casos que reportamos se correlaciona con las características clínicas, epidemiológicas, endoscópicas y factores de riesgo causales de la enfermedad. La presentación clínica más frecuente es el sangrado digestivo alto, que se debe correlacionar con el hallazgo endoscópico clásico. Nuestro primer caso reportado termina con la colocación de una gastrostomía para poder alimentarse. CONCLUSIÓN. El pronóstico de la necrosis esofágica aguda es malo y se requiere un alto índice de sospecha clínica y conocimiento de esta infrecuente patología para un diagnóstico temprano y un manejo oportuno. Se requiere una evaluación por endoscopia digestiva alta. Es una causa de sangrado gastrointestinal que conlleva tasas altas de mortalidad, principalmente en adultos mayores frágiles. El reconocimiento temprano y la reanimación agresiva son los principios fundamentales para un mejor resultado de la enfermedad.

INTRODUCTION. Acute esophageal necrosis is a rare syndrome that is characterized endoscopically by an irregular or diffuse circumferential black appearance of the intrathoracic esophageal mucosa, the involvement is generally of the distal esophagus and the abrupt transition of normal mucosa at the gastroesophageal junction, with variable proximal extension. CASES. Two cases are presented with different comorbidities, presentation of signs and symptoms, history and treatment, having in common the diagnosis through upper gastrointestinal endoscopy. RESULTS. Clinical case 1: clinical treatment based on hydration, oral suspension, intravenous omeprazole and sucralfate; poor clinical evolution characterized by: dysphagia, oral intolerance and recurrence of upper digestive bleeding, endoscopic gastrostomy placement was performed. Clinical case 2: esophagus with mucosa with fibrin and patches of extensive necrosis, compensation of both the pulmonary infectious focus and hydration and nutrition is performed, in complementary studies a colonic mass is observed, with a confirmatory histopathological study of colon adenocarcinoma in an advanced state. DISCUSSION. Acute necrotizing esophagitis is an unusual entity, with low prevalence and incidence, associated with states of systemic hypoperfusion and multiple comorbidities that favor an ischemic substrate. When reviewing the case reports in the medical literature, the cases we report correlate with the clinical, epidemiological, endoscopic characteristics and causal risk factors of the disease. The most common clinical presentation is upper gastrointestinal bleeding, which must be correlated with the classic endoscopic finding. Our first reported case ends with the placement of a gastrostomy to be able to feed. CONCLUSION. The prognosis of acute esophageal necrosis is poor and a high index of clinical suspicion and knowledge of this rare pathology is required for early diagnosis and timely management. Evaluation by upper gastrointestinal endoscopy is required. It is a cause of gastrointestinal bleeding that carries high mortality rates, mainly in frail older adults. Early recognition and aggressive resuscitation are the fundamental principles for a better outcome of the disease.

Higher Dose Noninvasive Transcutaneous Auricular Vagus Nerve Stimulation Increases Feeding Volumes and White Matter Microstructural Complexity in Open-Label Study of Infants Slated for Gastrostomy Tube.

OBJECTIVE: To determine whether transcutaneous auricular vagus nerve stimulation (taVNS) paired with twice daily bottle feeding increases the volume of oral feeds and white matter neuroplasticity in term-age-equivalent infants failing oral feeds and determined to need a gastrostomy tube. STUDY DESIGN: In this prospective, open-label study, 21 infants received taVNS paired with 2 bottle feeds for 2 - 3 weeks (2x). We compared 1) increase oral feeding volumes with 2x taVNS and previously reported once daily taVNS (1x) to determine a dose response, 2) number of infants who attained full oral feeding volumes, and 3) diffusional kurtosis imaging and magnetic resonance spectroscopy before and after treatment by paired t tests. RESULTS: All 2x taVNS treated infants significantly increased their feeding volumes compared with 10 days before treatment. Over 50% of 2x taVNS infants achieved full oral feeds but in a shorter time than 1x cohort (median 7 days [2x], 12.5 days [1x], P < .05). Infants attaining full oral feeds showed greater increase in radial kurtosis in the right corticospinal tract at the cerebellar peduncle and external capsule. Notably, 75% of infants of diabetic mothers failed full oral feeds, and their glutathione concentrations in the basal ganglia, a measure of central nervous system oxidative stress, were significantly associated with feeding outcome. CONCLUSIONS: In infants with feeding difficulty, increasing the number of daily taVNS-paired feeding sessions to twice-daily significantly accelerates response time but not the overall response rate of treatment. taVNS was associated with white matter motor tract plasticity in infants able to attain full oral feeds. TRIAL REGISTRATION: Clinicaltrials.gov (NCT04643808).

Troubleshooting the pediatric gastrostomy.

Gastrostomy tubes benefit patients but also introduce hazards and costs. Most of these costs tend to be administratively invisible, but clinically expensive. Nurses, residents, emergency physicians, surgeons, and others routinely manage complaints about gastrostomy tubes or sites, and the time and effort costs are enormous. Despite widespread use of gastrostomy tubes and the large "cost of ownership," scant instruction guides practitioners on troubleshooting the panoply of tube-related problems. Instead, clinical folk-wisdom leaves staff disarmed, resorting to lore or maladaptive work-arounds that are futile or even harmful. But tubes and gastrostomies fail in predictable ways. This guide reviews commonly used gastrostomy tubes and how they are placed. Routine care of these tubes both in the immediate postoperative period and long-term is detailed. Then, specific gastrostomy tube complications and their principle-based countermeasures are described, organized by presenting complaint. Throughout, specific clinical pitfalls are called out along with their remedies. The aim is to demystify these devices and dispel myths that lead to error.

Understanding the current nutritional management for people with amyotrophic lateral sclerosis - A mapping review.

BACKGROUND & AIMS: Poor nutritional outcomes are observed in people with Amyotrophic Lateral Sclerosis (pwALS) including weight loss and poor dietary intake. Surveys of healthcare professionals have highlighted the lack of evidence and knowledge regarding nutritional management of ALS throughout the disease course. Furthermore, national evidence-based guidance is lacking. This mapping review aims to understand the structure and input of nutritional management services for pwALS. METHODS: Systematic searches were conducted across eight electronic databases to identify qualitative and quantitative research on structure and input of nutritional care in ALS. Supplementary searches included grey literature, citation and reference list searching of included studies and key reviews, web searching and contacting experts and organisations that provide ALS services to identify guidelines. Study selection and data extraction were undertaken independently by at least two reviewers. Data was synthesised using a narrative approach. RESULTS: One hundred and nine documents were identified. These consisted of journal articles, guidelines and related documents that contributed evidence towards mapping of nutritional management of pwALS. No evidence on commissioning of nutritional care was identified. Guidelines provided high-level overviews and gave general guidance or recommendations for care; however, these typically focused on gastrostomy with limited guidance on broader aspects, including oral nutrition support. Evidence from primary studies found nutritional care delivery in ALS consisted of multiple types of nutritional management, at different time points during the disease course and involving a range of professionals. There was little evidence relating to proactive nutritional care. Details of healthcare setting, number of professionals involved in care, team composition and how services were delivered in community settings were sparse. Although the role of the speech and language therapist in swallowing assessment and provision of advice on the management of swallowing difficulties was consistent; there was limited evidence on care provided by dietitians. In addition, a small number of studies reported on the use of screening tools. Overall, evidence was consistent that weight management, including monitoring of weight change by professionals and patients, was central and recommended that this should be part of nutritional assessment and follow-up. CONCLUSIONS: The evidence identified in this mapping review has highlighted the requirement for further primary research providing specific details on how nutritional management of pwALS is structured and delivered.

A European survey on the practice of nutritional interventions in head-neck cancer patients undergoing curative treatment with radio(chemo)therapy.

PURPOSE: As the practice of nutritional support in patients with head and neck cancer (HNC) during curative radio(chemo)therapy is quite heterogeneous, we carried out a survey among European specialists. METHODS: A 19-item questionnaire was drawn up and disseminated via the web by European scientific societies involved in HNC and nutrition. RESULTS: Among 220 responses, the first choice was always for the enteral route; naso-enteral tube feeding was preferred to gastrostomy in the short term, while the opposite for period longer than 1 month. Indications were not solely related to the patient's nutritional status, but also to the potential burden of the therapy. CONCLUSION: European HNC specialists contextualize the use of the nutritional support in a comprehensive plan of therapy. There is still uncertainty relating to the role of naso-enteral feeding versus gastrostomy feeding in patients requiring < 1 month nutritional support, an issue that should be further investigated.

Endoscopic Removal Through a Gastrostomy of Swallowed Acupuncture Needles.

Acupuncture is a representative treatment field in oriental medicine that is used widely in various medical conditions. Although acupuncture is considered a safe procedure, it can cause complications. This paper reports the case of a 44-year-old quadriplegic woman who received a percutaneous gastrostomy (PEG) tube and was referred for the endoscopic removal of swallowed acupuncture needles. The needles were removed successfully by endoscopy through the PEG tube using the rendezvous technique without significant complications.

Education Following Pediatric Gastrostomy Tube Placement: An Integrative Review.

BACKGROUND: There is a gap in knowledge regarding the necessary components for pediatric gastrostomy tube education. This integrative review addresses the question "What are the educational components following pediatric gastrostomy placement?" METHODS: A literature search was conducted using PubMed, CINAHL, and Cochrane Library electronic databases, along with a hand search. Articles for review included those in the pediatric population, English language, and publication dates between 2010 and 2020. RESULTS: Ultimately, 7 articles met the inclusion criteria for review. Articles were all pediatric focused (0-18 years), and were a mix of quantitative and qualitative designs, along with one non-research paper. Three major themes were identified from the literature including that gastrostomy tube education should be a multidisciplinary effort, that education should take a standardized approach, and that it should include psychosocial elements that enhance caregiver knowledge and empowerment. DISCUSSION: This review demonstrates that while there is no consensus on a superior mode or means of education, pediatric gastrostomy discharge education must be standardized and high quality to promote the best patient and caregiver outcomes. Further research should aim to address which forms of education, if any, lead to the best outcomes, and how education can best be delivered to promote caregiver knowledge and ease.

Percutaneous Endoscopic Gastrostomy Feeding in Children with Cerebral Palsy.

AIM: The prevalence of congenital cerebral palsy (CP) worldwide ranges from 0.15 to 0.4%. CP causes several gastrointestinal complications that inhibit normal eating behavior. This single-center observational study aimed to determine the tolerability and benefits of percutaneous endoscopic gastrostomy (PEG) in pediatric CP patients with malnutrition. MATERIALS AND METHODS: The study included 41 pediatric CP patients with malnutrition. All patient data were retrospectively obtained from Bakirköy Dr. Sadi Konuk Research and Training Hospital, Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Istanbul, Turkey. In addition to baseline measurements of weight, height, triceps skinfold thickness, 1,25-hydroxyvitamin D3, folate, iron, zinc, vitamin B12, hemoglobin, and mean corpuscular volume, data analyzed included follow-up measurements recorded at 3 and 6 months of PEG (standard polymeric enteral supplementation as 1.0 kcal mL-1). RESULTS: There was significant improvement in both height, weight, and triceps skinfold thickness in all patients at 3 and 6 months of PEG (p < 0.05). In terms of blood parameters, there was not significant improvement, except that the number of patients with a low hemoglobin count significantly decreased at 3 and 6 months of (p = 0.022). Moreover, the number of patients with vomiting after PEG also significantly decreased at 3 and 6 months of (p = 0.004). CONCLUSION: PEG significantly improves malnutrition in pediatric CP patients and does not cause any major complications. Based on these findings, we think PEG is a beneficial and cost-effective intervention with a high rate of tolerability in pediatric CP patients with malnutrition.

An expanding role for interventional radiology: Medicare trends in fluoroscopic, endoscopic, and surgical enteric tube placement and maintenance from 2010 to 2018.

BACKGROUND: The purpose of this study is to provide an update on trends in physician volume and payments for enteric tube placement and maintenance procedures by method, provider specialty, and practice setting amongst Medicare beneficiaries from 2010 to 2018. MATERIALS AND METHODS: Claims from the Medicare Part B Physician/Supplier Procedure Summary Master File (PSPSMF) for the years 2010 to 2018 were extracted using current procedural terminology (CPT) codes for gastrostomy and jejunostomy placement, as well as conversion of gastrostomy to gastrojejunostomy, fluoroscopy guided and non-image guided replacement. Total volumes and provider reimbursement were analyzed by provider specialty and practice setting. RESULTS: Volume of de novo placement of all enteric tubes decreased from 157,123 to 106,549 (-32.2%). While endoscopic placement decreased from 133,658 to 81,171 (-39.3%), the volume of fluoroscopic placement increased from 17,999 to 21,277 (18.2%). Fluoroscopic placement was largely performed by interventional radiology (IR) (91.7% in 2018). Surgical placement decreased from 5466 to 4101 (-25.0%). Volume of fluoroscopic replacement increased from 24,799 to 38,470 (55.1%), while non-image guided replacements decreased from 61,377 to 55,116 (-10.2%). Share of both fluoroscopic and non-image guided replacements by advanced practice providers (APPs) more than doubled over this time period. CONCLUSION: De novo placement of enteric tubes decreased from 2010 to 2018, likely related to increased awareness of the complications and limited benefits in scenarios such as end of life care. In contrast to the diminishing volume for gastroenterologists, there was increased participation by IR in both placement and maintenance procedures under fluoroscopic guidance. SUMMARY STATEMENT: Decreasing placement of enteric tubes suggests shifting attitudes and recommendations around end-of-life care. Increase in role by IR/APPs highlights the need for comprehensive care in these patients.

Vitamin D in dysphagic patients who have undergone endoscopic gastrostomy for long-term enteral feeding.

OBJECTIVE: Vitamin D plays a major role in biological processes. Its deficiency is associated with increased morbidity and mortality. Patients who have undergone endoscopic gastrostomy (PEG) present with protein-energy malnutrition, and may be at risk for Vitamin D deficiency, due to their age, less sunlight exposure and lower dietary intake. We aimed to determine the prevalence of hypovitaminosis D in PEG-patients, its change under PEG-feeding, and its relationship with serum proteins and risk factors for Vitamin D deficiency. METHODS: This was a prospective observational study, over 4 weeks, after gastrostomy. Data were collected at the initial PEG procedure (T0), and after 4 weeks (T1). Initial evaluation included age, gender, underlying disorder, NRS-2002, BMI, serum albumin, transferrin and Vitamin D. At T1 we assessed Vit. D, albumin, and transferrin. Vitamin D was performed with Electrochemiluminescence through Elecsys 2010 assay. Patients were fed with blended homemade meals. RESULTS: 200 patients (118 males), 22-92 years of age, were studied. There were initial low values for Vit. D (181), albumin (96), transferrin (121), and BMI (124). A correlation was found between Vit. D and serum albumin (r=0.49, p=0.005) but not with transferrin (r=0.26, p=0.195). At T1 the subgroup who had Vit. D levels assessed (n=48) was part of the initial study group maintained low levels of Vitamin D despite nutritional intervention. CONCLUSION: We recommend systematic Vitamin D supplementation of PEG fed patients using homemade meals or at least screening for hypovitaminosis D as a routine part of their care.

Terapia nutricional de paciente com ataxia-telangiectasia: relato de caso / Nutrition therapy of a patient with ataxia-telangiectasia: case report

Neste artigo relatamos a terapia nutricional de um paciente com ataxia-telangiectasia (A-T) utilizando a gastrostomia (GTM) como via alternativa para alimentação. Paciente do sexo masculino, 13 anos de idade, com diagnóstico clínico de A-T aos 6 anos. Aos 8 anos e 7 meses o paciente foi identificado com risco nutricional (ZIMC/I: -1,67). Após 1 ano, evoluiu de forma desfavorável (ZIMC/I: -2,51) apesar da intervenção nutricional, sendo indicada a GTM aos 9 anos e 11 meses. No entanto, em decorrência da dificuldade de aceitação dos pais, o procedimento foi realizado somente quando o adolescente completou 11 anos e 7 meses. Inicialmente foi prescrita para oferta pela GTM dieta enteral normocalórica e normoproteica, correspondendo a 45,8% da necessidade energética diária. Após um mês, com estabilidade metabólica, houve a transição para uma dieta enteral hipercalórica e hiperproteica, fornecendo 91,6% da necessidade energética diária. Após 6 meses com a GTM, verificou-se ganho de peso total de 3,3 Kg (ZIMC/I -2,97), após 1 ano de 4,7 Kg (ZIMC/I -2,59), e após 1 ano e 9 meses de 6,7 Kg (ZIMC/I -2,63). Apesar da desnutrição nos pacientes com A-T ter origem multifatorial, o uso da GTM como via alternativa para alimentação por esse paciente resultou em uma evolução favorável dos seus indicadores antropométricos, sendo relatadas poucas intercorrências com a sua utilização. Portanto, sugere-se que pacientes com A-T devam ser monitorados periodicamente por equipe multiprofissional visando à identificação precoce de potenciais agravos.

In this article we report the nutritional therapy of a patient with ataxia-telangiectasia (A-T) using percutaneous endoscopic gastrostomy (PEG) as an alternative way of feeding. The patient was a 13-year-old male diagnosed with A-T at the age of 6 years. At 8 years and 7 months, the patient was at nutritional risk (body mass index z-score [BMIZ]: -1.67). After 1 year, he had an unfavorable evolution (BMIZ: -2.51), despite nutritional intervention; then, a PEG was indicated when he was 9 years and 11 months. However, due to the difficulty of parental acceptance, the procedure was performed when the adolescent was 11 years and 7 months. At first, a standard energy and protein enteral formula was prescribed, reaching 45.8% of his daily energy requirement. After 1 month, with metabolic stability, there was a transition to a high-energy and protein enteral formula providing 91.6% of his daily energy requirement. After 6 months of PEG placement, the patient had a total body weight gain of 3.3 kg (BMIZ: -2.97); subsequently, body weight increased by 4.7 kg (BMIZ: -2.59) after 1 year, and by 6.7 kg (BMIZ: -2.63) after 1 year and 9 months. Despite the multifactorial origin of malnutrition in A-T patients, PEG placement as an alternative way of feeding for this patient resulted in favorable evolution of his anthropometric indicators, and only a few complications were reported with its use. Therefore, it is suggested that patients with A-T should be monitored periodically by a multidisciplinary team for early identification of potential damages.

Gastrostomía por minilaparotomía / PERCUTANEOUS GASTROSTOMY WITHOUT LAPAROTOMY

Introducción: la cirugía percutánea constituye sin lugar a dudas la técnica de elección para la realización de la gastrostomía para alimentación enteral. No obstante sus ventajas, requiere de costosos sets y una complejidad para su realización, que no siempre tenemos al alcance en nuestro medio. Todo esto nos llevó a buscar una alternativa que fuese segura, de fácil manejo domiciliario y económicamente factible en todos los casos que se presentan en nuestro medio. Material y Método: se trata de un estudio retrospectivo de 18 pacientes tratados entre 2005 y 2008 por medio de esta técnica: laparotomía mínima (3 Cm), para mediana izquierda por debajo del reborde costal identificación de la porción ascendente del estómago, colocación de una sonda Foley N° 18 y fijación del estómago a la pared durante el cierre de la laparotomía. Resultados: en los pacientes de la serie estudiada no se observaron complicaciones graves, salvo alguna dermatitis por reflujo peri tubo y un prolapso de mucosa. Se observó también un fácil manejo domiciliario y una buena aceptación por parte de los pacientes. Discusión: se trata de una técnica segura y de bajo costo, que si bien no constituye el procedimiento de primera elección, permite en medios económicamente limitados como el nuestro, la realización de una vía de alimentación enteral segura, de bajo costo y con resultados similares. Introducción: la cirugía percutánea constituye sin lugar a dudas la técnica de elección para la realización de la gastrostomía para alimentación enteral. No obstante sus ventajas, requiere de costosos sets y una complejidad para su realización, que no siempre tenemos al alcance en nuestro medio. Todo esto nos llevó a buscar una alternativa que fuese segura, de fácil manejo domiciliario y económicamente factible en todos los casos que se presentan en nuestro medio. Material y Método: se trata de un estudio retrospectivo de 18 pacientes tratados entre 2005 y 2008 por medio de esta técnica: laparotomía mínima (3 Cm), para mediana izquierda por debajo del reborde costal identificación de la porción ascendente del estómago, colocación de una sonda Foley N° 18 y fijación del estómago a la pared durante el cierre de la laparotomía. Resultados: en los pacientes de la serie estudiada no se observaron complicaciones graves, salvo alguna dermatitis por reflujo peri tubo y un prolapso de mucosa. Se observó también un fácil manejo domiciliario y una buena aceptación por parte de los pacientes. Discusión: se trata de una técnica segura y de bajo costo, que si bien no constituye el procedimiento de primera elección, permite en medios económicamente limitados como el nuestro, la realización de una vía de alimentación enteral segura, de bajo costo y con resultados similares.

Introduction: Percutaneous surgery is undoubtedly the preferred technique to perform a gastrostomy for enteral feeding. Despite its advantages, it requires expensive sets and a complex procedure, which are not always available in our locations. All this led us to look for a safe alternative, easy to manage at home, and economically viable in all cases that occur in our locations. Material and Method: This is a retrospective study that includes 18 patients treated between 2005 and 2008 using the technique of minimal laparotomy (3 cm) for left median below the costal ridge, detection of the ascending portion of the stomach, placement of a Foley tube No. 18 and fixation of the stomach to the wall during the closure of the incision. Results: No serious complications were observed in the patients included in this study, except for some peri-tube reflux dermatitis and a mucous membrane prolapse. Easy home management and good patient tolerance were also observed. Discussion: Although this procedure is not the first-line treatment of choice, it is a safe and low-cost technique, which allows the placement of a safe, low-cost enteral feeding route with similar results in areas with scarce economic means like ours.

Growth in the High-Risk Newborn Infant Post-Discharge: Results from a Neonatal Intensive Care Unit Nutrition Follow-up Clinic.

Growth and nutrition in preterm infants have long-term implications for neurodevelopmental and cardiometabolic outcomes. Many infants are discharged from the neonatal intensive care unit (NICU) with growth restriction, but often without a specialized team to monitor postdischarge growth. At our institution, we addressed our ongoing concerns for the health and growth of these infants post-discharge by creating a Nutrition NICU Graduate Clinic. This clinic serves infants discharged from our NICU who were born with very low birth weight, had difficulty growing or feeding while inpatient, had a gastrostomy tube placed during hospitalization, or were deemed high risk for other reasons by our neonatal team, with the first clinic visit within 5 weeks of discharge. Data from our first 227 patients at time of discharge, first clinic visit, and any available second clinic visits are described. Anthropometrics show a high rate of extrauterine growth restriction at time of discharge with continued growth restriction at follow-up. Feeding regimens prescribed at discharge and variations from the prescribed regimen at time of follow-up are described. At time of first clinic visit, most patients (92.2%) required a medical or dietary intervention by our team. Our findings illustrate the need for early and specialized nutrition follow-up in this patient population to improve growth trajectory post-discharge.

Medical grade honey for the treatment of paediatric abdominal wounds: a case series.

OBJECTIVE: Children are at high risk of injuries and wounds. The application of medical grade honey is a promising approach to improving the healing of wounds of various origin and severity. However, the use of medical grade honey in young paediatric patients remains limited. The aim of this study is to show the safety, efficacy and usefulness of medical grade honey in abdominal wounds, of different causes, in paediatric patients. METHOD: This was a prospective, observational case series evaluating five young infants with abdominal wounds at the General Hospital in Thessaloniki. All wounds were treated in the same manner with daily medical grade honey applied to the wound area and closely monitored. RESULTS: All treated wounds rapidly presented granulation tissue formation and underwent re-epithelialisation. Peripheral oedema and inflammation decreased upon initial application. Necrotic tissue was effectively debrided when present. Slough was removed and no signs of infection were detected, irrespective of initial wound presentations. Scar formation was minimal and the full range of motion was preserved in all cases. CONCLUSION: Based on this case study, medical grade honey is safe and effective in treating different abdominal wounds, including infected or dehisced wounds as well as burns. The easy application and broad applicability make medical grade honey recommendable as a first-line treatment in paediatric patients.

Life, Love, Hope, Faith, and Death-Too Complex for Likert.

More research to examine factors contributing to health-care disparities at the end of life is greatly needed. This article outlines a failed attempt to quantify some of the motivators in medical decision-making for African American families faced with a decision to pursue or forego a percutaneous endoscopic gastrostomy in a loved one at the end of life. It explores the complexities of spirituality, history, culture, and death in our patient population in Charleston, South Carolina, where health-care disparities are well-documented, and distrust has deep historical roots. It outlines the need for qualitative research, where the defining role of the researcher is to practice the paramount palliative skill of listening.

Documentation of everyday life and health care following gastrostomy tube placement in children: a content analysis of medical records.

Background: Everyday routines play a vital role in child functioning and development. This study explored health professionals' documentation of everyday life and health care during the first year following gastrostomy tube placement in children and the content of intervention goals.Methods: The medical records of 39 children (median age 38 months, min-max: 15-192) in one region of Sweden were analysed. A content analysis approach was used with an inductive qualitative analysis supplemented by a deductive, quantitative analysis of documented intervention goals following the ICF-CY.Results: One overall theme, "Seeking a balance", captured the view of life with a gastrostomy and the health care provided. Two categories, "Striving for physical health" and "Depicting everyday life" with seven sub-categories, captured the key aspects of the documentation. Twenty-one children (54%) had intervention goals related to the gastrostomy, and these goals primarily focused on the ICF-CY component "Body functions".Conclusions: To some extent the medical records reflected different dimensions of everyday life, but the intervention goals clearly focused on bodily aspects. Understanding how health care for children using a gastrostomy is documented and planned by applying an ecocultural framework adds a valuable perspective and can contribute to family-centred interventions for children using a gastrostomy.Implications for RehabilitationThere is a need for increased awareness in healthcare professionals for a more consistent and holistic healthcare approach in the management of children with gastrostomy tube feeding.This study suggests that an expanded focus on children's participation in everyday mealtimes and in the healthcare follow-up of gastrostomy tube feeding is important in enhancing the intervention outcome.Multidisciplinary teams with a shared bio-psycho-social understanding of health would contribute to a situation in which the everyday lives of households adapt to living with gastrostomy.Routine care for children with gastrostomy should follow a checklist combining crucial physiological aspects of gastrostomy tube feeding with seemingly mundane family functions in order to achieve a successful gastrostomy tube feeding intervention.

Gastrostomy tube placement via a laparotomic procedure in growing conventional piglets to perform multi-dose preclinical paediatric drug studies.

The use of juvenile conventional pigs as a preclinical animal model to perform pharmacokinetic (PK), pharmacodynamic (PD) and safety studies for the paediatric population is increasing. Repetitive oral administration of drugs to juvenile pigs is however challenging. A representative method which can be used from birth till adulthood is necessary. The current study presents the placement and use of a gastrostomy button in pigs with a weight ranging from 2.4 to 161 kg. The surgical placement was performed via a laparotomic procedure on, each time, 12 pigs (six male, six female) of 1 week, 4 weeks, 8 weeks and 6-7 months old. For every age category, eight pigs were part of a PK study with a non-steroidal anti-inflammatory drug (NSAID) and four pigs served as a control group. No severe complications were observed during surgery. The button remained functional for 10 days in 40 out of 48 pigs. No significant differences in body temperature or white blood cell count were observed during the trial. Three control pigs showed signs of inflammation indicating a NSAID might be warranted. Autopsy revealed minimal signs of major inflammation in the abdominal cavity or the stomach. A limited number of pigs showed mucosal inflammation, ulcers or abscesses in the stomach or around the fistula. These results indicate that the laparotomic placement of a gastrostomy button might be considered safe and easy in growing pigs to perform repetitive oral dosing preclinical studies. However, the method is not advised in pigs weighing more than 100 kg.

Cannabis Use in Children With Pantothenate Kinase-Associated Neurodegeneration.

BACKGROUND: Pantothenate kinase-associated neurodegeneration is characterized by severe, progressive dystonia. This study aims to describe the reported usage of cannabis products among children with pantothenate kinase-associated neurodegeneration. METHODS: A cross-sectional, 37-item survey was distributed in April 2019 to the families of 44 children who participate in a clinical registry of individuals with pantothenate kinase-associated neurodegeneration. RESULTS: We received 18 responses (40.9% response rate). Children were a mean of 11.0 (SD 4.3) years old. The 15 respondents with dystonia or spasticity were on a median of 2 tone medications (range 0-9). Seven children had ever used cannabis (38.9%). The most common source of information about cannabis was other parents. Children who had ever used cannabis were on more tone medications, were more likely to have used opiates, were less likely to be able to roll, and less likely to sit comfortably, than children who had never used cannabis. Four children reported moderate or significant improvement in dystonia with cannabis. Other areas reported to be moderate or significantly improved were pain (n = 3), sleep (n = 4), anxiety (n = 3), and behavior (n = 2). Adverse effects included sadness (n = 1), agitation/behavior change (n = 1), and tiredness (n = 1). CONCLUSION: Cannabis use was commonly reported among children with pantothenate kinase-associated neurodegeneration whose parents responded to a survey, particularly when many other dystonia treatments had been tried. Physicians should be aware that parents may treat their child with severe, painful dystonia with cannabis. Placebo-controlled studies of products containing cannabidiol and 9-tetrahydrocannabinol are needed for pediatric tone disorders.