[Update on the effectiveness and evidence of ante-natal perineal massage].

The impact and morbidity generated by perineal trauma during vaginal delivery justifies the need to find strategies to minimize it. Ante-natal perineal massage (APM) is proposed as a technique that increases the elasticity of the perineum and that could reduce damage to the pelvic floor. This review set out to discover the effectiveness and the scientific evidence that supports this procedure. The Medline, Cochrane, Tripdatabase and Cuiden databases for the last six years were consulted, in Spanish and English. Ten studies with different levels of evidence were found. All of them favoured the use of this technique. Although further research is needed, evidence currently available suggests that the use of APM in late pregnancy could be an effective and safe procedure to reduce perineal trauma in childbirth, especially in primiparous women, and postpartum pain in multiparous women.

Defining an Opioid Sparing Treatment Pathway for Chronic Abdominal Pain of Somatic and Visceral Origin: A Case Series.

Chronic non-malignant abdominal pain presents a treatment challenge for pain physicians. Treatment algorithms are often defined by single specialty and are unimodal with a dependence on opioids. We present a treatment algorithm for chronic abdominal pain using a combination of interventional therapy using transversus abdominis plane (TAP) blocks along with post injection medical management for treatment of somatic and visceral pain. This is a case series of 4 patients presenting with diverse causes of chronic abdominal pain were treated with the treatment algorithm defined below. Patients received either bilateral or unilateral TAP blocks based on pain location using a combination of 0.25% bupivicaine 10ml, 40mg triamcinolone, and clonidine 50 mcg by a single physician upon admission to our acute care hospital. Follow up treatment included a combination of gabapentin, nortriptyline, and an opioid + acetaminophen combination (hydrocodone/APAP vs. oxycodone/APAP) or continuation of the patient's outpatient opioid regimen. Pre-injection opioid milligram morphine equivalents (MME) and post-injection MME were measured as well as pain along the visual analog scale (VAS). Readmissions for pain were also noted. Patients receiving TAP blocks along with post injection medical management saw their VAS scores decrease by 68.5%. Their total daily milligram morphine equivalents (MME) consumption decreased by a mean of 68.9%. There were no readmissions for abdominal pain within the 1 year follow up period.

[Pays de la Loire Pneumococcus Observatory: antimicrobial resistance of Streptococcus pneumoniae in 2007]. / Observatoire régional du pneumocoque en région Pays de la Loire: résistance de Streptococcus pneumoniae aux antibiotiques en 2007.

OBJECTIVES: Between 1st January and 31st December 2007, 331 Streptococcus pneumoniae strains were collected from 20 participating laboratories in the Pneumococcus Network Pays de la Loire county to assess their susceptibility to antibiotics and to evaluate serogroups of strains. METHOD: The coordinating centre performed MICs of penicillin G, amoxicillin and cefotaxime by the reference agar dilution method. Results were interpreted according to CA-SFM breakpoints. Sensitivity to other antibiotics were studied and serotyping of each strain performed. RESULTS: Three hundred and thirty one strains were isolated in 2007. They were collected from 30 cerebrospinal fluids, 239 blood samples, 53 middle ear fluids and nine pleural fluids. The percentage of pneumococci with decreased susceptibility to penicillin G (PDSP) was 39% and was higher in children (51%) than in adults (35%). The PDSP were often multidrug resistants especially with a high percentage of resistance to erythromycin (87.6% versus 8.4% for pneumococci sensitive to penicillin G). Finally, the most prevalent serogroup was the serogroup 19 (29.6% of isolates). CONCLUSION: A decrease of PDSP was observed since 2001 and high-level resistant strains to beta-lactams remain low. The rate of PDSP in Pays de la Loire is in the national average.

[Intestinal invagination: change in its incidence from 1987 to 2008]. / Invaginación intestinal: cambio en su incidencia desde 1987 a 2008.

Some series have shown a decrease in the incidence of intestinal invaginations in last years. Moreover, the recent introduction of new types of rotavirus vaccines increases the interest of invagination' s incidence. To this purpose, reliable local epidemiological data are needed. In order to ascertain the trend in the incidence of invaginations and their current value in our area we have performed a retrospective review of patients under 3 years of age with the diagnosis of intussusception and confiemes with barium enema or ultrasound examination during the past 21 years. Our results show a statistically significant decrease in the incidence rate, with an incidence rate of one year from the previous 0.82 (95% 0,78-0, 86) from an estimated incidence for 1987 of 17.74 cases per 10,000 girls and 30.04 cases per 10,000 boys, in 2008 an estimated incidence of 0.27 cases per 10,000 girls and 0.49 cases per 10,000 boys. We conclude that in our population during the dtudy period a significant decrease of invagination' sincidence has been seen, especially in patients younger than one year. The current incidence is 0.27 cases per 10,000 girls and 0.49 cases per 10,000 boys less than 3 years old.

[Utility of Pediatric Appendicitis Score and abdominal ultrasound in the diagnostic process of acute appendicitis]. / Utilidad del Pediatric Appendicitis Score y la ecografía abdominal en el proceso diagnóstico de apendicitis aguda.

INTRODUCTION: Pain in the right iliac fossa is a frequent reason for consultation and the diagnosis of appendicitis remains a challenge. The Pediatric Appendicitis Score (PAS) stratifies the risk of suffering appendicitis, and abdominal ultrasound provides information without irradiation. This study aims to correlate the score and the ultrasound with the screening of appendicitis and evaluate its efficiency. PATIENTS AND METHODS: Prospective study of cases and controls, analytical, observational and longitudinal. Patients <15 years of age, treated for suspected appendicitis in the emergency department of a II level center, were evaluated for 6 months. The data were analyzed univariate and bivariate, using nonparametric and parametric tests according to the distribution. RESULTS: 68 patients with pain in the right iliac fossa were included: 26 appendicitis (cases) (38.2%) and 42 (61.7%) other diagnoses (controls). The PAS in appendicitis was 7.5±1.8 and in other diagnoses 5.4±1.8 (p <0.01). At 70.5% with PAS ≥4 an ultrasound was performed (diagnosis of appendicitis 58.1%, discarded 25.6% and inconclusive 16.3%). Sensitivity and specificity were calculated by PAS groups only, and including ultrasound. The best result was for PAS ≥4 with ultrasound with a sensitivity of 96.2%, specificity 94.1%, PPV 96.1% and NPV 94.1%. CONCLUSIONS: PAS is a good screening tool for the diagnosis of appendicitis. Ultrasound presents a high efficiency for the diagnosis of appendicitis. This efficiency improves when performed in the group of patients with PAS ≥4.

INTRODUCCION: El dolor en fosa ilíaca derecha es un motivo frecuente de consulta y el diagnóstico de apendicitis sigue siendo un reto. El Pediatric Appendicitis Score (PAS) estratifica el riesgo de padecer apendicitis, y la ecografía abdominal aporta información sin irradiación. Este estudio pretende correlacionar su puntuación y la ecografía con el despistaje de apendicitis y valorar su rendimiento. MATERIAL Y METODOS: Estudio prospectivo de casos y controles, analítico, observacional y longitudinal. Se evaluó a los pacientes <15 años, atendidos por sospecha de apendicitis en urgencias de un centro de II nivel, durante 6 meses. Se analizaron los datos de forma univariante y bivariante, utilizando pruebas no paramétricas y paramétricas según la distribución. RESULTADOS: Se incluyeron 68 pacientes con dolor en fosa ilíaca derecha: 26 apendicitis (casos) (38,2%) y 42 (61,7%) otros diagnósticos (controles). El PAS en apendicitis fue de 7,5±1,8 y en otros diagnósticos de 5,4±1,8 (p <0,01). Al 70,5% con PAS ≥4 se les realizó una ecografía (diagnósticas de apendicitis 58,1%, descartaron 25,6% y no concluyentes 16,3%). Se calculó la sensibilidad y especificidad por grupos de PAS solamente, e incluyendo la ecografía. El mejor resultado fue para PAS ≥4 con realización de ecografía con una sensibilidad 96,2%, especificidad 94,1%, VPP 96,1% y VPN 94,1%. CONCLUSIONES: El PAS es una buena herramienta de cribado para el diagnóstico de apendicitis. La ecografía presenta un alto rendimiento para el diagnóstico de apendicitis. Este rendimiento mejora al realizarla en el grupo de pacientes con PAS ≥4.

Endothelial damage is aggravated in acute GvHD and could predict its development.

The aim of the present study was to explore whether there is enhanced endothelial dysfunction in patients developing acute GvHD (aGvHD) after allogeneic hematopoietic cell transplantation (allo-HCT) and to identify biomarkers with predictive and/or diagnostic value. In in vitro experiments, endothelial cells (ECs) were exposed to serum from patients with (aGvHD, n=31) and without (NoGvHD, n=13) aGvHD, to evaluate changes in surface adhesion receptors, the reactivity of the extracellular matrix by measuring the presence of Von Willebrand factor (VWF) and platelet adhesion, and the activation of intracellular signaling proteins. Plasma levels of VWF, ADAMTS-13, TNF receptor 1 (TNFR1), soluble vascular cell adhesion molecule 1 and soluble intercellular adhesion molecule 1 were also measured. In vitro results showed a more marked proinflammatory and prothrombotic phenotype in ECs in association with aGvHD. Regarding circulating biomarkers, levels of VWF and TNFR1 above an optimal cutoff score, taken independently or combined, at day 7 after allo-HCT, would be able to positively predict that around 90% of patients will develop aGvHD. Our results demonstrate that endothelial damage is aggravated in those allo-HCT recipients developing aGvHD, and that VWF and TNFR1 are promising predictive aGvHD biomarkers. These findings could contribute to improve the understanding of the pathophysiology of aGvHD.

Actualización sobre la efectividad y evidencia del masaje perinealante-natal / Update on the effectiveness and evidence of ante-natal perineal massage

El impacto y la morbilidad que genera el traumaperineal durante el parto vaginal justifica la necesidadde encontrar estrategias que lo minimicen. El masajeperineal antenatal (MPA) se plantea como una técnicaque incrementa la elasticidad del periné y que podríareducir el daño en el suelo pélvico. La presente revisiónpretendió conocer la efectividad y la evidencia científica que avala este procedimiento. Se consultaron las bases de datos Medline, Cochrane, Tripdatabase y Cuiden,en español y en inglés, de los últimos seis años. Se encontraron diez artículos con diferentes niveles de evidencia. Todos ellos fueron favorables al empleo de estatécnica. Aunque es necesaria investigación adicional, laevidencia disponible actualmente sugiere que el uso delMPA al final del embarazo podría ser un procedimientoefectivo y seguro para reducir el trauma perineal en elparto, especialmente en primigestas, y el dolor postparto en multíparas.

The impact and morbidity generated by perineal trauma during vaginal delivery justifies the needto find strategies to minimize it. Ante-natal perinealmassage (APM) is proposed as a technique that increases the elasticity of the perineum and that couldreduce damage to the pelvic floor. This review setout to discover the effectiveness and the scientificevidence that supports this procedure. The Medline,Cochrane, Tripdatabase and Cuiden databases for thelast six years were consulted, in Spanish and English.Ten studies with different levels of evidence werefound. All of them favoured the use of this technique.Although further research is needed, evidence currently available suggests that the use of APM in latepregnancy could be an effective and safe procedureto reduce perineal trauma in childbirth, especially inprimiparous women, and postpartum pain in multiparous women.(AU)

Ocular colobomata.

Ocular colobomata present diagnostic and therapeutic challenges in patients of all ages, but especially in young children. The "typical" coloboma, caused by defective closure of the fetal fissure, is located in the inferonasal quadrant, and it may affect any part of the globe traversed by the fissure from the iris to the optic nerve. Ocular colobomata are often associated with microphthalmia, and they may be idiopathic or associated with various syndromes. Types and severity of complications vary depending on the location and size of the colobomata. This article reviews the pathogeneses, categorization, genetic bases, differential diagnoses and management of ocular coloboma.

Does sucralfate prevent apoptosis occurring in the ischemia/reperfusion-induced intestinal injury?

BACKGROUND/PURPOSE: We have shown in a previous study that sucralfate is beneficial in the prophylaxis and treatment of hypoxia/reoxygenation-induced intestinal injury. The aim of this study is to investigate whether sucralfate has any effect on the prevention of apoptosis in the ischemia/reperfusion (I/R)-induced intestinal injury. METHODS: Rats were randomized into three groups. Group 1 and 2 were subjected to I/R. Group 1 (treatment group) received sucralfate while group 2 (treatment control group) did not. Group 3 served as a normal control group (sham group). The terminal ileum was harvested for histopathologic investigation by light microscopy. The presence of apoptotic enterocytes (DNA fragmentation in cell nuclei) was detected by terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick-end-labeling (TUNEL) reaction. RESULTS: In treatment control group, 3 of 7 rats had severe inflammation. None of the sucralfate-treated rats showed severe inflammation, 6 of them only showed mild inflammatory changes (p < 0.05). The apoptotic percentage was found to be 37.1 +/- 9.4 in the sucralfate-treated group (group 1), whereas it was 45.4 +/- 3.9 in the untreated group (group 2) (p < 0.05). The sham group had a completely normal intestinal architecture. CONCLUSIONS: The present study shows that 1) the experimental model of I/R-induced intestinal injury induces enterocyte apoptosis; 2) sucralfate decreases enterocyte apoptosis in the experimental model of I/R-induced intestinal injury which may play a key role in the pathophysiological events leading to failure of the intrinsic gut barrier defense mechanisms.

Testis fixation in prepubertal rats: fibrin glue versus transparenchymal sutures reduces testicular damage.

Experimental studies have shown that different suture materials used in testis fixation cause some degree of inflammation in the testis. This study was planned to compare the histological changes that were caused by fibrin glue which is a tissue sealant and by silk and polypropylene for transparenchymal testis fixation. 28 prepubertal rats were divided into 4 groups. Testis was fixed to the tunica vaginalis by fibrin glue in group 1, by silk in group 2 and by polypropylene in group 3. Group 4 was planned as a control. Testicular inflammation and seminiferous tubular diameter were evaluated for histological changes. The least inflammation was observed in the fibrin glue group, while the most inflammation occurred in the silk group. Seminiferous tubular diameter was 241.55 +/- 45.90 in the fibrin glue group, 151.90 +/- 8.34 in the silk group and 161.36 +/- 9.96 in the polypropylene group. In conclusion, fibrin glue, when used for testis fixation, causes less inflammation and less destruction of seminiferous tubular diameter compared with silk and polypropylene.

Inguinoscrotal hematocele of the newborn.

Neonatal inguinoscrotal hematocele is a very rare disease of the first few days of life. The cause of this pathology is thought to be related with the umbilical plastic clamp, with an incorrect clamping technique or with the infant's lying over the clamp. Surgical treatment is not necessary as long as testicular torsion is excluded. In this report, three cases of inguinoscrotal hematocele diagnosed at surgical exploration in our clinic are reported and the literature reviewed.

Teratoid Wilms' tumor: a case report.

Teratoid Wilms' tumor is rarely seen and is a description used only recently. The term describes classical nephroma with a diversity of cell types and tissues. In this reported case, the epithelial component consisting of squamous areas made up 70 percent of the tumor; no criteria of dysplasia nor any nephroblastomatosis areas or endodermal elements were presented. Although it is reported that teratoid Wilms' tumor is not usually aggressive or metastatic, a case of unilateral teratoid Wilms' tumor in a 2.5-year-old-boy who died because of metastatic disease is presented and the literature reviewed.

Utilidad del Pediatric Appendicitis Score y la ecografía abdominal en el proceso diagnóstico de apendicitis aguda / Utility of Pediatric Appendicitis Score and abdominal ultrasound in the diagnostic process of acute appendicitis

Introducción: El dolor en fosa ilíaca derecha es un motivo frecuente de consulta y el diagnóstico de apendicitis sigue siendo un reto. El Pediatric Appendicitis Score (PAS) estratifica el riesgo de padecer apendicitis, y la ecografía abdominal aporta información sin irradiación. Este estudio pretende correlacionar su puntuación y la ecografía con el despistaje de apendicitis y valorar su rendimiento. Pacientes y métodos: Estudio prospectivo de casos y controles, analítico, observacional y longitudinal. Se evaluó a los pacientes <15 años, atendidos por sospecha de apendicitis en urgencias de un centro de II nivel, durante 6 meses. Se analizaron los datos de forma univariante y bivariante, utilizando pruebas no paramétricas y paramétricas según la distribución. Resultados: Se incluyeron 68 pacientes con dolor en fosa ilíaca derecha: 26 apendicitis (casos) (38,2%) y 42 (61,7%) otros diagnósticos (controles). El PAS en apendicitis fue de 7,5±1,8 y en otros diagnósticos de 5,4±1,8 (p<0,01). Al 70,5% con PAS ≥4 se les realizó una ecografía (diagnósticas de apendicitis 58,1%, descartaron 25,6% y no concluyentes 16,3%). Se calculó la sensibilidad y especificidad por grupos de PAS solamente, e incluyendo la ecografía. El mejor resultado fue para PAS ≥4 con realización de ecografía con una sensibilidad 96,2%, especificidad 94,1%, VPP 96,1% y VPN 94,1%. Conclusiones: El PAS es una buena herramienta de cribado para el diagnóstico de apendicitis. La ecografía presenta un alto rendimiento para el diagnóstico de apendicitis. Este rendimiento mejora al realizarla en el grupo de pacientes con PAS ≥4

Introduction: Pain in the right iliac fossa is a frequent reason for consultation and the diagnosis of appendicitis remains a challenge. The Pediatric Appendicitis Score (PAS) stratifies the risk of suffering appendicitis, and abdominal ultrasound provides information without irradiation. This study aims to correlate the score and the ultrasound with the screening of appendicitis and evaluate its efficiency. Patients and methods: Prospective study of cases and controls, analytical, observational and longitudinal. Patients <15 years of age, treated for suspected appendicitis in the emergency department of a II level center, were evaluated for 6 months. The data were analyzed univariate and bivariate, using nonparametric and parametric tests according to the distribution. Results: 68 patients with pain in the right iliac fossa were included: 26 appendicitis (cases) (38.2%) and 42 (61.7%) other diagnoses (controls). The PAS in appendicitis was 7.5±1.8 and in other diagnoses 5.4±1.8 (p <0.01). At 70.5% with PAS ≥4 an ultrasound was performed (diagnosis of appendicitis 58.1%, discarded 25.6% and inconclusive 16.3%). Sensitivity and specificity were calculated by PAS groups only, and including ultrasound. The best result was for PAS ≥4 with ultrasound with a sensitivity of 96.2%, specificity 94.1%, PPV 96.1% and NPV 94.1%. Conclusions: PAS is a good screening tool for the diagnosis of appendicitis. Ultrasound presents a high efficiency for the diagnosis of appendicitis. This efficiency improves when performed in the group of patients with PAS ≥4

Niña de 8 años de edad con una masa genital poco frecuente / 8 years old girl with unusual genital mass

Introducción: Las tumoraciones interlabiales en las niñas son una patología poco frecuente. Abarcan un amplio espectro de posibles lesiones que pueden generar confusión en su diagnóstico y manejo. Caso clínico: Niña de 8 años de edad que acude al servicio de urgencias por presentar flujo vaginal sanguinolento y prurito de 5 días de evolución. Inicialmente se orientó como himenitis, pero ante la persistencia de la clínica, se realizó una vaginoscopia y una cistoscopia, en las que se observó un prolapso de la mucosa uretral de grado II-III. Se trató la afección de manera conservadora con estrógenos tópicos y baños de asiento, y la paciente no ha precisado cirugía hasta el momento. Las masas interlabiales en las niñas generan confusión en su diagnóstico, manejo y pronóstico. Discusión: Conocer las características clínicas propias de cada entidad permitirá hacer un buen diagnóstico, sin precisar pruebas invasivas y más costosas, y asimismo, evitará un retraso en el diagnóstico. Conclusiones: Presentamos un caso clínico de tumoración interlabial en una niña en edad prepuberal como forma de presentación del prolapso uretral, una patología poco frecuente en la infancia

Introduction: Interlabial tumors in children are a rare finding. They cover a broad spectrum of possible causes that can lead to confusion in diagnosis and management. Case report: A 8-year-old
girl who was referred to the emergency room for 5 days of bloody vaginal discharge and itching. Initially a hymenitis was suspected but due to the persistence of the symptoms a cystoscopy was performed, showing prolapsed urethral mucosa grade II-III. She was treated conservatively with topical estrogens and sitz baths without needing surgery so far. Discussion: Genital masses in girls generate confusion in diagnosis, management and prognosis. Knowing the clinical features of each entity may allow us a good diagnosis without requiring more invasive and expensive tests and thus also avoid a delay in the diagnosis. Conclusion: We present a case of interlabial mass as a form of presentation of urethral prolapse, a rare pathology in childhood

Estudio de la población nacida pequeña para la edad gestacional en tratamiento con hormona del crecimiento / Study of small for gestational age in treatment with growth hormone

Objetivo: El objetivo principal de este estudio es analizar los cambios producidos en la velocidad de crecimiento durante los 2 primeros años de terapia con hormona del crecimiento recombinante humana (rhGH) en niños pequeños para su edad gestacional (PEG), en estadio I de Tanner, atendidos en el servicio de pediatría del hospital de referencia de la provincia de Lleida. Material y métodos: Se han recogido los datos de los pacientes PEG que han seguido tratamiento con rhGH durante al menos 2 años, en estadio I de Tanner al inicio y al final del periodo. Se han utilizado como referencia los datos del estudio español de crecimiento de 2010. Resultados: El número de pacientes que cumplen estos criterios es de 58 (un 45% varones y un 55% mujeres). La media de edad al inicio del tratamiento fue de 8 ± 2,7 años. La velocidad de crecimiento (VC) previa al tratamiento era de 5,2 ± 2,8 cm. En el primer año de tratamiento la VC fue de 8,6 ± 1,9 cm y en el segundo de 7 ± 2,1 cm. El análisis de regresión lineal ajustado por la edad del niño muestra un aumento significativo en la VC después del primer y segundo año respecto al valor inicial pretratamiento, mayor tras el primer año que tras el segundo. La desviación estándar (DE) de la talla previa al tratamiento era de -2,6 ± 0,4 (-2,1 ± 0,5 en el primer año y -1,8 ± 0,6 en el segundo). El análisis de regresión lineal muestra un aumento significativo en la DE después del primer y segundo año respecto al valor inicial pretratamiento, es decir, una aproximación progresiva a los valores normales. La dosis inicial de rhGH fue de 0,035 mg/kg/día. Durante el periodo estudiado no se han producido efectos secundarios que hayan precisado la suspensión del tratamiento en ningún caso. Conclusiones: Los datos incluidos en este estudio demuestran que el tratamiento con rhGH favorece el crecimiento en los niños PEG, observándose su máximo efecto durante el primer año (AU)

Objective: To analyze the changes produced in the growth velocity among small for gestational age (SGA) children in Tanner's first stage, receiving recombinant human growth hormone therapy (rhGH), in the Paediatric Department of Hospital Universitari Arnau de Vilanova, hospital of reference in province of Lleida in northern Spain. Material and methods: Patient information was collected before and after treatment for two years with rhGH. Data from the Spanish growth study of 2010 were used as reference. Results: The number of patients who fulfilled inclusion criteria was 58 (45% male; 55% female). The average age at the beginning of treatment was 8 ± 2.7 years. The growth velocity (GV) prior to treatment was 5.2 ± 2.8 cm per year. In the first year of treatment, the GV increased to 8.6 ± 1.9 cm/yr and in the second year of the study, to 7 ± 2.1 cm/yr. Linear regression analysis adjusted for age showed a significant increase in GV after the first and second year compared to the pretreatment value, with a greater increase in the first year of treatment than in the second. The standard deviation (SD) of size prior to treatment was -2.6 ± 0.4 (-2.1 ± 0.5 in the first year and -1.8 ± 0.6 in the second year). Linear regression analysis showed a significant increase in the SD after the first and second years of treatment compared to the pretreatment value; in other words, a progressive return to normal values was found. The initial dose of rhGH was 0.035 mg/kg/day. During the study period there were no reported adverse effects which necessitated suspension of treatment. Conclusion: The data found in this study show that treatment with rhGH promotes growth in SGA children, producing a maximum effect in the first year of treatment (AU)