Pediatric anesthesia in Europe: Variations within uniformity.

Organization of healthcare strongly differs between European countries and results in country-specific requirements in postgraduate medical training. Within the European Union (EU), the European Board of Anaesthesiology has set recommendations of training for the Specialty of Anaesthesiology including standards for Postgraduate Medical Specialist training including a description for providing service in pediatric anesthesia. However, these standards are advisory and not mandatory. Here we aimed to review the current state and associated challenges of pediatric anesthesia training in Europe. We report an important country-specific variability both in training and regulations of practice of pediatric anesthesia in the EU and in the United Kingdom. The requirements for training in pediatric anesthesia varies between nothing specified (Belgium) or providing anesthesia with direct supervision to a minimum of 50 cases below 5 years of age (Germany) to 3-6 month clinical practice in a specialized pediatric hospital (France). Likewise, the regulations for providing anesthesia to children varies from no regulations at all (Belgium) to age specific requirements and centralization of all children below 4 years of age to specified centers (United Kingdom). Officially recognized pediatric anesthesia fellowship programs are not available in most countries of Europe. It remains unclear if and how country-specific differences in pediatric anesthesia training are associated with clinical outcomes in pediatric perioperative care. There is converging interest and support for the establishment of a European pediatric anesthesia curriculum.

Chondromesenchymal Hamartoma in Ectopic Thyroid Tissue in a Neonate.

A full-term male neonate presented with a left sided cervical lump at the level of the thyroid gland. Magnetic resonance imaging (MRI) showed a benign heterogeneous solid mass with lobulated margins. The tumor underwent complete excision. Histology revealed the diagnosis of chondromesenchymal hamartoma in ectopic thyroid tissue.

Dynamics of nitroglycerin-induced exhaled nitric oxide after lung transplantation: evidence of pulmonary microvascular injury?

BACKGROUND: In search of real-time molecular correlates to ischemia-reperfusion-induced lung injury, we explored the hypothesis that liberation of nitric oxide (NO) into exhaled breath after pulmonary microvascular bioconversion of nitroglycerin (GTN) is attenuated in clinical lung transplantation. METHODS: Exhaled NO was measured under basal conditions and after intravenous administration of GTN in patients undergoing lung transplantation. Patients undergoing routine cardiac surgery served as controls. Basal and GTN-induced exhaled NO was also measured in donors before retrieval and after implantation in recipients. RESULTS: The characteristic GTN-induced exhaled NO response observed in cardiac surgical patients before cardiopulmonary bypass and in lung transplant and multiple-organ donors was nearly totally abolished in lung transplant recipients. This response was also attenuated to a lesser degree in the routine cardiac surgery patients after cardiopulmonary bypass. CONCLUSIONS: These results suggest a graded influence of time-factored complete and partial ischemia on GTN-induced evolution of NO into exhaled breath, providing biochemical evidence for a degree of microvascular injury, which can be monitored non-invasively at the bedside.

Correlation between pulmonary gas exchange and basal and nitroglycerin (GTN)-induced exhaled nitric oxide (eNO) in patients undergoing cardiac surgery.

The relationship between eNO and events in the alveolar-capillary unit in acute lung injury remains to be established. Since endogenous eNO largely originates from the airway epithelium, but nitroglycerin (GTN)-induced eNO is due to microvascular/alveolar metabolism, we have proposed to use basal and GTN-induced eNO as metabolic markers of the airway--and microvascular/alveolar function, respectively. The current work investigates the relationship between basal and GTN-induced eNO and oxygenation parameters (PaO(2)/FiO(2) ratio) in patients undergoing cardiac surgery utilising cardiopulmonary bypass (CPB). Breath by breath eNO measurements were made in 10 patients before, and 1 and 3 h after CPB either under basal conditions or following intravenous administration of GTN (1, 2 and 3 microg/kg). Basal eNO remained unchanged, whereas GTN-induced eNO was reduced following CPB. Also, there was a transient reduction in PaO(2)/FiO(2) ratio 1 h after CPB (32+/-4 vs. 44+/-3 kPa). A negative correlation was found between oxygenation and basal eNO by Pearson's correlation test and linear regression analysis suggesting that decreased oxygenation was associated with increased basal eNO. In contrast, a decrease in GTN-induced eNO positively correlated with reduced oxygenation index (R=0.533, p=0.002). These data suggest that differential relationships exist between basal and nitrovasodilator-induced eNO and oxygenation indices during subclinical lung injury in patients following CPB and that GTN-induced eNO evolution may reflect better microvascular events and injury.

Extremely long frenulum leading to a giant preputial sac associated with concealed penis.

We describe a case involving an abnormally long frenulum leading to a giant preputial sac on micturition associated with a concealed penis. The diagnosis, differential diagnosis and surgical correction are detailed.

A long-term follow-up of five patients with atresia of the common bile duct.

BACKGROUND/PURPOSE: Description of the long-term follow-up of 5 patients operated on for atresia of the common bile duct. METHODS: During a 25-year period (1960 to 1985) 45 infants underwent surgical exploration for biliary atresia (BA), of which, 5 (11.1%) were found to have atresia of the common bile duct. The children were followed up into adult life by pediatric surgeons, pediatricians, and later, adult hepatologists with the range of 19 to 36 years. Liver function tests, histology, complications, and somatic development (including sexual maturation and mental development) were obtained continuously. RESULTS: Liver function test results were normal in all but 1 patient. Repeated ultrasound scan and postoperative liver biopsies were normal in 2 patients and moderately and mildly abnormal in 3 patients, respectively, suggesting hepatic fibrosis. HIDA hepatic scans in all but 1 patient showed prompt uptake by the liver with passage into the bowel within 30 minutes. Endoscopic retrograde cholangiography (ERCP; 1 patient) and duodenography (4 patients) showed, at most, mild reflux of contrast material into the extra- or intrahepatic bile ducts. One patient with cholecysto-duodenostomy had 3 episodes of clinically proven ascending cholangitis. All 5 patients had normal physical growth and mental development, they are all age-appropriate schooled, and they are working and living a normal life. CONCLUSIONS: Long-term favorable outcome has been suggested to be more influenced by anatomic and biological features rather than the surgical correction. The hypothesis is supported that BA is not a static congenital malformation but a progressive inflammatory panductular obliterative disease of the bile ducts starting in the antenatal period, which might cease, either early at birth or any time in infancy. The destructive inflammatory process might involve only the distal part of the extrahepatic bile duct causing obstruction and leaving the proximal ducts patent.

[Changes of exhaled nitrogen-monoxide concentration in acute ischemia-reperfusion injury of the lung]. / A kilégzett nitrogén-monoxid koncentrációjának változása a tüdó akut ischaemia-reperfuziós károsodásaiban.

INTRODUCTION: Nitric oxide (NO) plays an important role in both the physiological control of the pulmonary vascular bed and in the pathophysiology of several lung diseases. Though our knowledge regarding NO has became wider several aspects are still a matter of debate. The technical developments allowing direct measurements of NO in the expired air have provided an opportunity to evaluate NO production and consumption in the clinical setting and exhaled NO has become a diagnostic and monitoring tool in acute and chronic lung diseases. AIMS: The aim of our study was to evaluate the severity of different levels of ischaemia-reperfusion related lung injury by measuring nitric oxide in the exhaled air. After presenting our data regarding exhaled NO in ischaemia-reperfusion related acute lung injury associated with cardiothoracic surgery we discuss the physiology of exhaled NO and the technical aspects of measuring NO in the expired breath. METHODS: Comparing basal and GTN-induced exhaled NO data after two types of heart and lung surgery--routine open-heart surgery utilizing CPB and lung transplantation--we studied the effects of different levels of lung ischaemia on NO production. RESULTS: Following transient and incomplete lung ischaemia in the clinical setting of routine cardiac surgery utilizing cardiopulmonary bypass (CPB) both the airway epithelial and the vascular endothelial function remained preserved. However, prolonged and complete lung ischaemia during lung transplantation was associated with severe dysfunction resulted in a marked reduction of both the endogen and the induced levels of exhaled NO.