Diferencias clínicas entre los pacientes con dolor crónico primario y secundario atendidos por una unidad multidisciplinar de dolor crónico infantil / Clinical differences in a multidisciplinary pediatric pain unit between primary and secondary chronic pain

Introducción: El dolor crónico afecta a un porcentaje significativo de la población pediátrica en los países desarrollados, y puede tener una causa médica bien definida en el dolor crónico secundario (DCS), o desconocida en el dolor crónico primario (DCP). En España, hasta el momento, no existe información acerca de las diferencias clínicas de los pacientes atendidos en unidades multidisciplinarias. Métodos: Análisis retrospectivo de las historias clínicas de los pacientes atendidos en 2018 por la Unidad de Dolor Crónico Infantil del Hospital Universitario La Paz. Resultados: Se incluyeron los 92 pacientes atendidos, con edades comprendidas entre 2 y 19 años, y una edad media de 12,4 (SD=4,1) años, mayoritariamente de sexo femenino (55%) y una duración media del dolor de 11,3 (SD=10,4) meses. Los resultados de comparar pacientes con DCP (n=31) y DCS (n=61) mostraron que ambos grupos presentaban dolor medio con una gran intensidad (x=5,9; SD=2,2; rango=0-10), con duración y repercusión funcional similares, aunque el DCP se asoció menos a descriptores de tipo neuropático que el DCS (p=0,040) y era más extenso en su localización (p<0,001). Ambos grupos recibieron similar tratamiento basado en rehabilitación, psicoterapia, técnicas invasivas y tratamiento con medicación analgésica, aunque los pacientes del grupo DCP recibieron menos medicaciones analgésicas (gabapentinoides y opiáceos) que el DCS (p=0,011). Conclusión: Los pacientes con DCP o DCS, aunque tengan un perfil clínico similar, presentan diferencias en el número y tipo de analgésicos empleados, lo que avalaría la importancia del diagnóstico de la causa para adecuar el tratamiento farmacológico subsiguiente.(AU)

Introduction: Chronic pain affects an important part of the pediatric population in developed countries. secondary chronic pain (SCP) can have a well-defined medical cause, but primary chronic pain (PCP) can have an unknown etiology. In Spain, there is as yet no information on the clinical differences between patients treated in multidisciplinary units. Methods: Retrospective analysis of the clinical records of patients seen in 2018 at the Children's Chronic Pain Unit in University La Paz Hospital. Results: A total of 92 patients were included (age between 3 and 19 years), with a mean age of 12.4 (SD=4.1) years, mostly female (55%), with a mean duration of pain of 11.3 (SD=10.4) months. A comparison of patients with PCP (n=31) and SCP (n=61) showed that both groups, on average, presented intense pain (X=5.9; SD=2.2; range=0-10), with similar duration and functional repercussions, although PCP was less likely to be associated with neuropathic descriptors than SCP (p=.040), and was more extensive (p<.001). Both groups received similar treatment, based on rehabilitation, psychotherapy, invasive techniques and analgesic medication, although patients in the PCP group received less analgesic medication (gabapentinoids and opioids) than the SCP (p=.011). Conclusion: Patients treated in a multidisciplinary Child Pain Unit for PCP or SCP present a very similar clinical profile, though with differences in the number and type of analgesic drugs used. This shows the importance of etiologic diagnosis for adequate pharmacological treatment.(AU)

Clinical differences in a multidisciplinary pediatric pain unit between primary and secondary chronic pain.

INTRODUCTION: Chronic pain affects an important part of the pediatric population in developed countries. secondary chronic pain (SCP) can have a well-defined medical cause, but primary chronic pain (PCP) can have an unknown etiology. In Spain, there is as yet no information on the clinical differences between patients treated in multidisciplinary units. METHODS: Retrospective analysis of the clinical records of patients seen in 2018 at the Children's Chronic Pain Unit in University La Paz Hospital. RESULTS: A total of 92 patients were included, (age between 3 and 19 years), with a mean age of 12.4 (SD = 4.1) years, mostly female (55%), with a mean duration of pain of 11.3 (SD = 10.4) months. A comparison of patients with PCP (n = 31) and SCP (n = 61) showed that both groups, on average, presented intense pain (X = 5.9; SD = 2.2; range = 0-10), with similar duration and functional repercussions, although PCP was less likely to be associated with neuropathic descriptors than SCP (p = 0.040), and was more extensive (p < 0.001). Both groups received similar treatment, based on rehabilitation, psychotherapy, invasive techniques and analgesic medication, although patients in the PCP group received less analgesic medication (gabapentinoids and opioids) than the SCP (p = 0.011). CONCLUSION: Patients treated in a multidisciplinary Child Pain Unit for PCP or SCP present a very similar clinical profile, though with differences in the number and type of analgesic drugs used. This shows the importance of etiologic diagnosis for adequate pharmacological treatment.

Presentación clínica y tratamiento de las artritis sépticas en niños / Clinical presentation and treatment of septic arthritis in children

Introducción. El objetivo de este estudio es determinar las características epidemiológicas, la presentación clínica y el tratamiento de los niños con artritis séptica en nuestro medio. Material y método. Se revisaron retrospectivamente 141 niños con una artritis séptica tratados en el Hospital Universitario La Paz (Madrid) entre los años 2000 y 2013. Se recogieron datos relativos al paciente, la articulación afectada, la presentación clínica, los valores analíticos, el aspecto, la tinción Gram y el cultivo del líquido articular, las pruebas de imagen y el tratamiento. Resultados. El 94% de los pacientes eran menores de 2 años de edad. La localización más frecuente fue la rodilla (52%), seguida de la cadera (21%). La artritis séptica se confirmó en el 53% de los pacientes. El 49% de ellos no presentaron fiebre ni febrícula inicialmente y el 18% tenían una VSG (mm/h) o PCR (mg/l) menor de 30 en la analítica inicial. El líquido articular fue purulento en el 45% de los casos y turbio en el 12%. La tinción Gram mostró bacterias en el 4%. El cultivo del líquido fue positivo en el 17%. Staphylococcus aureus fue el patógeno más frecuente, seguido de Streptococcus agalactiae, Streptococcus pneumoniae y Kingella kingae. La antibioterapia se administró por vía intravenosa 7 días, seguido de vía oral 21 días. Se realizó una cirugía en el 18% de los pacientes. Conclusiones. La confirmación diagnóstica solo se obtuvo en el 53% de los pacientes. Algunas artritis sépticas confirmadas no presentaron el cuadro clínico/analítico clásico, por lo que es necesario un alto índice de sospecha inicial de la enfermedad por parte del traumatólogo o del pediatra (AU)

Introduction. The aim of this study is to determine the epidemiological features, clinical presentation, and treatment of children with septic arthritis. Material and method. A retrospective review was conducted on a total of 141 children with septic arthritis treated in Hospital Universitario La Paz (Madrid) between the years 2000 to 2013. The patient data collected included, the joint affected, the clinical presentation, the laboratory results, the appearance, Gram stain result, and the joint fluid culture, as well as the imaging tests and the treatment. Results. Most (94%) of the patients were less than 2 years-old. The most common location was the knee (52%), followed by the hip (21%). The septic arthritis was confirmed in 53%. No type of fever was initially observed in 49% of them, and 18% had an ESR (mm/h) or CRP (mg/l) less than 30 in the initial laboratory analysis. The joint fluid was purulent in 45% and turbid in 12%. The Gram stain showed bacteria in 4%. The fluid culture was positive in 17%. Staphylococcus aureus was the most common pathogen found, followed by Streptococcus agalactiae, Streptococcus pneumoniae, and Kingella kingae. Antibiotic treatment was intravenous administration for 7 days, followed by 21 days orally. Surgery was performed in 18% of cases. Conclusions. The diagnosis was only confirmed in 53% of the patients. Some of the confirmed septic arthritis did not present with the classical clinical/analytical signs, demonstrating that the traumatologist or paediatrician requires a high initial level of clinical suspicion of the disease (AU)

Clinical presentation and treatment of septic arthritis in children. / Presentación clínica y tratamiento de las artritis sépticas en niños.

INTRODUCTION: The aim of this study is to determine the epidemiological features, clinical presentation, and treatment of children with septic arthritis. MATERIAL AND METHOD: A retrospective review was conducted on a total of 141 children with septic arthritis treated in Hospital Universitario La Paz (Madrid) between the years 2000 to 2013. The patient data collected included, the joint affected, the clinical presentation, the laboratory results, the appearance, Gram stain result, and the joint fluid culture, as well as the imaging tests and the treatment. RESULTS: Most (94%) of the patients were less than 2 years-old. The most common location was the knee (52%), followed by the hip (21%). The septic arthritis was confirmed in 53%. No type of fever was initially observed in 49% of them, and 18% had an ESR (mm/h) or CRP (mg/l) less than 30 in the initial laboratory analysis. The joint fluid was purulent in 45% and turbid in 12%. The Gram stain showed bacteria in 4%. The fluid culture was positive in 17%. Staphylococcus aureus was the most common pathogen found, followed by Streptococcus agalactiae, Streptococcus pneumoniae, and Kingella kingae. Antibiotic treatment was intravenous administration for 7 days, followed by 21 days orally. Surgery was performed in 18% of cases. CONCLUSIONS: The diagnosis was only confirmed in 53% of the patients. Some of the confirmed septic arthritis did not present with the classical clinical/analytical signs, demonstrating that the traumatologist or paediatrician requires a high initial level of clinical suspicion of the disease.

[Dysplasia in the development of the hip]. / Displasia del desarrollo de la cadera.

Developmental dysplasia of the hip (DDH) causes anatomical changes that cause early coxarthrosis. Although risf factors have been determined, the aetiology and physiopathology remains exactly unknown. Neonatal screening with physical examination and ultrasound have been stablished in order to diagnose this disease early in life. A diagnosis in the first months of life is essential as it enables a normal hip to form and prevent the appearance of early coxarthrosis. Treatment principles are to be able to reduce the hip without provoking avascular necrosis of the femoral head, and to normalize the acetabular development. Knowledge of the orthopaedic and surgical options is essential in order to achieve success in the treatment.

Displasia del desarrollo de la cadera / Dysplasia in the development of the hip

La displasia del desarrollo de la cadera provoca cambios anatómicos que dan lugar a una coxartrosis precoz. La etiología y la patofisiología de la displasia de cadera no se conocen con exactitud, aunque se han determinado factores de riesgo. Se han establecido programas de despitaje neonatal clínicos y ecográficos que lleven a un diagnóstico precoz de esta afección. Un diagnóstico en los primeros meses de vida es fundamental porque permite obtener una cadera normal y evitar la aparición de una coxartrosis precoz. El tratamiento debe conseguir reducir la cadera, evitando la aparición de una necrosis avascular de la cabeza femoral, y normalizar el desarrollo del acetábulo. Existen opciones ortopédicas y quirúrgicas que deben ser conocidas para lograr un éxito en el tratamiento (AU)

Developmental dysplasia of the hip (DDH) causes anatomical changes that cause early coxarthrosis. Although risf factors have been determined, the aetiology and physiopathology remains exactly unknown. Neonatal screening with physical examination and ultrasound have been stablished in order to diagnose this disease early in life. A diagnosis in the first months of life is essential as it enables a normal hip to form and prevent the appearance of early coxarthrosis. Treatment principles are to be able to reduce the hip without provoking avascular necrosis of the femoral head, and to normalize the acetabular development. Knowledge of the orthopaedic and surgical options is essential in order to achieve success in the treatment (AU)

Enfermedad de Legg-Calvé-Perthes / Legg-Calvé-Perthes disease

La enfermedad de Perthes es una necrosis isquémica idiopática de la epífisis femoral proximal en niños. La prueba diagnóstica más utilizada es la radiografía simple, que además permite clasificar la enfermedad en función de su evolución y de su extensión. Aunque su historia natural, autolimitada en el tiempo, es generalmente benigna, existen una serie de factores asociados a un pronóstico menos favorable. Estos factores son la edad, la extensión de la enfermedad y determinados signos radiológicos, y definen a aquellos pacientes que más se van a beneficiar del tratamiento. La contención de la cabeza femoral en el acetábulo para permitir un óptimo remodelado de la misma es el objetivo del tratamiento que actualmente se basa en métodos quirúrgicos como las osteotomías femorales o acetabulares. Los métodos de contención ortopédicos como las ortesis de abducción no han demostrado obtener mejores resultados (AU)

Perthes´disease is an idiopathic avascular necrosis of the proximal femoral epiphysis in children. Plain radiograph is the main diagnosis tool and is also used to classify the phase and the extent of the disease. Although it is a self-limited condition and its natural history is often benign, there are several factors that can worsen prognosis. Those factors are age, extent of the disease and some radiological signs and are useful to identify patients who will benefit the most from treatment. Adequate containment of the femoral head within the acetabulum resulting in a more spherical and congruous joint is the main goal of treatment, which is based mainly on surgical techniques, such as femoral or acetabular osteotomies. It has been shown that orthopaedic containment methods, like abduction orthosis, have not achieved better results (AU)

Immunohistochemical localization of progesterone receptor isoforms in the chick pre-follicular ovary.

The distribution of progesterone receptor A and B isoforms in different cell types of the chick pre-follicular ovary was studied by immunohistochemistry. Newly hatched chicks were killed and the left ovary was removed, fixed and embedded in paraplast. Sections (5 microns thick) were made for the detection of progesterone receptor isoforms, using a technique of indirect immunoperoxidase. The results indicate that progesterone receptors were localized in the nuclei of germinal epithelium and germ cells of the ovarian cortex and in the interstitial and epithelial cells of the lacunar channels of the ovarian medulla. Undifferentiated cells did not present progesterone receptors. In all cell subpopulations progesterone receptor B was the predominantly expressed isoform. These data suggest that progesterone receptor isoforms are differentially expressed in the chick pre-follicular ovary and that progesterone effects in this tissue are mediated by the progesterone receptor B isoform.

Femoral fractures in children from 4 years to 10 years: conservative treatment.

Some authors have widened the indications for surgical management of isolated femoral shaft fractures in children between 4 years and 10 years of age. We address this study to evaluate the results of such femoral fractures treated conservatively in 41 children. All fractures were closed, isolated, and diaphyseal. The mean age was 6.5 years (standard deviation, 1.7 years) and the mean follow-up was 2.3 years (standard deviation, 1.7 years). All fractures were managed conservatively with skin traction (mean hospitalization time, 20.7 days), alignment of the fragments was serially followed by X-ray, and a spica cast was applied (9.7 weeks), usually without a general anesthesia. Angular deformity was assessed by measurement of the fracture-site diaphyseal angle as well as by measurement of the interphyseal angle described by Wallace and Hoffman. No significant complications were recorded regarding leg-length discrepancy, deformity, refractures, etc. Mean cost is not a factor in determining method of treatment at our hospital. We feel that this type of fracture in the 4 years to 10 years age group can be safely treated with a conservative approach.

Effect of luteinising-hormone in vivo on ovarian cell subpopulations of newly-hatched chicks.

1. We analysed the number and size of different ovarian cell subpopulations of newly-hatched chicks by ovarian cell suspension count and morphometric/stereological methods as well as delta5-3beta-hydroxysteroid dehydrogenase (delta5-3beta HSD) activity in these cells treated in vivo with LH during embryonic development. 2. Fertile White Leghorn eggs received 1 microg LH applied to the chorioallantoic membrane on days 13, 15, and 17 of incubation. All animals were killed within 24 h after hatching, the left ovary was dissected and processed. 3. The results indicate that the number of germ, pregranulosa, interstitial and undifferentiated cells was not affected by LH treatment. However, we observed an increase in the size of individual interstitial cells of the ovarian medulla. In these cells, delta5-3beta HSD activity was increased in response to LH. 4. These findings suggest that LH does not exert a proliferative effect on the cells of the prefollicular ovary of the chick and that interstitial cells can be target cells for LH, increasing their steroidogenic activity due to LH treatment.

Histomorphometric and progesterone receptor immunohistochemical analysis in the oviduct of newly hatched chicks treated with follicle-stimulating hormone during embryonic development.

In this study we evaluated the histomorphology and ultrastructure of the oviduct of newly hatched chicks, as well as the immunohistochemical expression of progesterone receptor (PR) in this tissue after follicle-stimulating hormone (FSH) treatment on days 13, 15 and 17 of embryonic development. Results indicated a marked difference in the histology of the oviduct of newly hatched chicks treated with FSH. Magnum mucosa from these animals presented a pseudostratified epithelium with evaginations from the lumen into the epithelium and from the latter into the stroma beneath where tubular glands are formed. In contrast magnum mucosa from control animals presented columnar epithelium with no evaginations. In magnum epithelium FSH also induced the formation of cilia and microvilli projections into the lumen as well as an increase in the wall and lumen areas and in the density of nuclei per unitarea. PR immunoreactivity was only observed in the oviduct of FSH treated animals. PR was located in the nucleus of epithelial luminal cells, mucosal stromal cells and smooth muscle cells. These findings suggest that FSH induces an adequate hormonal milieu for the cytodifferentiation and PR gene expression in the chick oviduct.

Effect of follicle-stimulating hormone on different cell sub-populations in the ovary of newly hatched chicks treated during embryonic development.

1. Cell sub-populations of the ovary of newly-hatched chicks were assessed following follicle stimulating hormone (FSH) treatment during embryonic development. Changes in cell number and the amount of oestradiol in serum were determined. 2. White Leghorn chick embryos received 1 microgram FSH applied to the chorioallantoic membrane at 13, 15, and 17 d of incubation. Within 24 h after hatching, animals were killed and blood was collected. The left ovary was immediately removed then weighed and processed by an enzymatic-mechanical dissociation method for total cell count. An air-drying method was also used for meiotic preparations to study the germinal cells. 3. The pre-follicular ovary is able to respond to FSH by inducing an increase both in the serum oestradiol concentration and in the number of steroidogenic cells and of poorly differentiated cells of the ovarian medulla. 4. FSH increases the number of oogonia, which are responsible for a sharp increase in the total population of germ cells in the FSH-treated ovary. 5. It is possible that FSH acts to increase the proliferation of oogonia and a delay in the meiotic prophase through a change in the microenvironment rather than by a direct effect on germ cells.

Histomorphometric analysis in the ovary of newly hatched chicks treated with follicle-stimulating hormone during embryonic development.

We studied the histomorphometric changes induced in the left ovary of newly hatched chicks treated with follicle stimulating hormone (FSH) during embryonic development. After FSH treatment the thickness of the ovarian cortex, the number per unit of area and total mass per ovary of germ and pregranulosa cells increased, accompanied by hypertrophy of the pregranulosa cells. The volume of interstitial cell cords, lacunar system, and blood capillaries was increased and modifications in poorly differentiated cells were also observed. The number of interstitial cells and the average volume of interstitial cells also increased, from which we can deduce that these two last events are important in the enlargement of the interstitial cell cords. These findings suggest that the prefollicular ovary is able to respond to FSH, inducing structural changes both in the ovarian cortex as well as in the subcortical medulla.

Results after preoperative traction and pinning in slipped capital femoral epiphysis: K wires versus cannulated screws.

We have retrospectively reviewed 53 cases (62 hips) with a diagnosis of slipped capital wedge epiphysis. After admission to our Hospital, a skin longitudinal traction was applied for 2 weeks, All patients were treated afterward with pinning in situ without manipulation in the operating room. Group A (31 hips) consisted of patients treated with smooth K wires and group B (31 hips) of patients treated with cannulated screws. We found a high incidence of pin penetration in group A (27 hips), whereas there was just one case in group B. Physical closure was considered when 75% of proximal growth plate disappeared in the frog lateral view and both groups showed similar values (7 months). Chondrolysis was observed in just three cases in group A, and one case had an avascular necrosis. Few complications were observed compared with the high rate of pin penetration, and we suggest that preoperative traction may be a relevant factor contributing to the low incidence of avascular necrosis (1.6%).

A stereological study of the different cell populations in chicken testes treated with follicle-stimulating hormone during embryonic development.

Quantitative morphological methods were used to analyse the histomorphometric changes and variations in the number and size of cells from diverse cellular populations in testes of newly hatched chicks treated with follicle stimulating hormone (FSH) during embryonic development. The tissue was fixed and embedded in Epon and sections were morphometrically measured under light microscopy, using point counting for volume densities and the Floderus equation to determine numerical density. The average volume of the individual cell was determined by dividing the volume density by the numerical density. Results indicate that FSH administration causes an increase in the number of Sertoli cells and spermatogonia, as well as enlargement of the individual Sertoli cells leading consequently to an increase in the diameter and volume density of the testicular seminiferous tubules. Results also reveal an increase in the volume density of the interstitial cords of the Leydig cells, this expansion is due to the enlargement of the individual Leydig cells and not to an increase in their number, which remains constant. We conclude that testes of chick embryos are able to respond to FSH treatment, as revealed by the changes in the number and size of the cells conforming the diverse cellular populations of the testis. FSH treatment during embryonic development induces histomorphometric changes in both the interstitial tissue and seminiferous tubules, accelerating their growth and differentiation.

Femoral head avascular necrosis associated with metaphyseal aneurysmal bone cyst.

A 12-year-old girl had an aneurysmal bone cyst in the proximal femoral metaphysis simultaneously with an avascular necrosis of the femoral head, as seen on radiological examination. No extension of the lesion across the growth plate into the femoral epiphysis was observed. The expansive behavior of this lesion (ABC) could have compromised the posterosuperior vascular supply of the femoral epiphysis, since no radiographic signs of fractures could be found. Vascular anomalies within the lesion that increase venous pressure could be another factor responsible for the decrease in the blood supply of the femoral epiphysis and could cause necrosis, hence compromising the morphology of the hip joint at maturity.

Ultrastructure of the ovarian medulla in the newly hatched chick treated with human chorionic gonadotropin.

The ultrastructural characteristics of the ovarian medulla of the newly hatched white leghorn chick were studied in control animals and compared with chicks that were treated with human chorionic gonadotropin during embryonic development. The ovarian medulla was mainly occupied by epithelial cells which formed cords or islets surrounded by a basal lamina. Within this epithelial compartment, steroidogenic cells, poorly differentiated cells and a lacunary system could be recognized. When chicks were treated with human chorionic gonadotropin, steroidogenic cells became discernible; there was an increment in the amount of cytoplasm and the area of mitochondria. Poorly differentiated cells exhibited signs of stimulation, and transitional images suggested the transformation of these cells into steroidogenic cells. The epithelial cells of the lacunar system also displayed stimulated cytoplasmic organelles. Evidence was supplied suggesting that relatively undifferentiated cells persist in the ovarian medulla until hatching and can develop into steroidogenic cells under gonadotropic stimulation.

Morphological changes in the ovary of newly hatched chickens treated with chorionic gonadotropin during embryonic development.

The present study describes morphological changes produced in the ovary of newly hatched chickens by treatment with human chorionic gonadotropin (hCG). Morphometric measurements of the volume of steroidogenic cells and structures of the ovarian medulla were performed in controls and experimental chickens treated with hCG (1.0 IU/embryo) at 13, 15, and 17 days of embryonic development. After hCG treatment, the volume of interstitial cell cords increased, and modifications in poorly differentiated cells neighbouring the interstitial cells were also observed. Other changes obtained after hCG treatment were an increment in the development of the lacunar system and blood capillaries, as well as a reduction in the number of germ cells in the stroma of the ovarian medulla.