Surgical Ligation Versus Percutaneous Closure of Patent Ductus Arteriosus in Very Low-Weight Preterm Infants: Which are the Real Benefits of the Percutaneous Approach?

Percutaneous treatment of patent ductus arteriosus (PDA) in extreme premature infants is technically difficult, and therefore, often not consider as an alternative to surgery. The main objective of our work was to compare respiratory status prior and post ductal closure and morbi-mortality, in our series of preterm infants with percutaneous PDA closure versus surgical ligation in the same time-period. Retrospective review of all premature infants submitted to percutaneous and surgical PDA closure from January 2011 to December 2016. All the antenatal, perinatal, and postnatal characteristics were collected. The main outcome was the assessment of the pulmonary status before and after ductal closure using a pulmonary score. Secondary outcomes included moderate-severe disability in neurodevelopment, death before discharge, moderate-severe chronic lung disease, and morbidity at discharge. 25 patients with a mean weight of 1330 g (± 280) underwent percutaneous closure of PDA with ADO-II-AS, and a total of 53 underwent surgical ligation. 28/53 with similar gestational age, birth weight, and procedure weight to those in the percutaneous group, were selected to perform the comparative study. Ductal closure (percutaneous and surgical) resulted in improved respiratory status. However, percutaneous group achieved a fastest respiratory improvement, than surgical group. The surgical closure group associated higher morbidity among survivors (HIV, number of sepsis, need, and duration of inotropics post-interventionism). The incidence of recurrent laryngeal nerve palsy among the surgical group was 17%. Percutaneous closure of PDA in carefully selected low-weight preterm infants is a safe and reliable alternative to surgical ligation.

Calidad de la coronariografía 3D por resonancia magnética en los pacientes con D-transposición de las grandes arterias intervenidos con switch arterial de Jatene / Quality of 3D magnetic resonance imaging of coronary arteries in patients with D-transposition of the great arteries after the Jatene switch procedure

Objetivos. Valorar la calidad de imagen de la secuencia 3D de todo el corazón (3D balanced fast field echo, whole heart [WH3D]) para estudiar la anastomosis coronaria y las estenosis coronarias en los pacientes con D-transposición de las grandes arterias intervenidos con switch arterial de Jatene. Material y métodos. Rescatamos de la base de datos de RM cardiaca pediátrica 100 exploraciones en 83 pacientes intervenidos con la técnica de Jatene y secuencia WH3D. Cumplían criterios de inclusión en el estudio 84 exploraciones. Valoramos las estenosis coronarias mediante WH3D y su correlación con la TC coronaria o la angiografía por catéter. Estudiamos retrospectivamente la calidad de la imagen de las arterias coronarias proximales con una escala de 4 puntos y la correlación con la edad, frecuencia cardiaca y tamaño cardiaco. Resultados. Cuatro de los 84 estudios (4,8%) mostraron calidad «insuficiente» para el diagnóstico, 7 (8,3%) «discreta», 23 (27,4%) «buena» y 50 (59,5%) «excelente». La frecuencia cardiaca y la calidad de la imagen coronaria se relacionaron estadísticamente. Con la RM detectamos estenosis en el origen coronario en 9 exploraciones (10,7%). Conclusión. La calidad de imagen con la secuencia WH3D fue diagnóstica en la mayoría de los pacientes intervenidos con la técnica de Jatene, mejor en pacientes con menor frecuencia cardiaca. En el 10,7% se diagnosticó una estenosis del origen coronario que obligó a nuevas exploraciones (AU)

Objectives. To evaluate the quality of images obtained with 3D balanced fast-field echo whole heart (WH3D) MRI sequences for assessing the coronary anastomosis and coronary stenosis in patients with D-transposition of the great arteries who have undergone the Jatene switch procedure. Material and methods. We retrieved 100 WH3D studies done in 83 patients who had undergone the Jatene switch procedure from our pediatric cardiac MRI database; 84 of these studies fulfilled the criteria for inclusion in the study. We evaluated coronary stenoses on WH3D MR images and their correlation with coronary CT or angiography images. We retrospectively studied the quality of the images of the proximal coronary arteries using a four-point scale and correlating the findings with age, heart rate, and heart size. Results. Of the 84 studies, 4 (4.8%) were of a quality considered «insufficient for diagnosis», 7 (8.3%) were considered «fair», 23 (27.4%) «good», and 50 (59.5%) «excellent». The quality of the image of the coronary arteries was significantly correlated with heart rate. MRI detected stenosis in the origin of the coronary arteries in 9 (10.7%) studies. Conclusion. Images obtained with the WH3D MRI sequence in patients who had undergone the Jatene procedure were of diagnostic quality in most cases and were better in patients with lower heart rates. In 10.7%, stenosis in the origin of the coronary arteries that required new studies was detected (AU)

[Quality of 3D magnetic resonance imaging of coronary arteries in patients with D-transposition of the great arteries after the Jatene switch procedure]. / Calidad de la coronariografía 3D por resonancia magnética en los pacientes con D-transposición de las grandes arterias intervenidos con switch arterial de Jatene.

OBJECTIVES: To evaluate the quality of images obtained with 3D balanced fast-field echo whole heart (WH3D) MRI sequences for assessing the coronary anastomosis and coronary stenosis in patients with D-transposition of the great arteries who have undergone the Jatene switch procedure. MATERIAL AND METHODS: We retrieved 100 WH3D studies done in 83 patients who had undergone the Jatene switch procedure from our pediatric cardiac MRI database; 84 of these studies fulfilled the criteria for inclusion in the study. We evaluated coronary stenoses on WH3D MR images and their correlation with coronary CT or angiography images. We retrospectively studied the quality of the images of the proximal coronary arteries using a four-point scale and correlating the findings with age, heart rate, and heart size. RESULTS: Of the 84 studies, 4 (4.8%) were of a quality considered «insufficient for diagnosis¼, 7 (8.3%) were considered «fair¼, 23 (27.4%) «good¼, and 50 (59.5%) «excellent¼. The quality of the image of the coronary arteries was significantly correlated with heart rate. MRI detected stenosis in the origin of the coronary arteries in 9 (10.7%) studies. CONCLUSION: Images obtained with the WH3D MRI sequence in patients who had undergone the Jatene procedure were of diagnostic quality in most cases and were better in patients with lower heart rates. In 10.7%, stenosis in the origin of the coronary arteries that required new studies was detected.

Avances en el intervencionismo para el tratamiento de cardiopatías congénitas. ¿Qué podemos tratar sin cirugía? / Advances in interventionism for the treatment of congenital heart disease: What can we treat without surgery?

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Assessing pulmonary hypertensive vascular disease in childhood. Data from the Spanish registry.

RATIONALE: There is a lack of knowledge regarding the epidemiology, clinical characterization, and survival in pediatric pulmonary hypertension. OBJECTIVES: To describe the epidemiology, outcomes, and risk factors for mortality in pediatric pulmonary hypertension in Spain. METHODS: We analyzed data from the Spanish Registry for Pediatric Pulmonary Hypertension. From January 2009 to June 2012, a total of 225 patients diagnosed with pulmonary hypertension in 1998 or after were collected from 21 referral and nonreferral centers. We included all Nice etiologies, estimated incidence and prevalence of pulmonary hypertension in the Spanish pediatric population, and analyzed risk factors for mortality (Nice etiologic group, clinical and hemodynamic variables). Patients were classified as follows: group I, pulmonary arterial hypertension (n = 142; 61%); group II, left heart disease (n = 31; 14%); group III, respiratory disease (n = 41; 18%); group IV, thromboembolic pulmonary hypertension (n = 2; 1%); or group V, mostly inherited metabolic diseases (n = 10; 4.5%). Of the patients studied, 31% had multifactorial pulmonary hypertension. MEASUREMENTS AND MAIN RESULTS: Mean age at diagnosis was 4.3 ± 4.9 years (50% < 2 yr). Survival rates at 1 and 3 years were 80 and 74% for the whole cohort, and 89 and 85% for patients with pulmonary arterial hypertension. Independent risk factors for mortality included an etiologic group other than pulmonary arterial hypertension (P < 0.001), age at diagnosis younger than 2 years old (P < 0.001), advanced functional class at diagnosis (P < 0.001), and high right atrial pressure at diagnosis (P = 0.002). CONCLUSIONS: In moderate to severe pediatric pulmonary hypertension, the prognosis is better in pulmonary arterial hypertension than in other Nice categories. In pediatric pulmonary hypertension age at diagnosis younger than 2 years is a risk factor for mortality, in addition to the previously established risk factors.

Uso de diálisis peritoneal en neonatos tras cirugía cardiaca con circulación extracorpórea / Use of peritoneal dialysis in newborns undergoing cardiac surgery with cardiopulmonary bypass

Introducción: La terapia de sustitución renal es necesaria hasta en el 10% de los niños que sufren cirugía cardiaca. La diálisis peritoneal (DP) es la modalidad preferida en el periodo neonatal. Objetivo: Evaluar la seguridad, la eficacia y los factores perioperatorios asociados a la necesidad de DP. Material y métodos: Revisión retrospectiva de neonatos sometidos a cirugía cardiaca con circulación extracorpórea (CEC) durante 2 años. Seleccionamos para su análisis y comparación un grupo de casos que precisaron de DP y otro aleatorizado de controles que no precisaron ninguna técnica de depuración extrarrenal. Resultados: Setenta y seis neonatos fueron sometidos a cirugía cardiaca con CEC y 24 precisaron DP. La necesidad de DP se asoció al bajo gasto en el postoperatorio inmediato y al mayor tiempo de ventilación mecánica. La indicación más frecuente fue la oligoanuria relativa. La técnica fue efectiva en el 66% de los pacientes. Solo en un caso registramos complicaciones. Conclusiones: La indicación más frecuente de DP tras la cirugía cardiaca mediante CEC en neonatos es la oligoanuria. La necesidad de depuración extrarrenal se asocia con el bajo gasto y conlleva mayor tiempo de ventilación mecánica. La DP es una técnica eficaz y con pocas complicaciones en estos pacientes (AU)

Introduction: Renal replacement therapy is required in up to 10% of children undergoing cardiac surgery. Peritoneal dialysis (PD) is the preferred treatment method in the neonatal period. Objective: To evaluate safety, efficacy and perioperative factors associated with the need forPD. Material and methods: Retrospective review of clinical charts over a two-year period of newborns undergoing cardiac surgery with cardiopulmonary bypass (CPB). The group of cases requiring PD were compared with a group of random controls that did not require any renal replacement therapy. Results: A total of 76 infants underwent cardiac surgery with CPB, of which 24 required PD. The need for PD was associated with low cardiac output in the immediate postoperative period and longer mechanical ventilation. The most frequent indication was fluid overload. The technique was effective in 66% of patients. Complications were only recorded in one patient. Conclusions: The most common indication for PD after cardiac surgery with CPB in neonates is fluid overload. The need for renal replacement therapy is associated with low cardiac output and a longer duration of mechanical ventilation. PD is an effective technique with few complications in these patients (AU)

[Use of peritoneal dialysis in newborns undergoing cardiac surgery with cardiopulmonary bypass]. / Uso de diálisis peritoneal en neonatos tras cirugía cardiaca con circulación extracorpórea.

INTRODUCTION: Renal replacement therapy is required in up to 10% of children undergoing cardiac surgery. Peritoneal dialysis (PD) is the preferred treatment method in the neonatal period. OBJECTIVE: To evaluate safety, efficacy and perioperative factors associated with the need for PD. MATERIAL AND METHODS: Retrospective review of clinical charts over a two-year period of newborns undergoing cardiac surgery with cardiopulmonary bypass (CPB). The group of cases requiring PD were compared with a group of random controls that did not require any renal replacement therapy. RESULTS: A total of 76 infants underwent cardiac surgery with CPB, of which 24 required PD. The need for PD was associated with low cardiac output in the immediate postoperative period and longer mechanical ventilation. The most frequent indication was fluid overload. The technique was effective in 66% of patients. Complications were only recorded in one patient. CONCLUSIONS: The most common indication for PD after cardiac surgery with CPB in neonates is fluid overload. The need for renal replacement therapy is associated with low cardiac output and a longer duration of mechanical ventilation. PD is an effective technique with few complications in these patients.

Estimulación precoz en los recién nacidos con peso al nacer entre 1.000 y 1.500 g. ¿Es siempre necesaria? / Early stimulation in newborns with birth weight between 1, 000 and 1, 500 g: is it always necessary?

Objetivo: Determinar si la práctica actualmente generalizada de envío de todos los prematuros nacidos entre 1.000 y 1.500 g al nacer a centros de atención temprana es necesaria desde el punto de vista neurológico o si es posible establecer unos criterios de selección. Material y métodos: Estudio retrospectivo de los recién nacidos (RN) en nuestro hospital entre enero de 1998 y diciembre de 2004 con peso al nacer comprendido entre 1.000 y 1.500 g, y seguidos al menos 2 años en la consulta de neuropediatría. Se analiza la significación pronóstica neurológica de las diferentes variables existentes en el periodo neonatal y con las de mayor significado se estableció un score para decidir el inicio de tratamiento de estimulación precozal alta de neonatología. Resultados: 194 recién nacidos cumplieron los criterios mencionados. Las variables de mayor significación fueron: edad gestacional (EG) < 28 semanas, sexo varón, hemorragia intraventricular de grado > I, antecedentes de embarazo de riesgo, sepsis, anemia con repercusión hemodinámica y fundamentalmente exploración neurológica anormal al alta (odds ratio de 16).Se elaboró un score pronóstico cuyo punto de corte fue 4, con área bajo la curva del 88,3%. El valor predictivo positivo y el valor predictivo negativo fueron del 43,75 y el 96,2% respectivamente, con sensibilidad del 84,8% y especificidad del 78,9%.Conclusiones: Los RN con peso al nacer entre 1.000 y 1.500 g, con exploración neurológicanormal al alta y score pronóstico menor de 4 puntos no precisan estimulación precoz desde el punto de vista neurológico dada su previsible buena evolución (AU)

Objective: To determine whether the currently widespread practice of sending all premature infants with birth weight between 1,000 and 1,500 g to early care centres is necessary from a neurological point of view, or if it is possible to establish selection criteria. Material and methods: A retrospective study of newborns (NB) at our hospital between January 1998 and December 2004 with birth weight between 1,000 and 1,500 g, and followed up for atleast two years in a paediatric neurology clinic. We analysed the prognostic significance of the different neurological variables in the neonatal period, and those of greater significance were set at a score for deciding the start of early stimulation treatment on discharge from neonatology. Results: A total of 194 infants met the above criteria. The most significant neurological prognostic variables were: gestational age < 28 weeks, male sex, intraventricular haemorrhage grade >I, history of high risk pregnancy, sepsis, anaemia with haemodynamic repercussion and fundamentally abnormal neurological examination at discharge (odds ratio of 16). A prognostic score was developed with a cut-off of 4 points, with an area under the curve of 88.3%. The positive predictive value and negative predictive value were 43.75% and 96.2%, respectively, with 84.8%sensitivity and 78.9% specificity. Conclusions: The newborns with birth weight between 1,000 and 1,500 g and normal neurological examination at discharge, with a score of less than 4 points, do not require early stimulation treatment from a neurological standpoint, given its predictable good outcome (AU)

[Early stimulation in newborns with birth weight between 1,000 and 1,500 g: is it always necessary?]. / Estimulación precoz en los recién nacidos con peso al nacer entre 1.000 y 1.500g. ¿Es siempre necesaria?

OBJECTIVE: To determine whether the currently widespread practice of sending all premature infants with birth weight between 1,000 and 1,500 g to early care centres is necessary from a neurological point of view, or if it is possible to establish selection criteria. MATERIAL AND METHODS: A retrospective study of newborns (NB) at our hospital between January 1998 and December 2004 with birth weight between 1,000 and 1,500 g, and followed up for at least two years in a paediatric neurology clinic. We analysed the prognostic significance of the different neurological variables in the neonatal period, and those of greater significance were set at a score for deciding the start of early stimulation treatment on discharge from neonatology. RESULTS: A total of 194 infants met the above criteria. The most significant neurological prognostic variables were: gestational age < 28 weeks, male sex, intraventricular haemorrhage grade > I, history of high risk pregnancy, sepsis, anaemia with haemodynamic repercussion and fundamentally abnormal neurological examination at discharge (odds ratio of 16). A prognostic score was developed with a cut-off of 4 points, with an area under the curve of 88.3%. The positive predictive value and negative predictive value were 43.75% and 96.2%, respectively, with 84.8% sensitivity and 78.9% specificity. CONCLUSIONS: The newborns with birth weight between 1,000 and 1,500 g and normal neurological examination at discharge, with a score of less than 4 points, do not require early stimulation treatment from a neurological standpoint, given its predictable good outcome.

Cystosarcoma phyllodes of the breast: a case report in a 12-year-old girl

Breast tumors in adolescents are very rare and mostly benign. Fibroadenomas are the most frequent, but within the extensive differential diagnosis, the phyllodes tumor must be mentioned, which accounts for about 1% of breast tumors and the diagnosis of which is very rare in patients younger than 20 years. There are no specific symptoms or radiological images to distinguish phyllodes tumor from fibroadenoma; therefore, histological examination is mandatory for diagnosis. Histology also allows the classification of phyllodes tumor into benign, borderline, or malignant types for appropriate surgical treatment: freemargin excision in benign tumors and mastectomy in the other two types. Fortunately, the majority of these tumors are benign, and treatment maximizes breast conservation with free infiltration margins surgery, given that this fact is the most important factor to prevent local recurrence. In this article, we describe a rare case of borderline cystosarcoma phyllodes in a 12-year-old girl (AU)

Atelectasia en niños: ¿qué es lo que parece estar detrás? / Atelectasis in children: what appears to be the cause?

Presentamos un caso de tuberculosis pulmonar en una niña de 15 meses de edad enviada a nuestra consulta para efectuar un estudio de su neumonía recurrente. La radiografía de tórax pone de manifiesto una condensación localizada en el lóbulo medio, con signos sugestivos de atelectasia. La atelectasia es un problema común en los pacientes pediátricos, generalmente secundaria a una obstrucción bronquial por tapones de moco. Se analizan los tipos de atelectasia y sus causas más comunes, y se insiste en la utilidad de ciertas técnicas consideradas agresivas, como la fibrobroncoscopia, que en realidad son pruebas sencillas y con una gran validez diagnóstica y terapéutica. El manejo de las atelectasias depende de la causa subyacente. Es primordial tratar de forma conjunta la enfermedad de base y el colapso pulmonar, y en la mayoría de los casos es suficiente mantener una actitud conservadora (AU)

We report on a case of pulmonary tuberculosis in a fifteen month-old girl who was referred to our practice for tests following recurrent pneumonia. The chest X-ray showed localized condensation in the middle lobe with signs suggestive of atelectasis. Atelectasis is a common problem in paediatric patients, and tends to be secondary to bronchial obstruction due to mucus plugs. We analyse the types of atelectasis and their most common causes. Moreover, we stress the usefulness of certain techniques that are considered to be aggressive, like the fibrobronchoscopy, but which in reality are simple tests with a high level of diagnostic and therapeutic productivity. The approach to atelectases depends on the underlying cause, and it is essential to treat both the underlying disease as well as the collapsed lung; in most cases, a conservative approach is sufficient (AU)

No todas las adenopatías hiliares son de origen tuberculoso. ¿Están justificadas pruebas complemetarias invasivas en niños con adenopatías hiliares? / Not all enlarged hilar lymph nodes have a tuberculous origin. Are complementary invasive tests justified in children with enlarged hilar lymph nodes?

Presentamos a una paciente en edad escolar con adenopatías hiliares en el contexto de neumonías de repetición. Se describe el diagnóstico diferencial razonado que se debe realizar en estos casos, y se discute si son necesarias pruebas complementarias más agresivas en los casos con buena evolución y sin datos sugestivos de enfermedad grave. Se insiste en la importancia de la historia clínica y el beneficio de pruebas complementarias básicas analíticas y de imagen. Se concluye que una actitud expectante, sin realización de pruebas invasivas y con revisiones seriadas, en un proceder útil en estos casos (AU)

We present the case of a school-aged female patient with en larged hilar lymph nodes in the context of recurrent pneumonias. The reasoned differential diagnosis that should be performed in these cases is described and it is discussed whether more aggressive complementary tests are necessary in cases having good evolution and without data suggestive of severe disease. The importance of the clinical history and the benefit of basic complementary laboratory analysis and imaging tests are stressed. It is concluded that a waiting attitude, without performing invasive test and with seriated reviews, is a useful procedure in these cases (AU)

Piomiositis primaria en un niño: difícil diagnóstico inicial. A propósito de un caso y revisión de la bibliografía / Primary pyomyositis in a child: difficult initial diagnosis. Report of a case and a review of the literature

La piomiositis es una infección bacteriana profunda del músculo esquelético, que muestra predilección por los grandes grupos musculares. Esta entidad clínica, frecuente en países de clima tropical, en nuestro medio tiene escasa incidencia. La falta de conciencia de la enfermedad y la presentación insidiosa de los síntomas hacen que a menudo se demore su diagnóstico. Ante un niño con fiebre sin foco aparente, debe considerarsela piomiositis como posible causa, teniendo gran importancia antecedentes como la vacunación previa, debido a que la lesión muscular puede condicionar la infección local tras una bacteriemia. En estas páginas presentamos un caso de piomiositis de glúteo mayor en un paciente de 15 meses de edad que cursó con bacteriemia por Staphylococcus aureus y planteó dificultades en el diagnóstico inicial (AU)

Pyomyositis is a deep bacterial infection of skeletal muscle, which has a predilection for large muscle groups. This clinicalentity is frequently detected in tropical countries, but is not common in our region. Due to a lack of awareness of the disease and the insidious presentation of the clinical symptoms, the final diagnosis is often delayed. Pyomyositis should be considered in every febrile child with no apparent origin. It is very important to take into account the previous history of the patient, including vaccinations. A vaccine can be the origin of muscle injury, which could result in infection due to bacteremia. We present a case of pyomyositis of the gluteus maximus in a 15-month-old child with Staphylococcus aureus bacteremia, and discuss the difficulties encountered in the initial diagnosis (AU)