Clinical Ethics in Pediatrics: An International Perspective.

In this article, we first review the development of clinical ethics in pediatrics in the United States. We report that, over the last 40 years, most children's hospitals have ethics committees but that those committees are rarely consulted. We speculate that the reasons for the paucity of ethics consults might be because ethical dilemmas are aired in other venues. The role of the ethics consultant, then, might be to shape the institutional climate and create safe spaces for the discussion of difficult and sometimes contentious issues. Finally, we report how pediatric clinical ethics has evolved differently in a number of other countries around the world.

Efficacy and safety of an abbreviated perioperative care bundle versus standard perioperative care in children undergoing elective bowel anastomoses: A randomized, noninferiority trial.

PURPOSE: The aim was to evaluate if an abbreviated perioperative care bundle (APCB) is noninferior to the standard care, in terms of efficacy and safety, in pediatric patients undergoing bowel anastomoses. METHODS: A randomized, open, noninferiority trial with two parallel groups of equal size was carried out at the National Institute of Pediatrics in Mexico City, Mexico, from April 2016 to July 2018. The total number analyzed was 74 (37 per group). The APCB comprised same day admission, avoidance of mechanical bowel preparation, optimized antibiotic prophylaxis, and early feeding. Statistical analysis was done with Fisher's exact test or Chi2, and Student's T test. RESULTS: No significant differences were found for demographic variables and type of disease, either for the safety (anastomotic leakage, p 0.753; organ/space surgical site infection, p 0.500) or for some efficacy outcomes (ileus or bowel obstruction, p 0.693). Other efficacy outcomes were better in the study group, with shorter median times for feeding tolerance (19 h vs. 92 h, p < 0.001), for first bowel movement (15 h vs. 36 h, p < 0.001), and for discharge (1 vs. 6 days, p < 0.001). CONCLUSION: The abbreviated care bundle was proven to be as safe but more efficacious than the standard care. LEVEL OF EVIDENCE: I - randomized controlled trial with adequate statistical power.

Error traps and culture of safety in pediatric surgical oncology.

This article reviews technical issues to improve surgical safety and avoid surgical errors in pediatric surgical oncology, particularly in the three most common extracranial solid tumors: neuroblastoma, hepatoblastoma and Wilms tumor. The use of adjuvant chemotherapy - when indicated - the use of tumor specific classifications, adequate surgical planning, that may include the use of 3D printable models, improved surgical instruments and technology, and following surgical guidelines, would result in avoiding error, increased safety, and therefore in improved surgical outcomes.

Effectiveness of senna vs polyethylene glycol as laxative therapy in children with constipation related to anorectal malformation.

PURPOSE: Constipation is present in 80% of children with corrected anorectal malformations, usually associated to rectal dilation and hypomotility. Osmotic laxatives are routinely used for idiopathic constipation. Senna is a stimulant laxative that produces contractions improving colonic motility without affecting the stool consistency. We designed this trial to study the effectiveness of Senna versus polyethylene glycol for the treatment of constipation in children with anorectal malformation. METHODS: A randomized controlled crossover design clinical trial, including a washout period, was conducted, including children with corrected anorectal malformations with fecal continence and constipation. The sample size was calculated for proportions (n=28) according to available data for Senna. Effectiveness of laxative therapy was measured with a three variable construct: 1) daily bowel movement, 2) fecal soiling, 3) a "clean" abdominal x-ray. Data analysis included descriptive statistics and a Fisher's exact test for the outcome variable (effectiveness). RESULTS: The study was terminated early because the interim analysis showed a clear benefit toward Senna (p = 0.026). The sample showed a normal statistical distribution for the variables age and presence of megarectum. The maximum daily dose of Senna (sennosides A and B) was 38.7mg and 17g for polyethylene glycol. No adverse effects were identified. CONCLUSION: Therapy with Senna should be the laxative treatment of choice as part of a bowel management program in children with repaired anorectal malformations and constipation, since the stimulation of colonic propulsion waves could lead to stool evacuation without modification of its consistency which can affect fecal continence. LEVEL OF EVIDENCE: I - randomized controlled trial with adequate statistical power.

Assessment of the Mexican Board of Pediatric Surgery Certification System.

OBJECTIVE: To evaluate the quality of the Mexican Board of Pediatric Surgery (MBPS) certifying system, using contemporary international guidelines. DESIGN: Retrospective assessment of evidence collected during the design and implementation processes of 2 consecutive applications of the MBPS certifying examination, using Cizek's checklist for evaluating credential-testing programs. It includes the relevant guidelines from the American Education Research Association, the American Psychological Association, the National Council on Measurement in Education, and the National Commission for Certifying Agencies. Four independent and previously trained raters used the checklist. They underwent a 2-week training using frame-of-reference and performance dimensions methodologies. SETTING: Certification examinations of MBPS. POPULATION: The 2013 and 2014 MBPS certification examinations, with 111 evidence items of the processes, followed for the assessment of 86 examinees. RESULTS: The checklist internal consistency was 0.89. Absolute interrater agreement was 0.34 for the 2013 and 0.66 for the 2014 editions of the examination. The 2013 examination complied with 55 (64%) of the checklist 86 items, in 2014 with 72 (84%). CONCLUSION: In 2014, the certifying system reached a quality of 84%. For optimal fulfillment of its social responsibility, the MBPS is required to maintain its level of quality and attempt to improve its performance.

Usefulness of intravenous heparin to prevent thrombosis of central venous catheter in children.

BACKGROUND: central venous catheter (CVC) thrombosis in children is a main issue and its prevention with intravenous heparin is still controversial. The aim of this study was to evaluate efficacy of intravenous heparin in preventing CVC thrombosis both clinically and macroscopically. METHODS: we conducted a randomized clinical trial in a tertiary care children's hospital with patients <18 years of age with CVC. Experimental group included addition of heparin at 2 IU/ml of intravenous fluids (IV), whereas the control group did not include heparin. RESULTS: seventy six lumen of catheters were included, 38 in each group. Both groups were homogeneous in epidemiological variables. Macroscopic thrombus was found in 27 (35.5%) lumen of catheters. The group with heparin showed thrombus in 7.8% and 63% in the control group (p <0.0001 with relative risk (RR) of 20 and confidence interval (CI) at 95% (5.1-77.2). Clinical evaluation showed adequate flow in the IV of the heparin group in 94.7% and 57.8% in the control group (p <0.001). Blood return through the lumen of catheters with heparin was present in 86.8% and 42.1% in the control group (p <0.001). Mean time for catheters was 14.3 days. There were no side effects or prolonged partial thromboplastin time. CONCLUSIONS: heparin infusion at 2 IU/ml is safe and effective in preventing CVC thrombosis in children.

Síndrome de Pierre-Robin y hepatoblastoma: reporte de un caso / Pierre-Robin syndrome and hepatoblastoma: a case report

Introducción. La secuencia de Pierre-Robin (SPR) es una afección congénita caracterizada por micrognatia, glosoptosis y fsura del paladar blando. La prevalencia es 1:8500 recién nacidos (RN) vivos. El hepatoblastoma (HB) es el tumor maligno primario de hígado más frecuente en pediatría. Afecta niños menores de 3 años. Caso clínico. Se trata de un paciente masculino de 2 años de edad, producto de la gesta II, de término, obtenido por cesárea, peso al nacer de 2, 750 g, con diagnóstico de SPR. A los 2 años se detecta masa abdominal dependiente de hígado. Se diagnostica HB, por lo que requiere quimioterapia y cirugía (lobectomía izquierda). A 5 años de seguimiento está vivo sin actividad tumoral. Conclusiones. La asociación de SPR y HB no se encontró reportada previamente en la literatura. Ambas presentan alteraciones en el cromosoma 2. Dado que el cáncer cursa con alteraciones citogenéticas, debemos de establecer asociaciones entre aquellos pacientes que cursan con síndromes genéticos. Esto permite evaluar blancos moleculares útiles y diseñar terapias dirigidas. También permite detectar poblaciones de riesgo de padecer cáncer y crear programas de seguimiento y evaluación que permitan una detección temprana para mejorar la sobrevida de dichos grupos. Se trata del primer caso de asociación entre estas dos patologías reportado en nuestro instituto y en el mundo.

Background. Pierre-Robin Sequence (PRS) is a congenital disease characterized by micrognatia, glosoptosis and U-shaped posterior cleft palate. Its prevalence is 1:8500 newborns. Hepatoblastoma (HB) is the most frequent hepatic malignant tumor in childhood and affects patients <3 years of age. Case report. A 2-year old male with PRS was diagnosed with HB. The boy was the product of the second full term pregnancy. He was born by cesarean with a birth weight of 2750 g. The patient presented with a 1-month history of abdominal mass. Diagnosis of HB was done by biopsy. The patient received chemotherapy with cisplatin, vincristin and 5-fuorouracil as well as left lobectomy. Five years later he is alive without tumor activity. Conclusions. PRS and HB association has not been reported in the literature. Both entities have chromosome 2 alterations. Because cancer is associated with cytogenetic alterations, future considerations must be made to fnd a relationship between cancer patients and other genetic entities. This will be useful for fnding molecular targets. We can also detect the at-risk population in order to create follow-up programs that will allow an early diagnosis with an improved better survival. It is the frst case of PRS and HB reported in either the national or international literature.

Aggressive bladder carcinoma in a child.

The brief report describes an unusual case of high grade bladder neoplasm with divergent differentiation in a 31 month-old child. The presentation included hematuria with tissue fragments and the tumor was confined to the bladder. The tumor behaved aggressively despite radical cystectomy, chemotherapy with agents known to be effective against epithelial and mesenchymal tumors and radiation therapy. Although rare, most malignant bladder neoplasms in children are low grade and present in early stages. Sarcomatoid differentiation in the setting of high-grade urothelial carcinoma portends a poor prognosis.

Relaciones anatómicas de la vena subclavia en un grupo de recién nacidos con puntos de orientación óseos para su mejor punción con técnica infraclavicular y supraclavicular

Introducción. Objetivo: corroborar de manera objetiva las diferencias anatómicas existentes en el trayecto de la vena subclavia en un grupo de recién nacidos para describir la mejor técnica de punción subclavia en este grupo de edad. Material y métodos. Estudio quirúrgico-radiológico, descriptivo, prolectivo, midiendo distancias de la vena subclavia con relación a la clavícula y la articulación esterno-clavicular. Resultados. El punto donde cruza la vena a la clavícula es más lateral respecto a lo reportado en la literatura. La profundidad de la vena respecto a la clavícula es de 3.2 mm para el lado izquierdo (2-5) y de 2.0 mm para el lado derecho, el ángulo ascendente que sigue la vena es en promedio de 38° del lado izquierdo y de 34° del lado derecho. El punto más alto de la vena sobre la articulación es de 9 mm del lado izquierdo y 7 mm del lado derecho. Los ángulos en la porción descendente de la vena subclavia son en promedio de 27° del lado izquierdo y de 81° del lado derecho. Conclusiones. Se propone una técnica de punción de la vena subclavia tanto con técnica supra como infraclavicular en recién nacidos, basada en los hallazgos anatómicos.

Introduction. To correlate in an objective manner the anatomical differences of the subclavian vein in newborns for a better approach to it's puncture. Material and methods. A descriptive, surgical and pathological study in cadavers measuring the subclavian vein related to the clavicle and the sterno-clavicular joint. Results. The specific point where the subclavian vein cross the clavicle is lateral than the 1 reported in literature. The deepness of the vein with respect to the clavicle is 3.2 mm for the left side and 2 mm for the right, the ascending angle of the vein is 38° on the left and 34° on the right side. The highest point of the vein over the joint is 9 mm on the left and 7 mm on the right side. The descending angles of the vein are 27° on the left and 81° on the right side in average. Conclusions. We propose, based on our results, a puncture technique for the subclavian vein in newborns either with the supra or infraclavicular technique.