We have made a retrospective comparative study of patients with spinal cord injury, nine with a diaphragmatic pacemaker and 13 with mechanical ventilation. Clinical outcome, cost and subjective satisfaction with both modalities have been evaluated. The functional status was the same with both types of treatment. Proper management of an electric wheelchair and optimal phonation were attained, respectively, in 100% and 89% of pacers and in 77% and 77% of mechanically ventilated. The rate of hospital discharge and satisfaction with the treatment were significantly better for pacers. The time devoted to ventilatory assistance and cost were also more favourable in this group.
Exclusive enteral nutrition (EEN) has been shown to be more effective than corticosteroids in achieving mucosal healing in children with Crohn´s disease (CD) without the adverse effects of these drugs. The aims of this study were to determine the efficacy of EEN in terms of inducing clinical remission in children newly diagnosed with CD, to describe the predictive factors of response to EEN and the need for treatment with biological agents during the first 12 months of the disease. We conducted an observational retrospective multicentre study that included paediatric patients newly diagnosed with CD between 2014–2016 who underwent EEN. Two hundred and twenty-two patients (140 males) from 35 paediatric centres were included, with a mean age at diagnosis of 11.6 ± 2.5 years. The median EEN duration was 8 weeks (IQR 6.6–8.5), and 184 of the patients (83%) achieved clinical remission (weighted paediatric Crohn’s Disease activity index [wPCDAI] < 12.5). Faecal calprotectin (FC) levels (μg/g) decreased significantly after EEN (830 [IQR 500–1800] to 256 [IQR 120–585] p < 0.0001). Patients with wPCDAI ≤ 57.5, FC < 500 μg/g, CRP >15 mg/L and ileal involvement tended to respond better to EEN. EEN administered for 6–8 weeks is effective for inducing clinical remission. Due to the high response rate in our series, EEN should be used as the first-line therapy in luminal paediatric Crohn’s disease regardless of the location of disease and disease activity.
Background and Aims: Diagnostic delay (DD) is especially relevant in children with inflammatory bowel disease, leading to potential complications. We examined the intervals and factors for DD in the pediatric population of Spain. Methods: We conducted a multicentric prospective study, including 149 pediatric inflammatory bowel disease patients, obtaining clinical, anthropometric, and biochemical data. Time to diagnosis (TD) was divided into several intervals to identify those where the Jiménez Treviño et al. Pediatric IBD Diagnostic Delay in Spain DD was longer and find the variables that prolonged those intervals. Missed opportunities for diagnosis (MODs) were also identified. Results: Overall TD was 4.4 months (interquartile range [IQR] 2.6-10.4), being significantly higher in Crohn's disease (CD) than in ulcerative colitis (UC) (6.3 [IQR 3.3-12.3] vs. 3 [IQR 1.6-5.6] months, p = 0.0001). Time from the visit to the first physician until referral to a pediatric gastroenterologist was the main contributor to TD (2.4 months [IQR 1.03-7.17] in CD vs. 0.83 months [IQR 0.30-2.50] in UC, p = 0.0001). One hundred and ten patients (78.3%) visited more than one physician (29.9% to 4 or more), and 16.3% visited the same physician more than six times before being assessed by the pediatric gastroenterologist. The number of MODs was significantly higher in CD than that in UC patients: 4 MODs (IQR 2-7) vs. 2 MODs ([IQR 1-5], p = 0.003). Referral by pediatricians from hospital care allowed earlier IBD diagnosis (odds ratio 3.2 [95% confidence interval 1.1-8.9], p = 0.025). Conclusions: TD and DD were significantly higher in CD than those in UC. IBD patients (especially those with CD) undergo a large number of medical visits until the final diagnosis.
Three children, aged 6-10 years, in whom cervical cord injury at the CI-C2 level resulted in apnoea had bilateral implantation of diaphragm pacemakers. With periods of gradual conditioning of the diaphragm muscle to low frequency stimulation and slow respiratory rates they adapted to continuous ventilatory support by simultaneous stimulation of both hemidiaphragms without evidence of fatigue, so far for periods of 23-47 months.Continuous support of ventilation by electrical stimulation of the phrenic nerves was first reported in an adult quadriplegic patient with respiratory muscle paralysis by Glenn etal in 1972 Recent laboratory studies to determine the optimal settings for diaphragmatic pacing have shown that continuous bilateral simultaneous pacing is possible without injury to the phrenic nerve or diaphragm muscle if wide pulse interval stimulation of the phrenic nerve at a slow pulse train repetition (respiratory) rate is used.4 This technique has been applied to older children and adult quadriplegic patients with diaphragmatic paralysis and has provided continuous ventilation without evidence of diaphragm fatigue over extended periods.56The present report describes the results in three quadriplegic children with paralysis of the diaphragm who had diaphragm pacemakers implanted and were able to adapt, through gradual conditioning to pacing, to continuous ventilatory support by simultaneous stimulation of both phrenic nerves, which they have had for from 23 to 47 months. Three quadriplegic children, one boy and two girls (patients 1, 2, and 3) aged 10, six and six years respectively, suffered from traumatic lesions of the cervical cord at the level of C1-C2 as a result of motor vehicle accidents. The time between injury and pacemaker implantation was one year in patient I and 10 and nine months respectively in patients 2 and 3. During this time they were mechanically ventilated continuously via a tracheostomy.Preoperative studies consisted of fluoroscopic confirmation of immobility of the diaphragm and determination of viability of the phrenic nerves through transcutaneous stimulation of the phrenic nerves in the neck.7 8 The operative techniques for implantation of the diaphragm pacemaker have been described in detail by Glenn et al.2 The phrenic nerve was exposed through a thoracotomy in the second intercostal space anteriorly. A monopolar electrode was inserted behind the phrenic nerve in the mediastinal portion midway between the base of the heart and the apex of the thoracic cavity, where it was fixed in place with prolene sutures. The radio receiver was implanted subcutaneously through an incision in the anterolateral axillary line at the costal margin in a pocket developed between the costal margin and the inframammary fold. The pocket was about 10cm deep and extended laterally and medially for a distance of some 3-4cm to accommodate the electronic parts (receiver, anode electrode plate and electrode receiver connectors). A receiver electrode assembly was implanted on the right and left side...
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