In the past two decades, flexible bronchoscopy (FB) has gained increasing popularity among pediatric pulmonologists. The objective of this study was to review our experience with pediatric flexible bronchoscopy over the past 15 years, with special focus on route of bronchoscopy. This is a retrospective study. We reviewed our pediatric FB procedures performed at the University of Michigan, Mott Children's Hospital, from 1988-2003. The study included 1,947 procedures in 1,548 patients, with a mean of 1.3 procedures/patient. The male:female ratio was 1.66:1, and age was 4.9 +/- 5.6 years (mean +/- SD). Patients <2 years of age represented 46.6% of the study population. The laryngeal mask airway (LMA) was the most common route for flexible bronchoscopy in children 2 years of age and above. Complication rates were lower with the use of the LMA (1.9%) compared to the nasal route (3.5%). Stridor was the most common indication in the age group <2 years (20.8%), while persistent pulmonary infiltrates were more common in the older age groups (32.2-37%). Laryngomalacia was the most common finding in patients with stridor (31.5%), while inflammatory changes were more common with other indications. Procedure-related complications were reported in 2.3% of procedures. Bronchoalveolar lavage (BAL) samples were obtained and analyzed in 51.2% of FB procedures (n=1,000), of which 19.4% yielded positive microbiology cultures. In conclusion, FB is a safe procedure in pediatrics. Children less than 7 years of age represent the majority of FB subjects. The LMA offered a lower rate of procedure-related complications when compared to the nasal route or endotracheal tube. It also reduced procedure time and anesthesia time.

The study results suggest that CF is more common in Egypt than previously anticipated. Larger studies are warranted to identify the incidence, molecular basis and clinical pattern of CF in the Egyptian population.

BackgroundNephrotoxicity is a major hazard complicating the use of platinum based drugs (PBD), which can hinder using higher doses protocols to maximize the therapeutic gain. Shortage of serum creatinine level as an accurate biomarker for acute kidney injuries (AKI) necessitates searching for novel biomarkers with better sensitivity and specificity in patients on PBD.MethodsIn a prospective cohort design, 132 patients receiving PBD were selected for the study. AKI was diagnosed by continuous follow up of serum creatinine level according to Kidney Disease: Improving Global Outcomes (KDIGO) guidelines 2012. Serum creatinine and urinary biomarkers (KIM-1, NGAL and cystatin C) was measured in the day of treatment and for 3 days after PBD cycle.ResultsAKI occurred in 35 patients (26.52% of patients). KIM-1, Cystatin C, and NGAL showed significant increase in samples collected in the day of AKI in comparison to their corresponding basal levels (P <  0.0001). In addition, significant increase in urinary levels of the biomarkers in samples collected 1 day before AKI in comparison to their basal levels (P <  0.0001, P <  0.0001, and P = 0.013 for KIM-1, NGAL and Cystatin C respectively). Furthermore KIM-1 data showed a significant increase 2 days before serum creatinine rise in comparison to the corresponding KIM-1 levels in patients who developed AKI (P = 0.001).ConclusionsUrinary KIM-1, Cystatin C and NGAL can predict PBD induced AKI in earlier stages than serum createnine. KIM-1 is the most sensitive biomarker for early detection of AKI in patients receiving PBD.

This editorial accompanies an article by Kent et al., Anaesthesia 2018; 73: 1079-89.'There is nothing more deceptive than an obvious fact. ' -Sir Arthur Ignatius Conan Doyle (May 1859-July 1930)In this issue of Anaesthesia, Kent et al. [1] report that administration of neostigmine 2.5 mg (mean (SD) dose 35 (6) lg.kg À1 ) plus glycopyrrolate 450 lg to a small number of healthy volunteers, in the absence of a previously administered non-depolarising neuromuscular blocker (NMB), resulted in manifestations of a depolarising neuromuscular block: muscle weakness, fasciculations and multiple subjective symptoms such as diplopia and dysphagia. These data appear to stand in marked contrast to the observations of a recent investigation by Murphy et al. [2] whose findings could not have been more different. In the latter study, the authors administered neostigmine 40 lg.kg À1 once the train-of-four (TOF) ratio had spontaneously recovered to a value > 0.90 from an initial dose of rocuronium. Neostigmine was not associated with any objective evidence of anticholinesterase-induced muscle weakness, and was also associated with decreased incidence of postoperative diplopia [2]. Who should we believe, Kent or Murphy? The answer is that both sets of observations are credible, but the study of Kent probably has little or no clinical relevance. In the peri-operative setting, neostigmine is never administered in the absence of a preceding dose of a non-depolarising NMB. Kent's observations appear to be valid only when neostigmine administration is not preceded by a non-depolarising NMB. This difference in response to neostigmine probably is the result of continued receptor occupancy by the nondepolarising NMB. Even when the TOF ratio approaches unity following recovery from a non-depolarising block, there is still a substantial degree of receptor occupancy at the neuromuscular junction. Waud and Waud estimated that at full return of the TOF ratio, 70-75% of postsynaptic receptors are still occupied [3]. Kopman found that following recovery to a TOF ratio of 0.95 post mivacurium administration that the ED 50 (the dose the caused 50% reduction of twitch height) value for the relaxant was decreased by 56% [4]. Thus, partial receptor occupancy undoubtedly persists at a time when even objective evidence (e.g. the TOF ratio) is indicative of full recovery of neuromuscular function. It appears that this receptor occupancy provides a protective effect from the depolarising actions of excess acetylcholine. The notion that neostigmine administration at a time when spontaneous clinical recovery from non-depolarising block is almost complete may have adverse clinical consequences has been disputed [2, 5-7]. Murphy's observations are not unique. Choi [8] and Schaller [9] report successful reversal of residual neuromuscular block at a TOF ratio of 0.50 with neostigmine ≤ 40 lg.kg À1 and others [10, 11] found that even lower doses of neostigmine (10-30 lg.kg À1 ) are required at TOF ratios of 0.60. Furthermore, Harper et al. [12] administered a l...