Neuromodulación periférica transcutánea en el manejo de la vejiga hiperactiva pediátrica

84 páginas.Trabajo Fin de Máster Universitario en Urología Pediátrica. Tutor: Dr. Pedro López Pereira ; Cotutor: Dr. Iván Somoza Argibay. INTRODUCCIÓN La electroneuroestimulación vesical con TENS ha surgido como nueva alternativa en el manejo de las disfunciones del tracto urinario inferior. Nuestro objetivo fue evaluar la eficacia y seguridad de esta terapia en niños con diagnóstico de vejiga hiperactiva. MATERIAL Y MÉTODOS Estudio prospectivo de pacientes con diagnóstico de vejiga hiperactiva y tratados con electroneuroestimulación. El TENS se mantuvo durante 6 meses. Evaluamos la severidad de la sintomatología urinaria utilizando el cuestionario PLUTSS (Pediatric Lower Urinary Tract Symptoms Score). Evaluamos la calidad de vida percibida por los pacientes antes y al finalizar el tratamiento con una escala subjetiva numérica (0 no afectación-3 afectación máxima). RESULTADOS Un total de 21 pacientes (13 niñas) fueron incluidos en el estudio, con una edad media de 10 años (Rango: 6-16). Los síntomas más frecuentes fueron: Urgencia (100%) e incontinencia (89%). Encontramos diferencias estadísticamente significativas (p<0.05) en los valores medios del PLUTSS antes de iniciar tratamiento y al finalizar el mismo: PLUTSS inicial 17.8 (Rango: 10-29), a los 3 meses: 7.21 (Rango: 2-16), a los 6 meses: 5.6 (Rango: 3-12). El volumen miccional máximo de todos los pacientes aumentó a los 6 meses de tratamiento. Todos los pacientes sintieron una mejora en su calidad de vida al finalizar el estudio (p<0.05). CONCLUSIONES La electroneuromodulación con TENS parece una opción segura y eficaz en el manejo de la vejiga hiperactiva, sin embargo, deben ser realizados más estudios randomizados para demostrar su efectividad y protocolizar su aplicación en los pacientes en edad pediátrica.INTRODUCTION Electroneurostimulation of the bladder with TENS (transcutaneous electrical nerve stimulation) has emerged in recent years as a new alternative in the management of the dysfunctions of the lower urinary tract. Our objective was to evaluate the efficacy and safety of this therapy in children with overactive bladder. MATERIAL AND METHODS This is a prospective study of patients diagnosed with overactive bladder and treated with electroneuro-stimulation. The system was maintained for 6 months. We evaluated the severity of urinary symptomatology using the PLUTSS (Pediatric Lower Urinary Tract Symptoms Score) questionnaire. A subjetive escale was used to establish the quality of life of all patients and their families. RESULTS A total of 21 patients were included in the study, with an average age of 10 years (Range: 6- 16). The most frequent symptoms were: urgency (100%) and incontinence (89%). We found statistically significant differences (p<0.05) in the mean PLUTSS values before starting treatment and at the end of treatment: initial PLUTSS was 17.8 (Range: 10-29), at 3 months was 7.21 (Range: 2-16), at 6 months: 5.6 (Range: 3-12). The maximum voiding volume of all patients increased after 6 months of treatment. All patients felt an improvement in their quality of life at the end of the study (p<0.05). CONCLUSIONS The electroneuromodulation with TENS is a safe and effective option in the management of the overactive bladder in paediatric population, however, more randomized studies should be done to protocolize and clarify the effectiveness of this therapeutic approach

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Evaluación de la eficacia y seguridad de la neuromodulación eléctrica transcutánea no invasiva en el manejo de la vejiga hiperactiva en la población pediátrica

Programa Oficial de Doutoramento en Ciencias da Saúde. 5007V01[Resumen] La electroterapia sacra presenta un perfil de seguridad superior y una tasa de curación mayor que la oxibutinina