Respiratory and pharmacological management in severe acute bronchiolitis: Were clinical guidelines not written for critical care?

PURPOSE: The treatment applied for children admitted to the pediatric intensive care unit (PICU) for severe acute bronchiolitis may differ from general recommendations. The first objective of our study was to describe the treatments offered to these children in a Spanish tertiary PICU. The second objective was to analyse the changes in management derived from the publication of the American Academy of Pediatrics (AAP) bronchiolitis guideline in 2014. METHODS: This was a retrospective-prospective observational study conducted during two epidemic waves (2014-2015 and 2015-2016). The AAP guidelines were distributed and taught to PICU staff between both epidemic waves. RESULTS: A total of 138 children were enrolled (78 male). In the first period, 78 children were enrolled. The median age was 1.8 months (IQR 1.1-3.6). There were no differences between the management in the two periods, except for the use of high-flow oxygen therapy (HFOT); its use increased in the second period. Overall, 83% of patients received non-invasive ventilation or HFOT. Children older than 12 months received HFOT exclusively. In comparison, continuous positive airway pressure and bi-level positive airway pressure were used less during the period 2015-2016 (P=0.036). Regarding pharmacological therapy, 70% of patients received antibiotics, 23% steroids, 33% salbutamol, 31% adrenaline, and 7% hypertonic saline. The mortality rate was zero. CONCLUSIONS: Our PICU did not follow the AAP recommendations. There were no differences between the two periods, except in the use of HFOT. All children older than 12 months received HFOT exclusively. The rate of using invasive mechanical ventilation was also low.

Accuracy of CD64 expression on neutrophils and monocytes in bacterial infection diagnosis at pediatric intensive care admission.

The CD64 receptor has been described as an interesting bacterial infection biomarker. Its expression has not been studied in previously healthy children admitted to pediatric critical care unit (PICU). Our objective was firstly to describe the CD64 expression and secondly study its diagnostic accuracy to discriminate bacterial versus viral infection in this children. We made a prospective double-blind observational study (March 2016-February 2018). A flow cytometry (FC) was done from peripheral blood at PICU admission. We studied the percentage of CD64+ neutrophils and the CD64 mean fluorescence intensity (MFI) on neutrophils (nCD64) and monocytes (mCD64). Statistical analyses were performed with non-parametric tests (p < 0.05). Twenty children in the bacterial infection group (BIG) and 25 in the viral infection group (VIG). Children in BIG showed higher values of CD64+ neutrophils (p = 0.000), nCD64 (p = 0.001), and mCD64 (p = 0.003). In addition, CD64+ neutrophils and nCD64 expression have positive correlation with procalcitonin and C reactive protein. The nCD64 area under the curve (AUC) was 0.83 (p = 0.000). The %CD64+ neutrophils showed an AUC of 0.828 (p = 0.000). The mCD64 AUC was 0.83 (p = 0.003). The nCD64 and %CD64+ neutrophils also showed higher combined values of sensitivity (74%) and specificity (90%) than all classical biomarkers.In our series CD64 expression allows to discriminate between bacterial and viral infection at PICU admission. Future studies should confirm this and be focused in the study of CD64 correlation with clinical data and its utility as an evolution biomarker in critical care children.

Impact of NEGR1 genetic variability on psychological traits of patients with eating disorders.

Genetics variants in the NEGR1 gene, strongly expressed in the brain, have been reported to affect the neuronal control of food intake therefore inducing obesity. With the same rationale, we hypothesized that this genetic variability may be associated with psychological traits commonly displayed by eating disorder (ED) patients and/or with the risk for the disorder. We analyzed 21 tag-single-nucleotide polymorphisms (SNPs) in the coding sequence and adjacent regions of the NEGR1 gene. A total of 169 ED patients (106 with anorexia nervosa (AN) and 63 with bulimia nervosa (BN)) and 312 healthy subjects were genotyped. Personality traits and general psychopathological symptoms were assessed by the Eating Disorders Inventory Test-2 (EDI-2) and Symptom Checklist 90 Revised inventories. None of the SNPs or haplotypes analyzed were associated with a greater risk of ED or correlated with anthropometric parameters. However, in patients with BN, four SNPs (rs12740031, rs10789322, rs6659202 and rs591540) correlated with the scores in Drive for Thinness (DT), Ineffectiveness (I) and Interoceptive Awareness (IA) (Bonferroni-P<0.05 in all instances). The first two SNPs along with rs954299 and rs2422021 formed a haplotype block, which showed a consistent association with the EDI-2 score in BN patients (Bonferroni-P=0.01). A subsequent three-SNP sliding-window approach identified a central area, encompassing both the haplotype block and the individually relevant SNPs that strongly correlated with the scores of BN patients in DT, I, IA and Bulimia. No associations were identified in the AN group. These preliminary results indicate that NEGR1 could be an important locus influencing certain personality dimensions in BN patients.

[Aplastic crisis due to parvovirus B19 and Epstein-Barr virus in a patient with hereditary spherocytosis]. / Crisis aplásica por Parvovirus B19 y virus de Epstein-Barr en paciente con esferocitosis hereditaria.

Anemic syndrome in childhood requires a diagnosis and urgent treatment guided by systematic protocols that can avoid unnecessary additional testing. The case of a 4 year-old girl with fatigue and intermittent fever of 7 days duration, accompanied by abdominal pain is presented. She had regular general health status, with mucocutaneous jaundice, a grade III/VI/iv murmur, and painful abdomen with hepatosplenomegaly. The blood analysis showed a hypo-regenerative anemia with increased LDH and indirect bilirubin. The Coombs Test was negative, with spherocytes being observed in the peripheral blood smear. The IgM and IgG were positive for parvovirus B19 IgM and Epstein Barr virus, leading to the diagnosis of aplastic crisis in a patient with hereditary spherocytosis. No specific treatment was required. Under the suspicion of anemic syndrome in emergencies, the ABCDE sequence must be followed. Through the history, physical examination and basic laboratory tests, an initial diagnostic approach can be made. Specific etiological tests should be based on this first study.

[Fiberoptic bronchoscopy, 3-D reconstruction of the airway and virtual bronchoscopy in patients with airway malformations. Preliminary report]. / Fibrobroncoscopia, reconstrucción tridimensional de la vía aérea y broncoscopia virtual en pacientes con patología de la vía aérea: estudio preliminar.

UNLABELLED: Bronchoscopy is the diagnostic gold standard in patients with airway malformations. Helical CT scan has produced studies such as virtual bronchoscopy or 3-D reconstruction of the airway. The purpose of this study is to analyze the correlation between fiberoptic bronchoscopy, virtual bronchoscopy and 3-D reconstruction of the airway in patients with airway malformations. METHODS: From January 2001 to March 2002 we evaluated the airway of 17 patients with airway malformations by means of a diagnostic protocol consisting on fiberoptic bronchoscopy, and Helical CT scan with 3-D reconstruction of the airway and virtual bronchoscopy. The radiologist had no access to bronchoscopic information. Age at study, associated cardiovascular anomalies, indications, localization, degree of diagnostic concordance, etiology and influence in treatment were analyzed. RESULTS: 20 studies were done to 17 patients whose mean age was 1.64 +/- 0.48 years (7 days-7 years). Twelve patients had associated anomalies of the aorta, pulmonary arteries or supraortic vessels. Excellent concordance was obtained in 13 cases (65%), good in 6 (30%) and poor in one (5%). 3-D reconstruction of the airway and adjacent vascular structures provided additional information in 14 cases (70%): in 3 exact length of the tracheal lesion and in 11 defined the cause of the compression. In all the cases, absolute concordance in localization was obtained. CT scan information modified treatment in 6 patients (35%). In 7 patients with associated vascular anomalies, no further image studies were done, confirming the anatomy concordance during surgery. CONCLUSIONS: 3-D reconstruction of the airway and virtual bronchoscopy are excellent diagnostic tools in patients with airway malformations, and contribute to define the etiology, length and diameter of the lesion. Excellent diagnostic correlation was obtained between analogic and virtual bronchoscopies, although further multicentric studies should be conducted.

[Familial aggregation in 91 families of hypercholesterolemic children]. / Estudio de la agregación familiar en 91 familias de niños hipercolesterolémicos.

OBJECTIVE: The aim of this study was to evaluate both the importance of the screening strategy and the familial aggregation characteristics of families with hypercholesterolemic children. PATIENTS AND METHODS: Ninety-one families (369 subjects) with one hypercholesterolemic child were studied. In addition to clinical and general biochemical evaluation, lipids including apo A-I and B-100 were examined. LDL was quantified under ultracentrifugation. RESULTS: Among the 91 children studied, 10 (10.99%) suffered heterozygous hypercholesterolemia, while 81 (89.01%) suffered polygenic hypercholesterolemia. Following a diet, polygenic children exhibited normal lipid parameters. In heterozygous children a decrease of 19% for total cholesterol, 19.9% for LDL-cholesterol and 16.3% for apo B were observed. When starting the study, 77.5% of the family members thought that they had normal serum lipid values. At the end of the study it was confirmed that only 28% were really normolipemic, indicating that 49.4% of the individual did not know that they were suffering dyslipemia. The study also showed that fathers exhibited the highest incidence of hypercholesterolemia (80.2%) followed by brothers (65.6%) and mothers (61.5%). Therefore, 69.4% of the individuals studied exhibited dyslipemia. CONCLUSIONS: The screening strategy allows one to diagnose a high percentage (almost 50%) of individuals suffering hypercholesterolemia in families with a child previously diagnosed of this pathology. Moreover, in these families there is a high degree of familiar aggregation of dyslipemia.

[Disseminated Kaposi's sarcoma with hepatosplenic involvement in AIDS]. / Sarcoma de Kaposi diseminado con afectación hepatosplénica en el SIDA.

Kaposi sarcoma (KS) is the most frequent neoplasm found in AIDS patients. The disease is often disseminated and preferentially involves the skin and the lymphatic and digestive systems. Hepatosplenic involvement which is considered as a frequent autopsy finding is rarely diagnosed at life. A 27-year-old male HIV positive patient with severe immunosuppression who developed a rapidly progressive laterocervical cutaneous KS confirmed by pathologic study is presented. Abdominal echography and thoracoabdominal CT scand demonstrated lesions highly suggestive of pulmonary, lymph node, hepatic, splenic and rectal involvement by KS. The administration of 2 chemotherapy cycles produced subjective improvement and remission of the cutaneous lesions. Severe pulmonary superinfection led to death. An autopsy study was not performed. Hepatosplenic involvement by KS, diagnosed while the patient is alive is rare. The imaging techniques are useful to diagnose with high probability visceral involvement of KS. Systemic searching for visceral involvement in KS patients would lead to a marked increase in the cases such as that herein described with evident therapeutic and prognostic implications.

Localized right upper lobe edema.

One of the lesser known atypical forms of radiographic presentation of pulmonary edema is the isolated or predominant affection of the upper right lobe in patients with mitral valve insufficiency. As a possible cause of this distribution, it has been established that the regurgitation jet during the ventricular systole may be directed selectively toward the orifice of the right upper lobe vein, locally accentuating the forces responsible for edema formation. There are few cases with these characteristics in the literature reviewed. We present an additional three cases, concluding that localized pulmonary edema secondary to mitral insufficiency should be suspected in the presence of any type of airspace consolidation in the right upper lobe, with or without associated affection of the middle lobe, in patients with a history of mitral valve insufficiency, especially when there are radiologic signs of left heart failure.

Sonography of the painful hip in children: 500 consecutive cases.

Five hundred children with a painful hip or a limp were evaluated prospectively by plain films and sonography. The clinical, radiographic, and sonographic findings were correlated with the final diagnoses. Sonography disclosed hip effusion in 235 patients, and plain films were abnormal in 58 of these 235 patients and in four others. Both sonography and plain films were normal in 261 patients. No sonographic signs served to differentiate sterile, purulent, or hemorrhagic effusion. Follow-up sonograms were performed in 202 patients. Sonography showed that 73% of patients with presumed transient synovitis had no effusion 2 weeks after diagnosis. Patients with hip disorders other than transient synovitis had persistent effusion for more than 2 weeks; however, that was also observed in 27% of patients with presumed transient synovitis. Sonography was more sensitive than plain films for detecting hip effusion. However, sonographic detection of effusion changed the therapeutic approach in only six patients.