Noninvasive hemoglobin monitoring in critically ill pediatric patients at risk of bleeding. / Monitorización no invasiva transcutánea de la concentración de hemoglobina en pacientes críticos pediátricos con riesgo de sangrado.

OBJECTIVE: To determine the accuracy and usefulness of noninvasive continuous hemoglobin (Hb) monitoring in critically ill patients at risk of bleeding. DESIGN: An observational prospective study was made, comparing core laboratory Hb measurement (LabHb) as the gold standard versus transcutaneous hemoglobin monitoring (SpHb). SETTING: Pediatric Intensive Care Unit of a tertiary University Hospital. PATIENTS: Patients weighing >3kg at risk of bleeding. INTERVENTIONS: SpHb was measured using the Radical7 pulse co-oximeter (Masimo Corp., Irvine, CA, USA) each time a blood sample was drawn for core laboratory analysis (Siemens ADVIA 2120i). VARIABLES: Sociodemographic characteristics, perfusion index (PI), pleth variability index, heart rate, SaO2, rectal temperature, low signal quality and other events that can interfere with measurement. RESULTS: A total of 284 measurements were made (80 patients). Mean LabHb was 11.7±2.05g/dl. Mean SpHb was 12.32±2g/dl (Pearson 0.72, R2 0.52). The intra-class correlation coefficient was 0.69 (95%CI 0.55-0.78)(p<0.001). Bland-Altman analysis showed a mean difference of 0.07 ±1.46g/dl. A lower PI and higher temperature independently increased the risk of low signal quality (OR 0.531 [95%CI 0.32-0.88] and 0.529 [95%CI 0.33-0.85], respectively). CONCLUSIONS: SpHb shows a good overall correlation to LabHb, though with wide limits of agreement. Its main advantage is continuous monitoring of patients at risk of bleeding. The reliability of the method is limited in cases with poor peripheral perfusion.

Espondilodiscitis: diagnóstico y seguimiento a medio-largo plazo de 18 casos / Spondylodiscitis: Diagnosis and medium-long term follow up of 18 cases

Introducción: La espondilodiscitis en niños es poco frecuente. Es habitual un retraso en el diagnóstico y errores en el mismo. Objetivos: Revisar las características clínicas, analíticas y radiológicas de los niños con espondilodiscitis en el Hospital Materno-Infantil Carlos Haya de Málaga. Pacientes y métodos: Estudio retrospectivo de los niños diagnosticados de espondilodiscitis en este hospital, durante un período de 10 años. Resultados: Se estudiaron 18 pacientes. Fue más frecuente en menores de 3 años y mayores de 12. El tiempo medio de retraso en el diagnóstico resultó de 26,9 días, con diagnóstico inicial erróneo en 8 casos. Se presentaron 3 patrones clínicos: en menores de 3 años, rechazo de la marcha y sedestación (100%) e irritabilidad (42%); entre 3 y 12 años, impotencia funcional de extremidades inferiores (EEII) (100%) y dolor abdominal (100%); en adolescentes, molestias de la espalda (75%). Apareció fiebre en el 38% de los casos y febrícula en 8 casos (44%). El 50% presentó leucocitosis moderada, con discreta elevación de la velocidad de sedimentación globular. Las localizaciones más frecuentes fueron L3-L4 y L4-L5. La radiografía al diagnóstico resultó patológica en el 83% de los casos. La RM al ingreso fue diagnóstica en el 100%. Detectó además afectación de raíces nerviosas (5 casos), masas inflamatorias/abscesos paravertebrales (5), absceso epidural (1) y abscesos del psoas (2). Recibió tratamiento antibiótico el 94% de los niños e inmovilización el 100%. Todos experimentaron rápida mejoría tras el inicio del tratamiento, excepto los afectados de abscesos del psoas. El seguimiento radiológico, realizado en 17 pacientes (12 mediante RM), a los 14 meses de media (rango 1–48), mostró disminución o desaparición del espacio discal en el 100% de los niños y mejoría de las masas de partes blandas. En el seguimiento clínico (recogido en 11 pacientes) todos conservaban motilidad normal y el 27% dolor leve-moderado. Conclusión: La espondilodiscitis, cuyo retraso en el diagnóstico es frecuente, no es una entidad banal, ya que puede complicarse con abscesos y daño de raíces nerviosas. La RM es la prueba de elección para determinar su extensión a los tejidos vecinos (AU)

Introduction: Spondylodiscitis is an uncommon disease in children. It is often misdiagnosed or the diagnosis is made late in the course of illness. Objectives: To review the clinical, analytical and radiological characteristics of children with spondylodiscitis in the Materno-Infantil Hospital of Malaga. Patients and methods: Retrospective cohort study on children diagnosed with spondylodiscitis, during a period of 11 years. Results: Eighteen patients were included in the study. Spondylodiscitis was more frequent in patients younger than 3 years old and older than 12 years old. The average time of delay in diagnosis was 26.9 days. In 8 cases the diagnosis was missed initially. Three clinical patterns appeared: in children under 3 years of age, refusing to walk and sit (100%) and irritability (42%); between 3 and 12 years of age, limb (100%) and abdominal pain (100%); in adolescents, back pain (75%). Fever was present in 38% of the cases, and low-grade fever in 8 (44%). A total of 50% of the patients had a moderate leucocytosis, and a slight increase in ESR; the most frequent location was L3-L4. X-ray diagnosis was pathological in 88% of the cases. The initial MRI diagnosed 100% of the cases. In addition, nerve roots damage (5 cases), inflammatory masses/paravertebral abscesses (5), epidural abscess (1) and psoas abscesses (2) were detected. A total of 94% of the children received antibiotics and 100% of the children underwent immobilization. All patients recovered early after the beginning of treatment, with the exception of those affected by psoas abscesses. The radiological follow-up was done in 17 patients (12 by MRI). After a mean of 14 months (rank 1–48), persistent diminution of disc space was seen in 100% of the children, and improvement of soft-tissue inflammation. Clinically (follow-up only in 11 patients) all patients regained normal mobility and only 27% had moderate pain. Conclusion: Spondylodiscitis, whose delay in the diagnosis is frequent, is a serious illness. Complications include abscesses and nerve root damage. MRI is the study of choice to determine the extension to neighbouring tissues (AU)

[Spondylodiscitis: Diagnosis and medium-long term follow up of 18 cases]. / Espondilodiscitis: diagnóstico y seguimiento a medio-largo plazo de 18 casos.

INTRODUCTION: Spondylodiscitis is an uncommon disease in children. It is often misdiagnosed or the diagnosis is made late in the course of illness. OBJECTIVES: To review the clinical, analytical and radiological characteristics of children with spondylodiscitis in the Materno-Infantil Hospital of Malaga. PATIENTS AND METHODS: Retrospective cohort study on children diagnosed with spondylodiscitis, during a period of 11 years. RESULTS: Eighteen patients were included in the study. Spondylodiscitis was more frequent in patients younger than 3 years old and older than 12 years old. The average time of delay in diagnosis was 26.9 days. In 8 cases the diagnosis was missed initially. Three clinical patterns appeared: in children under 3 years of age, refusing to walk and sit (100%) and irritability (42%); between 3 and 12 years of age, limb (100%) and abdominal pain (100%); in adolescents, back pain (75%). Fever was present in 38% of the cases, and low-grade fever in 8 (44%). A total of 50% of the patients had a moderate leucocytosis, and a slight increase in ESR; the most frequent location was L3-L4. X-ray diagnosis was pathological in 88% of the cases. The initial MRI diagnosed 100% of the cases. In addition, nerve roots damage (5 cases), inflammatory masses/paravertebral abscesses (5), epidural abscess (1) and psoas abscesses (2) were detected. A total of 94% of the children received antibiotics and 100% of the children underwent immobilization. All patients recovered early after the beginning of treatment, with the exception of those affected by psoas abscesses. The radiological follow-up was done in 17 patients (12 by MRI). After a mean of 14 months (rank 1-48), persistent diminution of disc space was seen in 100% of the children, and improvement of soft-tissue inflammation. Clinically (follow-up only in 11 patients) all patients regained normal mobility and only 27% had moderate pain. CONCLUSION: Spondylodiscitis, whose delay in the diagnosis is frequent, is a serious illness. Complications include abscesses and nerve root damage. MRI is the study of choice to determine the extension to neighbouring tissues.

[New methods in training of paediatric emergencies: medical simulation applied to paediatrics]. / Nuevas metodologías en el entrenamiento de emergencias pediátricas: simulación médica aplicada a pediatría.

Patient safety constitutes one of the main objectives in health care. Among other recommendations, such as the creation of training centres and the development of patient safety programmes, of great importance is the creation of training programmes for work teams using medical simulation. Medical simulation is defined as "a situation or environment created to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation or to understand systems or human actions". In this way, abilities can be acquired in serious and uncommon situations with no risk of harm to the patient. This study revises the origins of medical simulation and the different types of simulation are classified. The main simulators currently used in Pediatrics are presented, and the design of a simulation course applied to the training of pediatric emergencies is described, detailing all its different phases. In the first non face-to-face stage, a new concept in medical training known as e-learning is applied. In the second phase, clinical cases are carried out using robotic simulation; this is followed by a debriefing session, which is a key element for acquiring abilities and skills. Lastly, the follow-up phase allows the student to connect with the teachers to consolidate the concepts acquired during the in-person phase. In this model, the aim is to improve scientific-technical abilities in addition to a series of related abilities such as controlling crisis situations, correct leadership of work teams, distribution of tasks, communication among the team members, etc., all of these within the present concept of excellence in care and medical professionalism.

Nuevas metodologías en el entrenamiento de emergencias pediátricas: simulación médica aplicada a pediatría / New methods in training of paediatric emergencies: medical simulation applied to paediatrics

La seguridad del paciente constituye uno de los principales objetivos de los sistemas sanitarios y, entre otras recomendaciones para su mejora, destaca el establecimiento de programas de entrenamiento de equipos de trabajo con simulación médica. Ésta se define como una situación o lugar creado para permitir que un grupo de personas experimenten una representación de un acontecimiento real con el propósito de practicar, aprender, evaluar o entender sistemas o acciones humanas. De este modo, se podrán adquirir habilidades en situaciones graves y poco frecuentes, sin perjuicio para el paciente. En este trabajo se recuerdan los orígenes de la simulación médica y se clasifican los distintos tipos de simulación actuales. Se exponen los principales simuladores utilizados actualmente en pediatría, y se describe el diseño de un curso de simulación aplicado al entrenamiento de emergencias pediátricas, detallando las distintas fases del mismo. En la primera fase, no presencial, se aplica un nuevo concepto de formación denominado e-learning, nueva metodología de uso de tecnologías de información para la formación de profesionales. En la segunda fase, esencialmente práctica, se desarrollan los casos clínicos con simulación robótica y posteriormente el análisis-debate o debriefing, elemento clave para la adquisición de habilidades. Por último, en la fase de seguimiento, el alumno dispone de conexión con los docentes para consolidar los conceptos adquiridos durante la fase presencial. En este modelo se pretende mejorar las habilidades científicos-técnicas y además una serie de habilidades relacionales como son el control de la situación de crisis, el liderazgo adecuado de un grupo de trabajo, el reparto de tareas, la comunicación entre los miembros del equipo, etc., todas ellas encuadradas en el actual concepto de excelencia de cuidados y del profesionalismo medico (AU)

Patient safety constitutes one of the main objectives in health care. Among other recommendations, such as the creation of training centres and the development of patient safety programmes, of great importance is the creation of training programmes for work teams using medical simulation. Medical simulation is defined as "a situation or environment created to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation or to understand systems or human actions". In this way, abilities can be acquired in serious and uncommon situations with no risk of harm to the patient. This study revises the origins of medical simulation and the different types of simulation are classified. The main simulators currently used in Pediatrics are presented, and the design of a simulation course applied to the training of pediatric emergencies is described, detailing all its different phases. In the first non face-to-face stage, a new concept in medical training known as e-learning is applied. In the second phase, clinical cases are carried out using robotic simulation; this is followed by a debriefing session, which is a key element for acquiring abilities and skills. Lastly, the follow-up phase allows the student to connect with the teachers to consolidate the concepts acquired during the in-person phase. In this model, the aim is to improve scientific-technical abilities in addition to a series of related abilities such as controlling crisis situations, correct leadership of work teams, distribution of tasks, communication among the team members, etc., all of these within the present concept of excellence in care and medical professionalism (AU)

Agujeros parietales / Parietal foramina

No disponible

[Metastatic Crohn's disease in childhood]. / Enfermedad de Crohn metastásica.

Crohn's disease (CD) is an intestinal inflammatory disease of unknown origin that is sometimes associated with cutaneous manifestations. These skin lesions are usually nonspecific (erythema nodosum, erythema multiforme and pyoderma gangrenosum) and should be differentiated from the cutaneous lesions corresponding to the typical histological pattern of CD; most of these extend directly from the involved bowel. Noncaseating granulomatous infiltration in skin anatomically distant from areas of gastrointestinal CD and separated by normal skin is extremely rare. This entity, known as metastatic Crohn's disease, can be the first symptom of CD or even more unusually can appear during the course of the disease.We report the case of a 9-year-old boy, previously diagnosed with ileocolic and perianal CD, who had been receiving treatment with mesalazine, prednisone and 6-mercaptopurine for 3 years. He presented with swelling of the penis and scrotum of 2 weeks' evolution, without any other symptoms. Testicular ultrasound showed thickening of the scrotal wall and increased flux at this site. Skin biopsy showed noncaseating granulomas. Results of special staining techniques were negative for the presence of microorganisms. The prednisone dose was increased and metronidazole was added, with noticeable improvement in the lesions. Due to reappearance of cutaneous lesions when the prednisone dose was reduced, the patient currently receives maintenance treatment.