Lung ultrasound in children with pneumonia: interoperator agreement on specific thoracic regions.

The objective of this study was to evaluate the interoperator agreement of lung ultrasonography (LUS) on specific thoracic regions in children diagnosed with pneumonia and to compare the findings of the LUS with the chest X-ray. Participants admitted to the ward or PICU underwent LUS examinations performed by an expert and a novice operator. A total of 261 thoracic regions in 23 patients were evaluated. Median age and weight of participants were 30 months and 11.6 kg, respectively. A substantial overall agreement between operators was found for normal lung tissue (κ = 0.615, 95% confidence interval (95% CI) = 0.516-0.715) and for consolidations (κ = 0.635, 95% CI = 0.532-0.738). For B-lines, a moderate agreement was observed (κ = 0.573, 95% CI = 0.475-0.671). An almost perfect agreement was found for pleural effusion (κ = 0.868, 95% CI = 0.754-0.982). The diagnosis of consolidations by LUS showed a high sensitivity (93% for both operators) but a low specificity (14% for expert and 25% for novice operator). While intubated patients presented significantly more consolidations, nonintubated patients presented more normal ultrasound patterns.Conclusion: Even when performed by operators with very distinct degrees of experience, LUS had a good interoperator reliability for detecting sonographic patterns on specific thoracic regions. What is Known: • Lung ultrasound is feasible, safe, and highly accurate for the diagnosis of pneumonia in children; however, it does not allow global visualization of the thorax in a single moment as in chest X-rays, and, similar to the stethoscope, partial thorax assessments must be performed sequentially. What is New: • This is the first study evaluating the agreement of LUS on specific thoracic regions between operators with distinct degrees of experience performing the sonograms. • There is a good agreement between an expert operator and a novice operator who underwent a brief theoretical-practical training program on LUS.

Associação de meningite e pericardite na doença pneumocócica invasiva: um caso raro / Association of meningitis and pericarditis in invasive pneumococcal disease: a rare case

RESUMO Objetivo: Relatar um caso raro de uma criança com meningite associada a pericardite na doença pneumocócica invasiva. Descrição do caso: Este relato descreve uma evolução clínica desfavorável de um lactente feminino de 6 meses de idade, previamente hígido, que apresentou inicialmente sintomas respiratórios e febre. A radiografia de tórax revelou um aumento da área cardíaca sem alterações radiográficas nos pulmões. Após a identificação do derrame pericárdico, o paciente apresentou convulsões e entrou em coma. Pneumonia foi descartada durante a investigação clínica. Contudo, foi identificado Streptococcus pneumoniae nas culturas de líquor e sangue. O exame neurológico inicial foi compatível com morte encefálica, posteriormente confirmada pelo protocolo. Comentários: A pericardite purulenta tornou-se uma complicação rara da doença pneumocócica invasiva desde o advento da terapia antibiótica. Pacientes com pneumonia extensa são primariamente predispostos e, mesmo com tratamento adequado e precoce, estão sujeitos a altas taxas de mortalidade. A associação de meningite pneumocócica e pericardite é incomum e, portanto, de difícil diagnóstico. Por isso, uma alta suspeição diagnóstica é necessária para instituir o tratamento precoce e aumentar a sobrevida.

ABSTRACT Objective: To report a rare case of a child with invasive pneumococcal disease that presented meningitis associated with pericarditis. Case description: This report describes the unfavorable clinical course of a previously healthy 6-months-old female infant who initially presented symptoms of fever and respiratory problems. A chest X-ray revealed an increased cardiac area with no radiographic changes in the lungs. After identifying a pericardial effusion, the patient experienced seizures and went into coma. Pneumonia was excluded as a possibility during the clinical investigation. However, Streptococcus pneumoniae was identified in the cerebrospinal fluid and blood cultures. An initial neurological examination showed that the patient was brain dead, which was then later confirmed according to protocol. Comments: Purulent pericarditis has become a rare complication of invasive pneumococcal disease since the advent of antibiotic therapy. Patients with extensive pneumonia are primarily predisposed and, even with early and adequate treatment, are prone to high mortality rates. The association of pneumococcal meningitis and pericarditis is uncommon, and therefore difficult to diagnose. As such, diagnostic suspicion must be high in order to institute early treatment and increase survival.

ASSOCIATION OF MENINGITIS AND PERICARDITIS IN INVASIVE PNEUMOCOCCAL DISEASE: A RARE CASE. / ASSOCIAÇÃO DE MENINGITE E PERICARDITE NA DOENÇA PNEUMOCÓCICA INVASIVA: UM CASO RARO.

OBJECTIVE: To report a rare case of a child with invasive pneumococcal disease that presented meningitis associated with pericarditis. CASE DESCRIPTION: This report describes the unfavorable clinical course of a previously healthy 6-months-old female infant who initially presented symptoms of fever and respiratory problems. A chest X-ray revealed an increased cardiac area with no radiographic changes in the lungs. After identifying a pericardial effusion, the patient experienced seizures and went into coma. Pneumonia was excluded as a possibility during the clinical investigation. However, Streptococcus pneumoniae was identified in the cerebrospinal fluid and blood cultures. An initial neurological examination showed that the patient was brain dead, which was then later confirmed according to protocol. COMMENTS: Purulent pericarditis has become a rare complication of invasive pneumococcal disease since the advent of antibiotic therapy. Patients with extensive pneumonia are primarily predisposed and, even with early and adequate treatment, are prone to high mortality rates. The association of pneumococcal meningitis and pericarditis is uncommon, and therefore difficult to diagnose. As such, diagnostic suspicion must be high in order to institute early treatment and increase survival.

OBJETIVO: Relatar um caso raro de uma criança com meningite associada a pericardite na doença pneumocócica invasiva. DESCRIÇÃO DO CASO: Este relato descreve uma evolução clínica desfavorável de um lactente feminino de 6 meses de idade, previamente hígido, que apresentou inicialmente sintomas respiratórios e febre. A radiografia de tórax revelou um aumento da área cardíaca sem alterações radiográficas nos pulmões. Após a identificação do derrame pericárdico, o paciente apresentou convulsões e entrou em coma. Pneumonia foi descartada durante a investigação clínica. Contudo, foi identificado Streptococcus pneumoniae nas culturas de líquor e sangue. O exame neurológico inicial foi compatível com morte encefálica, posteriormente confirmada pelo protocolo. COMENTÁRIOS: A pericardite purulenta tornou-se uma complicação rara da doença pneumocócica invasiva desde o advento da terapia antibiótica. Pacientes com pneumonia extensa são primariamente predispostos e, mesmo com tratamento adequado e precoce, estão sujeitos a altas taxas de mortalidade. A associação de meningite pneumocócica e pericardite é incomum e, portanto, de difícil diagnóstico. Por isso, uma alta suspeição diagnóstica é necessária para instituir o tratamento precoce e aumentar a sobrevida.

Ultrasound Guidance for Pediatric Central Venous Catheterization: A Meta-analysis.

: media-1vid110.1542/5828324804001PEDS-VA_2018-1719Video Abstract CONTEXT: Central venous catheterization is routinely required in patients who are critically ill, and it carries an associated morbidity. In pediatric patients, the procedures can be difficult and challenging, predominantly because of their anatomic characteristics. OBJECTIVE: To determine whether ultrasound-guided techniques are associated with a reduced incidence of failures and complications when compared with the anatomic landmark technique. DATA SOURCES: We conducted a systematic search of PubMed and Embase. STUDY SELECTION: We included randomized controlled trials and nonrandomized studies in which researchers compare ultrasound guidance with the anatomic landmark technique in children who underwent central venous catheterization. DATA EXTRACTION: Study characteristics, sample sizes, participant characteristics, settings, descriptions of the ultrasound technique, puncture sites, and outcomes were analyzed. Pooled analyses were performed by using random-effects models. RESULTS: A total of 23 studies (3995 procedures) were included. Meta-analysis revealed that ultrasound guidance significantly reduced the risk of cannulation failure (odds ratio = 0.27; 95% confidence interval: 0.17-0.43), with significant heterogeneity seen among the studies. Ultrasound guidance also significantly reduced the incidence of arterial punctures (odds ratio = 0.34; 95% confidence interval: 0.21-0.55), without significant heterogeneity seen among the studies. Similar results were observed for femoral and internal jugular veins. LIMITATIONS: Potential publication bias for cannulation failure and arterial puncture was detected among the studies. However, no publication bias was observed when analyzing only the subgroup of randomized clinical trials. CONCLUSIONS: Ultrasound-guided techniques are associated with a reduced incidence of failures and inadvertent arterial punctures in pediatric central venous catheterization when compared with the anatomic landmark technique.

Relationships between body weight and milk yield during the early postpartum period and bull and technician and the reproductive performance of high producing dairy cows.

The aim of this study was to evaluate the effect of body weight (BW) change during the early postpartum period and BW on day 50 post partum on the subsequent expression of estrus and fertility at first insemination before day 90 post partum. The data were derived from 1036 postpartum cows reaching 90 days in milk. The following data were recorded for each animal: lactation number, daily milk production at day 50 post partum, calving date, days in milk at estrus and at AI, insemination date, insemination number, inseminating bull, AI technician and body weight at calving, at day 50 post partum and at AI. Of the 1036 cows registered, 817 (78.9%) showed first estrus before day 90 post partum and were inseminated. Using logistic regression procedures and based on the odds ratio a one unit (kg) increase in the daily milk production at day 50 post partum and a one unit (kg) decrease in the BW between calving and day 50 post partum were related to a 1.03-fold increase and a 0.97-fold decrease in the estrus expression rate before day 90 post partum, respectively. Of the 817 cows inseminated before day 90 post partum, 437 became pregnant (53.5%). A one unit increase in the BW at day 50 post partum produced a 1.003-fold increase in the early fertility rate. Pregnancy rate before day 90 was also influenced by the season at calving, bull providing semen and technician. In conclusion, the register of BW during the postpartum period may be a useful tool for evaluating the nutritional status and its relationship with the subsequent reproductive efficiency in dairy cows.

Effects of cumulative stressful and acute variation episodes of farm climate conditions on late embryo/early fetal loss in high producing dairy cows.

The aim of this study was to determine possible relationships between farm climate conditions, recorded from day 0 to day 40 post-artificial insemination (AI), and late embryo/early fetal loss in high producing dairy cows. Pregnancy was diagnosed by rectal ultrasonography between 28 and 34 days post-AI. Fetal loss was registered when a further 80- to 86-day diagnosis proved negative. Climate variables such as air temperature and relative humidity (RH) were monitored in the cubicles area for each 30-min period. Temperature-humidity indices (THI); cumulative stressful values and episodes of acute change (defined as the mean daily value 1.2 times higher or lower than the mean daily values of the 10 previous days) of the climate variables were calculated. The data were derived from 759 cows in one herd. A total of 692 pregnancies (91.2%) carried singletons and 67 (8.8%) carried twins. No triplets were recorded. Pregnancy loss was recorded in 6.7% (51/759) of pregnancies: 5.6% (39/692) in single and 17.9% (12/67) in twin pregnancies. Using logistic regression procedures, a one-unit increase in the daily cumulative number of hours for the THI values higher than 85 during days 11-20 of gestation caused a 1.57-fold increase in the pregnancy loss, whereas the likelihood of fetal loss increased by a factor of 1.16 for each additional episode of acute variation for the maximum THI values during gestation days 0-40. THI values higher than 85 and episodes of acute variation for the maximum THI values were only recorded during the warm and cool periods, respectively. The presence of twins led to a 3.98-fold increase in pregnancy loss. In conclusion, our findings show that cumulative stressful and episodes of acute variation of climatic conditions can compromise the success of gestation during both the cool and warm periods of the year. Twin pregnancy was confirmed as a main factor associated with pregnancy loss.