Evaluation of a prophylactic transfusion program on obstetric outcomes in pregnant women with sickle cell disease: A single centre retrospective cohort study.

OBJECTIVE: To evaluate the effects of a prophylactic transfusion program (TP) on obstetric and perinatal outcomes in pregnant women with sickle cell disease (SCD). METHODS: This retrospective cohort study included all singleton pregnancies among women with SCD in a French university tertiary care center between 1 January 2004 and 31 December 2017. The TP group included patients selected according to the French guidelines who received regular red blood cell transfusions during pregnancy until delivery. The factors associated with TP indication [year of birth, SCD genotype, history of acute chest syndrome and delayed hemolysis transfusion reaction (DHTR) risk score] were taken into account in a propensity score. A composite obstetric adverse outcome was defined associating birth before 34 gestational weeks and/or pre-eclampsia and/or small for gestational age and/or abruption and/or stillbirth and/or maternal death and/or neonatal death. RESULTS: In total, 246 pregnancies in 173 patients were analyzed. Twenty-two pregnancies with a history of DHTR were excluded. A higher frequency of TP was found before 2013 [119/148 (80.4%) vs 38/76 (50%); p < 0.001]. Rates of preterm birth before 34 gestational weeks (5.6% vs 19.7%; p = 0.001), vaso-occlusive crisis (36.5% vs. 61.8%; p < 0.001), and acute chest syndrome (6.1% vs. 14.5%; p = 0.04) during pregnancy were decreased significantly in the TP group. Among the groups with and without composite obstetric adverse outcomes, the frequency of TP was 52.6% and 74.7%, respectively [odds ratio (OR) 0.30, 95% confidence interval (CI) 0.09-1.02]. The multivariate analysis shows that the TP was associated with a significant reduction in the risk of composite obstetric adverse outcomes (OR 0.28, 95% CI 0.08-0.97; p = 0.04). CONCLUSION: A red blood cell TP may have an independent protective effect on maternal and perinatal adverse outcomes during pregnancy in women with SCD.

[Use of pocket-sized ultrasound in internal medicine (hospitalist) practice: Feedback and perspectives]. / Échographie ultraportable en médecine interne : retour d'expérience et point de vue.

INTRODUCTION: Point of care ultrasound (POCUS) is routinely used by intensivists and emergency physicians for many years. Its interest is not arguable any more for these specialists, despite the large variety of diseases they care. Hospitalists and internists also should find some interest in POCUS, which convenience and wide range of indications responds well to the variety of their practice. However, it is still not widely used in internal medicine departments. METHODS: We here report our experience of using a pocket-sized ultrasound device in a French internal medicine department. The device used was a Vscan Dual Probe, GE, whose two probes and presets allow for cardiac, abdominal, pulmonary, obstetric, vascular, pulmonary, and superficial soft tissue exploration. One physician of the ward received a course for POCUS that was initially dedicated for emergency physicians. This study reports on the results of the examinations made between January and September 2015. For each examination performed, clinical usefulness was assessed at the time of patient discharge, by two independent physicians who reviewed the clinical course and the results of conventional imaging and rated their evaluation on a Likert scale. RESULTS: One hundred and four examinations were evaluated. The mean duration of the ultrasound examination was 9±5minutes. The POCUS conclusions were corrected by disease course or the results of conventional imaging in 10 (9.6%) cases. The presets of the device: heart, soft tissue, lung, abdomen and vascular were used respectively in 32, 30, 21, 12 and 5% of the examinations. The main indications of POCUS examination were for identification of pleural, pericardial or peritoneal effusion, and to assess the central venous pressure by inferior vena cava examination. Eighteen examinations were performed for puncture of effusion. The retrospectively evaluated clinical benefit was clearly demonstrated in 78% of cases. The agreement between the two blinded assessors was good (kappa coefficient at 0.82). CONCLUSION: Pocket-sized ultrasound device could be used in internal medicine wards. However, its limited performance compared to more sophisticated echography limits the possible explorations and their reliability, which encourages caution and makes critical the question of the initial training of doctors and medical students.

¿Podemos predecir qué niños con neumonía van a tener un pronóstico grave? / Can we predict which children with pneumonia will have a severe prognosis?

En este artículo se presenta la valoración crítica de un estudio observacional prospectivo para la realización de una guía de predicción clínica. Conclusiones de los autores del estudio: se presentan tres modelos de riesgo para poder estimar con precisión el riesgo de neumonía grave en niños, lo que permitirá mejorar el tratamiento y el pronóstico en esta población. Comentario de los revisores: el estudio propone una herramienta, simple y de fácil aplicabilidad, para predecir el curso clínico de la neumonía que aún debe ser validada internacionalmente (AU)

This paper presents the critical appraisal of a prospective observational study for the implementation of a clinical prediction guide. Authors’ conclusions: three risk models are presented that accurately estimate the risk for severe pneumonia in children, which will improve treatment and prognosis in this population. Reviewers’ commentary: the study proposes a promissory clinical tool to predict pneumonia´s outcomes that could be validated internationally (AU)

Mitos y realidades sobre la erupción dentaria primaria: ¿realmente produce tantos síntomas? / Myths and realities of primary tooth eruption. Does it really produce so many symptoms?

En este artículo se presenta la valoración crítica de una revisión sistemática, probablemente la única, sobre la sintomatología atribuible a la erupción dentaria primaria. La revisión bibliográfica fue amplia, pero algunos de los estudios incluidos son de calidad metodológica dudosa. Los síntomas y signos más frecuentemente detectados fueron irritación gingival, irritabilidad y babeo. Otros, de mayor a menor frecuencia, fueron pérdida de apetito, sueño inquieto, mucosidad, aumento de la temperatura y diarrea. Ninguno de los síntomas o signos referidos es específico de la erupción dentaria primaria y atribuirlos a la misma podría retrasar o impedir el diagnóstico de enfermedades coincidentes con la salida de los dientes (AU)

This paper presents the critical appraisal of a systematic review, probably the only one, on signs and symptoms attributable to primary tooth eruption. The bibliographic review was comprehensive, but some of the included studies had methodological limitations. The signs and simptoms most frequently found were gingival irritation, irritability and drooling. Others, in decreasing frequency were loss of appetite, restless sleeping, running nose, rising of temperature and diarrhoea. None of the referred signs and symptoms are specific to primary tooth eruption so attributing them to it could delay or hamper the diagnosis of conditions coinciding with tooth eruption (AU)

La ley antitabaco en espacios públicos se relaciona con la disminución de ingresos por asma infantil / The smoking ban in public places is related to the decrease in child asthma admissions

Este artículo es la valoración crítica de un estudio de cohortes. Conclusiones de los autores del estudio: la implantación de la ley antitabaco parece relacionarse con una disminución de la tasa de ingresos hospitalarios por asma infantil. Comentario de los revisores: este estudio apoya la asociación entre la disminución de ingresos por asma y la menor exposición al tabaquismo pasivo. Aunque el tamaño del efecto fue pequeño y no puede excluirse la participación de otros factores implicados como un mejor tratamiento del asma o el control de otros contaminantes ambientales, el impacto clínico es relevante debido a la elevada prevalencia del asma. Sería adecuado, tanto la difusión de estos efectos para fomentar la evitación del tabaquismo pasivo en niños y adolescentes, como el desarrollo de estudios prospectivos que valorasen el impacto de estas medidas legislativas (AU)

This paper is the critical appraisal of a cohort study. Conclusions of the study: the implementation of the smoking ban appears to be associated with a decrease in the rate of hospital admissions for childhood asthma. Reviewers’ commentary: this study supports the association between the decrease in asthma admissions and reduced exposure to passive smoking. Although the effect size was small and the participation of other factors involved, as better asthma control or other environmental pollutants cannot be excluded, the clinical impact is relevant due to the high prevalence of asthma. It would be appropriate, both the dissemination of these effects to encourage avoidance of passive smoking in children and adolescents, and the development of prospective studies to rate the impact of these legislative measures (AU)

Migraña en la infancia / Migraine in childhood

No disponible

Bronquiolitis aguda / Acute bronchiolitis

No disponible

¿Se puede predecir clínicamente qué niños pueden presentar complicaciones intracraneales después de sufrir un traumatismo craneal leve? / Is it possible to predict clinically which children may have intracranial complications after suffering a mild head trauma?

Conclusiones de los autores del estudio: la alteración en el nivel de conciencia, la presencia de focalidad neurológica y los cambios de conducta se han asociado con la aparición de complicaciones intracraneales en niños con traumatismo craneal leve (TCL). Debido a la falta de consenso, las reglas de decisión clínica pueden ser una herramienta útil para indicar a qué pacientes se deben realizar pruebas de imagen o indicar su ingreso hospitalario para observación. Comentario de los revisores: en este estudio se establecen los principales datos clínicos que pueden predecir la aparición de complicaciones intracraneales en niños con TCL. Las reglas de decisión clínica encontradas en la literatura y las propuestas por los autores parecen útiles para unificar la práctica clínica en el manejo de esta patología. Sin embargo, existe cierta variabilidad, por lo que sería deseable realizar más estudios para elaborar reglas de decisión clínica útiles o que validen las ya existentes(AU)

Adherencias de los labios menores en niñas prepuberales asintomáticas: tratar o no tratar / No disponible

Escenario clínico: niña de 2 años que acude a la consulta para un control de salud. En la exploraciónse aprecia adherencia en los labios menores (sinequia vulvar). Ante este hallazgo, lospadres preguntan por qué se ha producido y, sobre todo, si es necesario un tratamiento. Ustedconoce el tratamiento tópico con crema de estrógenos, pero tiene dudas sobre su eficacia y sobresi está indicado si la niña se muestra asintomática.Pregunta clínica: en niñas pequeñas con adherencias de los labios menores, ¿está indicadoel tratamiento tópico con estrógenos?Justificación: la adherencia de los labios menores es uno de los problemas ginecológicosmás frecuentes en niñas prepuberales. El 1,8% de éstas la padece en algún momento de su vida.El pico de mayor incidencia (3,3%) se produce entre los 13 y los 23 meses de edad. Los estrógenostópicos se han indicado como tratamiento médico inicial en la mayoría de los casos,aunque en algunas ocasiones se ha optado por la separación manual e incluso la quirúrgica, sobretodo en casos graves. Sin embargo, no están claras ni la indicación ni la eficacia de los citadostratamientos. Tampoco se conoce el pronóstico a largo plazo de esos procedimientos.Resolución del escenario clínico: cuando los padres vuelven a la consulta, les explica quedebido a que la niña no presenta síntomas, existe la posibilidad de que las adherencias se resuelvanespontáneamente con el tiempo, así como que el no tratarlas inicialmente no aumentael riesgo de que aparezcan síntomas, por lo que no cree indicado iniciar ningún tipo de tratamiento.Acuerda con la familia hacer un seguimiento clínico y explica los síntomas que debenvigilar; asimismo, les informa también de las posibilidades terapéuticas que existen en el casode que la niña dejara de estar asintomática(AU)

Clinical scenario: a two year old girl is taken to the office for a well child care control.Labial adhesions are noticed in the clinical exam. The parents ask about the reason of thiscondition and, more important, if it is necessary to treat it. You know the topical treatment with estrogens, but you doubt about its effectiveness and if it is indicated if the girl is asymptomatic.Clinical question: in small girls with labial adhesions, is the estrogen topical therapy indicated?Justification: labial adhesions is one of the most frequent gynecologic disorders in prepubertalgirls; 1.8% of them suffer from it during some time in their lives. The highest incidence(3.3%) happens between 13 and 23 months of age. Topical estrogens have been usedas the initial therapy in most of the cases, although manual separation or even surgery havebeen undertaken, especially in severe cases. However, the indication and effectiveness ofthe mentioned treatments are not clear. The long time prognosis of these procedures is notknown either.Clinical scenario resolution: when the parents come back to the office, you explainthem that due to the fact that the girl doesn’t have symptoms, there is the possibility thatthe adhesions solve spontaneously with time, and not treating them initially doesn’t increasethe risk of symptoms, so that you don’t consider to start any kind of therapy. You agreewith the family on a clinical follow up and explain them the symptoms to keep watch on;also, you inform them on the existing possibilities of therapy in case the girl stopped beenasymptomatic(AU)

La vacunación frente a la rubéola en mujeres embarazadas no se asocia con efectos adversos en el embarazo ni en el recién nacido / No disponible

No disponible

Una vacuna cuatrivalente contra el virus del papiloma humano, previene las lesiones cervicales de alto grado de malignidad asociadas a los serotipos 16 y 18, en mujeres jóvenes sin infección previa / No disponible

No disponible

La aplicación generalizada de medidas preventivas en la embarazada con infección por virus de la inmunodeficiencia humana puede evitar su transmisión vertical / No disponible

No disponible

En la fimosis es aconsejable el tratamiento con corticoides tópicos antes de plantearse una opción quirúrgica / No disponible

A propósito del caso de un niño de 5 años con fimosis, se planteó la siguiente preguntaclínica: ¿cuál es la eficacia del tratamiento con corticoides tópicos para evitar el tratamientoquirúrgico? y ¿qué tipo de corticoides tópicos son los más eficaces? Tras la búsqueda bibliográficarealizada en TRIP, MEDLINE y en la Biblioteca Cochrane Plus, se recuperaron tresdocumentos: dos ensayos clínicos, aleatorizados y controlados y un estudio prospectivocontrolado no aleatorizado. Al realizar la lectura crítica de estos estudios y a pesar de las limitacionesmetodológicas que se describen, se concluye que, por su seguridad y eficacia, eltratamiento tópico con corticoides para la fimosis en niños, se puede considerar de primeraelección antes de plantearse la opción quirúrgica

The case report of a 5 years old child with phimosis, arose the following clinicalquestion: what is the efficiency of topical steroid treatment in order to avoid surgery?and, what kind of topical steroids are most efficient? The bibliographic search in TRIP,MEDLINE and the Cochrane Plus Library, retrieved three documents: two randomizedcontrolled clinical trials, and one prospective, controlled, not randomized study. The criticalappraisal of these studies, although their methodological limitations that we describe,concludes that, because its safety and efficiency, steroid topical treatment in children’phimosis, can be considered first line management before taking into consideration surgicaloptions (AU)

Rapid identification of Salmonella typhimurium, S. enteritidis and S. virchow isolates by polymerase chain reaction based fingerprinting methods.

In this study we used and evaluated three rapid molecular typing methods for the identification of three frequent, clinically significant Salmonella serovars on the basis of the ease, simplicity and reproducibility of the chosen methods. We determined the genetic diversity among several isolates of Salmonella enteritidis, S. typhimiurium and S. virchow, and compared them with other enterobacteria by using the repetitive extragenic palindromic (REP) sequences, the enterobacterial repetitive intergenic consensus (ERIC) sequences, and the 16S-23S rDNA intergenic spacer region (ITS 1). The objective was to evaluate their potential application to discriminate among members of the species Salmonella enterica subspecies enterica using the genetic diversity of the group found by genomic fingerprinting. The three different serovars of Salmonella studied gave reproducible and distinguishable profiles using whichever of the above mentioned polymerase chain reaction (PCR) methods assayed. The conserved patterns in each serovar allowed for easy differentiation from other serovars of Salmonella.

[Multicystic encephalomalacia. Review of 19 cases]. / Encefalomalacia multiquística. Revisión de 19 casos.

OBJECTIVE: Multicystic encephalomalacia (EMQ) is a pediatric entity where the brain tissue is substituted by cavities of variably sizes. PATIENTS AND METHODS: Nineteen children diagnosed of EMQ were studied retrospectively. We analyzed the etiology, diagnosis and the clinical and radiological evolution. RESULTS: There were three different etiologies: twin pregnancy, 12 cases; perinatal hypoxia, 4 cases; perinatal infection, 1 case; cardiac arrest, 1 case; and 1 patient with multiple embolism of unknown cause. The diagnosis of EMQ was made with cerebral ultrasonography (14 patients), computed tomography (19 patients) and magnetic resonance imaging (5 patients). We stress the utility of cerebral ultrasonography in early and reliable diagnosis of EMQ. The clinical development was unfavorable. We studied the outcome of 15 patients. Two children died. Eleven patients (73%) show severe consequences (mental retardation, microcephaly, spastic tetraplegia, and in 7 children epilepsy). In 2 cases, the radiological development was hydranencephaly. Examination of the 4 remaining children (26.66%) revealed a spastic hemiplegia. CONCLUSIONS: EMQ is a rare disease in childhood and has a very poor outcome, for this reason early diagnosis is very important. To this effect, cerebral ultrasonography is the imaging modality of choice.