NUM-score: A clinical-analytical model for personalised imaging after urinary tract infections.

AIM: To identify predictive variables and construct a predictive model along with a decision algorithm to identify nephrourological malformations (NUM) in children with febrile urinary tract infections (fUTI), enhancing the efficiency of imaging diagnostics. METHODS: We performed a retrospective study of patients aged <16 years with fUTI at the Emergency Department with subsequent microbiological confirmation between 2014 and 2020. The follow-up period was at least 2 years. Patients were categorised into two groups: 'NUM' with previously known nephrourological anomalies or those diagnosed during the follow-up and 'Non-NUM' group. RESULTS: Out of 836 eligible patients, 26.8% had underlying NUMs. The study identified six key risk factors: recurrent UTIs, non-Escherichia coli infection, moderate acute kidney injury, procalcitonin levels >2 µg/L, age <3 months at the first UTI and fUTIs beyond 24 months. These risk factors were used to develop a predictive model with an 80.7% accuracy rate and elaborate a NUM-score classifying patients into low, moderate and high-risk groups, with a 10%, 35% and 93% prevalence of NUM. We propose an algorithm for approaching imaging tests following a fUTI. CONCLUSION: Our predictive score may help physicians decide about imaging tests. However, prospective validation of the model will be necessary before its application in daily clinical practice.

Lung Ultrasound: A Useful Prognostic Tool in the Management of Bronchiolitis in the Emergency Department.

Lung ultrasound, a non-invasive bedside technique for assessing paediatric patients with acute respiratory diseases, is becoming increasingly widespread. The aim of this prospective, observational cohort study was to evaluate the effectiveness of a clinical ultrasound score in assessing infants with acute bronchiolitis in the emergency department and its ability to accurately identify patients at a higher risk of clinical deterioration. Infants under 6 months of age with clinical symptoms compatible with acute bronchiolitis were enrolled and underwent clinical and lung ultrasound evaluations. The study included 50 patients, the median age of which was 2.2 months (IQR: 1-5), and the primary outcome was respiratory support. Infants requiring invasive or non-invasive ventilation showed higher scores (5 points [IQR: 3.5-5.5] vs. 2.5 [IQR: 1.5-4]). The outcome had an AUC of 0.85 (95%CI: 0.7-0.98), with a sensitivity of 87%, specificity of 64%, and negative predictive value of 96.4% for a score <3.5 points. Children who scored ≥3.5 points were more likely to require respiratory support within the next 24 h (estimated event-free survival of 82.9% compared to 100%, log-rank test p-value = 0.02). The results suggest that integrating lung ultrasound findings into clinical scores when evaluating infants with acute bronchiolitis could be a promising tool for improving prognosis.

Hyponatremia and other potential markers of ultrasound abnormalities after a first febrile urinary tract infection in children.

Urinary tract infections are the initial manifestation in 30% of urinary tract malformations. Identifying these patients, who could benefit from a specific treatment, is still challenging. Hyponatremia during urinary tract infection has been proposed as a urinary tract malformation marker. We evaluate the prevalence of hyponatremia during febrile urinary tract infections and its association with subjacent urinary tract malformations. We performed a retrospective study of healthy patients under 16 years, diagnosed with a first episode of febrile urinary tract infection, who had undergone blood testing in the acute episode and at least one renal ultrasound during follow-up (January 2014-November 2020). Hyponatremia was defined as (serum sodium ≤ 130 mEq/L). According to imaging findings, we classified patients into three groups: normal kidney ultrasound, mild pelviectasis, and significant urinary tract malformation. We performed logistic regression models to identify independent risk factors for urinary tract malformation and mild pelviectasis. We included 492 patients and 2.8% presented hyponatremia. We identified normal ultrasound in 77%, mild pelviectasis in 10.8%, and urinary tract malformation in 12% of patients. We found an association between mild pelviectasis and hyponatremia [OR 6.6 (CI95% 1.6-26.6)]. However, we found no association between hyponatremia and urinary tract malformation. The parameters that were associated with malformations were presenting a non-E. coli infection, C-reactive-protein levels over 80 mg/L, and bacteremia. CONCLUSION: Hyponatremia during the first episode of febrile urinary tract infection is present in 2.8% of patients and is associated with mild pelviectasis in imaging. However, hyponatremia does not indicate a greater need for complementary tests to screen for urinary tract malformations. WHAT IS KNOWN: • Urinary tract infection is the first manifestation in 30% of children with urinary tract malformation. • Hyponatremia could be a marker to identify these children and guide the imaging approach. WHAT IS NEW: • Around 12% of children with a first episode of febrile urinary tract infection have a urinary tract malformation. • Non-E. coli infection, C-reactive protein levels over 80 mg/L, and bacteremia are markers for malformations to guide diagnostic imaging tests, but hyponatremia (Na ≤ 130 mEq/l) is not a reliable marker.

Blood analysis for screening of electrolyte and kidney function alterations in patients with febrile urinary tract infection.

AIM: To describe the prevalence, severity, risk factors, and clinical relevance of electrolyte disturbances and acute kidney injury (AKI) during febrile urinary tract infection (fUTI). METHODS: Retrospective observational study of well/fair-appearing patients between 2 months and 16 years, with no previous relevant medical history, diagnosed with fUTI in the paediatric emergency department (PED) with subsequent microbiological confirmation. Analytical alteration (AA) data were considered: AKI (creatinine elevation × 1.5 the median for age), plasma sodium alteration (≤130 or ≥150 mEq/L), and potassium alteration (≤3 or ≥6 mEq/L). RESULTS: We included 590 patients, 17.8% presented AA (13 hyponatremia, 7 hyperkalaemia, and 87 AKI). No patient presented severe analytic alterations or a higher frequency of symptoms potentially attributable to these alterations (seizures, irritability, or lethargy). Risk factors associated with these AA were clinical dehydration (OR = 3.5 95% CI: 1.04-11.7; p = 0.044) and presenting a temperature >39°C (OR = 1.9 95% CI: 1.14-3.1; p = 0.013). CONCLUSIONS: Electrolyte and renal function disturbances are infrequent in the previously healthy paediatric population with a fUTI. If present, they are asymptomatic and not severe. Based on our results, performing systematic blood analysis to rule out AA appears no longer justified, especially in the absence of risk factors.

Vólvulo intestinal en niños de edad escolar: reto diagnóstico en urgencias / Intestinal volvulus in school-age children: an emergency care challenge

El dolor abdominal supone uno de los motivos de consulta más frecuentes en los Servicios de Urgencias Pediátricas. El vólvulo intestinal es una entidad infrecuente pero que sin un diagnóstico y tratamiento quirúrgico precoces tiene consecuencias devastadoras, siendo una de las urgencias que todos los pediatras deben conocer. Los vólvulos suponen hasta el 14% de las causas de síndrome de intestino corto que pueden llegar a precisar trasplante intestinal. Requiere un alto índice de sospecha, ya que las pruebas complementarias pueden ser inespecíficas y su normalidad no descarta esta patología. Únicamente la intervención quirúrgica confirma el diagnóstico de vólvulo intestinal. Presentamos los casos de cuatro pacientes que acudieron al Servicio de Urgencias y fueron diagnosticados de vólvulo intestinal. (AU)

Abdominal pain is one of the most frequent reasons for visiting paediatric emergency departments. Intestinal volvulus is an infrequent condition, but without early diagnosis and surgical treatment it has devastating consequences, and it is one of the emergencies that paediatricians must be aware of. Intestinal volvulus accounts for up to 14% short bowel syndrome cases that may require bowel transplantation. A high level of suspicion must be maintained, as the results of diagnostic tests may be nonspecific and normal results do not rule it out. Surgical intervention is the only way to confirm the diagnosis of intestinal volvulus. We present the cases of 4 patients who attended the emergency department and received a diagnosis of volvulus. (AU)

PCR urgente de Bordetella en lactantes menores de 3 meses, una herramienta útil en el Servicio de Urgencias Pediátricas / Urgent Bordetella PCR in infants under 3 months, a useful tool in the Pediatric Emergency Department

Introducción: En pacientes menores de 3 meses con sospecha de tosferina se recomienda ingreso y tratamiento con azitromicina debido a su mayor morbimortalidad, por lo que muchos pacientes con tos sin otros signos de alarma ingresan con antibioterapia hasta obtener el resultado de la PCR de Bordetella. La realización de esta técnica de forma urgente proporciona el diagnóstico en pocas horas. Nuestro objetivo fue determinar si su introducción en los servicios de Urgencias mejoraba el manejo de estos pacientes. Métodos: Estudio de cohortes histórico de pacientes menores de 3 meses a los que se realizó en Urgencias la PCR de Bordetella de secreciones respiratorias desde marzo de 2011 hasta diciembre de 2017. A partir de diciembre de 2015 era procesada de forma urgente. Resultados: Se realizaron 158 PCR, 16 (10%) de las cuales resultaron positivas para B. pertussis. Los resultados negativos (142; 90%) se dividen en 2 grupos de estudio: PCR-convencional, con 74 casos, y PCR-urgente, con 68 casos. Los 2 grupos son homogéneos en cuanto a características clínicas y analíticas. En el grupo PCR-urgente se realizaron un 18% menos de radiografías de tórax (p=0,008) e ingresaron 33 pacientes (48,5%), frente a 49 (66,2%) en el grupo PCR-convencional (p=0,042). Recibió tratamiento antibiótico el 32% en el grupo PCR-urgente frente al 67% en el PCR-convencional (p=0,000047), sin aumento significativo de las reconsultas en Urgencias ni peor evolución. Conclusiones: La PCR urgente de Bordetella es una herramienta útil en los servicios de Urgencias para el manejo de los lactantes menores de 3 meses con sospecha de tosferina, ya que puede evitar ingresos, pruebas y tratamientos antibióticos innecesarios.(AU)

Introduction: Whooping cough in patients aged under 3 months has higher rates of morbimortality. Hospitalization and treatment with azithromycin is generally recommended. Many patients with cough without other signs of alarm, are admitted and started antibiotic therapy until a result of Bordetella-PCR is available. This technique, when performed urgently, can provide the diagnosis in a few hours. The objective of this study is to determine if its generalisation in the Emergency Department allows to improve patient management. Methods: Retrospective cohort study of patients aged under 3 months who underwent Bordetella-PCR testing from upper respiratory tract secretions since March 2011 to December 2017. From December 2015 the test was performed urgently. Results: One hundred and fifty-eight PCR were performed, 16 (10%) were positive for B. pertussis. Negative results (142; 90%) were divided in 2 cohorts: conventional-PCR, with 74 cases, and urgent-PCR, with 68 cases. The 2 groups were homogeneous in terms of clinical and analytical characteristics. In the urgent-PCR group there was 18% reduction in chest X-rays performed (P=.008). There were 33 (48.5%) patients admitted in the urgent-PCR group, compared to 49 (66.2%) in the conventional-PCR (P=.042). Antibiotic treatment was initiated in 32% of the patients in the urgent-PCR group compared to 67% in the conventional-PCR group (P=.000047), without observing any significant increase in the number of visits to the Emergency Department or worse clinical performance. Conclusions: The introduction of urgent PCR in the Emergency Department is a useful tool in the management of infants under 3 months of age with suspected pertussis, since it can avoid unnecessary admissions, diagnostic tests and antibiotic treatments.(AU)

Handlebar Hernia: An Uncommon Traumatic Abdominal Hernia.

ABSTRACT: Handlebar hernia is a type of traumatic abdominal wall hernia caused by the impact of a bicycle handlebar against the abdominal wall. A good anamnesis and physical examination are important for the correct diagnosis, and ultrasonography is an accessible tool in the emergency department for imaging confirmation. We describe a case of an 11-year-old girl who presented to the emergency department after an abdominal trauma caused by a handlebar. Ultrasonography revealed an abdominal wall defect with herniation of omentum and bowel loops. Conservative management was initially established, followed by surgical treatment due to persistent symptoms.

Urgent Bordetella PCR in infants under 3 months, a useful tool in the Pediatric Emergency Department. / PCR urgente de Bordetella en lactantes menores de 3 meses, una herramienta útil en el Servicio de Urgencias Pediátricas.

INTRODUCTION: Whooping cough in patients aged under 3 months has higher rates of morbimortality. Hospitalization and treatment with azithromycin is generally recommended. Many patients with cough without other signs of alarm, are admitted and started antibiotic therapy until a result of Bordetella-PCR is available. This technique, when performed urgently, can provide the diagnosis in a few hours. The objective of this study is to determine if its generalisation in the Emergency Department allows to improve patient management. METHODS: Retrospective cohort study of patients aged under 3 months who underwent Bordetella-PCR testing from upper respiratory tract secretions since March 2011 to December 2017. From December 2015 the test was performed urgently. RESULTS: One hundred and fifty-eight PCR were performed, 16 (10%) were positive for B. pertussis. Negative results (142; 90%) were divided in 2 cohorts: conventional-PCR, with 74 cases, and urgent-PCR, with 68 cases. The 2 groups were homogeneous in terms of clinical and analytical characteristics. In the urgent-PCR group there was 18% reduction in chest X-rays performed (P=.008). There were 33 (48.5%) patients admitted in the urgent-PCR group, compared to 49 (66.2%) in the conventional-PCR (P=.042). Antibiotic treatment was initiated in 32% of the patients in the urgent-PCR group compared to 67% in the conventional-PCR group (P=.000047), without observing any significant increase in the number of visits to the Emergency Department or worse clinical performance. CONCLUSIONS: The introduction of urgent PCR in the Emergency Department is a useful tool in the management of infants under 3 months of age with suspected pertussis, since it can avoid unnecessary admissions, diagnostic tests and antibiotic treatments.