Factores pronósticos precoces de morbimortalidad en el traumatismo craneoencefálico grave en niños. Experiencia en una unidad de politraumatismo infantil / Early prognostic factors for morbidity and mortality in severe traumatic brain injury. Experience in a child polytrauma unit

Objetivo Identificar factores pronósticos precoces que conduzcan a un mayor riesgo de pronóstico desfavorable. Diseño Estudio de cohortes observacional de octubre 2002 a octubre 2017. Pacientes y ámbito Se incluyeron pacientes menores de 18 años con TCE grave ingresados en cuidados intensivos (UCIP). Variables e intervenciones Se recogieron variables epidemiológicas, clínico-analíticas y terapéuticas. Se valoró la capacidad funcional del paciente a los 6 meses mediante la Glasgow Outcome Scale (GOS). Se consideró pronóstico desfavorable un GOS menor o igual a 3. Se realizó un análisis univariante para comparar grupos de buen y mal pronóstico y su relación con las diferentes variables. Se realizó un análisis multivariante para predecir el pronóstico del paciente. Resultados 98 pacientes, 61,2% varones, mediana de edad 6,4 años (RIQ 2.49–11.23). El 84,7% fueron atendidos por los servicios de emergencias extrahospitalarios. A los 6 meses, el 51% presentaba recuperación satisfactoria, 26,5% secuelas moderadas, 6,1% secuelas graves y 2% estado vegetativo. Fallecieron el 14,3%. Hubo significación estadística entre la puntuación en la escala de coma de Glasgow (ECG) prehospitalaria, reactividad pupilar, hipotensión arterial, hipoxia, ciertas alteraciones analíticas y radiológicas (compresión de las cisternas basales), con pronóstico desfavorable. El análisis multivariante demostró que es posible realizar modelos predictores de la evolución de los pacientes. Conclusiones Es posible identificar factores pronósticos de mala evolución en las primeras 24 horas postraumatismo. Su conocimiento puede ayudar a la toma de decisiones clínicas y ofrecer una mejor información a las familias (AU)

Objective To identify early prognostic factors that lead to an increased risk of unfavorable prognosis. Design Observational cohort study from October 2002 to October 2017. Setting and patients Patients with severe TBI admitted to intensive care were included. Variables and interventions Epidemiological, clinical, analytical and therapeutic variables were collected. The functional capacity of the patient was assessed at 6 months using the Glasgow Outcome Scale (GOS). An unfavorable prognosis was considered a GOS less than or equal to 3. A univariate analysis was performed to compare the groups with good and bad prognosis and their relationship with the different variables. A multivariate analysis was performed to predict the patient's prognosis. Results 98 patients were included, 61.2% males, median age 6.4 years (IQR 2.49–11.23). 84.7% were treated by the out-of-hospital emergency services. At 6 months, 51% presented satisfactory recovery, 26.5% moderate sequelae, 6.1% severe sequelae, and 2% vegetative state. 14.3% died. Statistical significance was found between the score on the prehospital Glasgow coma scale, pupillary reactivity, arterial hypotension, hypoxia, certain analytical and radiological alterations, such as compression of the basal cisterns, with an unfavorable prognosis. The multivariate analysis showed that it is possible to make predictive models of the evolution of the patients. Conclusions it is possible to identify prognostic factors of poor evolution in the first 24 h after trauma. Knowledge of them can help clinical decision-making as well as offer better information to families (AU)

Early prognostic factors for morbidity and mortality in severe traumatic brain injury. Experience in a child polytrauma unit.

OBJECTIVE: To identify early prognostic factors that lead to an increased risk of unfavorable prognosis. DESIGN: Observational cohort study from October 2002 to October 2017. SETTING AND PATIENTS: Patients with severe TBI admitted to intensive care were included. VARIABLES AND INTERVENTIONS: Epidemiological, clinical, analytical and therapeutic variables were collected. The functional capacity of the patient was assessed at 6 months using the Glasgow Outcome Scale (GOS). An unfavorable prognosis was considered a GOS less than or equal to 3. A univariate analysis was performed to compare the groups with good and bad prognosis and their relationship with the different variables. A multivariate analysis was performed to predict the patient's prognosis. RESULTS: 98 patients were included, 61.2% males, median age 6.4 years (IQR 2.49-11.23). 84.7% were treated by the out-of-hospital emergency services. At 6 months, 51% presented satisfactory recovery, 26.5% moderate sequelae, 6.1% severe sequelae, and 2% vegetative state. 14.3% died. Statistical significance was found between the score on the prehospital Glasgow coma scale, pupillary reactivity, arterial hypotension, hypoxia, certain analytical and radiological alterations, such as compression of the basal cisterns, with an unfavorable prognosis. The multivariate analysis showed that it is possible to make predictive models of the evolution of the patients. CONCLUSIONS: it is possible to identify prognostic factors of poor evolution in the first 24 h after trauma. Knowledge of them can help clinical decision-making as well as offer better information to families.

Early prognostic factors for morbidity and mortality in severe traumatic brain injury. Experience in a child polytrauma unit. / Factores pronósticos precoces de morbimortalidad en el traumatismo craneoencefálico grave en niños. Experiencia en una unidad de politraumatismo infantil.

OBJECTIVE: To identify early prognostic factors that lead to an increased risk of unfavorable prognosis. DESIGN: Observational cohort study from October 2002 to October 2017. SETTING AND PATIENTS: Patients with severe TBI admitted to intensive care were included. VARIABLES AND INTERVENTIONS: Epidemiological, clinical, analytical and therapeutic variables were collected. The functional capacity of the patient was assessed at 6 months using the Glasgow Outcome Scale (GOS). An unfavorable prognosis was considered a GOS ≤3. A univariate analysis was performed to compare the groups with good and bad prognosis and their relationship with the different variables. A multivariate analysis was performed to predict the patient's prognosis. RESULTS: A total of 98 patients were included, 61.2% males, median age 6.4years (IQR 2.49-11.23). 84.7% were treated by the out-of-hospital emergency services. At 6 months, 51% presented satisfactory recovery, 26.5% moderate sequelae, 6.1% severe sequelae, and 2% vegetative state. 14.3% died. Statistical significance was found between the score on the prehospital Glasgow coma scale, pupillary reactivity, arterial hypotension, hypoxia, certain analytical and radiological alterations, such as compression of the basal cisterns, with an unfavorable prognosis. The multivariate analysis showed that it is possible to make predictive models of the evolution of the patients. CONCLUSIONS: It is possible to identify prognostic factors of poor evolution in the first 24hours after trauma. Knowledge of them can help clinical decision-making as well as offer better information to families.

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.

Proposal for a preventive protocol for medication-related osteonecrosis of the jaw.

BACKGROUND: Medication-related osteonecrosis of the jaw (MRONJ) is a severe adverse reaction experienced by some patients exposed to certain drugs (antiresorptives such as bisphosphonates or denosumab, and antiangiogenic drugs). From a review of the literature it appears that there is no uniform criterion when selecting preventive measures; these vary according to author. Likewise, the measures recommended are usually general, so that in few cases they result in specific actions to be applied depending on the different variables involved such as the type of drug used, the duration of its application, the underlying pathology, the presence or absence of risk factors, etc. The aim of this study has been to design a preventive protocol which can be easily applied in any clinic or by any dental care service. MATERIAL AND METHODS: We undertook an exhaustive literature review to find any articles related to the topic of study, namely, preventive measures for medication-related osteonecrosis of the jaw, on the one hand generically and on the other focusing on dental implant treatment. The most part the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. From 3946 items, we selected a total of 21 items. RESULTS: From the analysis of the selected articles, several protocols have been developed that are easy to apply in a dental clinic.: Protocol 1. Before starting treatment with antiresorptives (Patients who are going to be treated for osteoporosis / Patients who are going to be treated for cancer). Protocol 2. Once treatment is initiated with antiresorptives (Patients being treated for osteoporosis / Patients being treated for cancer). CONCLUSIONS: The application of these protocols requires an interdisciplinary team which can handle the various treatments and apply the measures contained in them. Along with a team of well-educated and trained dentists, it is equally important to maintain contact with the medical team involved in the treatment of the underlying pathology, especially rheumatologists, oncologists, internists and gynaecologists. All the above requires a great staff learning and organization effort, continuous training and coordination of the whole team involved in the preventive management of these patients.

CD64 expression on monocytes and granulocytes in pediatric acute appendicitis scenario: A pilot study in pediatric critical care / Expresión de CD64 en monocitos y granulocitos en apendicitis aguda: estudio piloto en cuidados intensivos pediátricos

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Flow cytometry analysis of CD64, CD18, CD11a and CD11b in four children with Bordetella pertussis infection and admitted to critical care: New biomarkers? / Análisis mediante citometría de flujo de CD64, CD18, CD11a and CD11b en cuatro niños con infección grave por Bordetella pertussis: ¿Nuevos biomarcadores?

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Revisión narrativa sobre humanización en cuidados intensivos pediátricos: ¿dónde estamos? / Narrative review of pediatric critical care humanization: Where we are?

La corriente humanizadora surge como respuesta a un hecho que parece indiscutible: el desarrollo científico y tecnológico de las Unidades de Cuidados Intensivos. Este ha mejorado el cuidado del paciente crítico en términos cuantitativos y ha relegado, quizá, las necesidades humanas y emocionales de pacientes, familias y profesionales a un segundo plano. La humanización debe ser objeto de debate, sin que esto se confunda con poner en duda la humanidad desplegada por los profesionales. Se analizan y describen en este trabajo las líneas estratégicas sobre las que pivota el cuidado humanizado del paciente crítico, adaptándolas al ámbito pediátrico

The humanization of care emerges as a response to something that seems indisputable: the scientific and technological developments in Intensive Care Units. Such development has improved the care of the critically ill patient in quantitative terms, but has perhaps caused the emotional needs of patients, families and professionals to be regarded as secondary concerns. The humanization of healthcare should be discussed without confusing or discussing the humanity displayed by professionals. In this paper we review and describe the different strategic lines proposed in order to secure humanized care, and adopt a critical approach to their adaptation and current status in the field of pediatric critical care

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.

Narrative review of pediatric critical care humanization: Where we are? / Revisión narrativa sobre humanización en cuidados intensivos pediátricos: ¿dónde estamos?

The humanization of care emerges as a response to something that seems indisputable: the scientific and technological developments in Intensive Care Units. Such development has improved the care of the critically ill patient in quantitative terms, but has perhaps caused the emotional needs of patients, families and professionals to be regarded as secondary concerns. The humanization of healthcare should be discussed without confusing or discussing the humanity displayed by professionals. In this paper we review and describe the different strategic lines proposed in order to secure humanized care, and adopt a critical approach to their adaptation and current status in the field of pediatric critical care.

Mortalidad y adecuación del esfuerzo terapéutico en un servicio terciario de cuidados intensivos pediátricos: revisión de 11 años / Mortality and adequacy of therapeutic effort in a tertiary pediatric intensive care department: An 11-year review

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Fiebre e impotencia funcional en lactante de cinco meses: cuando las cosas no son lo que parecen / Fever and functional impotence in a five-month-old infant: when things are not what they seem

Lactante de cinco meses traído al Servicio de Urgencias por fiebre e impotencia funcional del miembro superior izquierdo. Tras las pruebas complementarias correspondientes, es diagnosticado de encefalitis herpética. El texto repasa las novedades en cuanto al tratamiento, la necesidad de profilaxis y la inmunodeficiencia específica (AU)

A five-month-old infant brought to the Emergency Room due to fever and functional impotence of the left arm. After various additional tests, the infant is diagnosed with herpes simplex encephalitis. The article reviews recent developments regarding herpes simplex encephalitis treatment, the need for prophylaxis and the infant´s immunodeficiency (AU)

Trombocitosis extrema reactiva en un niño sano de 6 años / Extreme reactive thrombocytosis in a healthy 6 year-old child

La trombocitosis es un hallazgo casual frecuente en pediatría. En niños, predominan las formas secundarias, siendo las infecciones su causa más prevalente. Se distinguen 4 grados de trombocitosis en función del número de plaquetas; en la forma extrema, se supera el 1.000.000/mm3. Se presenta un caso de trombocitosis extrema reactiva en un niño sano de 6 años, que requirió ingreso en cuidados intensivos para tratamiento y diagnóstico (cifra máxima de plaquetas de 7.283.000/mm3). Se revisan las diferentes causas de trombocitosis en la infancia, se describe el diagnóstico diferencial y se discute sobre los diferentes tratamientos disponibles ante un caso como el descrito

Thrombocytosis is usually a casual finding in children. Reactive or secondary thrombocytosis is the more common form, being the infections diseases the most prevalent cause of it. Regarding the number of platelets there are four degrees of thrombocytosis; in its extreme degree the number of platelets exceeds 1,000,000/mm3. We describe a case of extreme reactive thrombocytosis in a healthy 6-year-old child. He required critical care admission for diagnosis and treatment (maximum number of platelets 7,283,000/mm3). We review the different causes of thrombocytosis in childhood, the differential diagnosis, and the available treatments in case of extreme thrombocytosis

TLR2-TLR4/CD14 polymorphisms and predisposition to severe invasive infections by Neisseria meningitidis and Streptococcus pneumoniae

PURPOSE: Streptococcus pneumoniae and Neisseria meningitidis are major causes of severe invasive bacterial infections in some individuals. Apparently the genetic is a major susceptibility determinant to these infectious diseases. We study if the functional polymorphisms within genes of the innate immune system (TLR2---TLR4 and CD14) are related to the predisposition to severe invasive infections caused by S. pneumoniae and N. meningitidis. MATERIAL AND METHODS: Prospective descriptive study. Sixty-six Caucasian healthy children and173 consecutive Caucasian children with invasive bacterial infections by N. meningitidis (n = 59)and S. pneumoniae (n = 114) were enrolled between January 1, 2008 and December 31, 2010.All blood samples were genotyped with description of the coding polymorphisms in p.R753Q ofTLR2 gene and p.D299G of TLR4 gene as well as the promotor polymorphism c.-159C>T of theCD14 gene. RESULTS: Compared to the controls the p.753Q allele of TLR2 and the allele c.-159T of CD14 were more frequent in patients with S. pneumoniae (p < 0.0001 and p = 0.0167) and meningococcal infections (p = 0.0003 and p = 0.0276 respectively). CONCLUSIONS: Genetical variations in the innate immune system by polymorphisms in the TLR2 and CD14, could be related with an increases susceptibility to severe invasive infections by S. pneumoniae and N. meningitidis

OBJETIVO: Streptococcus pneumoniae y Neisseria meningitides son causantes de infección bacteriana grave en algunos individuos. Cierta susceptibilidad genética puede ser determinante para este hecho. Nuestro objetivo es determinar si el polimorfismo de genes relacionados con el sistema inmune innato (Toll like receptor 2 y 4 junto con CD14) se relaciona con la predisposición a sufrir infecciones graves por los citados patógenos. MATERIAL Y MÉTODOS: Estudio prospectivo observacional (desde el 1 de enero de 2008 hasta el31 de diciembre de 2010). Se incluye a 66 niños sanos y 173 niños con infección bacteriana grave(59 por Neisseria meningitidis y 114 por Streptococcus pneumoniae). Todas las muestras fueron genotipadas para los polimorfismos p.R753Q de TLR2, p.D299G de TLR4 y c.---159C > T del CD14.RESULTADOS: Comparados con los controles, los polimorfismos p.753Q de TLR2 y c.---159C > T deCD14 fueron más frecuentes en pacientes con infección neumocócica (p < 0,0001 y p = 0,0167)y meningocócica (p = 0,0003 y p = 0,0276).CONCLUSIONES: Las variaciones genéticas en el sistema inmune innato mediante polimorfismos en TLR2 y CD14 podrían estar relacionadas con la susceptibilidad a las infecciones graves por Streptococcus pneumoniae y Neisseria meningitides

[Extreme reactive thrombocytosis in a healthy 6 year-old child]. / Trombocitosis extrema reactiva en un niño sano de 6 años.

Thrombocytosis is usually a casual finding in children. Reactive or secondary thrombocytosis is the more common form, being the infections diseases the most prevalent cause of it. Regarding the number of platelets there are four degrees of thrombocytosis; in its extreme degree the number of platelets exceeds 1,000,000/mm(3). We describe a case of extreme reactive thrombocytosis in a healthy 6-year-old child. He required critical care admission for diagnosis and treatment (maximum number of platelets 7,283,000/mm(3)). We review the different causes of thrombocytosis in childhood, the differential diagnosis, and the available treatments in case of extreme thrombocytosis.

TLR2-TLR4/CD14 polymorphisms and predisposition to severe invasive infections by Neisseria meningitidis and Streptococcus pneumoniae.

PURPOSE: Streptococcus pneumoniae and Neisseria meningitidis are major causes of severe invasive bacterial infections in some individuals. Apparently the genetic is a major susceptibility determinant to these infectious diseases. We study if the functional polymorphisms within genes of the innate immune system (TLR2-TLR4 and CD14) are related to the predisposition to severe invasive infections caused by S. pneumoniae and N. meningitidis. MATERIAL AND METHODS: Prospective descriptive study. Sixty-six Caucasian healthy children and 173 consecutive Caucasian children with invasive bacterial infections by N. meningitidis (n=59) and S. pneumoniae (n=114) were enrolled between January 1, 2008 and December 31, 2010. All blood samples were genotyped with description of the coding polymorphisms in p.R753Q of TLR2 gene and p.D299G of TLR4 gene as well as the promotor polymorphism c.-159C>T of the CD14 gene. RESULTS: Compared to the controls the p.753Q allele of TLR2 and the allele c.-159T of CD14 were more frequent in patients with S. pneumoniae (p<0.0001 and p=0.0167) and meningococcal infections (p=0.0003 and p=0.0276 respectively). CONCLUSIONS: Genetical variations in the innate immune system by polymorphisms in the TLR2 and CD14, could be related with an increases susceptibility to severe invasive infections by S. pneumoniae and N. meningitidis.

Extreme reactive thrombocytosis in a healthy 6 year-old child.

Thrombocytosis is usually found by chance in children. Reactive or secondary thrombocytosis is the more common form, with infectious diseases being the most prevalent cause of it. Regarding the number of platelets there are four degrees of thrombocytosis; in its extreme degree the number of platelets exceeds 1,000,000/mm3. We describe a case of extreme reactive thrombocytosis in a healthy 6-year-old child. He required critical care admission for diagnosis and treatment (maximum number of platelets 7,283,000/mm3). We review the different causes of thrombocytosis in childhood, the differential diagnosis, and the available treatments in case of extreme thrombocytosis.

La trombocitosis es un hallazgo casual frecuente en pediatría. En niños, predominan las formas secundarias, siendo las infecciones su causa más prevalente. Se distinguen 4 grados de trombocitosis en función del número de plaquetas; en la forma extrema, se supera el 1.000.000/mm3. Se presenta un caso de trombocitosis extrema reactiva en un niño sano de 6 años, que requirió ingreso en cuidados intensivos para tratamiento y diagnóstico (cifra máxima de plaquetas de 7.283.000/mm3). Se revisan las diferentes causas de trombocitosis en la infancia, se describe el diagnóstico diferencial y se discute sobre los diferentes tratamientos disponibles ante un caso como el descrito.