Takayasu's arteritis as an incidental finding in a patient with celiac disease: the importance of positron emission computed tomography.

BACKGROUND: Takayasu arteritis is a large-vessel vasculitis which affects large-caliber elastic arteries, primarily the aorta and its main branches. It mainly affects women between 20-30 years, so it is rare in children. CASE REPORT: We describe the case of a 15-year-old female who was followed up since she was 9 years old due to celiac disease. At the age of 13, anaemia of chronic disorders associated to elevated C-reactive protein and erythrocyte sedimentation were detected. The patient remained asymptomatic. After excluding other diseases, we requested a positron emission computed tomography (PET-CT); lesions compatible with large-vessel vasculitis were detected. Cardiology evaluation showed an aneurysm in the right coronary artery. Angio-CT suggested Takayasu type III arteritis. CONCLUSIONS: The delay in the diagnosis of Takayasu arteritis in pediatric patients is quite common. In this case, we have found phase II lesions, with no previous phase I symptoms. However, PET-CT allowed the diagnosis of vasculitis, key to the diagnosis of the patient.

INTRODUCCIÓN: La arteritis de Takayasu es una vasculitis de grandes vasos que afecta a las arterias elásticas de gran calibre, fundamentalmente la aorta y sus ramas principales. Ocurre frecuentemente en mujeres entre los 20-30 años, por lo que es muy infrecuente en la edad pediátrica. CASO CLÍNICO: Se presenta el caso de una paciente de 15 años en seguimiento desde los 9 años por enfermedad celiaca. A los 13 años se detectó anemia de trastornos crónicos, elevación de proteína C reactiva y velocidad de sedimentación globular. La paciente permaneció en todo momento asintomática. Tras descartar otros procesos, se solicitó tomografía computarizada por emisión de positrones (PET-TC), donde se detectaron lesiones compatibles con vasculitis de grandes vasos. La valoración por Cardiología evidenció un aneurisma en coronaria derecha. Se realizó angio-TC, que sugirió arteritis de Takayasu tipo III. CONCLUSIONES: Es frecuente un retraso en el diagnóstico de la arteritis de Takayasu en los pacientes pediátricos. En este caso se encontraron lesiones de la fase II sin la presencia de síntomas correspondientes a la fase I. El PET-TC permitió el diagnóstico de vasculitis, clave para el diagnóstico de la paciente.

Arteritis de Takayasu como hallazgo incidental en un paciente con enfermedad celiaca: la importancia de la tomografía computarizada por emisión de positrones / Takayasu's arteritis as an incidental finding in a patient with celiac disease: the importance of positron emission computed tomography

Resumen Introducción: La arteritis de Takayasu es una vasculitis de grandes vasos que afecta a las arterias elásticas de gran calibre, fundamentalmente la aorta y sus ramas principales. Ocurre frecuentemente en mujeres entre los 20-30 años, por lo que es muy infrecuente en la edad pediátrica. Caso clínico: Se presenta el caso de una paciente de 15 años en seguimiento desde los 9 años por enfermedad celiaca. A los 13 años se detectó anemia de trastornos crónicos, elevación de proteína C reactiva y velocidad de sedimentación globular. La paciente permaneció en todo momento asintomática. Tras descartar otros procesos, se solicitó tomografía computarizada por emisión de positrones (PET-TC), donde se detectaron lesiones compatibles con vasculitis de grandes vasos. La valoración por Cardiología evidenció un aneurisma en coronaria derecha. Se realizó angio-TC, que sugirió arteritis de Takayasu tipo III. Conclusiones: Es frecuente un retraso en el diagnóstico de la arteritis de Takayasu en los pacientes pediátricos. En este caso se encontraron lesiones de la fase II sin la presencia de síntomas correspondientes a la fase I. El PET-TC permitió el diagnóstico de vasculitis, clave para el diagnóstico de la paciente.

Abstract Background: Takayasu arteritis is a large-vessel vasculitis which affects large-caliber elastic arteries, primarily the aorta and its main branches. It mainly affects women between 20-30 years, so it is rare in children. Case report: We describe the case of a 15-year-old female who was followed up since she was 9 years old due to celiac disease. At the age of 13, anaemia of chronic disorders associated to elevated C-reactive protein and erythrocyte sedimentation were detected. The patient remained asymptomatic. After excluding other diseases, we requested a positron emission computed tomography (PET-CT); lesions compatible with large-vessel vasculitis were detected. Cardiology evaluation showed an aneurysm in the right coronary artery. Angio-CT suggested Takayasu type III arteritis. Conclusions: The delay in the diagnosis of Takayasu arteritis in pediatric patients is quite common. In this case, we have found phase II lesions, with no previous phase I symptoms. However, PET-CT allowed the diagnosis of vasculitis, key to the diagnosis of the patient.

Effect of an intervention to improve the prescription of antifungals in pediatric hematology-oncology.

BACKGROUND: The use of antifungals has expanded in pediatric hematology-oncology, and the need to develop pediatric-based surveillance and education activities is becoming crucial. The aims of this study were to evaluate the impact of a multidisciplinary protocol on the adequacy of antifungal prescription in a pediatric hematology-oncology unit and to assess the effect of an educational intervention to improve the knowledge of prescribing pediatricians over time. METHODS: A multidisciplinary team established a protocol for the management of invasive fungal disease (IFD). The use of antifungals before (January 2012-May 2013) and after the protocol (June 2013-December 2015) was evaluated. Prescribing pediatricians attended a training course on IFD and were evaluated before 0, 6, and 12 months after the intervention. RESULTS: During the study period, antifungal agents were used in 185 episodes (56 children, 39.3% females), and were administered as prophylaxis (58.9%), empiric (34.6%), or targeted therapy (6.5%). Antifungal prescriptions were inadequate in 7% of the episodes, related to drug selection (53.8%), dosage (38.5%) and route of administration (7.7%). After protocol implementation, inadequate prescriptions decreased 9.9% (15.2% vs 5.3%; P = .04). Following the educational activity, the percentage of adequate responses to the questionnaire improved significantly compared to baseline, and persisted over time (19.7% improvement at 0 months [P < .0001]; 21.1% at 6 months [P < .0001]; 16.6% at 12 months [P = .002]). CONCLUSIONS: The establishment of multidisciplinary protocols and education activities improved the quality of antifungal prescription and the knowledge of prescribers regarding antifungal therapy. Therefore, these activities may be important for the implementation of antifungal stewardship programs in pediatrics.

Low-risk factors for severe bacterial infection and acute chest syndrome in children with sickle cell disease.

INTRODUCTION: The rate of bacterial infections in children with sickle cell disease (SCD) has decreased in recent years, mainly due to penicillin prophylaxis and vaccination. OBJECTIVES: To determine the rate of severe bacterial infection (SBI) in a cohort of children with SCD and to describe low-risk factors for confirmed SBI (CSBI) and acute chest syndrome (ACS). METHODS: This 11-year retrospective cohort study included children with febrile SCD admitted to a reference hospital in Spain. A case-control study was performed comparing patients diagnosed with SBI to those without SBI, and subanalyses for groups with CSBI and ACS were carried out. RESULTS: A total of 316 febrile episodes were analyzed; 69 (21.8%) had confirmed or possible SBI. Thirteen of those had CSBI (4.1%), eight urinary tract infection, and five bacteremia/sepsis. Among the cases of possible SBI, the majority had ACS (54/56; 96.4%). Age >3 years, absence of central venous catheter, hemodynamic stability, and procalcitonin <0.6 ng/ml were low-risk factors for CSBI, whereas normal oxygen saturation and C-reactive protein <3 mg/dl were low-risk factors for ACS, with negative predictive values (NPV) of 98.3%, 97.4%, 96%, 97.2%, 87.5%, and 85.8%, respectively. CONCLUSION: In this cohort of children with SCD who were well vaccinated and received adequate prophylaxis, we found a low rate of bacteremia and CSBI. We described several low-risk factors for CSBI and ACS, all of them with a high NPV. These findings may help to develop a risk score to safely select the patients that could be managed with a more conservative approach.

Evaluación del manejo del dolor de la patología facial y oral en un Servicio de Urgencias Pediátrico y tras el alta domiciliaria / Assessment of orofacial pain management in a pediatric emergency department and at home after discharge

Introducción. El manejo inadecuado del dolor es frecuente en Urgencias. El objetivo fue analizar el manejo del dolor de niños con patología infecciosa o traumática del área facial/oral en Urgencias y evaluar el cumplimiento y satisfacción sobre la analgesia prescrita al momento del alta. Población y métodos. Estudio transversal, observacional y analítico en niños que acudieron a Urgencias con patología infecciosa/traumática de la región facial/oral durante 2 meses. Se recogieron el manejo del dolor en Urgencias, la analgesia prescrita para el domicilio y, tras el contacto telefónico con los padres, el tratamiento realizado y su adecuación al dolor del niño. Resultados. Fueron incluidos 252 pacientes (edad media de 4,5 años, desvío estándar 3,89). En 8,7%, figuraba la evaluación del dolor en triaje y, en 3,6%, en el informe médico. Se administró analgesia en Urgencias al 41,3%. Al momento del alta, en un 13,9%, no se prescribió analgesia; en 25,4%, se prescribió pautada y, en 60,3%, a demanda. Los pediatras usaron más analgesia pautada que los cirujanos (34,4% vs. 16,5%, p < 0,01). En el domicilio, no administraron analgesia en el 39,3%; en un 36,1%, pautada y, en un 23%, a demanda. Existió escasa correlación entre la pauta al momento del alta y la administrada en el domicilio (kappa: 0,178). Se consideró la analgesia adecuada en el 84%, con más frecuencia en patología traumática que infecciosa (85,7% vs. 14,3%, p < 0,01). Conclusiones. Se observó escasa evaluación y tratamiento del dolor en Urgencias. La prescripción más usada fue a demanda en vez de pautada, al contrario de lo recomendado en las guías. El control analgésico fue mejor en patología traumática que infecciosa.

Introduction. An inadequate pain management is common in the emergency department. Our objective was to analyze pain management among children with an orofacial infection or trauma in the emergency department and to assess compliance and satisfaction with analgesia prescribed at discharge. Population and methods. Cross-sectional, observational and analytical study in children attending the emergency department for an orofacial infection or trauma over 2 months. Pain management in the emergency department, analgesia prescribed at home and, following a call to parents, treatment provided and its adequacy to control pain were registered. Results. In total, 252patients (mean age: 4.5 years, SD: 3.89) were included. Pain assessment was recorded at the triage for 8.7%, and in the medical report, for 3.6%. Analgesia was administered to 41.3% in the emergency room. At discharge, no analgesia was prescribed to 13.9%; scheduled analgesia, to 25.4%; and as needed, to 60.3%. Pediatricians prescribed scheduled analgesia more frequently than surgeons (34.4% versus 16.5%, p < 0.01). At home, no analgesia was administered to 39.3%; scheduled analgesia, to 36.1%; and as needed, to 23%. There is little correlation between prescription at discharge and at home (Kappa: 0.178). Analgesia was considered adequate in 84% of cases, and was more frequent in trauma injuries than in infections (85.7% versus 14.3%, p < 0.01). Conclusions. Pain assessment and management was scarce in the emergency department. The most common prescription was as needed, contrary to what is recommended in the guidelines. Analgesic control worked better for trauma injuries than for infections.

Assessment of orofacial pain management in a pediatric emergency department and at home after discharge. / Evaluación del manejo del dolor de la patología facial y oral en un Servicio de Urgencias Pediátrico y tras el alta domiciliaria.

INTRODUCTION: An inadequate pain management is common in the emergency department. Our objective was to analyze pain management among children with an orofacial infection or trauma in the emergency department and to assess compliance and satisfaction with analgesia prescribed at discharge. POPULATION AND METHODS: Cross-sectional, observational and analytical study in children attending the emergency department for an orofacial infection or trauma over 2 months. Pain management in the emergency department, analgesia prescribed at home and, following a call to parents, treatment provided and its adequacy to control pain were registered. RESULTS: In total, 252patients (mean age: 4.5 years, SD: 3.89) were included. Pain assessment was recorded at the triage for 8.7%, and in the medical report, for 3.6%. Analgesia was administered to 41.3% in the emergency room. At discharge, no analgesia was prescribed to 13.9%; scheduled analgesia, to 25.4%; and as needed, to 60.3%. Pediatricians prescribed scheduled analgesia more frequently than surgeons (34.4% versus 16.5%, p < 0.01). At home, no analgesia was administered to 39.3%; scheduled analgesia, to 36.1%; and as needed, to 23%. There is little correlation between prescription at discharge and at home (Kappa: 0.178). Analgesia was considered adequate in 84% of cases, and was more frequent in trauma injuries than in infections (85.7% versus 14.3%, p < 0.01). CONCLUSIONS: Pain assessment and management was scarce in the emergency department. The most common prescription was as needed, contrary to what is recommended in the guidelines. Analgesic control worked better for trauma injuries than for infections.

INTRODUCCIÓN: El manejo inadecuado del dolor es frecuente en Urgencias. El objetivo fue analizar el manejo del dolor de niños con patología infecciosa o traumática del área facial/oral en Urgencias y evaluar el cumplimiento y satisfacción sobre la analgesia prescrita al momento del alta. POBLACIÓN Y MÉTODOS: Estudio transversal, observacional y analítico en niños que acudieron a Urgencias con patología infecciosa/traumática de la región facial/oral durante 2 meses. Se recogieron el manejo del dolor en Urgencias, la analgesia prescrita para el domicilio y, tras el contacto telefónico con los padres, el tratamiento realizado y su adecuación al dolor del niño. RESULTADOS: Fueron incluidos 252 pacientes (edad media de 4,5 años, desvío estándar 3,89). En 8,7%, figuraba la evaluación del dolor en triaje y, en 3,6%, en el informe médico. Se administró analgesia en Urgencias al 41,3%. Al momento del alta, en un 13,9%, no se prescribió analgesia; en 25,4%, se prescribió pautada y, en 60,3%, a demanda. Los pediatras usaron más analgesia pautada que los cirujanos (34,4% vs. 16,5%, p < 0,01). En el domicilio, no administraron analgesia en el 39,3%; en un 36,1%, pautada y, en un 23%, a demanda. Existió escasa correlación entre la pauta al momento del alta y la administrada en el domicilio (kappa: 0,178). Se consideró la analgesia adecuada en el 84%, con más frecuencia en patología traumática que infecciosa (85,7% vs. 14,3%, p < 0,01). CONCLUSIONES: Se observó escasa evaluación y tratamiento del dolor en Urgencias. La prescripción más usada fue a demanda en vez de pautada, al contrario de lo recomendado en las guías. El control analgésico fue mejor en patología traumática que infecciosa.