Servicio de Urgencias de Pediatría del Hospital Universitario Cruces / Pediatrics Emergency Department of the Hospital Universitario Cruces

El Servicio de Urgencias de Pediatría (SUP) del Hospital Universitario de Cruces ha experimentado durante los últimos 15 años cambios profundos en su estructura, organización y profesionalización de su equipo médico y de enfermería. La implantación de un sistema de gestión de la calidad, en el año 2004, en el SUP ha impulsado mejoras en su actividad asistencial, docente y de investigación. Nuestro Servicio ofrece una atención integral al niño, lo que comprende aspectos tan trascendentes y polivalentes como la atención inicial al niño politraumatizado,reanimación cardiopulmonar, el uso de técnicas de analgesia y sedación, reparación de heridas, urgencias oftalmológicas y ORL, urgencias traumatológicas, además de todas las urgencias de tipo médico. La docencia e investigación son parte fundamental de las actividades del Servicio y son responsables en gran manera de su desarrollo actual. La participación en reuniones científicas y el desarrollo de redes de investigación de ámbito nacional e internacional, han sido y son motores de la mejora de la calidad del Servicio (AU)

The Pediatric Emergency Department (PED) of the Cruces University Hospital has experienced over the last 15 years profound changes in its structure, organization and professionalism of the medical team and nursing. The implementation of a system of quality management, in 2004, in the PED has driven improvements in their daily work, teaching and research. Our service offers comprehensive care for children, which indudes such important and versatile aspects such as multiple trauma care, resuscitation, use of analgesia and sedation techniques, wound repair, ophthalmology and ENT emergencies, orthopedic emergencies, as well of all medical conditions. Teaching and research are an essential part of the activities of the PED and are responsible largely on its current deve!opment. Participation in scientific meetings and developing research networks nationally and internationally, have been and are engines improving the quality of service (AU)

Actualización del sistema de codificación diagnóstica de la Sociedad Española de Urgencias de Pediatría / An update of the diagnostic coding system by the Spanish Society of Pediatric Emergencies

Se presenta la actualización del listado de codificación diagnóstica de la Sociedad Española de Urgencias de Pediatría (SEUP) que ha realizado el Grupo de Trabajo de Calidad de dicha Sociedad. El listado original fue elaborado y publicado en ANALES DE PEDIATRÍA el año 2000, basándose en la edición existente en aquel momento del sistema de codificación internacional CIE-9-MC. Siguiendo la misma metodología utilizada en aquel momento, y basándose en la edición del año 2014 del CIE-9-MC, se han añadido el listado 35 nuevos códigos, se han actualizado 15 y se ha añadido un listado de referencia con los diagnósticos traumatológicos más frecuentes en pediatría. El listado de diagnósticos SEUP actual refleja los importantes cambios experimentados por los Servicios de Urgencia Pediátricos en el último decenio (AU)

The Quality Working Group of the Spanish Society of Pediatric Emergencies (SEUP) presents an update of the diagnostic coding list. The original list was prepared and published in ANALES DE PEDIATRÍA in 2000, being based on the International Coding system ICD-9-CM current at that time. Following the same methodology used at that time and based on the 2014 edition of the ICD-9-CM, 35 new codes have been added to the list, 15 have been updated, and a list of the most frequent references to trauma diagnoses in pediatrics have been provided. In the current list of diagnoses, SEUP reflects the significant changes that have taken place in Pediatric Emergency Services in the last decade (AU)

[An update of the diagnostic coding system by the Spanish Society of Pediatric Emergencies]. / Actualización del sistema de codificación diagnóstica de la Sociedad Española de Urgencias de Pediatría.

The Quality Working Group of the Spanish Society of Pediatric Emergencies (SEUP) presents an update of the diagnostic coding list. The original list was prepared and published in Anales de Pediatría in 2000, being based on the International Coding system ICD-9-CM current at that time. Following the same methodology used at that time and based on the 2014 edition of the ICD-9-CM, 35 new codes have been added to the list, 15 have been updated, and a list of the most frequent references to trauma diagnoses in pediatrics have been provided. In the current list of diagnoses, SEUP reflects the significant changes that have taken place in Pediatric Emergency Services in the last decade.

Cumplimiento de los requisitos de los servicios de urgencias de España: encuesta de autoevaluación / Compliance with the requirements of paediatric emergency departments in Spain: a self-assessment survey

Introducción: La medicina de urgencias pediátrica en España se practica en servicios de distinta configuración. Nuestro objetivo es conocer su situación y adaptación a los requisitos del Cuerpo Doctrinal de la Sociedad Española de Urgencias Pediátricas. Método: Se envió por correo electrónico una encuesta con el cuestionario de Autoevaluación del Cuerpo Doctrinal a los responsables de 47 servicios. Consta de 101 ítems, 69 considerados de cumplimiento obligatorio. Se establecieron 4 grupos de servicios según el cumplimiento de esos 69 ítems: I o situación óptima (cumplen 69); II o que precisan cambios mínimos (cumplen 62-68); III o que precisan cambios mayores (cumplen 41-61); IV o que precisan grandes modificaciones (cumplen menos de 41). Resultados: Contestaron 39 servicios, que atienden una media de 35.310 urgencias anuales (5.000-115.000). Ninguno ha quedado incluido en el grupo I, 6 en el II, 27 en el III y 6 en el IV. Hay una tendencia a un mayor cumplimiento en los servicios más frecuentados, pero sin relación significativa entre el número de urgencias y los ítems cumplimentados. Conclusiones: 1) Muchos servicios de urgencias pediátricos en España tienen problemas estructurales y funcionales que pueden dificultar dar una asistencia de calidad, sin relación significativa con el volumen de urgencias atendidas; 2) los puntos de mejora afectan principalmente a cuestiones funcionales, que deben ser acometidas por sus responsables; 3) un número significativo tienen serios problemas arquitectónicos y de dotación, que precisarían medidas económicas por parte de sus órganos directivos, y 4) nuestro cuestionario de autoevaluación permite identificar acciones de mejora (AU)

Background: Paediatric emergency medicine in Spain is practiced in differently configured departments, staffing and organisation. Our goal was to determine the situation in Paediatric Emergency Departments (PED) and their adaptation to the quality standards proposed by the Spanish Society of Paediatric Emergencies. Method: A self-assessment questionnaire on standards performance was sent to 47 PED directors by e-mail. It consisted of 101 items, 69 considered mandatory. According to the fulfilment of these 69 items 4 PED groups were selected: group I: in the best position (met 69), group II: requiring minimal changes (meeting 62-68), group III: requiring major changes (meeting 41-61); group IV: requiring a lot of major changes (meeting less than 41). Results: Thirty nine questionnaires were completed in full. The PED included in the study tended to an average of 35310 annual emergencies (5000-115000). No PED was included in group I, 6 in II 27 in III and 6 in IV. There was a tendency towards higher compliance with standards in larger PED, but there was no significant relationship between the number of emergencies and the number of items fulfilled. Conclusions: 1. Staffing and architectural and organizational aspects may not be adequate to achieve optimal patient outcome in many PED in Spain. This fact does not appear to be related to the annual patient census. 2. The areas for improvement mainly affect functional issues that must be undertaken by those responsible. 3. A significant number of PED have serious architectural and staffing deficiencies, which would require economic measures by their managers. 4. Our self-assessment questionnaire identifies improvement actions (AU)

[Compliance with the requirements of paediatric emergency departments in Spain: a self-assessment survey]. / Cumplimiento de los requisitos de los servicios de urgencias de España: encuesta de autoevaluación.

BACKGROUND: Paediatric emergency medicine in Spain is practiced in differently configured departments, staffing and organisation. Our goal was to determine the situation in Paediatric Emergency Departments (PED) and their adaptation to the quality standards proposed by the Spanish Society of Paediatric Emergencies. METHOD: A self-assessment questionnaire on standards performance was sent to 47 PED directors by e-mail. It consisted of 101 items, 69 considered mandatory. According to the fulfilment of these 69 items 4 PED groups were selected: group I: in the best position (met 69), group II: requiring minimal changes (meeting 62-68), group III: requiring major changes (meeting 41-61); group IV: requiring a lot of major changes (meeting less than 41). RESULTS: Thirty nine questionnaires were completed in full. The PED included in the study tended to an average of 35310 annual emergencies (5000-115000). No PED was included in group I, 6 in II 27 in III and 6 in IV. There was a tendency towards higher compliance with standards in larger PED, but there was no significant relationship between the number of emergencies and the number of items fulfilled. CONCLUSIONS: 1. Staffing and architectural and organizational aspects may not be adequate to achieve optimal patient outcome in many PED in Spain. This fact does not appear to be related to the annual patient census. 2. The areas for improvement mainly affect functional issues that must be undertaken by those responsible. 3. A significant number of PED have serious architectural and staffing deficiencies, which would require economic measures by their managers. 4. Our self-assessment questionnaire identifies improvement actions.

Eficacia de los enemas salinos en el tratamiento de la impactación fecal en urgencias de pediatría / Saline enemas as treatment of faecal impaction in paediatric emergencies

Objetivo: Evaluar la eficacia y tolerabilidad del tratamiento, además de conocer la percepción y aceptación del procedimiento por parte del paciente y su familia y del personal sanitario. Material y método: Estudio descriptivo prospectivo de los niños y niñas, de entre 0 y 14 años, que al acudir al servicio de Urgencias del Hospital de Cruces fueron diagnosticados de impactación fecal y el facultativo que les atendió decidió realizar un tratamiento con enemas salinos. Se recogieron en un formulario los datos. Resultados: Durante el periodo de tiempo comprendido entre enero a junio del 2008, fueron estudiados 79 pacientes, con una edad media de 5,8 ± 3,4 años. El tiempo de respuesta medio tras la administración del enema fue de 26 ± 24,16 minutos. Un 38% de los niños refirieron no tener alivio y un 62% si presentó alivio, de los que el 49,4% fue alivio sintomático y un 12,7% alivio completo. De los niños 7 años el 75 %. Según el peso, el 48,6% de los niños de de 30k. En la valoración del tratamiento de los padres y del investigador, la puntuación media en una escala de 0 (totalmente insatisfactorio) a 10 (muy satisfactorio), fue de 5. Un 50% de los niños refirieron algún grado de molestias, en un 83% de los casos, leves. Conclusiones: La administración de enemas de suero salino produce alivio sintomático de la impactación fecal en un porcentaje elevado de los pacientes. Este tratamiento es en general bien tolerado, sin efectos adversos importantes y aceptablemente valorado por la familia del niño y por el personal sanitario (AU)

Objective: To evaluate the efficacy and tolerability of the treatment and to know the perception and acceptance of the procedure on the part of the patient, his family and the sanitary staff. Material and methods: Descriptive and prospective study of the children between 0 and 14 years of age who were diagnosed of faecal impaction at the time when they came to the Paediatric Emergency Department of the Cruces Hospital and the professional who cared for them decided to make a treatment with saline enemas. In a form were picked up the variables. Results: During the period of time between January and June of 2008, 79 patients were studied, with a mean age of 5,8 ± 3,4 years. The mean time response after the enema administration was 26 ± 24,16 minutes. A 38% of the children reported to have no relief and a 62% did report relief, of which 42,9% felt a symptomatic relief and 12,7% a complete relief. Of the child <3 years, the 48,6% showed some degree of relief, between 3 and 7 years the 70,4% and the >7 years the 75%. According to the weight, the 48,6% of the children <20kg felt relief, the 78,3% of the children between 20 and 30kg and the 65% of the >30kg. In the evaluation of the treatment by the parents and the investigator, the mean punctuation in a scale from 0 (completely unsatisfactory) to 10 (very satisfactory), was of 5. A 50% of the children referred some degree of discomfort, in the 83% of cases, slight (AU)

[Saline enemas as treatment of faecal impaction in paediatric emergencies]. / Eficacia de los enemas salinos en el tratamiento de la impactación fecal en urgencias de pediatría.

OBJECTIVE: To evaluate the efficacy and tolerability of the treatment and to know the perception and acceptance of the procedure on the part of the patient, his family and the sanitary staff. MATERIAL AND METHODS: Descriptive and prospective study of the children between 0 and 14 years of age who were diagnosed of faecal impaction at the time when they came to the Paediatric Emergency Department of the Cruces Hospital and the professional who cared for them decided to make a treatment with saline enemas. In a form were picked up the variables. RESULTS: During the period of time between January and June of 2008, 79 patients were studied, with a mean age of 5.8 +/- 3.4 years. The mean time response after the enema administration was 26 +/- 24.16 minutes. A 38% of the children reported to have no relief and a 62% did report relief, of which 42.9% felt a symptomatic relief and 12.7% a complete relief. Of the child <3 years, the 48.6% showed some degree of relief, between 3 and 7 years the 70.4% and the >7 years the 75%. According to the weight, the 48.6% of the children <20 kg felt relief, the 78.3% of the children between 20 and 30 kg and the 65% of the >30 kg. In the evaluation of the treatment by the parents and the investigator, the mean punctuation in a scale from 0 (completely unsatisfactory) to 10 (very satisfactory), was of 5. A 50% of the children referred some degree of discomfort, in the 83% of cases, slight. CONCLUSIONS: The administration of saline enemas relieves the symptoms of faecal impaction in a high percentage of patients. This treatment is generally well tolerated, with no significant adverse effects and is well accepted by the children's families and by the healthcare staff.

[Accidental ingestion of superwarfarins]. / Ingesta accidental de superwarfarinas.

Superwarfarins were developed around 1970 in order to resolve the resistance developed by the rodents to the previously existing rodenticides. Superwarfarins cause, nowadays, most of the poisonings due to rodenticides. However, in our environment, it has been extremely uncommon to attend children with such poisonings. We present five children aged less than 4 years with unintentional ingestion of a superwarfarin, admitted in a Pediatric Emergency Department in 1 year time, and a revision of the literature.

Ingesta accidental de superwarfarinas / Accidental ingestion of superwarfarins

Las denominadas superwarfarinas se desarrollaron a partir de la década de 1970 como solución a las resistencias que habían desarrollado los roedores a los raticidas hasta entonces existentes. Las superwarfarinas motivan hoy en día la mayoría de las intoxicaciones por raticidas, aunque, en nuestro país, han sido excepcionales en edad pediátrica. Se presentan cinco casos correspondientes a ingestas accidentales de superwarfarinas en menores de 4 años atendidos en 1 año en un servicio de urgencias pediátrico y una revisión de la literatura médica (AU)

Superwarfarins were developed around 1970 in order to resolve the resistance developed by the rodents to the previously existing rodenticides. Superwarfarins cause, nowadays, most of the poisonings due to rodenticides. However, in our environment, it has been extremely uncommon to attend children with such poisonings. We present five children aged less than 4 years with unintentional ingestion of a superwarfarin, admitted in a Pediatric Emergency Department in 1 year time, and a revision of the literatura (AU)

Consensus Statement on the Management of Paediatric Asthma. Update 2007

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Bronquiolitis aguda: ¿por qué no se aplica lo que se publica? Barreras en la transmisión del conocimiento / No disponible

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[Impact of pneumococcal vaccination on the management of infants with fever according to vaccination rates]. / Impacto de la vacunación neumocócica en el manejo del lactante con fiebre, en relación al porcentaje de vacunación.

OBJECTIVE: To calculate the impact of the heptavalent pneumococcal conjugate vaccine (PCV-7) in the management of fever without source (FWS) in infants according to vaccination rates. METHODS: The rate of pneumococcal vaccination in infants visiting 14 pediatric emergency departments (PEDs) was calculated. For the statistical analysis, two groups were established; group A: hospitals with vaccination rates of > or = 40%, and group B: hospitals with vaccination rates of < 40 %. A survey was carried out among pediatricians from 14 PEDs on the specific management of two hypothetical clinical cases of FWS (case 1: 7-month-old girl; case 2: 20-month-old girl) depending on their pneumococcal vaccination status (no vaccination, 1 o 2 doses, or 3 doses). RESULTS: In February 2005, data were collected in 1357 patients, aged 3 to 36 months; 568 (41.86 %) had received at least one dose of PCV-7. A total of 235 questionnaires were collected, 104 in group A and 131 in group B. Pneumococcal vaccination would lead (with statistically significant differences) to fewer diagnostic tests (complete blood cell counts and blood culture). This decrease would be more pronounced in group A than in group B (56.7 % vs 26.7 % and 55.8 vs 26.7 % in case 1 and 54.8 % vs 26 % and 57.7 vs 13.7 %, case 2, respectively), p < 0.05. Infants who had received complete pneumococcal vaccination would receive fewer antibiotics and would be more likely to be discharged directly from hospital (p < 0.001). CONCLUSIONS: In the previously vaccinated infant with FWS, there would be a significant reduction in the number of diagnostic tests, need for observation in the PED, rates of hospitalization and antibiotic therapy. The reduction in diagnostic tests would increase in areas with higher rates of pneumococcal vaccination.

Impacto de la vacunación neumocócica en el manejo del lactante con fiebre, en relación al porcentaje de vacunación / Impact of pneumococcal vaccination on the management of infants with fever according to vaccination rates

Objetivo. Estimar el impacto de la vacuna neumocócica conjugada heptavalente (VCN-7) en el manejo del lactante con fiebre sin focalidad (FSF) en relación al porcentaje de vacunación. Método. Se estimó el porcentaje VCN-7 en los lactantes con FSF que consultaron en 14 servicios de urgencias pediátricos (SUP). Para el análisis estadístico, se establecieron 2 grupos. Grupo A: hospitales con porcentaje de vacunación igual o superior a 40 %; y grupo B: hospitales con porcentaje de vacunación inferior a 40 %. Se realizó una encuesta sobre el manejo concreto de 2 casos clínicos hipotéticos de FSF (caso 1: niña de 7 meses; y caso 2: niña de 20 meses) en tres situaciones: sin vacunar; con 1 o 2 dosis de la VCN-7 o con 3 dosis. Resultados. Durante el mes de febrero de 2005 se recogieron en 14 SUP, datos de 1.357 lactantes (3 a 36 meses); 568 (41,86 %) habían recibido alguna dosis de VCN-7. Se reunieron 235 cuestionarios, 104 del grupo A y 131 del grupo B. La VCN-7 daría origen de forma significativa a la realización de menos estudios complementarios (hemograma y hemocultivo). Este descenso sería más acusado en el grupo A frente a grupo B (56,7 % frente a 26,7 % y 55,8 frente a 26,7 % en el caso 1 y 54,8 % frente a 26 % y 57,7 frente a 13,7 %, en el caso 2, respectivamente; p < 0,05). En ambos grupos de estudio, en los lactantes con VCN-7 completa, se reduciría la administración de antibióticos y se incrementaría el alta hospitalaria directa (p < 0,001). Conclusiones. En el lactante con FSF y VCN-7, se produciría una disminución significativa en el número de pruebas diagnósticas, la estancia del paciente en el SUP, la tasa de hospitalización y tratamiento antibiótico. La reducción en el número de pruebas diagnósticas sería más acusado en aquellas áreas con porcentajes superiores de VCN-7

Objective. To calculate the impact of the heptavalent pneumococcal conjugate vaccine (PCV-7) in the management of fever without source (FWS) in infants according to vaccination rates. Methods. The rate of pneumococcal vaccination in infants visiting 14 pediatric emergency departments (PEDs) was calculated. For the statistical analysis, two groups were established; group A: hospitals with vaccination rates of >= 40%, and group B: hospitals with vaccination rates of < 40 %. A survey was carried out among pediatricians from 14 PEDs on the specific management of two hypothetical clinical cases of FWS (case 1: 7-month-old girl; case 2: 20-month-old girl) depending on their pneumococcal vaccination status (no vaccination, 1 o 2 doses, or 3 doses). Results. In February 2005, data were collected in 1357 patients, aged 3 to 36 months; 568 (41.86 %) had received at least one dose of PCV-7. A total of 235 questionnaires were collected, 104 in group A and 131 in group B. Pneumococcal vaccination would lead (with statistically significant differences) to fewer diagnostic tests (complete blood cell counts and blood culture). This decrease would be more pronounced in group A than in group B (56.7 % vs 26.7 % and 55.8 vs 26.7 % in case 1 and 54.8 % vs 26 % and 57.7 vs 13.7 %, case 2, respectively), p < 0.05. Infants who had received complete pneumococcal vaccination would receive fewer antibiotics and would be more likely to be discharged directly from hospital (p < 0.001). Conclusions. In the previously vaccinated infant with FWS, there would be a significant reduction in the number of diagnostic tests, need for observation in the PED, rates of hospitalization and antibiotic therapy. The reduction in diagnostic tests would increase in areas with higher rates of pneumococcal vaccination

Traumatismo craneoencefálico en la infancia / Head trauma in children

El trauma craneoencefálico (TCE) es un motivo de consulta frecuente en las urgencias pediátricas. El principal reto para el pediatra radica en detectar lesiones intracraneales (LIC), sobre todo, en niños con TCE leve. La escala del coma de Glasgow es la mejor herramienta para valorar la gravedad del TCE y la posibilidad de existencia de LIC. En general, siempre que exista una puntuación en la escala de Glasgow < 15, estará indicada la realización de una tomografía computarizada (TAC). La presencia de focalidad neurológica tras el TCE es otra indicación de TAC. Otros síntomas, como cefalea y vómitos, son muy comunes y, en general, su presencia no incrementa la posibilidad de LIC. Aunque la presencia de una fractura craneal incrementa la incidencia de LIC, su ausencia no la descarta. La radiografía de cráneo tiene un papel muy secundario en la valoración del TCE y únicamente estaría indicada en el lactante asintomático ante la presencia de un cefalohematoma importante o la sospecha de maltrato (AU)

Head trauma (HT) is a common reason for medical evaluation in a paediatric emergency department. The main challenge for the paediatrician is to identify children on risk of intracranial lesion (IL) especially in those who have suffered a minor head trauma. Glasgow Coma Scale (CGS) is the best independent tool to evaluate HT severity and therefore the possibility of IL. A punctuation in CGS under 15 and the presence of a focal neurological abnormality are the best predictors of IL and therefore an indication of brain CT. Posttraumatic vomiting and headache are very common symptoms but they are not independent factors for predicting IL. The presence of a cranial fracture increases the possibility of IL but its absence doesn’t permit to rule out this condition. Cranial radiograph should be not obtained in most cases, only it should be ordered in infants with a significant cephalohematom and in those cases where abuse is suspected (AU)

Apendicitis aguda en la infancia. Factores asociados al retraso diagnóstico / Acute appendicitis in childhood. Factors associated to diagnostic delay

Objetivo: Establecer si existen diferencias clínicas, analíticas y de estudios de imagen en los niños diagnosticados de apendicitis, en la segunda o sucesivas consultas, respecto a los diagnosticados en su primera consulta, en nuestro servicio de urgencias. Método: Estudio retrospectivo de las historias clínicas de los 252 niños con diagnóstico anatomopatológico de apendicitis, durante los años 1999 y 2000. Se clasificaron los pacientes en 2 grupos. Los diagnosticados en su primera consulta (A), versus los que lo fueron en la segunda o sucesivas (B). Resultados: De los 252 niños diagnosticados de apendicitis, 38 (15%) habían consultado previamente en el mismo episodio. Los diagnósticos al alta en esa primera consulta fueron: Dolor abdominal inespecífico (26), diarrea (9), vómitos (2), adenitis mesentérica (1). Se encontraron diferencias significativas en el tiempo de evolución de los síntomas en su primera consulta en urgencias, A (26,84 ± 32,11 horas) versus B (11,31 ± 7,28 horas); edad media, A (114,07 ± 35,63 meses) versus B (98,24 ± 40,5 meses); presencia de diarrea, A (15; 7%) versus B ( 8; 23,6%); presencia de dolor localizado en fosa ilíaca derecha, A (144; 67%) versus B (12; 31%) y exploración física sugestiva, A (138; 64%) versus B (5; 13%). También en el número de pruebas radiológicas realizadas hubo diferencias significativas. Se realizó Rx de abdomen a 200 niños del grupo A (93%) versus 14 del grupo B (37%); ecografía abdominal a 89 niños del grupo A (42%) versus 7 del B (21%). Dentro de las pruebas analíticas se encontró diferencia significativa en el valor de la proteína C reactiva, grupo A (5,01 ± 7,2 mg/dl), versus grupo B (2,2 ± 2,3 mg/dl). En el grupo A hubo 70 (33%) apendicitis perforadas versus 25 (66%) en el B. La media de días de hospitalización fue de 5,75 ± 3,9 para el grupo A versus 7,84 ± 5,5 para el B, siendo también una diferencia significativa. No se encontraron diferencias entre los dos grupos en la presencia de fiebre, vómitos ni leucocitosis. Conclusiones: El retraso en el diagnóstico en la apendicitis aguda se asocia a: un aumento del número de apendicitis perforadas, con el consiguiente incremento de la morbi-mortalidad y aumento de días de hospitalización. Los errores diagnósticos en la primera consulta en urgencias se deben sobre todo al menor tiempo de evolución de los síntomas. También influyen la presencia de síntomas inespecíficos como la diarrea y la menor edad de los pacientes. Las pruebas diagnósticas tienen un escaso valor en los casos poco evolucionados (AU)

Aim: To assess whether clinical, analytical and/or image studies differences do exist among children with a diagnosis of appendicitis in second or successive visits as compared to those diagnosed on the first visit in our Emergency Outpatient Ward. Methods: Retrospective study of the clinical records of 252 children with an anatomopathological diagnosis of appendicitis between 1999 and 2000. Patients were classified into two groups: those diagnosed during the first visit (A), versus those diagnosed in the second or successive visits (B). Results: From among the 252 children with a diagnosis of appendicitis, 38 (15%) had a previous consultation during the same episode. The discharge diagnoses upon that first visit (consultation) were “non-specific abdominal pain” (n = 26), “diarrhoea” (n = 9), “vomiting” (n = 2) and “mesenteric adenitis” (n = 1). Statistically significant differences were seen in a number of criteria: period of evolution of symptoms upon the first Outpatient Emergency Ward consultation (A, 26.84 ± 32.11 hours; B, 11.31 ± 7.28 hours), mean age (A, 114.07 ± 35.63 months; B, 98.24 ± 40.5 months), presence of diarrhoea (A, n = 15, 7%; B, n = 8, 23.6%), presence of right iliac fossa pain (A, n = 144, 67%; B, n = 12, 31%), and suggestive physical examination (A, n = 138, 64%; B, n = 5, 13%). There were also significant differences in the number of radiologic examinations performed: a plain film of the abdomen was carried out in 200 children in group A (93%) versus 14 in group B (37%), and abdominal ultrasound scans were carried out in 89 children in group A (42%) versus 7 in group B (21%). Among the laboratory tests, a significant difference was observed in the C-reactive protein level: 5.01 ± 7.2 mg/dl in group A, versus 2.2 ± 2.3 mg/dl in group B. There were 70 cases of perforated appendicitis (33%) in group A versus 25 (66%) in group B. The mean duration of hospital admission was 5.75 ± 3.9 days for group A and 7.84 ± 5.5 days for group B (also a statistically significant difference). There were no inter- group differences in presence of vomiting, fever or leukocytosis. Conclusions: The delay in diagnosis of acute appendicitis is associated to an increase in the number of perforated appendicitides, with the subsequent increase in morbi-mortality and in the duration of hospital admission. Diagnostic errors on the first consultation at the Outpatient Emergency Ward were mainly due to the shorter period of symptom evolution. The presence of nonspecific symptoms such as diarrhoea and the shorter age of the patients also have an influence. The diagnostic tests are of little value in cases with a short evolution (AU)

Cambios de los hábitos poblacionales en el tratamiento de la fiebre en la infancia / Change in habits among the population in the management of childhood fever

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[Acute onset ataxia in infancy: its aetiology, treatment and follow-up]. / Ataxia de aparición aguda en la infancia: etiología, tratamiento y seguimiento.

INTRODUCTION: Acute childhood ataxia is a cause of referency to the pediatric emergency room. AIM. To characterize the etiology, clinical picture, management, and outcome of acute ataxia in our hospital. PATIENTS AND METHODS: A prospective study was undertaken including 39 children with acute ataxia who were admitted between January 1, 2001 and December 31, 2003. RESULTS: During the study period 159,002 episodes were evaluated, 39 children (0.024%) with acute ataxia. The most common diagnoses were post-infectious ataxia (51.2%) and toxic exposure (25.6%). The mean age at presentation in post-infectious ataxia was 55 +/- 27.61 months, 60% females. A prodromal febrile illness was noted in 95%: varicella (10), nonspecific viral infection (6), mycoplasma, enterovirus, and Epstein-Barr virus. The latency from the prodromal illness to the onset of ataxia was 5.86 +/- 3.78 days. Lumbar punctures were altered in 11/17. All computed tomography scans performed were normal. At follow up, one boy presented asymmetric signs of cerebellar dysfunction secondary to hemicerebellitis. The media of the patient who showed full-gait recovery was 18 days, and was complete in all children, except one boy who presented hemophagocytic lymphohistiocytosis. Toxic ingestion was the second most common cause. Boys less than 6 years were more commonly affected. CONCLUSIONS: Acute childhood ataxia are an uncommon cause of presentation to our pediatric emergency room. Postinfectious ataxia and drug ingestion are the most common diagnosis, with a usually benign and self-limited process. A thorough history and neurology examination should be guided to etiology. Neuroimaging studies and hospitalization are needed only if atypical presentation, asymmetric neurologic examination and prolonged ataxia.