Mediastinitis secondary to invasive infection by group A Streptococcus in Spain.

This study describes 5 mediastinitis cases secondary to invasive group A Streptococcus (iGAS) disease in a recent outbreak in Spain. Among 398 iGAS cases between January 2019-March 2023, 5 (1.3%) were mediastinitis, 4 occurring in December 2022, all secondary to pneumonia or deep neck infection. We outline the clinical outcome with a review of the scarce pediatric literature.  Conclusion: mediastinistis is a rare but severe complication of iGAS and a high level of suspicion is required to diagnose it. What is Known: • Group A Streptococcus can cause invasive and severe infections in children. • Mediastinitis is a severe complication from some bacterial infections, mainly secondary due to deep-neck abscesses. What is New: • Mediastinitis is an unrecognized complication due to an invasive group A Streptococcus (iGAS) infection. • In cases of a deep-neck abscess or complicated pneumonia a high clinical suspicion of iGAS mediastinitis is required, especially when the clinical course is not favorable.

Paciente pediátrico crítico. Cuidados Intensivos Pediátricos, Hospital Infantil La Paz / Critical pediatric patient. Pediatric intensive cares, Hospital Infantil La Paz

Los Cuidados Intensivos Pediátricos (CIPs) iniciaron su actividad en el Hospital Infantil La Paz en el año 1074. El servicio actual dispone de 16 camas, cuatro de cuidados medios, ocho de cuidados intensivos y cuatro de aislamiento con exclusa y filtros HEPA (High Efficiency Particulate Air). En los últimos 6 años (2006-2010) se han atendido 3.674 pacientes, media de 612 pacientes año, con una ocupación media anual del 83,4% y mortalidad media anual del 4,9%. Al ser considerado un servicio polivalente, se ha establecido una estrecha colaboración prácticamente con la totalidad de los servicios y especialidades pediátricas médico-quirúrgicas del hospital, con mayor o menor frecuencia según las patologías asistidas, destacando entre las patologías asistidas, destacado entre las patologías quirúrgicas los pacientes con asistencia ventricular (Berlin Hear), ECMO (Extracorporeal Membrane Oxygenation) y trasplante cardiaco; así como tratamiento psotoepratorio de los trasplantes hepáticos, renales, intestinales y multiviscerales. Entre las líneas de trabajo, hay que destacar el tratamiento intracoronario con células progenitoras autólogas de médula ósea en pacientes con miocardiopatía dilatada e insuficiencia cardíaca; creación de un equipo mixto, médico y de enfermería para el abordaje guiado por ecografía, de accesos venosos centrales insertados periféricamente; registro de una patente europea de válvula de cierre ultrarrápido y sin fugas para respiradores; utilización a nivel pediátrico de la tecnología ventilatoria NAVA (Neurally Adjusted Ventilatory Asist); monitorización hemodinámica con el monitor PiCCO2 (Pulsion Medical System); la promoción de la ecuación médica basada en la simulación de ata fidelidad y la implantación de la asistencia ventricular externa en Pediatría (AU)

The Pediatric Intensive Care Unit of La Paz Universitary Hospital, was founded in 1974. It is now a polyvalent medical-surgical tertiary unit, equipped with 4 intermediate care beds, 8 intensive care beds and 4 isolation beds with airlock and HEPA filters for the treatment of transplanted and immunocompromised patients. In the last 6 years, 3674 patients have been treated (mean 612 patients/year) with a mean occupancy rate of 83,4% and a mortality rate of 4,9&. As the polyvalent unit it is, PICU staff maintains close and daily contact and cooperation with almost all the rest of the medical and surgical departments of the hospital. In this regard Critically ill cardiac patients are admitted in the PICU ( for the treatment with ECMO and ventricular assist devices (EXCOR Berlin Heart), as well as post-operative patients after cardiac, liver, renal, intestinal and multivisceral transplantation. Of all the achievements and current lines of work of the department, it can be highlighted the intracoronary treatment with autologous bone marrow derived progenitor cells in patients with dilated cardiomyopathy, the implantation development of a pediatric ventricular assist program, the echo guided cannulation of peripherally inserted central venous catheter by a especially trained intravenous therapy team, the registration of a European patent for a ultrarapid shutoff respirator valve, the incorporation of NAVA mode for mechanically ventilated patients and the PiCCO2 monitor for the hemodynamic monitorization of patient with cardiovascular dysfunction, and the promotion of medical education based on high-fidelity simulation (AU)

Intoxicación aguda por organofosforados. A propósito de un caso / Acute intoxication due to organophosphates. A case report

Las intoxicaciones constituyen un motivo de consulta frecuente en urgencias pediátricas. En los pacientes con bajo nivel de conciencia y afectación multiorgánica, las intoxicaciones deben considerarse como primera sospecha diagnóstica. Presentamos el caso de una niña de 3 años de edad con dolor abdominal, vómitos, dificultad respiratoria, sensación de mareo, agitación y disminución del nivel de conciencia. Los padres referían que cuando la niña presentó el cuadro estaba comiendo un caramelo, por lo que ante la sospecha de aspiración, se le realizó una intubación y una broncoscopia rígida, con la que se descartó la existencia de un cuerpo extraño y se observó una mucosa traqueobronquial con lesiones difusas. Durante la broncoscopia la paciente sufrió una crisis convulsiva; se le administró midazolam y se realizó una tomografía computarizada craneal, que resultó normal. Se ingresó a la paciente en la unidad de cuidados intensivos pediátricos, donde se mantuvo en ventilación mecánica. Los padres referían que su hija padecía una pediculosis, tratada en las últimas horas con un insecticida (Floricruz Cruz Verde®), compuesto por un organofosforado (diazinón) y un hidrocarburo (nafta) (AU)

Poisoning represents a frequent reason for consultation in emergency pediatrics. In patients with a low level of consciousness and other organs involvement, should be regarded as a first diagnosis suspicion. We present a three year old girl who presents stomach-ache, vomits, respiratory distress, sensation of dizziness, agitation and a decrease of consciousness. Her parents refer she was eating a candy, so an accidental ingestion is suspected. She was intubated and underwent rigid bronchoscopy. There is nothing in the airway but there are a lot of erosions in the tracheal and bronchial mucosa. The girl suffers a convulsive crisis during the bronchoscopy and she is treated with midazolam. Brain CT scan is normal. She is admitted in the Pediatric Intensive Care Unit (PICU) and connected to mechanical ventilation. The parents are interrogated again and they refer she has a pediculosis which they have treated in the last few hours with insecticide(Floricruz Cruz Verde®), which contains an organophosphate(diazinon) and a hydrocarbon (naphta) (AU)

Síndrome de apnea obstructiva del sueño con repercusión sistémica. A propósito de un caso / Obstructive sleep apnea syndrome with systemic repercussion. Case report

Presentamos el caso de un niño de 4 años que ingresa en la unidad de cuidados intensivos pediátricos (UCIP) por mal estado general, dificultad respiratoria severa con débil esfuerzo y ronquido inspiratorio. La auscultación cardiopulmonar muestra hipoventilación y ritmo de galope, tiene hepatomegalia y, desde el punto de vista neurológico, presenta disminución del nivel de conciencia (Glasgow 6/15). En las pruebas complementarias, se observa un daño hipóxico-isquémico generalizado(creatinina sérica de 1,8 mg/dL; GOT de 23.730 UI/L y GPT de 5.771 UI/L; actividad de protrombina del 31% y troponina de1,73 ng/mL). La radiografía de tórax muestra una discreta cardiomegalia y la ecocardiografía hipertensión pulmonar. En la eco-Doppler abdominal se observa una severa hiperecogenicidad cortical renal y hepatomegalia. En el electroencefalograma hay signos de afectación cerebral generalizada, y en la tomografía computarizada (TC) craneal aparecen dos áreas cerebrales sugestivas de infartos isquémicos e hipertrofia adenoidea. A los pocos días del ingreso, se realiza una adenoamigdalectomía. En el momento del alta, los parámetros analíticos son normales, y en la ecocardiografía no se observa hipertensión pulmonar (AU)

We present a case report of a four year old child who is admittedat the PICU due to general bad condition, serious respiratorydifficulty with low effort and inspiratory snoring. The cardiopulmonarauscultation shows hypoventilation and gallop rhythm.He also shows hepatomegaly and awareness reduction at aneurological level (Glasgow 6/15). The complementary testsshow a generalized hypoxic-ischemic injury (serum creatinine of1.8 mg/dL; GOT of 23,730 IUI/L and GPT of 5,771 IU/L; prothrombinactivity 31% and troponin 1.73 ng/mL). Thorax X-rayshows cardiomegaly and the echocardiography pulmonary hypertension.The abdominal echo-doppler shows a serious renalcortical hyperechogenicity and hepatomegaly. At the electroencephalographthere are some signs of generalized cerebraldamage and in the cranial scan there are two cerebral areasthat suggest ischemic infarctions and adenoid hypertrophy. Atonsillectomy is performed some days after admission. At thedischarge, the analytical parameters are normal and there is nopulmonary hypertension (PHT) in the echocardiography (AU)

[Pneumococcal conjugate vaccine failure in HIV-infected child. Clinical case]. / Fallo de la vacuna antineumocócica conjugada en un niño VIH positivo. A propósito de un caso.

Despite appropriate antimicrobial therapy and vaccination, invasive pneumococcal infections remain associated with significant mortality, especially in selected high-risk groups (asplenic, humoral immunity deficient patients, etc.). We present a 13-year-old caucasian boy with HIV infection (vertical transmission). He received treatment with highly-active antiretroviral therapy (amprenavir, lamivudine and zidovudine) and vaccination with 23-valent vaccine (6 years old) and 7-valent pneumococcal conjugate vaccine (10 years old). His CD4 count and his viral load at these times were 2,063/microl and 13461 cop/ml, when he was 6 years old and 1,315/microl and 32400 cop/ml when he was 10 years old, respectively. The latest CD4 count (1,000/microl) and his viral load (3800 cop/ml) confirmed satisfactory control of the disease. He was referred to our emergency department presenting with fever, head and stomach-ache and vomiting. In the following hours his condition continued to deteriorate and depressed level of consciousness and meningismus were observed. Streptococcus pneumoniae, serotype 18 C, was detected in blood and cerebrospinal fluid cultures. Despite appropriate treatment with antibiotics (cefotaxime and vancomycin) and anti-oedema medications, brain-death was confirmed 24 hours after his admittance.

Fallo de la vacuna antineumocócica conjugada en un niño VIH positivo. A propósito de un caso / Pneumococcal conjugate vaccine failure in HIV-infected child

La infección neumocócica sigue asociada con una importante mortalidad, especialmente en grupos de riesgo (esplenectomizados, déficit de la inmunidad humoral, etc.) a pesar de vacunas y antibióticos adecuados. Presentamos a un niño de 13 años VIH positivo por transmisión vertical tratado con triple terapia (amprenavir, lamivudina y zidovudina). Fue vacunado con vacuna 23-valente a los 6 años y conjugada heptavalente a los 10 años de edad. El recuento de células CD4 y su carga viral a los 6 años eran de 2.063/μl y 13.461 copias/ml, respectivamente. A los 10 años el recuento de CD4 y su carga viral eran de 1.315/μl y 32.400 copias/ml, respectivamente. El último recuento de CD4 (1.000/μl) y la carga viral (3.800 copias/ml) confirmaban un buen control de la enfermedad 15 días antes del ingreso. Acude a urgencias por fiebre, dolor abdominal y vómitos. Hay un progresivo deterioro del nivel de conciencia y signos meníngeos. En el hemocultivo y en el cultivo de LCR crece Streptococcus pneumoniae serotipo 18C, y es tratado con cefotaxima y vancomicina, así como medidas antiedema cerebral, pero evoluciona a muerte cerebral en 24 h (AU)

Despite appropriate antimicrobial therapy and vaccination, invasive pneumococcal infections remain associated with significant mortality, especially in selected high-risk groups (asplenic, humoral immunity deficient patients, etc.). We present a 13-year-old caucasian boy with HIV infection (vertical transmission). He received treatment with highly-active antiretroviral therapy (amprenavir, lamivudine and zidovudine) and vaccination with 23-valent vaccine (6 years old) and 7-valent pneumococcal conjugate vaccine (10 years old). His CD4 count and his viral load at these times were 2,063/μl and 13461 cop/ml, when he was 6 years old and 1,315/μl and 32400 cop/ml when he was 10 years old, respectively. The latest CD4 count (1,000/μl) and his viral load (3800 cop/ml) confirmed satisfactory control of the disease. He was referred to our emergency department presenting with fever, head and stomach-ache and vomiting. In the following hours his condition continued to deteriorate and depressed level of consciousness and meningismus were observed. Streptococcus pneumoniae, serotype 18 C, was detected in blood and cerebrospinal fluid cultures. Despite appropriate treatment with antibiotics (cefotaxime and vancomycin) and anti-oedema medications, brain-death was confirmed 24 hours after his admittance (AU)

La psicosis única (I) / Unique psychosis (I)

No disponible

[Diagnostic effectiveness of CT and MR in local staging of renal tumors]. / Eficacia diagnóstica del TC y RM en el estadiaje local de los tumores renales.

The aim of this paper is to study the pre-operative staging of renal tumours, comparing CT and MR, and the imaging criteria used, examining the diagnostic efficacy for each of them. Thirty-four tumours were obtained from 29 patients. All cases were studied with CT and MR. To measure diagnostic efficacy, both for each technique and the criteria used in 2 different readings, a diagnostic performance curve (DPC) is calculated. Neither CT nor MR show infiltration of renal capsule. With regard to perinephritic fat, fascia and adjacent organ invasion, both techniques lead to overstaging, mainly CT. When applying more conservative reading criteria, the results are much improved, specially in relation to CT, although results with MR continue to be more favourable. MR is better to study vascular invasion, providing no false results. Of 22 tumours undergoing surgery, first option was the correct staging in 14 tumour with CT and in 16 with MR. When selecting the best imaging technique to stage renal tumours, MR allows a better and simpler radiologic reading. Nevertheless, considering the high correlation between CT and MR, CT can be used more reliably in institutions where no easy access to a MR unit is available. Both CT and MR overstage renal tumours.

Carcinoma of prostatic ducts.

Carcinoma of prostatic ducts is a rare clinical feature. We have reviewed 398 histories of patients with histologic diagnosis of prostatic carcinoma and found 10 patients with the ductal variety (2.51%). Four had pure ductal transitional cell carcinoma, 5 had mixed acinar adenocarcinoma plus ductal transitional cell carcinoma, and the last one had mixed acinar and ductal adenocarcinoma. Age, symptoms, physical findings, and imaging diagnoses were similar to those of acinar carcinoma. Rectal examination disclosed hard prostate in 9 patients. The metastatic way depended on the histologic elements present in each patient. Cystoscopy showed a malignant-resembling image in 4 cases. The mean survival (23 months) was lower than that of patients with acinar carcinoma. Early diagnosis and radical surgery still are the only way to increase the expectation of life of patients affected by this pathology.

[Penoscrotal gangrene: our series of cases]. / Gangrena penoescrotal: nuestra casuística.

Ten cases of penoscrotal gangrene seen in our department over the last 8 years are presented. In 80% of patients causative factors of the gangrenous process were demonstrated and were equally distributed between urology and colorectal pathologies. The most commonly associated pathology was diabetes mellitus affecting up to 50% of our patients. Two or more germs were isolated from the necrotic-purulent material for cultures, mainly E. coli (90%) and Proteus mirabilis (50%) as aerobic organisms, and Bacteroides fragilis (40%) in the anaerobic group. Despite emergency surgical therapy and high doses of broad spectrum antibiotics, mortality in our series was about 20%.

[Surgical treatment of urinary stress incontinence in women]. / Tratamiento quirúrgico de la incontinencia urinaria de esfuerzo en la mujer.

Long-term results obtained in 54 surgical procedures to correct effort urinary incontinence performed in 49 patients with this pathology are reviewed. One group was treated with suprapubic urethrovesical suspension with the Marshall-Marchetti-Krantz technique; the other group with endoscopic suspension of the neck of the bladder, with the Stamey technique and the third group with sling techniques. The authors conclude that any of the surgical techniques achieving a correct reposition of urethrovesical anatomy, rising the posterior urethra to its primitive anatomical bed, obtain a similar success rate.

Follow-up of superficial bladder cancer: how to spare cystoscopies?

To study the efficacy, specificity and sensitivity of ultrasonography, cytology and phospholipid/fatty acid quotient (PL/FA) in the detection of recurrences in patients with superficial bladder cancer we performed these three examinations simultaneously with cystoscopy. In over 405 cystoscopies, 348 were negative and 57 were positive for tumor. Sensitivity, the most important parameter, was 73% for the three examinations together. Each method separately had the following sensitivity: ultrasound 26%; cytology 14%, and PL/FA 47%. Considering that there were only 15 false-negatives, with this follow-up scheme we save the patient from a lot of cystoscopies, avoiding their inherent morbidity.

[Volumetric and structural changes of prostatic carcinoma under hormonal treatment]. / Cambios volumétricos y estructurales del carcinoma prostático con tratamiento hormonal.

The evolution of the ultrasonographic images of 25 patients with advanced carcinoma of the prostate receiving antiandrogen (cyproterone acetate) and LH-RH analogue therapy were studied. Thirteen patients were on daily LH-RH analogue therapy while the remaining patients received a monthly depot dose. At 6 months, the ultrasound follow-up revealed a 20.4% reduction of the transverse and a 19.8% reduction of the anteroposterior diameter for the first patient group. Similar results were observed for the second group comprised of 12 patients who received depot therapy; a mean reduction of the diameters of 119.9% and 18.7%, respectively. At 6 months, 66% of the patients in the first group and 59% of the second group showed an improvement of ultrasound patterns. Infiltration of the seminal vesicles improved for both groups, 41% and 38% of patients, respectively. However, at 12 months this rose to 50% improvement for the group on the daily treatment regimen. The follow-up data after 6 months are as yet unavailable for the group on depot therapy. Transrectal ultrasound is an easy, reproducible method that is very useful in the follow-up of patients with advanced cancer of the prostate receiving hormone therapy.

ABO blood groups and bladder carcinoma.

Following some reports concerning the possible influence of ABO blood groups on constitutional types and different features of human pathology, we have investigated if there are relationships between ABO blood groups and bladder tumors. Our findings show that tumoral behavior in patients with bladder carcinoma and blood group O has a tendency to an increased aggressivity with higher tumoral grade and more relapses than what is seen in tumors of patients with A blood group. Although this difference is not statistically significant, we believe that blood group ABO should be considered as a constitutional prognostic factor in bladder carcinoma and further investigations in this field are needed.

Selective chemoprophylaxis guided by multifactorial analysis in superficial bladder cancer.

One hundred and five patients with superficial bladder cancer (60 primary and 45 recurrent tumors) entered a prospective chemoprophylaxis trial after transurethral resection of the tumor. The drug for chemoprophylaxis was chosen by a computer which received the tumor data and analyzed them through a previous program of recurrence risk factors (multivariant analysis). In comparison with the aleatory selection of the drug, this statistical computerized choice has diminished the recurrence index (from 8 to 3) and increased the interval free of disease (from 70 to 83.5 months) in this group of patients.

[Disseminated renal adenocarcinoma. Developmental study]. / Adenocarcinoma renal diseminado. Estudio evolutivo.

A study was undertaken on 57 patients diagnosed as having disseminated renal adenocarcinoma. The interval between the onset of symptomatology and diagnosis ranged from 1 to 48 months. The tumor frequently metastasized to lungs and bone. To evaluate survival, this patient population was divided into two groups: those who underwent nephrectomy, 17 patients (9 patients also underwent lymphadenectomy), and those who were put on drug therapy alone. No significant difference was observed with respect to survival for both patient groups.

[Percutaneous nephrostomy as a technic for emergency drainage: review of cases]. / La nefrostomía percutánea como técnica de derivación de urgencia: revisión de casos.

Percutaneous nephrostomy (PCN) is currently one of the procedures of choice for emergency drainage of the upper urinary tract. Moreover, it permits morphologic and functional diagnostic possibilities as well as a wide variety of new and frequently definitive therapeutic procedures. We report on 58 PCN procedures performed in 55 patients from May 1983 to February 1989. PCN was indicated for complicated or uncomplicated uni- or bilateral supravesical obstruction, with infection and/or azotemia. All patients submitted to PCN for complicated obstruction with infection and/or azotemia showed a marked clinical and analytical improvement. Apart from resolving this emergency, it reduced the morbidity and mortality rate of subsequent surgical treatment of the underlying cause of obstruction because patient status was markedly improved. The major complications, retroperitoneal hematoma and sepsis, were rare. We frequently observed that the catheter had come out or become obstructed in our series. PCN affords the following advantages: it can be performed with local anesthesia; it is a simple technique; there are no absolute contraindications; its morbidity and mortality rates are low; and, it can be easily converted into a permanent procedure. In our view, all the foregoing advantages, as well as its therapeutic and morphologic and functional diagnostic possibilities, make PCN one of the procedures of choice in emergency treatment of upper urinary tract obstruction.

[Calcification and contamination as complications in the use of double-J catheters: incidence and correlation]. / Calcificación y contaminación como complicaciones en el uso de catéteres ureterales doble-J: incidencia y correlación.

We present a series of cases of complex renal lithiasis, in which we carried out temporary internal urinary bypassing, prior to extracorporeal lithotripsy, by means of the retrograde insertion of a double-J urethral catheter, studying the time of stay, the presence or not of contamination in the catheter and its relationship with the calcifications found in them. We also carried out a metabolic-functional study of each patient, determining the urinary pH and the serum and urinary calcium, phosphorous and uric acid concentrations, and observing their possible influence on the above-mentioned complications. Of the 25 catheters studied, we observed calcification in 11 cases (44%). In these we observed urealytic germs (Proteus and Pseudomonas), without finding modifications of urinary pH. We observed no relationship between the calcium deposits and serum and urinary calcium, phosphorous and uric acid concentration.

[Kidney pelvis calcification around a double-J ureteral catheter which was impossible to extract. Apropos of a case]. / Calcificación piélica en catéter ureteral doble-J que imposibilita su extracción. A propósito de un caso.

We present a case of pyelorenal calcification on double-J ureteral catheter, which made endoscopic extraction impossible. We review the literature and describe the incidence, methods of diagnosis and treatment of this complication, as well as the means used to avoid it.