Outbreak of brainstem encephalitis associated with enterovirus-A71 in Catalonia, Spain (2016): a clinical observational study in a children's reference centre in Catalonia.

OBJECTIVES: To describe the characteristics of an outbreak of brainstem encephalitis and encephalomyelitis related to enterovirus (EV) infection in Catalonia (Spain), a setting in which these manifestations were uncommon. METHODS: Clinical and microbiological data were analysed from patients with neurological symptoms associated with EV detection admitted to a reference paediatric hospital between April and June 2016. RESULTS: Fifty-seven patients were included. Median age was 27.7 months (p25-p75 17.1-37.6). Forty-one (72%) were diagnosed with brainstem encephalitis, seven (12%) with aseptic meningitis, six (11%) with encephalitis, and three (5%) with encephalomyelitis (two out of three with cardiopulmonary failure). Fever, lethargy, and myoclonic jerks were the most common symptoms. Age younger than 12 months, higher white-blood-cell count, and higher procalcitonin levels were associated with cardiopulmonary failure. Using a PAN-EV real-time PCR, EV was detected in faeces and/or nasopharyngeal aspirate in all the patients, but it was found in cerebrospinal fluid only in patients with aseptic meningitis. EV was genotyped in 47 out of 57 and EV-A71 was identified in 40 out of 47, being the only EV type found in patients with brainstem symptoms. Most of the detected EV-A71 strains were subgenogroup C1. Intravenous immunoglobulins were used in 34 patients. Eight cases (14%) were admitted to the intensive care unit. All the patients but three, those with encephalomyelitis, showed a good clinical course and had no significant sequelae. No deaths occurred. CONCLUSIONS: The 2016 outbreak of brainstem encephalitis in Catalonia was associated with EV-A71 subgenogroup C1. Despite the clinical manifestations of serious disease, a favourable outcome was observed in the majority of patients.

Evaluation of the bedside Quikread go® CRP test in the management of febrile infants at the emergency department.

Recently C-reactive protein (CRP) point-of-care tests have been developed. We aimed to validate a bedside CRP test (QuikRead go® CRP), to compare it with the laboratory CRP (ARCHITECT c8000 Abbott, Germany) test in children with fever without source (FWS), and to evaluate the optimal CRP cut-off value to identify those patients at a high risk for serious bacterial infection (SBI). The CRP bedside test was prospectively performed in capillary blood samples concurrently with the laboratory CRP testing for 283 well-appearing infants aged 1 to 24 months with FWS attending the emergency department (ED) between May 2013 and August 2015. The mean difference between the laboratory CRP and the QuikRead go CRP values was 0.71 mg/L (p = 0.444). Pearson's correlation coefficient between the CRPs was r = 0.929 (p < 0.001). SBI was diagnosed in 34 patients (12.0%). The area under the receiver operating characteristics (ROC) curve obtained was 0.87 (95%CI: 0.82-0.90) for an optimal CRP cut-off value of > 10 mg/L (sensitivity: 94.1%, specificity: 49.0%, positive predictive value: 20.1%, negative predictive value: 98.4%), as a predictor of SBI. Nearly 45% of the patients were at a low risk for SBI according to CRP value; thus, additional laboratory tests would have been hypothetically avoided. There was a very strong, positive correlation between the QuikRead go CRP test and laboratory CRP determination. The QuikRead go CRP test provides reliable results to rule out SBI. Its implementation at the ED would improve the management of infants with FWS.

Outcomes and infectious etiologies of febrile neutropenia in non-immunocompromised children who present in an emergency department.

There are no unified protocols governing the management of healthy children with febrile neutropenia in the emergency department (ED). Conservative management is the norm, with admission and empirical broad-spectrum antibiotics prescribed, although viral infections are considered the most frequent etiology. The aim of this study was to describe the clinical outcomes and identified etiologies of unsuspected neutropenia in febrile immunocompetent children assessed in the ED. This was a retrospective study: well-appearing healthy children <18 years old with febrile moderate [absolute neutrophil count (ANC) 500-999 neutrophils ×10(9)/l] or severe (ANC <500 neutrophils ×10(9)/l) neutropenia diagnosed in ED between 2005 and 2013 were included. Patients newly diagnosed with hematologic or oncologic disease were excluded. We included 190 patients: 158 (83.2 %) with moderate and 32(16.8 %) with severe neutropenia. One hundred and one (53.2 %) were admitted; 48(47.5 %) with broad-spectrum antibiotics. The median length of stay was 3 days (IQR 3-5) and the median duration of neutropenia was 6 days (IQR 3-12). An infectious agent was identified in 23(12.1 %); 21 (91.3 %) were viruses. Four (2.1 %) children had a serious bacterial infection (SBI): urinary tract infection and lobar pneumonia (two cases each). All blood cultures performed (144; 75.8 %) were negative. Over the 1-year follow-up, one or several blood tests were performed on 167 patients (87.9 %); two (1.2 %) were diagnosed with autoimmune chronic neutropenia. Previously healthy children with moderate or severe febrile neutropenia have a low risk of SBI and a favorable clinical outcome. Less aggressive management could be carried out in most of them. Although chronic hematological diseases are infrequently diagnosed, serial ANC are necessary to detect them.

Ahogamientos por inmersión no intencional. Análisis de las circunstancias y perfil epidemiológico de las víctimas atendidas en 21 servicios de urgencias españoles / Unintentional drowning by immersion. Epidemiological profile of victims attended in 21 Spanish emergency departments

Objetivos: Conocer la frecuencia de los ahogamientos por inmersión no intencional (AINI) como motivo de consulta en los servicios de urgencias pediátricos. Definir el perfil epidemiológico de las víctimas. Analizar las circunstancias relacionadas con el pronóstico y la supervivencia. Pacientes y métodos: Estudio multicéntrico, prospectivo y descriptivo sobre víctimas de ahogamientos por inmersión no intencional, visitados en 21 servicios de urgencias pediátricos entre junio y septiembre del 2009 y del 2010, respectivamente. Se recogieron datos de filiación, el entorno, la seguridad, la vigilancia, la necesidad de maniobras de reanimación cardiopulmonar (RCP), la tasa de hospitalización, las secuelas y la mortalidad. Resultados: Sobre 234.566 consultas, 53 correspondieron a ahogamientos no intencionales por inmersión (frecuencia: 2,2/10.000 consultas en periodo estival; 64,2% varones). La mediana de edad fue 3,5 años (p25-75: 2,6-8,4), 34 tenían menos de 6 años. Ingresaron 32 niños. La mayoría de los ahogamientos ocurrieron de tarde (40), en agua dulce (49), en piscinas privadas (33) y desprotegidas (33). Las víctimas, principalmente niños sanos (40), no sabían nadar (38) ni llevaban sistema de flotación (37/38). En 42 casos falló la vigilancia. Acidosis (20) e hipoxemia (18) fueron los hallazgos más frecuentes. Murieron 5 niños, 4 eran sanos, ninguno sabía nadar ni llevaban flotador y en todos falló la vigilancia. Requirieron RCP 36 niños, mayormente aplicadas por familiares (15). En los fallecidos, la RCP se inició después de 3min. Dos sobrevivientes presentaron hemiparesia. Conclusiones: Los AINI constituyen un motivo de consulta poco frecuente en los servicios de urgencias. Tener menos de 6 años de edad, no saber nadar, no usar flotadores en piscinas privadas desprotegidas y una vigilancia inadecuada aumentan el riesgo de sufrir un AINI y su morbilidad. Un tiempo de inmersión>10min, inicio de RCP>3min, acidosis, hiponatremia e hipotermia al llegar a urgencias aumentan la mortalidad. Capacitar a familiares en reanimación cardiopulmonar puede resultar útil (AU)

Objectives: To determine the frequency of accidental drowning seen in paediatric emergency departments, to define the epidemiological profile of the victims, and to analyse the circumstances related to prognosis and survival. Patients and methods: A multicentre, prospective and descriptive study was conducted on victims of accidental drowning seen in 21 paediatric emergency departments between June and September 2009 and 2010. We collected personal, environmental, safety, security data, as well as the need for cardiopulmonary resuscitation (CPR), hospitalisation rate, sequelae and mortality. Results: Out of 234,566 emergency department cases, 53 were due to accidental drowning (frequency: 2.2/10,000 consultations during the summer period, 64.2% males). The median age was 3.5 years (p25-75: 2.6-8.4), with 34 had less than 6 years. Thirty-two children were hospitalised. Most drowning occurred in the afternoon (40), in freshwater (49), in private pools (33) and unprotected (33). The victims, mostly healthy children (40), did not know how to swim (38) and were not wearing flotation systems (37/38). There was lack of supervision in 42 cases. Acidosis (20) and hypoxaemia (18) were the most frequent findings. Five children died, 4 were healthy, none knew how to swim or had a float device, and none were supervised. Thirty six children required CPR, mostly applied by family (15). In the children who died, CPR was started after 3min. Two survivors had hemiparesis. Conclusions: Accidental drowning was a rare cause of consultation in paediatric emergency departments. In children less than 6 years, who did not know how to swim, did not use flotation devices in unprotected private pools, and were not properly supervised, there is an increased of suffering from accidental drowning and its associated morbidity. An immersion time> 10min, starting CPR > 3min, acidosis, hyponatraemia, and hypothermia on arrival at the emergency department increases mortality. Training family members in cardiopulmonary resuscitation can be useful (AU)

[Unintentional drowning by immersion. Epidemiological profile of victims attended in 21 Spanish emergency departments]. / Ahogamientos por inmersión no intencional. Análisis de las circunstancias y perfil epidemiológico de las víctimas atendidas en 21 servicios de urgencias españoles.

OBJECTIVES: To determine the frequency of accidental drowning seen in paediatric emergency departments, to define the epidemiological profile of the victims, and to analyse the circumstances related to prognosis and survival. PATIENTS AND METHODS: A multicentre, prospective and descriptive study was conducted on victims of accidental drowning seen in 21 paediatric emergency departments between June and September 2009 and 2010. We collected personal, environmental, safety, security data, as well as the need for cardiopulmonary resuscitation (CPR), hospitalisation rate, sequelae and mortality. RESULTS: Out of 234,566 emergency department cases, 53 were due to accidental drowning (frequency: 2.2/10,000 consultations during the summer period, 64.2% males). The median age was 3.5 years (p25-75: 2.6-8.4), with 34 had less than 6 years. Thirty-two children were hospitalised. Most drowning occurred in the afternoon (40), in freshwater (49), in private pools (33) and unprotected (33). The victims, mostly healthy children (40), did not know how to swim (38) and were not wearing flotation systems (37/38). There was lack of supervision in 42 cases. Acidosis (20) and hypoxaemia (18) were the most frequent findings. Five children died, 4 were healthy, none knew how to swim or had a float device, and none were supervised. Thirty six children required CPR, mostly applied by family (15). In the children who died, CPR was started after 3 min. Two survivors had hemiparesis. CONCLUSIONS: Accidental drowning was a rare cause of consultation in paediatric emergency departments. In children less than 6 years, who did not know how to swim, did not use flotation devices in unprotected private pools, and were not properly supervised, there is an increased of suffering from accidental drowning and its associated morbidity. An immersion time> 10 min, starting CPR > 3 min, acidosis, hyponatraemia, and hypothermia on arrival at the emergency department increases mortality. Training family members in cardiopulmonary resuscitation can be useful.

Comparison of an in-house real-time RT-PCR assay with a commercial assay for detection of enterovirus RNA in clinical samples.

Molecular detection of enterovirus (EV) RNA based on PCR methods is a quicker and more sensitive approach than culture methods. At present, different PCR-based methods for EV RNA detection are available, but comparisons of results obtained according to the different approaches are limited. We evaluated an in-house real-time RT-PCR assay with a commercialized TaqMan real-time RT-PCR kit for detection of EV. Consecutive clinical specimens from paediatric patients less than 6 years old with clinical suspicion of EV infection were analyzed between July and November 2010. After RNA extraction, samples were amplified both by the real-time RT-PCR commercial assay and the in-house assay. A total of 19 of 132 patients (14.4%) involving 20 samples (14 plasma samples and 6 CSF) were positive in at least one of the two assays. The sensitivity of the in-house assay when the MutaPLATE® assay was used as a reference was 90% (IC 95%; 74.35-100) and the specificity was 100% (IC 95%; 99.63-100). Cts results of two methods were statistically correlated (r = 0.774; P = 0.01). In conclusion, these two real-time RT-PCR assays are rapid and easy methods for detection of EV.

Efectividad y seguridad del uso de óxido nitroso para sedoanalgesia en urgencias / Safety and effectiveness of nitrous oxide for sedation-analgesia in emergency departments

Objetivos: Principales: evaluar la seguridad y la efectividad (mediante el análisis de la conducta del paciente) con el uso de óxido nitroso durante la realización de procedimientos dolorosos en los servicios de urgencias pediátricos (SUP); secundarios: evaluar su manejabilidad y su aceptación por el equipo médico y el paciente. Pacientes y métodos: Estudio post-autorización, prospectivo, observacional, multicéntrico, no aleatorizado y abierto (noviembre 2007-diciembre 2008), en el que participaron 7 SUP nacionales. Se incluyó a los pacientes de 2-18 años en los que se utilizó óxido nitroso para la realización de procedimientos dolorosos. Resultados: Se incluyó a 213 pacientes (27,2% < 5 años). La conducta del paciente fue considerada «buena/muy buena» en el 79,7%. El porcentaje de casos con conducta «mala/acepta con dificultad» fue mayor en < 5 años (33,3% vs. 15,1%; p=0,006), no detectándose diferencias significativas en función del procedimiento. Se registraron efectos adversos en 17 casos (7,9%), sin diferencias significativas en función de la edad, estar o no en ayunas ni la asociación de otros fármacos. Los más frecuentes fueron mareo y/o cefalea (10), seguido de vómitos (3). La administración fue considerada fácil por parte del equipo médico en el 96,6%. En el 92,7%, los padres aceptarían que volviera a ser utilizado en su hijo en una situación similar. Conclusiones: La administración de óxido nitroso logra una adecuada sedoanalgesia para la realización de procedimientos dolorosos, sobre todo en niños mayores de 5 años. Los efectos adversos registrados son escasos, leves y conocidos. La mayoría de los padres aceptaría nuevamente su uso en condiciones similares (AU)

Objectives: Primary objectives: to assess the safety and the effectiveness (analysing the behaviour of the patient) with the use of nitrous oxide during the performance of painful procedures in the Paediatric Emergency Departments (PED); secondary objectives: to evaluate the manageability of the method and its acceptance by both the medical team and the patient. Patients and methods: Post-marketing observational, prospective, multicentre, non-randomised and open (November 2007-December 2008) study, which involved seven national PED. We included patients between 2 and 18 years-old on whom a painful procedure was performed in the PED and nitrous oxide was used. Results: A total 213 patients were included (27,2% < 5years). Patient behaviour was considered «good/very good» in 79,7%, with no statistically significant difference in relation to the procedure performed. Patient behaviour was more often classified as «bad/accept with difficulty» among those < 5years (33.3% vs 15.1%, P=0.006). Adverse events occurred in 17 cases (7.9%), with no significant difference in the rate in relation to the age, fasting or not or in association with other drugs; the most frequent were dizziness and/or headache (10), followed by vomiting (3). The administration was considered easy by the medical team in the 96.6% of the cases. Parents would accept the use of nitrous oxide in their child in a similar situation in 92.7% of the cases. Conclusions: Administration of nitrous oxide achieves proper sedation and analgesia during painful procedures, especially in children older than 5years. Adverse events reported were few, mild and expected. Most parents would accept its use again in a similar situation (AU)

Consulta en urgencias de pediatría por intoxicación aguda por drogas de abuso / Drugs of abuse acute intoxication in paediatric emergencies

Los casos documentados demuestran que la intoxicación aguda por drogas de abuso en niños es con frecuencia la primera evidencia clínica de una exposición repetida crónica. Se revisan los casos clínicos publicados de intoxicaciones agudas por drogas de abuso en niños, especialmente aquellos en los cuales se detecta además una exposición crónica por la misma o por otra sustancia. Se revisan las diferentes matrices biológicas y los biomarcadores de exposición que pueden utilizarse en el estudio toxicológico en pediatría. En toxicología, se habla de biomarcadores para referirse a las sustancias madre originales y a sus metabolitos, y de matrices biológicas para referirse a las sustancias procedentes de los organismos en las que se detectan los biomarcadores. En estas matrices se puede detectar la exposición aguda a la sustancia o la exposición crónica durante los días, semanas o incluso meses anteriores. El análisis del pelo ha pasado a considerarse el patrón de oro para la detección de exposición crónica a drogas de abuso por múltiples motivos. Se recomienda la documentación de exposición previa crónica a estas sustancias mediante el estudio del pelo de los niños y de los padres. Ha de realizarse en todos los pacientes pediátricos que acudan al servicio de urgencias con síntomas de intoxicación aguda por drogas ilícitas, en los casos en los que se sospeche abuso de drogas por los padres cuando la historia de consumo sea difícil de obtener y/o en aquellos que provengan de un ambiente de riesgo (AU)

Documented cases show that acute drugs of abuse intoxication in children usually is the Fritz clinical evidence of a chronic exposure. Published clinical reports of drugs of abuse acute poisonings in children are reviewed, above all those with an underlying chronic exposure to the same or another substance. Biological matrices and exposure biomarkers useful in toxicology analysis in Paediatrics are reviewed. In toxicology, biomarkers refer to original parental substances and its metabolites and matrices refer to body substances where biomarkers are detected. In these matrices acute and chronic (previous days, weeks or months) exposures can be detected. Hair analysis has become the gold standard of drugs of abuse chronic exposure. Recomendation includes to confirm previous chronic exposure to drugs of abuse by hair analysis of children and their parents. This protocol must be applied in all cases with suspicion of acute drugs of abuse intoxication, parental consumption and/or children living in a risk environment (AU)

[Safety and effectiveness of nitrous oxide for sedation-analgesia in emergency departments]. / Efectividad y seguridad del uso de óxido nitroso para sedoanalgesia en urgencias.

PRIMARY OBJECTIVES: to assess the safety and the effectiveness (analysing the behaviour of the patient) with the use of nitrous oxide during the performance of painful procedures in the Paediatric Emergency Departments (PED); secondary objectives: to evaluate the manageability of the method and its acceptance by both the medical team and the patient. PATIENTS AND METHODS: Post-marketing observational, prospective, multicentre, non-randomised and open (November 2007-December 2008) study, which involved seven national PED. We included patients between 2 and 18 years-old on whom a painful procedure was performed in the PED and nitrous oxide was used. RESULTS: A total 213 patients were included (27,2% < 5 years). Patient behaviour was considered «good/very good¼ in 79,7%, with no statistically significant difference in relation to the procedure performed. Patient behaviour was more often classified as «bad/accept with difficulty¼ among those < 5 years (33.3% vs 15.1%, P=.006). Adverse events occurred in 17 cases (7.9%), with no significant difference in the rate in relation to the age, fasting or not or in association with other drugs; the most frequent were dizziness and/or headache (10), followed by vomiting (3). The administration was considered easy by the medical team in the 96.6% of the cases. Parents would accept the use of nitrous oxide in their child in a similar situation in 92.7% of the cases. CONCLUSIONS: Administration of nitrous oxide achieves proper sedation and analgesia during painful procedures, especially in children older than 5 years. Adverse events reported were few, mild and expected. Most parents would accept its use again in a similar situation.

[Drugs of abuse acute intoxication in paediatric emergencies]. / Consulta en urgencias de pediatría por intoxicación aguda por drogas de abuso.

Documented cases show that acute drugs of abuse intoxication in children usually is the Fritz clinical evidence of a chronic exposure. Published clinical reports of drugs of abuse acute poisonings in children are reviewed, above all those with an underlying chronic exposure to the same or another substance. Biological matrices and exposure biomarkers useful in toxicology analysis in Paediatrics are reviewed. In toxicology, biomarkers refer to original parental substances and its metabolites and matrices refer to body substances where biomarkers are detected. In these matrices acute and chronic (previous days, weeks or months) exposures can be detected. Hair analysis has become the gold standard of drugs of abuse chronic exposure. Recommendation includes to confirm previous chronic exposure to drugs of abuse by hair analysis of children and their parents. This protocol must be applied in all cases with suspicion of acute drugs of abuse intoxication, parental consumption and/or children living in a risk environment.

[Acute cholestatic hepatitis after atorvastatin reintroduction]. / Hepatitis colestásica aguda tras la reintroducción de atorvastatina.

Consumption of 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMG-CoA) inhibitors, known as statins, has been associated with elevated transaminase levels but rarely with acute hepatitis. Recently, several cases of acute hepatitis secondary to atorvastatin therapy have been published. We report the case of a 72-year-old man who developed acute cholestatic hepatitis after reinitiating treatment with atorvastatin at a higher dose than that previously prescribed. After treatment discontinuation, the patient made a full recovery, with normalization of clinical and laboratory findings.

Hepatitis colestásica aguda tras la reintroducción de atorvastatina / Acute cholestatic hepatitis after atorvastatin reintroduction

El consumo de los inhibidores de la 3-hidroxi-3-metilglutaril-coenzima A (HMG-CoA) reductasa, conocidos como estatinas, se ha asociado a la elevación de transaminasas y, menos frecuentemente, con cuadros de hepatotoxicidad. Recientemente se han comunicado varios casos de toxicidad hepática aguda por atorvastatina. Presentamos el caso de un varón de 72 años que desarrolló una hepatitis colestásica aguda tras la reintroducción de atorvastatina a una dosis superior a la previamente prescrita. La suspensión del fármaco permitió una total recuperación clínica y analítica

Consumption of 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMG-CoA) inhibitors, known as statins, has been associated with elevated transaminase levels but rarely with acute hepatitis. Recently, several cases of acute hepatitis secondary to atorvastatin therapy have been published. We report the case of a 72-year-old man who developed acute cholestatic hepatitis after reinitiating treatment with atorvastatin at a higher dose than that previously prescribed. After treatment discontinuation, the patient made a full recovery, with normalization of clinical and laboratory findings

Hepatitis colestásica aguda tras la reintroducción de atorvastatina / Acute cholestatic hepatitis after atorvastatin reintroduction

El consumo de los inhibidores de la 3-hidroxi-3-metilglutaril-coenzima A (HMG-CoA) reductasa, conocidos como estatinas, se ha asociado a la elevación de transaminasas y, menos frecuentemente, con cuadros de hepatotoxicidad. Recientemente se han comunicado varios casos de toxicidad hepática aguda por atorvastatina. Presentamos el caso de un varón de 72 años que desarrolló una hepatitis colestásica aguda tras la reintroducción de atorvastatina a una dosis superior a la previamente prescrita. La suspensión del fármaco permitió una total recuperación clínica y analítica

Consumption of 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMG-CoA) inhibitors, known as statins, has been associated with elevated transaminase levels but rarely with acute hepatitis. Recently, several cases of acute hepatitis secondary to atorvastatin therapy have been published. We report the case of a 72-year-old man who developed acute cholestatic hepatitis after reinitiating treatment with atorvastatin at a higher dose than that previously prescribed. After treatment discontinuation, the patient made a full recovery, with normalization of clinical and laboratory findings

Bronquiolitis: factores predictivos de la duración del ingreso hospitalario / Predictive factors of duration of hospital admission for bronchiolitis

Objetivo. Determinar qué parámetros son más útiles en el momento del ingreso de niños con bronquiolitis para prever la duración de la estancia hospitalaria. Metodología. Estudio retrospectivo por revisión de historias clínicas. Se incluyen los pacientes ingresados en nuestro centro por bronquiolitis durante el año 1999. Los enfermos se dividen en dos grupos según la duración de la estancia hospitalaria: el grupo I con una estancia de 3 días o menos y el II, con más de 3 días. Se analizan datos clínicos, analíticos y radiológicos según el protocolo realizado para este estudio. Resultados. Se incluyen un total de 271 pacientes, 73 pertenecen al primer grupo y 198 al segundo. Se objetivan diferencias estadísticamente significativas en la duración de la estancia hospitalaria con relación al antecedente de prematuridad, la edad del paciente, la existencia de VRS positivo, la presencia de fiebre, la puntuación en la escala de gravedad para bronquiolitis HSJD, el hallazgo de alteraciones radiológicas, la realización de analítica y la necesidad de tratamiento con antibióticos, oxígeno y alimentación por sonda nasogástrica. No hay diferencias en cuanto al sexo, los antecedentes de cardiopatía o displasia broncopulmonar (DBP), los resultados analíticos y la necesidad de tratamiento con broncodilatadores. La presencia de tres de los siguientes factores de riesgo: prematuridad, VRS positivo, fiebre, radiografía de tórax alterada, edad 6, tiene una sensibilidad del 63.5% y una especificidad del 79.5% como predictor de la duración superior a 72 horas de un ingreso por bronquiolitis. Si se tienen en cuenta sólo dos de los factores, aumenta la sensibilidad hasta el 89.8% en detrimento de la especificidad, que baja al 46.6%. Conclusión. Analizar conjuntamente determinados factores de riesgo en el momento del ingreso de una bronquiolitis mejora las previsiones en cuanto a la duración de la estancia en el hospital y facilita una distribución más adecuada de los recursos disponibles

Objectives. To determine the clinical factors that may help anticipate the length of hospital stay in children with bronchiolitis. Methods. Retrospective study based on the analysis of medical records of all children admitted to St Joan de Deu Hospital (SJDH) with the diagnosis of bronchiolitis in 1999. Patients were divided into two groups according to the duration of the admission. Group I: children who were hospitalized for >= 3 days. Group II: children who were hospitalised for > 3 days. Clinical, laboratory, and radiological data were reviewed. Results. 271 cases (Group I, 73; Group II, 198) were reviewed. We identified a significant relationship between the length of stay and the following parameters: prematurity, age, respiratory syncitial virus (RSV) infection, fever, high score in the SJDH bronchiolitis scale, abnormal imaging, need for laboratory evaluation, administration of antibiotics, need for oxygen supplementation, and need for nasogastric tube feeding. No relationship with duration of admission was found for gender, presence of congenital heart disease, bronchopulmonary dysplasia (BPD), results of laboratory evaluation, and need for bronchodilators. These results indicate a sensitivity of 63.5% and a specificity of 79.5% as predictor of admission > 72 hours if the patient has 3 of the following risk factors: prematurity, RSV infection, fever, radiological abnormalities, age < 2 months, and more than 6 points in the SJDH bronchiolitis score at the time of admission. The presence of two risk factors increases sensitivity to 89.8%, but the specificity decreases to 46.6%. Conclusion. The analysis of risk factors at the time of admission of patients with bronchiolitis may help in anticipating the duration of stay and facilitates the allocation of resources

[Invasive disease caused by Streptococcus pyogenes. Report of a case with cutaneous and kidney metastasis]. / Enfermedad invasiva por Streptococcus pyogenes. A propósito de un caso con metástasis cutáneas y renales.

Few cases of invasive disease due to Streptococcus pyogenes in children have been described. Greater knowledge of this disease is needed due to its increasing incidence and seriousness. New serotypes have been discovered with greater virulence due to exotoxin production and to the development of resistance to phagocytosis. We present a case of invasive disease due to S. pyogenes with bacteremia and cutaneous and kidney metastasis, in a non-immunodeficient child. The case is of interest because kidney dissemination has not been described in the literature and because evolution was satisfactory with endovenous beta-lactamica treatment during 15 days for only 48 hours. The importance of ruling out multi-organ metastatic foci, including use of urine cultures to rule out kidney involvement are highlighted. The epidemiological, pathogenic, clinical and diagnostic aspects of this entity, as reported in recent literature, are described.

Enfermedad invasiva por streptococcus pyogenes. A propósito de un caso con metástasis cutáneas y renales / Invasive disease due to streptococcus pyogenes. Apropos of a case with cutaneous and kidney metastasis

Los casos descritos de enfermedad invasiva por Streptococcus pyogenes (EISP) en el niño son escasos, pero el aumento de incidencia de esta patología, así como de su gravedad, hacen necesario un mejor conocimiento del problema. Se han descubierto nuevos serotipos, con mayor virulencia gracias a la capacidad de producir exotoxinas y al desarrollo de resistencia frente a la fagocitosis. Presentamos un caso de metástasis cutáneas y renales, en un huésped no inmunodeprimido. Resulta de interés, al no estar descrita la diseminación renal en la literatura y la excelente respuesta a la antibioterapia con betalactámicos, pese a mantener tan sólo la antibioterapia intravenosa durante 48 horas, para proseguir con la vía oral hasta un total de 15 días. Destacamos, en los casos de EISP, la importancia de descartar focos metastásicos multiorgánicos, descartando siempre la afectación renal mediante urinocultivo. Describimos los factores epidemiológicos, patógenicos, clínicos, diagnósticos y de tratamiento que conciernen a esta entidad según la literatura más reciente (AU)

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Diagnostic approach to inborn errors of metabolism in an emergency unit.

OBJECTIVES: Our aim was to review the patients with a final diagnosis of inborn error of metabolism (IEM) who had previously required clinical attention at the emergency unit of our hospital over the last 9 years. METHODS: From the 184 patients with IEM, we selected 53 patients who required clinical attention at the EU as a prior step that led to a definitive diagnosis. We analyzed the frequency of the various IEM, their clinical presentations, and basic biochemical abnormalities in decompensation. RESULTS: We detected a predominance of neurologic signs (in 85% of our patients), followed by digestive symptoms (58.5%). Both were associated in 51% of patients. Vomiting and other digestive signs were observed in the same proportion as described in other series, but dehydration was only seen in three of our patients, probably because of early attention and fluid correction. CONCLUSIONS: 1) the diagnosis of an IEM has often been made after the first consultation at the EU, leading to hospitalization; 2) we should suspect an IEM in patients with neurologic abnormalities (eg, developmental delay, hypotonus or feeding difficulties), especially in those patients with multisystem involvement who appear with acute symptoms; 3) it is of the greatest importance that the appropriate sample collection be made before starting any treatment, because abnormal biochemical data can yield a first approach and allow the definitive diagnosis; and 4) the diagnosis of a patient with an IEM is not based on a single clinical or biochemical data but rather on all abnormal features taken together.

[Antibiotic sensitivity of Streptococcus pyogenes in pediatrics]. / Sensibilidad antibiótica de Streptococcus pyogenes en pediatría.

BACKGROUND: The purpose of this study was to set up the current level of Streptococcus pyogenes sensitivity, in pediatric patients in our community, to penicillin, clindamycin, clarithromycin, erythromycin and azithromycin. MATERIAL AND METHODS: 100 strains were collected between October 1996 to July 1997. 79 were pharyngeal and 21 were non-pharyngeal strains. The MICs were obtained by the E-test method, and furthermore the results were compared by the Kirby-Bauer method. RESULTS: All strains were sensitive to penicillin and except one (inducible resistance) to clindamycin. 19% were resistant to macrolide, without differences among clarithromycin, erythromycin and azithromycin. From 13 strains (16.5%) of pharyngeal and 6 (28.5%) from non-pharyngeal samples, 4 of these from cutaneous samples, showed resistance. 18 of the resistance strains belonged to novel resistance fenotip and one to 10 inducible fenotip. Only minor discrepancies about erythromycin and clindamycin were observed between E-test and Kirby-Bauer methods. CONCLUSIONS: This study confirms a remarkable level of resistance to macrolides in pediatric patients, mainly in the cutaneous samples. Due to the reduced prevalence of macrolide-susceptible strains, in vitro susceptibility testing appears necessary in case of macrolide chemotherapy.