Management of Acute Appendicitis in Children in a University Hospital.

OBJECTIVE: Little is known about the positive predictive value of diagnostic tools for severe acute appendicitis (AA). Our objective was to study a retrospective cohort of patients with AA, emphasizing its laboratory and radiologic features, to establish risk factors for more severe cases of AA. METHODS: A retrospective cohort study with patients with AA confirmed by biopsy was performed. In each case, examinations were reviewed, data were compared, and laboratory and radiologic findings were established to identify risk factors for severe AA. RESULTS: During the studied period, 405 children, with a mean age of 120 months, were evaluated. Most of the patients were boys (63.2%). C-reactive protein was the best parameter for the diagnosis of perforated AA, with a sensitivity of 88% for values above 173 mg/dL. A total of 64.4% of the patients underwent abdominal ultrasound, and 26% had normal results. CONCLUSIONS: Acute appendicitis is a disease with a wide spectrum of complications; thus, it is important to recognize the markers associated with severe cases of AA. High levels of C-reactive protein were the best markers associated with perforated appendicitis, and ultrasound was requested in most of the cases but was not helpful in most of them.

Comment on Tsai, Y.-C., et al. Association of Stress-Induced Hyperglycemia and Diabetic Hyperglycemia with Mortality in Patients with Traumatic Brain Injury: Analysis of a Propensity Score-Matched Population. Int. J. Environ. Res. Public Health 2020, 17, 4266.

I read carefully the great study published by Tsai, Y [...].

Propofol use in newborns and children: is it safe? A systematic review / Utilização do propofol em recém-nascidos e crianças: é segura? Uma revisão sistemática

Abstract Objectives: To determine the main indications and assess the most common adverse events with the administration of hypnotic propofol in most pediatric clinical scenarios. Sources: A systematic review of PubMed, SciELO, Cochrane, and EMBASE was performed, using filters such as a maximum of five years post-publication, and/or references or articles of importance, with emphasis on clinical trials using propofol. All articles of major relevance were blind-reviewed by both authors according to the PRISMA statement, looking for possible bias and limitations or the quality of the articles. Summary of the findings: Through the search criterion applied, 417 articles were found, and their abstracts evaluated. A total of 69 papers were thoroughly studied. Articles about propofol use in children are increasing, including in neonates, with the majority being cohort studies and clinical trials in two main scenarios: upper digestive endoscopy and magnetic resonance imaging. A huge list of adverse events has been published, but most articles considered them of low risk. Conclusions: Propofol is a hypnotic drug with a safe profile of efficacy and adverse events. Indeed, when administered by non-anesthesiologists, quick access to emergency care must be provided, especially in airway events. The use of propofol in other scenarios must be better studied, aiming to reduce the limitations of its administration by general pediatricians.

Resumo Objetivos: Determinar as principais indicações e examinar os eventos adversos mais comuns com uso do hipnótico propofol na maioria dos cenários clínicos pediátricos. Fontes: Realizada revisão sistemática da literatura nas bases de dados PubMed, Scielo, Cochrane e EMBASE, aplicando-se filtros como máximo de cinco anos de publicação e/ou referências ou publicações relevantes em outras hipóteses com enfoque em ensaios clínicos envolvendo o propofol. Todos os artigos de maior relevância foram avaliados cegamente pelos dois autores, de acordo com o PRISMA Statement, observando os riscos de vieses e qualidades ou limitações dos estudos. Resumo dos achados: Através dos mecanismos de pesquisa, 417 artigos foram encontrados e separados logo após, de acordo com os critérios de inclusão. Um total de 69 artigos foram estudados. Destacam-se a produção científica crescente sobre o propofol em crianças, incluindo recém-nascidos, sendo a grande maioria dos trabalhos coortes retrospectivos ou prospectivos, bem como ensaios clínicos com o propofol nos principais cenários: endoscopia digestiva alta e ressonância magnética. Ampla gama de eventos adversos foi citada, mas a maioria dos trabalhos não as consideraram significativas. Conclusões: O propofol apresenta um seguro perfil de eficácia e segurança. Quando administrado por médicos não anestesistas, deve-se redobrar o cuidado para ação rápida em emergências, especialmente de vias aéreas. A aplicação do fármaco em outros contextos deve ser estudada em maior profundidade, a fim de dirimir a dificuldade do uso por pediatras.

Manejo atual da bacteremia oculta do lactente / Current management of occult bacteremia in infants

Resumo Objetivos: Listar as principais entidades clínicas associadas a quadros de febre sem sinais localizatórios (FSSL) em lactentes, bem como o manejo dos casos de bacteremia oculta com ênfase na avaliação laboratorial e na antibioticoterapia empírica. Fonte dos dados: Foi feita revisão não sistemática da literatura nas bases de dados PubMed, Embase e Scielo de 2006 a 2015. Síntese dos dados: A ocorrência de bacteremia oculta vem diminuindo sensivelmente em lactentes com FSSL, principalmente devido à introdução da vacinação conjugada contra Streptococcus pneumoniae e Neisseria meningitidis nos últimos anos. Juntamente disso, uma redução constante na solicitação de hemogramas e hemoculturas em lactentes febris acima de três meses vem sendo observada. A infecção do trato urinário é a infecção bacteriana mais prevalente no paciente febril. Algoritmos consagrados, como o de Boston e Rochester, podem guiar a decisão clínica inicial para estimar o risco de bacteremia em lactentes entre um e três meses de vida. Conclusões: Não há esquema padronizado para a estimativa do risco de bacteremia oculta em lactentes febris, porém deve-se considerar fortemente o manejo ambulatorial de lactentes acima de três meses com FSSL em bom estado geral e com esquema vacinal completo. São necessários dados atualizados sobre a incidência de bacteremia oculta em crianças vacinadas em nosso meio.

Abstract Objectives: To summarize the main clinical entities associated with fever without source (FWS) in infants, as well as the clinical management of children with occult bacteremia, emphasizing laboratory tests and empirical antibiotics. Sources: A non-systematic review was conducted in the following databases–PubMed, EMBASE, and SciELO, between 2006 and 2015. Summary of the findings: The prevalence of occult bacteremia has been decreasing dramatically in the past few years, due to conjugated vaccination against Streptococcus pneumoniae and Neisseria meningitidis. Additionally, fewer requests for complete blood count and blood cultures have been made for children older than 3 months presenting with FWS. Urinary tract infection is the most prevalent bacterial infection in children with FWS. Some known algorithms, such as Boston and Rochester, can guide the initial risk stratification for occult bacteremia in febrile infants younger than 3 months. Conclusions: There is no single algorithm to estimate the risk of occult bacteremia in febrile infants, but pediatricians should strongly consider outpatient management in fully vaccinated infants older than 3 months with FWS and good general status. Updated data about the incidence of occult bacteremia in this environment after conjugated vaccination are needed.

Current management of occult bacteremia in infants.

OBJECTIVES: To summarize the main clinical entities associated with fever without source (FWS) in infants, as well as the clinical management of children with occult bacteremia, emphasizing laboratory tests and empirical antibiotics. SOURCES: A non-systematic review was conducted in the following databases--PubMed, EMBASE, and SciELO, between 2006 and 2015. SUMMARY OF THE FINDINGS: The prevalence of occult bacteremia has been decreasing dramatically in the past few years, due to conjugated vaccination against Streptococcus pneumoniae and Neisseria meningitidis. Additionally, fewer requests for complete blood count and blood cultures have been made for children older than 3 months presenting with FWS. Urinary tract infection is the most prevalent bacterial infection in children with FWS. Some known algorithms, such as Boston and Rochester, can guide the initial risk stratification for occult bacteremia in febrile infants younger than 3 months. CONCLUSIONS: There is no single algorithm to estimate the risk of occult bacteremia in febrile infants, but pediatricians should strongly consider outpatient management in fully vaccinated infants older than 3 months with FWS and good general status. Updated data about the incidence of occult bacteremia in this environment after conjugated vaccination are needed.

Estado nutricional, autopercepção do estado nutricional e experimentação de drogas lícitas em adolescentes / Nutritional status, nutritional self-perception, and use of licit drugs in adolescents

Objetivo:Associar o estado nutricional e a autopercepção do estado nutricional com a experimentação de drogas lícitas em adolescentes.Métodos:Estudo transversal no qual 210 adolescentes responderam a um questionário sobre experimentação de álcool e tabaco e sobre suas autopercepções nutricionais. Foi analisada a concordância entre autopercepção nutricional do adolescente e seu estado nutricional, bem como associações entre o estado nutricional, a autopercepção nutricional, sexo, idade e presença de tabagistas em casa com a experimentação de álcool e tabaco. As variáveis foram analisadas separadamente em análise bivariada e, a seguir, análise múltipla determinou fatores associados à experimentação.Resultados:Participaram do estudo 210 adolescentes com mediana de idade de 148 meses, 56,6% do sexo feminino. Do total da amostra, 6,6% já experimentaram cigarro e 20% já experimentaram álcool; 32,3% tinham Z-escore IMC≥1 e 12,85% tinham Z-escore IMC≥2 e 50,7% acertaram suas classificações nutricionais. Após análise multivariada, apenas a autoimagem sobre o peso influenciou estatisticamente na experimentação de fumo. Pacientes que se identificavam com peso muito alto apresentaram maior chance de experimentação de fumo (odds ratio (OR) 13,57; intervalo de confiança (95% IC) 2,05-89,8; p=0,007); em relação ao uso de álcool, adolescentes que se identificavam com peso alto apresentaram chance de uso de álcool 2,40 vezes maior do que crianças que se viam com peso normal (IC 95% 1,08-5,32; p=0,031).Conclusões:Adolescentes com autopercepção de excesso de peso podem constituir um grupo de risco para a experimentação de álcool e tabaco.

Objective:To associate the nutritional status and the self-perception of nutritional status with the use of licit drugs among adolescents.Methods:A cross-sectional study was conducted in which 210 adolescents answered a questionnaire on alcohol and tobacco experimentation and self-perceptions about their nutritional status. The correspondence between the adolescents' perception of their own nutritional status and actual nutritional status was analyzed, as well as associations between nutritional status, self-perception of nutritional status, gender, age, and presence of smokers at home with alcohol and tobacco use. The variables were analyzed separately in a bivariate analysis and, subsequently, a multivariate analysis determined the factors associated with drug use.Results:The study included 210 adolescents with a median age of 148 months; 56.6% were females. Of the total sample, 6.6% have tried cigarettes, and 20% have tried alcohol; 32.3% had BMI Z-Score ≥1, 12.85% had BMI Z-Score ≥2, and 50.7% had a correct perception of his/her weight. After a multivariate analysis, only the self-perception about weight statistically influenced experimentation of tobacco, and patients who identified themselves as having very high weight were more likely to experiment tobacco (odds ratio (OR) 13.57; confidence interval (95% CI) 2.05-89.8; p=0.007); regarding alcohol use, adolescents who identified themselves as having high weight were 2.4 times more likely to experiment with alcohol than adolescents that identified themselves as having normal weight (95% CI 1.08-5.32, p=0.031).Conclusions:Adolescents with self-perception of excess weight may constitute a risk group for alcohol and tobacco use.

Intranasal dexmedetomidine for sedation for pediatric computed tomography imaging.

UNLABELLED: This prospective observational pilot study evaluated the aerosolized intranasal route for dexmedetomidine as a safe, effective, and efficient option for infant and pediatric sedation for computed tomography imaging. The mean time to sedation was 13.4 minutes, with excellent image quality, no failed sedations, or significant adverse events. TRIAL REGISTRATION: Registered with ClinicalTrials.gov: NCT01900405.

[Nutritional status, nutritional self-perception, and use of licit drugs in adolescents]. / Estado nutricional, autopercepção do estado nutricional e experimentação de drogas lícitas em adolescentes.

OBJECTIVE: To associate the nutritional status and the self-perception of nutritional status with the use of licit drugs among adolescents. METHODS: Cross-sectional study in which 210 adolescents answered a questionnaire on alcohol and tobacco experimentation and self-perceptions about their nutritional status. The correspondence between the adolescents' perception of their own nutritional status and actual nutritional status was analyzed, as well as associations between nutritional status, self-perception of nutritional status, gender, age, and presence of smokers at home with alcohol and tobacco use. The variables were analyzed separately in a bivariate analysis and, subsequently, a multivariate analysis determined the factors associated with drug use. RESULTS: The study included 210 adolescents with a median age of 148 months; 56.6% were females. Of the total sample, 6.6% have tried cigarettes, and 20% have tried alcohol; 32.3% had BMI Z-Score≥1, 12.85% had BMI Z-Score≥2, and 50.7% had a correct perception of his/her weight. After a multivariate analysis, only the self-perception about weight statistically influenced experimentation of tobacco, and patients who identified themselves as having very high weight were more likely to experiment tobacco (odds ratio (OR) 13.57; confidence interval (95% CI) 2.05-89.8; p=0.007); regarding alcohol use, adolescents who identified themselves as having high weight were 2.4 times more likely to experiment with alcohol than adolescents that identified themselves as having normal weight (95% CI 1.08-5.32, p=0.031). CONCLUSIONS: Adolescents with self-perception of excess weight may constitute a risk group for alcohol and tobacco use.

Cerebrospinal fluid lactate level as a diagnostic biomarker for bacterial meningitis in children.

BACKGROUND: Cerebrospinal fluid (CSF) lactate is a potential biomarker for bacterial meningitis in children. To this end, we performed a single-center retrospective cohort study of children from Sao Paulo, Brazil, with CSF pleocytosis to evaluate the ability of CSF lactate to distinguish between children with bacterial and aseptic meningitis. We determined the optimum cutoff point for CSF lactate using receiver-operator curve (ROC) analysis. FINDINGS: We identified 451 children of whom 40 (9%) had bacterial meningitis. Children with bacterial meningitis had a higher median CSF lactate level [9.6 mmol/l, interquartile range (IQR) 3.2-38.5 mmol/l bacterial meningitis vs. 2.0 mmol/l, IQR 1.2-2.8 mmol/l aseptic meningitis]. A CSF lactate cutoff point of 3.0 mmol/l had a sensitivity of 95% [95% confidence interval (CI) 83-99%), specificity of 94% (95% CI 90-96%) and negative predictive value of 99.3% (95% CI 97.7-99.9%) for bacterial meningitis. CONCLUSIONS: In combination with a validated meningitis clinical prediction rule, the CSF lactate level can be used to distinguish between bacterial and aseptic meningitis in children with CSF pleocytosis.

The bacterial meningitis score to distinguish bacterial from aseptic meningitis in children from Sao Paulo, Brazil.

In a retrospective cohort of 494 children with meningitis in Sao Paulo, Brazil, the Bacterial Meningitis Score identified all the children with bacterial meningitis (sensitivity 100%, 95% confidence interval: 92-100% and negative predictive value 100%, 95% confidence interval: 98-100%). Addition of cerebrospinal fluid lactate to the score did not improve clinical prediction rule performance.

Aerosolized intranasal midazolam for safe and effective sedation for quality computed tomography imaging in infants and children.

This pilot study introduces the aerosolized route for midazolam as an option for infant and pediatric sedation for computed tomography imaging. This technique produced predictable and effective sedation for quality computed tomography imaging studies with minimal artifact and no significant adverse events.