Airway opening pressure maneuver to detect airway closure in mechanically ventilated pediatric patients.

Background: Airway closure, which refers to the complete collapse of the airway, has been described under mechanical ventilation during anesthesia and more recently in adult patients with acute respiratory distress syndrome (ARDS). A ventilator maneuver can be used to identify airway closure and measure the pressure required for the airway to reopen, known as the airway opening pressure (AOP). Without that maneuver, AOP is unknown to clinicians. Objective: This study aims to demonstrate the technical adaptation of the adult maneuver for children and illustrate its application in two cases of pediatric ARDS (p-ARDS). Methods: A bench study was performed to adapt the maneuver for 3-50 kg patients. Four maneuvers were performed for each simulated patient, with 1, 2, 3, and 4 s of insufflation time to deliver a tidal volume (Vt) of 6 ml/kg by a continuous flow. Results: Airway closure was simulated, and AOP was visible at 15 cmH2O with a clear inflection point, except for the 3 kg simulated patient. Regarding insufflation time, a 4 s maneuver exhibited a better performance in 30 and 50 kg simulated patients since shorter insufflation times had excessive flowrates (>10 L/min). Below 20 kg, the difference in resistive pressure between a 3 s and a 4 sec maneuver was negligible; therefore, prolonging the maneuver beyond 3 s was not useful. Airway closure was identified in two p-ARDS patients, with the pediatric maneuver being employed in the 28 kg patient. Conclusions: We propose a pediatric AOP maneuver delivering 6 ml/kg of Vt at a continuous low-flow inflation for 3 s for patients weighing up to 20 kg and for 4 s for patients weighing beyond 20 kg.

Cardiovascular adaptation to extrauterine life after intrauterine growth restriction.

Introduction The adaptive changes of the foetal heart in intrauterine growth restriction can persist postnatally. Data regarding its consequences for early circulatory adaptation to extrauterine life are scarce. The aim of this study was to assess cardiac morphometry and function in newborns with late-onset intrauterine growth restriction to test the hypothesis that intrauterine growth restriction causes cardiac shape and functional changes at birth. METHODS: A comprehensive echocardiographic study was performed in 25 neonates with intrauterine growth restriction and 25 adequate-for-gestational-age neonates. RESULTS: Compared with controls, neonates with intrauterine growth restriction had more globular ventricles, lower longitudinal tricuspid annular motion, and higher left stroke volume without differences in the heart rate. Neonates with intrauterine growth restriction also showed subclinical signs of diastolic dysfunction in the tissue Doppler imaging with lower values of early (e') diastolic annular peak velocities in the septal annulus. Finally, the Tei index in the tricuspid annulus was higher in the intrauterine growth restriction group. CONCLUSION: Neonates with history of intrauterine growth restriction showed cardiac remodelling and signs of systolic and diastolic dysfunction. Overall, there was a significant tendency to worse cardiac function results in the right heart. The adaptation to extrauterine life occurred with more globular hearts, higher stroke volumes but a similar heart rate compared to adequate-for-gestational-age neonates.

Entrevista clínica a l'adolescent a urgències. Quan tot sol? / Entrevista clínica al adolescente en urgencias. ¿Desde cuando a solas? / Clinical interview of the adolescent int he emergency department: when alone?

Fonament: durant l'adolescència es passa de ser una per-sona dependent de l'estructura familiar a ser independent, capaç de prendre decisions sobre la salut. Objectiu: valorar la informació que els adolescents són capaços d'aportar per si mateixos en la consulta mèdica iconèixer la preferència en l'acompanyament de la visita. Mètode: estudi prospectiu (1/1/2010 - 31/12/2011) basaten enquestes a adolescents (12-18 anys) que consulten aurgències i que inclouen preguntes dirigides a conèixer laseva autonomia en l'entrevista clínica. També es valora lapreferència de fer la visita mèdica sol o acompanyat. Resultats: s'inclouen 279 adolescents (51,3% dones; edatmitjana 14,5 anys; 22,2% immigrants). En el 93,9% s'objectiva coincidència entre les respostes dels adolescents iles dels seus acompanyants en simptomatologia referida; en el 89,6% en la durada de la clínica i en el 71,7% en eltractament fet prèviament a la consulta. Es considera el78,9% dels adolescents autònoms. El 51,6% prefereixen estar acompanyats durant la visita. No s'observen diferències significatives en autonomia i preferència d'acompanyament segons sexe, edat i origen del pacient. Conclusions: la majoria dels adolescents són capaços derespondre una anamnesi completa i fiable sense el suportd'un adult. La meitat dels adolescents prefereixen estar acompanyats durant la visita mèdica

Fundamento. Durante la adolescencia se pasa de ser una persona dependiente de la estructura familiar a ser independiente, capaz de tomar decisiones sobre la salud. Objetivo. Valorar la información que los adolescentes son capaces de aportar por sí solos en la consulta médica y conocer la preferencia en el acompañamiento de la visita. Método. Estudio prospectivo (1/1/2010 - 31/12/2011) basado en encuestas a adolescentes (12-18 años) que acuden a urgencias y que incluye preguntas dirigidas a conocer su autonomía en la entrevista clínica. También se valora la preferencia de realizar la visita médica solo o acompañado. Resultados. Se incluyen 279 adolescentes (51,3% mujeres; edad media 14,5 años; 22,2% inmigrantes). En el 93,9% se objetiva coincidencia entre sus respuestas y las de su acompañante en sintomatología referida; en el 89,6% en duración de la clínica y en el 71,7% en el tratamiento realizado previamente a la consulta. Se considera al 78,9% de adolescentes autónomos. El 51,6% prefieren estar acompañados durante la visita. No se observan diferencias significativas en autonomía y preferencia de acompañamiento según sexo, edad y origen del paciente. Conclusiones. La mayoría de los adolescentes son capaces de responder una anamnesis completa y fiable sin el apoyo de un adulto. La mitad de los adolescentes prefiere estar acompañado durante la visita médica (AU)

Background. During adolescence, a transition from being dependent on the family structure to becoming independent and being able to make decisions on own health occurs. Objectives. To evaluate the information that adolescents are able to provide for themselves during medical visits and to know their preference in terms of being accompanied during the visit. Method. Prospective study (1/1/2010 - 31/12/2011) based on surveys of adolescents (12-18 years) being seen in an Emergency Department. The study included questions to assess the autonomy of adolescents during the clinical interview as well as their preference on being accompanied by their parents. Results. 270 patients (51.3% women) were included; 22.2% were immigrants, and mean age was 14.5 years. There was agreement between the adolescents and their companions in types of symptoms in 93.9% of the cases, in clinical duration in 89.6%, and in treatment in 71.7% of cases. 78.9% of adolescents were considered to be autonomous, and 51.6% preferred to be accompanied during the visit. No statistically significant differences were found in autonomy and preference of accompaniment according to sex, age, and national origin of the patient. Conclusions. The majority of adolescents are able to provide comprehensive and reliable information during the clinical interview without the participation of an adult. Half of the adolescents prefer to be accompanied during the medical visit (AU)

Pediatric Chagas disease in Europe: 45 cases from Spain and Switzerland.

BACKGROUND: Chagas disease, a potentially fatal parasitic infection, is emerging in Europe in the context of international migration but there is little public health attention and frequent lack of clinicians' awareness. To date, there is no published information about clinical characteristics in children. METHODS: We reviewed the medical files of all children (<18 years) with Chagas disease managed in 2 hospitals in Barcelona, Spain and Geneva, Switzerland between January 2004 and July 2012. RESULTS: Forty-five cases were identified. Two children (4.4%) were diagnosed during the acute phase and the remaining 43 (95.6%) were in the chronic phase of the infection. All but 1 were asymptomatic. Of the 41 treated children, 40 (97.6%) completed 60 days of treatment. Thirty-five (85.4%) received benznidazole, 5 (12.2%) nifurtimox and 1 (2.4%) both drugs consecutively. There were 2 (4.9%) treatment interruptions due to adverse events. The most frequent adverse events were rash (24.4%), anorexia or insufficient weight gain (14.6%) and anemia (2.4%). Twenty-nine (64.4%) children were followed up by serology after 2 years. Five (17.2%) were cured. CONCLUSIONS: Pediatric Chagas disease is an emerging health issue in Europe that requires enhanced attention. Greater emphasis should be put on screening pregnant women at risk and their newborns in case of infection along with older children and relatives. Pediatricians have a central role to play in providing families with information and offering testing in situations of risk.

Combination of vancomycin and rifampicin for the treatment of persistent coagulase-negative staphylococcal bacteremia in preterm neonates.

UNLABELLED: Coagulase-negative staphylococci are the most common cause of late-onset sepsis in premature neonates. The optimal approach in persistent coagulase-negative staphylococcal bacteremia, despite adequate treatment with glycopeptides, is not well established. A retrospective study was conducted on preterm neonates with persistent coagulase-negative staphylococcal bacteremia treated with the combination of vancomycin-rifampicin. Ten cases were included, with a median gestational age of 26 weeks (range 24 weeks + 3 days-31 weeks + 4 days, interquartile range 25 weeks + 3 days-29 weeks + 3 days) and a median birth weight of 715 g (range 555-2,030). The median age at the onset of infection was 9 days (range 5-37). The most frequent clinical presentation was apnea or increased ventilatory support. Bacteremia persisted for a median of 9 (range 6-19) days until rifampicin initiation. Bacteremia was resolved in all cases on vancomycin-rifampicin with no serious side effects. CONCLUSION: Our study provides data supporting the safety and efficacy of vancomycin-rifampicin combination for the treatment of persistent coagulase-negative staphylococcal bacteremia in preterm neonates.