Risk Factors Associated with Intensive Care Admission in Children with Severe Acute Respiratory Syndrome Coronavirus 2-Related Multisystem Inflammatory Syndrome (MIS-C) in Latin America: A Multicenter Observational Study of the REKAMLATINA Network.

Background: Multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 varies widely in its presentation and severity, with low mortality in high-income countries. In this study in 16 Latin American countries, we sought to characterize patients with MIS-C in the pediatric intensive care unit (PICU) compared with those hospitalized on the general wards and analyze the factors associated with severity, outcomes, and treatment received. Study Design: An observational ambispective cohort study was conducted including children 1 month to 18 years old in 84 hospitals from the REKAMLATINA network from January 2020 to June 2022. Results: A total of 1239 children with MIS-C were included. The median age was 6.5 years (IQR 2.5-10.1). Eighty-four percent (1043/1239) were previously healthy. Forty-eight percent (590/1239) were admitted to the PICU. These patients had more myocardial dysfunction (20% vs 4%; P < 0.01) with no difference in the frequency of coronary abnormalities (P = 0.77) when compared to general ward subjects. Of the children in the PICU, 83.4% (494/589) required vasoactive drugs, and 43.4% (256/589) invasive mechanical ventilation, due to respiratory failure and pneumonia (57% vs 32%; P = 0.01). On multivariate analysis, the factors associated with the need for PICU transfer were age over 6 years (aOR 1.76 95% CI 1.25-2.49), shock (aOR 7.06 95% CI 5.14-9.80), seizures (aOR 2.44 95% CI 1.14-5.36), thrombocytopenia (aOR 2.43 95% CI 1.77-3.34), elevated C-reactive protein (aOR 1.89 95% CI 1.29-2.79), and chest x-ray abnormalities (aOR 2.29 95% CI 1.67-3.13). The overall mortality was 4.8%. Conclusions: Children with MIS-C who have the highest risk of being admitted to a PICU in Latin American countries are those over age six, with shock, seizures, a more robust inflammatory response, and chest x-ray abnormalities. The mortality rate is five times greater when compared with high-income countries, despite a high proportion of patients receiving adequate treatment.

Management and outcomes of bronchiolitis in Italy and Latin America: a multi-center, prospective, observational study.

We aimed to describe differences in the epidemiology, management, and outcomes existing between centers located in countries which differ by geographical location and economic status during to post-pandemic bronchiolitis seasons.  This was a prospective observational cohort study performed in two academic centers in Latin America (LA) and three in Italy. All consecutive children with a clinical diagnosis of bronchiolitis were included, following the same data collection form.  Nine hundred forty-three patients have been enrolled: 275 from the two Latin American Centers (San Jose, 215; Buenos Aires, 60), and 668 from Italy (Rome, 178; Milano, 163; Bologna, 251; Catania, 76). Children in LA had more frequently comorbidities, and only rarely received palivizumab. A higher number of patients in LA had been hospitalized in a ward (64% versus 23.9%, p < 0.001) or in a PICU (16% versus 6.2%, p < 0.001), and children in LA required overall more often respiratory support, from low flow oxygen to invasive mechanical ventilation, except for CPAP which was more used in Italy. There was no significant difference in prescription rates for antibiotics, but a significantly higher number of patients treated with systemic steroids in Italy. CONCLUSIONS: We found significant differences in the care for children with bronchiolitis in Italy and LA. Reasons behind such differences are unclear and would require further investigations to optimize and homogenize practice all over the world. WHAT IS KNOWN: • Bronchiolitis is among the commest cause of morbidity and mortality in infants all over the world. WHAT IS NEW: • There are significant differences on how clinicians care for bronchiolitis in different centers and continents. Differences in care can be principally due to different local practices than differences in patients severity/presentations. • Understanding these differences should be a priority to optime and standardize bronchiolitis care globally.

Initial dysnatremia and clinical outcomes in pediatric traumatic brain injury: a multicenter observational study.

PURPOSE: We aimed to investigate the association between initial dysnatremia (hyponatremia and hypernatremia) and in-hospital mortality, as well as between initial dysnatremia and functional outcomes, among children with traumatic brain injury (TBI). METHOD: We performed a multicenter observational study among 26 pediatric intensive care units from January 2014 to August 2022. We recruited children with TBI under 18 years of age who presented to participating sites within 24 h of injury. We compared demographics and clinical characteristics between children with initial hyponatremia and eu-natremia and between those with initial hypernatremia and eu-natremia. We defined poor functional outcome as a discharge Pediatric Cerebral Performance Category (PCPC) score of moderate, severe disability, coma, and death, or an increase of at least 2 categories from baseline. We performed multivariable logistic regression for mortality and poor PCPC outcome. RESULTS: Among 648 children, 84 (13.0%) and 42 (6.5%) presented with hyponatremia and hypernatremia, respectively. We observed fewer 14-day ventilation-free days between those with initial hyponatremia [7.0 (interquartile range (IQR) = 0.0-11.0)] and initial hypernatremia [0.0 (IQR = 0.0-10.0)], compared to eu-natremia [9.0 (IQR = 4.0-12.0); p = 0.006 and p < 0.001]. We observed fewer 14-day ICU-free days between those with initial hyponatremia [3.0 (IQR = 0.0-9.0)] and initial hypernatremia [0.0 (IQR = 0.0-3.0)], compared to eu-natremia [7.0 (IQR = 0.0-11.0); p = 0.006 and p < 0.001]. After adjusting for age, severity, and sex, presenting hyponatremia was associated with in-hospital mortality [adjusted odds ratio (aOR) = 2.47, 95% confidence interval (CI) = 1.31-4.66, p = 0.005] and poor outcome (aOR = 1.67, 95% CI = 1.01-2.76, p = 0.045). After adjustment, initial hypernatremia was associated with mortality (aOR = 5.91, 95% CI = 2.85-12.25, p < 0.001) and poor outcome (aOR = 3.00, 95% CI = 1.50-5.98, p = 0.002). CONCLUSION: Among children with TBI, presenting dysnatremia was associated with in-hospital mortality and poor functional outcome, particularly hypernatremia. Future research should investigate longitudinal sodium measurements in pediatric TBI and their association with clinical outcomes.

Ectomycorrhizal fungal communities in natural and urban ecosystems: Quercus humboldtii as a study case in the tropical Andes.

Worldwide urban landscapes are expanding because of the growing human population. Urban ecosystems serve as habitats to highly diverse communities. However, studies focusing on the diversity and structure of ectomycorrhizal communities are uncommon in this habitat. In Colombia, Quercus humboldtii Bonpl. is an ectomycorrhizal tree thriving in tropical montane forests hosting a high diversity of ectomycorrhizal fungi. Q. humboldtii is planted as an urban tree in Bogotá (Colombia). We studied how root-associated fungal communities of this tree change between natural and urban areas. Using Illumina sequencing, we amplified the ITS1 region and analyzed the resulting data using both OTUs and Amplicon Sequence Variants (ASVs) bioinformatics pipelines. The results obtained using both pipelines showed no substantial differences between OTUs and ASVs for the community patterns of root-associated fungi, and only differences in species richness were observed. We found no significant differences in the species richness between urban and rural sites based on Fisher's alpha or species-accumulation curves. However, we found significant differences in the community composition of fungi present in the roots of rural and urban trees with rural communities being dominated by Russula and Lactarius and urban communities by Scleroderma, Hydnangium, and Trechispora, suggesting a high impact of urban disturbances on ectomycorrhizal fungal communities. Our results highlight the importance of urban trees as reservoirs of fungal diversity and the potential impact of urban conditions on favoring fungal species adapted to more disturbed ecosystems.

Functional differences between Andean oak (Quercus humboldtii Bonpl.) populations: The importance of intraspecific variation.

Monodominant tree communities can have phenotypic trait variation (intraspecific variation) as extreme as the trait variation across a forest with higher species diversity. An example of such forests is those composed of Quercus, an important genus of woody angiosperms in the montane neotropical forest. The Andean oak, or Quercus humboldtii Bonpl., is the sole member of this genus in South America and a characteristic component of montane ecosystems. Although there are several studies on the ecology and genetic structure of this species, there are few studies on the functional trait diversity among populations. Understanding functional traits can improve our comprehension of how organisms respond to various environmental conditions. In this study, we aimed to evaluate differences in six functional traits in individuals of the Andean oak, in two ontogenetic stages (juveniles and adults) from three populations with contrasting environmental conditions. Additionally, using T-statistics, we assessed the impact of external filters (e.g., climate, resource availability, large-scale biotic interactions) on population assembly. We found a remarkable level of functional differentiation among Andean oak forests, with all traits differing between populations and five traits differing between ontogenetic stages. External filters had a stronger influence in populations with more extreme environmental conditions. These findings emphasize the dynamic and context-dependent nature of functional traits in this species. However, given the limited exploration of functional diversity in Andean oak populations, further studies are needed to inform conservation efforts.

Analysis of guideline recommendations for treatment of asthma exacerbations in children: a Pediatric Emergency Research Networks (PERN) study.

RATIONALE: There is significant practice variation in acute paediatric asthma, particularly severe exacerbations. It is unknown whether this is due to differences in clinical guidelines. OBJECTIVES: To describe and compare the content and quality of clinical guidelines for the management of acute exacerbations of asthma in children between geographic regions. METHODS: Observational study of guidelines for the management of acute paediatric asthma from institutions across a global collaboration of six regional paediatric emergency research networks. MEASUREMENTS AND MAIN RESULTS: 158 guidelines were identified. Half provided recommendations for at least two age groups, and most guidelines provided treatment recommendations according to asthma severity.There were consistent recommendations for the use of inhaled short-acting beta-agonists and systemic corticosteroids. Inhaled anticholinergic therapy was recommended in most guidelines for severe and critical asthma, but there were inconsistent recommendations for its use in mild and moderate exacerbations. Other inhaled therapies such as helium-oxygen mixture (Heliox) and nebulised magnesium were inconsistently recommended for severe and critical illness.Parenteral bronchodilator therapy and epinephrine were mostly reserved for severe and critical asthma, with intravenous magnesium most recommended. There were regional differences in the use of other parenteral bronchodilators, particularly aminophylline.Guideline quality assessment identified high ratings for clarity of presentation, scope and purpose, but low ratings for stakeholder involvement, rigour of development, applicability and editorial independence. CONCLUSIONS: Current guidelines for the management of acute paediatric asthma exacerbations have substantial deficits in important quality domains and provide limited and inconsistent guidance for severe exacerbations.

Prehospital and emergency management of pediatric traumatic brain injury: a multicenter site survey.

OBJECTIVE: There is a paucity of information on pediatric traumatic brain injury (TBI) care in Asia and Latin America. In this study, the authors aimed to describe the clinical practices of emergency departments (EDs) participating in the Saline in Asia and Latin-America Neurotrauma in the Young (SALTY) study, by comparing designated trauma centers (DTCs) and nontrauma centers (NTCs) in their networks. METHODS: The authors performed a site survey study on pediatric TBI management in the EDs in 14 countries. Two European centers joined other participating sites in Asia and Latin America. Questions were formulated after a critical review of current TBI guidelines and published surveys. The authors performed a descriptive analysis and stratified centers based on DTC status. RESULTS: Of 24 responding centers (70.6%), 50.0% were DTCs, 70.8% had academic affiliations, and all centers were in urban settings. Patients were predominantly transferred to DTCs by centralized prehospital services compared to those sent to NTCs (83.3% vs 41.7%, p = 0.035). More NTCs received a majority of their patients directly from the trauma scene compared to DTCs (66.7% vs 25.0%, p = 0.041). Ten centers (41.7%) reported the use of a TBI management guideline, and 15 (62.5%) implemented CT protocols. Ten DTCs reported implementation of intervention strategies for suspected raised intracranial pressure (ICP) before conducting a CT scan, and 6 NTCs also followed this practice (83.3% vs 50.0%, p = 0.083). ED management for children with TBI was comparable between DTCs and NTCs in the following aspects: neuroimaging, airway management, ICP monitoring, fluid resuscitation, anticoagulant therapy, and serum glucose control. Hyperventilation therapy for raised ICP was used by 33.3% of sites. CONCLUSIONS: This study evaluated pediatric TBI management and infrastructure among 24 centers. Limited differences in prehospital care and ED management for pediatric patients with TBI were observed between DTCs and NTCs. Both DTCs and NTCs showed variation in the implementation of current TBI management guidelines. There is an urgent need to investigate specific barriers to guideline implementation in these regions.

Estado actual de recursos generales y funcionamiento de servicios hospitalarios de emergencias pediátricas con gestión pública en Latinoamérica (Estudio Rfsepla) / Current status of general resources and operation of pediatric emergency departments of Latin American public hospitals (Study RFSEPLA)

Introducción. Para mejorar la calidad de atención en los Servicios de Emergencias Pediátricas (SEP), es indispensable realizar mediciones y relevamientos. Objetivo. Describir los recursos y funcionamiento de los SEP de hospitales públicos de Latinoamérica. Métodos. Estudio descriptivo, cuantitativo y retrospectivo. Encuesta realizada en SEP de hospitales latinoamericanos con financiación pública y con Unidad de Cuidados Intensivos Pediátricos (UCIP) (2019). Datos procesados mediante programas REDcap e InfoStat. Se presentan variables continuas como medianas y rangos; variables categóricas, como porcentajes; relaciones de productividad/recursos como razón. Se realizó análisis univariado. Resultados.De 371 servicios en 17 países, 107 (28,8%) contestaron la encuesta. Ciento dos servicios (95,3%) tienen sector de observación y 42(39,3%), salas de aislamiento. La mediana de consultas anuales/cama de observación fue 4830,6; la mediana de consultas diarias/consultorio 24,4. 6,1% de las consultas requirieron internación y 2,0% fueron asistidas en el Sector de Reanimación. Treinta y siete SEP (34,6%) disponen de > 80% de 27 ítems considerados imprescindibles por la Federación Internacional de Emergencias; 43 SEP (40,2%) carecen de equipo completo de vía aérea.En 74 servicios (69,2%) se realiza triaje. La mediana de consultas diarias es de 38,4/médico y 35,3/enfermero.En 83(77,6%) centros se manejan datos informatizados. En 68 SEP (64,1%) se utilizan cinco protocolos de situaciones críticas. En 10(9,4%) el personal médico cuenta con horario de docencia/investigación. Existe plan de mejora de calidad en 43 (41%) servicios. Conclusión. La información obtenida sobre los recursos y funcionamiento de los SEP públicos en Latinoamérica revela brechas importantes.

Introduction: To improve the quality of care in Pediatric Emergency Services (SEP) it is essential to carry out measurements and surveys. Purpose: Describe the resources and operation of the SEPs of public hospitals in Latin America. Methods: Descriptive, quantitative and retrospective study. Survey conducted in SEP of Latin American hospitals with public funding and with PICU (2019). Data processed by REDcap and InfoStat programs. Continuous variables are presented as medians and ranges; categorical variables as percentages; productivity / resource ratios as a ratio. Univariate analysis was performed. Results: Of 371 services in 17 countries, 107 (28.8%) answered the survey; 102 (95.3%) have an observation area and 42 (39.3%) have isolation rooms. The medians of annual visits / observation bed and daily visits / clinic were 4830.6 and 24.4, respectively. The number of beds increased by 74.1% in the seasonal peak, 6.1% of the consultations required hospitalization and 2.0% were assisted in the Resuscitation Sector. 37 (34.6%) SEP have> 80% of 27 items considered essential by the International Emergency Federation, 43 (40.2%) lack complete airway equipment and 74 (69.2%) perform triage. The median number of daily consultations is 38.4 / doctor and 35.3 / nurse. In 72 (67.9%) SEP there is a doctor and a nurse coordinator per shift, in 83 (77.6%) computerized data are handled, in 25 (23.4%) they do not perform diagnostic coding and in 16 (15% ) discharge summary is not prepared. 68 (64.1%) SEP use 5 protocols for critical situations, in 10 (9.4%) the medical personnel have teaching / research hours and in 43 (41%) there is a quality improvement plan. Conclusions:The information obtained regarding resources and operation of public PEDs in Latin America reveals important gaps.

Tendencias en las consultas a los servicios de emergencias durante la pandemia por covid-19 / Trends in emergency department admissions during the COVID-19 pandemic

Resumen Objetivo: En Costa Rica se observó una disminución en las atenciones en los Servicios de Emergencias al inicio de la pandemia por lo que el objetivo de este estudio es la descripción de este fenómeno, su duración, así como implicaciones en nuestro país. Métodos: Es un estudio descriptivo observacional retrospectivo de las atenciones en los Servicios de Emergencias de los Hospitales pertenecientes a la Caja Costarricense del Seguro Social durante el 1 de enero al 31 de diciembre del 2020. Resultados: Se incluyeron 25 Servicios de Emergencias. Las atenciones durante el periodo de estudio fueron de 1.549.024 millones de visitas y la cantidad de revaloraciones a 4,038,029. El rango de atenciones en los diferentes SEM tuvo un rango de 19070 mil a 122251 mil durante el periodo del estudio. Se observó que 850 707 (54,9%) eran del sexo femenino. La mayor cantidad de pacientes atendidos en los SEM tenían edades entre los 20 a 44 años con 693 379 (44.7%) atenciones, seguido del grupo entre los 45 a 64 años con 328 979 (21.2%). Lo que respecta a la clasificación de la agudeza de los pacientes por medio del sistema de triaje canadiense, un 40% (620 449) fueron catalogados como categoría 3, un 39.8%(616 855) categoría 4, 14%(218 124), 5.3%(82 360) categoría 2 y por último 0.6%(9206) pacientes como categoría 1. Respeto a pacientes con el diagnóstico asociado a SARS CoV-2 se observó que 88 793 en los Servicios de Emergencias tuvieron dichos diagnósticos durante el periodo del estudio. Conclusiones: La tendencia a la baja en las consultas al Servicio de Emergencias en Costa Rica, reproduce las tendencias reportadas en la bibliografía a nivel mundial. La explicación para este fenómeno es multifactorial. Existen una gran cantidad de cambios "estructurales" tanto en los servicios de emergencias como en hospitalización y el sistema de salud en general, que con mucha probabilidad deberán cambiarse de manera definitiva y prioritaria. No solo para la atención de esta pandemia sino con miras a que dichos sistemas se encuentren mejor preparados para próximos eventos infecciosos de cualquier tipo.

Abstract Aim: In Costa Rica, a decrease in the admissions in the emergency departments were observed at the beginning of the pandemic and the objective of this study was to describe this phenomenon, its duration, as well as its implications in our country. Methods: It is a retrospective descriptive observational study of the admissions in the Emergency Departments of the Hospitals belonging to the Costa Rican Social Security from January 1 to December 31, 2020. Results: 25 emergency departments were included. Admissions during the study period was 1,549,024 million visits and the number of re-evaluations to 4,038,029. The range of visits in the different emergency departments were from 19,070,000 to 122,251,000 during the study period. It was observed that 850 707 (54.9%) were female. The lar- gest number of patients treated in the emergency departments were aged between 20 to 44 years with 693,379 (44.7%) visits, followed by the group between 45 to 64 years with 328,979 (21.2%). The acuity of the patients using the Canadian triage system were classified 40% (620,449) as category 3, 39.8% (616,855) as category 4, 14% (218,124), 5.3% (82,360) as category 2 and finally 0.6% (9,206) patients as category 1. In regards of patients with the diagnosis associated with SARS CoV-2, it was observed that 88,793 were seen in the emergency departments with such diagnoses during the study period. Conclusions: The downward trend in consultations to the emergency departments in Costa Rica reproduces the trends reported in the literature worldwide. The explanation for this phenomenon is multifactorial. There are many "structural" changes both in the emergency departments and in hospitalization and the Health System in general, which will most likely have to be changed definitively and as a priority. Not only for the attention of this Pandemic but with a view to future infectious events of any kind.

Epidemiología, manifestaciones clínicas y microbiología de los pacientes con fascitis necrosante en el Hospital Nacional de Niños de Costa Rica / Epidemiology, clinical manifestations and microbiology of children with necrotizing fasciitis in a Costa Rican pediatric hospital

Resumen Introducción: A pesar de la morbilidad significativa asociada a la fascitis necrosante (FN), hay pocas publicaciones al respecto y esta es la serie pediátrica más grande proveniente de Latinoamérica. Objetivo: Describir la epidemiología, características clínicas y microbiología de la FN en niños costarricenses. Pacientes y Métodos: Revisión de registros clínicos y anatomo-patológicos, período abril de 2002 a abril de 2014 en pacientes bajo 13 años de edad. Resultados: Cumplían requisito de inclusión 19/22 pacientes, 12 tenían co-morbilidad: 26% con antecedente de cirugía reciente y 21% eran neonatos. Etiología se documentó en hemocultivos en 26% y mediante cultivo de tejidos en 63% (un tercio de ellos polimicrobianos). Pseudomonas aeruginosa, Escherichia coli y Staphylococcus aureus fueron los agentes etiológicos más comúnmente hallados. La tasa de fatalidad fue de 42%, una de las más altas de la región. Conclusiones: La FN es una patología grave, inusual, asociada frecuentemente a neonatología y pacientes post-quirúrgicos, con etiología mixta que requiere de asociación de antimicrobianos y cirugía precoz. Su letalidad es elevada en nuestro medio, por sobre series previamente publicadas.

Abstract Background: Despite the significant associated morbidity of necrotizing fasciitis (NF), few studies have been published and this is the larger pediatric series in Latin America. Aim: To describe the epidemiology, clinical characteristics and microbiology of NF in Costa Rican children. Methods: Review of clinical and pathological records, period April 2002 to April 2014, in patients under 13 years of age. Results: 19/22 patients met the inclusion requirement, 12 had co-morbidity: 26% with a history of recent surgery and 21% were neonates. Etiology was documented in blood cultures in 26% and by tissue culture in 63% (one third of them polymicrobial). Pseudomonas aeruginosa, Escherichia coli and Staphylococcus aureus were the three most common etiologic agents. Case fatality rate was 42%, one of the highest in our region. Conclusion: NF is a serious, unusual pathology, frequently associated with neonatology and post-surgical patients, with a mixed etiology that requires the association of antimicrobials and early surgery. Its lethality is high in our setting, over previously published series.

Consenso de Recomendaciones Para El Traslado Interhospitalario de pacientes sospechosos/confirmados con COVID-19: Grupo de trabajo de Transporte De La Sociedad Latinoamericana de Emergencias Pediátricas (SLEPE)

RESUMEN El transporte del paciente pediátrico en estado crítico en tiempos de COVID 19 representa un desafío, especialmente en un entorno de recursos limitados. Es posible que los hospitales regionales en muchas partes del mundo no estén completamente equipados para tratar a niños con necesidades médicas complejas y en casos de infección por coronavirus. En muchos casos, los equipos de transporte deben tomar decisiones complejas durante todo el proceso, desde la llamada inicial al hospital receptor y la atención del paciente. Los niños en un entorno de recursos limitados tienen un mayor riesgo de eventos adversos y deterioro clínico. El objetivo de este documento es estandarizar aspectos relacionados con el transporte de pacientes sospechosos / confirmados de COVID-19, a fin de reducir el riesgo de transmisión durante el proceso, proteger al personal de salud, evitar el deterioro fisiológico de los pacientes durante el transporte y el posterior contagio de otros pacientes que puedan ser trasladados en la ambulancia.

ABSTRACT Transporting the critically ill pediatric patient in times of COVID 19 is challenging, especially in a resource-limited setting. Regional hospitals in many parts of the world may not be fully equipped to treat children with complex medical needs and coronavirus infection. In many cases, transportation teams must make complex decisions throughout the care process, from the initial call at the receiving hospital to all aspects of caring for the patient. Children in a resource-limited setting are at increased risk for adverse events and clinical decline. The purpose of this document is to standardize aspects related to the transport of suspected / confirmed COVID-19 patients, in order to reduce transmission risk during the process, protect health-care personnel, avoid clinical deterioration of patients during transport and prevent subsequent virus transmission to other patients who may later be transferred in the same ambulance.