2021 clinical practice guidelines in the evaluation and management of pediatric community-acquired pneumonia

Preface@#The Clinical Practice Guidelines (CPG) for the Diagnosis and Management of Pediatric Community-Acquired Pneumonia (PCAP) was initiated by the Philippine Academy of Pediatric Pulmonologists, Inc. (PAPP) and the Pediatric Infectious Disease Society of the Philippines (PIDSP), in cooperation with Philippine Pediatric Society, Inc. (PPS) way back in 2004. Several CPG updates were then undertaken by the PAPP PCAP CPG Task Force from 2008 to 2016. Clinically-relevant research questions were answered with recent and current recommendations based on evidence from local and international data. The 2021 PCAP CPG initiative was envisioned in March 2018 upon the recommendations of the 2018 PAPP Board for the purpose of updating the evidence in the PCAP CPG 2016 clinical questions. This led to the collaboration of PAPP and PIDSP to develop this CPG. Individual members were identified from each society as content experts to form the Steering Committee along with a clinical epidemiologist and technical writer as review experts. The committee identified the scope and target end user of the CPG as well as additional clinical questions to be included in the 2021 update aside from the questions on the previous CPGs. Selected members from the two societies formed the Technical Working Group (TWG) who did the literature search, appraisal of evidences, and formulation of recommendations. These recommendations were then presented to the stakeholders who became part of the consensus panel. There was no identified conflict of interest among the CPG developers, TWG members and stakeholders. A survey to determine potential competing interests were conducted during the development of this CPG. This initiative was fully funded by the PAPP and PIDSP societies. The 2021 PCAP CPG significantly differs from the previous CPGs in several aspects. First, the current guideline is a consensus between two pediatric societies. Second, much of the literature review has been centered on meta-analyses or systematic reviews instead of individual studies. Finally, appraisal of published literature was based on Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. Such methodological differences may provide difficulties in defining evolution of care through the years. As identified in the previous CPG updates, there is lack of local data hence most of the evidences gathered came from international studies. The applicability of such data to the local setting needs to be critically assessed for its value and relevance. Corollary to this, several gaps in knowledge are identified and these may serve as a guide for future research.

Immunohistochemical Analysis of CD99 and PAX8 in a Series of 15 Molecularly Confirmed Cases of Ewing Sarcoma.

Ewing sarcomas are an uncommon group of malignant neoplasms. A multidisciplinary approach is highly recommended to reach a correct diagnosis, considering the clinical, radiological, and histopathological aspects. Since in up to 90% of cases, the translocation t (11; 22) (q24; q12) occurs resulting in a chimeric fusion transcript EWSR1-FLI-1. The pathologist has several tools in addition to conventional techniques (hematoxylin and eosin), such as immunohistochemistry, which plays a very important role in the differential diagnosis. We present a series of 15 cases of molecularly confirmed ES, in which we found a sensitivity of 100% for CD99 and 80% for PAX8 by immunohistochemistry. This indicates a high sensitivity; however, it is known that both CD99 and PAX8 are also expressed in other tumours. Therefore, molecular confirmation should be performed in all cases.

Epidemiology of painful procedures performed in neonates: A systematic review of observational studies.

BACKGROUND AND OBJECTIVE: Procedural pain in neonates has been a concern in the last two decades. The purpose of this review was to provide a critical appraisal and a synthesis of the published epidemiological studies about procedural pain in neonates admitted to intensive care units. The aims were to determine the frequency of painful procedures and pain management interventions as well as to identify their predictors. DATABASES AND DATA TREATMENT: Academic Search, CINAHL, LILACS, Medic Latina, MEDLINE and SciELO databases were searched for observational studies on procedural pain in neonates admitted to intensive care units. Studies in which neonatal data could not be extracted from the paediatric population were excluded. RESULTS: Eighteen studies were included in the review. Six studies with the same study duration, the first 14 days of the neonate life or admission in the unit of care, identified 6832 to 42,413 invasive procedures, with an average of 7.5-17.3 per neonate per day. The most frequent procedures were heel lance, suctioning, venepuncture and insertion of peripheral venous catheter. Pharmacological and nonpharmacological approaches were inconsistently applied. Predictors of the frequency of procedures and analgesic use included the neonate's clinical condition, day of unit stay, type of procedure, parental presence and pain assessment. The existence of pain protocols was not a predictor of analgesia. CONCLUSIONS: Painful procedures were performed frequently and often with inadequate pain management. Unlike neonate clinical factors, organizational factors may be modified to promote a context of care more favourable to pain management.

Scanning electron microscopy of legs of two species of sucking lice (Anoplura: Phthiraptera).

Pretarsal, tarsal and tibial structures of the forelegs, midlegs and hindlegs of Pediculus humanus of humans and of Haematopinus apri Goureau, 1866 (Phthiraptera), a parasite of feral hogs, were studied using light microscopy and scanning electron microscopy. Details of the tibial thumb-like process (tl) with the spine of the thumb (spn), tarsal apophysis (ta) and the coupled finger-like process (cfl) can be observed in the leg photomicrograph of both species. A frontal view of the leg in open position shows the articulation of the claw: the structures of an open-closed system, a tooth row (te), rack-system (rs) and two telescopic columns (tc) which are present near the base of the claw in both species. In H. apri, we observed a pad-like structure, the flap-like tibial lobe (fl) on the ventral surface on the tarsus, the euplantulae, with several sensilla basiconica, which is present in each leg.

Pseudotumor inflamatorio pleural múltiple / No disponible

El pseudotumor inflamatorio pleural múltiple es una rara entidad,recientemente descrita en la literatura. Es uno de los tumoresbenignos que se manifiestan en niños, y aparecen en tejidos blandosy serosas, como pleura y peritoneo. Su patogénesis no esta bienestablecida. Existen pocas referencias bibliográficas de esta entidad.Los casos publicados, se suelen diagnosticar en gente joven ytienen buen pronóstico. El tratamiento de elección es la cirugía.Presentamos un caso de un paciente de 23 años, que mostraba enuna radiografía de tórax, realizada en el estudio de una lumbalgiacrónica de meses de evolución, una tumoración para vertebralderecha en mediastino posterior (AU)

The calcifying fibrous multiple pleural pseudotumor is a rarelesion, which has been recently incorporated into the medical literature.Is one of the benign tumours which appears in children,soft tissues and serous locations (peritoneal and pleural). Thepathogenesis origin has not been clearly established yet. There arenot many bibliographic references of this type in literature. Thosecases already published, were discovered in young population andhave good prognostic. The treatment to be selected is surgical. Wehere in below present the case of a 23 years old patient, whichshown- in a thorax radiography taken during the study of a cronicalumbalgia after several months of evolution- a right para-vertebraltumoracion in mediastino posterior (AU)

Prevalence of hepatitis A and B markers and vaccine indication in cirrhotic patients evaluated for liver transplantation in Spain.

Vaccination against hepatitis A virus (HAV) and hepatitis B virus (HBV) is generally recommended for patients with chronic liver disease and those evaluated for liver transplantation in the absence of immunity. HAV and HBV infections after liver transplantation are frequent and associated with a worse prognosis. The data suggest that the number of patients with chronic liver disease without naturally acquired immunity against HAV and HBV is substantial, and that new vaccination strategies are needed. The aim of this study was to determine the level of immunity from hepatitis A and B infections and the need for HBV and HAV vaccination among cirrhotic patients evaluated for liver transplantation. We studied HBV and HAV serological markers (HbsAg, anti-HBc, anti-HBs, IgG anti-HAV) in 451 cirrhotic patients evaluated for liver transplantation to investigate the association with gender, age, and etiology of cirrhosis. Negative HBV markers were observed in 57% of patients with 43% displaying one positive HBV marker: HBsAg (+), 9.5%; anti-HBc (+)/anti-HBs (-), 11.5%; anti-HBc (-)/anti-HBs(+), 4.2%; anti-HBc(+)/anti-HBs(+), 17.7%. HBV vaccine indication established in 68.5% of patients was greater among women and hepatitis C virus-negative patients. No differences were observed in age or cause of cirrhosis. HAV vaccination indicated in 6.7% of patients (IgG anti-HVA-negative) was greater among patients with negative HBV markers (9.3% vs 3.3%, P = .018) and younger patients (25.3% of patients

Scanning electron microscopy of foreleg tarsal sense organs of the poultry red mite, Dermanyssus gallinae (DeGeer) (Acari:Dermanyssidae).

Scanning electron microscopy (SEM) studies on the poultry red mite, Dermanyssus gallinae (DeGeer), showed that the tip of the foreleg tarsus of both sexes and early instar stages (larvae, protonymph and deutonymph) bears a cluster of 10 blunt peg-type sensillae. Diversity in size, shape and surface features of the wall of these sensillae characterize the sensilla complex (sensory field). Two short setae (1 and 2) with smooth walls lack detectable pores, whereas three medium-sized setae (4, 5 and 8) bear pores in the wall. Four medium or long setae (3, 6, 7 and 9) have longitudinal grooves or ribs in the wall, whilst one seta (10) possesses both pores and grooves in the wall. Based on the morphology, it is suggested that the porous setae could be olfactory receptors, and the grooved setae could be mechanoreceptors.

Consecuencias del precondicionamiento sobre los efectos de la isquemia intestinal en un modelo experimental en ratas / Consequences of preconditioning on the effects of intestinal ischemia in a rat experimental model

Introducción. El precondicionamiento isquémico se define como el efecto protector frente a la isquemia de larga duración experimentado por un órgano si previamente ha sido sometido a cortos períodos de isquemia. El fenómeno no es bien conocido y su duración y el grado de protección que proporciona varía según el tipo de tejido y modelo experimental utilizado. El objetivo de la presente publicación es estudiar el efecto del precondicionamiento en un modelo de isquemia/reperfusión intestinal en la rata evaluando los valores de superóxido dismutasa (SOD), principal enzima detoxificante, frente a los radicales libres del oxígeno, la lesión histológica y la mortalidad.Material y métodos. Se han utilizado ratas adultas, aleatoriamente asignadas a tres grupos: grupo simulado, grupo control en el que se provocó isquemia intestinal y grupo de estudio en el que, antes de la isquemia, los animales fueron sometidos a precondicionamiento. La isquemia se realizó por pinzamiento de la arteria mesentérica en su origen durante 90 min. El precondicionamiento consistió en 5 min de isquemia seguidos de 10 min de reperfusión previos a la isquemia de 90 min. Estudiamos la supervivencia a las 24 y 72 h, los niveles de SOD en la pared intestinal y los cambios morfológicos de la mucosa intestinal.Resultados. En los animales sometidos a precondicionamiento, se evidencian mayores valores de SOD y un incremento de la supervivencia con respecto a los grupos sin precondicionamiento, tanto a las 24 h (el 84 frente al 73 por ciento) como a las 72 h (el 83 frente al 53 por ciento) aunque estas diferencias no resultan significativas. El estudio histológico objetiva un menor grado de lesión de la pared intestinal en los animales sometidos a precondicionamiento (predominio de lesiones de los grados I y II de Chiu).Conclusiones. La realización de cortos períodos de isquemia intestinal provoca aumento de la resistencia del intestino a isquemias posteriores de mayor duración. Este efecto beneficioso se objetiva por un incremento de la supervivencia y un menor grado de lesión histológica del intestino, y se asocia con valores significativamente más elevados de SOD en la pared intestinal. (AU)

Autotransfusión postoperatoria en cirugía ortopédica. Un análisis de la calidad, seguridad y eficacia de la sangre recuperada de los drenajes postoperatorios / Autotransfusion after orthopedic surgery. Analysis of quality, safety and efficacy of salvaged shed blood

En los procesos quirúrgicos pueden evidenciarse una serie de mecanismos de inmunosupresión, mediados tanto por las células del sistema inmunitario como por factores humorales, a los que se les pueden sumar los efectos inmunosupresores de la anestesia y las transfusiones sanguíneas, que pueden deteriorar aún más el estado inmunológico del paciente, lo que puede tener importantes repercusiones clínicas como aumento de infecciones postoperatorias o de recidivas tumorales.La autotransfusión, en sus distintas modalidades, se presenta como una alternativa eficaz a las transfusiones de sangre homóloga al evitar los efectos inmunosupresores de las mismas. La autotransfusión preoperatoria (donación preoperatoria de sangre autóloga) ha demostrado ser una de las técnicas transfusionales más seguras y eficaces y constituye el "patrón oro" en autotransfusión. Los problemas de sobrecolección, anemización y sobretransfusión que a veces presenta la donación preoperatoria de sangre autóloga pueden solucionarse con una mejor selección de los pacientes.Mediante la autotransfusión intra y postoperatoria se obvian por completo estos problemas. No obstante, la autotransfusión intraoperatoria sólo es coste-efectiva en determinadas intervenciones (hemorragia > 1.000-1.500 ml) y no es aplicable en otras, como la cirugía protésica de rodilla. Por su parte, la autotransfusión postoperatoria, además de ser un buen complemento del resto de técnicas de autotransfusión, en determinadas intervenciones quirúrgicas, como la de prótesis de rodilla, puede ser la técnica de elección, máxime si la donación preoperatoria de sangre autóloga está contraindicada en el paciente o es logísticamente difícil de implantar en el centro.Sin embargo, a pesar de haber demostrado su eficacia, la autotransfusión postoperatoria en forma de sangre filtrada cuenta aún con un gran número de detractores, los cuales advierten sobre una serie de posibles efectos adversos y preconizan el uso de sangre lavada, lo que encarecería enormemente el procedimiento, salvo que se realice con el mismo equipo utilizado para la autotransfusión intraoperatoria durante la intervención. Por ello, en la presente revisión se lleva a cabo un análisis detallado de las características hematológicas de la sangre filtrada, el estado metabólico y la supervivencia de sus hematíes, el contenido en componentes del sistema hemostásico y de mediadores inflamatorios, el contenido de partículas grasas y las posibilidades de eliminación y la incidencia de complicaciones infecciosas y de diseminación de células tumorales. De este análisis se puede llegar a la conclusión de que la sangre total filtrada y no lavada es una fuente de eritrocitos de calidad suficiente para ser reinfundidos sin problemas, y que su reinfusión contribuye significativamente a una reducción de las necesidades de sangre homóloga (AU)

No disponible

Análisis de la relación coste-efectividad de un programa de autotransfusión en cirugía protésica primaria de rodilla y cadera / Analysis of the cost-effectiveness relation is an autotransfusion program in primary prosthetic surgery of the knee and hip

No disponible

Structures of the preantennal region of several species of Damalinia (Phthiraptera: Trichodectidae).

A comparative study was made of the structures of the preantennal region of nine species of Damalinia Mjöberg, 1910 (Phthiraptera: Trichodectidae). Variability in the form of the head, ventral carina, pulvinus, mandibles, and labrum was observed by light and scanning electron microscopy. According to previous studies, the form of the head is possibly influenced by the density and texture of the hair of the host. The ventral carina, which maybe sharp or blunt, and the pulvinus, a membranous lobe, of these parasite species of different hosts, were studied. Photographs of the mandibles and labrum show a high variability according to species.

Participación de los radicales libres del oxígeno en el proceso de cicatrización de las anastomosis cólicas isquémicas / Role of oxygen free radicals in healing of ischemic colonic anastomosis

Introducción. Se estudia la participación de los radicales libres del oxígeno en la cicatrización de las anastomosis cólicas realizadas en condiciones de isquemia. Métodos. Se han utilizado ratas adultas a las que se realizó una anastomosis en colon normal y en colon previamente desvascularizado (anastomosis isquémica).Se han cuantificado las concentraciones de radicales super óxido (medida de los aniones superóxido y de la mieloperoxidasa), las principales enzimas desintoxicantes (superóxido-dismutasa y glutatión-peroxidasa), la producción de colágeno (OH-prolina) y la tensión de rotura. Resultados. En las anastomosis realizadas en condiciones de isquemia se observa una menor síntesis de colágeno y, por consiguiente, su tensión de rotura es significativamente menor. Las concentraciones detectadas de radicales libres de oxígeno (mayores valores de anión superóxido y mayor grado de infiltración leucocitaria) son significativamente más elevadas que en las anastomosis realizadas en condiciones normales. Conclusión. Nuestros resultados demuestran que los radicales libres de oxígeno están aumentados en las anastomosis con deficiente perfusión sanguínea de los extremos anastomosad (AU)

[Pre and post-operative autotransfusion. A comparative study of hematology, biochemistry and red cell metabolism in pre-donated blood and blood from post-operative surgical drainage]. / Autotransfusión pre y postoperatoria. Estudio comparativo de la hematología, bioquímica y metabolismo eritrocitario en sangre predonada y sangre de drenaje postoperatorio.

PURPOSE: The widespread use of aggressive surgical procedures, along with the increasing incidence of traffic accidents, has raised the necessity of homologous blood beyond the supplies of blood banks. This fact, plus the risks of homologous transfusion and the costs of blood bank maintenance, has prompted the advance of blood saving procedures such as autotransfusion, both in the pre-deposit (preoperative autotransfusion, POA) and the surgical drainage reinfusion (postoperative autotransfusion, SDR) modalities. As there is some controversy about the use of one or the other of the above procedures, the purposes of this study were: 1) to analyse the haematological and biochemical characteristics of blood, both pre-donated and stored at 4 degrees C for 4 weeks, and that recovered from surgical drains, from patients subjected to programmed orthopaedic or heart surgery; 2) to assess the metabolic and functional state of red cells attained from that blood, and 3) to compare the results achieved. MATERIAL AND METHODS: The following data were examined: red cell count, haematocrit, haemoglobin, red cell indicates, white cell count, platelet count, free plasma haemoglobin, red cell morphology, glucose, cholesterol, triglycerides, phospholipids, serum proteins and their fractions, ions, histamine, red cell glucose and amino acid transport, and ATP and 2,3-DPG content. RESULTS: The red cells, haemoglobin and haematocrit concentrations in POA blood did not show significant variations during the storage for 4 weeks and their values were significantly higher than found in drained blood. The biochemical values showed heterogeneous variations. Glucose and amino acid uptake by red cells of POA blood slightly decreased in the first 2 weeks of storage but always less than measured in SDR red cells. In POA blood it was noticed a progressive decrease in intra-erythrocytic ATP and 2,3 DPG, those levels being normal in SDR. DISCUSSION: In spite of lower haematocrit and haemoglobin but higher free plasma haemoglobin content, drained blood had higher ATP and 2,3-DPG concentration than pre-deposit, stored blood. Drained blood showed also less ion alterations and probably a lesser immunosuppressor capability. Thus, postoperative blood recovery seems a good source of red cell, with high oxygen transport power, and so, alone or in combination with pre-donated blood, it may contribute to reduce the necessities for homologous blood and decrease its risks.

[Leiomyosarcoma and rhabdomyosarcoma: rare tumors of the kidney]. / Leiomiosarcoma y rabdomiosarcoma: tumores raros del riñón.

Renal sarcoma represents 2.8% of all renal malignant tumours. The most common kind is leiomyosarcoma while rhabdomyosarcoma is the most unusual. Clinical presentation and diagnosis of both types of tumours are unspecific. Treatment is controversial and the overall prognosis poor. The present paper presents two cases, one leiomyosarcoma and one rhabdomyosarcoma which were treated surgically and were followed by chemo- and radiotherapy. A revision of the criteria for grading these as primary tumours of the kidney is also included.

Comparative rearing of Wohlfahrtia magnifica (Diptera: Sarcophagidae) in dead and living tissues and the impact of cold storage on pupal survival.

Larvae from adults of Wohlfahrtia magnifica (Schiner) emerging from pupal cold storage (4 degrees C for 80-100 d) were reared in wound and dead tissues. Of 2,150 first instars placed on a mixture of muscle + liver in a climate-controlled room, 47.1% molted to 2nd instar, 6.1% to 3rd instar, and 4.6% pupated. Two females emerged from these pupae after 14 d. To synchronize adult emergence, 191 pupae that were reared in living or dead tissues and were 2, 8, and 11 d old were cold-stored in lots according to age. Adult emergence was greatest in pupae of 2-d-old (57.1%) and, pupae developing in living and dead tissues, 22.5 and 8.7%, respectively. When the experiment was repeated with cold-stored pupae from 0 to 11 d old, developing in living tissues, the highest emergence was again in 2-d-old pupae (55.0%). These data have important implications for the control of adult emergence which may be used in further biological studies.

In vivo rearing and development of Wohlfahrtia magnifica (Diptera: Sarcophagidae).

Wohlfahrtia magnifica (Schiner, 1862) has a seasonal cycle from May to September. The main objective of the current study is the rearing and development in the laboratory, outside its natural life cycle. The free and obligate parasite phases were reared in the laboratory during 7 mo, from 16 September to 26 March. Between 97.49 and 98.27% of the third instars reached the pupal stage (at 24 degrees C and under natural light cycle). Between 73.98 and 92.24% of the pupae developed into adults (at 70% RH and 22 degrees C). In the induced cycle the ratio of females to males was between 1.87:1.00 and 1.40:1.00, at 70% RH and 24 degrees C. In the trials involving the diapause pupae, 35.29% emerged as adults during a period of 53 d (from 23 January to 20 March), when held at an average storage temperature of 18 degrees C. Eighty-five percent emerged during 2 d (23 and 24 February) when the storage temperature was 4 degrees C.

Superoxide dismutase (SOD) and neutrophil infiltration in intestinal ischaemia-revascularization.

SOD is the main detoxifying enzyme of OFRs which have been mainly purported to participate in ischaemia revascularization lesions. A study was made of the behaviour of SOD during ischaemia and the response to pharmacological doses of SOD in Wistar rats in which ischaemia was induced by 90 min of clamping and followed by revascularization. SOD levels were determined in the intestinal wall, evaluating the degree of infiltration of neutrophils, leucocytes and monocytes by immunohistochemical methods. Ischaemia led to a significant decrease in intestinal wall SOD levels (p = 0.003). The administration of pharmacological doses of SOD was observed to improve survival of the animals (p = 0.001) and significantly decreased the infiltration of leucocytes only during revascularization measured by MPO and LCA. Beneficial effects of SOD could be explained by its effect as scavenger of OFRs and by its action on the neutrophil infiltration.