Clinical presentation of pediatric patients with symptomatic SARS-CoV-2 infection during the first months of the COVID-19 pandemic in a single center in Mexico City.

Background: The clinical spectrum of COVID-19 is broad, from asymptomatic to severe cases and death. The objective of this study is to analyze the clinical course of patients attended during the first months of the SARS-CoV-2 pandemic in a third-level pediatric hospital. Methods: Design: prospective cohort study. Patients with viral respiratory disease or suspected cases of COVID-19 were evaluated at the Pediatric Hospital, National Medical Center XXI Century, Mexico City, from 21 March 2020 to 13 January 2021. Statistical analysis: Chi-square test and Fisher's exact test were used for comparisons; a logistic regression model was constructed to identify clinical or laboratory characteristics associated with critical disease. A p-value < 0.05 was considered statistically significant. Results: A total of 697 patients met the operational definition of viral respiratory disease or suspected cases of COVID-19 and underwent real-time reverse transcription polymerase chain reaction (rRT-PCR) SARS-CoV-2 testing. Patients with a positive result were included. Of the 181 patients (26%), 121 (66.8%) had mild disease and were treated as outpatients and 60 (33.1%) were hospitalized. A total of six patients met the criteria for multisystem inflammatory syndrome in children (MIS-C). Of the 60 inpatients, 65% were males, and 82% had one or more comorbidities. The main comorbidities were cancer (42%) and overweight (15%). The median hospital stay was 9 days. The inpatients had a higher frequency of fever, general malaise, dyspnea, chills, polypnea, and cyanosis than the outpatients (p < 0.05). Only 21.4% of the outpatients had one or more comorbidities, which were lower than in the hospitalized patients (p < 0.001). Laboratory data at admission were similar between critically ill and those with moderate and severe disease. The patients who developed pneumonia were at higher risk of critical disease, while older age was associated with a better prognosis. A total of 13 of the 60 inpatients died (mortality 7.1%). All but one had one or more comorbidities: four had cancer, four congenital heart disease, one chronic kidney disease and epilepsy, one Epstein-Barr virus-induced hemophagocytic lymphohistiocytosis, one obesity, and one diabetes mellitus. Conclusion: Hospital mortality is high, especially in children with comorbidities. Despite 2 years having passed since the beginning of the COVID-19 pandemic, the epidemiological and clinical data on children are still helpful to improve their prognosis.

Guía de práctica clínica para el diagnóstico y el tratamiento de la otitis media aguda en niños.

BACKGROUND: Acute otitis media (AOM) is one of the most prevalent acute conditions in the pediatric population worldwide. This work aimed to elaborate a Clinical Practice Guideline with clinical recommendations systematically developed to assist decision-making of specialists, patients, caregivers, and public policymakers involved in managing patients with AOM in children. METHODS: This document was developed by the College of Pediatric Otorhinolaryngology and Head, and Neck Surgery of Mexico (COPEME) in compliance with international standards. The SIGN quality of evidence classification was used. On behalf of the COPEME, the Guideline Development Group (GDG) was integrated, including otolaryngologists, infectologists, pediatricians, general practitioners, and methodologists with experience in systematic literature reviews and the development of clinical practice guidelines. RESULTS: A consensus was reached on 18 clinical questions, covering what was previously established by the GDG in the scope document of the guidelines. Scientific evidence answering each of these clinical questions was identified and critically evaluated. The GDG agreed on the final wording of the clinical recommendations using the modified Delphi panel technique. Specialists and patient representatives conducted an external validation. CONCLUSIONS: This Clinical Practice Guideline presents clinical recommendations for the prevention, diagnosis, and management of AOM to assist shared decision-making among physicians, patients, and caregivers and improve the quality of clinical care.

INTRODUCCIÓN: La otitis media aguda (OMA) es uno de los padecimientos agudos más prevalentes en la población pediátrica a escala global. El objetivo de este trabajo fue elaborar una guía de práctica clínica con recomendaciones para asistir la toma de decisiones de médicos especialistas, pacientes, cuidadores de pacientes y elaboradores de políticas públicas involucrados en el manejo de la OMA en niños. MÉTODOS: El documento ha sido desarrollado por parte del Colegio de Otorrinolaringología y Cirugía de Cabeza y Cuello Pediátricas de México (COPEME) en cumplimiento con los estándares internacionales. Se empleó la clasificación de calidad de la evidencia de SIGN. En representación del COPEME, se integró el Grupo de Desarrollo de la Guía (GDG), que incluyó otorrinolaringólogos, infectólogos, pediatras, médicos generales y metodólogos con experiencia en revisiones sistemáticas de la literatura y el desarrollo de guías de práctica clínica. RESULTADOS: Se consensuaron 18 preguntas clínicas que abarcaron lo establecido previamente por el GDG en el documento de alcances de la Guía. Se identificó la evidencia científica que responde a cada una de estas preguntas clínicas y se evaluó críticamente. El GDG acordó la redacción final de las recomendaciones clínicas mediante la técnica Delphi de panel. Se llevó a cabo una validación externa por colegas especialistas y representantes de pacientes. CONCLUSIONES: En esta Guía de Práctica Clínica se presentan recomendaciones clínicas para la prevención, el diagnóstico y el manejo de la OMA, con el fin de asistir la toma de decisiones compartidas entre médicos, pacientes y cuidadores con la intención de contribuir a mejorar la calidad de la atención clínica.

Guía de práctica clínica para el diagnóstico y el tratamiento de la otitis media aguda en niños / Clinical practice guidelines for diagnosis and management of acute otitis media in children

Resumen Introducción: La otitis media aguda (OMA) es uno de los padecimientos agudos más prevalentes en la población pediátrica a escala global. El objetivo de este trabajo fue elaborar una guía de práctica clínica con recomendaciones para asistir la toma de decisiones de médicos especialistas, pacientes, cuidadores de pacientes y elaboradores de políticas públicas involucrados en el manejo de la OMA en niños. Métodos: El documento ha sido desarrollado por parte del Colegio de Otorrinolaringología y Cirugía de Cabeza y Cuello Pediátricas de México (COPEME) en cumplimiento con los estándares internacionales. Se empleó la clasificación de calidad de la evidencia de SIGN. En representación del COPEME, se integró el Grupo de Desarrollo de la Guía (GDG), que incluyó otorrinolaringólogos, infectólogos, pediatras, médicos generales y metodólogos con experiencia en revisiones sistemáticas de la literatura y el desarrollo de guías de práctica clínica. Resultados: Se consensuaron 18 preguntas clínicas que abarcaron lo establecido previamente por el GDG en el documento de alcances de la Guía. Se identificó la evidencia científica que responde a cada una de estas preguntas clínicas y se evaluó críticamente. El GDG acordó la redacción final de las recomendaciones clínicas mediante la técnica Delphi de panel. Se llevó a cabo una validación externa por colegas especialistas y representantes de pacientes. Conclusiones: En esta Guía de Práctica Clínica se presentan recomendaciones clínicas para la prevención, el diagnóstico y el manejo de la OMA, con el fin de asistir la toma de decisiones compartidas entre médicos, pacientes y cuidadores con la intención de contribuir a mejorar la calidad de la atención clínica.

Abstract Background: Acute otitis media (AOM) is one of the most prevalent acute conditions in the pediatric population worldwide. This work aimed to elaborate a Clinical Practice Guideline with clinical recommendations systematically developed to assist decision-making of specialists, patients, caregivers, and public policymakers involved in managing patients with AOM in children. Methods: This document was developed by the College of Pediatric Otorhinolaryngology and Head, and Neck Surgery of Mexico (COPEME) in compliance with international standards. The SIGN quality of evidence classification was used. On behalf of the COPEME, the Guideline Development Group (GDG) was integrated, including otolaryngologists, infectologists, pediatricians, general practitioners, and methodologists with experience in systematic literature reviews and the development of clinical practice guidelines. Results: A consensus was reached on 18 clinical questions, covering what was previously established by the GDG in the scope document of the guidelines. Scientific evidence answering each of these clinical questions was identified and critically evaluated. The GDG agreed on the final wording of the clinical recommendations using the modified Delphi panel technique. Specialists and patient representatives conducted an external validation. Conclusions: This Clinical Practice Guideline presents clinical recommendations for the prevention, diagnosis, and management of AOM to assist shared decision-making among physicians, patients, and caregivers and improve the quality of clinical care.

Impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Hand Hygiene Approach During 3 Years in 6 Hospitals in 3 Mexican Cities.

OBJECTIVES: To evaluate the impact of the International Nosocomial Infection Control Consortium (INICC) multidimensional hand hygiene (HH) approach in Mexico, and analyze predictors of poor HH compliance. METHODS: From June 2002 to April 2006, we conducted a prospective, observational, before-and-after study in 8 intensive care units (ICUs) from 6 hospitals in 3 cities of Mexico. The approach included administrative support, availability of supplies, education and training, reminders in the workplace, process surveillance, and performance feedback. RESULTS: A total of 13,201 observations for HH opportunities were done in each ICU, during randomly selected 30-minute periods. Overall, HH compliance increased from 45% to 79% (95% confidence interval [CI], 69.1-86.5; P = 0.01). Univariate and multivariate analyses showed that several variables were significantly associated with poor HH compliance: males versus females (61% versus 66%; 95% CI, 0.91-0.96; P = 0.0001), physicians versus nurses (62% versus 67%; 95% CI, 0.91-0.97; P = 0.0001), and adult versus neonatal ICUs (67% versus 54%; 95% CI, 0.79-0.84; P = 0.0001), among others. CONCLUSIONS: Hand hygiene programs should focus on variables found to be predictors of poor HH compliance.

[The research protocol VI: How to choose the appropriate statistical test. Inferential statistics]. / El protocolo de investigación VI: cómo elegir la prueba estadística adecuada. Estadística inferencial.

The statistical analysis can be divided in two main components: descriptive analysis and inferential analysis. An inference is to elaborate conclusions from the tests performed with the data obtained from a sample of a population. Statistical tests are used in order to establish the probability that a conclusion obtained from a sample is applicable to the population from which it was obtained. However, choosing the appropriate statistical test in general poses a challenge for novice researchers. To choose the statistical test it is necessary to take into account three aspects: the research design, the number of measurements and the scale of measurement of the variables. Statistical tests are divided into two sets, parametric and nonparametric. Parametric tests can only be used if the data show a normal distribution. Choosing the right statistical test will make it easier for readers to understand and apply the results.

El análisis estadístico se divide en 2 grandes componentes: el análisis descriptivo y el análisis inferencial. Una inferencia es la elaboración de conclusiones a partir de las pruebas que se realizan con los datos obtenidos de una muestra. Las pruebas estadísticas se emplean con la finalidad de establecer la probabilidad de que una conclusión que se obtiene a partir de una muestra sea aplicable a la población de la cual se obtuvo. Sin embargo, la elección de la prueba estadística apropiada, en general, representa un reto para los investigadores principiantes. Para elegir la prueba estadística es necesario tomar en cuenta 3 aspectos: el diseño de la investigación, el número de mediciones y la escala de medición de las variables. Las pruebas estadísticas se dividen en 2 conjuntos: las paramétricas y las no paramétricas. Las pruebas paramétricas solamente se pueden utilizar si los datos muestran una distribución normal. La elección de la prueba estadística adecuada facilitará la comprensión y aplicación de los resultados de cualquier estudio de investigación.

Genotype-guided antiretroviral regimens in children with multidrug-resistant HIV-1 infection.

BACKGROUND: Genotyping tests were developed to attenuate the impact of viral resistance. Information about the efficacy in genotype base antiretroviral therapy in children is rare and even more in low- and middle-income countries. METHODS: Sixteen children with antiretroviral therapy (ART) failure and triple-class drug-resistant viruses were included in this study. Protease and retrotranscriptase genotypes were available for all patients. Switch of ART regimen was guided by genotyping data. The primary end point was virological suppression (<50 copies/ml) and immunological improvement after 48 wk of treatment with the new ART regimen. RESULTS: The median age of the patients was 14.5 y (interquartile range (IQR) 11-16.5). Median HIV-1 RNA viral load was 4.2 log10 (IQR: 3.4-4.8). The primary end point was found in 11 children (69%), and 13 children (81%) had an HIV-1 RNA viral load <200 copies/ml. Median (IQR) for the baseline CD4(+) cell count was 382 cells/µl (281-686 cells/µl), whereas after 48 wk of treatment with the new ART regimen, it was 640 cells/µl (361-936 cells/µl) (P < 0.001). CONCLUSION: Darunavir/ritonavir, raltegravir, and etravirine were well tolerated in the present pediatric population. These drugs provide good options for children exposed to extensive ART. Regimens guided by genotyping data were effective for children who had ART failure and multidrug-resistant HIV-1 infection.

[Clinical characteristics of pediatric patients treated for influenza A (H1N1). The 2009 pandemic in Mexico]. / Características de los pacientes pediátricos atendidos por influenza A H1N1. La pandemia de 2009 en México.

BACKGROUND: Pandemic influenza A (H1N1) virus was first reported in April 2009. The aim of this study is to describe the clinical course of patients with influenza-like illness treated in a tertiary care pediatric hospital. METHODS: Cross-sectional analytical study, encompassing the period from April 2009 to March 2010. Clinical and demographic information was obtained from clinical records. Data analysis was carried out using descriptive statistics, using a univariate analysis with the chi-square test, the exact Fisher test, and the Mann-Whitney U test for quantitative variables. RESULTS: 240 patients were included, out of which 53.9 % were female; median age was 5 years. Sixty four cases (26.6 %) were confirmed, 38 % had and underlying condition, and 10 % had received the influenza vaccine. One hundred and sixteen patients (48 %) were hospitalized. With regard to mortality, 10 out of 64 confirmed cases died, 3 of the 86 of the disregarded cases, and 2 of 90 without a confirmatory test died (p < 0.05). The patients who died started antiviral treatment on day 7; conversely, those who survived started the treatment on day 4 (p < 0.05). CONCLUSIONS: Lethality was higher in patients with confirmed infection. Antiviral treatment within the first 48 hours was observed to be essential for patients with risk for the development of complications.

INTRODUCCIÓN: en abril de 2009 se informó por primera vez del virus pandémico de la influenza A H1N1. El objetivo del presente estudio es describir el curso clínico de los pacientes atendidos con enfermedad tipo influenza en un hospital pediátrico de tercer nivel. MÉTODOS: estudio transversal analítico que comprendió el periodo de abril de 2009 a marzo de 2010. La información clínica y demográfica se obtuvo de los expedientes clínicos. El análisis de los datos se llevó a cabo mediante estadística descriptiva e inferencial, para lo cual se aplicó análisis univariado mediante chi cuadrada, prueba exacta de Fisher y U de Mann-Whitney para las variables cuantitativas. RESULTADOS: se incluyeron 240 pacientes, 53.9 % del sexo femenino; la mediana de la edad fue de cinco años. Se confirmaron 64 casos (26.6 %), 38 % tenía enfermedad subyacente y 10 % había sido vacunado contra el virus de la influenza. Fueron hospitalizados 116 pacientes (48 %). Respecto a la mortalidad, 10 casos fallecieron de los 64 confirmados, tres de los 86 casos descartados y dos de los 90 que carecían de prueba confirmatoria (p < 0.05). Los pacientes que fallecieron iniciaron tratamiento antiviral el séptimo día; por su parte, los que no fallecieron iniciaron el tratamiento en el cuarto día (p < 0.05). CONCLUSIONES: la letalidad fue mayor en los pacientes con infección confirmada. Se observó que el tratamiento antiviral en las primeras 48 horas es esencial para los pacientes con riesgo para desarrollar complicaciones.

Frecuencia de infección y enfermedad por citomegalovirus y factores de riesgo para su desarrollo en pacientes pediátricos / Frequency of infection and disease due to cytomegalovirus and risk of development in pediatric kidney transplant patients

Introducción. Como complicaciones asociadas al trasplante, las infecciones representan una de las principales causas de muerte y pérdida del injerto. De ellas, las infecciones virales son la principal causa. El objetivo de este trabajo fue determinar la frecuencia de infección o enfermedad por citomegalovirus (CMV) y sus características clínicas en una cohorte de pacientes pediátricos con trasplante renal, así como los factores de riesgo asociados a su desarrollo. Métodos. Se analizó una cohorte retrospectiva. Se revisaron los expedientes de pacientes en los que se realizaron trasplantes renales desde 2004 hasta 2006, y que tuvieron al menos seguimiento por 6 meses. Se consideró como infección activa la presencia de IgM para CMV posterior al trasplante o de seroconversión o de antigenemia pp65 positiva o determinación positiva de CMV-DNA por PCR. Se definieron como casos aquellos pacientes con infección activa o enfermedad por CMV, y controles aquellos pacientes sin infección o enfermedad. Los factores de riesgo fueron edad, sexo, estado serológico para CMV previo al trasplante, tipo de donador (cadáver o vivo relacionado), profilaxis farmacológica adecuada, año de trasplante y trasfusiones sanguíneas. Resultados. De 120 trasplantes totales realizados, 81 llenaron los criterios de inclusión; de estos, 53% fueron del sexo masculino, y la media de edad de 12 años. Durante el seguimiento, 4 pacientes presentaron sospecha de infección (4.9%), en 10 pacientes se diagnóstico infección (12.3%), 2 pacientes tuvieron la enfermedad (2.5%), 1 paciente presentó rechazo del injerto más infección (1.2%), 15 pacientes presentaron rechazo por otras causas (18%) y 49 pacientes (60.5%) no presentaron complicaciones. El factor de riesgo para el desarrollo de infección o enfermedad que resultó significativo fue la serología negativa previa para CMV en el receptor [RM 3.5 (IC95% 0.94-14.74) p = 0.035]. La frecuencia de infección fue mayor en el 2004 (12/17). La profilaxis fue administrada de forma correcta únicamente en 28.9% de los pacientes. Conclusiones. La frecuencia de infección por CMV en pacientes pediátricos trasplantados fue de 20%. En pacientes de alto riesgo fue de 34% y en los de bajo riesgo, 9%. El 60% se presentaron asintomáticos, 30% con síntomas generales y 10% con síntomas específicos de enfermedad por CMV, así como alteraciones en pruebas de laboratorio. El diagnóstico en 70% se basó en determinaciones serológicas con una respuesta inmune (IgM para CMV). El único factor de riesgo significativo fue la falta de respuesta inmune contra CMV previa al trasplante.

Background. In regard to transplant-associated complications, infections represent one of the principal causes of death and graft loss. Of these, viral infections are the principal cause. The aim of this study was to determine the frequency of infection and/or disease due to cytomegalovirus (CMV) and clinical presentation in a cohort of pediatric kidney transplant patients as well as to present the risk factors associated with its development. Methods. We carried out a retrospective cohort study. Clinical files of patients who underwent kidney transplantation between 2004 and 2006 and with a minimum of 6 months of follow-up were reviewed. Active infection was considered if a positive IgM to CMV after transplant was detected or seroconversion or positive pp65 antigenemia or CMV-DNA positive PCR test. Cases represented patients with active infection or disease and controls were patients without infection and/or disease. Risk factors investigated were age, serological status previous to transplant, donor, drug prophylaxis, year of transplant and blood transfusions. Results. Of 120 transplant patients, 81 fulfilled the inclusion criteria; 53% were male and 47% female with a median age of 12 years. During follow-up, four patients presented a probable infection (4.9%), ten patients had active infection (12.3%), two patients had CMV disease (2.5%), and one patient experienced rejection plus infection (1.2%). Fifteen patients presented rejection due to different causes (18%) and 49 patients (60.5%) did not develop complications. The only significant risk factor for development of infection or disease was a previous negative serological status for CMV (OR 3.58 95% CI 0.94-14.74, p = 0.035). Frequency of infection was higher in the year 2004 (12/17 patients). Prophylaxis was administered correctly in only 28.9% of the patients. Conclusions. Frequency of CMV infection in pediatric kidney transplant patients was 20%. Among high-risk groups, frequency was 34% and decreased to 9% among low-risk groups. Most infected patients were asymptomatic, 30% presented general symptoms and 10% presented specific signs of CMV disease. Serological diagnosis was performed for most of the cases (IgM to CMV). The only significant risk factor for development of CMV infection was negative serological status for CMV previous to transplant.

[Kawasaki disease: clinical behaviour and cardiovascular complications in children in a tertiary-care level hospital]. / Enfermedad de Kawasaki: comportamiento clínico y complicaciones cardiovasculares en niños atendidos en un hospital de tercer nivel.

OBJECTIVES: To describe the clinical characteristics, outcome, and treatment response in a series of patients with Kawasaki disease (KD). METHODS: Case-series, review of clinical records of children with KD diagnosis cared for from november 1999 to september 2006. RESULTS: 22 patients were included, male:female ratio, 1.4:1, 82% younger than 5 years, 14% with atypical presentation. Of the 22 patients, 10 (45%) received intravenous gammaglobulin (IVGG) in the first 10 days of symptoms onset at the recommended dose; four of them had coronary artery damage but none developed residual aneurysmatic lesions. Eight received IVGG in a different dose or after 10 days, six of them had coronary lesions and in two the damage was permanent. Four patients did not receive IVGG, and two had residual aneurysmatic lesions. None of those who received adequate treatment developed coronary residual damage, in comparison with 33% who received inadequate or no treatment, but difference was not statistically significant (P =.06). CONCLUSIONS: KD is a rare clinical entity in our country; even though most of the cases occurred with classic clinical criteria, late referral and delay of treatment worsen the prognosis.

Enfermedad de Kawasaki: comportamiento clínico y complicaciones cardiovasculares en niños atendidos en un hospital de tercer nivel / Kawasaki disease: clinical behaviour and cardiovascular complications in children in a tertiary-care level hospital

OBJECTIVES: To describe the clinical characteristics, outcome, and treatment response in a series of patients with Kawasaki disease (KD). METHODS: Case-series, review of clinical records of children with KD diagnosis cared for from november 1999 to september 2006. RESULTS: 22 patients were included, male:female ratio, 1.4:1, 82% younger than 5 years, 14% with atypical presentation. Of the 22 patients, 10 (45%) received intravenous gammaglobulin (IVGG) in the first 10 days of symptoms onset at the recommended dose; four of them had coronary artery damage but none developed residual aneurysmatic lesions. Eight received IVGG in a different dose or after 10 days, six of them had coronary lesions and in two the damage was permanent. Four patients did not receive IVGG, and two had residual aneurysmatic lesions. None of those who received adequate treatment developed coronary residual damage, in comparison with 33% who received inadequate or no treatment, but difference was not statistically significant (P =.06). CONCLUSIONS: KD is a rare clinical entity in our country; even though most of the cases occurred with classic clinical criteria, late referral and delay of treatment worsen the prognosis.

[Direct fluorescent and indirect immunofluorescent assay in buffy coat for candidemia diagnosis in pediatric patients: a comparative study]. / Fluorescencia directa e inmunofluorescencia indirecta en extensión leucocitaria para el diagnóstico de candidemia en pacientes pediátricos: estudio comparativo.

The diagnosis of candidemia by blood culture has poor sensitivity; therefore, immunossupresed patients and those with risk factors may receive empirical antifungal therapy, wich is potentially toxic. Fluorescent tests have been developed to obtain an early and more sensitive diagnosis than blood culture. The aim of this study was to compare indirect immunofluorescence vs direct calcofluor white fluorescence in buffy coat for candidemia diagnosis. Sensitivity, specificity, predictive values, of positive and negative samples were 60%, 86%, 33%, 95% and 90%, 80%, 35%, 99%, for indirect immunofluorescence and calcofluor white, respectively.