A pleural ultrasound image of a collapsed lung surrounded by pleural fluid ("jellyfish sign") may correspond to an intrapericardial mass.

Lung ultrasound has been shown to be a valuable diagnostic tool. It has become the main way to get to the diagnosis of pleural effusion with much more specificity and sensibility than the x-ray. The diagnosis of pleural effusion with ultrasound is easily obtained after the visualization of hypoechoic fluid surrounding the lung. Sometimes it appears as an image of a collapsed lung moving with the surrounded pleural fluid ("jellyfish sign"). Until now this sign was almost pathognomonic of pleural effusion, but we explore a case in which this sign could have led to a misleading diagnosis. We present the case of a child admitted to intensive care with respiratory distress. In the point of care lung ultrasound we believed to see a pleural effusion with a collapsed lung moving into the effusion. Due to the enlargement of the pericardial sac, we did not realize that what we thought to be the pleural space was in fact the pericardial space. Unfortunately, there was a more echogenic area inside the pericardial effusion which led to a misleading fake lung atelectasis with pleural effusion ("jellyfish sign"). The correct diagnosis was properly obtained after assessing a cardiac point of care ultrasound using a four chambers view. The left side of the thorax is more difficult to be sonographed than the right due to the presence of the heart fossa that occupies a significant part of that side. Obtaining the diagnosis of pleural effusion on that side is more difficult for this reason and can sometimes be misleading with a pericardial effusion. The presence of the "jellyfish sign" is not pathognomonic and may lead to an error if we are guided only by the presence of that sign. To avoid such a misleading diagnosis, we highly recommend performing a point of care cardiac ultrasound if a pleural effusion is primarily seen in the lung ultrasound.

Seroprevalences of antibodies against ToRCH infectious pathogens in women of childbearing age residing in Brazil, Mexico, Germany, Poland, Turkey and China.

Determination of antibodies against ToRCH antigens at the beginning of pregnancy allows assessment of both the maternal immune status and the risks to an adverse pregnancy outcome. Age-standardised seroprevalences were determined in sera from 1009 women of childbearing age residing in Mexico, Brazil, Germany, Poland, Turkey or China using a multiparametric immunoblot containing antigen substrates for antibodies against Toxoplasma gondii, rubella virus, cytomegalovirus (CMV), herpes simplex viruses (HSV-1, HSV-2), Bordetella pertussis, Chlamydia trachomatis, parvovirus B19, Treponema pallidum and varicella zoster virus (VZV). Seroprevalences for antibodies against HSV-1 were >90% in samples from Brazil and Turkey, whereas the other four countries showed lower mean age-adjusted seroprevalences (range: 62.5-87.9%). Samples from Brazilian women showed elevated seroprevalences of antibodies against HSV-2 (40.1%), C. trachomatis (46.8%) and B. pertussis (56.6%) compared to the other five countries. Seroprevalences of anti-T. gondii antibodies (0.5%) and anti-parvovirus B19 antibodies (7.5%) were low in samples from Chinese women, compared to the other five countries. Samples from German women revealed a low age-standardised seroprevalence of anti-CMV antibodies (28.8%) compared to the other five countries. These global differences in immune status of women in childbearing age advocate country-specific prophylaxis strategies to avoid infection with ToRCH pathogens.

Evaluation of the vasoactive-inotropic score, mid-regional pro-adrenomedullin and cardiac troponin I as predictors of low cardiac output syndrome in children after congenital heart disease surgery / Evaluación de la escala vasoactiva-inotrópica, pro-adrenomedulina y troponina cardiaca-I como factores predictivos del síndrome de bajo gasto cardiaco en niños tras corrección quirúrgica de cardiopatías congénitas

Objective: To determine the predictive value of the inotropic score (IS) and vasoactive-inotropic score (VIS) in low cardiac output syndrome (LCOS) in children after congenital heart disease surgery involving cardiopulmonary bypass (CPB), and to establish whether mid-regional pro-adrenomedullin (MR-proADM) and cardiac troponin I (cTn-I), associated to the IS and VIS scores, increases the predictive capacity in LCOS. Design: A prospective observational study was carried out. Setting: A Paediatric Intensive Care Unit. Patients: A total of 117children with congenital heart disease underwent CPB. Patients were divided into two groups: LCOS and non-LCOS. Interventions: The clinical and analytical data were recorded at 2, 12, 24 and 48h post-CPB. Logistic regression was used to develop a risk prediction model using LCOS as dependent variable. Main outcome measures: LCOS, IS, VIS, MR-proADM, cTn-I, age, sex, CPB time, PIM-2, Aristotle score. Results: While statistical significance was not recorded for IS in the multivariate analysis, VIS was seen to be independently associated to LCOS. On the other hand, VIS>15.5 at 2h post-CPB, adjusted for age and CPB timepoints, showed high specificity (92.87%; 95%CI: 86.75-98.96) and increased negative predictive value (75.59%, 95%CI: 71.1-88.08) for the diagnosis of LCOS at 48h post-CPB. The predictive power for LCOS did not increase when VIS was combined with cTn-I >14ng/ml at 2h and MR-proADM >1.5nmol/l at 24h post-CPB. Conclusions: The VIS score at 2h post-CPB was identified as an independent early predictor of LCOS. This predictive value was not increased when associated with LCOS cardiac biomarkers. The VIS score was more useful than IS post-CPB in making early therapeutic decisions in clinical practice post-CPB

Objetivo: Estudiar el valor predictivo de la escala inotrópica (IS) y la escala vasoactiva-inotrópica (VIS) en el síndrome de bajo gasto cardiaco (SBGC) en niños poscirugía de cardiopatías congénitas mediante bypass cardiopulmonar (BCP). Determinar si adrenomedulina (MR-proADM) y troponina cardiaca-I (cTn-I) asociadas con IS y VIS incrementan su capacidad predictora de SBGC. Diseño: Estudio prospectivo y observacional. Ámbito: Cuidados intensivos pediátricos. Pacientes: Ciento diecisiete pacientes pediátricos con cardiopatías congénitas corregidos mediante BCP, clasificados en función de la presencia o no de SBGC. Intervenciones: Los datos analíticos y clínicos se midieron a las 2, 12, 24 y 48h post-BCP. Las principales variables se analizaron mediante regresión logística multivariante, considerando SBGC como variable dependiente. Variables de interés principales: SBGC, IS, VIS, MR-proADM, cTn-I, edad, sexo, BCP, PIM-2 y escala Aristóteles. Resultados: El IS no alcanzó significación estadística en el estudio multivariante; sin embargo, el VIS se asoció independientemente a SBGC. El VIS>15,5 a las 2h del ingreso en CIP, ajustado por edad y tiempo de CEC, muestra alta especificidad (92,87%; IC 95%: 86,75-98,96%) y alto valor predictivo negativo (75,59%; IC 95%: 71,10-88,08) para predecir SBGC a las 48h post-BCP. La capacidad predictora no se incrementa al incorporar cTn-I>14ng/ml a las 2h y ADM>1,5nmol/l a las 24h del postoperatorio. Conclusiones: El VIS a las 2h post-BCP es un predictor independiente precoz de SBGC. Este valor no se incrementa al asociarse biomarcadores cardiacos de LCOS. La escala de VIS fue más útil que la escala de IS en la toma de decisiones terapéuticas tras la cirugía cardiaca

Evaluation of the vasoactive-inotropic score, mid-regional pro-adrenomedullin and cardiac troponin I as predictors of low cardiac output syndrome in children after congenital heart disease surgery.

OBJECTIVE: To determine the predictive value of the inotropic score (IS) and vasoactive-inotropic score (VIS) in low cardiac output syndrome (LCOS) in children after congenital heart disease surgery involving cardiopulmonary bypass (CPB), and to establish whether mid-regional pro-adrenomedullin (MR-proADM) and cardiac troponin I (cTn-I), associated to the IS and VIS scores, increases the predictive capacity in LCOS. DESIGN: A prospective observational study was carried out. SETTING: A Paediatric Intensive Care Unit. PATIENTS: A total of 117children with congenital heart disease underwent CPB. Patients were divided into two groups: LCOS and non-LCOS. INTERVENTIONS: The clinical and analytical data were recorded at 2, 12, 24 and 48h post-CPB. Logistic regression was used to develop a risk prediction model using LCOS as dependent variable. MAIN OUTCOME MEASURES: LCOS, IS, VIS, MR-proADM, cTn-I, age, sex, CPB time, PIM-2, Aristotle score. RESULTS: While statistical significance was not recorded for IS in the multivariate analysis, VIS was seen to be independently associated to LCOS. On the other hand, VIS>15.5 at 2h post-CPB, adjusted for age and CPB timepoints, showed high specificity (92.87%; 95%CI: 86.75-98.96) and increased negative predictive value (75.59%, 95%CI: 71.1-88.08) for the diagnosis of LCOS at 48h post-CPB. The predictive power for LCOS did not increase when VIS was combined with cTn-I >14ng/ml at 2h and MR-proADM >1.5nmol/l at 24h post-CPB. CONCLUSIONS: The VIS score at 2h post-CPB was identified as an independent early predictor of LCOS. This predictive value was not increased when associated with LCOS cardiac biomarkers. The VIS score was more useful than IS post-CPB in making early therapeutic decisions in clinical practice post-CPB.

Short-Term Evaluation of Left Ventricular Mass and Function in Children With Growth Hormone Deficiency After Replacement Treatment.

Background: Our study was designed to assess the effects of GHD on nutritional and metabolic parameters, brain natriuretic peptide (BNP) levels, and left ventricular mass (LVM) in prepubertal children and after short-term GH replacement therapy. Materials and Methods: This prospective study enrolled 81 children. We compared 40 GHD children (16 males and 24 females) to 41 healthy children (control group) (18 males and 23 females). All subjects were at Tanner Stage I (aged 7-11 years). At the baseline, a blood sample was drawn and echocardiographic images were obtained. These tests were repeated on the GHD subjects after 6 months of GH replacement therapy. Body surface, weight, size, blood pressure, heart rate, glucose, insulin, HOMA-IR, HOMA-ß, QUICKI, cholesterol, HDLc, LDLc, triglycerides, IGF1, and IGFBP3 were measured. Indexed LVM, diastolic and systolic diameter (dD-sD), diastolic and systolic LV function, isovolumic relaxation time, right ventricle function, and BNP levels were obtained through echocardiography. These parameters were correlated to growth factors. Data were analyzed using Student's t-test or U-Mann-Whitney-test and Pearson's correlation, considering p < 0.05 to be significant. Results: Indexed LVM was smaller in GHD patients than in controls, whereas diastolic and systolic functions, BNP, metabolic, and nutritional profiles were similar. After treatment, nutritional and metabolic profiles significantly improved, though diastolic and systolic functions did not seem to have changed. There was a significant increase in LVM. Indexed LVM was similar to that of controls. Significant correlations were obtained between LVM-IGF1 and sD-IGFBP3. Conclusions: GHD in childhood is associated with a lower indexed LVM. In the short-term, GH increases the indexed LVM, while maintaining normal systolic and diastolic functions, BNP, and an improved lipid profile.

Seguridad de la vacunación triple vírica en pacientes con alergia al huevo. Respuesta de los autores / Safety of MMR immunization in egg-allergic children. Authors’ response

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Seguridad de la vacunación triple vírica en pacientes con alergia al huevo / Safety of MMR immunization in egg-allergic children

En España la alergia al huevo se ha considerado durante mucho tiempo una contraindicación de la administración de vacunas incubadas en células de embrión de pollo, como la triple vírica o la antigripal. Por ese motivo, en niños alérgicos al huevo, se ha indicado sistemáticamente una vacuna alternativa (Triviraten®) incubada en células diploides humanas, sin plantear si podrían tolerar la vacunación SaRuPa (Sarampión-Rubéola-Parotiditis) estándar. Tras el cese de la producción de Triviraten® por parte del Laboratorio Biotech Berna se ha eliminado dicha alternativa para niños con alergia al huevo, que deben recibir la primovacunación a los 15 meses y una dosis de recuerdo a los 3 años, de acuerdo con el calendario vacunal vigente en la actualidad. En este contexto, durante el período noviembre 2004-junio 2005 se realizó vacunación triple vírica convencional en 40 niños alérgicos al huevo, sin que ninguno de ellos presentase reacción adversa tras su administración, por lo que se puede concluir que esta es segura en el citado grupo de pacientes

In Spain, for many years allergy to eggs was considered to contraindicate vaccines cultured in fibroblasts from chick embryos such as the measles, mumps, rubella (MMR) and influenza vaccines. Consequently, an alternative vaccine (Triviraten Berna®) incubated in diploid human cells has been systematically administered to children who are allergic to eggs, without questioning tolerance to the standard MMR vaccine. After Biotech Bern Laboratory discontinued the production of Triviraten®, this alternative was no longer available for children with egg allergy, who should receive a first dose of the MMR vaccine at the age of 15 months and a second one (booster dose) at the age of 3 years. In this context, from November 2004 to June 2005, a single dose of the MMR vaccine was administered to 40 children with allergy to eggs and none showed an adverse reaction. We conclude that this vaccine can be safely administered to this group of patients