Racial and Ethnic Differences in Hospital Admission and Diagnostic Evaluation for Febrile Seizures in the Emergency Department.

OBJECTIVE: To examine differences in hospital admission and diagnostic evaluation for febrile seizure by race and ethnicity. STUDY DESIGN: We conducted a cross-sectional study among children 6 months to 6 years with simple or complex febrile seizure between January 1, 2016, and December 31, 2021, using data from the Pediatric Health Information System. The primary outcome was hospital admission. Secondary outcomes included the proportion of encounters with neuroimaging or lumbar puncture. We used mixed-effects logistic regression model with random intercept for hospital and patient to estimate the association between outcomes and race and ethnicity after adjusting for covariates, including seizure type. RESULTS: In total, 94 884 encounters were included. Most encounters occurred among children of non-Hispanic White (37.0%), Black (23.9%), and Hispanic/Latino (24.6%) race and ethnicity. Black and Hispanic/Latino children had 29% (aOR 0.71; 95% CI 0.66-0.75) and 26% (aOR 0.74; 95% CI 0.69-0.80) lower odds of hospital admission compared with non-Hispanic White children, respectively. Black and Hispanic/Latino children had 21% (aOR 0.79; 95% CI 0.73-0.86) and 22% (aOR 0.78; 95% CI 0.71-0.85) lower adjusted odds of neuroimaging compared with non-Hispanic White children. For complex febrile seizure, the adjusted odds of lumbar puncture was significantly greater among Asian children (aOR 2.12; 95% CI 1.19-3.77) compared with non-Hispanic White children. There were no racial differences in the odds of lumbar puncture for simple febrile seizure. CONCLUSIONS: Compared with non-Hispanic White children, Black and Hispanic/Latino children with febrile seizures are less likely to be hospitalized or receive neuroimaging.

Normal pressure hydrocephalus: Diagnostic delay. / Hidrocefalia de presión normal: demora en el diagnóstico

INTRODUCTION: Normotensive hydrocephalus is a differential diagnosis in the evaluation of the dementia syndrome. The diagnostic protocols would allow detecting this pathology that has more effective treatment than other dementias. OBJECTIVE: To describe a population with clinical suspicion of normal pressure hydrocephalus evaluated in a Colombian psychiatric hospital and discuss the possible reasons for its diagnostic and therapeutic delay. MATERIALS AND METHODS: We conducted a retrospective study of medical records to identify patients with suspected normal pressure hydrocephalus during a 5-year period. RESULTS: Thirty-five patients with suspected normal pressure hydrocephalus underwent diagnostic lumbar puncture and five of them were considered candidates for a peritonealvenous shunt, but none underwent this surgical procedure. After three to six months of the lumbar puncture, the gait pattern improved in 22.8% of the patients, cognition in 22.8%, and sphincter control in 11.4%. Improvement was not sustained in the long term (1 year) in any of them. CONCLUSION: This study suggests the poor implementation of the protocols for evaluating patients with cognitive deficits and delays in the diagnosis of normal pressure hydrocephalus. A small number of patients were identified as candidates for treatment. Normal pressure hydrocephalus is a potentially reversible clinical entity with the placement of a peritoneal ventricular shunt, but delays in diagnosis and treatment have deleterious consequences for patients and their families.

Introducción. La hidrocefalia normotensiva es un diagnóstico diferencial en la evaluación del síndrome demencial. Los protocolos diagnósticos permitirían detectar esta condición, cuyo tratamiento es más efectivo que el de otras demencias. Objetivo. Describir una población con sospecha clínica de hidrocefalia normotensiva evaluada en un hospital psiquiátrico colombiano y discutir las posibles razones de la demora en el diagnóstico y en la terapia de esta condición clínica. Materiales y métodos. Se hizo un estudio retrospectivo de los registros médicos para detectar pacientes con sospecha de hidrocefalia normotensiva durante un período de cinco años. Resultados. A 35 pacientes con sospecha de hidrocefalia normotensiva se les hizo una punción lumbar diagnóstica. Cinco de ellos se consideraron candidatos para una derivación ventrículo-peritoneal, pero ninguno se sometió a este procedimiento quirúrgico. A los 3-6 meses de la punción lumbar, se observó una mejoría del patrón de la marcha en el 22,8 % de los pacientes, de la cognición en el 22,8 % y del control del esfínter en el 11,4 %. La mejoría no se mantuvo a largo plazo (un año) en ningún paciente. Conclusión. Se encontró una implementación deficiente de los protocolos de evaluación de los pacientes con déficit cognitivos y demoras en el diagnóstico de la hidrocefalia normotensiva, así como un número reducido de pacientes clasificados como candidatos para el tratamiento. La hidrocefalia normotensiva es una condición clínica potencialmente reversible con la colocación de una derivación ventrículo-peritoneal. Los retrasos en el diagnóstico y en el tratamiento tienen consecuencias perjudiciales para los pacientes y sus familias.

Early lumbar puncture and risk of intraventricular hemorrhage in very low birth weight infants.

BACKGROUND: Lumbar puncture (LP) is the gold standard for diagnosing meningitis; however it is unknown whether early LP (≤3days of life) is associated with increased risk of intraventricular hemorrhage (IVH) in very low birth weight (VLBW) infants. OBJECTIVE: To determine whether early LP in VLBW infants is associated with severe IVH. METHODS: VLBW infants from a cohort of 1,158,789 infants discharged from 382 neonatal intensive care units (1997-2015) were enrolled. EXCLUSION CRITERIA: infants with major congenital anomalies, outborns, died/transferred prior to day of life 3, and those who had an LP performed only after day of life 3. Logistic regression was used to determine the association between early LP and the incidence of severe IVH (IVH grades 3/4) by 28days of life for each day of life from day 0 (birth) to day 3, adjusting for clinical covariates. RESULTS: 106,461 infants were included: 754 received an LP on Day-0, 640 on Day-1, 559 on Day-2 and 483 on Day-3. Severe IVH occurred in 4% (4130/104,025) of the infants in the no LP group and 9% (217/2436) of the LP group. Severe IVH was higher for infants with early LP: adjusted OR (95% confidence interval)=2.64 (1.96-3.54) on Day-0; 2.21 (1.61-3.04) on Day-1; 1.55 (1.03-2.34) on Day-2; and 2.25 (1.50-3.38) on Day-3. CONCLUSIONS: Early LP was associated with severe IVH in VLBW infants by 28days of life. LP is either a surrogate for an unrecognized factor or is itself associated with an increased risk of IVH.

[Children less than 3 months hospitalised due to acute febrile syndrome. 5 years clinical experience]. / Lactantes menores de 3 meses hospitalizados por síndrome febril agudo. Experiencia clínica de 5 años.

INTRODUCTION: Acute fever of unknown origin (AFUO) is established when the anamnesis and physical examination cannot identify the cause. In infants less than 3 months-old this is situation for concern, due to the risk of a serious bacterial infection. OBJECTIVE: To describe the clinical and laboratory variable of patients with AFUO, in order to look for clues in order to base studies on the decisions arising drom this problem. PATIENTS AND METHODS: A report is presented on a retrospective study conducted on a cohort of children less than three months-old admitted to the Hospital Roberto del Río (2007-2011) due to an AFUO. Clinical histories were reviewed and the patients were grouped, according to the severity of the admission diagnosis, into severe and non-severe. They were compared in strata determined by the variables of clinical interest. RESULTADOS: A total of 550 children were admitted with AFUO during the study period. There was low agreement between the severity on admission and at discharge (kappa=0.079; P=.26). There were 23.8% of children in the severe group and 76.2% in the non-severe group. Urinary tract infection predominated in the severe group (68.7%) and 40.7% with acute febrile syndrome in the non-severe group. The cut-off levels for C-reactive protein, white cells, and neutrophils per mm(3), to calculate the fixed and variable indices, only showed negative predictive values of some use for ruling out serious bacterial infection. The ROC curves with white cell and neutrophil counts and C-reactive protein, did not provide andy fixed indices of clinical use. More than one-third (34.6%) of lumbar punctures were traumatic or failures. CONCLUSIONS: According to the results of this study, there is an obvious excess of hospital admissions, little usefulness in the examinations to identify serious bacterial infection, a high percentage lumbar punctures traumatic and lumbar punctures failures, and an excess of antibiotic treatments. A review of clinical criteria and procedures is needed.

Lactantes menores de 3 meses hospitalizados por síndrome febril agudo: Experiencia clínica de 5 años / Children less than 3 months hospitalised due to acute febrile syndrome: 5 years clinical experience

Introducción: La fiebre aguda de origen no precisado (FAONP) es planteada cuando la anamnesis y el examen físico no permiten identificar la causa. En menores de 3 meses esta situación es preocupante, por el riesgo de una infección bacteriana grave. Objetivo: Describir variables clínicas y de laboratorio de pacientes con FAONP, buscando pistas para basar estudios sobre las decisiones a que da lugar este problema. Pacientes y Método: Describimos retrospectivamente una cohorte de menores de 3 meses internados en el Hospital Roberto del Río (2007-2011) por FAONP. Se revisaron las historias clínicas y se efectuó una dicotomización de los pacientes según gravedad del diagnóstico de egreso, en graves y no graves. Se compararon en estratos determinados por variables con interés clínico. Resultados: Durante el periodo de estudio se ingresaron 550 niños con FAONP. La concordancia entre gravedad al ingreso y egreso fue baja (kappa = 0,079; p = 0,26). El 23,8% de los niños fueron graves y el 76,2% no graves. En el grupo de los graves predominó la infección del tracto urinario (68,7%) y en los no graves el síndrome febril agudo (40,7%). Los niveles de corte para la proteína C reactiva, leucocitos y neutrófilos/mm³, para calcular índices fijos y variables, solo mostraron valores predictivos negativos de alguna utilidad para descartar infección bacteriana grave. Las curvas ROC con recuento de leucocitos, neutrófilos y proteína C reactiva, no ofrecen índices fijos de utilidad clínica. El 34,6% de las punciones lumbares fueron traumáticas o fallidas). Conclusiones: De acuerdo a nuestros resultados, parece evidente un exceso de hospitalizaciones, la poca utilidad de exámenes para identificar infección bacteriana grave, un alto porcentaje de punciones lumbares traumáticas o fallidas y excesos de terapias antibióticas. Se hace necesaria una revisión de criterios y procedimientos clínicos.

Introduction: Acute fever of unknown origin (AFUO) is established when the anamnesis and physical examination cannot identify the cause. In infants less than 3 months-old this is situation for concern, due to the risk of a serious bacterial infection. Objective: To describe the clinical and laboratory variable of patients with AFUO, in order to look for clues in order to base studies on the decisions arising drom this problem. Patients and Methods: A report is presented on a retrospective study conducted on a cohort of children less than three months-old admitted to the Hospital Roberto del Río (2007-2011) due to an AFUO. Clinical histories were reviewed and the patients were grouped, according to the severity of the admission diagnosis, into severe and non-severe. They were compared in strata determined by the variables of clinical interest. Resultados: A total of 550 children were admitted with AFUO during the study period. There was low agreement between the severity on admission and at discharge (kappa = 0.079; P = .26). There were 23.8% of children in the severe group and 76.2% in the non-severe group. Urinary tract infection predominated in the severe group (68.7%) and 40.7% with acute febrile syndrome in the non-severe group. The cut-off levels for C-reactive protein, white cells, and neutrophils per mm³, to calculate the fixed and variable indices, only showed negative predictive values of some use for ruling out serious bacterial infection. The ROC curves with white cell and neutrophil counts and C-reactive protein, did not provide andy fixed indices of clinical use. More than one-third (34.6%) of lumbar punctures were traumatic or failures. Conclusions: According to the results of this study, there is an obvious excess of hospital admissions, little usefulness in the examinations to identify serious bacterial infection, a high percentage lumbar punctures traumatic and lumbar punctures failures, and an excess of antibiotic treatments. A review of clinical criteria and procedures is needed.

Reduction of contractility and reactivity in isolated lymphatics from hemorrhagic shock rats with resuscitation

PURPOSE: To evaluate the changes of contractility and reactivity in isolated lymphatics from hemorrhagic shock rats with resuscitation. METHODS: Six rats in the shock group suffered hypotension for 90 min by hemorrhage, and resuscitation with shed blood and equal ringer's solution. Then, the contractility of lymphatics, obtained from thoracic ducts in rats of the shock and sham groups, were evaluated with an isolated lymphatic perfusion system using the indices of contractile frequency (CF), tonic index (TI), contractile amplitude (CA) and fractional pump flow (FPF). The lymphatic reactivity to substance P (SP) was evaluated with the different volume of CF, CA, TI and FPF between pre- and post-treatment of SP at different concentrations. RESULTS: The CF, FPF, and TI of lymphatics obtained from the shocked rats were significantly decreased than that of the sham group. After SP stimulation, the ∆CF (1×10-8, 3×10-8, 1×10-7, 3×10-7 mol/L), ∆FPF (1×10-8, 3×10-8, 1×10-7 mol/L), and ∆TI (1×10-8 mol/L) of lymphatics in the shock group were also obviously lower compared with the sham group. In addition, there were no statistical differences in CA and ∆CA between two groups. CONCLUSION: Lymphatic contractility and reactivity to substance P appears reduction following hemorrhagic shock with resuscitation. .

Current treatment pathways in ALS: a South American perspective.

This article presents the findings relating to the South American subgroup of 60 patients in an international survey of the current diagnosis and treatment of patients with amyotrophic lateral sclerosis (ALS). The mean time between first symptoms and first consultation with a physician was 3.7 months, and mean delay in seeing a neurologist was then 5.6 months, giving a mean time from symptom onset to confirmation of diagnosis of 16.6 months. The time to confirmation of diagnosis was much longer for patients with symptoms of limb onset (17.5 months) than for those with bulbar onset (10.0 months). Cases with symptoms of upper-limb onset were diagnosed more rapidly (14.9 months) than those with symptoms of lower-limb onset (21.8 months). The diagnosis was confirmed in 48% of cases within 15 months of symptom onset, and a further 27% were diagnosed within 15-24 months; 47% of cases were confirmed within 4 months of consulation with a neurologist and a further 17% within 4-6 months. The first physician seen was the general practitioner in 47% of cases overall. When the neurologist was the first physician seen (27% of patients in Brazil, 0% in Argentina), diagnosis was achieved within 14 months in 88% of cases. EMG was performed in almost all patients. MRI and CT were widely used, which may cause delays. Announcement of the diagnosis was made immediately to 75% of patients overall. Riluzole was prescribed for 23% of patients in Brazil and for 67% of patients in Argentina.

Lumbar puncture in children with periorbital and orbital cellulitis.

OBJECTIVE: To measure the frequency with which lumbar puncture (LP) was performed in children with periorbital and orbital cellulitis in the years 1979 through 1991, and to examine its value as a diagnostic test in these patients. DESIGN: Retrospective review of both computerized discharge diagnoses and medical records. SETTING: Tertiary care hospital. PATIENTS: Two hundred fourteen children younger than 18 years of age discharged between Jan. 1, 1979, and Dec. 31, 1991, with a final diagnosis of periorbital or orbital cellulitis. MAIN OUTCOME MEASURES: Rates of LP and of bacterial meningitis. RESULTS: Of the 214 patients, 96 (45%) had LPs. Two children (1%) had meningitis; in both, the diagnosis was strongly suspected before the LP was performed. No other subject had a discharge diagnosis of meningitis. During the 13 years of study, the proportion of patients in whom LP was performed increased from 14% in the first 6 years (1979 through 1984) to 62% from 1985 through 1991 (p < 0.0001). Those older than 2 months who were afebrile on arrival in the emergency department were 12.4 times more likely to have an LP in 1985 through 1991 than in 1979 through 1984 (p = 0.005). CONCLUSIONS: The increase in the number of LPs performed from 1985 through 1991 in children with periorbital or orbital cellulitis was not accompanied by an increase in the diagnosis of early or unsuspected meningitis. These data suggest the need for more judicious use of LP in children with periorbital swelling.