Respiratory and pharmacological management in severe acute bronchiolitis: Were clinical guidelines not written for critical care?

PURPOSE: The treatment applied for children admitted to the pediatric intensive care unit (PICU) for severe acute bronchiolitis may differ from general recommendations. The first objective of our study was to describe the treatments offered to these children in a Spanish tertiary PICU. The second objective was to analyse the changes in management derived from the publication of the American Academy of Pediatrics (AAP) bronchiolitis guideline in 2014. METHODS: This was a retrospective-prospective observational study conducted during two epidemic waves (2014-2015 and 2015-2016). The AAP guidelines were distributed and taught to PICU staff between both epidemic waves. RESULTS: A total of 138 children were enrolled (78 male). In the first period, 78 children were enrolled. The median age was 1.8 months (IQR 1.1-3.6). There were no differences between the management in the two periods, except for the use of high-flow oxygen therapy (HFOT); its use increased in the second period. Overall, 83% of patients received non-invasive ventilation or HFOT. Children older than 12 months received HFOT exclusively. In comparison, continuous positive airway pressure and bi-level positive airway pressure were used less during the period 2015-2016 (P=0.036). Regarding pharmacological therapy, 70% of patients received antibiotics, 23% steroids, 33% salbutamol, 31% adrenaline, and 7% hypertonic saline. The mortality rate was zero. CONCLUSIONS: Our PICU did not follow the AAP recommendations. There were no differences between the two periods, except in the use of HFOT. All children older than 12 months received HFOT exclusively. The rate of using invasive mechanical ventilation was also low.

Accuracy of CD64 expression on neutrophils and monocytes in bacterial infection diagnosis at pediatric intensive care admission.

The CD64 receptor has been described as an interesting bacterial infection biomarker. Its expression has not been studied in previously healthy children admitted to pediatric critical care unit (PICU). Our objective was firstly to describe the CD64 expression and secondly study its diagnostic accuracy to discriminate bacterial versus viral infection in this children. We made a prospective double-blind observational study (March 2016-February 2018). A flow cytometry (FC) was done from peripheral blood at PICU admission. We studied the percentage of CD64+ neutrophils and the CD64 mean fluorescence intensity (MFI) on neutrophils (nCD64) and monocytes (mCD64). Statistical analyses were performed with non-parametric tests (p < 0.05). Twenty children in the bacterial infection group (BIG) and 25 in the viral infection group (VIG). Children in BIG showed higher values of CD64+ neutrophils (p = 0.000), nCD64 (p = 0.001), and mCD64 (p = 0.003). In addition, CD64+ neutrophils and nCD64 expression have positive correlation with procalcitonin and C reactive protein. The nCD64 area under the curve (AUC) was 0.83 (p = 0.000). The %CD64+ neutrophils showed an AUC of 0.828 (p = 0.000). The mCD64 AUC was 0.83 (p = 0.003). The nCD64 and %CD64+ neutrophils also showed higher combined values of sensitivity (74%) and specificity (90%) than all classical biomarkers.In our series CD64 expression allows to discriminate between bacterial and viral infection at PICU admission. Future studies should confirm this and be focused in the study of CD64 correlation with clinical data and its utility as an evolution biomarker in critical care children.

Mortalidad y adecuación del esfuerzo terapéutico en un servicio terciario de cuidados intensivos pediátricos: revisión de 11 años / Mortality and adequacy of therapeutic effort in a tertiary pediatric intensive care department: An 11-year review

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[Aplastic crisis due to parvovirus B19 and Epstein-Barr virus in a patient with hereditary spherocytosis]. / Crisis aplásica por Parvovirus B19 y virus de Epstein-Barr en paciente con esferocitosis hereditaria.

Anemic syndrome in childhood requires a diagnosis and urgent treatment guided by systematic protocols that can avoid unnecessary additional testing. The case of a 4 year-old girl with fatigue and intermittent fever of 7 days duration, accompanied by abdominal pain is presented. She had regular general health status, with mucocutaneous jaundice, a grade III/VI/iv murmur, and painful abdomen with hepatosplenomegaly. The blood analysis showed a hypo-regenerative anemia with increased LDH and indirect bilirubin. The Coombs Test was negative, with spherocytes being observed in the peripheral blood smear. The IgM and IgG were positive for parvovirus B19 IgM and Epstein Barr virus, leading to the diagnosis of aplastic crisis in a patient with hereditary spherocytosis. No specific treatment was required. Under the suspicion of anemic syndrome in emergencies, the ABCDE sequence must be followed. Through the history, physical examination and basic laboratory tests, an initial diagnostic approach can be made. Specific etiological tests should be based on this first study.

Impact of NEGR1 genetic variability on psychological traits of patients with eating disorders.

Genetics variants in the NEGR1 gene, strongly expressed in the brain, have been reported to affect the neuronal control of food intake therefore inducing obesity. With the same rationale, we hypothesized that this genetic variability may be associated with psychological traits commonly displayed by eating disorder (ED) patients and/or with the risk for the disorder. We analyzed 21 tag-single-nucleotide polymorphisms (SNPs) in the coding sequence and adjacent regions of the NEGR1 gene. A total of 169 ED patients (106 with anorexia nervosa (AN) and 63 with bulimia nervosa (BN)) and 312 healthy subjects were genotyped. Personality traits and general psychopathological symptoms were assessed by the Eating Disorders Inventory Test-2 (EDI-2) and Symptom Checklist 90 Revised inventories. None of the SNPs or haplotypes analyzed were associated with a greater risk of ED or correlated with anthropometric parameters. However, in patients with BN, four SNPs (rs12740031, rs10789322, rs6659202 and rs591540) correlated with the scores in Drive for Thinness (DT), Ineffectiveness (I) and Interoceptive Awareness (IA) (Bonferroni-P<0.05 in all instances). The first two SNPs along with rs954299 and rs2422021 formed a haplotype block, which showed a consistent association with the EDI-2 score in BN patients (Bonferroni-P=0.01). A subsequent three-SNP sliding-window approach identified a central area, encompassing both the haplotype block and the individually relevant SNPs that strongly correlated with the scores of BN patients in DT, I, IA and Bulimia. No associations were identified in the AN group. These preliminary results indicate that NEGR1 could be an important locus influencing certain personality dimensions in BN patients.

[Fiberoptic bronchoscopy, 3-D reconstruction of the airway and virtual bronchoscopy in patients with airway malformations. Preliminary report]. / Fibrobroncoscopia, reconstrucción tridimensional de la vía aérea y broncoscopia virtual en pacientes con patología de la vía aérea: estudio preliminar.

UNLABELLED: Bronchoscopy is the diagnostic gold standard in patients with airway malformations. Helical CT scan has produced studies such as virtual bronchoscopy or 3-D reconstruction of the airway. The purpose of this study is to analyze the correlation between fiberoptic bronchoscopy, virtual bronchoscopy and 3-D reconstruction of the airway in patients with airway malformations. METHODS: From January 2001 to March 2002 we evaluated the airway of 17 patients with airway malformations by means of a diagnostic protocol consisting on fiberoptic bronchoscopy, and Helical CT scan with 3-D reconstruction of the airway and virtual bronchoscopy. The radiologist had no access to bronchoscopic information. Age at study, associated cardiovascular anomalies, indications, localization, degree of diagnostic concordance, etiology and influence in treatment were analyzed. RESULTS: 20 studies were done to 17 patients whose mean age was 1.64 +/- 0.48 years (7 days-7 years). Twelve patients had associated anomalies of the aorta, pulmonary arteries or supraortic vessels. Excellent concordance was obtained in 13 cases (65%), good in 6 (30%) and poor in one (5%). 3-D reconstruction of the airway and adjacent vascular structures provided additional information in 14 cases (70%): in 3 exact length of the tracheal lesion and in 11 defined the cause of the compression. In all the cases, absolute concordance in localization was obtained. CT scan information modified treatment in 6 patients (35%). In 7 patients with associated vascular anomalies, no further image studies were done, confirming the anatomy concordance during surgery. CONCLUSIONS: 3-D reconstruction of the airway and virtual bronchoscopy are excellent diagnostic tools in patients with airway malformations, and contribute to define the etiology, length and diameter of the lesion. Excellent diagnostic correlation was obtained between analogic and virtual bronchoscopies, although further multicentric studies should be conducted.

Fibrobroncoscopia, reconstrucción tridimensional de la vía aérea y broncoscopia virtual en pacientes con patología de la vía aérea: Estudio preliminar / Fiberoptic bronchoscopy, 3-D reconstruction of the airway and virtual bronchoscopy in patients with airway malformations. Preliminary report

La broncoscopia es el medio de diagnóstico estándar en pacientes con malformaciones de la vía aérea. El TAC helicoidal ha hecho realidad estudios como la broncoscopia virtual y la reconstrucción tridimensional de la luz traqueobronquial. El propósito de este trabajo es analizar la correlación entre la fibrobroncoscopia analógica; la reconstrucción 3-D de la vía aérea y la broncoscopia virtual en pacientes con malformaciones de la vía aérea.Material y métodos. Desde enero de 2001 a marzo de 2002 hemos evaluado la vía aérea de 17 pacientes con malformaciones de la vía aérea mediante un protocolo de diagnóstico consistente en fibrobroncoscopia y TAC torácico helicoidal con reconstrucción 3-D de la vía aérea y broncoscopia virtual. El radiólogo que interpretó el TAC no tuvo acceso al diagnóstico broncoscópico. Se analizaron la edad al diagnóstico, la malformación cardiovascular asociada, la indicación del estudio, localización de la lesión de la vía aérea, otros datos aportados por el TAC, el grado de concordancia diagnóstica, la causa de la lesión y el grado de influencia en el tratamiento quirúrgico aplicado. Resultados. Se realizaron 20 exploraciones a 17 pacientes con una edad en el momento de la exploración de 1,64 ñ 0,48 años (7 días-7 años). Doce pacientes tenían anomalías asociadas de la aorta, las arterias pulmonares o los troncos supra-aórticos. En 13 casos la concordancia diagnóstica fue excelente (65 por ciento), buena en 6 (30 por ciento) y pobre en un caso (5 por ciento). La reconstrucción 3-D de la vía aérea aportó información extra-traqueobronquial en 14 casos (70 por ciento): en tres exactitud en la extensión de la lesión traqueal y en 11 definió la causa de la compresión. En el 100 por ciento de las exploraciones se obtuvo una concordancia total en cuanto a la localización de la lesión traqueobronquial. En 6 pacientes la información del TAC helicoidal modificó el tratamiento (35 por ciento). En 7 de los 11 pacientes con malformación cardiovascular asociada no se realizaron estudios posteriores de imagen, comprobándose durante la cirugía una concordancia anatómica exacta en todos ellos. Conclusiones. La reconstrucción 3-D de la vía aérea y la broncoscopia virtual proporcionadas por el TAC helicoidal constituyen una excelente herramienta diagnóstica en pacientes con patología congénita traqueobronquial, y específicamente contribuyen de forma definitiva a la determinación de la localización de la lesión, diámetro y extensión de la misma. La correlación entre la broncoscopia analógica y virtual es excelente, aunque son necesarios estudios multicéntricos para determinar con exactitud su valor diagnóstico (AU)