Cupriavidus pauculus bacteremia related to parenteral nutrition. Case series report.

Cupriavidus pauculus is a Gram negative rod that is usually isolated in water and has been extraordinarily isolated in patients with vascular access and / or immunosuppression. In this work we present a series of cases of patients with positive blood cultures for cupríavidus pauculus, during a short period of time in our hospital center. The only characteristic related to all cases was the use of parenteral nutrition. It highlights the rareness of the microorganism and the susceptibility identified in the antibiogram, which may be useful for future cases.

Value of chest radiography in predicting treatment response in children aged 3-59 months with severe pneumonia.

SETTING: International multicentric study at nine tertiary care centres. OBJECTIVE: The World Health Organization (WHO) currently does not recommend chest radiographs (CXRs) for routine management of pneumonia. We evaluated the use of CXR for the prediction of treatment failure in children with severe pneumonia. DESIGN: We used WHO vaccine trials radiographic assessment, clinical and nasopharyngeal microbiological data from 1121 3-59-month-old children recruited using the WHO definition of severe pneumonia in the Amoxicillin Penicillin Pneumonia International Study (APPIS). Using Poisson regression, we estimated the relative risk of developing clinical treatment failure and predictive preventive benefit of the CXR and examined the concordance of the CXR findings with the nasopharyngeal microbiological data. RESULTS: A CXR with 'significant pathology' (defined by the WHO algorithm as end-point consolidation, pleural fluid and other infiltrates) was associated with a high risk of treatment failure, especially in children who received penicillin as compared to oral amoxicillin. Significant pathology was also associated with nasopharyngeal isolation of penicillin-resistant Streptococcus pneumoniae. Children with a normal CXR had a reduced risk of clinical treatment failure. CONCLUSIONS: CXR with significant pathology independently and additively predicts clinical treatment failure. If CXR and the WHO tool are available, they can be used in the management of severe pneumonia.

Brief hospitalization and pulse oximetry for predicting amoxicillin treatment failure in children with severe pneumonia.

OBJECTIVE: In settings with limited assessment tools, we sought to determine whether early clinical signs and symptoms and blood oxygen saturation would predict amoxicillin treatment failure in children with severe pneumonia (as defined by the World Health Organization). METHODS: Data were from a previously reported, multinational trial of orally administered amoxicillin versus injectable penicillin for the treatment of World Health Organization-defined severe pneumonia in children 3 to 59 months of age. We assessed all 857 participants assigned randomly to the experimental amoxicillin arm. Six multivariate logistic regression models were created and evaluated for their ability to predict failure after 48 hours of therapy. Regression models included vital signs, symptoms, and laboratory data collected at baseline and after 12 or 24 hours of observation. Oxygen saturation data were included in 3 models. RESULTS: Clinical treatment failure occurred for 18% of children. Younger age, increased initial respiratory rate, and baseline hypoxia predicted treatment failure in all models. Data available after 24 hours improved the ability to predict failure compared with data available at baseline or 12 hours. The inclusion of oximetry data improved the predictive ability at baseline, 12 hours, and 24 hours. The ability to predict failure after 12 hours of observation with oximetry data was similar to the predictive ability after 24 hours without pulse oximetry data. CONCLUSIONS: Assessment of clinical parameters at presentation and after 24 hours improved the ability to predict clinical failure of oral amoxicillin therapy, compared with assessment at presentation alone or at presentation and after only 12 hours, for children with World Health Organization-defined severe pneumonia.

Are oxygen indices effective for predicting pathological intrapulmonary shunt in mechanically ventilated children?

BACKGROUND: This study was undertaken to evaluate whether oxygen indices accurately predict pathological intrapulmonary shunt (Qsp/Qt), and to evaluate the sensitivity and specificity of the FiO2-required formula to obtain a desired arterial oxygen tension (PaO2) in mechanically ventilated children. METHODS: A prospective, hospital-based, comparative study was conducted on 50 mechanically ventilated children at the Intensive Care Units of the National Institute of Pediatrics (INP) in Mexico City. Blood gas data were prospectively collected from 50 critically ill, mechanically ventilated children, 50 taken before and 40 after FiO2 change. Assessment of Qsp/Qt, P(A-a)O2, PaO2/FiO2, PaO2/PAO2, and P(A-a)O2/PaO2 was carried out before and after FiO2 change. RESULTS: In first blood gas data, 31 patients were hypoxemic (PaO2 < 90 Torr), 10 were normal, and 9 were hyperoxemic (PaO2 > 100 Torr). Forty patients required FiO2 modifications that were carried out according to Maxwell's formula. Five children showed persistent oxygen disturbance after FiO2 changes. P(A-a)O2, PaO2/FiO2, PaO2/PAO2, and P(A-a)O2/PaO2 had sensitivities of 0.66, 0.71, 0.98, and 0.93, respectively, and specificities of 0.79, 0.91, 0.29, and 0.64, respectively, to detect pathological Qsp/Qt. All oxygen indices changed significantly after FiO2 modifications compared from initials; Qsp/Qt also showed significant change after FiO2 change. Pearson product-moment showed lineal correlation between each index, and Qsp/Qt demonstrated their significant correlation (p < 0.01). Correlation of Qsp/Qt and PaO2/FiO2 and PaO2/PAO2 was significantly higher in younger children (< 13 years) p < 0.05. The FiO2-required formula to obtain a desired PaO2 had a sensitivity of 0.93 and a specificity of 0.75. CONCLUSIONS: The oxygen indices showed sufficient efficacy to detect pathological intrapulmonary shunt, and to have a statistically significant lineal correlation that permits its use during the clinical evaluation of oxygen transport data in most mechanically ventilated children, which is consistent with other reports on adult populations. However, one limitation for its use in clinical assessment, as reported in previous studies, would be that all indices in the present study are FiO2-dependent; therefore, when the FiO2 varies, the use is misleading. The FiO2-required formula is efficient for defining the appropriated FiO2 for the obtaining of the desired PaO2, but will always be merely a guide that should be confirmed through blood gas analysis.

[Nutritional impact of whole milk supplemented with vitamins and minerals in children]]. / Impacto nutricio del consumo de una leche entera adicionada con vitaminas y minerales en niños.

OBJECTIVE: To evaluate the nutritional impact of the ingestion of a fortified whole milk in children. MATERIAL AND METHODS: Prospective, longitudinal assay in 227 children aged 8-60 months. INTERVENTION: Daily consumption of 500 ml of fortified milk during 90 days. We registered milk acceptance and assessed weight, height; hemoglobin, serum iron, vitamin B12, and folic acid, at the beginning and the end of the study. Statistical evaluation were done with central and dispersion indices in the dimensional variables, using Student's t test and chi 2 test for compare nominal variables at initial and the end of the study. RESULTS: At admission, 45 children were malnourished and 36 were anemic. At the end of the supplementation period there was a reduction to 35 malnourished (p < 0.21) and 18 anemic (p < 0.01). Anthropometric weight/height score in Z at the beginning and end of the study (x +/- S.D) were -0.35 +/- 0.88 vs -0.14 +/- 9 (p < 0.01); Hb g/dl: 11 +/- 1.3 vs 11.9 +/- 1.9 (p < 0.001), Iron mg/dl: 108 +/- 44 vs 115 +/- 31 (p = 0.06) and vitamin B12 pg/ml: 649 +/- 494 to 1053 +/- 854 (p < 0.001). The milk was well tolerated and widely accepted. CONCLUSIONS: The consumption of a fortified whole milk during 90 days improved significantly the nutritional status of the children, the weight for height Z score, the plasma level of vitamin B12 and Hb, and decreased the number of anemic and malnourished children.

The association between cesarean delivery and breast-feeding outcomes among Mexican women.

OBJECTIVES: This study examined the impact of cesarean section delivery on the initiation and duration of breast-feeding in the 1987 Mexican Demographic and Health Survey. METHODS: The subsample (n = 2517) was restricted to women whose delivery of their last-born children (aged 5 years and younger) was attended by a physician. Multivariate logistic regression was used to examine the association between cesarean section and likelihood of either not initiating breast-feeding or doing so for less than 1 month. Among women who breast-fed for 1 month or more, multivariate survival analysis was used to examine the relationship between cesarean section and breast-feeding duration. RESULTS: Cesarean section was a risk factor for not initiating breast-feeding (odds ratio [OR] = 0.64, 95% confidence interval [CI] = 0.50, 0.82) and for breast feeding for less than 1 month (OR = 0.58, 95% CI = 0.37, 0.91) but was unrelated to breast-feeding duration among women who breast-fed for 1 month or more (OR = 0.97, 95% CI = 0.86, 1.11). CONCLUSIONS: It is desirable to provide additional breast-feeding support during the early postpartum period to women who deliver via cesarean sections.

[Plasma fibronectin in pediatric patients]. / Fibronectina plasmática en pacientes pediátricos.

OBJECTIVE: To determine the levels of plasma fibronectin (FBN) in pediatric patients and to correlate them with serum albumin (ALB). METHODOLOGY: The FBN was measured by nephelometry and ALB by enzymatic analysis in samples from 95 healthy Mexican pediatric patients seen in the ambulatory surgery department. RESULTS: The levels of FBN was similar in boy and girls (mean +/- SD) 273 +/- 90 and 268 +/- 106 micrograms/mL respectively. FBN was significantly lower in children less than 6 months old. We found seven patients with ALB < 3.0 g/dL who had significantly lower values of FBN than the normoalbuminemic patients. The correlation of FBN and ALB was low (r = 0.23). CONCLUSIONS: FBN in pediatric patients is significatively lower than in adults. The lowest concentrations were seen in children less than 6 months old. These lower FBN may be an additional factor for immunodeficiency in this group at risk.

PRISM score evaluation to predict outcome in pediatric patients on admission at an emergency department.

This study was undertaken in order to evaluate for the first time the usefulness of PRISM score to predict outcome in pediatric patients in the Intensive Care Area of the Emergency Department at the Instituto Nacional de Pediatría in Mexico City. A prolective evaluation of PRISM score was done using 100 consecutive pediatric patients admitted to INP-ED between July and November 1992 and considered critically ill by the attending pediatricians to calculate by a lineal logistic model the expected mortality and compare with the observed one. Using a cut-off of r = 0, we evaluated at the same time the sensitivity, specificity and efficiency of this score. Fifty-eight patients were male and 42 were female. The mean age was 51 months with a range of 3 days -192 months. PRISM score for survivors was in general 8.7 +/- 7.2 and 25.8 +/- 14 for nonsurvivors (p < 0.001). Based on the logistic regression coefficients defined by Pollack et al., our sample of 100 patients was estimated to expect 12.91 deaths whereas in fact 11 were observed. Inspection of the survival rates across the different categories of expected mortality showed agreement and consistency in relation to original reports (9). The sensitivity, specificity and efficiency in general were 1.0, 0.98 and 0.98, respectively. The PRISM is an objective and efficient method which helps physicians to predict patients' outcome and risk of mortality, providing the medical staff with an epidemiological criteria. Additionally, it may be helpful in decision-making for ICU admissions and correct identification of patients who can benefit from that level of care.

Comparison of a rice-based, mixed diet versus a lactose-free, soy-protein isolate formula for young children with acute diarrhea.

A randomized clinical trial was completed to compare the efficacy of a mixed diet composed of locally available foods versus a lactose-free, soy-based formula for the management of young Mexican children with acute diarrhea and dehydration. A total of 87 patients between 5 and 36 months of age received either a blended mixed diet containing rice, chicken, carrots, beans, and vegetable oil (group MD) or a soy formula (group SF) immediately after standard oral rehydration therapy. The initial clinical characteristics of the patients in each group were similar, as were their stool outputs during the first 6-hour period of rehydration before the diets were offered. There were six treatment failures, all of which were in group SF (p < 0.01). The stool outputs of children in group MD and in group SF were 82 +/- 55 versus 112 +/- 88 gm/kg per day, respectively, on day 1 (p = 0.037), and 48 +/- 33 versus 66 +/- 55 gm/kg per day on day 2 (p = 0.109). The duration of diarrhea among those in group MD was significantly reduced compared with those in group SF (29 vs 67 hours; p < 0.001). We conclude that the mixed diet resulted in improved clinical outcomes compared with the lactose-free, soy protein isolate formula.

Safety and efficacy of a rice-based oral rehydration salt solution in the treatment of diarrhea in infants less than 6 months of age.

The safety and efficacy of a rice-based oral rehydration salt (ORS) solution for the treatment of acute diarrhea in infants < 6 months of age was compared to those of a standard glucose-based ORS solution. A total of 97 infants aged 1-6 months who had a history of acute diarrhea for 120 h or less and showed signs of mild to moderate dehydration and no complications was recruited. Subjects were assigned to two treatment groups and received either standard glucose-based ORS solution or rice-based ORS solution until cessation of diarrhea. There was no significant difference between the two treatment groups with regard to the main outcome variables, including total stool output (84 [95% confidence interval (CI), 56-126] vs. 106 (95% CI, 76-148) g/kg], total ORS solution intake [171 (95% CI, 149-197) vs. 187 (95% CI, 161-218) ml/kg], or duration of diarrhea (35 +/- 31 vs 38 +/- 32 h). In addition, the fact that there was no difference between treatment groups in the presence of reducing substances in the stools suggests that rice was digested and absorbed by these infants. The results of our study support the conclusion that for infants < 6 months of age, rice-based ORS solution is safe and as efficacious as standard glucose-based ORS solution in the treatment of acute diarrhea.

[Status epilepticus in children. Study of 70 cases]. / Estado epiléptico en niños. Estudio de 70 casos.

We presented the experience at the Emergency Unit of the National Institute of Pediatrics with children with Status Epilepticus (SE). This series studied 70 patients, the greatest frequency was seen among infants (55%), followed by preschool children (17%). The most frequent type of SE was generalized tonic clonic (54%) also being the most critical. The simple partial status or epilepsia partialis continua was found to be another frequent variety. In newborns babies the most common type of SE was generalized tonic. Sixty percent originated as acute process, their main causes were central nervous infections, ischemic-hypoxic encephalopathy, intracranial hemorrhages and intoxications. The remaining 40% were due to chronic processes, the most important was secondary epilepsy. Among these children the main cause was the irregular use of antiepileptic drugs. Other factors were intercurrent infections with fever, head trauma and hyponatremia. Only 12.8% of the cases were idiopathic. Fifteen percent of the SE were successfully treated with diazepam; 44% with phenytoin plus phenobarbital, in 34.2% we used generalized anesthesia with thiopental. In 33% of the acute cases os SE there were sequelae, there were nine deaths (12.8%) all of them with serious illness of the central nervous system.