Epidemiology of brief resolved unexplained events and impact of clinical practice guidelines in general and pediatric emergency departments.

OBJECTIVES: The aim of this study was to describe the incidence of brief resolved unexplained events (BRUEs) and compare the impact of a national clinical practice guideline (CPG) on admission and diagnostic testing practices between general and pediatric emergency departments (EDs). METHODS: Using the Nationwide Emergency Department Sample for 2012-2019, we conducted a cross-sectional study of children <1 year of age with an International Classification of Diseases diagnostic code for BRUE. Population incidence rate was estimated using Centers for Disease Control and Prevention birth data. ED incidence rate was estimated for all ED encounters. We used interrupted time series to evaluate the associated impact of the CPG publication on the outcomes of ED disposition (discharge, admission, and transfer) and electrocardiogram (ECG) use. RESULTS: Of 133,972 encounters for BRUE, 80.0% occurred in general EDs. BRUE population incidence was 4.28 per 1000 live births and the annual incidence remained stable (p = 0.19). BRUE ED incidence was 5.06 per 1000 infant ED encounters (p = 0.14). The impact of the BRUE CPG on admission rates was limited to pediatric EDs (level shift -23.3%, p = 0.002). Transfers from general EDs did not change with the CPG (level shift 2.2%, p = 0.17). After the CPG was published, ECGs increased by 13.7% in pediatric EDs (p = 0.005) but did not change in general EDs (level shift -0.2%, p = 0.82). CONCLUSIONS: BRUEs remain a common pediatric problem at a population level and in EDs. Although a disproportionate number of infants present to general EDs, there is differential uptake of the CPG recommendations between pediatric and general EDs. These findings may support quality improvement opportunities aimed at improving care for these infants and decreasing unnecessary hospital admissions or transfers.

Explanatory Diagnoses Following Hospitalization for a Brief Resolved Unexplained Event.

BACKGROUND AND OBJECTIVES: Most young infants presenting to the emergency department (ED) with a brief resolved unexplained event (BRUE) are hospitalized. We sought to determine the rate of explanatory diagnosis after hospitalization for a BRUE. METHODS: This was a multicenter retrospective cohort study of infants hospitalized with a BRUE after an ED visit between October 1, 2015, and September 30, 2018. We included infants without an explanatory diagnosis at admission. We determined the proportion of patients with an explanatory diagnosis at the time of hospital discharge and whether diagnostic testing, consultation, or observed events occurring during hospitalization were associated with identification of an explanatory diagnosis. RESULTS: Among 980 infants hospitalized after an ED visit for a BRUE without an explanatory diagnosis at admission, 363 (37.0%) had an explanatory diagnosis identified during hospitalization. In 805 (82.1%) infants, diagnostic testing, specialty consultations, and observed events did not contribute to an explanatory diagnosis, and, in 175 (17.9%) infants, they contributed to the explanatory diagnosis (7.0%, 10.0%, and 7.0%, respectively). A total of 15 infants had a serious diagnosis (4.1% of explanatory diagnoses; 1.5% of all infants hospitalized with a BRUE), the most common being seizure and infantile spasms, occurring in 4 patients. CONCLUSIONS: Most infants hospitalized with a BRUE did not receive an explanation during the hospitalization, and a majority of diagnoses were benign or self-limited conditions. More research is needed to identify which infants with a BRUE are most likely to benefit from hospitalization for determining the etiology of the event.

Brief Resolved Unexplained Events: Analysis of an Apparent Life Threatening Event Database.

OBJECTIVE: To identify the proportion of patients previously diagnosed with apparent life-threatening events (ALTE) who would meet criteria for brief resolved unexplained events (BRUE) and to identify rates of adverse outcomes in subgroups: ALTE not meeting criteria for BRUE, lower-risk BRUE, and higher-risk ALTE. METHODS: We performed a secondary analysis of a single-center prospective registry of patients diagnosed with ALTE in a tertiary care emergency department from March 1, 1997 to October 31, 2007. We identified the proportion of patients meeting criteria for BRUE, and the proportion of patients with BRUE meeting lower-risk criteria. We assessed outcomes of patients in subgroups. RESULTS: Seven hundred and sixty-two patients were included. Adverse outcomes included recurrent ALTE (n = 49), aspiration (n = 9), trauma (n = 8), and death (n = 4). Three hundred and twenty-six of 762 (42.8%) met criteria for BRUE. Seventy of 326 (21.5%) met criteria for lower-risk BRUE. Adverse outcomes occurred in 40 of 436 (9.2%) with ALTE not meeting criteria for BRUE, 2 of 70 (2.9%) with lower-risk BRUE, and 23 of 256 (9.0%) with higher-risk BRUE. Of 4 patients who died, 1 had an ALTE not meeting criteria for BRUE and 3 had non-lower-risk BRUE. The BRUE risk criteria identified all BRUE patients that died or had substantial morbidity as higher-risk. CONCLUSIONS: Less than half of patients with ALTE meet criteria for BRUE. Of those who do, one-fifth is lower-risk. In this series, the risk-stratification in the BRUE criteria identified those patients at highest risk of adverse outcomes. Further research is required to risk-stratify patients with BRUE.

El desafío de la cronicidad compleja y la atención paliativa en la pediatría / The challenge of comlex chronicity and palliative care in paediatrics

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Unidad de Cuidados Paliativos pediátricos del Hospital Sant Joan de Déu / Pediatric palliative cares units of the Hospital Sant Joan de Déu

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Esophageal multichannel intraluminal impedance and pH testing in the study of apparent life threatening episode incidents in infants.

INTRODUCTION: The conventional 24-hour pH monitoring is the gold standard for the diagnosis of gastro-esophageal reflux (GER), a possible cause of Apparent Life Threatening Episodes (ALTE). However, multichannel intraluminal impedance (MII) may provide advantages. OBJECTIVES: Comparison of the results of MII and pH monitoring in patients undergoing MII-pH monitoring in the 3-year study period because of having suffered from ALTE. MATERIAL AND METHODS: Prospective study of MII-pH monitoring performed in our unit to infants < 12 months of ageadmitted for ALTE for a 3-year period. RESULTS: Thirty nine patients studied. 2,692 pH monitoring episodes, with median of 24 (IQ: 15-44) episodes/patient, 1.30 (IQ: 0.80-2.60) reflux/hour, 1 (IQ: 0-4) reflux episode > 5 min per patient and clearance of 1.20 (IQ: 0.70-2.20) min/reflux. With pH monitoring analysis, 14 children (35.9 %) could have been diagnosed as GER (8 mild, 4 moderate and 2 severe) based on the classical criteria. MII identified a total of 8,895 events; only 3,219 among them were refluxes, with a median of 75 (IQ: 54-111) per patient, 1.30 (IQ: 1.3-2.6) episodes/hour). With MII-pH monitoring combination there were 21.60 (SD 15.21) acid reflux episodes, 67.33 weekly acid (SD 32.09) and 3.34 (SD 7.23) non-acid, being finally diagnosed 33 patients as GER. CONCLUSIONS: The association of pH monitoring and MII provides additional information that improves GER diagnostic performance without posing any additional risk to the infant patient. The non-acid/weekly acid refluxes, not detected by pH monitoring, account for a high percentage of episodes, this may have diagnostic and therapeutic significance, especially in infants. Further studies are needed to assess the normality of MMI in pediatric patients.

Caracterización actualizada del síndrome de ALTE / Upadated characterization of ALTE syndrome

El ALTE no es una enfermedad específica en sí misma, sino una forma de presentación clínica de diversas enfermedades, su incidencia se estima en 6 por 1 000 en aquellos lactantes nacidos a término, y asciende a un 86 por 1 000 en los nacidos pretérmino. Su etiología es multifactorial, el diagnóstico es difícil y precisa de experiencia, y la conducta depende de las causas que lo originen. Esta afección poco reconocida en la práctica médica actual, genera una enorme ansiedad en la familia, y constituye un desafío en cuanto al diagnóstico, manejo y consejos por parte del pediatra

Apparent life-threatening event (ALTE) is not a specific disease, rather a form of clinical presentation of several diseases. Its incidence rate is estimated to be 6 per 1000 in the term infants and 86 per 1000 in preterm infants. The etiology of the event is multifactoral, the diagnosis is difficult and requires experience, and the behavior to be adopted depends on the causes that bring it about. This poorly recognized illness in the present medical practice gives rise to a lot of anxiety for the family and represents a true challenge in terms of diagnosis, management and counseling by the pediatrician

Caracterización actualizada del síndrome de ALTE / Upadated characterization of ALTE syndrome

El ALTE no es una enfermedad específica en sí misma, sino una forma de presentación clínica de diversas enfermedades, su incidencia se estima en 6 por 1 000 en aquellos lactantes nacidos a término, y asciende a un 86 por 1 000 en los nacidos pretérmino. Su etiología es multifactorial, el diagnóstico es difícil y precisa de experiencia, y la conducta depende de las causas que lo originen. Esta afección poco reconocida en la práctica médica actual, genera una enorme ansiedad en la familia, y constituye un desafío en cuanto al diagnóstico, manejo y consejos por parte del pediatra(AU)

Apparent life-threatening event (ALTE) is not a specific disease, rather a form of clinical presentation of several diseases. Its incidence rate is estimated to be 6 per 1000 in the term infants and 86 per 1000 in preterm infants. The etiology of the event is multifactoral, the diagnosis is difficult and requires experience, and the behavior to be adopted depends on the causes that bring it about. This poorly recognized illness in the present medical practice gives rise to a lot of anxiety for the family and represents a true challenge in terms of diagnosis, management and counseling by the pediatrician(AU)

Caracterización actualizada del síndrome de ALTE / Upadated characterization of ALTE syndrome

El ALTE no es una enfermedad específica en sí misma, sino una forma de presentación clínica de diversas enfermedades, su incidencia se estima en 6 por 1 000 en aquellos lactantes nacidos a término, y asciende a un 86 por 1 000 en los nacidos pretérmino. Su etiología es multifactorial, el diagnóstico es difícil y precisa de experiencia, y la conducta depende de las causas que lo originen. Esta afección poco reconocida en la práctica médica actual, genera una enorme ansiedad en la familia, y constituye un desafío en cuanto al diagnóstico, manejo y consejos por parte del pediatra(AU)

Apparent life-threatening event (ALTE) is not a specific disease, rather a form of clinical presentation of several diseases. Its incidence rate is estimated to be 6 per 1000 in the term infants and 86 per 1000 in preterm infants. The etiology of the event is multifactoral, the diagnosis is difficult and requires experience, and the behavior to be adopted depends on the causes that bring it about. This poorly recognized illness in the present medical practice gives rise to a lot of anxiety for the family and represents a true challenge in terms of diagnosis, management and counseling by the pediatrician(AU)

Episodis aparentment letals en el lactant. Revisió de tres anys i proposta de protocol diagnòstic / Episodios aparentemente letales en el lactante. Revisión de tres años y propuesta de protocolo diagnóstico / Apparent life-threatening events in children review of a 3-year experience and proposal of a diagnostic algorithm

Fonament. Els episodis aparentment letals (EAL) són una entitat freqüent als serveis d’urgències, pel que es considera imprescindible optimitzar el seu maneig diagnòstic i terapèutic. Objectiu. Revisar factors de risc, característiques, etiologia i evolució dels EAL, i la utilitat de la monitorització domiciliària. Mètode. Estudi retrospectiu durant des de gener 1999 a desembre 2001 dels EAL ingressats al nostre centre i portadors de monitorització domiciliària i comparació dels resultats obtinguts amb la bibliografia. Resultats. 223 nens portadors de monitor domiciliari revisats: 90 per EAL (40.3%). Edat mitja de presentació: 2.35 mesos; 81% menors de 2 anys. 51% sexe femení. 38% durant l’hivern, en clara relació amb catarro de vies altes (CVA) concurrent. Cianosi : 52%, alteració del to muscular 38%. 36% relacionats amb la ingesta; d’aquests, 75% presentaven alteracions al trànsit esofagogastroduodenal (TEGD) o a la pHmetria. Exploració física alterada en 33%; la meitat orientaven al diagnòstic final. Analítica de sang, ecografia cerebral, electrocardiograma (ECG) i fons d’ull aporten poc al diagnòstic final. Polisomnografia patològica en 17 de 65 casos. Estudi de deglució alterat en un 12% i exploració otorrinolaringològica en un 11%. Aspirats nasofaringis patològics en 6 pacients. Etiologia: reflux gastroesofàgic (RGE) (51%), laringomalàcia (7%), alteracions de la deglució (6%), idiopàtics (13%). Temps mig de monitorització: 7.5 mesos. Recurrències en un 12%. Conclusions. 1) El 81% eren menors de 2 mesos amb una distribució per sexes homogènia. 2) En 50% dels casos amb exploració física alterada, aquesta orientava al diagnòstic. 3) Algunes proves complementàries incloses al nostre protocol aporten molt poc al diagnòstic etiològic. 4) La causa més freqüent a la nostra població és el RGE. 5) És bàsic establir la relació causal entre RGE i EAL: la realització de la polisomnografia-pHmetria simultània adquireix un protagonisme capital. 6) Un 84% dels casos es resol espontàniament sense requerir reanimació per part de pares ni personal sanitari. 7) És indispensable un seguiment multidisciplinari d’aquests nens i les seves famílies (AU)

Fundamento. Los episodios aparentemente letales (EAL) son una entidad frecuente en los servicios de urgencias, por lo que se considera imprescindible optimizar su manejo diagnóstico y terapéutico. Objetivo. Revisar factores de riesgo, características, etiología y evolución de los episodios aparentemente letales (EAL), y utilidad de la monitorización domiciliaria. Método. Estudio retrospectivo de enero 1999 a diciembre 2001 de los EAL ingresados en nuestro centro y portadores de monitorización domiciliaria y comparación de los resultados obtenidos con la bibliografía. Resultados. 223 niños portadores de monitor domiciliario revisados: 90 por un EAL (40.3%). Edad media de presentación: 2.35 meses; 81% menores de 2 años. 51% sexo femenino. 38% en invierno, en clara relación con un catarro de vías altas (CVA) concurrente. Cianosis: 52%, alteración del tono muscular: 38%. 36% relacionados con la ingesta; de estos, 75% presentaban alteraciones en el tránsito esofagogastroduodenal (TEGD) o en la pHmetria. Exploración física alterada en 33%; la mitad orientaban al diagnóstico final. Analítica de sangre, ecografía cerebral, electrocardiograma (ECG) y fondo de ojo aportaron poco al diagnóstico final. Polisomnografía patológica en 17 de 65 casos. Estudio de deglución alterado en un 12% y exploración otorrinolaringológica en un 11%. Aspirados nasofaríngeos patológicos en 6 pacientes. Etiología: reflujo gastroesofágico (RGE) (51%), laringomalacia (7%), alteraciones de la deglución (6%), idiopáticos (13%). Tiempo medio de monitorización: 7.5 meses. Recurrencias en un 12%. Conclusiones. 1) El 81% eran menores de 2 meses con una distribución por sexos homogénea. 2) En 50% de los casos con exploración física alterada, ésta orientaba al diagnóstico. 3) Algunas de las pruebas complementarias incluidas en nuestro protocolo aportan muy poco al diagnóstico etiológico. 4) La causa más frecuente en nuestra población es el RGE. 5) Es básico establecer la relación causal entre RGE y EAL: la realización de la polisomnografíapHmetría adquiere un protagonismo capital. 6) Un 84% de los casos se resuelven espontáneamente sin requerir reanimación por parte de padres ni personal sanitario. 7) Es indispensable un seguimiento multidisciplinario de estos niños y sus familias (AU)

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