G. Claret Teruel

Guía de práctica clínica sobre la bronquiolitis aguda: recomendaciones para la práctica clínica

There are scientific controversies about the management of acute bronchiolitis that generate a great variability in the approach to this entity. A clinical practice guideline (CPG) is a set of systematically developed recommendations to assist practitioners and patients to make decisions based on evidence. A working group (WG) of experts has been selected and they have developed the clinical questions. A systematic search for evidence on the acute bronchiolitis has been done and the evidence has been assessed. The information obtained has been summarized in evidence tables and recommendations have been done from them. The WG has produced a total of 46 clinical questions grouped into sections (diagnosis, complementary tests, treatment, monitoring, prevention and evolution), resulting in 133 recommendations. The CPG on acute bronchiolitis provides an opportunity to unify clinical practice based on scientific evidence, which could rationalize the use of health resources, improving health care quality and equity of access to services.

Variability of immunodeficiency associated with ataxia telangiectasia and clinical evolution in 12 affected patients

Ataxia telangiectasia (AT) is an infrequent condition, which is difficult to diagnose in children. The objective was to describe the evolution of all affected patients controlled in our hospital and to highlight the keys for an early diagnosis considering the variability of immunological disorders. The present study is a retrospective review of all patients diagnosed and controlled of AT in our hospital. Twelve patients were found, including two couples of siblings. The most frequent reason for consultation was unstable gait. Seven patients suffered repeated infections, being pneumonia the most frequent cause of infection, followed by sinusitis. One of the patients developed Burkitts lymphoma, and another patient, Hodgkins lymphoma, which caused the death of the patient at the age of 11. A couple of siblings aged 17 and 22 years developed insulin‐resistant diabetes mellitus. The most frequent immunity disorders were the IgG deficiency and the decrease of T lymphocytes. Seven patients were treated with non‐specific gamma‐globulin. By the end of the follow‐up, 8 patients (ages ranged 7 to 12 years) lost gait. Molecular genetic testing was conducted in patients who are still cared for in our hospital. Clinical suspicion of this entity will lead to an early diagnosis, the treatment of complications, and to provide genetic counselling for the families.

Lesión medular aguda en edad pediátrica

Introduccion La lesion medular aguda es una entidad de escasa frecuencia en edad pediatrica pero adquiere especial relevancia debido a las graves secuelas y a las prolongadas estancias que provoca. Objetivos Conocer la epidemiologia, forma de presentacion, pruebas diagnosticas, tratamiento y evolucion de las lesions medulares agudas ingresadas en un hospital pediatrico de tercer nivel. Determinar el efecto que puede tener la traqueostomia precoz en el tiempo de estancia en la Unidad. Pacientes y metodos Se trata de un estudio retrospectivo de cohortes que revisa las lesiones medulares agudas ingresadas en nuestro centro desde el ano 1992. Resultados Se recogieron 16 pacientes, 12 varones (75%) con edades al ingreso comprendidas entre las pocas horas de vida y los 19 anos. Los dias de ingreso en la unidad de cuidados intensivos oscilaron entre 12 h y 6 anos. En 4 casos la causa fue una lesion obstetrica; uno de ellos fallecio y el resto se encuentran en su domicilio con ventilacion mecanica. En 7 casos la causa fue traumatica; fallecieron 2 pacientes, otros dos residen en un centro sociosanitario y tres en su domicilio. En 2 casos la causa fue una malformacion vascular medular y los tres ultimos se presentaron en el postoperatorio inmediato de una cirugia de columna. De los 16 pacientes recogidos el 56,2% fueron traqueostomizados y el 83 % de los supervivientes residen en su domicilio. Conclusiones La realizacion precoz de la traqueostomia, la posibilidad de la ventilacion mecanica domiciliaria y la instruccion de las familias ha permitido reducir la estancia de estos pacientes en la Unidad y que puedan residir en su casa.

Oral therapy for urinary tract infections in infants aged 3 to 12 months

Urinary tract infections (UTI) are one of the most common serious bacterial infections in infants. Guidelines in the past recommended intravenous (IV) antibiotics for the treatment of febrile UTI [1, 2]. However, a randomized controlled trial and a Cochrane systematic review demonstrated that oral cefixime is a safe and effective treatment [3, 4]. Oral amoxicillin-clavulanic acid has also been demonstrated to be as effective as initial IV antibiotics [5]. Oral therapy would preclude the costs associated with hospitalization. The choice of initial antimicrobial should be guided by local resistance patterns [5]. In our environment, cefixime or amoxicillin-clavulanic acid could be regarded as safe options [6, 7]. The aim of our study was to evaluate response to oral amoxicillin-clavulanic acid in children aged 3 to 12 months with their first episode of UTI and to compare the response with that of a historical cohort of patients treated in our center with IV therapy. We conducted a prospective study between November 2005 and September 2006. Children aged 3 to 12 months were considered to be eligible if they had an axillary temperature of 38°C or more at presentation or within 24 h and were suspected of having a UTI because of the presence of any degree of bacteriuria. Final eligibility required that there be a positive urine culture (≥10,000 colony-forming units/ml, single pathogen) from a specimen obtained by catheter. Children were excluded if they had hypersensitivity to penicillin, a history of UTI or abnormalities of the urinary tract, had received a systemic antimicrobial in the previous 48 h, had an underlying chronic disease, or had not completed the follow-up protocol. Infants assessed as toxic, dehydrated, or unable to retain oral intake were also excluded from the study. All children included in the study received oral amoxicillinclavulanic acid (Augmentine® oral solution 100/12.5, GlaxoSmithKline, Madrid, Spain) 40 mg/kg/day for 10 days. We modified the treatment in children with persistent fever (>38°C) in the 72 h after the start of treatment and those with intolerance or an adverse reaction to the drugs used. Renal ultrasound and a voiding cystourethrogram (VCUG) were performed within 10 days from the diagnosis and a Tcdimercaptosuccinic acid (Tc-DMSA) renal scan was performed 6 months later. We also conducted a retrospective study including infants with UTI aged 3 to 12 months treated with IV amoxicillin-clavulanic acid 100 mg/kg/day for 3 days or until they became afebrile, before the implementation of the new guidelines, from June 2004 to November 2005. The inclusion and exclusion criteria were the same as for the prospective study group. Outcomes of the group treated with oral amoxicillin-clavulanic acid were comparedwith outcomes of the retrospective group. Eur J Clin Microbiol Infect Dis (2008) 27:887–889 DOI 10.1007/s10096-008-0517-3

Paraparesia aguda no traumática

Se trata de un varón de 14 años remitido desde otro hospital porque 7 h antes presentó dolor en la zona interescapular de aparición brusca, sin antecedente traumático previo y que se autolimitó. Una hora más tarde aparecieron parestesias en extremidades inferiores y cuando a las 2 h de iniciarse el cuadro intentó levantarse presentó debilidad muscular que le impedía la sedestación y la deambulación. A su llegada a urgencias era incapaz de movilizar las extremidades inferiores y el hemiabdomen inferior y se observó hipoestesia en ambas extremidades inferiores y nivel sensitivo claro a nivel de hemiabdomen superior. Los reflejos rotulianos y aquíleos estaban abolidos bilateralmente y el reflejo cutáneo plantar era en flexión. No era capaz de controlar los esfínteres y no refería dolor. Con la sospecha de un síndrome de compresión medular aguda se inició tratamiento con metilprednisolona por vía intravenosa en dosis de shock medular (bolo inicial de 30 mg/kg seguido de 5 mg/kg/h durante 23 h) en espera de poder precisar la etiología del proceso. La RM medular mostró una lesión en D2 compatible con una malformación arteriovenosa (MAV) de tipo II o III, sangrado adyacente en C7 y mielopatía asociada desde C3 a D5 (fig. 1). La RM craneal fue normal. A las pocas horas se realizó una arteriografía con embolización de la MAV (fig. 2). Actualmente el niño se encuentra en programa de rehabilitación con secuelas graves.