Inês Azevedo

Clinical assessment of pediatric obstructive sleep apnea: A systematic review and meta‐analysis

Clinical symptoms and signs are routinely used to investigate pediatric obstructive sleep apnea (OSA). This study aimed to systematically assess the evidence for the diagnostic accuracy of individual or combined clinical symptoms and signs in predicting pediatric OSA.

Follow-up of the survivors of congenital diaphragmatic hernia

INTRODUCTION Survivors of congenital diaphragmatic hernia have increased with the introduction of new treatment modalities and have been reported to experience ongoing medical morbidity until adulthood. AIM To describe the long-term functional impact of congenital diaphragmatic repair on the survivors of a single institution cohort of newborns over a 14-year period. METHODS The follow up medical charts of 39 congenital diaphragmatic hernia survivors treated at a tertiary neonatal intensive care unit, from January 1997 to December 2010, were analyzed. RESULTS The median age at follow up was 70 (4-162) months. Gastrointestinal sequelae were the most common with 12 (30.7%) patients affected by failure to thrive. Chronic lung disease occurred in 5 (12.8%) patients, neurodevelopmental delay in 5 (12.8%), musculoskeletal sequelae in 6 (15.3%), recurrence of hernia in 4 (10.2%) and 2 (7.6%) were deceased. CONCLUSION Congenital diaphragmatic hernia survivors are a group of patients that requires long term periodic follow up in a multidisciplinary setting to provide adequate support and improve their quality of life.

Unattended sleep studies in pediatric OSA: a systematic review and meta-analysis.

The objective of this study was to systematically assess the evidence for the diagnostic accuracy of unattended type 2 or type 3 multichannel studies for predicting and monitoring pediatric obstructive sleep apnea (OSA). Four medical databases were searched for eligible studies. Only studies that evaluated the ability of unattended multichannel devices to accurately diagnose or monitor OSA in children were included. Those with appropriate data were selected for meta‐analysis. Study quality was assessed by using the Quality Assessment Tool for Diagnostic Accuracy Studies tool. Summary estimates of diagnostic accuracy were determined by using sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, summary receiver operating characteristics, and the area under the curve (AUC). Ten diagnostic studies with 724 patients were included in the systematic review, which was followed by a meta‐analysis using studies that provided sufficient information for the calculation of diagnostic parameters. The overall analysis revealed a moderate sensitivity of 76% (95% confidence interval [CI]: 64%‐85%), a moderate specificity of 76% (95% CI: 60%–88%), and a pooled diagnostic odds ratio of 15.18 (95% CI: 3.52–65.43). The AUC (0.88) indicated that unattended multichannel devices showed good diagnostic performance for predicting pediatric OSA. Using a cutoff of AHI >1 for the diagnosis of OSA, the results appeared to be more useful, with a higher sensitivity (88%) while maintaining a moderate specificity (71%). These findings suggest that unattended sleep studies are a good tool for predicting both the presence and severity of OSA in children, especially in those with mild‐to‐moderate disease.

Derrames pleurais parapneumónicos em pediatria: Experiência num hospital central universitário

Resumo Introducao: Os derrames pleurais podem complicar as pneumonias na populacao pediatrica. Assumem especial importância pelas implicacoes na duracao do internamento, geralmente prolongado, e pela morbilidade associada. Objectivos: Caracterizar uma populacao de doentes com pneumonia complicada de derrame; determinar os possiveis factores de prognostico a partir de dados clinicos, radiologicos e analiticos na admissao; e avaliar a influencia das intervencoes terapeuticas na evolucao da doenca. Metodos: Revisao casuistica dos doentes com idade inferior a 18 anos e derrame pleural parapneu monico, internados de Julho de 1997 a Junho de 2004 (7 anos). Resultados: Foram estudados 118 casos, 60% do sexo masculino, com idade media 7 anos. A incidencia de derrame pleural aumentou ao longo do periodo do estudo. Verificou-se maior incidencia de casos no Outono e no Inverno. Na admissao, 60% dos doentes apresentavam sinais de dificuldade respiratoria e 39% dor toracica. Em 40% dos doentes foram detectados septos pleurais na admissao, o que se associou a maior duracao de internamento e de antibioticoterapia e mais frequente necessidade de cirurgia. Em 72% dos doentes foi efectuada toracocentese (pH medio: 7,24). Em 17% foi possivel isolar o agente: Streptococcus pneumoniae (cinco), Staphylococcus aureus (quatro) e Streptococcus pyogenes (quatro). Foram submetidos a drenagem pleural 52% e necessitaram de cirurgia 18%. A mediana da duracao de internamento foi de 15 dias e a media de 16,4 dias (2 a 51). Discussao : Associam-se a pior prognostico a presenca de: sinais de dificuldade respiratoria; septos; empiema; baixo valor no liquido pleural de pH, glicose ou proteinas; desidrogenase lactica elevada no liquido pleural e proteina C-reactiva sanguinea aumentada. A drenagem pleural e/ou cirurgia mais precoces provavelmente diminuem o tempo de doenca e de internamento. Conclusao : Os derrames parapneumonicos complicados sao tratados com exito em centros de referencia com experiencia nos diferentes tipos de intervencao que poderao ser necessarios. Rev Port Pneumol 2009; XV (2): 241-259

Asthma control in children is associated with nasal symptoms, obesity, and health insurance: a nationwide survey.

This study aimed to estimate the prevalence of asthma control and determinants of poor control in the Portuguese pediatric population (<18 years); secondarily, we described asthma‐related healthcare services and medication use.

Pos-infectious bronchiolitis obliterans in children

Bronchiolitis obliterans (BO) is a rare disease in immunocompetent children that usually occurs after infection of the lower airways. While a diagnosis of BO was usually confirmed by lung biopsy, identification of prior lung lesion plus a typical clinical course and a suggestive chest X-ray and CT scan have replaced the need for more invasive procedures. The authors reviewed the clinical records of 10 BO patients, followed in the Outpatients Paediatric Pulmonology Unit from January 1997 to December 2002, to identify the most common aetiology, clinical and radiological profiles, treatment and course. All patients maintained cough and/or wheezing after the initial acute episode. 80% had failure to thrive at the time of the diagnosis, mean age 16 months. Viral pneumonia was the main initial event (5 adenovirus, 3 respiratory syncytial virus, 1 parainfluenza virus, 1 unknown). Lung biopsies were not performed as clinical and radiological presentations were typical of BO. The follow-up (mean 36 months) revealed clinical resolution in 3 children and persistent symptoms in 6. One patient had progressive respiratory failure and died. Prompt recognition of the diagnosis with supportive treatment that included oxygen therapy and an aggressive nutrition plan helped to improve the clinical state of the children.

Acute viral bronchiolitis: Physician perspectives on definition and clinically important outcomes

Two key limitations hamper intervention research in bronchiolitis: the absence of a clear definition of disease, and the heterogeneous choice of outcome measures in current clinical trials. We assessed how paediatricians and general practitioners (GPs) perceived definition and clinically important outcomes in bronchiolitis.

Pediatric parapneumonic pleural effusions: Experience in a university central hospital

INTRODUCTION Pleural effusions can complicate pneumonias in children and adolescents and are usually associated with a long hospital stay and increased morbidity. AIMS To characterise a population of patients with parapneumonic pleural effusion and to establish possible prognostic factors on admission based on clinical, imaging and analytical data. To correlate treatment options with the outcome. METHODS Case review of patients under 18 years old with parapneumonic pleural effusion, admitted between July 1997 - June 2004 (7 years). RESULTS 118 patients were included, 60% male, with mean age 7 years. The incidence of pleural effusion increased throughout the period of the study. The admissions occurred predominantly in autumn and winter. On admission 60% of patients had respiratory distress and 39% chest pain. In 40% loculations were found on admission and were associated with longer hospital stay, longer course of antibiotic therapy and more frequent need for surgery. Thoracentesis was performed in 72% of patients (mean pH pleural fluid 7.24). The aetiologic agent was identified in 17% of cases: Streptococcus pneumoniae (five), Staphylococcus aureus (four) and Streptococcus pyogenes (four). In our study, 52% of patients underwent pleural drainage and 18% surgery. Median length of hospital stay was 15 days with mean 16.4 days (2 - 51). DISCUSSION Factors associated with worse prognosis were respiratory distress, loculations, empyema, low pH in pleural fluid, glucose or proteins in pleural fluid, high lactic dehydrogenase level in pleural fluid and high serum C-reactive protein. Pleural drainage and/or surgery can shorten hospital stay and improve outcome. CONCLUSION Complicated parapneumonic pleural effusions are managed successfully in centres with experience in the different types of procedure that might be necessary.

Congenital cystic adenomatoid malformation of the lung – The experience of five medical centres

BACKGROUND The clinical spectrum of congenital cystic adenomatoid malformation of the lung (CCAML) ranges from asymptomatic lesions to neonatal respiratory distress and hydrops fetalis. AIM To review our experience with CCAML, emphasising natural history, management and outcome. MATERIAL AND METHODS A retrospective chart review of all CCAML-diagnosed neonates admitted to the neonatal intensive care units of five tertiary medical centres in the north of Portugal between 1996 and 2005. RESULTS Fifteen neonates with CCAML were identified, 9F/6M, birth weight 3100 g (645-3975), gestational age 38 weeks (24-40). The incidence of CCAML was 1: 9300 births. There were 11 (73%) cases of cystic lung lesion diagnosed during pregnancy, median age 22 weeks (19-30). The lesion was right sided in six (40%) and left sided in nine (60%) cases. In utero spontaneous regression of the lesion was observed in two cases. Antenatal intervention (pleurocentesis and thoracoamniotic shunting) was performed in one foetus with impending hydrops. Normal lung radiographic findings at birth were present in five cases, with an abnormal CT scan. Three (20%) neonates became symptomatic during the neonatal period (respiratory distress) and one (70%) after the neonatal period (spontaneous pneumothorax). Two neonates (13%) died. Six (40%) patients underwent thoracotomy and appropriate excisional surgery. Histological examination showed definitive features of CCAML (Stocker classification: type I = 4; type II = 1; type III = 2). Eight (53%) patients remain asymptomatic and did not undergo surgery. CONCLUSIONS Antenatally diagnosed CCAML has a good prognosis in the absence of severe foetal distress; normal radiographic findings at birth do not rule out CCAML; treatment of asymptomatic CCAML is controversial; surgery may be advocated because of its low morbidity and the prevention of late complications such as malignancy.

Model for prediction of pediatric OSA: Proposal for a clinical decision rule

Obstructive sleep apnea (OSA) is a syndrome frequently diagnosed in children; however, it lacks optimal diagnostic methods. This study aimed to provide a clinical decision rule for predicting pediatric OSA using commonly available clinical information.