Search

Background Community-acquired pneumonia (CAP) represents a major cause of hospitalization, especially among young children. In the third world countries, information about CAP etiology is scarce. Therefore, rapid and highly sensitive diagnostic methods are crucial to determine etiologic agents. Methods Between March 2016 and March 2017, we have prospectively studied the clinical, radiologic, laboratory, and molecular aspects of patients with CAP at 2 tertiary-level hospitals in Santa Cruz de la Sierra, using a multiplex real-time polymerase chain reaction (RT-PCR). Results A total of 274 children were evaluated, with a median age of 13 months. An etiologic agent was identified in 187 patients (68.2%): 54% (n = 148) were viruses and 14.2% (n = 39) were bacteria. CAP prevalence was highest among children under 2 years (71%; 195/274); respiratory syncytial virus (RSV) was the most frequent cause in 22% (60/274), especially among infants, followed by influenza (14.5%; 40/274). Streptococcus pneumoniae accounted for 7% of the total (19/274), followed by Staphylococcus aureus (3%;8/274) and Haemophilus influenzae (1.4%;4/274). Together, these cases accounted for 79.5% (31/39) of all bacterial CAP. Pleural effusion (PE) complicated CAP in 13.8% (38/274), of which 29 were of bacterial etiology. RT-PCR increased the detection rate of pneumococcus by 47%. Coinfection occurred in 28 patients (10%); 26 (9.5%) required intensive care and 9 patients (3%) died. Conclusions RT-PCR provided additional diagnostic value to conventional, clinical, and laboratory methods. The higher prevalence of RSV, influenza, and Streptococcus pneumoniae reveals the need for preventive measures with better vaccine uptake and future research for RSV vaccines.

Objectifs: Developper le premier registre des traumatismes pediatriques espagnol pour apprecier les differents aspects des traumatismes dans notre population pediatrique. Methodes: De janvier 1995 a aout 1998, 35946 enfants de moins de 16 ans ont ete traites dans notre hopital pour traumatisme. 1500 etaient admis et inclus dans notre etude. Notre etude comporte 108 points incluant l'identification du patient, le type, la place et le mecanisme du traumatisme, les soins pre-hospitaliers, le transport, le bilan a l'admission, les scores de severite, le diagnostic, les traumatismes, la morbidite du traitement et la mortalite. Resultats: Les accidents etaient plus frequents chez les garcons (68%) que chez les filles. Le groupe predominant etait le groupe 12-15 ans (34%). Les accidents etaient plus frequents dans la rue (35,1%) qu'a la maison (18,9%) ou a l'ecole (13%). Les chutes et les accidents en rapport avec la circulation etaient la principale cause de blessures (39% et 21,2% respectivement). Deux cent trente-cinq (15,7%) avaient un « Pediatric Trauma Score » ≤ 8. Cinquante de ceux-ci presentaient un polytraumatisme (33%) (« Injury Severity Score » ≥ 15). Les traumatismes osseux et les traumatismes crâniens etaient les plus frequents (48,5% et 42,0% respectivement). Une intervention chirurgicale ou orthopedique etait realisee chez 906 patients (56,5%). La duree moyenne de sejour etait de 4,5 jours (moyenne 1,93 jours). Une alteration fonctionnelle chez des enfants de plus de 4 ans etait retrouvee chez 413 enfants (33,3%). Nous deplorons 7 morts parmi les 1500 patients et une mortalite de 0,5%. Ces 7 deces etaient observes seulement dans le groupe de patients avec un ISS > 15, avec un taux de mortalite de 14%. Conclusion: Le but de ce registre est d'etablir l'epidemiologie de la population pediatrique accidentee, de revoir la prise en charge des patients, de developper des programmes de prevention et de comparer les resultats avec ceux d'autres centres afin de corriger d'eventuels defauts de prise en charge.

The results of three different surgical procedures for the correction of bunions on 25 adolescent feet (distal soft-tissue procedure, proximal closing-wedge osteotomy of the first metatarsal with distal soft-tissue procedure, and proximal phalangeal osteotomy) are reviewed. The results with an average follow-up of 3.5 years were excellent or good in 21 cases, and fair or poor in 4. The average correction of the metatarsophalangeal angle, the intermetatarsal angle, and the hallux valgus interphalangeus angle was, respectively, 9.88, 3.11, and 0.0 degrees for the first procedure, 21.0, 6.87, and 0.0 degrees for the second, and 11.0 0.9, and 22.5 degrees for the third. We conclude that distal soft-tissue reconstruction allows only mild to moderate correction of the metatarsophalangeal and intermetatarsal angles, and the association of a proximal osteotomy of the first metatarsal produces an statistically significant better correction (p < 0.05). Hallux valgus interphalangeus deformities are corrected only by proximal phalanx osteotomies. The selection of a particular procedure should therefore be based on an appropriate preoperative planification.

Subluxation of the radial head is a common injury in young children. It occurs after longitudinal traction on the extended arm with the forearm in pronation. Diagnosis is made from history and clinical presentation. Closed reduction achieved by supination and flexion or by hyperpronating the affected arm can usually restore normal anatomy satisfactorily. Rarely, it requires open reduction. There are very few cases in the literature that have required open reduction and no article shows intraoperative photographs. We present two cases of delayed diagnosis owing to an atypical clinical history that required open reduction.

To identify the incidence of unplanned extubations (UE) in a general intensive care unit (ICU) and associated risk factors.An analytical, observational and prospective study was performed in an eight-bed general ICU over a 6-month period. The participants consisted of 79 consecutive patients who underwent mechanical ventilation for 12 h or more and who were under the ventilator weaning phase. The variables studied were age, days of endotracheal intubation, length of stay in the ICU, weaning phase and the APACHE II prognostic score; the degree of sedation and/or agitation was evaluated using Riker's Sedation-Agitation Scale. The incidence density of UEs was calculated and the variables measured in the extubated and non-extubated groups were compared using the Mann Whitney U-test.Among the 79 patients studied, UE occurred in 15 (18.9%). Of these events, 76.9% occurred during the ventilator weaning phase. There were 11 cases (73.3%) of self-extubations, three cases (20%) of accidental removal and one case (6.6%) of endotracheal tube obstruction. Age equal to or less than 60 years was a risk factor. No relationship was found with the remaining factors studied: days of hospital stay, days of endotracheal intubation or APACHE score.Patients at risk for UE were younger and showed agitation on the Riker scale. UEs usually occurred during the ventilator weaning phase.

Musculoskeletal complications are uncommon in HIV-infected patients. In adults, one manifestation is osteonecrosis which can be associated with risk factors such as alcohol consumption, smoking or use of corticosteroids. Such risk factors are rare in children. Over the last decade musculoskeletal complications have been observed in patients with advanced-stage disease or whose immune system has been reconstituted with highly active antiretroviral therapy (HAART). This complication has been reported in adults but to date not in children. We present the case of a 5-year-old child with AIDS (C stage 3) who developed osteonecrosis related to the advanced stage of the illness and to HAART. No risk factors were found.

Buts: Analyser les caracteristiques de la population pediatrique se presentant avec un traumatisme dans notre environnement. Evaluer l'importance des differents mecanismes etiologiques, etudier le managementpre et intra-hospitalier de ces enfants. Decrire les differentes lesions. Etablir l'importance du traumatisme pediatrique comme un probleme de societe en termes de morbidite et de mortalite. Materiel et Methodes: De Janvier 1995 a Avril 2002, un total de 2633 enfants ont ete admis dans notre centre (Hopital Universitaire Gregorio Maranon) ayant presente une blessure incluse dans notre registre des traumatismes. 108 variables ont ete analysees incluant l'identification du patient, le type, la localisation et le mecanisme de l'accident, les soins pre-hospitaliers, le transport, l'evaluation complete a l'admission, les indices de severite, les diagnostics, les lesions, les traitements realises, la morbidite, la mortalite. Resultats: Les accidents sont plus frequents chez les garcons que chez les filles (68,5% contre 31,5%). L'âge predominant est le groupe 12/15 ans (36,8%). Il y a une grande frequence d'accidents dans la rue (37,2%) plus qu'a la maison (19,4%) ou a l'ecole (13,8%). Le plus frequent des mecanismes est la chute (35,6%) suivi par les accidents de la circulation (23,7%). A l'admission, 14,7% des enfants ont un Paediatric Traumatisme Score (P.T.S.)

Epidemiological analysis of main factors affecting multiple trauma in children in our environment.We reviewed the data collected from the patients (n = 2.166) admitted to our hospital because of trauma and included in our Registry from January 1995 to December 2000. Among this group 79 patients were considered severely injured trauma patients according Injury Severity Score (ISS) (ISS15) and selected for the study. Statistical analysis was done using chi2 and Student t test, p values under 0.01 were considered significant.Group gender distribution was 49 males and 30 females, age average was 9.7 years (range 0-15 years) Traffic related injuries were the leading cause of trauma in this group (77,2%). Initial triage by using the Pediatric Trauma Score allowed identifying the injury severity in 73,4% of patients (58 children obtained a PTSor = 8). In 32,9% of the cases the patient was in coma at admission in the Emergency (Glasgow Coma Scaleor = 8, n = 26). ISS average was 23.4 (range 16-75). Most patients suffered from multiple injuries (87,3%), average of injuries number was 4,7 (range 1-9). The most frequent trauma localization was cranial trauma. Admission in the intensive care unit was necessary in 65,8% of patients, and any kind of surgical procedure was done in 35,4%. Average length of stay was 17,1 days (range 0-214 days). Injury severity was higher in automotive patients without restraining systems (I.S.S. average 27,2, mortality 16,6%). Overall mortality was 11,4% (n = 9), and 94.3% of patients presented any functional or anatomic disability.Traffic related injuries are the main cause of multiple trauma in children. The severity and high mortality of these injuries make imperative polytonal education systems and the use of restraining devices.

In 1997 we developed the "Pediatric Trauma Life Support Course"applied to every one who provide care for the pediatric trauma patient. Since November 1997 until December 2000, 14 courses were imparted inside of the "Comunidad de Madrid" with total number of 289 students. Thirty-eight students have been people who worked in the prehospital area inside of our Community. The aim of this paper is to determinate the possible impact of these Courses in the prehospital management of the pediatric trauma patient.We reviewed the Pediatric Trauma Registry inputs of our hospital since January 1995 until December 2000. A total number of 2166 patients required admission in our hospital after the injuries. 495 patients which moved to our Institution by medical people and a special transport (ambulance/medical van) were enrolled. The patients were classified into two groups. In the first group were included the children admitted between 1995 to 1997 (group 1, n = 232), before we had applied our Courses and in the second group, the patients admitted between 1998 to 2000 (group II, n = 263), after The Pediatric Trauma Life Support Course was conducted. Both groups seems to be equal if we compare the age, sex and severity of the injuries. We analysed the infant orotracheal intubation in a coma patient, gastric intubation in the several trauma patient, vascular access and apply a semirigid cervical collar into a head injury. If we think that the application of these manouvers will be a good quality index of the management of these patients in the prehospital area, we compare the index of application of these variables according to the years before and after the Courses were imparted. For this pourpose we used the X2 test shows significant differences within both groups if p0.05.All paramethers analyzed were better in group II than in group I (p0.05).The results of this paper shows that the use of this program for the management of the pediatric trauma patient is going well and the assessment is doing better than few years before.

Advances in obstetric practice have decreased birth traumas in the last years, although they are still an important chapter in neonatal age. Between 1993-1998 a total of 21,375 stillborns were registered with a total of 309 birth injuries in 303 neonates (1.44%). The diagnoses were: 2 liver subcapsular hematomas, 105 cephalohematomas, 16 parietal fractures, 11 subdural hemorrhages, 107 clavicular fractures, 10 miscellaneous fractures, 8 soft tissue injuries, 25 facial nerve injuries and 25 braquial palsy. About relation between type of labor and birth trauma was found that clavicular fracture and cephalic vaginal delivery were associated in 50% of the cases, cephalohematoma and forceps in 51%, braquial palsy and vaginal delivery in 44% and forceps in 36%. High weight at birth was another risk factor for entities such as clavicular fracture and braquial palsy. We conclude that birth trauma is a pathology with a relevant incidence and their epidemiology factor had to be known.

Objectives:To estimate the frequency of and risk factors for surgical-site infections (SSIs) in Bolivia, and to study the performance of the National Nosocomial Infections Surveillance (NNIS) System risk index in a developing country.Design:A prospective study with patient follow-up until the 30th postoperative day.Setting:A general surgical ward of a public hospital in Santa Cruz, Bolivia.Patients:Patients admitted to the ward between July 1998 and June 1999 on whom surgical procedures were performed.Results:Follow-up was complete for 91.5% of 376 surgical procedures. The overall SSI rate was 12%. Thirty-four (75.6%) of the 45 SSIs were culture positive. A logistic regression model retained an American Society of Anesthesiologists score of more than 1 (odds ratio [OR], 1.87), a not-clean wound class (OR, 2.28), a procedure duration of more than 1 hour (OR, 1.81), and drain (OR, 1.98) as independent risk factors for SSI. There was no significant association between the NNIS System risk index and SSI rates. However, a “local” risk index constructed with the above cut-off points showed a linear trend with SSI (P < .001) and a relative risk of 3.18 for risk class 3 versus a class of less than 3.Conclusions:SSIs cause considerable morbidity in Santa Cruz. Appropriate nosocomial infection surveillance and control should be introduced. The NNIS System risk index did not discriminate between patients at low and high risk for SSI in this hospital setting, but a risk score based on local cutoff points performed substantially better.

To assess the usefulness of a technique for inserting hookwires guided by computed tomography to locate and resect pulmonary nodules by video-assisted thoracoscopy. To describe the procedure and its complications.Nine pulmonary nodules were located in nine patients. All were/= 2 cm in diameter, radiologically undefined and of unknown origin. Four patients had a history of cancer. The nodules were located using the needle/hookwire system (Kopans), guided by computed tomography and were resected by video-assisted thoracic surgery.The hookwire was placed correctly in 8 patients and incorrectly in 1. Thoracotomy was necessary for 1 patient. The histologic diagnosis was benign for all 9 nodules; 5 were hamartomas, 2 were necrotic or fibrotic nodules, 1 was a granuloma and 1 was an anthracotic node. Hospital stay ranged from 1 to 8 days (mean 3.3 days).The location of pulmonary nodes by hookwire and needle for later resection by video-assisted thoracoscopic surgery is a simple, safe way to facilitate removal in some cases, for diagnosis and treatment.

Subacute osteomyelitis has a very anodyne symptomatology and is, therefore, difficult to diagnose. We studied 21 cases treated between 1984 and 1998 with subacute osteomyelitis of variable location and a mean diagnostic delay of 158.5 days. Of these, 10 cases could not be placed in the current classification. Diagnosis was radiologic in all cases, although in a few patients confirmation by isotopic bone scan and magnetic resonance imaging was required. Treatment was surgical in the first 11 cases to become, currently, predominantly conservative. The causal microorganism was only isolated in nine cases. Complete healing without sequelae was achieved in all but one case, which was of very tardy diagnosis and developed coxarthrosis.

Seven cases of premature physeal closure secondary to diaphyseal fractures of the tibia in adolescents between 12 and 15 years of age are presented. At the time of the accidents, there was no evidence of physeal lesion in any of the patients. After 4 to 13 months of follow-up (mean, 9 months), early closure was observed in the radiologic controls of one or more physes of the affected leg: distal femoral and proximal and distal tibial in three cases, isolated distal femoral physis in three cases, and both tibial physes without femoral damage in one case. Physeal closure was always central, and there was no case of angular deformity. After 15 to 42 months of follow-up (mean, 27 months), all patients had a leg-length discrepancy in the 8- to 30-mm range (mean, 18 mm). Only one patient required surgical correction (proximal epiphysiodesis of the contralateral tibia followed by tibial lengthening). Adolescents with diaphyseal fractures of the long bones should be monitored until they have stopped growing because of the risk of developing leg-length discrepancy as a consequence of premature closure of one or more leg physis.

A novel water quality intervention that consists of point-of-use water disinfection, safe storage and community education was field tested in Bolivia. A total of 127 households in two periurban communities were randomized into intervention and control groups, surveyed and the intervention was distributed. Monthly water quality testing and weekly diarrhoea surveillance were conducted. Over a 5-month period, intervention households had 44% fewer diarrhoea episodes than control households (P=0·002). Infants P=0·05) and children 5–14 years old (P=0·01) in intervention households had significantly less diarrhoea than control children. Campylobacter was less commonly isolated from intervention than control patients (P=0·02). Stored water in intervention households was less contaminated with Escherichia coli than stored water in control households (PE. coli contamination of stored water and less diarrhoea than control households. This promising new strategy may have broad applicability for waterborne disease prevention.

In order to collect and evaluate information concerning aspects of injuries in our pediatric population, we developed the first Spanish Pediatric Trauma Registry.During 1995, 11,307 patients were seen at our hospital for acute injuries: 521 were admitted to the hospital and are included in our database. Each patient's protocol consists of 103 data points including: patient identification, type, place and mechanism of injury, prehospital care, transport, assessment on admission, severity scores, diagnostic studies, injuries, treatment and morbidity-mortality.We found that accidents were more frequent in males (69) than in females. The predominant age group was 12-15 years (36%). Falls were the leading cause of injury (37%). A pediatric trauma score of 8 or less was seen in 13.4% of the cases. Twenty-nine patients were hospitalized in the Intensive Care Unit and 214 needed some surgical treatment.The utility of this registry is: 1) The knowledge of the epidemiology of our pediatric population. 2) To know and correct prehospital care deficiencies. 3) To improve hospital assistance and to recognize early prognosis factors.

We report the case of a patient who needed urgent surgical assistance because of massive lower gastrointestinal hemorrhage secondary to a jejunal angiodysplasia (cavernous hemangioma). These lesions are a rare cause of gastrointestinal bleeding of obscure origin. The use of preoperative diagnostic techniques such as oral fiber-optic endoscopy, barium intestinal studies and scintigraphy have little value when the origin of lower gastrointestinal bleeding is in the small bowel. The best yield is obtained with celiac or superior mesenteric angiography. There are some cases in which only an exploratory surgical laparotomy is useful for the diagnostic supported by intraoperative enteroscopy guided by the surgeon.

We present the experience with the use of intraoperative ultrasonography in detecting biliary calculi on 55 patients, 19 of which had lithiasis of the common bile duct. Operative ultrasonics imaging of the biliary tree and operative cholangiography had a similar accuracy when both explorations were performed. In this series, accuracy indexes of ultrasonography in diagnosing choledocholithiasis were: sensitivity, 84.21%; specificity, 100%; efficiency, 94%; predictability of a positive test, 100%; predictability of a negative test, 92%. We think ultrasonography is a better exploration in two conditions: when intrahepatic duct lithiasis exists and if calculi are at the end of choledochus, because differentiation with neoplastic changes is easier.

Report of two cases of eosinophilic gastroenteritis. In both cases the presentation was an acute abdomen syndrome. The etiological diagnosis was postoperative, because in the preoperative period there were no data characteristic of this entity. Probably this disease is more frequent than reported and although the treatment is medical, there are some cases in which surgery is justified.

Three cases of congenital superior ankyloglossia, two central and one lateral, are presented. All children had also other malformations. The embryology, etiology and syndromes including ankyloglossia are analysed and the authors review the world literature during de five last years founding only a few similar cases.

Twenty-three hepatic resections were performed over a period of four years with the use of a Lin liver clamp and an operative mortality rate of 17.3%. Indications for liver resections were: five primary liver malignancies, four metastatic liver tumors and 14 benign liver diseases. All of the 14 patients with benign diseases survived the operation without developing late symptoms or complications. The survival rate of five patients with malign diseases ranged from three to 31 months. The technical details, advantages and precautions involved in the use of the Lin liver clamp are discussed. This approach improved the rate of operative mortality and facilitated partial lobectomy in cirrhotic livers, but the long-term results are dependent on the disease rather than the result of the operation.