Predicting emergency health care demands due to respiratory diseases

BACKGROUND

Timely care in the health sector is essential for the recovery of patients, and even more so in the case of a health emergency. In these cases, appropriate management of human and technical resources is essential. These are limited and must be mobilised in an optimal and efficient manner.

OBJECTIVE

This paper analyses the use of the health emergency service in a city, Jaén, in the south of Spain. The study is focused on the most recurrent case in this service, respiratory diseases.

METHODS

Machine Learning algorithms are used in which the input variables are multisource data and the target attribute is the prediction of the number of health emergency demands that will occur for a selected date. Health, social, economic, environmental, and geospatial data related to each of the emergency demands were integrated and related. Linear and nonlinear regression algorithms were used: support vector machine (SVM) with linear kernel and generated linear model (GLM), and the nonlinear SVM with Gaussian kernel.

RESULTS

Predictive models of emergency demand due to respiratory disseases were generated with am absolute error better than 35 %.

CONCLUSIONS

This model helps to make decisions on the efficient sizing of emergency health resources to manage and respond in the shortest possible time to patients with respiratory diseases requiring urgent care in the city of Jaén.

Clinical characteristics of children hospitalized for COVID-19

Introduction

Most SARS-CoV2 infections in the pediatric population are asymptomatic or with mild symptoms, with a minimal proportion of severe cases described as SARS-CoV2-associated multi-system inflammatory syndrome (MIS-C).The objective was to describe the clinical and epidemiological characteristics of pediatric patients admitted with confirmed diagnosis of SARS-CoV2 infection from the beginning of the pandemic until May 2021.

Methods

Retrospective observational study of pediatric patients hospitalized with confirmed COVID-19, in a tertiary hospital. Epidemiological and clinical data, additional tests, treatments administered and evolution were collected.

Results

30 patients were included, classified into 3 groups according to diagnosis: respiratory infection, MIS-C and compatible symptoms. The patients with pneumonia were associated with age older, comorbidities and lymphopenia. MIS-C were more serious patients, with marked laboratory involvement and greater admission to PICU. Most of these were secondary cases of contact in the family environment.

Discussion

The most frequent clinical manifestations of COVID-19 in children are mild-moderate respiratory with good evolution. MIS-C is another form of expression of SARS-COV2 infection of greater severity, but usually with good prognosis after early diagnosis and frequent PICU admission.

Clinical characteristics of children hospitalized for COVID-19

INTRODUCTION

Most SARS-CoV-2 infections in the pediatric population are asymptomatic or with mild symptoms, with a minimal proportion of severe cases described as SARS-CoV-2-associated multi-system inflammatory syndrome (MIS-C). The objective was to describe the clinical and epidemiological characteristics of pediatric patients admitted with confirmed diagnosis of SARS-CoV-2 infection from the beginning of the pandemic until May 2021.

METHODS

Retrospective observational study of pediatric patients hospitalized with confirmed COVID-19, in a tertiary hospital. Epidemiological and clinical data, additional tests, treatments administered and evolution were collected.

RESULTS

30 patients were included, classified into 3 groups according to diagnosis: respiratory infection, MIS-C and compatible symptoms. The patients with pneumonia were associated with age older, comorbidities and lymphopenia. MIS-C were more serious patients, with marked laboratory involvement and greater admission to PICU. Most of these were secondary cases of contact in the family environment.

DISCUSSION

The most frequent clinical manifestations of COVID-19 in children are mild-moderate respiratory with good evolution. MIS-C is another form of expression of SARS-CoV-2 infection of greater severity, but usually with good prognosis after early diagnosis and frequent PICU admission.

Autoimmune neutropenia associated with influenza virus infection in childhood: a case report

BACKGROUND

Although neutropenia is relatively frequent in infants and children and is mostly a benign condition with a self-limited course, it can lead to life-threatening severe infections. Autoimmune neutropenia is a relatively uncommon hematological disorder characterized by the autoantibody-induced destruction of neutrophils. It is usually triggered by viral infections with very few documented cases after influenza virus.

CASE PRESENTATION

An 8-month-old male infant presented at the emergency room with a 5-days history of fever up to 39.7 °C, cough and runny nose. In the blood test performed, severe neutropenia was diagnosed (neutrophils 109/μL). A nasopharyngeal aspirate revealed a positive rapid test for Influenza A. Serum antineutrophil antibodies were determined with positive results. Neutropenia targeted panel showed no mutations. Despite maintenance of severe neutropenia for 9 months the course was uneventful without treatment.

CONCLUSIONS

When severe neutropenia is diagnosed and confirmed, it is essential to rule out some potential etiologies and underlying conditions, since the appropriate subsequent management will depend on it. Although autoimmune neutropenia triggered by viral infections has been widely reported, it has seldom been reported after influenza infection. The benign course of the disease allows a conservative management in most cases.

A Bayesian Model to Predict COVID-19 Severity in Children

BACKGROUND

We aimed to identify risk factors causing critical disease in hospitalized children with COVID-19 and to build a predictive model to anticipate the probability of need for critical care.

METHODS

We conducted a multicenter, prospective study of children with SARS-CoV-2 infection in 52 Spanish hospitals. The primary outcome was the need for critical care. We used a multivariable Bayesian model to estimate the probability of needing critical care.

RESULTS

The study enrolled 350 children from March 12, 2020, to July 1, 2020: 292 (83.4%) and 214 (73.7%) were considered to have relevant COVID-19, of whom 24.2% required critical care. Four major clinical syndromes of decreasing severity were identified: multi-inflammatory syndrome (MIS-C) (17.3%), bronchopulmonary (51.4%), gastrointestinal (11.6%), and mild syndrome (19.6%). Main risk factors were high C-reactive protein and creatinine concentration, lymphopenia, low platelets, anemia, tachycardia, age, neutrophilia, leukocytosis, and low oxygen saturation. These risk factors increased the risk of critical disease depending on the syndrome: the more severe the syndrome, the more risk the factors conferred. Based on our findings, we developed an online risk prediction tool (https://rserver.h12o.es/pediatria/EPICOAPP/, username: user, password: 0000).

CONCLUSIONS

Risk factors for severe COVID-19 include inflammation, cytopenia, age, comorbidities, and organ dysfunction. The more severe the syndrome, the more the risk factor increases the risk of critical illness. Risk of severe disease can be predicted with a Bayesian model.

Chorea as the presenting feature of acute rheumatic fever in childhood; case reports from a low-prevalence European setting

BACKGROUND

Despite a notable decrease in acute rheumatic fever (ARF) incidence in the past few decades, there are still cases in our setting. Sydenham chorea (SC) may be the initial manifestation for this condition in childhood in a significant proportion of children. We report two cases of choreoathetosis in children as the first manifestation of ARF.

CASE PRESENTATION

A previously healthy 8-year-old boy presented with right hemichorea with a predominance in the brachial region, orofacial dyskinesias and speech difficulties for the past 2 weeks. The only medical history of interest was a common catarrhal illness 3 weeks before and nonspecific bilateral tenosynovitis in both feet since a year prior. A brain computerized tomography was normal and the echocardiogram showed mild mitral and aortic regurgitation, meeting ARF criteria. He demonstrated clinical improvement with treatment based on prednisone and carbamazepine. The second patient was a 10-year-old girl with choreic movements of the right half of the body and repetitive right eye closure of 1 week duration. She had symptoms of fever and rash the previous week and pharyngitis that resolved without antibiotic 2 months before. Blood tests revealed elevated C reactive protein (12 mg/dl) and erythrocyte sedimentation rate (96 mm/h). Brain magnetic resonance was normal and echocardiogram showed left ventricle dilation and mild mitral regurgitation, leading to the diagnosis of ARF. Due to neurological involvement, she received corticosteroids and intravenous immunoglobulin treatment, with worsening of neurological symptoms that required valproic acid with remission of the hemichorea. In addition skin lessions compatible with erythema marginatum appeared on the upper limbs.

CONCLUSIONS

SC should be the main diagnostic consideration in cases of hemichorea with normal neuroimaging in children. The cases reported highlight the need to maintain a high index of suspicion even in settings where incidende of ARF is low and the need to perform cardiological investigations in all patients with suspected SC, due to the possibility of subclinical valve lesions. Good adherence to secondary prophylaxis is crucial to avoid chorea relapses and worsening valve disease.

Disseminated Tuberculosis Complicated With Pneumatoceles in 2 Infants

Pneumatoceles are rare complications of pulmonary tuberculosis in children. We present 2 cases in infants of disseminated tuberculosis complicated by pneumatoceles with different evolution. This complication should be considered if worsening of respiratory symptoms occurs after initiating anti-tuberculous treatment. Treatment of pneumatoceles is usually conservative and surgical treatment should be used in patients with giant cysts which cause respiratory distress.

Tuberculosis in the paediatric population of Madrid in the last 26 years

INTRODUCTION

Tuberculosis (TB) continues to be a serious public health problem and establishing a definitive diagnosis among children is extremely challenging. Pulmonary tuberculosis is the most prevalent form, with children under the age of 2 years being at greatest risk of severe and disseminated forms. The aim of this study was to describe TB among children in Spain in recent years.

PATIENTS AND METHODS

A retrospective study of paediatric patients diagnosed with TB in two hospitals of the Community of Madrid over a 26-year period (1991-2017). Epidemiological and clinical variables, additional tests and treatments received were analysed.

RESULTS

170 children were included. The two most-affected age groups were infancy and adolescence. 42.9% of patients were immigrant children (South-America or Morocco). The main reasons for consultation were TB contact (20.6%) and fever (15.3%). At diagnosis, 61.8% of cases referred an epidemic environment, and 30.6% were asymptomatic. The Mantoux tuberculin skin test was positive in 92.2% of patients and IGRA was positive in 70.6%. Pulmonary TB was identified in 91.8% of children vs. 8.2% with extrapulmonary forms. Gastric juice culture was positive in 36.9% of cases and three strains resistant to isoniazid were isolated. All patients were cured without complications except one who died.

CONCLUSIONS

Pulmonary TB continues to be the most prevalent form among children and presumptive diagnosis (symptoms consistent with positive Mantoux test or suggestive X-ray) is the most common form of diagnosis. It is important to conduct a contact investigation in order to control the spread of TB.

Clinical trial on the effect of tranexamic acid on bleeding and fibrinolysis in primary hip and knee replacement

BACKGROUND

Tourniquet-induced ischaemia could increase fibrinolysis and enhance tranexamic acid (TXA) efficacy in total knee arthroplasty (TKA) compared to total hip arthroplasty (THA). The aims of this study are to compare the effect of TXA on bleeding and fibrinolysis in both types of surgery, and to record thromboembolic complications.

METHODS

A prospective double-blind study was conducted on patients scheduled for TKA or THA who received TXA (2 bolus of 10mg/kg) or placebo. Bleeding and fibrinolysis were evaluated. Doppler-ultrasound and computed tomography were performed in order to assess any thromboembolic complications.

RESULTS

A total of 44 patients were included (11 THA and 11 TKA treated with TXA; 11 THA and 11 TKA as controls). Blood losses were significantly lower in the TXA group (mean 921mL vs 1,383mL in THA and 969mL vs 1,223mL in TKA), and no transfusions were needed with TXA, whereas 5 blood units were transfused in controls. TXA was equally effecting in reducing bleeding in both surgeries (33% in THA and 21% in TKA). The significant mean increase in D-dimers from baseline to 6 hours after surgery (1,004 ug/L to 10,284 ug/L in THA and 571 ug/L to 6,480 ug/L in TKA) was attenuated by TXA (1,077 ug/L to 2,590 ug/L in THA and 655 ug/L to 2,535 ug/L in TKA). There were no differences in thromboembolic episodes.

CONCLUSIONS

Prophylactic use of tranexamic acid is equally effective in reducing bleeding in TKA and THA. Both surgeries have a similar effect on fibrinolysis.

Fms-like tyrosine kinase 3 ligand-dependent dendritic cells in autoimmune inflammation

Dendritic cells (DCs) are specialized in capture, processing and presentation of antigens to T cells. Depending on the type of DC and its activation state, the interaction of DCs with naive T cells can lead to different types of immune response, or to T-cell tolerance. The existence of many specialized subtypes of DCs with particular functions has raised the need to distinguish DCs formed in steady-state from those produced during an inflammatory response. In patients with autoimmune disease and in experimental animal models of autoimmunity, DCs show abnormalities in both numbers and activation state, expressing immunogenic levels of co-stimulatory molecules and pro-inflammatory cytokines. Initial in vitro studies of cytokines in DC development revealed distinct and important roles for the receptor tyrosine kinases, granulocyte-macrophage colony-stimulating factor (GM-CSF), macrophage colony-stimulating factor (M-CSF, also called CSF1) and fms-like tyrosine kinase 3 ligand (Flt3L) in the generation of DCs. Flt3L is critical for instructing DC generation throughout different organs and regulates DC development from Flt3(+) lymphoid and myeloid-committed progenitors to DCs in vivo. The aim of this review is to provide an overview of the role of Flt3L-dependent DCs in the immunopathogenesis of autoimmunity and chronic inflammation and its potential as therapeutic targets.

[Influence of the grade of anxiety and level of cortisol on post-surgical recovery]

INTRODUCTION

The objective is to analyze the influence of several biological and/or psychological factors on postsurgery recovery.

METHOD

Our sample was made up of 42 inpatients waiting for surgery. The day before the intervention, they filled out Spielbergers' State/Trait Anxiety Inventory (STAI) and sample of saliva was collected at 8:00 in order to determine cortisol concentration. Recovery was codified as <<good>> or <<poor>> using the Moix criteria (1995).

RESULTS

Patients with higher scores on the STAI had higher levels of salivary cortisol and their recovery was worse compared with patients with low anxiety.

CONCLUSIONS

Our results confirm the relationship between specific psychological variables, cortisol levels and the characteristics of the surgery recovery process of the patients.

Hostility and helper T-cells in patients with bulimia nervosa

OBJECTIVE

The study aimed to analyze the correlation between lymphocyte counts and several psychopathological variables associated with psychological instability (depression, hostility, impulsivity, self-defeating personality traits, and borderline personality symptoms) in patients with bulimia nervosa (BN).

METHOD

Sixty BN patients were assessed, using specific scales for eating pathology, general psychopathology, impulsivity, depression, and borderline personality features. Lymphocyte and lymphocyte subset counts were performed. Plasma cortisol at 8:00, before and after administration of 1 mg of dexamethasone at 23:00, was determined. The influence of body weight, and the use of tobacco, alcohol, and caffeine was controlled. The relationship between each isolated variable and the number of immune cells was analyzed. In a second step, supplementary post-hoc analysis of the variables was introduced to confirm the accuracy of the psychopathological assessment.

RESULTS

Hostility was negatively correlated with the number of helper T-cells (CD4+). Patients with high hostility had lower CD4+ cell counts and lower CD4+/CD8+ ratios. In the post-hoc control study, hostility was significantly related with other "interpersonal" items.

CONCLUSIONS

These results support the idea that hostility, as an expression of disturbed interpersonal relationships, could play a role as a modulator of immune activity in patients with BN.

Subtype criteria for bulimia nervosa: short- versus long-term compensatory behaviors

Weight control methods used by a group of bulimic patients were studied, analyzing the relationship among compensatory strategies and other clinical variables. Sixty-nine female consecutive patients who sought help for DSM-IV bulimia nervosa were recruited for the study. The prevalence and frequency of use of binge eating and six compensatory methods (vomiting, laxatives, diuretics, diet pills, fasting, and compulsive exercise) were assessed in each patient. Factor analysis was used to group the variables, and a cluster analysis was performed on a second step. The clinical variables were finally analyzed in each of the groups isolated through cluster analysis. According to the results of the factor analysis, the compensatory strategies were identified as short-term compensatory methods (vomiting), long-term methods (diet pills, diuretics, and laxatives), and nonpurging methods (dieting and exercise). Three groups of patients were isolated through cluster analysis: short-term purgers (vomiting), long-term purgers (laxatives + diet pills + diuretics), and a mixed group (vomiting + laxatives). Long-term purgers were older and heavier, had a greater prevalence of past overweight, and used more compensatory methods. These results confirm the necessity to continue investigating alternative ways of classifying bulimia nervosa patients based on compensatory behaviors, considering the existence of clinical dimensions rather than rigid clinical subtypes.

Migraine, serum serotonin and platelet 5-HT2 receptors

In spite of recent theories about the aetiopathogenesis of migraine, serotonin continues to play a central role, explaining the efficacy of almost all migraine prophylactic drugs. In migraineurs with and without aura we measured (by HPLC-EC) the serum serotonin (5-HT) and 5-hydroxyindoleacetic acid (5-HIAA) levels between as well as during headache attacks. Between attacks of migraine with aura and at the beginning of attacks of both types of migraine the serum 5-HT and 5-HIAA concentration was significantly increased. These results were corroborated by 3H-spiperone binding to platelet membranes: in migraineurs with aura in the attack-free interval, there was a significant decrease in its Bmax, which suggests down-regulation of 5-HT2 receptors. In conclusion, we have verified that migraine with aura differs biochemically from migraine without aura.

[Hodgkin's disease in children. Modified COPP combined treatment and radiotherapy in advanced stages]

Twenty two children, under 15 years of age, from southern Chile's Tenth Region, with advanced stages of Hodgkin's disease (8 III-A, 6 III-B and 8 IV-B) were treated with chemotherapy (modified COPP protocol) and radiotherapy between 1976 and 1985 at Valdivia's Regional Hospital. Overall survival rate was 77.3% and disease-free survival rate was 64.5% after a follow-up period from 3 to 13 years (median 70 months). Five patients died during the first two years. One relapsed 10 years after beginning of therapy, but achieved a second complete remission. The survival rate in patients with lymphocytic depletion type (5 cases) was 20.0%, whereas that of the mixed cellularity type (14 cases) was 92.9% (p less than 0.01). No cases of second neoplasms related to chemotherapy and radiotherapy were seen in this series.

Clinical presentation of Bacillus Calmette-Guérin infections in patients with immunodeficiency syndromes

Nine children with immunodeficiency syndromes who developed persistent or disseminated Bacillus Calmette-Guérin (BCG) infections after BCG vaccination at birth were observed in Santiago, Chile, over a period of 10 years. This represents a risk for persistent or disseminated BCG infections of 3.4/1,000,000 vaccinated newborns. This may closely reflect the incidence of severe combined immunodeficiency syndromes, cellular immunodeficiency syndromes and chronic granulomatous disease in the study area. The clinical presentation and course of the infection varied considerably depending on the underlying immunodeficiency syndrome. Two patients with severe combined immunodeficiency presented with cutaneous nodules in the absence of any local reaction at the site of BCG vaccination. Both patients died of disseminated BCG infection within the first year of life. Four patients with cellular immunodeficiency syndromes presented with regional lymphadenitis resistant to treatment after the fifth month of life. Three of these patients had specific unresponsiveness to tuberculin and survived from 5 to 6 years of age. Two boys with X-linked chronic granulomatous disease presented with regional lymphadenitis in the first 3 months of life. A girl with autosomal recessive chronic granulomatous disease presented at 18 months of age with regional lymphadenitis. All three patients with chronic granulomatous disease had positive tuberculin reactions and died from infections other than BCG.

Plasmodium falciparum: characterization of a 33-kDa soluble antigen

A 33-kDa soluble antigen identified in the culture supernatant by patient serum and monoclonal antibodies was present in rings, trophozoites, schizonts, and merozoites of Plasmodium falciparum. The antigen which is released into the culture supernatant by growing parasites was also observed in the host cells of trophozoites and schizonts and could be localized on the host cell surface. Its specificity for the surface of trophozoites and schizonts was observed to decrease with increased duration without subculture. The antigen could then be detected on the surface of noninfected erythrocytes. The antigenicity of the 33-kDa antigen was destroyed by heating at 65 degrees C. Monoclonal and polyclonal specific antibodies weakly inhibited parasite growth in vitro. The antigen was present in both knob positive and knob negative parasites in all the P. falciparum isolates tested.

Toxoplasma gondii: antigenic differences between endozoites and cystozoites defined by monoclonal antibodies

The antigenic differences between endozoites and cystozoites of Toxoplasma gondii were analyzed by indirect immunofluorescent assay and Western blotting using monoclonal antibodies. An antigenic determinant of an antigen of 20 kDa mol. wt. that appeared to be localized in the cytoplasm was observed to be specific to cystozoites alone. The 20-kDa antigen was diffused throughout the parasite and was observed in cystozoites produced both in vivo and in vitro.

Cultivation of Plasmodium falciparum using animal serum (horse, calf and bovine) as human serum substitute

Horse, calf and bovine serum were successfully used as human serum substitutes in the in vitro cultivation of Plasmodium falciparum. Positive results were obtained only after gradually adapting the parasites to the substitute serum. Adapted lines were established within 4-5 weeks. 10% horse serum was observed to be the best substitute with growth rates comparable or even surprising that obtained in human serum. Pure calf or bovine serum supported stable growths of 20-30% less which was enhanced to comparable levels after addition of 1% glucose-peptone to the medium. Direct transfers of adapted cultures to human serum showed enhanced growth rates. Lower growth rates of adapted cultures (i.e. horse serum-adapted cultures) in other substitute sera (i.e. calf or bovine sera) were improved in subsequent subcultures. Similarly, there were no adverse effects when they were returned back to the substitute serum they were originally adapted to.

[Analysis of the socioeconomic and health data of families residing in the district of Botucatu (São Paulo, Brazil) in 1969]

Foi realizado, em 1969, um levantamento de dados sócio-econômicos e sanitários da zona urbana de Botucatu. Trezentas e cinco famílias amostradas foram entrevistadas sobre: constituição familiar, idade, ocupação, renda, grau de instrução, condições sanitárias dos domicílios, conhecimento e uso de vacinas, demanda e opiniões relativas aos serviços de saúde. Algumas respostas foram associadas ao "status" sócio-econômico das famílias. As condições de saneamento básico estavam dentro de padrões quantitativos razoáveis e era alto o desconhecimento sobre o valor e número de doses das vacinas. Constatou-se acentuada dispersão de recursos para saúde, indicando falta de coordenação dos órgãos assistenciais; a demanda ao Centro de Saúde era baixa, quase restrita às crianças, indicando distorsão da percepção da comunidade com relação aos serviços médico-sanitários e necessidade de desenvolvimento adequado desses serviços, além de educação sanitária sistemática.