Cierre de camas en pediatría: un desafío para la salud pública en Colombia

Colombia has faced a significant challenge in the provision of healthcare for children for over a decade, primarily due to the ongoing closure of pediatric hospitalization beds. This issue, evident over time in the Registro Especial de Prestadores de Salud (REPS), has been exacerbated by the SARS-CoV-2 pandemic. The continuous closure of these beds reflects the intricacies and challenges within our healthcare system, prompting concern and debate within the scientific community. This matter directly impacts the capacity for medical care and the well-being of citizens, particularly children who are constitutionally entitled to special protection (1).Hace más de una década, Colombia enfrenta un grave desafío en la atención a la niñez debido al cierre continuo de camas de hospitalización de pediatría, situación que se evidencia a través del tiempo en el Registro Especial de Prestadores de Salud (REPS) y que se agravó con la pandemia por SARS-CoV2. Este problema es un reflejo del modelo y la complejidad de nuestro sistema de salud y, por lo tanto, ha suscitado preocupación y debates en la sociedad científica ya que afecta directamente la capacidad de la atención médica y el bienestar de los ciudadanos, en este caso los niños y niñas que, según la Constitución, deben gozar de especial protección (1)

Fluids in the treatment of diabetic ketoacidosis in children:A systematic review

Aim: To determine the comparative effectiveness of fluid schemes for children with diabetic ketoacidosis (DKA). Methods: We conducted a systematic review with an attempt to conduct network meta-analysis (NMA). We searched MEDLINE, EMBASE, CENTRAL, Epistemonikos, Virtual Health Library, and gray literature from inception to July 31, 2022. We included randomized controlled trials (RCTs) in children with DKA evaluating any intravenous fluid schemes. We planned to conduct NMA to compare all fluid schemes if heterogeneity was deemed acceptable. Results: Twelve RCTs were included. Studies were heterogeneous in the population (patients and DKA episodes), interventions with different fluids (saline, Ringer's lactate (RL), and polyelectrolyte solution-PlasmaLyte®), tonicity, volume, and administration systems. We identified 47 outcomes that measured clinical manifestations and metabolic control, including single and composite outcomes and substantial heterogeneity preventing statistical combination. No evidence was found of differences in neurological deterioration (main outcome), but differences were found among interventions in some comparisons to normalize acid-base status (∼2 h less with low vs. high volume); time to receive subcutaneous insulin (∼1 h less with low vs. high fluid rate); length of stay (∼6 h less with RL vs. saline); and resolution of the DKA (∼3 h less with two-bag vs. one-bag scheme). However, available evidence is scarce and poor. Conclusions: There is not enough evidence to determine the best fluid therapy in terms of fluid type, tonicity, volume, or administration time for DKA treatment. There is an urgent need for more RCTs, and the development of a core outcome set on DKA in children.</p

Síndrome de Asma Crítica. Revisión narrativa

Asthma is the most common chronic lung disease in children. Near-fatal asthma, acute severe asthma, status asthmaticus, refractory asthma, or fragile asthma refers to suffering a life-threatening episode of severe asthmatic crisis and it occurs most frequently in patients with severe asthma but it can occur in mild or moderate asthma and in uncontrolled asthma patients. There is no standardized definition of the term. Therefore, the term Critical Asthma Syndrome (CAS) has been proposed as an umbrella term covering the terms historically used to refer to the risk of death from asthma due to sudden and severe deterioration of vital signs which could progress to respiratory failure and death.A search in the Pubmed database for the terms “status asthmaticus”, “severe asthma”, “severe asthma attack”, “life-threatening asthma”, “acute severe asthma”, “near fatal asthma”, “critical asthma”, “critical asthma syndrome” was carried out, followed by a narrative review of CAS taking into account epidemiological and pathophysiological aspects, clinical manifestations according to the phenotypes described, diagnosis, and treatment.El asma es la enfermedad pulmonar crónica más frecuente en la infancia. Asma casi fatal, asma severa aguda, estado asmático, asma refractaria o asma frágil se refiere a sufrir un episodio de crisis asmática severa con riesgo de morir y ocurre más frecuentemente en pacientes con asma grave, pero se puede presentar en asma leve o moderada y en asma no controlada. No existe una definición estandarizada del término, por lo tanto, se ha propuesto la expresión Síndrome de Asma Crítica (SAC) como término sombrilla que cubre los términos históricamente usados para aludir al riesgo de morir por asma debido al deterioro súbito y severo de los signos vitales, deterioro que podría progresar a falla respiratoria y muerte.En este marco de ideas, se realizó una búsqueda en la base de datos Pubmed de los términos “status asthmaticus”, “severe asthma”, “severe asthma attack”, “life threatening asthma”, “acute severe asthma”, “near fatal asthma”, “critical asthma”, “critical asthma syndrome” y posteriormente se llevó a cabo una revisión narrativa de SAC teniendo en cuenta los aspectos epidemiológicos, fisiopatológicos, las manifestaciones clínicas según los fenotipos descritos, el diagnóstico y el tratamiento

Tungiasis en el área urbana de Popayán, Colombia: reporte de caso

Tungiasis is an endemic ectoparasitosis in Latin America associated with risk factors such as rurality, poverty, and living with animals. In Popayán, a city in southwest Colombia, the disease was highly prevalent in the past, to such degree that its inhabitants were given the nickname of patojo, a word that describes the way of walking of people infested by the flea. However, it was believed eradicated at present.We present the case of a 12-year-old boy living in the urban area of Popayán, who presented with a one-month history of papular lesions with circular edges, blackish center, and hyperkeratotic halo on both feet. Tungiasis was suspected based on the clinical findings and ivermectin was administered. The lesions were surgically removed and sent for parasitological analysis, which confirmed the presence of Tunga penetrans. The patient evolved satisfactorily. The Secretaría de Salud Municipal de Popayán carried out an inspection of the patient’s home where migrant dogs from the Colombian Pacific were found in the surroundings, some with suspicious lesions of tungiasis.We document here the resurgence of this pathology in urban areas, probably secondary to the migration of animals from rural areas. It is important to recognize the existence of the flea in rural and urban areas, make a medical diagnosis, and report cases to the surveillance entities to enable appropriate management and sanitary control of this neglected ectoparasitosis in humans and animals.La tungiasis es una ectoparasitosis endémica en Latinoamérica y está asociada a factores de riesgo como la ruralidad, la pobreza y la convivencia con animales. Popayán, una ciudad al suroccidente de Colombia, fue históricamente afectada por la tungiasis, tanto así que a sus habitantes los apodan “patojos” debido a la forma de caminar de sus habitantes infestados por la pulga. Hoy la enfermedad se creía eliminada.Se presenta el caso de un niño de 12 años procedente del área urbana de Popayán, que consultó por lesiones papulares de bordes circulares, centro negruzco y halo hiperqueratósico en ambos pies, de un mes de evolución. Por los hallazgos clínicos se sospechó tungiasis y se le administró ivermectina. Las lesiones se removieron quirúrgicamente y se enviaron para análisis parasitológico, el cual confirmó la presencia de Tunga penetrans. La evolución del paciente fue satisfactoria. La Secretaría de Salud Municipal de Popayán inspeccionó el domicilio del paciente y encontró perros migrantes del Pacífico colombiano en sus alrededores, algunos con lesiones sospechosas de tungiasis.Se documenta, así, el resurgimiento de esta enfermedad en el área urbana, probablemente debido a la migración de animales desde las zonas rurales. Es importante reconocer la existencia de la pulga en zonas rurales y urbanas, hacer el diagnóstico médico y reportar los casos a los entes de vigilancia. Estas acciones permitirán ofrecer un apropiado manejo y control sanitario de esta ectoparasitosis desatendida en humanos y animales

Evaluación de la ansiedad preoperatoria en pacientes sometidos a anestesia general. Estudio observacional

Introduction. Anxiety is an adaptive response of the human being to danger. The surgical anesthetic act is considered a generator of anxiety that is related to greater vulnerability and difficult control of postoperative pain, prolonged hospital stay, higher rate of anesthetic events and vulnerability to infections. This study aims to estimate the prevalence of preoperative anxiety in a group of patients undergoing surgery under general anesthesia using the Amsterdam Preoperative Anxiety and Information Scale (APAIS). Methods. A cross-sectional observational study performed with surgical patients who received general anesthesia at a third-level hospital. Sociodemographic and clinical information were obtained. Prevalence of preoperative anxiety was estimated by using the APAIS scale (cut of 11) and potential associated factors were evaluated. A descriptive analysis and crude odds ratios were calculated. In addition, a logistic regression model was constructed to adjust the effect of covariates. Results. Prevalence of anxiety was 13% [IC95% 7%-18%]. No variables were found to be significantly associated with the presence of anxiety. 76.8% of the participants had a low need for information. Women, outpatients, ASA I classification and patients under major surgery without a history of previous surgical procedures presented a higher frequency of anxiety. The majority of patients presented a low need for information (76.8%). After the adjusted analysis, there were no variables related to the presentation of anxiety. Conclusions.&nbsp;A low prevalence of anxiety and a low need for information on the part of the participants were documented. It is necessary to do further research in this area in Colombia.Introducción. La ansiedad es una respuesta adaptativa del ser humano ante el peligro. El acto anestésico quirúrgico como generador de ansiedad se relaciona con mayor vulnerabilidad y difícil control del dolor postoperatorio, estancia hospitalaria prolongada, mayor tasa de accidentes anestésicos y vulnerabilidad a infecciones. Este estudio estimó la prevalencia de ansiedad preoperatoria en un grupo de pacientes sometidos a anestesia general mediante la escala de Ansiedad Preoperatoria y de Información de Ámsterdam (APAIS). Métodos. Estudio observacional de corte transversal con pacientes que recibieron anestesia general en un hospital de III nivel de atención. Se obtuvo información sociodemográfica y clínica. Se determinó la prevalencia de ansiedad preoperatoria mediante la escala APAIS (utilizando un punto de corte de 11) y los potenciales factores asociados. Se realizó un análisis descriptivo y se calcularon odds ratios para las asociaciones. Además, se construyó un modelo de regresión logística para ajustar el efecto de las covariables en la presentación de ansiedad. Resultados. La prevalencia de ansiedad fue de 13% [IC95% 7%-18%]. Las mujeres, los pacientes ambulatorios, clasificación ASA I y sometidos a cirugía mayor sin antecedentes de procedimientos quirúrgicos previos presentaron una mayor frecuencia de ansiedad. La mayoría de los pacientes presentaban una baja necesidad de información (76,8%). Tras el análisis ajustado, no se encontraron variables asociadas de forma importante a la presentación de ansiedad. Conclusiones. Se documentó una baja prevalencia de ansiedad y una baja necesidad de información por parte de los participantes. Se requiere continuar la investigación en el área en Colombia. &nbsp

Displasia broncopulmonar en pacientes de un programa madre canguro en Popayán-Colombia. Estudio de cohorte retrospectivo

Kangaroo-Mother Care (KMC) is a follow-up program for premature infants with comorbidities such as bronchopulmonary dysplasia (BPD). The objective was to characterize patients with BPD and describe their nutritional, neurological, and respiratory outcomes in a KMC. A retrospective cohort study of the KMC in a University Hospital between 2015-2018. Included patients with BPD and excluded major malformations. Nutritional, neurological, and respiratory outcomes were evaluated at 40 weeks, 6, and 12 months of corrected-age using scales recommended in Colombia. A descriptive analysis was carried out, the variables were compared according to the severity of BPD. The changes in the outcomes in patients with complete follow-up were evaluated. 490 patients were admitted in four years, 50 with BPD (10,2%); 58% with moderate-BPD, none with severe BPD. 46% were born at &lt;29 weeks of gestational-age, 96% had low socioeconomic status and 90% and 90% of these submitted&nbsp; to mechanical ventilation. In the follow-up, height-for-age remained at risk at 6 and 12 months. 98% had abnormal Amiel-Tisson test. Around 75% had respiratory symptoms between 6 and 12 months and 33% had at least one hospital readmission. Patients with BPD in KMC have alterations in height-for-age, neurodevelopment, and respiratory system when complete the follow-up.&nbsp;El Programa Madre Canguro (PMC) permite un seguimiento a prematuros con comorbilidades como displasia broncopulmonar (DBP). El objetivo fue caracterizar los pacientes con DBP, describir su compromiso nutricional, neurológico, respiratorio en un PMC. Se realizó un estudio de cohorte retrospectivo en el PMC de un Hospital Universitario con aprobación del comité de ética. Incluyó pacientes con DBP entre 2015-2018, sin malformaciones mayores. Evaluamos el estado nutricional, neurológico y respiratorio a las 40 semanas, 6 y 12 meses de edad corregida mediante escalas recomendadas en Colombia. Realizamos análisis descriptivo y comparación según severidad de la DBP. Describimos la evolución en pacientes con seguimiento completo. Ingresaron 490 pacientes en cuatro años, 50 con DBP (10,2%); 58% con DBP-moderada, ninguno con DBP-severa. 96% de estrato socioeconómico bajo, 46% &lt;29 semanas de edad gestacional y el 90% sometidos a ventilación mecánica. Encontramos compromiso del promedio de Talla/Edad a 6 y 12 meses. Prueba Amiel Tisson anormal en 98%. Cerca del 75% presentaron síntomas respiratorios entre 6 y 12 meses y 33% tuvo al menos un reingreso hospitalario. Los pacientes con DBP del PMC tienen compromiso en la Talla/Edad, neurodesarrollo y alteraciones respiratorias al completar el seguimiento

Quality and credibility of clinical practice guidelines recommendations for the management of neonatal hypoglycemia. A protocol for a systematic review and recommendations' synthesis.

IntroductionHypoglycemia is one of the most frequent metabolic conditions in neonates. Clinical practice guidelines (CPGs) influence clinical practice as high-quality CPGs facilitate the use of evidence in practice. This proposed study aims to systematically identify and appraise CPGs and CPG recommendations (CPGRs) for treating neonatal hypoglycemia (NH).Methods and analysisWe will conduct searches in MEDLINE, EMBASE, CINAHL, Cochrane Library, LILACS (Latin American & Caribbean Health Sciences Literature), and Epistemonikos. Authors will search CPGs-specific databases and grey literature. Two reviewers will independently perform the titles and abstract screening, full-text review, and data extraction. Two appraisers will assess the quality of the CPGs and their recommendations using AGREE II (Appraisal of Guidelines Research and Evaluation) and AGREE-REX (Appraisal of Guidelines Research and Evaluation-Recommendations Excellence) instruments. Scores of ≥ 60% in the rigour of development domain will be considered for defining high-quality with AGREE II tool. CPGRs with scores >60% in the three domains will be used to determine high quality with the AGREE REX tool. We will perform a synthesis of the CPGRs to identify the consistency among the CPGRs and the methodological quality of primary studies that support them.Ethics and disseminationThe results will help us to identify the methodological and quality gaps in the existing CPGs for the treatment of NH. Our findings will be submitted to peer-review journals and presented at academic conferences. Based on the study design, approval from the institutional ethics board is not required for this project.Trial registrationsSystematic Review Registration Number (PROSPERO): CRD 42021239921

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Clinical course of neonatal acute kidney injury: multi-center prospective cohort study

Background: Neonatal acute kidney injury (AKI) has been associated with unfavorable outcomes, including increased mortality. We aimed to describe the clinical course and outcomes during the first 7 days after diagnosis in newborns with AKI in three neonatal intensive care units in Popayán-Colombia. Methods: Multi-center prospective cohort study conducted between June 2019 and December 2020 in three NICUs after ethical approval. We included newborns between 2 and 28 days of life, first diagnosed with AKI using the KDIGO classification modified for newborns which consider increased serum creatinine values over baseline values as well as urine output over time in hours or both. Patients with chromosomal abnormalities, major kidney malformations, and complex congenital heart disease were excluded. Patients were followed for up to 7 days after diagnosis and the maximum KDIGO stage, recovery of kidney function, need for renal replacement therapy and cumulative incidence of death were evaluated. Results: Over the 18 months of the study, 4132 newborns were admitted to the NICUs, and 93 patients (2.25, 95% CI 1.82–2.75%) developed neonatal AKI. 59.1% of the newborns were premature and there were no differences in severity according to gestational age. During follow-up, the maximum KDIGO was 64.5% for AKI-stage 1, 11.8% for AKI-stage 2, and 23.7% for AKI-stage 3. Kidney function recovery was higher in AKI-stage 1 patients vs. AKI-severe (AKI-stage 2 and 3) (95% vs. 48.5%). Five patients (5.4%) received renal replacement therapy and 15 died (16.1%), four in AKI-stage 1 vs. 11 in AKI-severe (6.7% vs 33.3%). Conclusions: Newborns admitted to the NICUs can develop AKI regardless of gestational age, and it is more frequent between the second and ninth days of life. More patients whit AKI-stage 1 recover and die less than those in a severe stage