150 000 niños mueren por tuberculosis cada año: ¿cómo se pueden mejorar los tratamientos?

Agravada por la pandemia de covid-19, la tuberculosis sigue siendo un grave problema de salud global. En el caso de los niños, hay un problema añadido: no existen tratamientos específicamente diseñados para ellos

Outcomes of second-line antiretroviral therapy among children living with HIV: a global cohort analysis.

Introduction: Limited data describe outcomes on second-line antiretroviral therapy (ART) among children globally. Our objective was to contribute data on outcomes among children living with HIV after initiation of second-line ART in the context of routine care within a large global cohort collaboration. Methods: Patient-level data from 1993 through 2015 from 11 paediatric HIV cohorts were pooled. Characteristics at switch and through two years of follow-up were summarized for children who switched to second-line ART after starting a standard first-line regimen in North America, Latin America, Europe, Asia, Southern Africa (South Africa & Botswana) and the rest of sub-Saharan Africa (SSA). Cumulative incidences of mortality and loss to follow-up (LTFU) were estimated using a competing risks framework. Results: Of the 85,389 children on first-line ART, 3,555 (4%) switched to second-line after a median of 2.8 years on ART (IQR: 1.6, 4.7); 69% were from Southern Africa or SSA and 86% of second-line regimens were protease inhibitor-based. At switch, median age was 8.4 years and 50% had a prior AIDS diagnosis. Median follow-up after switch to second-line ranged from 1.8 years in SSA to 5.3 years in North America. Median CD4 counts at switch to second-line ranged from 235 cells/mm3 in SSA to 828 cells/mm3 in North America. Improvements in CD4 counts were observed over two years of follow-up, particularly in regions with lower CD4 counts at second-line switch. Improvements in weight-for-age z-scores were not observed during follow-up. Cumulative incidence of LTFU at two years was <5% in all regions except SSA (7.1%) and Southern Africa (7.4%). Risk of mortality was <3% at two years of follow-up in all regions, except Latin America (4.9%) and SSA (5.5%). Conclusions: Children switched to second-line ART experience CD4 count increases as well as low to moderate rates of LTFU and mortality within two years after switch. Severe immune deficiency at time of switch in some settings suggests need for improved recognition and management of treatment failure in children

Predictors of faster virological suppression in early treated infants with perinatal HIV from Europe and Thailand

Objective: To identify predictors of faster time to virological suppression among infants starting combination antiretroviral therapy (cART) early in infancy. Design: Cohort study of infants from Europe and Thailand included in studies participating in the European Pregnancy and Paediatric HIV Cohort Collaboration. Methods: Infants with perinatal HIV starting cART aged less than 6 months with at least 1 viral load measurement within 15 months of cART initiation were included. Multivariable interval-censored flexible parametric proportional hazards models were used to assess predictors of faster virological suppression, with timing of suppression assumed to lie in the interval between last viral load at least 400 and first viral load less than 400 copies/ml. Results: Of 420 infants, 59% were female and 56% from Central/Western Europe, 26% United Kingdom/Ireland, 15% Eastern Europe and 3% Thailand; 46 and 54% started a boosted protease inhibitor-based or nonnucleoside reverse transcriptase inhibitor-based regimen, respectively. At cART initiation, the median age, CD4+% and viral load were 2.9 [interquartile range (IQR): 1.4-4.1] months, 34 (IQR: 24-45)% and 5.5 (IQR: 4.5-6.0) log10 copies/ml, respectively. Overall, an estimated 89% (95% confidence interval: 86-92%) achieved virological suppression within 12 months of cART start. In multivariable analysis, younger age [adjusted hazard ratio (aHR): 0.84 per month older; P < 0.001], higher CD4+% (aHR: 1.11 per 10% higher; P = 0.010) and lower log10 viral load (aHR: 0.85 per log10 higher; P < 0.001) at cART initiation independently predicted faster virological suppression. Conclusion: We observed a significant independent effect of age at cART initiation, even within a narrow 6 months window from birth. These findings support the earliest feasible cART initiation in infants and suggest that early therapy influences key virological and immunological parameters that could have important consequences for long-term health

Renal Involvement in Congenital Cytomegalovirus Infection: A Systematic Review

t: Background: Congenital cytomegalovirus (cCMV) infection is the most frequent motherto-child transmitted infection worldwide and a prevalent cause of neonatal disease and long-term morbidity. The kidney is a target organ for CMV, which replicates in renal tubules and is excreted in large quantities in urine for years in children with cCMV infection. Nonetheless, kidney disease has rarely been reported in cCMV-infected patients. Objective: We aimed to describe the available data on renal involvement in patients with cCMV infection at the pathologic, functional, anatomical, and/or clinical levels. Methods: A systematic search was performed in the MEDLINE/PubMed, SCOPUS, and Cochrane databases. Studies describing any renal involvement in fetuses or neonates aged ≤3 weeks at diagnosis of microbiologically confirmed cCMV infection were eligible. Results: Twenty-four articles were included, with a very low level of evidence. Pathologic findings in autopsy studies universally described CMV typical inclusion bodies in tubular cells. No functional studies were identified. cCMV infection was not associated with an increased risk of kidney malformations. Congenital nephrotic syndrome was the most common clinical condition associated with cCMV, but a causal relationship cannot be established. Conclusions: Typical pathological features of cCMV infection are very common in renal tissue, but they do not seem to entail significant consequences at the anatomical or clinical level

Seminaris pràctics mitjançant l'aprenentatge basat en problemes en l'ensenyament de la pediatria

Podeu consultar la Setena trobada de professorat de Ciències de la Salut completa a: http://hdl.handle.net/2445/43352En 2011, se aplicó la metodología del aprendizaje basado en problemas (ABP) en los seminarios prácticos de Pediatría a los estudiantes de 6º de Medicina. La ABP invierte la organización tradicional de los procesos de aprendizaje: primero se presenta el problema, ya partir de la delimitación de lo que ya se conoce, se establecen los objetivos, se identifican las necesidades de aprendizaje, y se diseña y se sigue un plan de actuación, para que el aprendizaje se acompañe de la reso-lución del problema. Previamente, los profesores realizaron un curso específico so-bre ABP organizado por el IES. Transcurrido el primer curso de aplicación del ABP, se pretende evaluar el grado de satisfacción y de aprendizaje obtenidos de los seminarios prácticos ba-sados en el ABP por parte de los estudiantes

Malaltia de Kikuchi-Fujimoto: presentació d'un cas pediàtric

Introducció. La malaltia de Kikuchi-Fujimoto, o limfadenitis necrosant histiocítica, és una patologia benigna poc freqüent que es caracteritza per clínica de febre i limfadenopatia cervical. Predomina en noies joves i habitualment s'autolimita entre els 2 i els 4 mesos sense complicacions. Cas clínic. Es presenta el cas d'una pacient de 14 anys que presenta febre de tres dies d'evolució i adenopaties cervicals dretes. Les setmanes prèvies va presentar un quadre febril que es va autolimitar sense poder filiar-ne l'etiologia. S'amplia l'estudi amb proves complementàries, i es descarten amb l'analítica sanguínia i les proves d'imatge les causes infeccioses o tumorals. Es fa exèresi quirúrgica d'una adenopatia cervical amb intenció diagnosticoterapèutica. L'estudi immunohistoquímic presenta característiques típiques de la limfadenitis necrosant histiocítica. La pacient presenta remissió de la simptomatologia i desaparició de les adenopaties. Comentaris. La limfadenitis necrosant histiocítica és una malaltia poc freqüent, però és important tenir-la en compte en pacients joves amb quadre febril i adenopaties de llarga evolució. La biòpsia del gangli per al diagnòstic definitiu és important per evitar altres proves o tractaments més agressius i innecessaris

Premature aging and immune senescence in HIV-infected children

Objective: Several pieces of evidence indicate that HIV-infected adults undergo premature aging. The effect of HIV and antiretroviral therapy (ART) exposure on the aging process of HIV-infected children may be more deleterious since their immune system coevolves from birth with HIV. Design: Seventy-one HIV-infected (HIV+), 65 HIV-exposed-uninfected (HEU), and 56 HIV-unexposed-uninfected (HUU) children, all aged 0\u20135 years, were studied for biological aging and immune senescence. Methods: Telomere length and T-cell receptor rearrangement excision circle levels were quantified in peripheral blood cells by real-time PCR. CD4+ and CD8+ cells were analysed for differentiation, senescence, and activation/exhaustion markers by flow cytometry. Results: Telomere lengths were significantly shorter in HIV+ than in HEU and HUU children (overall, P < 0.001 adjusted for age); HIV+ ART-naive (42%) children had shorter telomere length compared with children on ART (P = 0.003 adjusted for age). T-cell receptor rearrangement excision circle levels and CD8+ recent thymic emigrant cells (CD45RA+CD31+) were significantly lower in the HIV+ than in control groups (overall, P = 0.025 and P = 0.005, respectively). Percentages of senescent (CD28-CD57+), activated (CD38+HLA-DR+), and exhausted (PD1+) CD8+ cells were significantly higher in HIV+ than in HEU and HUU children (P = 0.004, P < 0.001, and P < 0.001, respectively). Within the CD4+ cell subset, the percentage of senescent cells did not differ between HIV+ and controls, but programmed cell death receptor-1 expression was upregulated in the former. Conclusions: HIV-infected children exhibit premature biological aging with accelerated immune senescence, which particularly affects the CD8+ cell subset. HIV infection per se seems to influence the aging process, rather than exposure to ART for prophylaxis or treatmen

La importancia de una adherencia correcta al tratamiento antituberculoso

INTRODUCCIÓN. La tuberculosis (TB) sigue siendo una de las principales causas de morbimortalidad en muchos países y esto comporta un problema grave de salud pública. La adhe­rencia al tratamiento antituberculoso es un eje fundamental para el control de esta enfermedad. DESARROLLO. A nivel mundial existen grandes diferencias en función del territorio en cuanto a las tasas de prevalencia e incidencia de la enfermedad y su mortalidad. España presen­ta una tasa de incidencia superior a la de otros países de su entorno socioeconómico. El tratamiento es prolongado y con efectos secundarios im­portantes. La adherencia al tratamiento es fundamental para que este sea eficaz, para evitar las resistencias a los fármacos y controlar la enfermedad. Los niños son más vulnerables a desarrollar la enfermedad que el resto de la población. Existen distintos tipos de métodos, directos e indirectos, para medir esta adherencia al tratamiento, aunque ninguno es ideal. Están descritos una serie de factores de riesgo de tipo so­ciodemográfico que influyen en la adherencia, como la inmigración. A los factores que dificultan el seguimiento del tratamiento en el adulto se tienen que sumar otros más espe­cíficos a nivel infantil. CONCLUSIONES. La literatura revisada destaca la importancia de un adecuado seguimiento de los pacientes para aumentar la adherencia al tratamiento antituberculoso. El rol de la enfer­mera y sus intervenciones son muy importantes

Educational measure for promoting adherence to treatment for tuberculosis

The aim of this work is to determine the effect of the educational intervention to improve the language barrier on adherence to antituberculosis treatment in the paediatric population. Immigrant population is associated with factors that make it difficult to monitor the treatment and control of tuberculosis infection or disease properly such as language difficulties. 68 patients were included in this study. They came from 15 different countries. The patients/families were given written information (a leaflet) in the form of questions and answers about the most common doubts that people have about antituberculosis treatment. This leaflet was translated into 11 different languages: Spanish, Catalan, English, French, German, Italian, Russian, Romanian, Chinese, Urdu and Arabic. Six patients/families that presented language barrier had successfully completed the treatment. In this study, language barrier was not associated with poorer adherence. We believe delivering information written in the mother tongue can improve understanding about the importance of the tuberculosis disease and its treatment

Pediatric antimicrobial stewardship in the COVID-19 outbreak

Growing evidence supports the positive impact of antimicrobial stewardship programs (ASPs) on antimicrobial use, including pediatrics.1 Although short of the level of acceptance these have reached in the United States, the implementation of pediatric ASPs in European hospitals has increased over the last few years.1 It has been suggested that the ASP should be helpful in the preparation for and response to the SARS-CoV-2/COVID-19 outbreak, 2 but no formal recommendations have been published. Whether pediatric ASP remains an essential activity or not during the COVID-19 pandemic has yet to be clarified. Here, we describe how the COVID-19 pandemic has impacted antimicrobial use in a referral pediatric hospital, and we propose a supporting role for ASP teams in the local management of the outbreak. The first COVID-19 case in Catalonia, Spain, was reported on February 25, 2020. By mid-March, most pediatric and obstetrics departments in the region were shut to increase the capacity for adult COVID-19 patients. Hospital Sant Joan de Déu Barcelona (SJD) remained the largest pediatric and maternal referral center in the region. COVID-19 and non-COVID-19 pediatric and young adult patients were transferred to our wards and pediatric ICU (PICU), and the number of daily deliveries tripled, whereas all nonemergency clinical, teaching, and research activities were postponed. Compared to the same months in 2019, in March 2020, total hospital stays decreased by 0.8% in the PICU and 15.2% in non-PICU areas, and in April 2020, total hospital stays decreased by 23.7% in the PICU and 22.2% in non-PICU areas