Infecciones osteoarticulares en pediatría : diagnóstico, tratamiento y evaluación del abordaje conservador

Tesis inédita de la Universidad Complutense de Madrid, Facultad de Medicina, leída el 03-06-2022Las infecciones osteoarticulares (IOA) son relativamente comunes. No obstante, pueden ser potencialmente severas. Tradicionalmente, el manejo de esta patología estaba basado en antibioterapia prolongada, inicialmente intravenosa, asociando cirugía en caso de afectación articular o mala evolución. Sin embargo, en los últimos años, se ha descrito como opción igual de segura y eficaz disminuir la duración de tratamiento intravenoso a 2-4 días, especialmente en pacientes menores de 3 años sin factores de riesgo y fuera del periodo neonatal. Además, de manera progresiva, se han ido publicando nuevas series de pacientes con compromiso articular que presentaban buena evolución clínica habiendo sido abordados mediante artroscopia, artrocentesis con lavado articular o incluso únicamente con actitud expectante, reservando la cirugía únicamente para aquellos casos con evolución tórpida días después de haber iniciado antibioterapia. Asimismo, la implementación progresiva de las técnicas de detección molecular ha permitido la detección de gérmenes de crecimiento difícil en métodos de cultivo convencionales, como Kingella kingae. De hecho, actualmente este germen se ha descrito como el principal agente etiológico en pacientes entre 6 meses y 4 años de edad. La poca repercusión clínica y analítica que suele acompañar a este microorganismo, cuestiona si los pacientes con sospecha de IOA por K. kingae, o con bajo riesgo de secuelas, deberían ser manejados siguiendo las recomendaciones clásicas o si un abordaje mínimamente invasivo podría ser suficiente...Osteoarticular infections (OAI) are relatively common. However, they can be potentially serious. Traditionally, the management of this pathology was based on prolonged antibiotic therapy, initially intravenous, followed by surgery in case of joint involvement or poor evolution. However, recently, reducing the duration of intravenous treatment to 2-4 days has been described as an equally safe and effective option, especially in patients younger than 3 years without risk factors and outside the neonatal period. In addition, progressively, new series of patients with joint involvement who presented good clinical evolution have been published. Those patients had been approached by arthroscopy, arthrocentesis with joint lavage or even only with an expectant attitude, reserving surgery only for those cases with torpid evolution days after having started antibiotic therapy.Likewise, the progressive implementation of molecular detection techniques has allowed the detection of difficult-to-grow germs in conventional culture methods, such as Kingella kingae. In fact, this germ has now been described as the main etiological agent in patients between 6 months and 4 years of age.The subtle clinical and analytical repercussion that usually accompanies this microorganism, questions whether patients with suspected OAI due to K. kingae or with low risk of sequelae should be managed following the classic recommendations or if a minimally invasive approach could be sufficient...Fac. de MedicinaTRUEunpu

Colchicine treatment in children with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome: A multicenter study in Spain

Objective: To evaluate the efficacy of colchicine therapy in pediatric patients with PFAPA syndrome who present with an incomplete response to the standard treatment or with frequent episodes (an interval of less than 14 days between two disease flares). Methods: A multicenter cohort study of children diagnosed with PFAPA syndrome and treated with colchicine was performed in three separate hospitals located in Spain. The patients clinical and laboratory data were reviewed by accessing their medical records. Response to colchicine was evaluated after 12 months of treatment for frequency, duration, and intensity of PFAPA episodes. Results: A total of 13 children were included in our study, 43% of whom were boys. Median age of the colchicine therapy initiation was 6 years (interquartile range (IQR)=3-9.5). Following a 12-month period of colchicine therapy (median dosage of 0.02 mg/kg/day; IQR=0.02-0.03), a significant decrease in the median number of flares (median 8; IQR=7-14 vs 3; IQR=2-4; p=0.005) and the duration of disease episodes (median 4 days; IQR=3.25-5.125 vs 1 day; IQR=1-2; p=0.003) was observed. Furthermore, the highest degree of fever during disease flares was reduced from median 40ºC (IQR=39.5-40) to 38.5ºC (IQR=37.7-38.9) (p=0.002). Conclusion: Colchicine therapy decreased the frequency and intensity of PFAPA. The use of colchicine could be an effective treatment in pediatric patients with PFAPA syndrome who present with frequent or severe relapses

The Castilian Spanish version of the Juvenile Arthritis Multidimensional Assessment Report (JAMAR)

The Juvenile Arthritis Multidimensional Assessment Report (JAMAR) is a new parent/patient reported outcome measure that enables a thorough assessment of the disease status in children with juvenile idiopathic arthritis (JIA). We report the results of the cross-cultural adaptation and validation of the parent and patient versions of the JAMAR in the Castilian Spanish language. The reading comprehension of the questionnaire was tested in 10 JIA parents and patients. Each participating centre was asked to collect demographic, clinical data and the JAMAR in 100 consecutive JIA patients or all consecutive patients seen in a 6-month period and to administer the JAMAR to 100 healthy children and their parents. The statistical validation phase explored descriptive statistics and the psychometric issues of the JAMAR: the three Likert assumptions, floor/ceiling effects, internal consistency, Cronbach\u2019s alpha, interscale correlations, test\u2013retest reliability and construct validity (convergent and discriminant validity). A total of 526 JIA patients (8.6% systemic, 49.4% oligoarticular, 18.2% RF negative polyarthritis, 23.8% other categories) and 78 healthy children, were enrolled in six centres. The JAMAR components discriminated well healthy subjects from JIA patients. All JAMAR components revealed good psychometric performances. In conclusion, the Castilian Spanish version of the JAMAR is a valid tool for the assessment of children with JIA and is suitable for use both in routine clinical practise and clinical research

O106 / #796 FEASIBILITY OF TRANSCUTANEOUS SPINAL CORD STIMULATION COMBINED WITH ROBOTIC-ASSISTED GAIT TRAINING (LOKOMAT) FOR GAIT REHABILITATION FOLLOWING INCOMPLETE SPINAL CORD INJURY. A CASE SERIES STUDY

Transcutaneous electrical spinal cord stimulation (tSCS) is a non-invasive technique for neuromodulation with therapeutic potential for motor rehabilitation following spinal cord injury (SCI). The aim of the present study was to analyze the feasibility of a program of 20 sessions of 30-Hz tSCS combined with robotic-assisted gait training in incomplete SCI. The results of the present work partially belong to a randomized clinical trial that is in progress

Position statement on infection screening, prophylaxis, and vaccination in pediatric patients with rheumatic diseases and immunosuppressive therapies, part 2: infection prophylaxis

This study aims to provide practical recommendations on prophylaxis for infection in pediatric patients with immune-mediated rheumatic diseases receiving/scheduled to receive immunosuppressive therapy. A qualitative approach was applied. A narrative literature review was performed via Medline. Primary searches were conducted using MeSH terms and free text to identify articles that analyzed data on infections and vaccinations in pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapy. The results were presented and discussed in a nominal group meeting comprising a committee of 12 pediatric rheumatologists from the Prevention and Treatment of Infections Working Group of the Spanish Society of Pediatric Rheumatology. Several recommendations were generated. A consensus procedure was implemented via a Delphi process that was extended to members of the Spanish Society of Pediatric Rheumatology and the Vaccine Advisory Committee of the Spanish Association of Pediatrics. Participants produced a score ranging from 0 (completely disagree) to 10 (completely agree). Agreement was considered to have been reached if at least 70% of participants voted ≥ 7. The literature review included more than 400 articles. Overall, 63 recommendations were generated (23 on infection prophylaxis) and voted by 59 pediatric rheumatologists and other pediatric specialists, all of whom achieved the pre-established level of agreement. The recommendations on prophylaxis of infection cover vaccination and prophylaxis against varicella zoster virus, tuberculosis, Pneumocystis jiroveccii, and invasive fungal infections in pediatric patients with immune-mediated rheumatic diseases receiving/scheduled to receive immunosuppressive therapy. Conclusion: Based on current evidence and a Delphi process, we provided consensus and updated recommendations on prophylaxis and treatment of infections to guide those caring for pediatric rheumatology patients.Funding for open access charge: Universidad de Málaga/CBU

Humoral and cellular immune response to mRNA SARS-CoV-2 BNT162b2 vaccine in adolescents with rheumatic diseases

Background: Data about safety and efficacy of the mRNA SARS-CoV-2 vaccine in adolescents with rheumatic diseases (RD) is scarce and whether these patients generate a sufficient immune response to the vaccine remains an outstanding question. Objective: To evaluate safety and humoral and cellular immunity of the BNT162b2 vaccine in adolescents 12 to 18 years with RD and immunosuppressive treatment compared with a healthy control group. Methods: Adolescents from 12 to 18 years with RD followed at Hospital La Paz in Madrid (n = 40) receiving the BNT162b2 mRNA vaccination were assessed 3 weeks after complete vaccination. Healthy adolescents served as controls (n = 24). Humoral response was measured by IgG antiSpike antibodies, and cellular response by the quantity of IFN-γ and IL-2 present in whole blood stimulated with SARS-CoV-2 Spike and M proteins. Results: There were no differences in spike-specific humoral or cellular response between groups (median IFN-γ response to S specific protein; 528.80 pg/ml in controls vs. 398.44 in RD patients, p 0.78, and median IL-2 response in controls: 635.68 pg/ml vs. 497.30 in RD patients, p 0.22. The most frequent diagnosis was juvenile idiopathic arthritis (26/40, 65%) followed by Lupus (6/40, 15%). 60% of cases (23/40) received TNF inhibitors and 35% (14/40) methotrexate. 40% of patients (26/64) had previous SARS-CoV-2 infection, 9 in the control group and 17 in the RD patients without differences. Of note, 70% of infections were asymptomatic. A higher IFN-γ production was found in COVID-19 recovered individuals than in naive subjects in both groups (controls: median 859 pg/ml in recovered patients vs. 450 in naïve p 0.017, and RD patients: 850 in recovered vs. 278 in naïve p 0.024). No serious adverse events or flares were reported following vaccination. Conclusions: We conclude that standard of care treatment for adolescents with RD including TNF inhibitors and methotrexate did not affect the humoral and the cellular immunity to BNT162b2 mRNA vaccination compared to a healthy control group. The previous contact with SARS-CoV-2 was the most relevant factor in the immune response.This work has been partially supported by a grant from Merck & Co (USA) MISP Call, Reference # 60465.S

Tratamiento quirúrgico de la patologia urgente del colon izquierdo

El objetivo de este estudio es evaluar la morbilidad y mortalidad postoperatoria tras la aplicación de un protocolo terapéutico en los pacientes intervenidos de urgencia por patología del colon izquierdo. Como primera opción se practicó el Lavado Anterogrado Peroperatorio en todas las lesiones del colon izquierdo que precisaron intervención urgente. En lesiones irresecables, peritonitis fecaloidea, deterioro del estado general o lesiones asociadas en el resto del colon. se aplicaron otras opciones: la colostomía de descarga, la operación de Hartmann o la colectomía subtotal. Se practicaron 127 resecciones urgentes del colon izquierdo. En 56 casos se optó por la operación de Hartmann. en 38 por la colectomía subtotal y en 33 por el lAP. La complicación más frecuente fue la sepsis abdominal (29%). La mortalidad operatoria global fue del 24%. 390Ai para la operación de Hartmann. 16% para la colectomía subtotal y 6% para el LAP. El LAP es la intervención de elección en aquellos pacientes con buen estado general que presentan patología urgente del colon izquierdo sin peritonitis fecaloidea. ni lesión irreversible del colon derecho

Position statement on infection screening, prophylaxis, and vaccination of pediatric patients with rheumatic diseases and immunosuppressive therapies, part 3: precautions in situations of surgery, fever, and opportunistic infections

© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The objective of this study is to provide practical recommendations on the management of pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapies. The recommendations specifically address the cases of surgery, fever, and opportunistic infections (varicella, herpes-zoster, tuberculosis, invasive fungal disease). A qualitative approach was applied. A narrative literature review was performed via Medline. Primary searches were conducted using MeSH terms and free text to identify publications on infections and vaccinations in pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapies. The results were presented and discussed in a nominal group meeting, comprising a committee of 12 pediatric rheumatologists from the Infection Prevention and Treatment Working Group of the Spanish Society of Pediatric Rheumatology. Several recommendations were generated. A consensus procedure was implemented via a Delphi process; this was extended to members of the Spanish Society of Pediatric Rheumatology and Spanish Society of Pediatric Infectious Disease of the Spanish Association of Pediatrics. Participants produced a score ranging from 0 (totally disagree) to 10 (totally agree). Agreement was defined as a vote ≥ 7 by at least 70% of participants. The literature review included more than 400 articles. Overall, 63 recommendations (19 on surgery, fever, and opportunistic infections) were generated and voted by 59 pediatric rheumatologists and other pediatric specialists. Agreement was reached for all 63 recommendations. The recommendations on special situations cover management in cases of surgery, fever, and opportunistic infections (varicella, herpes-zoster, tuberculosis, and invasive fungal disease). Conclusions: Hereby, we provided consensus and updated of recommendations about the management of special situations such as surgery, fever, and opportunistic in children with immune-mediated rheumatic diseases receiving immunosuppressive therapies. Several of the recommendations depend largely on clinical judgement and specific balance between risk and benefit for each individual and situation. To assess this risk, the clinician should have knowledge of the drugs, the patient’s previous situation as well as the current infectious disease, in addition to experience.Funding for open access publishing: Universidad Málaga/CBUA. Open Access funding was provided thanks to the CRUE-CSIC agreement with Springer Nature. This project was partially funded by an unrestricted grant from Pfizer. Pfizer did not participate in the design or development of the project or in the drafting of the manuscript. SERPE also provided funds to the project.Peer reviewe

Elevated Autoantibodies in Subacute Human Spinal Cord Injury Are Naturally Occurring Antibodies

Spinal cord injury (SCI) results in long-term neurological and systemic consequences, including antibody-mediated autoimmunity, which has been related to impaired functional recovery. Here we show that autoantibodies that increase at the subacute phase of human SCI, 1 month after lesion, are already present in healthy subjects and directed against non-native proteins rarely present in the normal spinal cord. The increase of these autoantibodies is a fast phenomenon–their levels are already elevated before 5 days after lesion–characteristic of secondary immune responses, further supporting their origin as natural antibodies. By proteomics studies we have identified that the increased autoantibodies are directed against 16 different nervous system and systemic self-antigens related to changes known to occur after SCI, including alterations in neural cell cytoskeleton, metabolism and bone remodeling. Overall, in the context of previous studies, our results offer an explanation to why autoimmunity develops after SCI and identify novel targets involved in SCI pathology that warrant further investigation