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Objective: To determine the accuracy and usefulness of noninvasive continuous hemoglobin (Hb) monitoring in critically ill patients at risk of bleeding., Design: An observational prospective study was made, comparing core laboratory Hb measurement (LabHb) as the gold standard versus transcutaneous hemoglobin monitoring (SpHb)., Setting: Pediatric Intensive Care Unit of a tertiary University Hospital., Patients: Patients weighing >3kg at risk of bleeding., Interventions: SpHb was measured using the Radical7 pulse co-oximeter (Masimo Corp., Irvine, CA, USA) each time a blood sample was drawn for core laboratory analysis (Siemens ADVIA 2120i)., Variables: Sociodemographic characteristics, perfusion index (PI), pleth variability index, heart rate, SaO 2 , rectal temperature, low signal quality and other events that can interfere with measurement., Results: A total of 284 measurements were made (80 patients). Mean LabHb was 11.7±2.05g/dl. Mean SpHb was 12.32±2g/dl (Pearson 0.72, R 2 0.52). The intra-class correlation coefficient was 0.69 (95%CI 0.55-0.78)(p<0.001). Bland-Altman analysis showed a mean difference of 0.07 ±1.46g/dl. A lower PI and higher temperature independently increased the risk of low signal quality (OR 0.531 [95%CI 0.32-0.88] and 0.529 [95%CI 0.33-0.85], respectively)., Conclusions: SpHb shows a good overall correlation to LabHb, though with wide limits of agreement. Its main advantage is continuous monitoring of patients at risk of bleeding. The reliability of the method is limited in cases with poor peripheral perfusion., (Copyright © 2016 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.)

The consumption of herbal products is mainly due to the perception that being "natural" can only be beneficial and without risk to health. However the properties thereof are poorly studied and proven. Four episodes are presented of hepatotoxicity from the consumption of herbal products, by three children. We analyse the epidemiological and clinical characteristics of these products, and stress the importance of proper anamnesis for accurate diagnosis., (Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.)

Introduction: Spondylodiscitis is an uncommon disease in children. It is often misdiagnosed or the diagnosis is made late in the course of illness., Objectives: To review the clinical, analytical and radiological characteristics of children with spondylodiscitis in the Materno-Infantil Hospital of Malaga., Patients and Methods: Retrospective cohort study on children diagnosed with spondylodiscitis, during a period of 11 years., Results: Eighteen patients were included in the study. Spondylodiscitis was more frequent in patients younger than 3 years old and older than 12 years old. The average time of delay in diagnosis was 26.9 days. In 8 cases the diagnosis was missed initially. Three clinical patterns appeared: in children under 3 years of age, refusing to walk and sit (100%) and irritability (42%); between 3 and 12 years of age, limb (100%) and abdominal pain (100%); in adolescents, back pain (75%). Fever was present in 38% of the cases, and low-grade fever in 8 (44%). A total of 50% of the patients had a moderate leucocytosis, and a slight increase in ESR; the most frequent location was L3-L4. X-ray diagnosis was pathological in 88% of the cases. The initial MRI diagnosed 100% of the cases. In addition, nerve roots damage (5 cases), inflammatory masses/paravertebral abscesses (5), epidural abscess (1) and psoas abscesses (2) were detected. A total of 94% of the children received antibiotics and 100% of the children underwent immobilization. All patients recovered early after the beginning of treatment, with the exception of those affected by psoas abscesses. The radiological follow-up was done in 17 patients (12 by MRI). After a mean of 14 months (rank 1-48), persistent diminution of disc space was seen in 100% of the children, and improvement of soft-tissue inflammation. Clinically (follow-up only in 11 patients) all patients regained normal mobility and only 27% had moderate pain., Conclusion: Spondylodiscitis, whose delay in the diagnosis is frequent, is a serious illness. Complications include abscesses and nerve root damage. MRI is the study of choice to determine the extension to neighbouring tissues.

Patient safety constitutes one of the main objectives in health care. Among other recommendations, such as the creation of training centres and the development of patient safety programmes, of great importance is the creation of training programmes for work teams using medical simulation. Medical simulation is defined as "a situation or environment created to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation or to understand systems or human actions". In this way, abilities can be acquired in serious and uncommon situations with no risk of harm to the patient. This study revises the origins of medical simulation and the different types of simulation are classified. The main simulators currently used in Pediatrics are presented, and the design of a simulation course applied to the training of pediatric emergencies is described, detailing all its different phases. In the first non face-to-face stage, a new concept in medical training known as e-learning is applied. In the second phase, clinical cases are carried out using robotic simulation; this is followed by a debriefing session, which is a key element for acquiring abilities and skills. Lastly, the follow-up phase allows the student to connect with the teachers to consolidate the concepts acquired during the in-person phase. In this model, the aim is to improve scientific-technical abilities in addition to a series of related abilities such as controlling crisis situations, correct leadership of work teams, distribution of tasks, communication among the team members, etc., all of these within the present concept of excellence in care and medical professionalism.

Crohn's disease (CD) is an intestinal inflammatory disease of unknown origin that is sometimes associated with cutaneous manifestations. These skin lesions are usually nonspecific (erythema nodosum, erythema multiforme and pyoderma gangrenosum) and should be differentiated from the cutaneous lesions corresponding to the typical histological pattern of CD; most of these extend directly from the involved bowel. Noncaseating granulomatous infiltration in skin anatomically distant from areas of gastrointestinal CD and separated by normal skin is extremely rare. This entity, known as metastatic Crohn's disease, can be the first symptom of CD or even more unusually can appear during the course of the disease.We report the case of a 9-year-old boy, previously diagnosed with ileocolic and perianal CD, who had been receiving treatment with mesalazine, prednisone and 6-mercaptopurine for 3 years. He presented with swelling of the penis and scrotum of 2 weeks' evolution, without any other symptoms. Testicular ultrasound showed thickening of the scrotal wall and increased flux at this site. Skin biopsy showed noncaseating granulomas. Results of special staining techniques were negative for the presence of microorganisms. The prednisone dose was increased and metronidazole was added, with noticeable improvement in the lesions. Due to reappearance of cutaneous lesions when the prednisone dose was reduced, the patient currently receives maintenance treatment.