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The main objective of this study was to analyze the degree of knowledge and compliance of Spanish pediatricians with the "do not do" recommendations of the Spanish Association of Pediatrics. A nationwide cross-sectional, descriptive study was carried out using a 25-item questionnaire among Spanish pediatricians. Univariate, bivariate, and multivariate analyses were performed. A total of 1137 pediatricians participated in the study. Most of them were women (75.1%), older than 55 (28.3%), worked in specialized care (56.9%), with public financing (91.2%), and had been working for more than 20 years (44.9%). The median of inappropriate answers per question was 9.1%. The bivariate and multivariate analyses showed that the factors that influenced higher adequacy to the "do not do" recommendations were younger than 45 years, working in specialized care, and working in the public health system.This research is the first nationwide study in Spain to analyze the adequacy of "do not do" pediatric clinical recommendations. The study showed a high level of compliance by Spanish pediatricians with these recommendations. However, there is a lack of knowledge in less frequent infectious pathologies such as HIV or fungal infections, in not prolonging antibiotic treatment unnecessarily and directing it appropriately according to the antibiogram results. These aspects may be improved by designing measures to enhance pediatricians' knowledge in these specific aspects. Some demographical factors are related to higher adequacy. Performing this research in other countries may allow assessing the current clinical practice of pediatricians.• Low-value care is defined as care that delivers little or no benefit, may cause patients harm, or outcomes marginal benefits at a disproportionately increased cost. • Few nationwide studies have assessed adherence to "do not do" guidelines, especially in pediatric settings.• Albeit there is a high level of compliance by Spanish pediatricians with the «do not do» recommendations, there is a lack of knowledge in different aspects that may be improved. • Some demographical factors are related to higher adequacy. Performing this research in other countries may allow assessing the current clinical practice of pediatricians.

Resumen: Introducción: En 2014 se publicó el Documento de Consenso desarrollado por SEIP-SERPE-SEOP para el diagnóstico y el tratamiento de las infecciones osteoarticulares (IOA). En 2015 se constituyó RIOPed como red nacional multidisciplinar para la investigación en IOA. El objetivo del estudio ha sido valorar el grado de adecuación a las recomendaciones establecidas en el consenso durante un año de seguimiento. Material y métodos: Estudio prospectivo multicéntrico nacional realizado entre septiembre de 2015 y septiembre de 2016 en 37 hospitales con inclusión de pacientes menores de 16 años diagnosticados de IOA, confirmada mediante aislamiento microbiológico, o probable: artritis séptica (AS) con > 40.000 leucocitos en líquido sinovial u osteomielitis (OM)/osteoartritis (OA)/espondilodiscitis (ED) con prueba de imagen compatible. Los resultados se compararon con los obtenidos en el estudio retrospectivo realizado entre 2008 y 2012. Resultados: Se incluyeron 255 casos: 131 OM, 79 AS, 30 OA y 15 ED. Respecto a las pruebas complementarias que el consenso consideró de obligada realización, la radiografía se llevó a cabo en el 87,8% de los casos, el hemocultivo en el 91,6% y el cultivo de líquido sinovial en el 99% de AS. Se realizó RM en el 71% de las OM. La elección del tratamiento antibiótico intravenoso empírico se adecuó a las recomendaciones en el 65,1% de los casos, y en el 62,3% para el tratamiento oral. Se llevó a cabo cirugía en el 36,8% de las AS (85,7% artrotomía), con un descenso significativo respecto al estudio retrospectivo (p = 0,014). Solo el 58,5% de casos se ajustaron a las recomendaciones de duración del tratamiento; sin embargo, se comprobó una menor duración del tratamiento intravenoso. Conclusiones: En general, el grado de adecuación a las recomendaciones que marcaron el grupo de expertos es bueno para las pruebas complementarias y aceptable respecto a la elección del tratamiento antibiótico, aun detectándose casi un 40% de inadecuación. Se ha conseguido un descenso de la estancia hospitalaria. Abstract: Introduction: In 2014 the Consensus Document produced by the Spanish Paediatric Societies (SEIP-SERPE-SEOP) was published to help in the diagnosis and treatment of osteoarticular infections (OAI). In 2015 the RIOPed was considered as a multidisciplinary national network for the investigation into OAI. The aim of this study was to assess the level of adaption to the recommendations established in the Consensus during one year of follow-up. Material and methods: A prospective, national multicentre study was carried out in 37 hospitals between September 2015 and September 2016. The study included patients > 16 years-old with a diagnosis of OAI, confirmed by microbiological isolation, or probable: septic arthritis (SA) with > 40,000 white cells in synovial fluid, or osteomyelitis (OM)/spondylodiscitis (SD) with a compatible imaging test. The results were compared with those obtained in a retrospective study conducted between 2008 and 2012. Results: A total of 235 cases were included, of which 131 were OM, 79 SA, 30 OA, and 15 SD. As regards the complementary tests that the Consensus considered mandatory to perform, radiography was carried out on 87.8% of the cases, a blood culture on 91.6%, and culture of the synovial fluid in 99% of SA. A magnetic resonance (MR) was performed on 71% of the OM cases. The choice of intravenous empirical antibiotic treatment was adapted to the recommendations in 65.1% of cases, and in 62.3% for the oral treatment. Surgery was performed in 36.8% of SA cases (85.7% arthrotomy), with a significant decrease compared to the retrospective study (P = .014). Only 58.5% of cases followed the recommendations on the duration of the treatment; however, a lower duration of intravenous treatment was observed. Conclusions: In general, the level of adaptation to the recommendations that were set by the Expert Group, is good for the complementary tests, and acceptable as regards the choice of antibiotic treatment, although inadequate in almost 40% of cases. A decrease in hospital stay was achieved.

Here, we present a case of off-label successful use of the T2 MR (T2Candida® test) for the diagnosis of invasive candidiasis ( Candida albicans endolphthalmitis). This case demonstrates that T2Candida could be performed in sterile body fluids to improve microbiological diagnosis of invasive candidiasis.

Resumen Introduccion El sindrome PFAPA es una enfermedad autoinflamatoria de diagnostico clinico. Se han propuesto diversos tratamientos; entre ellos, la tonsilectomia podria ser un tratamiento efectivo. Material y metodos Estudio multicentrico retrospectivo. Se incluyeron pacientes diagnosticados de sindrome PFAPA, segun los criterios de Thomas, en 3 hospitales madrilenos, entre 2009-2013. Resultados Se incluyeron 32 casos. Las medianas de edad de inicio del cuadro y al diagnostico fueron 32 meses (RIQ 24-44) y 47,5 meses (RIQ 37-60), respectivamente. Se hallaron incrementos en las cifras de leucocitos (13.580/μl [RIQ 8.200-16.600] vs. 8.300/μl [RIQ 7.130-9.650], p = 0,005), neutrofilos (9.340/μl [RIQ 5.900-11.620] vs. 3.660/μl [RIQ 2.950-4.580], p = 0,002) y proteina C reactiva (11,0 mg/dl [RIQ 6,6-12,7] vs. 0,2 mg/dl [RIQ 0,1-0,6], p = 0,003) durante los episodios febriles, respecto a los periodos libres de sintomas. El 80,8% referia remision de los sintomas en 24 h tras corticoterapia oral. Fueron tonsilectomizados 14 pacientes. En 11 cesaron los episodios febriles, mientras que en 3 se redujo su frecuencia; hubo 2 sangrados posquirurgicos como complicacion. El cuadro se habia resuelto en el 56,3% de los pacientes, a una mediana de edad de 60 meses (RIQ 47-95), con una duracion similar entre los pacientes que fueron tonsilectomizados y los que no. Conclusiones Se presenta una cohorte amplia de ninos con sindrome de PFAPA en la que se confirma que, en nuestro medio, los ninos con este sindrome presentan unas caracteristicas clinicas y analiticas similares a las descritas en la literatura, con buena respuesta a corticoterapia y elevada resolucion de la clinica tras la amigdalectomia.

Introduction PFAPA syndrome is an autoinflammatory disease whose diagnosis is mainly clinical. Several treatments have been proposed; among them, tonsillectomy could be an effective one. Material and methods Retrospective multicenter study. Patients included were diagnosed with PFAPA syndrome, according to the Thomas criteria, in 3 hospitals in Madrid between 2009 and 2013. Results Thirty-two cases were included. Median age at onset and at diagnosis were 32 months (IQR 24–44) and 47.5 months (IQR 37–60), respectively. There were increases in leukocytes (13,580/μl [IQR 8200–16,600] vs 8300/μl [IQR 7130–9650], p = .005), neutrophils (9340/μl [IQR 5900–11,620] vs 3660/μl [IQR 2950–4580], p = .002) and C-reactive protein (11.0 mg/dl [IQR 6.6–12.7] vs 0.2 mg/dl [IQR 0.1–0.6], p = .003) during febrile episodes. In all, 80.8% of patients reported remission of symptoms within 24 h after oral corticosteroid therapy. Fourteen patients were tonsillectomised. In 11, the febrile episodes stopped while, in 3, the frequency was reduced; there were 2 cases of postoperative bleeding. The disease was resolved in 56.3% of the patients, at a median age of 60 months (IQR 47–95), with similar duration in patients who were tonsillectomised and those who were not. Conclusions We present a large cohort of children with PFAPA syndrome, with clinical and analytical features similar to those described in the literature, and a good response to corticosteroids and a high resolution rate of symptoms after tonsillectomy.

Here, we present a case of off-label successful use of the T2 MR (T2Candida

Pyogenic sacroilitis is an infrequent osteoarticular infection, and its diagnosis is a challenge in young children. A series of 20 cases is described. The median age was 15 months, 75% of them being under 2 years old. Fourteen (70%) reported fever. Refusal to sit was the main reason for consultation. Final diagnosis was confirmed by bone scintigraphy. All patients achieved a complete resolution without sequelae.

Objetivo Analizar la valoración de la atención a los niños con patología crónica compleja (NPCC) en atención primaria (AP), desde el punto de vista de sus médicos y de sus familias. Diseño Estudio observacional, descriptivo y transversal. Emplazamiento Pediatría de AP y unidad de patología crónica compleja (UPCC) del Hospital Universitario La Paz (HULP). Participantes Pacientes y familiares de la UPCC y sus médicos de AP de la Comunidad de Madrid (CAM). Intervenciones Realización de encuestas validadas presenciales y online. Mediciones principales Grado de satisfacción en la formación, capacitación y manejo específico del NPCC según escalas tipo Likert. Resultados Se encuestaron 53 familias y 170 médicos de AP (96,5% pediatras). Los resultados de la encuesta a familiares revelan descoordinación entre niveles asistenciales (73,6%), escasa confianza en el primer nivel asistencial e impresión de poca capacidad de resolución de problemas por parte de pediatría de AP (50%). Entre los médicos de AP destaca la poca formación para el seguimiento de los NPCC (96,5%), escasa experiencia en su manejo (93%) e insuficiente comunicación con el hospital (80,5%). La falta de tiempo en las consultas es un problema común, percibido por pediatras y pacientes. Conclusiones La falta de coordinación entre AP y atención hospitalaria (AH) se detecta como un problema importante en la continuidad asistencial de NPCC. Son necesarias intervenciones que mejoren esta coordinación. La AP es cercana a la familia, pero precisa mejorar la formación y capacitación de los profesionales en problemas de salud y soporte tecnificado de NPCC, así como incrementar el tiempo necesario para su atención.

An update of the Spanish consensus document on the diagnosis and treatment of acute tonsillopharyngitis in 2011 is presented. Clinical scores should not be used to prescribe antibiotics, unless microbiological tests are not available or there is a child at risk of rheumatic fever. There is no score better than those set out in the previous consensus. Microbiological tests are recommended in proposed cases, regardless of the result of the scores. Penicillin is the treatment of choice, prescribed twice a day for 10 days. Amoxicillin is the first alternative, prescribed once or twice a day for the same time. First-generation cephalosporins are the treatment of choice in children with non-immediate reaction to penicillin or amoxicillin. Josamycin and midecamycin are the best options for children with immediate penicillin allergic reactions, when non-beta-lactam antibiotics should be used. In microbiological treatment failure, and in streptococcal carriers, the treatments proposed in the previous consensus are still applicable. Resumen: Se presenta una actualización del documento de consenso sobre el diagnóstico y tratamiento de la faringoamigdalitis aguda, publicado en 2011. Las escalas de predicción clínica no deben ser utilizadas para iniciar antibioterapia, salvo que las pruebas microbiológicas no estén disponibles o exista riesgo de fiebre reumática. No existe ninguna escala que sea mejor que las expuestas en el consenso previo. Se proponen casos en los que se recomienda realizar pruebas microbiológicas, con independencia de los resultados de las escalas. El tratamiento de elección de la faringoamigdalitis estreptocócica es penicilina en dos dosis diarias y durante diez días. Amoxicilina, en una o dos dosis diarias y durante el mismo tiempo, es la primera alternativa terapéutica. Las cefalosporinas de primera generación son el tratamiento de elección en niños con reacción retardada no grave a penicilina o amoxicilina. En reacciones alérgicas inmediatas deben utilizarse antibióticos no betalactámicos, siendo josamicina y diacetil-midecamicina las mejores opciones. En el fracaso terapéutico bacteriológico, y en el estado de portador, los tratamientos planteados en el consenso previo siguen siendo válidos.

In 2014 the Consensus Document produced by the Spanish Paediatric Societies (SEIP-SERPE-SEOP) was published to help in the diagnosis and treatment of osteoarticular infections (OAI). In 2015 the RIOPed was considered as a multidisciplinary national network for the investigation into OAI. The aim of this study was to assess the level of adaption to the recommendations established in the Consensus during one year of follow-up.A prospective, national multicentre study was carried out in 37 hospitals between September 2015 and September 2016. The study included patients16years-old with a diagnosis of OAI, confirmed by microbiological isolation, or probable: septic arthritis (SA) with40,000 white cells in synovial fluid, or osteomyelitis (OM)/spondylodiscitis (SD) with a compatible imaging test. The results were compared with those obtained in a retrospective study conducted between 2008 and 2012.A total of 235 cases were included, of which 131 were OM, 79 SA, 30 OA, and 15 SD. As regards the complementary tests that the Consensus considered mandatory to perform, radiography was carried out on 87.8% of the cases, a blood culture on 91.6%, and culture of the synovial fluid in 99% of SA. A magnetic resonance (MR) was performed on 71% of the OM cases. The choice of intravenous empirical antibiotic treatment was adapted to the recommendations in 65.1% of cases, and in 62.3% for the oral treatment. Surgery was performed in 36.8% of SA cases (85.7% arthrotomy), with a significant decrease compared to the retrospective study (P=.014). Only 58.5% of cases followed the recommendations on the duration of the treatment; however, a lower duration of intravenous treatment was observed.In general, the level of adaptation to the recommendations that were set by the Expert Group, is good for the complementary tests, and acceptable as regards the choice of antibiotic treatment, although inadequate in almost 40% of cases. A decrease in hospital stay was achieved.

Respiratory viral infections, particularly respiratory syncytial virus (RSV) and rhinovirus, are the most importance risk factors for the onset of wheezing in infants and small children. Bronchiolitis is the most common acute respiratory infection in children under 1 year of age, and the most common cause of hospitalization in this age group. RSV accounts for approximately 70% of all these cases, followed by rhinovirus, adenovirus, metapneumovirus and bocavirus. The association between bronchiolitis caused by RSV and the development of recurrent wheezing and/or asthma was first described more than 40 years ago, but it is still unclear whether bronchiolitis causes chronic respiratory symptoms, or if it is a marker for children with a genetic predisposition for developing asthma in the medium or long term. In any case, sufficient evidence is available to corroborate the existence of this association, which is particularly strong when the causative agent of bronchiolitis is rhinovirus. The pathogenic role of respiratory viruses as triggers for exacerbations in asthmatic patients has not been fully characterized. However, it is clear that respiratory viruses, and in particular rhinovirus, are the most common causes of exacerbation in children, and some type of respiratory virus has been identified in over 90% of children hospitalized for an episode of wheezing. Changes in the immune response to viral infections in genetically predisposed individuals are very likely to be the main factors involved in the association between viral infection and asthma.

Resumen Las infecciones por virus respiratorios, especialmente virus respiratorio sincitial (VRS) y rinovirus, suponen el mayor factor de riesgo para la aparicion de episodios de sibilancias en lactantes y ninos pequenos. La bronquiolitis es la infeccion respiratoria aguda de vias respiratorias inferiores mas comun en menores de un ano y constituye la causa mas frecuente de hospitalizacion en este grupo de edad. El VRS causa aproximadamente el 70% de todas ellas, seguido por rinovirus, adenovirus, metapneumovirus o bocavirus. La asociacion entre bronquiolitis por VRS y desarrollo de sibilancias recurrentes y/o asma ha sido descrita hace mas de 4 decadas, aunque en la actualidad se desconoce con exactitud si la bronquiolitis es la causa de los sintomas respiratorios cronicos o si, mas bien, es un marcador que senala a los ninos con predisposicion genetica a desarrollar asma a medio o largo plazo. En cualquier caso, existe evidencia suficiente como para afirmar que esta asociacion existe y que es especialmente intensa si el agente asociado a la bronquiolitis es el rinovirus. El papel patogenico de los virus respiratorios como desencadenantes de exacerbaciones en el paciente asmatico no esta totalmente aclarado, pero sin duda los virus respiratorios, y en especial el rinovirus, son el desencadenante mas frecuente de exacerbaciones asmaticas en los ninos, llegando a identificarse algun virus respiratorio hasta en el 90% de los ninos hospitalizados por un episodio de sibilancias. Muy probablemente, las alteraciones en la respuesta inmune frente a las infecciones virales en sujetos geneticamente predispuestos sean los principales implicados en la asociacion virus-asma.

Infants affected by bronchiolitis during first months of life, frequently develop recurrent wheezing(RW) and asthma. The aim of this study was to analyse the innate immune response that characterise bronchiolitis (BQ) and RW. Method: Ninety-nine and seventy-two infants hospitalised with BQ or RW respectively, (October/2016-August/2017), and 23 healthy-infants were included. Nasopharyngeal aspirates (NPA) were processed. Type-2 innate lymphoid cells (ILC2) were evaluated by flow cytometry. Twenty-eight pro-inflammatory factors linked to innate immunity, inflammation and epithelial damage were evaluated in NPA supernatant by ELISA. Also, eleven genes were analyzed in NPA cells by quantitative PCR (qPCR). Results: Bronchiolitis presented a significant increase of ILC2 percentage compared with RW (P Conclusion: Differential innate immune response and epithelial repair mechanisms were observed between both diseases; however, BQ and RW share mechanisms such us monocyte activation, vascular damage and fibroblast repair.

BACKGROUND: Human metapneumovirus (HMPV) has an important etiological role in acute lower respiratory infections in children under five years. Our objectives were to estimate the relative contribution of HMPV to hospitalization in children with acute respiratory infection, to define the clinical and epidemiological features of HMPV single and multiple infections, and to compare HMPV infections with respiratory syncytial virus (HRSV), rhinovirus (HRV), adenovirus and human bocavirus infections in the same population. METHODS AND FINDINGS: A prospective study performed on all children less than 14 years of age with a respiratory tract disease admitted to a secondary hospital between September 2005- June 2014. Clinical characteristics of patients were analyzed. Nasopharyngeal aspirate was taken at admission for viral study with polymerase chain reaction for 16 respiratory viruses. A total of 3,906 children were included. At least one respiratory virus was detected in 75.2% of them. The most common identified virus was HRSV, followed by HRV. HMPV was detected in 214 cases (5.5%); 133 (62%) were single infections and the remaining were detected in coinfection with other viruses. 90.7% cases were detected between February and May. Children's mean age was 13.83 ± 18 months. Fever was frequent (69%), and bronchiolitis (27%), and recurrent wheezing (63%) were the main clinical diagnosis. Hypoxia was present in 65% of the patients and 47% of them had an infiltrate in X-ray. Only 6 (2.8%) children were admitted to the intensive care unit. Only the duration of the hospitalization was different, being longer in the coinfections group (p

Objective To demonstrate that heated humidified high-flow nasal cannula (HHHFNC) is superior to inhaled hypertonic saline solution (HSS) in improving respiratory distress in moderate bronchiolitis. In addition, it could improve comfort and reduce length of hospital stay (LOS) and admission to Paediatric Intensive Care Unit (PICU). Design Randomised Clinical Trial from 1 October 2010 to 31 December 2012. Setting Two urban secondary (no PICU available) paediatric hospitalisation units. Patients Hospitalised children aged up to 6 months with moderate acute bronchiolitis (Respiratory Distress Assessment Instrument, RDAI ≥4). Intervention Patients were randomised to HHHFNC or HSS. All of them received epinephrine as bronchodilator. Main outcomes Primary outcome was difference in mean Respiratory Assessment Change Score (RACS) between both groups measured in six previously defined consecutive moments. Secondary outcomes were difference in mean comfort scores in this period, LOS and rate of PICU admission. Results Seventy-five previously healthy patients were enrolled. Mean age was 2.4 months (95% CI 2.04 to 2.76). 43 were allocated to HSS group and 32 in HHHFNC. Data of 1 patient were lost, and 8 changed group over the study period. Intention-to-treat principle was applied. There were no significant differences in mean RACS and mean comfort scores between groups at the evaluation points. Median LOS or PICU admission rate were similar in both groups. No adverse events were observed. Conclusions HHHFNC was not superior to HSS in treatment of moderate acute bronchiolitis with respect to severity and comfort scores, LOS or PICU admission rate. Clinical Trial Registration ClinicalTrials.gov Identifier NCT01873144.

Resumen Objetivo Descripcion de la cobertura de la vacunacion antigripal en la embarazada. Analizar la proteccion que la vacunacion antigripal en la gestante proporcionaria al recien nacido (RN) en sus primeros meses de vida. Material y metodos 316 RN seguidos una temporada epidemica. Encuesta epidemiologica a las madres que incluye su estado vacunal. Llamadas quincenales con toma de muestras nasofaringeas y analisis virologico de estas cuando se objetivan datos clinicos que sugirieran infeccion. Resultados El 5,7% de las gestantes se vacunaron contra la gripe, un 17,4% de la misma muestra lo hicieron la temporada anterior. Solo factores como vacunacion en anos previos (odds ratio [OR] = 11,35 [7-31]) o en convivientes (OR = 19,9 [6,7-59,5)) influyeron sobre la vacunacion de forma significativa. No se detecto virus de la influenza en ningun caso. Conclusiones El porcentaje de gestantes vacunadas contra la gripe es muy bajo. La informacion podria mejorar estos resultados. No se puede obtener conclusiones sobre la hipotesis establecida.

Describimos un caso de sindrome SAPHO (sinovitis, acne, pustulosis, hiperostosis y osteitis) con una forma de presentacion poco habitual, en una nina de 14 anos de edad con febricula de 8 meses de duracion, dolor lumbar izquierdo y reactantes de fase aguda elevados con anemia normocitica y normocromica. En una radiografia de miembros inferiores se evidencio una imagen litica con osteitis e hiperostosis en perone derecho, como hallazgo casual tras una caida accidental. Estos datos, ademas del acne, la pustulosis, la artritis esternoclavicular y los estudios obtenidos por resonancia magnetica (RM) de columna y gammagrafia osea, orientaron el diagnostico de SAPHO.

We describe a case of SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) with an unusual presentation in a 14 year-old girl with low grade fever which lasts 8 months, left low back pain and elevated erythrocyte sedimentation rates and protein C-reactive with chronic anaemia. A radiograhy of the lower limbs showed a lytic image with osteitis and hyperostose in the right fibula, as a casual finding. This information, in addition to the acne, pustulosis, sternoclavicular arthritis, and the studies got from the magnetic resonance image (MR) of spine, pointed out the diagnosis of SAPHO.