Complicated pleural infection: Analysis of two consecutive cohorts managed with a different policy

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Moral, C. Loeda, F. Gómez, M.Á. Pena, M. Martínez, J.M. Cerdán, L. Lillo, T. Toral" "autores" => array:8 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Moral" "email" => array:1 [ 0 => "lmoralg@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "Loeda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "F." "apellidos" => "Gómez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "M.Á." "apellidos" => "Pena" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "M." "apellidos" => "Martínez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "J.M." "apellidos" => "Cerdán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "L." "apellidos" => "Lillo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "T." "apellidos" => "Toral" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Pediatrics, Hospital General Universitario de Alicante, Alicante, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Clinical Pharmacology, Hospital General Universitario de Alicante, Alicante, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Derrame paraneumónico complicado: análisis de dos cohortes consecutivas tratadas con distinto criterio" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2049 "Ancho" => 2499 "Tamanyo" => 292858 ] ] "descripcion" => array:1 [ "en" => "Initial and last chest X-ray of two representative patients with a very large complicated pleural effusion not drained. The time elapsed between the two images of each patient was (as usual in most of our cases) about 3 months." ] ] ] "textoCompleto" => "IntroductionPleural effusion and empyema are occasional complications of pneumonia in children that have been reported to have increased in recent years.<a class="elsevierStyleCrossRefs" href="#bib0160">1–4</a> Small effusions do not require invasive procedures for diagnosis and treatment, and do well with antibiotics alone. The treatment of large, organized and purulent effusions (fibrinopurulent stage) remains controversial and different approaches have been reported, from conservative antibiotic treatment to chest tube insertion or other surgical procedures, mainly video-assisted thoracoscopic surgery. Most guidelines consider that complicated pleural infection (CPI) should not be managed with antibiotics alone and recommend drainage,<a class="elsevierStyleCrossRefs" href="#bib0180">5–8</a> but some institutions have observed good outcomes without requiring a chest tube or surgery for many of the affected children, suggesting a benefit from a more individual approach.<a class="elsevierStyleCrossRefs" href="#bib0200">9,10</a>Our institution is the reference center for a population of almost 250,000 children under 15 years old when they require intensive care or pediatric surgery. Many children diagnosed with CPI are transferred from other hospitals for evaluation and treatment. In 2010, as a result of our experience and a recent report,<a class="elsevierStyleCrossRef" href="#bib0200">9</a> we moved from our previous adherence to authorized guidelines, resulting in draining most cases of CPI, to a more conservative and individualized management. We report our experience in the last 9 years, and compare patient characteristics, treatments and outcomes of children attending our hospital from 2005 to 2009, when a chest tube was usually inserted, depending on the characteristics of the effusion, with those who attended from 2010 to 2013, who were managed according to holistic clinical criteria, mainly the severity of appearance and respiratory difficulties based on physical examination.Patients and methodsSelection of patientsInformation on patients younger than 15 years old admitted between 2005 and 2013 inclusively, with a discharge diagnosis of pleural effusion or empyema, was retrieved from our hospital electronic database. The clinical records of these patients were retrospectively reviewed to select those with pleural effusion associated with a diagnosis of community-acquired pneumonia. Patients with an effusion associated with tuberculosis or other diseases were excluded. Parapneumonic effusions were considered to be CPI if the pleural space was bigger than 1cm as measured in plain chest roentgenogram and loculations or debris were observed by pleural ultrasound. Only patients with CPI were selected for analysis.Hospital managementPatients were admitted from the emergency department of our hospital or transferred from other hospitals. Two groups of patients are compared: those admitted between 2005 and 2009 (group 1) were managed according to the British Thoracic Society guidelines for the management of pleural infection in children,<a class="elsevierStyleCrossRef" href="#bib0180">5</a> and those admitted between 2010 and 2013 (group 2) were treated according to the clinical assessment of the attending pediatricians. The clinical findings driving a decision to drain the empyema in patients of group 2 included increased effort of breathing and severe or persistent septic condition.<a class="elsevierStyleCrossRefs" href="#bib0200">9,10</a> Persistent fever was not considered a reason to drain the effusion, because it has been reported to be long-standing irrespective of whether they are drained or not.<a class="elsevierStyleCrossRef" href="#bib0200">9</a> Chest tube insertion was usually performed by an interventional radiologist assisted by an anesthetist. The child was maintained under deep sedation and a small-bore pigtail catheter was inserted, with ultrasound guidance, using the Seldinger technique. Less frequently, a chest tube was inserted by a pediatric surgeon, more often for children admitted to the intensive care unit (ICU). Thoracentesis and computed tomography scan were usually not performed. All other decisions (chest tube removal, length of antibiotic treatment, discharge from hospital, etc.) were taken according to the best clinical judgment of the attending physicians.Data collectionThe clinical files of the patients selected were thoroughly reviewed and data were extracted for each patient, including sex, age, length of the hospital stay (LHS), comorbidities, signs and symptoms, duration of fever, blood and pleural fluid laboratory and bacteriological results, antibiotics administered, length of antibiotic treatment, oxygen therapy, admission to ICU, drain tube insertion, surgical interventions and complications. Pneumococcal vaccination status could not be analyzed due to inconsistent registration.OutcomesThe primary outcome measures for comparison between groups 1 and 2 were (1) the proportion of children with a chest tube inserted in our hospital and (2) the LHS. Secondary outcome measures for analysis were: treatments employed, length of antibiotic treatment and duration of fever. Length of primary fever was computed as the sum of number of days of fever before admission and the time to defervescence, considered as the time (in days) elapsed between admission and the first day with a temperature under 38°C for 24h. Fever reappeared in some patients after defervescence. In such cases, the total number of days with fever during admission and the total number of days from admission to complete disappearance of fever were calculated.StatisticsData were transferred to SPSS (v17.0 SPSS, Chicago, IL, USA). Descriptive analysis included frequencies and percentages for categorical variables, means, standard deviation (SD) and range for numerical variables with a normal distribution, and medians, interquartile range (IQR, 25th and 75th percentiles) and range for numerical variables with a non-normal distribution. Categorical variables were compared using the Fisher exact test or the chi-squared test for trend. Continuous variables were compared by means of t-test (with normal distribution) or Mann–Whitney U test (with non-normal distribution). Reported P values were two-tailed, and the level of significance was set at 0.05.EthicsThe study was approved by the Clinical Research Ethics Committee of our hospital.ResultsSelection of patientsTwo hundred children were discharged from our hospital between 2005 and 2013 with a diagnosis of pleural effusion. Twenty-four of them were not of infective origin and five were diagnosed with tuberculosis. The remaining 171 children had a parapneumonic pleural effusion and were selected for detailed review of their clinical records. Sixty-two had small simple effusions and were not considered to need a drainage procedure. The other 109 had large, complicated effusions, deemed to need drainage according to the main guidelines. These 109 patients were considered to have CPI and were the subject of our study. Sixty-four children were admitted in 2005–2009 (12.8/year) and 45 in 2010–2013 (11.3/year).Patients’ characteristicsThe main characteristics of patients on admission are depicted in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. A history of asthma or recurrent wheezing was present in 10% of patients, a frequency very close to that of the general pediatric population in our country.<a class="elsevierStyleCrossRef" href="#bib0210">11</a> One patient had cerebral palsy, two had epilepsy and another two had Down's syndrome. Two children had lesions of current chickenpox. Most of the patients were previously healthy or had other problems unrelated to the development of pneumonia or a pleural effusion.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>All patients had fever at some stage of the disease. Before admission, two patients had low-grade fever (less than 38°C) for only one day. The other 107 had fever (38°C or over) ranging from 1 to 10 days. The frequency of cough, respiratory distress and chest pain is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Other common signs and symptoms were (n): vomiting (28), abdominal pain (23), diarrhea (13), headache (6) and febrile seizure (2).In patients drained, pleural fluid median values (IQR) were: protein 4g/L (4–5), glucose 10mg/dL (2–31), leukocyte count 3.4×109/L (0.6–22.8). Bacterial cultures were positive in 30 patients (28%): Streptococcus pneumoniae was recovered from 17 patients (16%: 9 blood, 8 pleural fluid), Staphylococcus epidermidis from 4 (3 blood, 1 pleural fluid), Streptococcus pyogenes from 3 (1 blood and 3 pleural fluid), Staphylococcus aureus from 2 (1 blood, 1 pleural fluid) and other bacteria from 4 patients.General treatmentThe treatments are compared in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. Patients usually received more than one antibiotic, including oral antibiotics before and/or after hospitalization. Antibiotics were administered for a period of 7–34 days, but the mean was 2 days longer in the second group; the intravenous route was used for 0–26 days. Fifty-four patients needed oxygen for a median of 4 days (IQR 3–7 days, range 1–15 days). Thirteen patients were admitted to the pediatric ICU for a mean of 8.3 days (SD 6.9 days, range 1–23 days), but only two required assisted ventilation.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Pleural drainage treatmentA chest tube was placed in our hospital in 74 patients (68%): 83% of patients in group 1 and in 47% in group 2, and this was the most noticeable difference in their treatment (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Urokinase was administered in 85% of those drained (91% in group 1 and 71% in group 2, P=0.07). There was no significant trend in the percentage of patients drained between 2005 and 2009 (P=0.91), but a progressive reduction of chest tube placement was found between 2009 and 2013 after the change in treatment policy for empyema (P=0.006) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Thoracoscopy was performed in just one patient, due to treatment failure after 9 days with a chest tube. Two patients admitted to our center in 2009 had been drained before being transferred from their hospital. Exclusion of these two patients made no difference in the comparisons of treatments and outcomes.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>OutcomesThe main outcomes are depicted in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>. A 1-year-old girl transferred to our center in 2005 had a chest tube inserted, but was transferred the next day to another specialized center due to a pericardial effusion, where she was treated and recovered. This patient was excluded from the analysis of duration of antibiotics and outcomes. LHS (mean 11.8 days, SD 6.1, range 3–32 days) did not differ significantly between the two groups, even when the two patients drained in another hospital were excluded. Primary fever lasted 11.6 days (SD 5.0 days, range 1–25 days) and the time to defervescence after admission ranged from 0 to 21 days. Fever reappeared after defervescence during hospital stay in 22 patients after an apyretic period of 1–8 days, and the new fever lasted 1–12 days. There were no differences between groups in the total number of days with fever during admission (mean 7.7 days) and the total number of days from admission to complete disappearance of fever (mean 8.4 days). Only one patient presented pneumothorax before chest tube insertion. The mean LHS was longer in children with pneumothorax (18.0 vs. 10.6 days, P<0.001), even when only drained patients were analyzed (18.0 vs. 12.1 days, P<0.001). Although long-term outcomes were not systematically registered, all patients recovered and no permanent damage was observed on follow-up. <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> shows the initial and last chest X-ray of two representative patients with very large undrained CPI.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>Comparison of patients drained vs. not drainedPatients who were drained were similar to those who were not drained in their main characteristics on admission, but a right effusion was more commonly drained than a left one (80% vs. 59%, P=0.02). There were no differences in the antibiotics employed and the total length of antibiotic treatment, but drained patients had a longer duration of intravenous antibiotics (12.5 vs. 9.8 days, P=0.004), and more frequently required oxygen (59% vs. 29%, P=0.004) and ICU admission (18% vs. 0%, P=0.009). LHS was longer in drained patients (13.5 vs. 8.1 days, P<0.001), even if patients with pneumothorax were excluded (11.1 vs. 8.1 days, P<0.001).DiscussionMuch controversy surrounds the diagnosis and management of parapneumonic pleural effusion and empyema. Pleural infection is a continuum classically divided into stages. In line with BTS guidelines and other authors, we have diagnosed CPI (empyema included) when the fibropurulent stage was evidenced by the presence of a large (>1cm) effusion with echographic signs of organization.<a class="elsevierStyleCrossRefs" href="#bib0180">5,8</a> Since biochemical analysis has not been shown to be of any value in the practical management of children with infective pleural effusions, aspiration of pleural fluid was not normally performed solely for that purpose.<a class="elsevierStyleCrossRefs" href="#bib0180">5,12</a> When pleural fluid was available, results of biochemical and bacteriological analysis clearly showed that our patients were affected by complicated effusion and empyema.Unlike other studies searching for the best procedure for draining, the current study suggests that conservative management with antibiotics alone is a suitable way to treat many children with CPI. This study adds to a few recent similar observations,<a class="elsevierStyleCrossRefs" href="#bib0200">9,10</a> and widens the controversy about the best treatment for CPI, largely due to the lack of trials to answer this question. A recent systematic review found only four randomized trials and concluded that, in children who require pleural drainage, fibrinolysis could be as effective as video-assisted thoracic surgery and more effective than placebo to reduce LHS.<a class="elsevierStyleCrossRef" href="#bib0220">13</a> Another systematic review of studies comparing video-assisted thoracoscopic surgery versus chest drain with fibrinolytics arrived at similar conclusions.<a class="elsevierStyleCrossRef" href="#bib0225">14</a> In line with these results and most guidelines, most of our drained patients were treated with fibrinolytics. However, there are no trials comparing conservative versus invasive management of CPI. Antibiotic treatment alone is generally not recommended in current guidelines for CPI, but this recommendation has the lowest grade of evidence.<a class="elsevierStyleCrossRef" href="#bib0180">5</a> CPI is feared given the risk of death or permanent damage, possibly coming from past or adult experiences.<a class="elsevierStyleCrossRefs" href="#bib0230">15–17</a> However, the mortality in healthy children is remarkably low, and the long-term functional and radiological outcome is reported to be excellent.<a class="elsevierStyleCrossRefs" href="#bib0245">18–24</a> Accordingly, the management of CPI should be directed toward decreasing short-term morbidity, patient discomfort, LHS, and the cost of treatment.Epaud et al. evaluated the outcome of 65 patients with infective pleural effusion. In the first 15 months a chest tube was inserted according to the characteristics of pleural effusion (classical group). During the following 15 months, patients were drained according to clinical criteria (conservative group). Significantly fewer chest-tube insertions were performed in the conservative group (25% vs. 52%, P=0.03). The duration of temperature over 39°C was shorter in the conservative vs. classical group (10 vs. 14 days, P=0.01), without significant differences in LHS (16 days vs. 20, P=0.16).<a class="elsevierStyleCrossRef" href="#bib0200">9</a> More recently, Carter et al. published their 12-year experience of conservative treatment of pleural empyema in children. Patients who were clinically stable were started on IV antibiotics alone. If the patient's clinical condition did not improve within 48–72h, a drainage procedure was performed. Ninety-five of 182 patients (52%) were treated with antibiotics alone while 48% underwent drainage procedures, mainly those who needed ICU care or had large pleural effusions. Patients treated with antibiotics alone had a shorter LHS, fewer hospital days with fever, and briefer courses of IV antibiotics than those undergoing drainage procedures. There were six complications from drainage procedures: one patient had a liver laceration and five developed pneumothoraces. Their results suggest that some children with moderate or large parapneumonic effusions can be effectively managed with antibiotics alone: even 23% of patients with mediastinal shift were successfully managed this way.<a class="elsevierStyleCrossRef" href="#bib0205">10</a> Similar results have been observed in adult patients.<a class="elsevierStyleCrossRef" href="#bib0280">25</a> In a recent retrospective review of almost 15,000 children admitted with parapneumonic pleural effusion and empyema, significant variation in primary interventions between 40 USA children's hospitals was observed.<a class="elsevierStyleCrossRef" href="#bib0285">26</a> Treatment with antibiotics alone was the primary intervention in 52% of patients, ranging between 30 and 75% depending on the hospital. Interestingly, LHS and costs were lower in patients treated with antibiotics alone than in patients receiving invasive procedures, despite having a comparable severity of disease as shown by the need for mechanical ventilation and ICU. These findings underscore the importance of establishing which patients truly require drainage.Altogether, this and other reports clearly point out that the natural history of CPI in children treated with antibiotics and supportive measures usually lead to complete resolution. Fever is a bad indicator for improvement, because it usually persists for many days before subsiding, independently of the placement of the chest tube.<a class="elsevierStyleCrossRefs" href="#bib0200">9,27</a> It is not fever remission, but a very slow recovery (or just no worsening in the first few days) that points to a favorable outcome and precedes fever remission and healing.<a class="elsevierStyleCrossRef" href="#bib0205">10</a> On the other hand, invasive treatments are risky, painful, expensive and dependent on professional skills and sanitary resources.<a class="elsevierStyleCrossRefs" href="#bib0295">28,29</a> Pneumothorax was observed in a number of patients after the chest tube insertion and resulted in a significantly longer LHS. We do not know to what extent pneumothorax was related to the disease or to an iatrogenic complication of chest tube insertion, because both possibilities have been reported.<a class="elsevierStyleCrossRefs" href="#bib0200">9,30</a>Our work has the limitations of most other observational studies in this field, from a single institution, with a limited sample size. Nevertheless, patients in the two study periods were almost identical on admission and the only difference in the management was the policy regarding draining the effusion, resulting in a lower rate of chest tube insertion and a slightly longer total (mainly oral) antibiotic treatment, but similar outcomes. Patients who were drained in the second group were probably sicker or did not improve with antibiotics. We did not attempt to point out which patients should or should not be drained, or the complex reasons for that decision. Relying on clinical judgment for intervention has been adopted even in clinical trials in other respiratory diseases.<a class="elsevierStyleCrossRef" href="#bib0310">31</a> Instead, we have verified that some patients with CPI may avoid an invasive procedure and have a similar good progress. It is worth mentioning that a change in the policy regarding draining CPI from radiological to clinical criteria did not lead to a rapid but rather a progressive change in the number of patients not drained. Given the subjective nature of the interpretation of clinical findings, the clinicians became more confident about conservative treatment as clinical experience with this new policy showed good outcomes.In conclusion, many children with CPI could be treated with antibiotics, avoiding unpleasant, costly and risky invasive procedures. Randomized trials are finally needed to elucidate when a drainage procedure may actually benefit a child affected by CPI.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres818442" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec815476" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres818443" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec815477" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Selection of patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Hospital management" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Data collection" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Outcomes" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Statistics" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Ethics" ] ] ] 6 => array:3 [ "identificador" => "sec0045" "titulo" => "Results" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Selection of patients" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Patients’ characteristics" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "General treatment" ] 3 => array:2 [ "identificador" => "sec0065" "titulo" => "Pleural drainage treatment" ] 4 => array:2 [ "identificador" => "sec0070" "titulo" => "Outcomes" ] 5 => array:2 [ "identificador" => "sec0075" "titulo" => "Comparison of patients drained vs. not drained" ] ] ] 7 => array:2 [ "identificador" => "sec0080" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-11-06" "fechaAceptado" => "2015-02-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec815476" "palabras" => array:5 [ 0 => "Pleural infection" 1 => "Pleural empyema" 2 => "Chest tube" 3 => "Pleural drainage" 4 => "Antibiotics" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec815477" "palabras" => array:5 [ 0 => "Infección pleural" 1 => "Empiema pleural" 2 => "Tubo torácico" 3 => "Drenaje pleural" 4 => "Antibióticos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionThe treatment of complicated pleural infection (CPI) is controversial. Clinical guidelines recommend drainage, but with the lowest grade of evidence. Recent reports have observed good outcomes with antibiotics alone. We retrospectively compared the outcomes in two consecutive cohorts treated with different policies: the first treated according to pleural fluid characteristics (2005–2009, interventional-prone, group 1) and the second according to clinical assessment (2010–2013, conservative-prone, group 2). MethodsThe clinical records of all children treated for CPI in our hospital between 2005 and 2013 were thoroughly reviewed. Primary outcomes were the proportion of children drained and the length of hospital stay (LHS). ResultsOne hundred and nine patients (64 group 1 and 45 group 2) were analyzed. A chest tube was placed in 83% of patients in group 1 and 47% in group 2 (P<0.001). The mean LHS was 11.4 days for patients in group 1 and 12.3 for patients in group 2 (P=0.45); no differences were observed in other outcomes. ConclusionOur results add to few recent observations reporting good outcomes in many children treated with antibiotics alone and challenge the need to drain most children with CPI. Clinical trials are now needed to identify when a drainage procedure would be useful." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl tratamiento del derrame pleural paraneumónico complicado (DPC) es controvertido. Las principales guías recomiendan el drenaje, pero con el menor nivel de evidencia. En trabajos recientes se han observado buenos resultados solo con antibióticos. Hemos comparado retrospectivamente nuestros resultados en dos cohortes consecutivas de pacientes tratados con distinto criterio: en el grupo 1 (2005–2009, actitud intervencionista) el drenaje se decidía en función de las características del líquido pleural, de acuerdo con las principales guías; en el grupo 2 (2010–2013, actitud conservadora) el drenaje se decidía en función de la evolución clínica del paciente. MétodosSe revisaron las historias clínicas de los pacientes tratados por DPC entre 2005 y 2013. Las principales variables analizadas fueron la proporción de pacientes drenados y la duración de la estancia hospitalaria. ResultadosSe analizaron 109 pacientes (64 grupo 1 y 45 grupo 2). Se colocó un tubo de drenaje en el 83% de los pacientes del grupo 1 y en el 47% de los del grupo 2 (P<0,001). La duración media de la estancia hospitalaria fue de 11,4 días en el grupo 1 y 12,3 días en el grupo 2 (P=0,45). No se observaron otras diferencias destacables. ConclusiónNuestros resultados coinciden con los de otros estudios recientes que han observado una buena evolución en niños tratados solo con antibióticos y cuestionan la necesidad del drenaje en muchos de los niños que padecen un DPC. Son necesarios ensayos clínicos para identificar las circunstancias en las que se puede obtener un beneficio del drenaje en el DPC." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Moral L, Loeda C, Gómez F, Pena MÁ, Martínez M, Cerdán JM, et al. Derrame paraneumónico complicado: análisis de dos cohortes consecutivas tratadas con distinto criterio. An Pediatr (Barc). 2016;84:46–53." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "Preliminary results of this work have been presented to the XXXIV Reunión de la Sociedad Española de Neumología Pediátrica, San Sebastián, 2012." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 922 "Ancho" => 1568 "Tamanyo" => 59401 ] ] "descripcion" => array:1 [ "en" => "Percentage of children with complicated pleural infection managed with a chest tube in our hospital per year." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2049 "Ancho" => 2499 "Tamanyo" => 292858 ] ] "descripcion" => array:1 [ "en" => "Initial and last chest X-ray of two representative patients with a very large complicated pleural effusion not drained. The time elapsed between the two images of each patient was (as usual in most of our cases) about 3 months." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2005–2009 (n=64) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2010–2013 (n=45) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male sex, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (59) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (44) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age, years, median (IQR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.2 (2.1–5.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.4 (1.8–4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.46 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Children aged 1–5 years old, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 (78) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (71) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Transferred from another hospital, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46 (72) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (73) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">History of asthma/wheezing, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Fever before admission, days, mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.2 (2.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.7 (2.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cough, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 (83) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 (87) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.79 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Respiratory distress, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 (61) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (73) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Chest pain, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 (33) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (31) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Leukocytes×109/L (blood), mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20.1 (8.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20.4 (8.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.88 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Neutrophils×109/L (blood), mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.5 (8.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.8 (7.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.39 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">C-reactive protein, mg/dL, mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21.4 (11.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.7 (12.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.31 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Left side affected, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (69) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1375645.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of children with complicated pleural infection on admission." ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2005–2009 (n=64) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2010–2013 (n=45) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cefotaxime, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 (80) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (82) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.81 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Amoxicillin–clavulanate, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 (77) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 (80) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.82 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Vancomycin, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (36) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Macrolide, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (19) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Total duration of antibiotics,<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> days, mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.6 (5.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.9 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.02 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Duration of intravenous antibiotics,<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> days, mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.4 (4.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.0 (4.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Oxygen administration, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (42) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (60) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.08 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Stay in intensive care, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Chest tube, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 (83) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 (47) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1375646.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "One patient transferred to another center for treatment of pericardial effusion, excluded from these analyses." ] ] ] "descripcion" => array:1 [ "en" => "Treatment of children with complicated pleural infection." ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2005–2009 (n=63<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a>) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2010–2013 (n=45) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Length of hospital stay, days, mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.4 (5.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.3 (6.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.45 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Time to defervescence since admission, days, mean (SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.8 (4.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.9 (4.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.86 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Time to defervescence since admission longer than 12 days, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.73 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Reappearance of fever after defervescence, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (17) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (24) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.47 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pneumothorax, n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.60 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1375647.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "One patient transferred to another center for treatment of pericardial effusion, excluded from this analysis." ] ] ] "descripcion" => array:1 [ "en" => "Main outcomes of children hospitalized for complicated pleural infection." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:31 [ 0 => array:3 [ "identificador" => "bib0160" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The emergence of parapneumonic empyema in the United States" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C.G. Grijalva" 1 => "Y. Zhu" 2 => "J.P. Nuorti" 3 => "M.R. Griffin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2010.156406" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2011" "volumen" => "66" "paginaInicial" => "663" "paginaFinal" => "668" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21617169" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0165" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Increasing paediatric empyema admissions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R. Gupta" 1 => "S. Crowley" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2005.049510" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2006" "volumen" => "61" "paginaInicial" => "179" "paginaFinal" => "180" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16443710" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0170" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pediatric parapneumonic pleural effusion: epidemiology, clinical characteristics, and microbiological diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S. Hernández-Bou" 1 => "J.J. García-García" 2 => "C. Esteva" 3 => "A. Gené" 4 => "C. Luaces" 5 => "C. Muñoz Almagro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ppul.21114" "Revista" => array:6 [ "tituloSerie" => "Pediatr Pulmonol" "fecha" => "2009" "volumen" => "44" "paginaInicial" => "1192" "paginaFinal" => "1200" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19911359" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0175" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment trends and outcomes in U.S. hospital stays of children with empyema" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.M. Kelly" 1 => "K.A. Shadman" 2 => "M.B. Edmonson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/INF.0000000000000131" "Revista" => array:6 [ "tituloSerie" => "Pediatr Infect Dis J" "fecha" => "2014" "volumen" => "33" "paginaInicial" => "431" "paginaFinal" => "436" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24356254" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0180" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "BTS guidelines for the management of pleural infection in children" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I.M. Balfour-Lynn" 1 => "E. Abrahamson" 2 => "G. Cohen" 3 => "J. Hartley" 4 => "S. King" 5 => "D. Parikh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2004.030676" "Revista" => array:7 [ "tituloSerie" => "Thorax" "fecha" => "2005" "volumen" => "60" "numero" => "Suppl. 1" "paginaInicial" => "i1" "paginaFinal" => "i21" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15681514" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0185" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tratamiento de los derrames pleurales paraneumónicos" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "O. Asensio de la Cruz" 1 => "J. Blanco González" 2 => "A. Moreno Galdó" 3 => "J. Pérez Frías" 4 => "A. Salcedo Posadas" 5 => "L. Sanz Borrell" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "An Esp Ped" "fecha" => "2001" "volumen" => "54" "paginaInicial" => "272" "paginaFinal" => "282" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0190" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.S. Bradley" 1 => "C.L. Byington" 2 => "S.S. Shah" 3 => "B. Alverson" 4 => "E.R. Carter" 5 => "C. Harrison" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/cid/cir531" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2011" "volumen" => "53" "paginaInicial" => "e25" "paginaFinal" => "e76" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21880587" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0195" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The diagnosis and management of empyema in children: a comprehensive review from the APSA Outcomes and Clinical Trials Committee" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Islam" 1 => "C.M. Calkins" 2 => "A.B. Goldin" 3 => "C. Chen" 4 => "C.D. Downard" 5 => "E.Y. Huang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jpedsurg.2012.07.047" "Revista" => array:6 [ "tituloSerie" => "J Pediatr Surg" "fecha" => "2012" "volumen" => "47" "paginaInicial" => "2101" "paginaFinal" => "2110" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23164006" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0200" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Conservative use of chest-tube insertion in children with pleural effusions" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Epaud" 1 => "G. Aubertin" 2 => "M. Larroquet" 3 => "H. Ducou-le Pointe" 4 => "P. Helardot" 5 => "A. Clement" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00383-006-1645-4" "Revista" => array:6 [ "tituloSerie" => "Pediatr Surg Int" "fecha" => "2006" "volumen" => "22" "paginaInicial" => "357" "paginaFinal" => "362" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16491388" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0205" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of children with empyema: pleural drainage is not always necessary" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "E. Carter" 1 => "J. Waldhausen" 2 => "W. Zhang" 3 => "L. Hoffman" 4 => "G. Redding" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ppul.21200" "Revista" => array:6 [ "tituloSerie" => "Pediatr Pulmonol" "fecha" => "2010" "volumen" => "45" "paginaInicial" => "475" "paginaFinal" => "480" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20425855" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0210" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Stabilization of asthma prevalence among adolescents and increase among schoolchildren (ISAAC phases I and III) in Spain" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. García-Marcos" 1 => "A. Blanco Quirós" 2 => "G. García Hernández" 3 => "F. Guillén-Grima" 4 => "C. González Díaz" 5 => "I. Carvajal Ureña" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1398-9995.2004.00562.x" "Revista" => array:6 [ "tituloSerie" => "Allergy" "fecha" => "2004" "volumen" => "59" "paginaInicial" => "1301" "paginaFinal" => "1307" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15507099" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0215" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recommendations for managing paediatric empyema thoracis" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "on behalf of the Australian Research Network in Empyema (ARNiE)" "etal" => false "autores" => array:2 [ 0 => "R.E. Strachan" 1 => "A. 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Szajewska" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1651-2227.2010.01863.x" "Revista" => array:6 [ "tituloSerie" => "Acta Paediatr" "fecha" => "2010" "volumen" => "99" "paginaInicial" => "1449" "paginaFinal" => "1453" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20456264" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0225" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Video-assisted thorascopic surgery vs chest drain with fibrinolytics for the treatment of pleural empyema in children: a systematic review of randomized controlled trials" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Mahant" 1 => "E. Cohen" 2 => "M. Weinstein" 3 => "A. Wadhwa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archpediatrics.2009.271" "Revista" => array:6 [ "tituloSerie" => "Arch Pediatr Adolesc Med" "fecha" => "2010" "volumen" => "164" "paginaInicial" => "201" "paginaFinal" => "203" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20124153" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0230" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Parapneumonic empyema deaths during past century, Utah" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.M. Bender" 1 => "K. Ampofo" 2 => "X. Sheng" 3 => "A.T. Pavia" 4 => "L. Cannon-Albright" 5 => "C.L. Byington" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3201/eid1501.080618" "Revista" => array:6 [ "tituloSerie" => "Emerg Infect Dis" "fecha" => "2009" "volumen" => "15" "paginaInicial" => "44" "paginaFinal" => "48" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19116048" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0235" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "U.K. controlled trial of intrapleural streptokinase for pleural infection" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N.A. Maskell" 1 => "C.W.H. Davies" 2 => "A.J. Nunn" 3 => "E.L. Hedley" 4 => "F.V. Gleeson" 5 => "R. Miller" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa042473" "Revista" => array:7 [ "tituloSerie" => "N Engl J Med" "fecha" => "2005" "volumen" => "352" "paginaInicial" => "865" "paginaFinal" => "874" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15745977" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0140673615608224" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0240" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "BTS Pleural Disease Guideline Group. Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H.E. Davies" 1 => "R.J.O. Davies" 2 => "C.W.H. Davies" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2010.137000" "Revista" => array:7 [ "tituloSerie" => "Thorax" "fecha" => "2010" "volumen" => "65" "numero" => "Suppl. 2" "paginaInicial" => "ii41" "paginaFinal" => "ii53" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20696693" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0245" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary operative versus nonoperative therapy for pediatric empyema: a metaanalysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.R. Avansino" 1 => "B. Goldman" 2 => "R.S. Sawin" 3 => "D.R. Flum" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1542/peds.2004-1405" "Revista" => array:6 [ "tituloSerie" => "Pediatrics" "fecha" => "2005" "volumen" => "115" "paginaInicial" => "1652" "paginaFinal" => "1659" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15930229" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0250" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Empyema in children: clinical course and long-term follow-up" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F.J. McLaughlin" 1 => "D.A. Goldmann" 2 => "D.M. Rosenbaum" 3 => "G.B. Harris" 4 => "S.R. Schuster" 5 => "D.J. Strieder" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatrics" "fecha" => "1984" "volumen" => "73" "paginaInicial" => "587" "paginaFinal" => "593" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6718113" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0255" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Persistent abnormal lung function after childhood empyema" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "G.L. Kohn" 1 => "C. Walston" 2 => "J. Feldstein" 3 => "B.W. Warner" 4 => "P. Succop" 5 => "W.D. Hardie" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Respir Med" "fecha" => "2002" "volumen" => "1" "paginaInicial" => "441" "paginaFinal" => "445" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14720031" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0260" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lung function in children following empyema" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "G.J. Redding" 1 => "L. Walund" 2 => "D. Walund" 3 => "J.W. Jones" 4 => "D.C. Stamey" 5 => "R.L. Gibson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Dis Child" "fecha" => "1990" "volumen" => "144" "paginaInicial" => "1337" "paginaFinal" => "1342" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2244616" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0265" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Empyema in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "H. Sarihan" 1 => "A. Cay" 2 => "M. Aynaci" 3 => "R. Akyazici" 4 => "A. Baki" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Cardiovasc Surg (Torino)" "fecha" => "1998" "volumen" => "39" "paginaInicial" => "113" "paginaFinal" => "116" ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0270" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The long-term outcomes of pediatric pleural empyema: a prospective study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Cohen" 1 => "S. Mahant" 2 => "S.D. Dell" 3 => "J. Traubici" 4 => "A. Ragone" 5 => "A. Wadhwa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archpediatrics.2012.1055" "Revista" => array:6 [ "tituloSerie" => "Arch Pediatr Adolesc Med" "fecha" => "2012" "volumen" => "166" "paginaInicial" => "999" "paginaFinal" => "1004" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22945017" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0275" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Long-term recovery after paraneumonic empiema in children" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Honkinen" 1 => "E. Lahti" 2 => "E. Svedström" 3 => "T. Jartti" 4 => "R. Virkki" 5 => "V. Peltola" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ppul.22966" "Revista" => array:6 [ "tituloSerie" => "Pediatr Pulmonol" "fecha" => "2014" "volumen" => "49" "paginaInicial" => "1020" "paginaFinal" => "1027" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24339218" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0280" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Immediate drainage is not required for all patients with complicated parapneumonic effusions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H.A. Berger" 1 => "M.L. Morganroth" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1990" "volumen" => "97" "paginaInicial" => "731" "paginaFinal" => "735" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2306975" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0285" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outcomes associated with type of intervention and timing in complex pediatric empyema" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.B. Goldin" 1 => "C. Parimi" 2 => "C. LaRiviere" 3 => "M.M. Garrison" 4 => "C.L. Larison" 5 => "R.S. Sawin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjsurg.2012.01.005" "Revista" => array:6 [ "tituloSerie" => "Am J Surg" "fecha" => "2012" "volumen" => "203" "paginaInicial" => "665" "paginaFinal" => "673" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22459447" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0290" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predictive factors of morbidity in childhood parapneumonic effusion-associated pneumonia: a retrospective study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Picard" 1 => "L. Joseph" 2 => "S. Goldberg" 3 => "F.B. Mimouni" 4 => "M. Deeb" 5 => "D. Kleid" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/INF.0b013e3181dd1fc4" "Revista" => array:6 [ "tituloSerie" => "Pediatr Infect Dis J" "fecha" => "2010" "volumen" => "29" "paginaInicial" => "840" "paginaFinal" => "843" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20386141" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0295" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bilateral reexpansion pulmonary edema associated with pleural empyema: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.S. Paksu" 1 => "S. Paksu" 2 => "M. Akgün" 3 => "A.G. Kalayci" 4 => "K. Baysal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00431-011-1441-6" "Revista" => array:6 [ "tituloSerie" => "Eur J Pediatr" "fecha" => "2011" "volumen" => "170" "paginaInicial" => "1205" "paginaFinal" => "1207" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21394503" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0300" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Seldinger chest drain insertion: simpler but not necessarily safer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "N.A. Maskell" 1 => "A. Medford" 2 => "F.V. Gleeson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2009.117200" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2010" "volumen" => "65" "paginaInicial" => "5" "paginaFinal" => "6" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20029035" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0305" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Increased incidence of bronchopulmonary fistulas complicating pediatric pneumonia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.J. McKee" 1 => "A. Ives" 2 => "I.M. Balfour-Lynn" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ppul.21396" "Revista" => array:6 [ "tituloSerie" => "Pediatr Pulmonol" "fecha" => "2011" "volumen" => "46" "paginaInicial" => "717" "paginaFinal" => "721" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21626711" "web" => "Medline" ] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0310" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Inhaled adrenaline in acute bronchiolitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J. Ruiz-Contreras" 1 => "L.I. Gonzalez-Granado" 2 => "H.O. Skjerven" 3 => "K.H. Carlsen" 4 => "K.C.L. Carlsen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMc1308964#SA2" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2013" "volumen" => "369" "paginaInicial" => "1076" "paginaFinal" => "1077" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24024853" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000008400000001/v3_201703220337/S2341287915000393/v3_201703220337/en/main.assets" "Apartado" => array:4 [ "identificador" => "26005" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000008400000001/v3_201703220337/S2341287915000393/v3_201703220337/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287915000393?idApp=UINPBA00005H"]

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Complicated pleural infection: Analysis of two consecutive cohorts managed with a different policy

Derrame paraneumónico complicado: análisis de dos cohortes consecutivas tratadas con distinto criterio

L. Morala,

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lmoralg@gmail.com

Corresponding author.

, C. Loedaa, F. Gómeza, M.Á. Penab, M. Martíneza, J.M. Cerdána, L. Lilloa, T. Torala

a Department of Pediatrics, Hospital General Universitario de Alicante, Alicante, Spain

b Department of Clinical Pharmacology, Hospital General Universitario de Alicante, Alicante, Spain

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should not be managed with antibiotics alone and recommend drainage&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">5&#8211;8</span></a> but some institutions have observed good outcomes without requiring a chest tube or surgery for many of the affected children&#44; suggesting a benefit from a more individual approach&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Our institution is the reference center for a population of almost 250&#44;000 children under 15 years old when they require intensive care or pediatric surgery&#46; Many children diagnosed with CPI are transferred from other hospitals for evaluation and treatment&#46; In 2010&#44; as a result of our experience and a recent report&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> we moved from our previous adherence to authorized guidelines&#44; resulting in draining most cases of CPI&#44; to a more conservative and individualized management&#46; We report our experience in the last 9 years&#44; and compare patient characteristics&#44; treatments and outcomes of children attending our hospital from 2005 to 2009&#44; when a chest tube was usually inserted&#44; depending on the characteristics of the effusion&#44; with those who attended from 2010 to 2013&#44; who were managed according to holistic clinical criteria&#44; mainly the severity of appearance and respiratory difficulties based on physical examination&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Selection of patients</span><p id="par0015" class="elsevierStylePara elsevierViewall">Information on patients younger than 15 years old admitted between 2005 and 2013 inclusively&#44; with a discharge diagnosis of pleural effusion or empyema&#44; was retrieved from our hospital electronic database&#46; The clinical records of these patients were retrospectively reviewed to select those with pleural effusion associated with a diagnosis of community-acquired pneumonia&#46; Patients with an effusion associated with tuberculosis or other diseases were excluded&#46; Parapneumonic effusions were considered to be CPI if the pleural space was bigger than 1<span class="elsevierStyleHsp" style=""></span>cm as measured in plain chest roentgenogram and loculations or debris were observed by pleural ultrasound&#46; Only patients with CPI were selected for analysis&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Hospital management</span><p id="par0020" class="elsevierStylePara elsevierViewall">Patients were admitted from the emergency department of our hospital or transferred from other hospitals&#46; Two groups of patients are compared&#58; those admitted between 2005 and 2009 &#40;group 1&#41; were managed according to the British Thoracic Society guidelines for the management of pleural infection in children&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">5</span></a> and those admitted between 2010 and 2013 &#40;group 2&#41; were treated according to the clinical assessment of the attending pediatricians&#46; The clinical findings driving a decision to drain the empyema in patients of group 2 included increased effort of breathing and severe or persistent septic condition&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">9&#44;10</span></a> Persistent fever was not considered a reason to drain the effusion&#44; because it has been reported to be long-standing irrespective of whether they are drained or not&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> Chest tube insertion was usually performed by an interventional radiologist assisted by an anesthetist&#46; 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comorbidities&#44; signs and symptoms&#44; duration of fever&#44; blood and pleural fluid laboratory and bacteriological results&#44; antibiotics administered&#44; length of antibiotic treatment&#44; oxygen therapy&#44; admission to ICU&#44; drain tube insertion&#44; surgical interventions and complications&#46; Pneumococcal vaccination status could not be analyzed due to inconsistent registration&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Outcomes</span><p id="par0030" class="elsevierStylePara elsevierViewall">The primary outcome measures for comparison between groups 1 and 2 were &#40;1&#41; the proportion of children with a chest tube inserted in our hospital and &#40;2&#41; the LHS&#46; Secondary outcome measures for analysis were&#58; treatments employed&#44; length of antibiotic treatment and duration of fever&#46; Length of primary fever was computed as the sum of number of days of fever before admission and the time to defervescence&#44; considered as the time &#40;in days&#41; elapsed between admission and the first day with a temperature under 38<span class="elsevierStyleHsp" style=""></span>&#176;C for 24<span class="elsevierStyleHsp" style=""></span>h&#46; Fever reappeared in some patients after defervescence&#46; In such cases&#44; the total number of days with fever during admission and the total number of days from admission to complete disappearance of fever were calculated&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistics</span><p id="par0035" class="elsevierStylePara elsevierViewall">Data were transferred to SPSS &#40;v17&#46;0 SPSS&#44; Chicago&#44; IL&#44; USA&#41;&#46; Descriptive analysis included frequencies and percentages for categorical variables&#44; means&#44; standard deviation &#40;SD&#41; and range for numerical variables with a normal distribution&#44; and medians&#44; interquartile range &#40;IQR&#44; 25th and 75th percentiles&#41; and range for numerical variables with a non-normal distribution&#46; Categorical variables were compared using the Fisher exact test or the chi-squared test for trend&#46; Continuous variables were compared by means of <span class="elsevierStyleItalic">t</span>-test &#40;with normal distribution&#41; or Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test &#40;with non-normal distribution&#41;&#46; Reported <span class="elsevierStyleItalic">P</span> values were two-tailed&#44; and the level of significance was set at 0&#46;05&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethics</span><p id="par0040" class="elsevierStylePara elsevierViewall">The study was approved by the Clinical Research Ethics Committee of our hospital&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Selection of patients</span><p id="par0045" class="elsevierStylePara elsevierViewall">Two hundred children were discharged from our hospital between 2005 and 2013 with a diagnosis of pleural effusion&#46; Twenty-four of them were not of infective origin and five were diagnosed with tuberculosis&#46; The remaining 171 children had a parapneumonic pleural effusion and were selected for detailed review of their clinical records&#46; Sixty-two had small simple effusions and were not considered to need a drainage procedure&#46; The other 109 had large&#44; complicated effusions&#44; deemed to need drainage according to the main guidelines&#46; These 109 patients were considered to have CPI and were the subject of our study&#46; Sixty-four children were admitted in 2005&#8211;2009 &#40;12&#46;8&#47;year&#41; and 45 in 2010&#8211;2013 &#40;11&#46;3&#47;year&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Patients&#8217; characteristics</span><p id="par0050" class="elsevierStylePara elsevierViewall">The main characteristics of patients on admission are depicted in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; A history of asthma or recurrent wheezing was present in 10&#37; of patients&#44; a frequency very close to that of the general pediatric population in our country&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">11</span></a> One patient had cerebral palsy&#44; two had epilepsy and another two had Down&#39;s syndrome&#46; Two children had lesions of current chickenpox&#46; Most of the patients were previously healthy or had other problems unrelated to the development of pneumonia or a pleural effusion&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">All patients had fever at some stage of the disease&#46; Before admission&#44; two patients had low-grade fever &#40;less than 38<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; for only one day&#46; The other 107 had fever &#40;38<span class="elsevierStyleHsp" style=""></span>&#176;C or over&#41; ranging from 1 to 10 days&#46; The frequency of cough&#44; respiratory distress and chest pain is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Other common signs and symptoms were &#40;<span class="elsevierStyleItalic">n</span>&#41;&#58; vomiting &#40;28&#41;&#44; abdominal pain &#40;23&#41;&#44; diarrhea &#40;13&#41;&#44; headache &#40;6&#41; and febrile seizure &#40;2&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In patients drained&#44; pleural fluid median values &#40;IQR&#41; were&#58; protein 4<span class="elsevierStyleHsp" style=""></span>g&#47;L &#40;4&#8211;5&#41;&#44; glucose 10<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;2&#8211;31&#41;&#44; leukocyte count 3&#46;4<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L &#40;0&#46;6&#8211;22&#46;8&#41;&#46; Bacterial cultures were positive in 30 patients &#40;28&#37;&#41;&#58; <span class="elsevierStyleItalic">Streptococcus pneumoniae</span> was recovered from 17 patients &#40;16&#37;&#58; 9 blood&#44; 8 pleural fluid&#41;&#44; <span class="elsevierStyleItalic">Staphylococcus epidermidis</span> from 4 &#40;3 blood&#44; 1 pleural fluid&#41;&#44; <span class="elsevierStyleItalic">Streptococcus pyogenes</span> from 3 &#40;1 blood and 3 pleural fluid&#41;&#44; <span class="elsevierStyleItalic">Staphylococcus aureus</span> from 2 &#40;1 blood&#44; 1 pleural fluid&#41; and other bacteria from 4 patients&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">General treatment</span><p id="par0065" class="elsevierStylePara elsevierViewall">The treatments are compared in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Patients usually received more than one antibiotic&#44; including oral antibiotics before and&#47;or after hospitalization&#46; Antibiotics were administered for a period of 7&#8211;34 days&#44; but the mean was 2 days longer in the second group&#59; the intravenous route was used for 0&#8211;26 days&#46; Fifty-four patients needed oxygen for a median of 4 days &#40;IQR 3&#8211;7 days&#44; range 1&#8211;15 days&#41;&#46; Thirteen patients were admitted to the pediatric ICU for a mean of 8&#46;3 days &#40;SD 6&#46;9 days&#44; range 1&#8211;23 days&#41;&#44; but only two required assisted ventilation&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Pleural drainage treatment</span><p id="par0070" class="elsevierStylePara elsevierViewall">A chest tube was placed in our hospital in 74 patients &#40;68&#37;&#41;&#58; 83&#37; of patients in group 1 and in 47&#37; in group 2&#44; and this was the most noticeable difference in their treatment &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Urokinase was administered in 85&#37; of those drained &#40;91&#37; in group 1 and 71&#37; in group 2&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;07&#41;&#46; There was no significant trend in the percentage of patients drained between 2005 and 2009 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;91&#41;&#44; but a progressive reduction of chest tube placement was found between 2009 and 2013 after the change in treatment policy for empyema &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Thoracoscopy was performed in just one patient&#44; due to treatment failure after 9 days with a chest tube&#46; Two patients admitted to our center in 2009 had been drained before being transferred from their hospital&#46; Exclusion of these two patients made no difference in the comparisons of treatments and outcomes&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Outcomes</span><p id="par0075" class="elsevierStylePara elsevierViewall">The main outcomes are depicted in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; A 1-year-old girl transferred to our center in 2005 had a chest tube inserted&#44; but was transferred the next day to another specialized center due to a pericardial effusion&#44; where she was treated and recovered&#46; This patient was excluded from the analysis of duration of antibiotics and outcomes&#46; LHS &#40;mean 11&#46;8 days&#44; SD 6&#46;1&#44; range 3&#8211;32 days&#41; did not differ significantly between the two groups&#44; even when the two patients drained in another hospital were excluded&#46; Primary fever lasted 11&#46;6 days &#40;SD 5&#46;0 days&#44; range 1&#8211;25 days&#41; and the time to defervescence after admission ranged from 0 to 21 days&#46; Fever reappeared after defervescence during hospital stay in 22 patients after an apyretic period of 1&#8211;8 days&#44; and the new fever lasted 1&#8211;12 days&#46; There were no differences between groups in the total number of days with fever during admission &#40;mean 7&#46;7 days&#41; and the total number of days from admission to complete disappearance of fever &#40;mean 8&#46;4 days&#41;&#46; Only one patient presented pneumothorax before chest tube insertion&#46; The mean LHS was longer in children with pneumothorax &#40;18&#46;0 vs&#46; 10&#46;6 days&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; even when only drained patients were analyzed &#40;18&#46;0 vs&#46; 12&#46;1 days&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Although long-term outcomes were not systematically registered&#44; all patients recovered and no permanent damage was observed on follow-up&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the initial and last chest X-ray of two representative patients with very large undrained CPI&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Comparison of patients drained vs&#46; not drained</span><p id="par0080" class="elsevierStylePara elsevierViewall">Patients who were drained were similar to those who were not drained in their main characteristics on admission&#44; but a right effusion was more commonly drained than a left one &#40;80&#37; vs&#46; 59&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#46; There were no differences in the antibiotics employed and the total length of antibiotic treatment&#44; but drained patients had a longer duration of intravenous antibiotics &#40;12&#46;5 vs&#46; 9&#46;8 days&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41;&#44; and more frequently required oxygen &#40;59&#37; vs&#46; 29&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41; and ICU admission &#40;18&#37; vs&#46; 0&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#41;&#46; LHS was longer in drained patients &#40;13&#46;5 vs&#46; 8&#46;1 days&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; even if patients with pneumothorax were excluded &#40;11&#46;1 vs&#46; 8&#46;1 days&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Much controversy surrounds the diagnosis and management of parapneumonic pleural effusion and empyema&#46; Pleural infection is a continuum classically divided into stages&#46; In line with BTS guidelines and other authors&#44; we have diagnosed CPI &#40;empyema included&#41; when the fibropurulent stage was evidenced by the presence of a large &#40;&#62;1<span class="elsevierStyleHsp" style=""></span>cm&#41; effusion with echographic signs of organization&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">5&#44;8</span></a> Since biochemical analysis has not been shown to be of any value in the practical management of children with infective pleural effusions&#44; aspiration of pleural fluid was not normally performed solely for that purpose&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">5&#44;12</span></a> When pleural fluid was available&#44; results of biochemical and bacteriological analysis clearly showed that our patients were affected by complicated effusion and empyema&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Unlike other studies searching for the best procedure for draining&#44; the current study suggests that conservative management with antibiotics alone is a suitable way to treat many children with CPI&#46; This study adds to a few recent similar observations&#44;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">9&#44;10</span></a> and widens the controversy about the best treatment for CPI&#44; largely due to the lack of trials to answer this question&#46; A recent systematic review found only four randomized trials and concluded that&#44; in children who require pleural drainage&#44; fibrinolysis could be as effective as video-assisted thoracic surgery and more effective than placebo to reduce LHS&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">13</span></a> Another systematic review of studies comparing video-assisted thoracoscopic surgery versus chest drain with fibrinolytics arrived at similar conclusions&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">14</span></a> In line with these results and most guidelines&#44; most of our drained patients were treated with fibrinolytics&#46; However&#44; there are no trials comparing conservative versus invasive management of CPI&#46; Antibiotic treatment alone is generally not recommended in current guidelines for CPI&#44; but this recommendation has the lowest grade of evidence&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">5</span></a> CPI is feared given the risk of death or permanent damage&#44; possibly coming from past or adult experiences&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">15&#8211;17</span></a> However&#44; the mortality in healthy children is remarkably low&#44; and the long-term functional and radiological outcome is reported to be excellent&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">18&#8211;24</span></a> Accordingly&#44; the management of CPI should be directed toward decreasing short-term morbidity&#44; patient discomfort&#44; LHS&#44; and the cost of treatment&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Epaud et al&#46; evaluated the outcome of 65 patients with infective pleural effusion&#46; In the first 15 months a chest tube was inserted according to the characteristics of pleural effusion &#40;classical group&#41;&#46; During the following 15 months&#44; patients were drained according to clinical criteria &#40;conservative group&#41;&#46; Significantly fewer chest-tube insertions were performed in the conservative group &#40;25&#37; vs&#46; 52&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41;&#46; The duration of temperature over 39<span class="elsevierStyleHsp" style=""></span>&#176;C was shorter in the conservative vs&#46; classical group &#40;10 vs&#46; 14 days&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#44; without significant differences in LHS &#40;16 days vs&#46; 20&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;16&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> More recently&#44; Carter et al&#46; published their 12-year experience of conservative treatment of pleural empyema in children&#46; Patients who were clinically stable were started on IV antibiotics alone&#46; If the patient&#39;s clinical condition did not improve within 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h&#44; a drainage procedure was performed&#46; Ninety-five of 182 patients &#40;52&#37;&#41; were treated with antibiotics alone while 48&#37; underwent drainage procedures&#44; mainly those who needed ICU care or had large pleural effusions&#46; Patients treated with antibiotics alone had a shorter LHS&#44; fewer hospital days with fever&#44; and briefer courses of IV antibiotics than those undergoing drainage procedures&#46; There were six complications from drainage procedures&#58; one patient had a liver laceration and five developed pneumothoraces&#46; Their results suggest that some children with moderate or large parapneumonic effusions can be effectively managed with antibiotics alone&#58; even 23&#37; of patients with mediastinal shift were successfully managed this way&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> Similar results have been observed in adult patients&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">25</span></a> In a recent retrospective review of almost 15&#44;000 children admitted with parapneumonic pleural effusion and empyema&#44; significant variation in primary interventions between 40 USA children&#39;s hospitals was observed&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">26</span></a> Treatment with antibiotics alone was the primary intervention in 52&#37; of patients&#44; ranging between 30 and 75&#37; depending on the hospital&#46; Interestingly&#44; LHS and costs were lower in patients treated with antibiotics alone than in patients receiving invasive procedures&#44; despite having a comparable severity of disease as shown by the need for mechanical ventilation and ICU&#46; These findings underscore the importance of establishing which patients truly require drainage&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Altogether&#44; this and other reports clearly point out that the natural history of CPI in children treated with antibiotics and supportive measures usually lead to complete resolution&#46; Fever is a bad indicator for improvement&#44; because it usually persists for many days before subsiding&#44; independently of the placement of the chest tube&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">9&#44;27</span></a> It is not fever remission&#44; but a very slow recovery &#40;or just no worsening in the first few days&#41; that points to a favorable outcome and precedes fever remission and healing&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> On the other hand&#44; invasive treatments are risky&#44; painful&#44; expensive and dependent on professional skills and sanitary resources&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">28&#44;29</span></a> Pneumothorax was observed in a number of patients after the chest tube insertion and resulted in a significantly longer LHS&#46; We do not know to what extent pneumothorax was related to the disease or to an iatrogenic complication of chest tube insertion&#44; because both possibilities have been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">9&#44;30</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Our work has the limitations of most other observational studies in this field&#44; from a single institution&#44; with a limited sample size&#46; Nevertheless&#44; patients in the two study periods were almost identical on admission and the only difference in the management was the policy regarding draining the effusion&#44; resulting in a lower rate of chest tube insertion and a slightly longer total &#40;mainly oral&#41; antibiotic treatment&#44; but similar outcomes&#46; Patients who were drained in the second group were probably sicker or did not improve with antibiotics&#46; We did not attempt to point out which patients should or should not be drained&#44; or the complex reasons for that decision&#46; Relying on clinical judgment for intervention has been adopted even in clinical trials in other respiratory diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">31</span></a> Instead&#44; we have verified that some patients with CPI may avoid an invasive procedure and have a similar good progress&#46; It is worth mentioning that a change in the policy regarding draining CPI from radiological to clinical criteria did not lead to a rapid but rather a progressive change in the number of patients not drained&#46; Given the subjective nature of the interpretation of clinical findings&#44; the clinicians became more confident about conservative treatment as clinical experience with this new policy showed good outcomes&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In conclusion&#44; many children with CPI could be treated with antibiotics&#44; avoiding unpleasant&#44; costly and risky invasive procedures&#46; Randomized trials are finally needed to elucidate when a drainage procedure may actually benefit a child affected by CPI&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The treatment of complicated pleural infection &#40;CPI&#41; is controversial&#46; Clinical guidelines recommend drainage&#44; but with the lowest grade of evidence&#46; Recent reports have observed good outcomes with antibiotics alone&#46; We retrospectively compared the outcomes in two consecutive cohorts treated with different policies&#58; the first treated according to pleural fluid characteristics &#40;2005&#8211;2009&#44; interventional-prone&#44; group 1&#41; and the second according to clinical assessment &#40;2010&#8211;2013&#44; conservative-prone&#44; group 2&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The clinical records of all children treated for CPI in our hospital between 2005 and 2013 were thoroughly reviewed&#46; Primary outcomes were the proportion of children drained and the length of hospital stay &#40;LHS&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">One hundred and nine patients &#40;64 group 1 and 45 group 2&#41; were analyzed&#46; A chest tube was placed in 83&#37; of patients in group 1 and 47&#37; in group 2 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; The mean LHS was 11&#46;4 days for patients in group 1 and 12&#46;3 for patients in group 2 &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;45&#41;&#59; no differences were observed in other outcomes&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Our results add to few recent observations reporting good outcomes in many children treated with antibiotics alone and challenge the need to drain most children with CPI&#46; Clinical trials are now needed to identify when a drainage procedure would be useful&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El tratamiento del derrame pleural paraneum&#243;nico complicado &#40;DPC&#41; es controvertido&#46; Las principales gu&#237;as recomiendan el drenaje&#44; pero con el menor nivel de evidencia&#46; En trabajos recientes se han observado buenos resultados solo con antibi&#243;ticos&#46; Hemos comparado retrospectivamente nuestros resultados en dos cohortes consecutivas de pacientes tratados con distinto criterio&#58; en el grupo 1 &#40;2005&#8211;2009&#44; actitud intervencionista&#41; el drenaje se decid&#237;a en funci&#243;n de las caracter&#237;sticas del l&#237;quido pleural&#44; de acuerdo con las principales gu&#237;as&#59; en el grupo 2 &#40;2010&#8211;2013&#44; actitud conservadora&#41; el drenaje se decid&#237;a en funci&#243;n de la evoluci&#243;n cl&#237;nica del paciente&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se revisaron las historias cl&#237;nicas de los pacientes tratados por DPC entre 2005 y 2013&#46; Las principales variables analizadas fueron la proporci&#243;n de pacientes drenados y la duraci&#243;n de la estancia hospitalaria&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 109 pacientes &#40;64 grupo 1 y 45 grupo 2&#41;&#46; Se coloc&#243; un tubo de drenaje en el 83&#37; de los pacientes del grupo 1 y en el 47&#37; de los del grupo 2 &#40;P<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; La duraci&#243;n media de la estancia hospitalaria fue de 11&#44;4 d&#237;as en el grupo 1 y 12&#44;3 d&#237;as en el grupo 2 &#40;P<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;45&#41;&#46; No se observaron otras diferencias destacables&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nuestros resultados coinciden con los de otros estudios recientes que han observado una buena evoluci&#243;n en ni&#241;os tratados solo con antibi&#243;ticos y cuestionan la necesidad del drenaje en muchos de los ni&#241;os que padecen un DPC&#46; Son necesarios ensayos cl&#237;nicos para identificar las circunstancias en las que se puede obtener un beneficio del drenaje en el DPC&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Moral L&#44; Loeda C&#44; G&#243;mez F&#44; Pena M&#193;&#44; Mart&#237;nez M&#44; Cerd&#225;n JM&#44; et al&#46; Derrame paraneum&#243;nico complicado&#58; an&#225;lisis de dos cohortes consecutivas tratadas con distinto criterio&#46; An Pediatr &#40;Barc&#41;&#46; 2016&#59;84&#58;46&#8211;53&#46;</p>"
      ]
      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Preliminary results of this work have been presented to the XXXIV Reuni&#243;n de la Sociedad Espa&#241;ola de Neumolog&#237;a Pedi&#225;trica&#44; San Sebasti&#225;n&#44; 2012&#46;</p>"
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 922
            "Ancho" => 1568
            "Tamanyo" => 59401
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Percentage of children with complicated pleural infection managed with a chest tube in our hospital per year&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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            "Ancho" => 2499
            "Tamanyo" => 292858
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Initial and last chest X-ray of two representative patients with a very large complicated pleural effusion not drained&#46; The time elapsed between the two images of each patient was &#40;as usual in most of our cases&#41; about 3 months&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2005&#8211;2009 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2010&#8211;2013 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male sex&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38 &#40;59&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Age&#44; years&#44; median &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;2 &#40;2&#46;1&#8211;5&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;4 &#40;1&#46;8&#8211;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Children aged 1&#8211;5 years old&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50 &#40;78&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32 &#40;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Transferred from another hospital&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46 &#40;72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">History of asthma&#47;wheezing&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Fever before admission&#44; days&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;2 &#40;2&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;7 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cough&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53 &#40;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39 &#40;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Respiratory distress&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39 &#40;61&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33 &#40;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Chest pain&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;31&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Leukocytes<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L &#40;blood&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;1 &#40;8&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;4 &#40;8&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Neutrophils<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;L &#40;blood&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;5 &#40;8&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;8 &#40;7&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">C-reactive protein&#44; mg&#47;dL&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;4 &#40;11&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;7 &#40;12&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Left side affected&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31 &#40;69&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1375645.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Characteristics of children with complicated pleural infection on admission&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2005&#8211;2009 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2010&#8211;2013 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cefotaxime&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51 &#40;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin&#8211;clavulanate&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49 &#40;77&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36 &#40;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Vancomycin&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Macrolide&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Total duration of antibiotics&#44;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> days&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;9 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Duration of intravenous antibiotics&#44;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> days&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;50&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;08&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;00&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21 &#40;47&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
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        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:31 [
            0 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The emergence of parapneumonic empyema in the United States"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "C&#46;G&#46; Grijalva"
                            1 => "Y&#46; Zhu"
                            2 => "J&#46;P&#46; Nuorti"
                            3 => "M&#46;R&#46; Griffin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2010.156406"
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2011"
                        "volumen" => "66"
                        "paginaInicial" => "663"
                        "paginaFinal" => "668"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21617169"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0165"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Increasing paediatric empyema admissions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46; Gupta"
                            1 => "S&#46; Crowley"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2005.049510"
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2006"
                        "volumen" => "61"
                        "paginaInicial" => "179"
                        "paginaFinal" => "180"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16443710"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pediatric parapneumonic pleural effusion&#58; epidemiology&#44; clinical characteristics&#44; and microbiological diagnosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "S&#46; Hern&#225;ndez-Bou"
                            1 => "J&#46;J&#46; Garc&#237;a-Garc&#237;a"
                            2 => "C&#46; Esteva"
                            3 => "A&#46; Gen&#233;"
                            4 => "C&#46; Luaces"
                            5 => "C&#46; Mu&#241;oz Almagro"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/ppul.21114"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Pulmonol"
                        "fecha" => "2009"
                        "volumen" => "44"
                        "paginaInicial" => "1192"
                        "paginaFinal" => "1200"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19911359"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Treatment trends and outcomes in U&#46;S&#46; hospital stays of children with empyema"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46;M&#46; Kelly"
                            1 => "K&#46;A&#46; Shadman"
                            2 => "M&#46;B&#46; Edmonson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/INF.0000000000000131"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Infect Dis J"
                        "fecha" => "2014"
                        "volumen" => "33"
                        "paginaInicial" => "431"
                        "paginaFinal" => "436"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24356254"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0180"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "BTS guidelines for the management of pleural infection in children"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "I&#46;M&#46; Balfour-Lynn"
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                            2 => "G&#46; Cohen"
                            3 => "J&#46; Hartley"
                            4 => "S&#46; King"
                            5 => "D&#46; Parikh"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1136/thx.2004.030676"
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                        "tituloSerie" => "Thorax"
                        "fecha" => "2005"
                        "volumen" => "60"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "i1"
                        "paginaFinal" => "i21"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15681514"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0185"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Tratamiento de los derrames pleurales paraneum&#243;nicos"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "O&#46; Asensio de la Cruz"
                            1 => "J&#46; Blanco Gonz&#225;lez"
                            2 => "A&#46; Moreno Gald&#243;"
                            3 => "J&#46; P&#233;rez Fr&#237;as"
                            4 => "A&#46; Salcedo Posadas"
                            5 => "L&#46; Sanz Borrell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "An Esp Ped"
                        "fecha" => "2001"
                        "volumen" => "54"
                        "paginaInicial" => "272"
                        "paginaFinal" => "282"
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0190"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The management of community-acquired pneumonia in infants and children older than 3 months of age&#58; clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;S&#46; Bradley"
                            1 => "C&#46;L&#46; Byington"
                            2 => "S&#46;S&#46; Shah"
                            3 => "B&#46; Alverson"
                            4 => "E&#46;R&#46; Carter"
                            5 => "C&#46; Harrison"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/cid/cir531"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2011"
                        "volumen" => "53"
                        "paginaInicial" => "e25"
                        "paginaFinal" => "e76"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21880587"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0195"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The diagnosis and management of empyema in children&#58; a comprehensive review from the APSA Outcomes and Clinical Trials Committee"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46; Islam"
                            1 => "C&#46;M&#46; Calkins"
                            2 => "A&#46;B&#46; Goldin"
                            3 => "C&#46; Chen"
                            4 => "C&#46;D&#46; Downard"
                            5 => "E&#46;Y&#46; Huang"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jpedsurg.2012.07.047"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Pediatr Surg"
                        "fecha" => "2012"
                        "volumen" => "47"
                        "paginaInicial" => "2101"
                        "paginaFinal" => "2110"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23164006"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
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            ]
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Conservative use of chest-tube insertion in children with pleural effusions"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; Epaud"
                            1 => "G&#46; Aubertin"
                            2 => "M&#46; Larroquet"
                            3 => "H&#46; Ducou-le Pointe"
                            4 => "P&#46; Helardot"
                            5 => "A&#46; Clement"
                          ]
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                    0 => array:2 [
                      "doi" => "10.1007/s00383-006-1645-4"
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                        "tituloSerie" => "Pediatr Surg Int"
                        "fecha" => "2006"
                        "volumen" => "22"
                        "paginaInicial" => "357"
                        "paginaFinal" => "362"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16491388"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of children with empyema&#58; pleural drainage is not always necessary"
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                          "etal" => false
                          "autores" => array:5 [
                            0 => "E&#46; Carter"
                            1 => "J&#46; Waldhausen"
                            2 => "W&#46; Zhang"
                            3 => "L&#46; Hoffman"
                            4 => "G&#46; Redding"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/ppul.21200"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Pulmonol"
                        "fecha" => "2010"
                        "volumen" => "45"
                        "paginaInicial" => "475"
                        "paginaFinal" => "480"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20425855"
                            "web" => "Medline"
                          ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Stabilization of asthma prevalence among adolescents and increase among schoolchildren &#40;ISAAC phases I and III&#41; in Spain"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            1 => "A&#46; Blanco Quir&#243;s"
                            2 => "G&#46; Garc&#237;a Hern&#225;ndez"
                            3 => "F&#46; Guill&#233;n-Grima"
                            4 => "C&#46; Gonz&#225;lez D&#237;az"
                            5 => "I&#46; Carvajal Ure&#241;a"
                          ]
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                    0 => array:2 [
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                        "tituloSerie" => "Allergy"
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                        "volumen" => "59"
                        "paginaInicial" => "1301"
                        "paginaFinal" => "1307"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15507099"
                            "web" => "Medline"
                          ]
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                ]
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              "identificador" => "bib0215"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recommendations for managing paediatric empyema thoracis"
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                          "colaboracion" => "on behalf of the Australian Research Network in Empyema &#40;ARNiE&#41;"
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                            0 => "R&#46;E&#46; Strachan"
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Med J Aust"
                        "fecha" => "2011"
                        "volumen" => "195"
                        "numero" => "2"
                        "paginaInicial" => "95"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21770882"
                            "web" => "Medline"
                          ]
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                    ]
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                ]
              ]
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              "identificador" => "bib0220"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Local treatment of empyema in children&#58; a systematic review of randomized controlled trials"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "K&#46; Krenke"
                            1 => "J&#46; Peradzynska"
                            2 => "J&#46; Lange"
                            3 => "M&#46; Ruszczynski"
                            4 => "M&#46; Kulus"
                            5 => "H&#46; Szajewska"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1651-2227.2010.01863.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Acta Paediatr"
                        "fecha" => "2010"
                        "volumen" => "99"
                        "paginaInicial" => "1449"
                        "paginaFinal" => "1453"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20456264"
                            "web" => "Medline"
                          ]
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              ]
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              "identificador" => "bib0225"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Video-assisted thorascopic surgery vs chest drain with fibrinolytics for the treatment of pleural empyema in children&#58; a systematic review of randomized controlled trials"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "S&#46; Mahant"
                            1 => "E&#46; Cohen"
                            2 => "M&#46; Weinstein"
                            3 => "A&#46; Wadhwa"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archpediatrics.2009.271"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Pediatr Adolesc Med"
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                        "volumen" => "164"
                        "paginaInicial" => "201"
                        "paginaFinal" => "203"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20124153"
                            "web" => "Medline"
                          ]
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                ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Parapneumonic empyema deaths during past century&#44; Utah"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;M&#46; Bender"
                            1 => "K&#46; Ampofo"
                            2 => "X&#46; Sheng"
                            3 => "A&#46;T&#46; Pavia"
                            4 => "L&#46; Cannon-Albright"
                            5 => "C&#46;L&#46; Byington"
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                    ]
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                    0 => array:2 [
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                        "tituloSerie" => "Emerg Infect Dis"
                        "fecha" => "2009"
                        "volumen" => "15"
                        "paginaInicial" => "44"
                        "paginaFinal" => "48"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19116048"
                            "web" => "Medline"
                          ]
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                      ]
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                ]
              ]
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                    0 => array:2 [
                      "titulo" => "U&#46;K&#46; controlled trial of intrapleural streptokinase for pleural infection"
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                          "etal" => true
                          "autores" => array:6 [
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                            1 => "C&#46;W&#46;H&#46; Davies"
                            2 => "A&#46;J&#46; Nunn"
                            3 => "E&#46;L&#46; Hedley"
                            4 => "F&#46;V&#46; Gleeson"
                            5 => "R&#46; Miller"
                          ]
                        ]
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                    ]
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                      "Revista" => array:7 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2005"
                        "volumen" => "352"
                        "paginaInicial" => "865"
                        "paginaFinal" => "874"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15745977"
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                    ]
                  ]
                ]
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              "identificador" => "bib0240"
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                    0 => array:2 [
                      "titulo" => "BTS Pleural Disease Guideline Group&#46; Management of pleural infection in adults&#58; British Thoracic Society Pleural Disease Guideline 2010"
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                          ]
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                      "doi" => "10.1136/thx.2010.137000"
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                        "tituloSerie" => "Thorax"
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                        "numero" => "Suppl&#46; 2"
                        "paginaInicial" => "ii41"
                        "paginaFinal" => "ii53"
                        "link" => array:1 [
                          0 => array:2 [
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                            "web" => "Medline"
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                  ]
                ]
              ]
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              "identificador" => "bib0245"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Primary operative versus nonoperative therapy for pediatric empyema&#58; a metaanalysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46;R&#46; Avansino"
                            1 => "B&#46; Goldman"
                            2 => "R&#46;S&#46; Sawin"
                            3 => "D&#46;R&#46; Flum"
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                        ]
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                    ]
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                    0 => array:2 [
                      "doi" => "10.1542/peds.2004-1405"
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                        "tituloSerie" => "Pediatrics"
                        "fecha" => "2005"
                        "volumen" => "115"
                        "paginaInicial" => "1652"
                        "paginaFinal" => "1659"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15930229"
                            "web" => "Medline"
                          ]
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                  ]
                ]
              ]
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              "identificador" => "bib0250"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Empyema in children&#58; clinical course and long-term follow-up"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "F&#46;J&#46; McLaughlin"
                            1 => "D&#46;A&#46; Goldmann"
                            2 => "D&#46;M&#46; Rosenbaum"
                            3 => "G&#46;B&#46; Harris"
                            4 => "S&#46;R&#46; Schuster"
                            5 => "D&#46;J&#46; Strieder"
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                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatrics"
                        "fecha" => "1984"
                        "volumen" => "73"
                        "paginaInicial" => "587"
                        "paginaFinal" => "593"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6718113"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0255"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Persistent abnormal lung function after childhood empyema"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "G&#46;L&#46; Kohn"
                            1 => "C&#46; Walston"
                            2 => "J&#46; Feldstein"
                            3 => "B&#46;W&#46; Warner"
                            4 => "P&#46; Succop"
                            5 => "W&#46;D&#46; Hardie"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Med"
                        "fecha" => "2002"
                        "volumen" => "1"
                        "paginaInicial" => "441"
                        "paginaFinal" => "445"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14720031"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0260"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lung function in children following empyema"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "G&#46;J&#46; Redding"
                            1 => "L&#46; Walund"
                            2 => "D&#46; Walund"
                            3 => "J&#46;W&#46; Jones"
                            4 => "D&#46;C&#46; Stamey"
                            5 => "R&#46;L&#46; Gibson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Dis Child"
                        "fecha" => "1990"
                        "volumen" => "144"
                        "paginaInicial" => "1337"
                        "paginaFinal" => "1342"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2244616"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Empyema in children"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "H&#46; Sarihan"
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                            4 => "A&#46; Baki"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Cardiovasc Surg &#40;Torino&#41;"
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                        "volumen" => "39"
                        "paginaInicial" => "113"
                        "paginaFinal" => "116"
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0270"
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                    0 => array:2 [
                      "titulo" => "The long-term outcomes of pediatric pleural empyema&#58; a prospective study"
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                          "etal" => true
                          "autores" => array:6 [
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                            3 => "J&#46; Traubici"
                            4 => "A&#46; Ragone"
                            5 => "A&#46; Wadhwa"
                          ]
                        ]
                      ]
                    ]
                  ]
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                      "doi" => "10.1001/archpediatrics.2012.1055"
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                        "tituloSerie" => "Arch Pediatr Adolesc Med"
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                        "volumen" => "166"
                        "paginaInicial" => "999"
                        "paginaFinal" => "1004"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22945017"
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                  ]
                ]
              ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Long-term recovery after paraneumonic empiema in children"
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                            4 => "R&#46; Virkki"
                            5 => "V&#46; Peltola"
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                        "tituloSerie" => "Pediatr Pulmonol"
                        "fecha" => "2014"
                        "volumen" => "49"
                        "paginaInicial" => "1020"
                        "paginaFinal" => "1027"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24339218"
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                          ]
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                  ]
                ]
              ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Immediate drainage is not required for all patients with complicated parapneumonic effusions"
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                          "etal" => false
                          "autores" => array:2 [
                            0 => "H&#46;A&#46; Berger"
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                  "host" => array:1 [
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                        "tituloSerie" => "Chest"
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                        "paginaInicial" => "731"
                        "paginaFinal" => "735"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2306975"
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                          ]
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                    ]
                  ]
                ]
              ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Outcomes associated with type of intervention and timing in complex pediatric empyema"
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                            4 => "C&#46;L&#46; Larison"
                            5 => "R&#46;S&#46; Sawin"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.amjsurg.2012.01.005"
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                        "tituloSerie" => "Am J Surg"
                        "fecha" => "2012"
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                        "paginaInicial" => "665"
                        "paginaFinal" => "673"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22459447"
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2015.02.001

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	7	11	18
2024 October	48	44	92
2024 September	52	36	88
2024 August	63	62	125
2024 July	69	48	117
2024 June	76	38	114
2024 May	69	58	127
2024 April	40	32	72
2024 March	68	47	115
2024 February	70	43	113
2024 January	69	40	109
2023 December	91	53	144
2023 November	86	24	110
2023 October	99	31	130
2023 September	78	25	103
2023 August	58	23	81
2023 July	94	19	113
2023 June	84	34	118
2023 May	107	29	136
2023 April	96	26	122
2023 March	84	29	113
2023 February	81	31	112
2023 January	79	22	101
2022 December	117	32	149
2022 November	74	55	129
2022 October	73	46	119
2022 September	51	64	115
2022 August	66	56	122
2022 July	53	38	91
2022 June	66	36	102
2022 May	71	43	114
2022 April	52	49	101
2022 March	95	55	150
2022 February	55	24	79
2022 January	60	33	93
2021 December	52	41	93
2021 November	58	44	102
2021 October	75	50	125
2021 September	59	47	106
2021 August	34	36	70
2021 July	27	29	56
2021 June	40	33	73
2021 May	50	36	86
2021 April	110	68	178
2021 March	417	27	444
2021 February	41	14	55
2021 January	54	21	75
2020 December	48	25	73
2020 November	40	15	55
2020 October	33	21	54
2020 September	28	24	52
2020 August	24	11	35
2020 July	31	19	50
2020 June	45	12	57
2020 May	41	21	62
2020 April	27	23	50
2020 March	55	24	79
2020 February	59	23	82
2020 January	51	19	70
2019 December	47	27	74
2019 November	35	15	50
2019 October	39	11	50
2019 September	52	37	89
2019 August	33	19	52
2019 July	45	17	62
2019 June	25	28	53
2019 May	51	40	91
2019 April	30	50	80
2019 March	26	13	39
2019 February	36	12	48
2019 January	27	22	49
2018 December	41	29	70
2018 November	64	30	94
2018 October	166	34	200
2018 September	31	17	48
2018 August	2	0	2
2018 July	2	0	2
2018 June	3	0	3
2018 May	8	0	8
2018 April	18	0	18
2018 March	17	0	17
2018 February	15	0	15
2018 January	130	0	130
2017 December	161	0	161
2017 November	39	0	39
2017 October	9	0	9
2017 September	28	0	28
2017 August	12	0	12
2017 July	16	1	17
2017 June	34	11	45
2017 May	16	7	23
2017 April	9	10	19
2017 March	6	5	11
2017 February	12	9	21
2017 January	9	2	11
2016 December	19	7	26
2016 November	13	8	21
2016 October	30	8	38
2016 September	38	10	48
2016 August	25	4	29
2016 July	13	4	17

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