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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 2016&#44; the American Academy of Pediatrics &#40;AAP&#41; published a guideline recommending replacing the term <span class="elsevierStyleItalic">apparent life-threatening event</span> &#40;ALTE&#41; with the term <span class="elsevierStyleItalic">brief resolved unexplained event</span> &#40;BRUE&#41; with the aim of identifying lower-risk patients &#40;with a low probability of a repeat event or of severe underlying disease&#41; that do not require hospital admission or further investigation&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The authors of the guideline considered that a more specific term was necessary because ALTE is a concept that encompasses a broad range of disorders &#40;from periodic breathing to sepsis&#41;&#44; which can generate a feeling of uncertainty in the clinician and thus compel performance of unnecessary tests&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The alternative term&#44; BRUE&#44; is intended to reflect the transient nature and lack of clear aetiology of such events and remove the &#8220;life-threatening&#8221; notion that is the source of such anxiety&#46; The guideline proposed that the evaluation of each infant should be based on the level of risk of the event and established recommendations for the management of low-risk cases&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Based on this change&#44; we carried out a study with the aim of retrospectively reviewing the cases of patients admitted with a diagnosis of ALTE that met the criteria for BRUE&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Then&#44; we determined which cases in the group meeting the criteria for BRUE would qualify as higher or lower risk&#44; which would allow us to determine the number of infants in who performance of tests and hospital admission may have been deemed unnecessary&#46; Until May 2018&#44; our hospital had a protocol for management of ALTE that called for admission of all patients with ALTE&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Between January 2013 and December 2017&#44; there were 194 patients with an admitting diagnosis code of ALTE&#46; During this period&#44; there was no diagnosis code for BRUE&#46; We excluded 52 infants for who we did not find data allowing us to determine whether the event would qualify as a BRUE&#46; The final sample included 142 patients&#44; 68 female and 74 male&#44; with a median age at admission of 37 days &#40;range&#44; 2&#8211;461 days&#41;&#44; 95 of who were aged less than 2 months&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Of the 142 patients&#44; 68 &#40;48&#37;&#41; did not meet the criteria for BRUE because a cause for the event had been identified during the history-taking or physical examination &#40;cold symptoms&#44; fever&#44; vomiting&#44; abnormal breath sounds on auscultation&#41;&#44; the event had not resolved at the time of arrival to the emergency department&#44; or the patient was aged more than 1 year&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Of the 74 cases &#40;52&#37;&#41; that met the criteria for BRUE&#44; 69 &#40;93&#37;&#41; qualified as higher-risk BRUE&#46; The most frequent reasons for classification as higher-risk BRUE were age less than 2 months or corrected age less than 45 weeks &#40;51 cases&#41;&#44; repeat event &#40;18 cases&#41;&#44; event duration greater than 1&#8239;min &#40;16 cases&#41;&#44; concerning social assessment &#40;5 cases&#41; and family history of sudden death &#40;4 cases&#41;&#46; Several patients met more than one higher-risk criterion&#46; None of the infants was classified as higher-risk based on need for cardiopulmonary resuscitation &#40;CPR&#41; by a trained medical provider&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Of the 5 infants that met the criteria for lower-risk BRUE&#44; 3 underwent diagnostic tests &#40;blood tests&#44; cranial ultrasound&#44; echocardiogram&#44; electroencephalogram&#41;&#46; All test results were normal&#44; save for the incidental finding in the echocardiogram of a haemodynamically insignificant aorto-pulmonary collateral arteries and patent foramen ovale in 1 patient&#46; In these infants&#44; there were no abnormalities in the vital signs during the hospital stay&#44; repeat episodes or diagnosis of severe underlying disease&#46; The mean length of stay in these 5 patients was 1&#46;8 days&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the group of 69 patients that met the criteria for higher-risk BRUE&#44; diagnostic tests were performed in 48&#37; in the emergency department and in 74&#37; during the hospital stay&#46; Ten percent of these patients experienced a repeat event during the stay&#46; Abnormal test results or relevant diagnoses from testing included diagnosis of convulsive seizures in 1 infant&#44; 1 case of congenital hypothyroidism &#40;the results of the newborn screening for metabolic diseases became available during the hospital stay&#41;&#44; 1 case of respiratory infection by respiratory syncytial virus&#44; 1 case of meningitis caused by enterovirus and detection of haemodynamically insignificant aorto-pulmonary collateral arteries in 1 infant&#46; The mean length of stay in this group was 2&#46;6 days&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Recent guidelines recommend educating parents on how to perform CPR&#46; Such training was only delivered in 3 cases &#40;2&#37;&#41;&#58; all 3 met the criteria for higher-risk BRUE&#44; and 2 were managed with home cardiorespiratory monitoring&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">There are limitations to our study&#44; chief of which is its retrospective design&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Only half of the infants admitted due to ALTE met the criteria for BRUE&#46; Most infants that experienced these events were aged less than 2 months&#44; which made them qualify as higher risk on account of the age criterion&#46; Only 7&#37; of patients with BRUE met the criteria for lower risk BRUE&#44; so testing and hospital admission could only have been avoided in this percentage of the total&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Carbayo Jim&#233;nez T&#44; Romero PC&#44; S&#225;nchez IG&#46; Sustituci&#243;n de ALTE por BRUE&#58; revisi&#243;n retrospectiva de los ALTE que cumplen criterios de BRUE&#46; An Pediatr &#40;Barc&#41;&#46; 2020&#59;93&#58;261&#8211;262&#46;</p>"
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Scientific Letter
Replacing “Apparent Life Threatening Event” (ALTE) with “Brief Resolved Unexplained Event” (BRUE). A retrospective review of the ALTEs that meet the criteria of a BRUE
Sustitución de ALTE por BRUE: revisión retrospectiva de los ALTE que cumplen criterios de BRUE
Tania Carbayo Jiméneza,
Corresponding author
taniacarbayo@gmail.com

Corresponding author.
, Pilar Cedena Romerob, Isabel Gimeno Sánchezb
a Servicio de Neonatología, Hospital Doce de Octubre, Madrid, Spain
b Unidad de Lactantes y Pediatría General, Servicio de Pediatría, Hospital Doce de Octubre, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 2016&#44; the American Academy of Pediatrics &#40;AAP&#41; published a guideline recommending replacing the term <span class="elsevierStyleItalic">apparent life-threatening event</span> &#40;ALTE&#41; with the term <span class="elsevierStyleItalic">brief resolved unexplained event</span> &#40;BRUE&#41; with the aim of identifying lower-risk patients &#40;with a low probability of a repeat event or of severe underlying disease&#41; that do not require hospital admission or further investigation&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The authors of the guideline considered that a more specific term was necessary because ALTE is a concept that encompasses a broad range of disorders &#40;from periodic breathing to sepsis&#41;&#44; which can generate a feeling of uncertainty in the clinician and thus compel performance of unnecessary tests&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The alternative term&#44; BRUE&#44; is intended to reflect the transient nature and lack of clear aetiology of such events and remove the &#8220;life-threatening&#8221; notion that is the source of such anxiety&#46; The guideline proposed that the evaluation of each infant should be based on the level of risk of the event and established recommendations for the management of low-risk cases&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Based on this change&#44; we carried out a study with the aim of retrospectively reviewing the cases of patients admitted with a diagnosis of ALTE that met the criteria for BRUE&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Then&#44; we determined which cases in the group meeting the criteria for BRUE would qualify as higher or lower risk&#44; which would allow us to determine the number of infants in who performance of tests and hospital admission may have been deemed unnecessary&#46; Until May 2018&#44; our hospital had a protocol for management of ALTE that called for admission of all patients with ALTE&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Between January 2013 and December 2017&#44; there were 194 patients with an admitting diagnosis code of ALTE&#46; During this period&#44; there was no diagnosis code for BRUE&#46; We excluded 52 infants for who we did not find data allowing us to determine whether the event would qualify as a BRUE&#46; The final sample included 142 patients&#44; 68 female and 74 male&#44; with a median age at admission of 37 days &#40;range&#44; 2&#8211;461 days&#41;&#44; 95 of who were aged less than 2 months&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Of the 142 patients&#44; 68 &#40;48&#37;&#41; did not meet the criteria for BRUE because a cause for the event had been identified during the history-taking or physical examination &#40;cold symptoms&#44; fever&#44; vomiting&#44; abnormal breath sounds on auscultation&#41;&#44; the event had not resolved at the time of arrival to the emergency department&#44; or the patient was aged more than 1 year&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Of the 74 cases &#40;52&#37;&#41; that met the criteria for BRUE&#44; 69 &#40;93&#37;&#41; qualified as higher-risk BRUE&#46; The most frequent reasons for classification as higher-risk BRUE were age less than 2 months or corrected age less than 45 weeks &#40;51 cases&#41;&#44; repeat event &#40;18 cases&#41;&#44; event duration greater than 1&#8239;min &#40;16 cases&#41;&#44; concerning social assessment &#40;5 cases&#41; and family history of sudden death &#40;4 cases&#41;&#46; Several patients met more than one higher-risk criterion&#46; None of the infants was classified as higher-risk based on need for cardiopulmonary resuscitation &#40;CPR&#41; by a trained medical provider&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Of the 5 infants that met the criteria for lower-risk BRUE&#44; 3 underwent diagnostic tests &#40;blood tests&#44; cranial ultrasound&#44; echocardiogram&#44; electroencephalogram&#41;&#46; All test results were normal&#44; save for the incidental finding in the echocardiogram of a haemodynamically insignificant aorto-pulmonary collateral arteries and patent foramen ovale in 1 patient&#46; In these infants&#44; there were no abnormalities in the vital signs during the hospital stay&#44; repeat episodes or diagnosis of severe underlying disease&#46; The mean length of stay in these 5 patients was 1&#46;8 days&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the group of 69 patients that met the criteria for higher-risk BRUE&#44; diagnostic tests were performed in 48&#37; in the emergency department and in 74&#37; during the hospital stay&#46; Ten percent of these patients experienced a repeat event during the stay&#46; Abnormal test results or relevant diagnoses from testing included diagnosis of convulsive seizures in 1 infant&#44; 1 case of congenital hypothyroidism &#40;the results of the newborn screening for metabolic diseases became available during the hospital stay&#41;&#44; 1 case of respiratory infection by respiratory syncytial virus&#44; 1 case of meningitis caused by enterovirus and detection of haemodynamically insignificant aorto-pulmonary collateral arteries in 1 infant&#46; The mean length of stay in this group was 2&#46;6 days&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Recent guidelines recommend educating parents on how to perform CPR&#46; Such training was only delivered in 3 cases &#40;2&#37;&#41;&#58; all 3 met the criteria for higher-risk BRUE&#44; and 2 were managed with home cardiorespiratory monitoring&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">There are limitations to our study&#44; chief of which is its retrospective design&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Only half of the infants admitted due to ALTE met the criteria for BRUE&#46; Most infants that experienced these events were aged less than 2 months&#44; which made them qualify as higher risk on account of the age criterion&#46; Only 7&#37; of patients with BRUE met the criteria for lower risk BRUE&#44; so testing and hospital admission could only have been avoided in this percentage of the total&#46;</p></span>"
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    "fechaAceptado" => "2019-12-17"
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Carbayo Jim&#233;nez T&#44; Romero PC&#44; S&#225;nchez IG&#46; Sustituci&#243;n de ALTE por BRUE&#58; revisi&#243;n retrospectiva de los ALTE que cumplen criterios de BRUE&#46; An Pediatr &#40;Barc&#41;&#46; 2020&#59;93&#58;261&#8211;262&#46;</p>"
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ISSN: 23412879
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