[Kinetics of C-reactive protein and procalcitonin after paediatric cardiac surgery]. / Cinética de la proteína C reactiva y la procalcitonina en el postoperatorio de cirugía cardíaca en niños.

INTRODUCTION AND OBJECTIVES: The systemic inflammatory response syndrome developed after cardiac surgery impedes the detection of complications. The aim of our study was to examine the behaviour of C-reactive protein (CRP) and procalcitonin (PCT), as well as to evaluate its relationship with severity and to analyse its usefulness in the identification of complications. METHODS: A total of 59 children who underwent cardiac surgery with cardiopulmonary bypass were prospectively studied. CRP and PCT were determined after surgery and at 24, 48 and 72 hours. The relationships between both parameters and the clinical severity were analysed (evaluated with PRISM and TISS scoring systems), as well as with the incidence of complications (infectious and haemodynamics). RESULTS: Serum concentrations of CRP and PCT increased in the first 24 hours after surgery, with a gradual decrease over the following days. There was no association between CRP and severity or development of complications. A moderate correlation was observed between PCT after surgery, at 24 and 48 hours, and PRISM (r=0.548; 0.434 and 0.446) and a low correlation between PCT and TISS. When studying the identification of complications, we obtained cut-off values of PCT>0.17ng/ml (Ss 73.3%; Sp 72.2%) and PCT>1.98ng/ml (Ss 57.1%; Sp 87%) immediately and 48 hours after surgery. No differences were found in CPR and PCT levels among patients with infectious and haemodynamics complications. CONCLUSIONS: CPR does not correlate with the severity or the incidence of complications after paediatric cardiac surgery. PCT correlates with clinical severity and may be able to detect post-surgical complications.

[Family impact of rotavirus gastroenteritis in children under two years]. / Impacto familiar de la gastroenteritis por rotavirus en menores de dos años.

INTRODUCTION: Acute gastroenteritis (AGE) in infants has a significant impact on the quality of life of their parents. MATERIAL AND METHODS: Cross-sectional study on the sociological family impact related to rotavirus AGE in children under 2 years. The study was carried out in 25 hospitals and 5 primary care centres in Spain. Sociodemographic, epidemiological and clinical data were recorded, as well as the symptomatology of AGE and its severity measured by the Clark scale. Stool samples were tested to determine rotavirus positive (RV+) or negative (RV-). The parents were asked to complete a a family impact questionnaire. RESULTS: Stool specimens were tested in 1087 AGE cases (584 RV+ vs 503 RV-). The 99.5 % of parents whose children were RV+ reported more worries vs. the 97.7 % of RV-, and RV+ had a higher importance score (p < 0.05). A higher percentage of RV+ parents and those with a high importance score reported more time dedicated to dehydration treatment (p < 0.05). The 82.5 % vs. 73.9 % had disruption of their household tasks, with more importance scores (p < 0.05). RV+ had a higher percentage and importance score than RV- ones in all aspects of their child's AGE symptoms, except loss of appetite. CONCLUSION: AGE produces important dysfunctional experiences in daily family life. According to parental perceptions, RV+ produces greater worries and dysfunctions in child behaviour.

[Procalcitonin for the diagnosis of neonatal sepsis of vertical transmission]. / Procalcitonina para el diagnóstico de sepsis neonatal de transmisión vertical.

OBJECTIVE: To evaluate procalcitonin (PCT) as a diagnostic marker of neonatal sepsis of vertical transmission and to compare the results of PCT with those of the most widely used laboratory tests for sepsis. PATIENTS AND METHODS: A prospective study was conducted in 136 blood samples from 69 newborn infants admitted to a neonatal department. PCT, C-reactive protein (CRP), leukocyte count, and the immature-to-total neutrophil ratio (I/T ratio) were measured. The PCT reference range of controls from 0 to 72 hours of life was constructed, and the diagnostic efficiency of the tests was calculated, with their 95 % confidence intervals (95 % CI). RESULTS: This study included 35 controls, 24 neonates with noninfectious disorders, and 10 neonates with sepsis (5 with culture-proven sepsis). PCT, CRP, and the I/T ratio discriminated septic from nonseptic patients. Their areas under the ROC curve were 0.696 (p = 0.009), 0.735 (p = 0.002), and 0.703 (p = 0.006), respectively, with no statistically significant differences. The accuracy of PCT, CRP, and leukocyte count improved after 24 hours of life with areas under the ROC curve of 0.813 (p = 0.007), 0.826 (p = 0.005), and 0.841 (p = 0.003), respectively. Overall, PCT detected vertically transmitted sepsis with a sensitivity of 68.4 % (95 % CI: 46.0 %-84.6 %), specificity of 82.4 % (95 % CI: 72.2 %-89.4 %), positive likelihood ratio of 3.89 (95 % CI: 2.18 %-6.96 %), and negative likelihood ratio of 0.38 (95 % CI: 0.19 %-0.76 %), similar to those of CRP. CONCLUSIONS: PCT may be a useful marker for the diagnosis of vertically transmitted sepsis. Studies with larger sample sizes are required to establish the accuracy of PCT.

[Procalcitonin for the diagnosis of nosocomial neonatal sepsis]. / Procalcitonina para el diagnóstico de sepsis neonatal de origen nosocomial.

BACKGROUND: Nosocomial sepsis is a major problem in neonatal units. Because the clinical signs are nonspecific, highly reliable diagnostic markers are required to guide diagnosis. The aim of this study was to evaluate the utility of procalcitonin (PCT) as a diagnostic marker for nosocomial neonatal sepsis, and to compare the results of PCT with those of the most widely used laboratory tests for sepsis. PATIENTS AND METHODS: Twenty neonates with nosocomial sepsis and 20 controls aged 4-30 days were included in a prospective study performed in a neonatal intensive care unit. PCT, C-reactive protein (CRP), leukocyte count, and the immature-to-total neutrophil ratio (I/T ratio) were measured at onset of signs of infection. The sensitivity, specificity, and likelihood ratio for a positive (LR+) and a negative (LR-) result were calculated. RESULTS: PCT, CRP, and the I/T ratio discriminated septic from nonseptic patients. Their areas under the ROC curve were 0.849, 0.880, and 0.884, respectively, with no statistically significant differences. Optimal cut-off values were: PCT > or = 0.65 ng/ml (sensitivity 85 %, specificity 80 %, LR 1 4.25, LR- 0.19), PCR > or = 5 .g/ml (sensitivity 80 %, specificity 95 %, LR 1 16, LR- 0.21), and I/T > or = 0.03 (sensitivity 90 %, specificity 75 %, LR 1 3.6, LR- 0.13). CONCLUSIONS: PCT may be a useful marker for the diagnosis of nosocomial neonatal sepsis. Studies with larger samples are required to compare the accuracy of PCT with that of other markers of sepsis.

[Hypoacusis after the neonatal period. Situations requiring hearing assessment]. / Hipoacusia de detección posneonatal. Circunstancias que precisan evaluación auditiva.

INTRODUCTION: Because hearing plays a major role in language development, pediatric hypoacusis is especially damaging. The high frequency of hearing impairment in newborns and the need for an early diagnosis have led to the establishment of neonatal screening. Nevertheless, there are other situations which may compromise hearing quality in later stages and it is essential to identify them in order to be able to provide early and effective treatment. OBJECTIVES: To describe the most frequent reasons for referring patients for hearing evaluation to a third level hospital and to identify common situations that require hearing assessment among the pediatric population. PATIENTS AND METHODS: The clinical histories of 197 non-neonates evaluated for hypoacusis were reviewed. Clinical parameters and diagnosis were compared in patients with impaired and normal hearing. RESULTS: One hundred sixty-one patients had no previous known hypoacusis. The main reason for evaluation was suspicion by the family or child minder (53.4 %), followed by language underdevelopment. In the first examinations 78 children had hypoacusis (48.4 %), which was more frequently bilateral than unilateral. In 29.5 % of hypoacusic patients, the disease was related to recurrent otitis or adenoiditis and in 25.6 % it was genetic. The most frequent antecedent was deaf relatives in hypoacusic patients and abnormal phenotypes in children with normal hearing. Three patients with previous bacterial meningitis were studied and two of these had hypoacusis. CONCLUSIONS: Hypoacusic evaluation outside the context of newborn screening is mainly motivated by clinical suspicion of hypoacusis or language underdevelopment. Other situations such as recurrent otitis with effusion, syndromic phenotypic characteristics or bacterial meningitis are related to hearing problems and therefore require detailed evaluation.

[Pulmonary computed tomography in children with cystic fibrosis in Asturias (Spain)]. / Tomografía computarizada pulmonar en niños con fibrosis quística en Asturias.

INTRODUCTION: The advent of computed tomography (CT) has allowed the early detection of pathological changes in patients with cystic fibrosis (CF). Description of the early pathological changes and distribution of bronchiectasis in children with CF is limited, because most studies have been performed in older children and adults with well-established lung disease. The aim of this study was to describe the distribution pattern of this disease in Asturius. MATERIAL AND METHOD: We performed a retrospective study of the medical records and CT scans of patients followed up in our Cystic Fibrosis Unit. CT scans were scored by two radiologists according to Bhalla and Nathanson scores. Pathological changes were analyzed and correlated with clinical data and pulmonary function tests. RESULTS: The 41 CT reviewed contained between 10 and 47 slices, with a median of 16. The total number of slices was 758, of which 606 (79.95%) were considered acceptable and 152 were considered unacceptable by the radiologists. The most frequent lesions found were bronchiectasis (78.38%), followed by mucous plugs (37.84%). The most frequently affected bronchopulmonary segments were S1 and S2 in the right lung. Statistically significant correlations were found between Bhalla and Nathanson scores and disease duration. No statistically significant correlations were found between Bhalla and Nathanson scores and pulmonary function tests. CONCLUSIONS: The most frequent lesions in our environment were bronchiectasis followed by mucous plugs. The upper right lobe was the first to be affected, which correlates with findings in most published studies.

[Noninvasive ventilation in a pediatric intensive care unit]. / Aplicación de ventilación no invasiva en una unidad de cuidados intensivos pediátricos.

OBJECTIVE: To describe our experience of noninvasive positive-pressure ventilation (NIPPV). PATIENTS AND METHODS: We performed a retrospective study of all patients who underwent NIPPV in our unit over an 18-month period. To assess the effectiveness of NIPPV, respiratory rate, heart rate, inspired oxygen, and arterial blood gases PaO2 and PaCO2 were evaluated before and 2 hours after initiating NIPPV. RESULTS: Twenty-three patients with a mean age of 36.7 months underwent a total of 24 NIPPV trials. Indications for NIPPV were: hypoxemic acute respiratory failure (14 trials), hypercapnic acute respiratory failure (four trials), and postextubation respiratory failure (six trials). Conventional ventilators were used in 10 trials and specific noninvasive ventilators were used in 14. The main interfaces used were buconasal mask in patients older than 1 year, and pharyngeal prong in infants aged less than 1 year. In all groups, significant decreases in respiratory distress, defined as a reduction in tachypnea (45 +/- 16 breaths/min pre-treatment vs. 34 +/- 12 breaths/min post-treatment; p = 0.001), and tachycardia (148 +/- 27 beats/min pre-treatment vs. 122 +/- 22 beats/min (after or post) post-treatment; p < 0.001) were observed after initiation of NIPPV. The oxygenation index PaO2/FiO2 also improved (190 +/- 109 pre-treatment vs. 260 +/- 118 post-treatment; p = 0.010). Five patients (20.8 %) required intubation and conventional mechanical ventilation after NIPPV, of which three were aged less than 6 months. CONCLUSIONS: NIPPV should be considered as a ventilatory support option in the treatment of acute respiratory failure in selected children.

[Follow-up of longstanding ventricular septal defects]. / Seguimiento de las comunicaciones interventriculares de larga evolución.

OBJECTIVE: Ventricular septal defect is the most frequently diagnosed congenital heart defect. The prognosis is usually good. The aim of this study was to describe this idea to general pediatricians. MATERIAL AND METHODS: We review the follow-up of 81 patients with ventricular septal defect. Defects that spontaneously closed in the first 12 months of life and those that formed part of a malformative syndrome or a complex congenital heart defect were excluded. RESULTS: Localization was perimembranous, including all defects affecting mainly the septal membrane independent of whether the surrounding tissues were involved, in 66.7 %, muscular in 29.6 % and mixed in 3.7 %. Perimembranous position was more frequent among large and medium-sized defects. Large and perimembranous defects were characterized by holosystolic murmur; in small, muscular defects, murmur was cut off in mid-systole. In 45.8 % of large defects, weight development was delayed, but there was no appreciable effect on height. Generally we observed a tendency to partial closure and to improvement. Surgical closure was required in 9.8 %. CONCLUSIONS: Because of the trend to partial or complete spontaneous closure, the prognosis of ventricular septal defect is generally good.

[Care of critically-ill children in Asturias (Spain): characteristics and effectiveness]. / Asistencia a los niños críticamente enfermos en Asturias: características y efectividad.

OBJECTIVE: To describe the work performed in the Pediatric Intensive Care Unit of the Hospital Central de Asturias (Spain) in its first 5 years and to assess the effectiveness of the care provided. METHODS: A prospective study of the characteristics of critically-ill children admitted from 1996 to 2000 was performed. Effectiveness was defined as the ratio of observed to expected mortality, determined by pediatric risk of mortality (PRISM) score calculated 24 hours after admission. RESULTS: The median age of critically-ill children was 38 months and the mean length of stay was 6.8 days. Forty percent of the patients were transferred from other hospitals in Asturias and Leon. The most frequent causes of admission were respiratory, neurological and infectious diseases, and trauma. Overall mortality was 4.3 %. Over the years the severity of the patients increased with a consequent rise in mean length of stay, use of central venous access and mechanical ventilation. Forty-two percent of deaths were expected. The effectiveness of care was high among high-risk patients, among those with respiratory and metabolic diseases and in the postoperative period but was low among patients with hematologic and gastrointestinal diseases. Effectiveness increased over time. CONCLUSIONS: Studies analyzing pediatric intensive care units are useful for assessing and improving the effectiveness of care in these centers.

[The effects of phenobarbital, valproic acid and carbamazepine on the serum lipids and lipoproteins in a pediatric population]. / Efectos del fenobarbital, ácido valproico y carbamazepina sobre lípidos y lipoproteínas séricas en población infanto-juvenil.

Lipids and serum lipoproteins were analyzed in 432 epileptic children younger than 14 years of age who received chronic treatment (more than 6 months) with anticonvulsive drugs: phenobarbital (n = 255), valproic acid (n = 92) and carbamazepine (n = 85). The children were grouped according to sex, age and the drug administered and compared with 490 healthy children from the same social environment. The biochemical findings significantly different (p < 0.05) from the control population were as follows: phenobarbital increased serum total cholesterol levels in females and high density lipoproteins in both sexes. Valproic acid raised serum A-II apoprotein levels in every group and serum C-HDL levels in the 6 to 13 year old male group. Treatment with carbamazepine raised serum total cholesterol levels, C-HDL, phospholipid and A-I apoprotein in all groups, low density lipoproteins in females and B apoprotein males. The total cholesterol/LDL ratio was significantly lower in the 6 to 13 year old male group with any of the drugs used when compared to the control population.

[Nutritional status assessment in a group of cystic fibrosis patients]. / Valoración del estado nutricional en un grupo de pacientes con fibrosis quística.

The objectives of this study were to evaluate the nutritional status and the efficiency of high density oral supplements in patients with cystic fibrosis. Twenty patients with cystic fibrosis (10 boys and 10 girls) with a mean age of 11.63 years (SD:6.3) were studied. Sixty percent of these patients were receiving high density oral supplements. A clinical and nutritional evaluation, including a three day evaluation of food intake, were performed. Patients were separated into two groups according to oral supplement intake and the presence or not of pulmonary colonization. We found the patients to have a mild to moderate clinical status. Anthropometric values were lower than ideal. Intake of calories, macronutrients and micronutrients were similar (except for folic acid) in both groups of patients and were close or above the established dietetic recommendations for cystic fibrosis. Patients with pulmonary colonization scored lower in the Shwachman and Brasfield tests, had lower weights, subscapular skinfolds and nutritional indices, and higher plasma immunoglobulin A concentrations. We conclude that a free hypercaloric diet allows cystic fibrosis patients to maintain an adequate nutritional status. Oral supplements should be prescribed on an individual basis according to the results of periodic food records and clinical and anthropometric status evaluation.

[Childhood lead poisoning in Asturias]. / Epidemiología del saturnismo infantil en Asturias.

We have determined the blood lead levels of 1,242 children, from newborn to 14 years old, and 79 young mothers in a period of 10 months in Asturias (Spain). All of them were selected at random among those who consulted one of the three main hospitals in Asturias, but none were diagnosed as lead poisoning. We have found a mean blood lead level of 22.11 micrograms/dl; 23.55% had high levels (= 25 micrograms/dl). Sex was not significantly associated with blood lead levels either in the whole sample or in different age groups. Blood lead level increases rapidly from birth (19.3 micrograms/dl) to the age of one year (23.3 gamma/dl), fluctuating around this level until the age of 7. Then it declines with age until adolescence (19.6 micrograms/dl). From October (25.5 micrograms/dl) to July (20.9 micrograms/dl) the decrease in lead blood level was statistically significant. No difference has been found between urban and rural population. The decree of urbanization has not been found significant. The mean blood lead level in the mothers was 20.5 micrograms/dl.

[Pancreatic echography in infantile diabetes]. / La ecografía pancreática en la diabetes mellitus infantil reciente.

Our objective was to investigate the pancreatic ultrasonographic size in diabetic children in order to compare in with a healthy population of children and to relate it to the characteristics of their disease. Fifty-four children (age 8.59 +/- 3.38 years) with insulin-dependent diabetes mellitus of short evolution and 23 healthy children of similar ages and sex were investigated. Anteroposterior measurement of pancreatic head, body and tail with real time ultrasonography were performed searching for a relationship of these factors with the acinar and residual insular function. The pancreatic measurements in the diabetic patients were sizeable smaller than in the healthy children with no relationship to age, height, weight or body surface. There were no differences in the pancreatic measurements in relationship to the evolution time or residual insular function in the diabetics.

[Type 1 diabetes mellitus and nephropathy. Predicting factors in pediatric age]. / Diabetes mellitus tipo I y nefropatía. Factores predictores en la edad pediátrica.

OBJECTIVE: To find the existence of early relationships between alterations in the glucidic metabolism and the glomerular and tubular basal function in diabetic insulin-dependent children without clinical evidence of diabetic nephropathy (DN). METHODS: We determined blood pressure, basal plasma concentrations of glucose, glycosilated hemoglobin and total proteins, glomerular filtration rate (GFR), and the glucose, proteins, calcium, phosphorus, uric acid, sodium, potassium and chloride excretions in diurnal, nocturnal and 24-hour urine samples in 43 diabetic children and 13 healthy controls. RESULTS: The microproteinuria mean value in all urine samples (always less than 15 micrograms/min/1.73 m.2), the GFR and blood pressure were similar in both groups. In the diabetic children, we found an inverse correlation between age and 24-hour urine microproteinuria (r-0.33; p less than 0.05) and between age and nocturnal urine microproteinuria (r-0.35; p less than 0.05). There was also a highly significant correlation between microproteinuria and the albumin/creatinine ratio in urine samples (r = 0.94, p less than 0.0001). Diabetic children showed a greater nocturnal excretion of calcium (p less than 0.05) and phosphorus (p less than 0.05). CONCLUSIONS: Our results suggest that microproteinuria, GFR and blood pressure have not served as predictors of DN in pediatric patients.

[Esophageal atresia and associated anomalies]. / Atresia de esófago y anomalías asociadas.

Twenty-seven newborns with esophageal atresia were reviewed for the presence of other congenital associated anomalies. The incidence of esophageal atresia was 2.6 cases for every 10,000 live births. Associated anomalies were present in 59.25% of these cases. Cardiac malformations were the most frequent associated defect (40.7%). Ten infants met the criteria for VACTERL association. The birth weights and gestational ages were similar for both the surviving and deceased infants. Broncho-aspiration was the only significant factor associated with mortality: 75% of the infants who had broncho-aspiration died, versus only 26.3% if aspiration was not present. When associated anomalies were present, mortality was 56.25%, whereas only 18.18% of the infants without these anomalies died (p = 0.055). We conclude that only broncho-aspiration and associated anomalies relate to mortality in esophageal atresia, whereas the birth weight, the other Waterston's prognosis factor, is not important.