El tiempo de consulta ambulatoria en el Hospital Garrahan / Time of the outpatient visit at Garrahan Hospital

Mediano Riesgo es un servicio de atención ambulatoria del Hospital Garrahan. Se atienden pacientes con enfermedades prolongadas, que han realizado consultas en otros efectores de salud u otros servicios del Hospital, o que requieren segunda opinión o abordaje multidisciplinario. Objetivos: Mensurar el tiempo profesional invertido en la atención como herramienta para ponderar la complejidad de los pacientes. Identificar variables demográficas y del proceso de atención. Material y métodos: Investigación descriptiva, transversal sobre pacientes encuestados entre julio y diciembre de 2017 en el Sector de Mediano Riesgo. Se registraron: variables demográficas, proceso de atención, diagnósticos previos y finales, interconsultas, exámenes complementarios y tiempos de consulta profesional. Se tomó 65 minutos (mediana del tiempo profesional total) como punto de corte para definir dos grupos: tiempo de consulta corto o largo. Se realizó un análisis comparativo entre ambos. Resultados: se encuestaron 400 pacientes. Mediana de edad fue de 67,2 meses; 80,1% procedían de CABA y del GBA; mediana de duración del síntoma fue 4 meses; 25,8% tenía enfermedad de base; 62,5% fueron pacientes derivados (externos e internos); destino a pediatra zonal: 30%; interconsultas: 48,5%; tiempo total profesional: mediana 65 minutos (rango 12-460); diagnósticos simples: 37,2%. Variables con significación estadística para pertenecer al tiempo largo: número de diagnósticos finales, procedencia, diagnósticos no simples y presencia de enfermedad de base. Variables con tendencia a pertenecer a tiempo largo: duración del síntoma mayor de 1 mes, edad menor a 24 meses, patología tumoral, síndromes polimalformativos, abuso sexual infantil y problemas de lenguaje /aprendizaje. Conclusiones: el tiempo de consulta es un factor concurrente para la evaluación de la complejidad del proceso de atención. La identificación de variables que permitan preverlo es información relevante para la organización del sector, o de otros efectores de salud (AU)

The sector of Intermediate Risk is part of the outpatient clinics of Garrahan Hospital. In the sector patients with chronic diseases are seen, that have have consulted at other centers or other departments of the hospital, or that need a second opinion or a multidisciplinary approach. Objectives: To assess the professional time invested in care as a tool to evaluate the complexity of the patients, and to identify demographic variables and the care process. Material and methods: A cross-sectional, descriptive study on patients surveyed between July and December 2017 in the Sector of Intermediate Risk. The following data were recorded: Demographic features, care process, previous and final diagnoses, consultations, complementary studies, duration of the interview. A time of 65 minutes (median total time of the visit) was defined as the cut-off point to define two groups: Those with a long and a short interview. A comparative analysis was performed comparing both groups. Results: 400 patients were surveyed. Median age was 67.2 months; 80.1% were form the city of Buenos Aires and Greater Buenos Aires. Mean symptom duration was 4 months; 25.8% had an underlying disease; 62.5% of the patients was referred (either external or internally); referred by the local pediatrician: 30%; second opinions: 48,5%; total time of the interview: median 65 minutes (range, 12-460); simple diagnoses: 37.2%. Statistically significant variables for a long interview were: number of final diagnoses, place of origin, complicated diagnoses, and presence of underlying disease. Variables with a trend to a long interview were: symptom duration more than one month, age less than 24 months, a diagnosis of a tumor, polymalformation syndromes, sexual abuse, language/learning difficulties. Conclusions: The time of the interview is a concurrent factor for the assessment of the complexity of the care process. Identification of the variables that allow to anticipate these cases is relevant for the organization of the sector or other health care providers (AU)

Derecho de niños, niñas y adolescentes en la práctica clínica: Estrategias de capacitación durante la formación de pediatras / Rights of children and adolescents in clinical practice: Training strategies for pediatricians

Introducción: Los derechos de los niños, niñas y adolescentes (NNA) constituyen aspectos fundamentales durante el ejercicio profesional para todos aquellos que trabajan en salud infantil Objetivo: Comunicar la experiencia educativa: contenidos y estrategia pedagógica para abordarlos de una manera accesible y atractiva, a fin de facilitar el cumplimiento y asegurar la incorporación de conocimientos y valores considerados fundamentales en la formación de un pediatra. Métodos: Se realizó un curso virtual sobre derechos de NNA en la práctica clínica para residentes donde se esperaba: revisar las prácticas profesionales en salud desde la perspectiva de derechos de NNA, incorporar diversos lenguajes y estrategias a las situaciones de comunicación entre niños y profesionales de la salud para garantizar tales derechos. Se realizaron en torno a tres consideraciones pedagógicas: 1) Estructura de portal educativo, 2) lectura hipermedial e interactiva y 3) Retroalimentaciones constructivas. Resultados: Participaron 71 residentes, el 85% de los participantes fueron de 4to año, y el 100% de los mismos lo finalizaron. Conclusiones: La práctica asistencial supervisada ocupa gran parte del tiempo activo del residente. La oferta educativa a distancia a través de plataformas virtuales ofrece una alternativa valiosa siempre que se asegure el acceso y cumplimiento de las actividades; dichas premisas dependen en gran parte del diseño pedagógico y atractivo presentado (AU)

Introduction: The Rights of Children and Adolescents comprise aspects that are fundamental for professionals working in the field of healthcare in children. Objective: To describe the educational experience, contents, and strategy for an accessible and attractive approach to facilitate compliance and assure the incorporation of knowledge and values considered to be essential for the training in pediatrics. Methods: an online course on the Rights of Children and Adolescents in clinical practice for residents with the aim to revise practices of health care professionals for the point of view of Rights of Children and Adolescents, to incorporate different manners of speech and strategies in communication settings involving children and health care professionals to guarantee these rights. Interventions took place in three educational settings: 1) Structure of an educational website, 2) Multimedia and interactive reading, and 3) Constructive feedback. Results: 71 residents participated, 85% of whom were fourth year residents, and 100% completed the study. Conclusions: Supervised patient care makes up a large part of the work time of a resident. Online education through platforms provides a valuable alternative whenever access and compliance to the activities are assured. Compliance largely depends on the design and attractiveness of the material presented (AU)

Características de la atención pediátrica ambulatoria de familias nativas y migrantes / Characteristics of pediatric outpatient care of Argentine native and immigrant families

Introducción: Los procesos migratorios han aumentado a nivel mundial por múltiples causas. En nuestro país un 4.5% de población es extranjera y el 69% proviene de países limítrofes. La ley de Migraciones N°25.871 garantiza el goce igualitario de derechos a migrantes extranjeros y argentinos. La comuna 8 (CABA) presenta 19.9% de población extranjera. Su primer Nivel de Atención está a cargo, entre otros, de los Centros de Salud y Acción Comunitaria N° 5 y 18. El Hospital Juan P. Garrahan es centro de derivación regional. El objetivo de la investigación fue describir las características de la respuesta del Sistema de Salud, específicamente, comparar el acceso al primer nivel de prevención y la satisfacción con la actividad asistencial entre familias migrantes extranjeras y nativas. Métodos: Estudio multicéntrico, observacional y de corte transversal a través de entrevistas semiestructuradas a familias migrantes extranjeras y nativas entre Julio 2014 y Junio 2015. Los resultados se expresaron en frecuencias y porcentajes en forma global y comparativa entre ambos grupos. Resultados: Se encuestaron 287 familias, 52% nativas y 48% migrantes extranjeras. Se encontró menor acceso a trabajo formal en las últimas. Ambos grupos presentaron dificultad en la obtención de turnos, percibiendo trato más amable las primeras y mayor comprensión de indicaciones las segundas. En la asistencia médica se halló menor posibilidad de cumplir con indicaciones en familias migrantes. Conclusión: Los resultados reflejan similares características de atención pediátrica ambulatoria para familias nativas y migrantes extranjeras (AU)

Introduction: Migration has increased worldwide due to multiple causes. In our country, foreigners account for 4.5% of the population of whom 69% come from neighboring countries. The Law of Migration N°25.871 guarantees equal rights for immigrants and Argentinians. In Commune 8 (City of Buenos Aires) 19.9% of the population is foreign born. Their primary care attention is covered by, among others, Health Care and Community Action Centers N° 5 and 18. Hospital Juan P. Garrahan is a regional referral center. The aim of this study was to describe the characteristics of the response of the Health Care System, specifically, comparing access to and satisfaction with first-level care and disease prevention among immigrant and native Argentinian families. Methods: A multicenter, observational, cross-sectional study was conducted through semi-structured interviews with immigrant and native Argentinian families between July 2014 and June 2015. Results were expressed in rates and percentages overall and comparing both groups. Results: 287 families were interviewed, 52% were native and 48% immigrants. Reduced access to formal employment was found in the latter group. Both groups reported difficulties in obtaining appointments, perceiving a more friendly treatment in the former and better understanding of the indications in the latter group. Regarding medical care, less possibilities to adhere to the indications were found in immigrant families. Conclusion: Our results show similar pediatric outpatient health-care characteristics for native and immigrant families (AU)

Prevalencia de trastornos del desarrollo en consultorios de mediano riesgo del Hospital Garrahan / Prevalence of developmental disorders in patients seen at the aoutpatient clinic of the Garrahan Hospital

Los trastornos del desarrollo son problemas relevantes y de gran impacto para la familia y la sociedad. Según Glascoe aproximadamente el 15-18 por ciento de los niños en Estados Unidos tienen alteración del desarrollo o de la conducta. Los datos en países en vías de desarrollo son muy escasos. Objetivos. Determinar la prevalencia de trastornos del desarollo (TD) en niños de 1 año a 5 años, 11 meses y 29 días que asisten al consultorio de Mediano Riesgo (MR) del hospital de Pediatría Juan P. Garrahan. diferenciar y caracterizar a los niños con trastorno del desarrollo evidente o sospechoso. Materiales y métodos: Estudio de corte transversal, prospectivo y descriptivo realizado entre 07/2007 y 03/2008. Se incluyeron pacientes de 1 año a 5 años 11 meses y 29 días que consultaron al sector de Mediano Riesgo con trastornos del desarrollo evidente o sospechoso por evaluación clínica asistemática o presencia de factores de riesgo. Los evidentes fueron derivados para evaluación especifica del desarrollo. A los sospechosos se les realizó un interrogatorio del desarrollo y se les administró la prueba de pesquisa PRUNAPE. Resultados: Sobre un total de 922 pacientes elegidos al azar, el 45.5 por ciento (N=420) fueron incluidos por presentar alteraciones evidentes o sospechosas de trastornos del desarrollo para la población elegida en ese período fue del 20 por ciento (N=186) para los evidentes y 17.5 por ciento (N=161) para los sospechosos. Del grupo de pacientes sospechosos (N=161), el 62.2 por ciento (N=100) no pasó la prueba de pesquisa o presentó algún tipo de trastorno de conducta o disfluencia, que requirió intervención terapéutica orientada por el pediatra. Cuando la sospecha fue de los padres (N=20): un 75 por ciento falló en la PRUNAPE (N=15), un niño presentó trastorno de la conducta que requirió intervención terapéutica (N=1) y un niño disfluencia o trartamudez (N=1).

Epidural analgesia in children: planning, organization and development of a new program.

BACKGROUND: The goal of the present work is to describe the development and results of the pediatric epidural analgesia program at the ''Hospital Nacional de Pediatria Prof. Dr. J. P. Garrahan'' in Argentina. METHODS: Patients with thoracotomy, abdominal surgery, osteotomy, amputations or severe trauma were included in the program. The program provided training to the entire staff, control and record of pain treatment and its consequences, 24 h a day availability of anesthesia staff and standard polices and procedures. RESULTS: One hundred fifty children under 16 years of age (median age 11 years, median weight 35 kg) were included in the program during the first 18 months. The median of maximum pain reported during activity was 1 (interquartile range 1 to 4 points) using the Visual Analogue Scale (VAS) or Objective Pain Scale (OPS). Eighty seven children (CI 95% 50% to 67%) presented with postoperative nausea and vomiting, urinary retention, itching, motor blockade or sedation. No patient presented with respiratory depression, hypotension, local anaesthetic toxicity, epidural catheter related infection or death during the program evaluation. The postoperative care program enabled a 98-day reduction in treatment in the intensive care unit. CONCLUSION: The safe use of pediatric epidural analgesia in general wards may require the careful selection of patients, systematic assessment by trained personnel, training of medical and nursing personnel, clear distribution of responsibilities, use of printed indications, systematic record of pain, sedation and complications, information and education of patients and parents, supply of systems for airway resuscitation and management and continuous quality control and revision of the methods.

[Sonographic diagnosis of congenital dacryocystocele]. / Sonographische Diagnose kongenitaler Dakryozystozelen.

AIM: Congenital obstruction of the nasolacrimal drainage system occurs quite commonly. The reason is usually an impaired canalization at the distal end of the nasolacrimal duct with a residual membrane between the duct and the nasal cavity. Dacryocystocele is believed to result from a concomitant upper and lower system obstruction, causing fluid accumulation and distension of the lacrimal sac. The patient presents at birth with a tense, blue-grey swelling located just below the medial canthal tendon. The differential diagnosis for dacryocystocele includes haemangioma, encephalocele, glioma, dermoid cysts and malignant processes. MATERIAL AND METHODS: We demonstrate five typical cases to describe the sonographic features of dacryocystocele. RESULTS: Ultrasound is a simple, straight forward and gentle method to reliably distinguish dacryocystoceles from other pathologies. A sedation of the patient is not necessary. The sonographic appearance of a cystic mass medial and inferior of the orbit communicating with the dilated nasolacrimal duct as well as the typical content of fluid and debris was diagnostic of a nasolacrimal mucocele or dacryocystocele. Other more invasive imaging techniques as CT-scans and MRI are of benefit only if there is any doubt about the diagnosis.

In vitro and in vivo processing of cyanelle tmRNA by RNase P.

Ribonuclease P, the ubiquitous endonuclease required for generating mature tRNA 5' ends, is a ribonucleoprotein in most organisms and organelles, with the exception of mitochondria and chloroplasts of multicellular organisms. The cyanelle of the primitive alga Cyanophora paradoxa is the only photosynthetic organelle where the ribonucleoprotein nature of this enzyme has been functionally proven. tmRNA is another highly structured RNA: it can be aminoacylated with alanine, which is then incorporated into a tag peptide encoded on the same RNA molecule. This dual-function RNA has been found in bacteria, and its gene is also present in mitochondria and plastids from primitive organisms. Since nothing is known about the expression of this RNA in organelles, we have performed processing studies and determined the promoter of cyanelle pre-tmRNA. This RNA is transcribed as a precursor molecule in vivo. Synthetic transcripts of cyanelle pre-tmRNA, including or lacking the mature 3' CCA-end, are efficiently and correctly processed in vitro by bacterial RNase P ribo- and holoenzymes and by the homologous cyanelle RNase P. In addition to these experimental data, we propose a novel secondary structure model for this organellar tmRNA, which renders it more similar to its bacterial counterpart.

The first phytoplasma RNase P RNA provides new insights into the sequence requirements of this ribozyme.

A high variability of RNase P RNA structures is seen among members of the Mycoplasma group. To gain further insight into the structure-function relations of this ribozyme, we have searched for the RNase P RNA gene from more distant relatives, the phytoplasmas. These mycoplasma-like organisms are the aetiological agents of many severe plant diseases. We report the sequence and catalytic properties of RNase P RNA from the phytoplasma causing apple proliferation disease. The primary and postulated secondary structure of this 443 nt long RNA are most similar to those of Acholeplasma, supporting the phylogenetic position of this pathogen. Remarkably, the extremely AT-rich (73.6%) phytoplasma RNA differs from the known bacterial consensus sequence by a single base pair, which is positioned close to the substrate cleavage site in current three-dimensional models. Phytoplasma RNase P RNA functions as an efficient ribozyme in vitro. Conversion of its sequence to the full consensus and kinetic analysis of the resulting mutant RNAs suggests that neither the sequence alone, nor the type of pairing at this position is crucial for substrate binding or catalysis by the RNase P ribozyme. These results refine the bacterial consensus structure close to the catalytic core and thus improve our understanding of RNase P RNA function.

The role of endogenous growth factors to support corneal endothelial migration after wounding in vitro.

Previous studies have shown that corneal endothelial cells contain mRNA and protein of various growth factors. However, the role of these endogenous growth factors in corneal endothelial wound healing is not fully elucidated. In the present study, we investigated the role of endogenous factors and several growth factor inhibitors on migration of corneal endothelial cells in an in vitro model of wound healing. Bovine corneal endothelial cells (BCEC) were grown to confluency and experiments performed at passage 2 under serum reduced [2% fetal calf serum (FCS)] conditions. A central circular 'wound' (5 mm diameter) was made with an especially designed trephine. In different experiments, cells were incubated over different time periods (1-72 hr) either with the cellular debris produced by the wounding procedure or with previously prepared endothelial cell lysates (protein content 50-500 microg ml(-1)). Additionally, purified bovine polyclonal anti-BFGF antibodies (Ab) (4.5-27 microg ml(-1)), suramin (0.5 m M) or anti-FGF receptor-Ab (1 microg ml(-1)) were added to both experimental approaches, respectively. Migration was quantitated by counting the cells inside the denuded area in four different sections from the wound edge after 5 days. Cellular migration of cells adjacent to the wound was significantly stimulated by factors released during wounding or by endothelial cell lysates at protein concentrations >100 microg ml(-1). This increase in migrating cells was partially inhibited when the anti-bFGF antibody was incubated with the cell debris or the lysates. The addition of suramin at 0.5 m M almost completely blocked the migration activity. Incubation of the anti-FGF-receptor antibody prior to and >5 hr after wounding significantly reduced migration to nearly 50% of the rate in control cultures (P<0.001). In the present study, we demonstrate that intracellular growth factors released from corneal endothelial cells enhance the migration of surviving cells in vitro. The strong inhibitory effect of suramin indicates a major role of heparin-binding growth factors for cellular migration. bFGF and the regulation of bFGF-receptor expression on cells at the wound margin seem to be of crucial importance for the wound healing process.

A dual function alpha-dioxygenase-peroxidase and NAD(+) oxidoreductase active enzyme from germinating pea rationalizing alpha-oxidation of fatty acids in plants.

An enzyme with fatty acid alpha-oxidation activity (49 nkat mg(-1); substrate: lauric acid) was purified from germinating pea (Pisum sativum) by a five-step procedure to apparent homogeneity. The purified protein was found to be a 230-kD oligomer with two dominant subunits, i.e. a 50-kD subunit with NAD(+) oxidoreductase activity and a 70-kD subunit, homolog to a pathogen-induced oxygenase, which in turn shows significant homology to animal cyclooxygenase. On-line liquid chromatography-electrospray ionization-tandem mass spectrometry revealed rapid alpha-oxidation of palmitic acid incubated at 0 degrees C with the purified alpha-oxidation enzyme, leading to (R)-2-hydroperoxypalmitic acid as the major product together with (R)-2-hydroxypalmitic acid, 1-pentadecanal, and pentadecanoic acid. Inherent peroxidase activity of the 70-kD fraction decreased the amount of the (R)-2-hydroperoxy product rapidly and increased the level of (R)-2-hydroxypalmitic acid. Incubations at room temperature accelerated the decline toward the chain-shortened aldehyde. With the identification of the dual function alpha-dioxygenase-peroxidase (70-kD unit) and the related NAD(+) oxidoreductase (50-kD unit) we provided novel data to rationalize all steps of the classical scheme of alpha-oxidation in plants.

Identification of a small RNA within the pdh gene cluster of Mycoplasma pneumoniae and Mycoplasma genitalium.

A highly abundant and heterogeneous small RNA about 205 to 210 bases long named MP200 RNA has been identified in Mycoplasma pneumoniae. It was localized on the genome within a 319-bp-long intergenic space of the pyruvate dehydrogenase (pdh) gene cluster. A database search at the DNA level revealed the highest similarity to a sequence located within the pdh gene cluster of Mycoplasma genitalium that was also shown to be transcribed into two abundant, but smaller RNAs than the ones in Mycoplasma pneumoniae. The RNAs from both M. pneumoniae and M. genitalium have the potential to code for cysteine-rich 29- and 23-amino-acid-long peptides, but so far, these peptides have not been identified experimentally in bacterial protein extracts.

Ribonuclease P: the diversity of a ubiquitous RNA processing enzyme.

Ribonuclease P is the endonuclease required for generating the mature tRNA 5'-end. The ribonucleoprotein character of this enzyme has now been proven in most organisms and organelles. Exceptions, however, are still the chloroplasts, plant nuclei and animal mitochondria where no associated RNAs have been detected to date. In contrast to the known RNA subunits, which are fairly well-conserved in size and structure among diverse phylogenetic groups, the protein contribution to the holoenzyme is highly variable in size and number of the individual components. The structure of the bacterial protein component has recently been solved. In contrast, the spatial arrangement of the multiple subunits in eukaryotic enzymes is still enigmatic. Substrate requirements of the enzymes or their catalytic RNA subunits are equally diverse, ranging from simple single domain mimics to an almost intact three-dimensional structure of the pre-tRNA substrate. As an example for an intermediate in the enzyme evolution, ribonuclease P from the Cyanophora paradoxa cyanelle will be discussed in more detail. This enzyme is unique, as it combines cyanobacterial and eukaryotic features in its function, subunit composition and holoenzyme topology.

Cyanelle RNase P: RNA structure analysis and holoenzyme properties of an organellar ribonucleoprotein enzyme.

The cyanelle of the primitive alga Cyanophora paradoxa is the only photosynthetic organelle where the ribonucleoprotein nature of ribonuclease P has been functionally proven. To increase our knowledge about RNA structure and overall composition of this enzyme, we have now determined relevant physical parameters and performed RNA accessibility experiments. Buoyant density and relative molecular mass of cyanelle RNase P were more similar to the eukaryotic (nuclear or mitochondrial) than to the bacterial enzyme type, despite the close phylogenetic relationship between plastids and cyanobacteria. Enzymatic and chemical probing was used to establish the secondary structure of cyanelle RNase P RNA. The results obtained with the naked transcript support the previously proposed, phylogenetically derived structure. Probing of the RNA in the holoenzyme resulted in reduced sensitivity at a large number of positions, indicating that these regions might be located in the interior of the ribonucleoprotein. Protection of the RNA in cyanelle RNase P was more extensive than reported for the Escherichia coli holoenzyme, but similar to the pattern observed in yeast nuclear RNase P. Taken together, these results indicate that the protein contribution in cyanelle RNase P is much larger than in the bacterial enzymes, and that the overall composition of the holoenzyme resembles that found in eukaryotes.