[Successful oral desensitization to levothyroxine. Report of one case]. / Desensibilización a levotiroxina. Caso clínico.

We report a 39-year-old female who underwent a total thyroidectomy as treatment for a thyroid papillary cancer. She suffered several episodes of mild angioedema in lips and tongue, after using different commercial Levothyroxine formulations, with and without excipients. Given the need to use this drug, the patient was admitted in our hospital and we proceeded to desensitize her with oral Levothyroxine. The patient fasted throughout the whole procedure, was properly monitored and had an adequate peripheral venous access. On the first day of the procedure, a 15-step protocol was performed, first administering placebo and then, compounded formulations of Levothyroxine starting from 0.01 ug, followed by doubling doses every 15 minutes until the cumulative dose of 111.95 ug was completed, corresponding to the daily dose of Levothyroxine her endocrinologist prescribed (112 ug). The patient was monitored at baseline, between each dose and up to 3 hours after the procedure was completed. There were no incidents such as urticaria, angioedema, or others. On the second day, the patient received a single-full dose of 112 ug on an empty stomach. The medication was successfully tolerated and she was discharged. Thereafter, she tolerates daily Levothyroxine.

Costs, effects and cost-effectiveness of breast cancer control in Ghana.

OBJECTIVE: Breast cancer control in Ghana is characterised by low awareness, late-stage treatment and poor survival. In settings with severely constrained health resources, there is a need to spend money wisely. To achieve this and to guide policy makers in their selection of interventions, this study systematically compares costs and effects of breast cancer control interventions in Ghana. METHODS: We used a mathematical model to estimate costs and health effects of breast cancer interventions in Ghana from the healthcare perspective. Analyses were based on the WHO-CHOICE method, with health effects expressed in disability-adjusted life years (DALYs), costs in 2009 US dollars (US$) and cost-effectiveness ratios (CERs) in US$ per DALY averted. Analyses were based on local demographic, epidemiological and economic data, to the extent these data were available. RESULTS: Biennial screening by clinical breast examination (CBE) of women aged 40-69 years, in combination with treatment of all stages, seems the most cost-effective intervention (costing $1299 per DALY averted). The intervention is also economically attractive according to international standards on cost-effectiveness. Mass media awareness raising (MAR) is the second best option (costing $1364 per DALY averted). Mammography screening of women of aged 40-69 years (costing $12,908 per DALY averted) cannot be considered cost-effective. CONCLUSIONS: Both CBE screening and MAR seem economically attractive interventions. Given the uncertainty about the effectiveness of these interventions, only their phased introduction, carefully monitored and evaluated, is warranted. Moreover, their implementation is only meaningful if the capacity of basic cancer diagnostic, referral and treatment and possibly palliative services is simultaneously improved.

Prevention, screening and treatment of colorectal cancer: a global and regional generalized cost effectiveness analysis.

BACKGROUND: Regional generalized cost-effectiveness estimates of prevention, screening and treatment interventions for colorectal cancer are presented. METHODS: Standardised WHO-CHOICE methodology was used. A colorectal cancer model was employed to provide estimates of screening and treatment effectiveness. Intervention effectiveness was determined via a population state-transition model (PopMod) that simulates the evolution of a sub-regional population accounting for births, deaths and disease epidemiology. Economic costs of procedures and treatment were estimated, including programme overhead and training costs. RESULTS: In regions characterised by high income, low mortality and high existing treatment coverage, the addition of screening to the current high treatment levels is very cost-effective, although no particular intervention stands out in cost-effectiveness terms relative to the others.In regions characterised by low income, low mortality with existing treatment coverage around 50%, expanding treatment with or without screening is cost-effective or very cost-effective. Abandoning treatment in favour of screening (no treatment scenario) would not be cost effective.In regions characterised by low income, high mortality and low treatment levels, the most cost-effective intervention is expanding treatment. CONCLUSIONS: From a cost-effectiveness standpoint, screening programmes should be expanded in developed regions and treatment programmes should be established for colorectal cancer in regions with low treatment coverage.

Obesity and cardio-metabolic risk factors among children and adolescents with cerebral palsy.

INTRODUCTION: Background: obesity and associated cardiometabolic complications are increasing among adults with cerebral palsy (CP). Information in children is scarce, and there is no consensus definition of obesity. Objectives: to describe the frequency of obesity and metabolic complications in children and adolescents with CP. Methods: a descriptive, cross-sectional study performed in two outpatient pediatric special needs centers. Demographic, anthropometric (Brooks 2011), and motor function (GMFCS) data, as well as antiepileptic use, were recorded. Fasting triglycerides (TG), total cholesterol (TC), vitamin D (25OHD), glycemia (GLY), and insulinemia levels were measured. The HOMA index was calculated. Results: sixty-five patients were enrolled. Aage was 10.8 ± 4.9 years; 63.1 % were male; 81.6 % had GMFCS IV-V; 43.5 % had a gastrostomy; and 83.1 % were on antiepileptics. According to their BMI, 15.4 % were underweight (< 10th percentile) and 10.8 % overweight (> 75th percentile). Overall, 6.1 % had TC ≥ 200 mg/dL, 21.4 % had TG ≥ 110 or 130 mg/dL, 4.6 % had GLY ≥ 100 mg/dL, 16.9 % had HOMA ≥ 3, and 76.9 % had 25OHD < 30 ng/mL. Children with BMI ≥ 75th percentile had higher HOMA and insulin resistance rates than those with BMI < 75th percentile. Elevated TGs were associated with high motor impairment and low vitamin D. HOMA was associated to feminine gender and BMI ≥ 75th percentile. Conclusions: the frequency of cardiometabolic risk factors was high in this sample of pediatric patients with CP, associated with overweight, low mobility, and vitamin D deficiency. We propose a BMI > 75th percentile as cutoff point for metabolic risk factors.

INTRODUCCIÓN: Introducción: la obesidad y sus complicaciones cardiometabólicas han aumentado en los adultos con parálisis cerebral (PC). La información en la población pediátrica es escasa y no hay consenso en la definición de obesidad. Objetivos: describir la frecuencia de la obesidad y sus complicaciones metabólicas en niños y adolescentes con PC. Métodos: estudio transversal descriptivo realizado en dos centros pediátricos ambulatorios de pacientes con necesidades especiales de atención en salud. Se registraron datos demográficos, antropométricos (curvas de Brooks 2011), función motora (GMFCS) y medicamentos. En muestras sanguíneas en ayunas se midieron: triglicéridos (TG), colesterol total (CT), vitamina D (25OHD), glucemia (GLI) e insulinemia. Se calculó el índice HOMA. Resultados: participaron 65 pacientes con edades de 10,8 ± 4,9 años; el 63,1 % eran varones; el 81,6 % tenían GMFCS IV-V; el 43,5 % estaban gastrostomizados y el 83,1 % tomaban antiepilépticos. Según el IMC, el 15,4 % tenían bajo peso (< percentil 10) y el 10,8 % sobrepeso (≥ p75). Del grupo total, el 6,1 % tenían CT > 200 mg/dL, el 21,4 % TG > 110 o 130 mg/dL, el 4,6 % GLI ≥ 100 mg/dL, el 16,9 % HOMA > 3 y el 76,9 % 25OHD < 30 ng/mL. Los pacientes con IMC ≥ p75 tenían mayor frecuencia de HOMA >3 que aquellos con IMC < p75. La hipertrigliceridemia se asoció a mayor discapacidad motora y a baja vitamina D, y el HOMA al género femenino y a un IMC ≥ p75. Conclusiones: la frecuencia de los factores de riesgo cardiometabólico fue alta en esta muestra de pacientes pediátricos con PC, asociada al género, el sobrepeso, la baja movilidad y la deficiencia de vitamina D. Proponemos un IMC ≥ p75, según las curvas específicas de PC, como punto de corte para el mayor riesgo cardiometabólico.

Cancer control capacity in 50 low- and middle-income countries.

Within the World Health Organization-International Atomic Energy Agency (WHO-IAEA) collaboration for delivery of technical assistance to its Member States, the National Cancer Control Programme/Plan (NCCP) Core Capacity Self-Assessment Tool has been used to obtain a simple and quick qualitative overview of national cancer control planning and on-going activities. The NCCP tool was applied in 50 Member States, which were classified as low- and middle-income countries in 2012. Results show that half of these countries reported having officially endorsed an NCCP and 42% were in the process of preparing or updating one. Overall, the most relevant cancer control interventions reported to be partially developed or well established in most countries were related to the cancer prevention, early detection of cervical and breast cancers, as well as diagnosis and treatment of curable cancers. Contrarily, patient's rehabilitation, psychosocial support, human papilloma virus vaccination, breast cancer screening with mammography and control of occupational carcinogens were noted as being in early development phases. The availability of crucial resources to support interventions was perceived to be the highest in upper middle-income countries. These findings highlight specific areas where WHO, IAEA and partners could strengthen collaboration with countries to leverage on-going interventions and improve availability of resources.

Nutritional supplementation according to energy and protein requirements in malnourished HIV-infected patients.

To evaluate the effects of nutritional supplements on nitrogen and energy balances, body composition and immune parameters, HIV-infected malnourished adult outpatients were prospectively studied. Forty-six patients (4 females and 42 males; 37 +/- 12 y) were supplemented with a polymeric diet (PD) or regular foods (RF) on two consecutive 45-day periods on a crossover design. Weight, skinfold thicknesses, plasma albumin (PA), CD4 and CD8 lymphocyte counts (LC), resting energy expenditure (REE) and urinary nitrogen excretion were measured at baseline, 45 and 90-day. Food intake was weekly recorded by food surveys. Thirty-five patients completed the protocol (18 in Group 1:PD-->RF; 17 in Group 2:RF-->PD). In both groups, weight, fat free mass (FFM), energy balance (EB) and nitrogen balance (NB) increased significantly after PD, whereas LC and PA remained unchanged in both groups. The best results in terms of weight gain were obtained in the PD group and PD plus zidovudine subgroup (n = 8) during the first 45 days (weight gain/FFM gain: 4.8/2.6 kg and 6.8/3.1 kg, respectively). Nutritional supplement with PD, according to the EB and NB goals, was well tolerated and permitted to achieve a significant weight and FFM gain over a 90-day follow-up.

Desensibilización a levotiroxina: caso clínico / Successful oral desensitization to levothyroxine: report of one case

We report a 39-year-old female who underwent a total thyroidectomy as treatment for a thyroid papillary cancer. She suffered several episodes of mild angioedema in lips and tongue, after using different commercial Levothyroxine formulations, with and without excipients. Given the need to use this drug, the patient was admitted in our hospital and we proceeded to desensitize her with oral Levothyroxine. The patient fasted throughout the whole procedure, was properly monitored and had an adequate peripheral venous access. On the first day of the procedure, a 15-step protocol was performed, first administering placebo and then, compounded formulations of Levothyroxine starting from 0.01 ug, followed by doubling doses every 15 minutes until the cumulative dose of 111.95 ug was completed, corresponding to the daily dose of Levothyroxine her endocrinologist prescribed (112 ug). The patient was monitored at baseline, between each dose and up to 3 hours after the procedure was completed. There were no incidents such as urticaria, angioedema, or others. On the second day, the patient received a single-full dose of 112 ug on an empty stomach. The medication was successfully tolerated and she was discharged. Thereafter, she tolerates daily Levothyroxine.

Cost-effectiveness analysis of breast cancer control interventions in Peru.

OBJECTIVES: In Peru, a country with constrained health resources, breast cancer control is characterized by late stage treatment and poor survival. To support breast cancer control in Peru, this study aims to determine the cost-effectiveness of different breast cancer control interventions relevant for the Peruvian context. METHODS: We performed a cost-effectiveness analysis (CEA) according to WHO-CHOICE guidelines, from a healthcare perspective. Different screening, early detection, palliative, and treatment interventions were evaluated using mathematical modeling. Effectiveness estimates were based on observational studies, modeling, and on information from Instituto Nacional de Enfermedades Neoplásicas (INEN). Resource utilizations and unit costs were based on estimates from INEN and observational studies. Cost-effectiveness estimates are in 2012 United States dollars (US$) per disability adjusted life year (DALY) averted. RESULTS: The current breast cancer program in Peru ($8,426 per DALY averted) could be improved through implementing triennial or biennial screening strategies. These strategies seem the most cost-effective in Peru, particularly when mobile mammography is applied (from $4,125 per DALY averted), or when both CBE screening and mammography screening are combined (from $4,239 per DALY averted). Triennially, these interventions costs between $63 million and $72 million per year. Late stage treatment, trastuzumab therapy and annual screening strategies are the least cost-effective. CONCLUSIONS: Our analysis suggests that breast cancer control in Peru should be oriented towards early detection through combining fixed and mobile mammography screening (age 45-69) triennially. However, a phased introduction of triennial CBE screening (age 40-69) with upfront FNA in non-urban settings, and both CBE (age 40-49) and fixed mammography screening (age 50-69) in urban settings, seems a more feasible option and is also cost-effective. The implementation of this intervention is only meaningful if awareness raising, diagnostic, referral, treatment and basic palliative services are simultaneously improved, and if financial and organizational barriers to these services are reduced.

Screening, prevention and treatment of cervical cancer -- a global and regional generalized cost-effectiveness analysis.

The paper calculates regional generalized cost-effectiveness estimates of screening, prevention, treatment and combined interventions for cervical cancer. Using standardised WHO-CHOICE methodology, a cervical cancer model was employed to provide estimates of screening, vaccination and treatment effectiveness. Intervention effectiveness was determined via a population state-transition model (PopMod) that simulates the evolution of a sub-regional population accounting for births, deaths and disease epidemiology. Economic costs of procedures and treatment were estimated, including programme overhead and training costs. In regions characterized by high income, low mortality and high existing treatment coverage, the addition of any screening programme to the current high treatment levels is very cost-effective. However, based on projections of the future price per dose (representing the economic costs of the vaccination excluding monopolistic rents and vaccine development cost) vaccination is the most cost-effective intervention. In regions characterized by low income, low mortality and existing treatment coverage around 50%, expanding treatment with or without combining it with screening appears to be cost-effective or very cost-effective. Abandoning treatment in favour of screening in a no-treatment scenario would not be cost-effective. Vaccination is usually the most cost-effective intervention. Penta or tri-annual PAP smears appear to be cost-effective, though when combined with HPV-DNA testing they are not cost-effective. In regions characterized by low income, high mortality and low treatment levels, expanding treatment with or without adding screening would be very cost-effective. A one off vaccination plus expanding treatment was usually very cost-effective. One-off PAP or VIA screening at age 40 are more cost-effective than other interventions though less effective overall. From a cost-effectiveness perspective, consideration should be given to implementing vaccination (depending on cost per dose and longevity of efficacy) and screening programmes on a worldwide basis to reduce the burden of disease from cervical cancer. Treatment should also be increased where coverage is low.

[Innate immunity restoration in patients with HIV/AIDS infection associated with antiretroviral therapy]. / Restauración de la inmunidad innata en pacientes con infección por VIH/SIDA después de inicio de terapia antirretroviral.

BACKGROUND: Highly active antiretroviral therapy (HAART) in HIV/AIDS infection induces an important reduction of the viral load (VL) and an immune system reconstitution. CD4+ T lymphocyte count is the immunological measurement commonly used for the follow up of HIV/AIDS patients. AIM: To study prospectively the restoration of the innate immune system in patients with HIV/AIDS infection during their first year on HAART. PATIENTS AND METHODS: 25 naive HIV/AIDS patients, from San José Hospital and University of Chile Clinical Hospital, Santiago, Chile, were studied between years 2002-2003. Every 4 months after HAART initiation, CD3+, CD4+, CD8+ T lymphocytes and CD16/56+ natural killer (NK) cells were quantified by flow cytometry. NK cell cytotoxicity was measured using radioactive chrome liberation (Cr51). Tumor necrosis factor alpha (TNF-alpha) and interleukin-10 (IL-10) were measured in peripheral blood mononuclear cells and viral load was determined using Amplicor HIV-1 from Roche Diagnostics Systems. RESULTS: Thirteen of the 25 patients continued in the study. They were all males, average age 35 years old (23-50). At baseline average CD4+ count was 146 cells/microL (31-362) and average viral load was 82.000 copies/mL (4.000-290.000). A raise in CD3+, CD4+, CD8+, and CD16/56 cells was noted at months 9-12 of therapy. Viral load became undetectable in the same period. NK cell function was decreased at the beginning of the therapy (1-4 months), reaching its highest values at months 9-12. There was no significant change in IL-10. TNF-alpha increased in six patients during the study. CONCLUSIONS: In this group of patients, innate immunity was restored during HAART. These results should be confirmed in studies with a longer follow up period and also measuring cytokines such as MIP-1a, MIP-1ss and RANTES.

Effective cervical cytology screening programmes in middle-income countries: the Chilean experience.

OBJECTIVE: To demonstrate that an effective cervical cancer screening programme based on the Papanicolaou (Pap) smear can be organized in a middle-income country, such as Chile. METHODS: The cervical cytology screening programme in Chile is evaluated by comparing process measures and cervical cancer mortality before and after its reorganization in 1987. FINDINGS: Two decades of opportunistic annual screening for cervical cancer from the mid-1960s to the mid-1980s did not reduce cervical cancer mortality in Chile. In 1987, a public health oriented program was launched, based on screening women aged 25-64 every 3 years, rather than the annual screening of low risk women attending family planning clinics that gathered mainly women less than 25 years of age. The reoriented program emphasized the optimization of existing resources, the timeliness of diagnosis and treatment, reliability of the Pap smear and low cost screening promotion strategies at the community level. More than 80% of women with abnormal Pap smears received prompt medical attention and 100% of the public laboratories were subject to external quality control. According to biannual national surveys, coverage by Pap smear screening in the target group rose from 40% in 1990 to 66% in 1996. The age adjusted cervical cancer mortality rate decreased from 12.8 in 1980 to 6.8 per 100,000 women in 2001. CONCLUSIONS: Improved organization of the national cervical cancer screening programme in Chile and more efficient use of existing resources resulted in a decrease of cervical cancer mortality.

Prevalence of antiphospholipid and antiplatelet antibodies in human immunodeficiency virus (HIV)-infected Chilean patients.

Antiphospholipid (aPL) and antiplatelet (aPlt) antibodies, found in patients with autoimmune diseases, are also detected in infectious diseases. The purpose of this study was to examine the prevalence of these antibodies in HIV patients and to evaluate an association of these antibodies with thrombocytopenia and/or thrombosis. Sixty-three HIV-seropositive patients and 52 normal controls were studied. Anti-cardiolipin (aCL), anti-beta(2) glycoprotein I (anti-beta(2)GPI), and antiprothrombin (aPT) antibodies were determined and the lupus anticoagulant (LA) test was performed. Antiplatelet antibodies (aPlt) were also determined. Seven out of 63 (12.7%) HIV patients were positive for aCL, four of 63 (6.3%) for anti-beta(2)GPI, and five of 63 (7.9%) for aPT. No patients studied were LA positive. Six out of 63 (9.5%) patients were positive for aPlt. One of them showed weak reactivity for GPIb-IX. The platelet count of patients (202+/-63 x 10(3) platelets/microL) was significantly lower than in the controls (343+/-6 x 10(3) platelets/microL) (P<0.001). There was no correlation between the presence of aPL and/or aPlt and thrombocytopenia. Of the HIV-infected patients, 22.2% presented aPL and 9.4% aPlt antibodies. In this study, the presence of aPL and aPlt antibodies was not associated with the development of thrombosis and/or thrombocytopenia.

Gota familiar y nefropatía en una mujer joven: caso clínico / Familial gout and nephropathy in a young woman: clinical case

We report a 29 years old woman with a chronic tophaceous gout, whose disease started at the age of 18. On clinical examination, the blood pressure was elevated. The laboratory assessment showed a serum uric acid of 15 mg/dl, a urinary uric acid of 155 mg/24 h, a creatinine clearance of 59 ml/min/1.73 m2 and a uric acid excretion fraction off 1.3 per cent (normal 7 to 12 per cent). The clinical and laboratory features of this patient suggest the diagnosis of a familial juvenile gouty nephropathy

Nutritional supplementation according to energy and protein requirements in malnourished HIV-infected patients

To evaluate the effects of nutritional supplements on nitrogen and energy balances, body composition and immune parameters, HIV-infected malnourished adult outpatients were prospectively studied. Forty-six patients (4 females and 42 males; 37 +/- 12 y) were supplemented with a polymeric diet (PD) or regular foods (RF) on two consecutive 45-day periods on a crossover design. Weight, skinfold thicknesses, plasma albumin (PA), CD4 and CD8 lymphocyte counts (LC), resting energy expenditure (REE) and urinary nitrogen excretion were measured at baseline, 45 and 90-day. Food intake was weekly recorded by food surveys. Thirty-five patients completed the protocol (18 in Group 1:PD-->RF; 17 in Group 2:RF-->PD). In both groups, weight, fat free mass (FFM), energy balance (EB) and nitrogen balance (NB) increased significantly after PD, whereas LC and PA remained unchanged in both groups. The best results in terms of weight gain were obtained in the PD group and PD plus zidovudine subgroup (n = 8) during the first 45 days (weight gain/FFM gain: 4.8/2.6 kg and 6.8/3.1 kg, respectively). Nutritional supplement with PD, according to the EB and NB goals, was well tolerated and permitted to achieve a significant weight and FFM gain over a 90-day follow-up.

Estudio de la funcionalidad de las células NK en el embarazo / Functionality study of pregnancy NK cells

En los últimos años, la participación del sistema inmune innato en el desarrollo de la pre-eclampsia ha sido el objetivo de numerosos estudios. Sin embargo, el rol de las células agresoras naturales (NK) en esta patología no ha sido totalmente aclarado. Las células NK, componentes del sistema inmune innato, poseen actividad citotóxica espontánea, y secretan citoquinas tales como interferón gamma (INF-y ) y Factor de Necrosis Tumoral alfa (TNF-alfa). En el presente estudio hemos analizado la actividad funcional y el inmunofenotipo de células NK obtenidas desde sangre periférica de pacientes con pre-eclampsia, mujeres sanas embarazadas y mujeres sanas no embarazadas. Se cuantificó la actividad cititóxica usando el ensayo de liberación de51cromo. La producción de citoquinas en respuesta a activadores policlonales y el inmunofenotipo (CD3-CD16+CD56+) fueron determinados por citometría de flujo. Estos parámetros no evidenciaron diferencias significativas entre los grupos estudiados; sin embargo, en las pacientes con pre-eclampsia se observa una tendencia hacia una menor citotoxicidad y menor producción de TNF-alfa en células NK estimulada sin vitro, y una proporción aumentada del subtipo celular NK CD56-CD16+ en sangre periférica en relación con los otros dos grupos estudiados.

NK cells functionality during pregnancy. During the last few years, the role of innate immune system in development of pre-eclampsia has been the focus of a number of studies. However, the role of natural killer (NK) cells in pregnancy and pre-eclampsia has not been totally clarified. NK cells, an important component of innate immune system, normally exhibit spontaneus cytolytic activity and secrete cytokines such as interferon gamma (IFN-y) and tumor necrosis factor alpha (TNF-alpha). In current paper, we studied functional activity and immunophenotype of peripheral blood NKcells obtained from patients with pre-eclampsia, healthy pregnant women and non-pregnant healthy women. For this purpose, we quantified cytolytic activity using 51chromium release assay. We determined cytokine production in response to polyclonal activators and cells immunophenotype (CD3-CD16+CD56+) by flow cytometry. We found no significant differences in these parameters among the three groups studied, however, in patients with pre-eclampsia, there is a tendency to a decreased cytotoxic activity and less production of TNF-alpha by NK cells in vitro as well as an increased proportion of the NK subset CD56-CD16+, in peripheral blood.

Movilidad de columna lumbosacra en escolares / Lumbosacral spine mobility in school children

El segmento lumbosacro del raquis puede ser afectado por varias afecciones que afectan su movilidad, la que puede ser medida indirectamente, registrando la elongación que experimenta la piel que cubre los segmentos lumbar y sacro durante el movimiento. En este informe se describen las mediciones de elongación de la piel en 300 niños (150 mujeres) de 6 a 15 años mediante métodos (prueba de Schober modificada por Macrae-Wright) y una modificación adicional, para niños, de la precedente (prueba Burgos-Vargas III). Se analizaron por separado las mediciones obtenidas en los segmentos lumbar y sacro, y su comportamiento con respecto a sexo, edad, talla y peso. El coeficiente de varaiación interobservador mostró mejor reproductibilidad con el método 1 para medir el segmento lumbar (prueba de Schober). El estiramiento del segmento lumbar resultó significativamente mayor en las niñas (5,24 ñ 0,88 cm) vs (4,73 ñ 0,89 cm) en varones (p< 0,01), por el contrario, en el segmento sacro, los resultados fueron significativamente mayores en los varones (2,66 ñ 0,67 vs 2,22 ñ 0,61). La edad, el peso y la talla tienden a influir sobre la elongación de la piel sólo en las mujeres. En los niños parece recomendable hacer estas mediciones sólo en el segmento lumbar, considerando normales para mujeres estiramientos entre 4,36 y 6,12 cm y para normales de 3,84 a 5,62 cm