Allergenicity of casein containing chalk in milk allergic schoolchildren.

BACKGROUND: Nondietary exposure to milk proteins may be a risk for children who do not outgrow milk allergy by school age. OBJECTIVE: To study the allergenicity of casein containing chalk. METHODS: A 6-year-old, milk allergic child developed asthma and rhinoconjunctivitis while in school. The suspected cause was dust-free chalk containing casein. To study the relationship of dust-free chalk containing casein with asthma and rhinoconjunctivitis, 13 additional milk allergic patients were studied: 3 school-aged children, 8 preschool-aged infants, and 2 children with outgrown milk allergy. Skin tests and/or specific IgE with chalk and casein were performed. A chalk use test was performed in older children. Milk allergens contained in chalk were characterized by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, immunoblot, and IgE inhibition experiments. RESULTS: All school-aged, milk allergic children were exposed to chalk and reported symptoms attributed to chalk exposure. The skin test result to chalk was positive in 5 of 12 cases, and the specific IgE test result was positive in all 12 study participants in which it was performed. Casein strongly inhibited the binding of IgE to chalk. Chalk sodium dodecyl sulfate-polyacrylamide gel electrophoresis showed proteins with molecular weight similar to caseins. Immunoblot demonstrated strong binding of IgE to chalk in a blurred pattern and a band at 30 kDa, inhibited by casein. The chalk challenge test result was positive in 2 school-age children who had a positive skin test result to chalk. Their symptoms improved after avoidance of chalk in the school. In 2 other cases in which the challenge test result was negative, chalk was reintroduced without problems. CONCLUSION: Inhalation of chalk dust containing casein can induce asthma symptoms in milk allergic patients. Hidden and nondietary sources of exposure should always be considered in food allergic patients.

Sleep-related painful erection in a 50-year-old man successfully treated with cinitapride.

INTRODUCTION: The sleep-related painful erection (SRPE) is a well-established parasomnia characterized by episodes of penile pain during an erection and typically appears during REM sleep. It is associated with nocturnal awakenings, anxiety, and irritability. AIM: To report a case study that highlights the successful treatment of SRPE with cinitapride. METHODS: We present a case report of a 50-year-old man suffering from SRPE that was studied by polysomnography. RESULTS: Severe fragmentation of rapid eye movement (REM) sleep was observed, and nine episodes of sleep-related erections were observed through the night; they were associated with REM sleep, and five of them were classified as SRPE. Cinitapride before the onset of sleep was started. Both the frequency and intensity of SRPE gradually decreased during a period of 6 months with the maintenance of normal sexual function. CONCLUSION: Cinitapride can play a role in reducing SRPE at night probably due to central modulation of neurotransmitters mediating erection.

[Noninvasive mechanical ventilation in Valencia, Spain: from theory to practice]. / Ventilación mecánica no invasiva en la Comunidad Valenciana: de la teoría a la práctica.

OBJECTIVE: To obtain representative data on the frequency of use and availability of resources for noninvasive mechanical ventilation (NIV) in hospitals (acute respiratory failure) and at home (chronic respiratory failure). METHOD: We sent a purpose-designed questionnaire to all the hospitals in the Autonomous Community of Valencia, Spain and followed up with a telephone interview. RESULTS: Seventy percent of the hospitals responded to the survey. NIV was used to treat patients with acute respiratory episodes in 100% of the intensive care units and in 88% of the respiratory medicine departments. The most common diseases were chronic obstructive pulmonary disease (COPD) (mean [SD] 60% [20%]), obesity hypoventilation syndrome (22% [12%]), neuromuscular diseases (6.5% [8%]), and kyphoscoliosis (6.5% [7%]). Other diseases accounted for 4% [11%] of cases. Emergency departments used NIV in 69% of patients, internal medicine departments in 37%, hospital-based home care units in 19%, and other departments in 12%. None of the hospitals that responded to the survey had an intermediate care unit and considerable differences were found in terms of NIV systems used. Home NIV was provided by 88% of hospitals. Patients using home NIV had COPD (31% [18%]), obesity hypoventilation syndrome (30% [18%]), neuromuscular diseases (16% [23%]), kyphoscoliosis (12% [10%]), and other diseases (11% [17%]). Patient numbers varied greatly from one hospital to the next. Home NIV was delivered using a nasal interface in 65% (32%) of cases, an oral-nasal interface in 33% (33%), a tracheostomy tube in 2% (3%), and a mouthpiece in 1% (32%). Only 31.3% of hospitals has a specialized home NIV unit. Home monitoring was performed mainly by service providers. We calculated that home NIV was used in 29 individuals per 100 000 population. Only 50% of the respiratory medicine departments surveyed had written hospitalization protocols; the corresponding percentages for other departments were 44% for home care units, 19% for emergency departments, and 12% for internal medicine departments. CONCLUSIONS: We observed differences in the type of requirement used, and considerable deficiencies in the availability of human and material resources and support systems. Although NIV is mostly used in hospitals to treat patients with acute respiratory failure, home NIV is also very common and is characterized by greater variability in terms of the number and type of patients. We also observed deficiencies in terms of written protocols for patients with acute and chronic disease.

[Treatment of central sleep apnea syndrome of multifactorial origin by home ventilatory support]. / Síndrome de apnea central de origen multifactorial tratado mediante soporte ventilatorio domiciliario.

We report the case of a patient with chronic renal failure and primary hyperparathyroidism who developed nonhypercapnic central sleep apnea syndrome (CSAS), which was multifactorial in origin and attributed to metabolic factors. Given an inadequate response to oxygen therapy and continuous positive airway pressure (CPAP) revealed by several polygraph studies, the patient was treated with bilevel positive airway pressure ventilatory support. Three months after treatment commenced, a parathyroidectomy was performed and hemodialysis was initiated. At this point it was observed that the patient no longer experienced somnolence; moreover, polysomnography revealed partial improvement in the CSAS and normalization of ventilatory patterns on application of nasal CPAP at 7 cm H2O. We discuss the pathogenesis of CSAS associated with chronic kidney failure along with the treatment options and conclude that treatment should be customized due to the lack of predictability of patient response.

[Sleep apnea-hypopnea syndrome in a pediatric population: differences between children with tonsillar hypertrophy and those with concomitant disease]. / Síndrome de apneas-hipopneas durante el sueño en población infantil: diferencias en su expresión entre niños con hipertrofia amigdalar y con enfermedad concomitante.

OBJECTIVE: Our aim was to compare clinical and polysomnographic variables in pediatric patients with sleep apnea-hypopnea syndrome (SAHS) secondary to tonsillar hypertrophy with those in patients with concomitant disease. PATIENTS AND METHODS: We studied 42 children with SAHS (mean [SD] age, 8 [4] years; body mass index [BMI], 19.6 [5.2] kg/m2; neck circumference, 29 [4] cm; and BMI percentile, 67 [36]), 26 of whom were otherwise healthy (group A) and 16 of whom had concomitant disease (group B). RESULTS: A comparison of groups A and B showed no significant differences in age (7.7 [3.9] years vs 8.4 [3.9] years; P=not significant [NS]); sex, BMI (17.6 [4] kg/m2 vs 20.4 [6] kg/m2; P=NS), neck circumference (29.3 [4.7] cm vs 30.7 [3.5] cm; P=NS), or BMI percentile (61 [37] vs 76 [34]; P=NS). Tonsillar hypertrophy was more frequent in group A (P=.02) and craniofacial abnormalities (P=.008), macroglossia (P=.04), and dolichocephalia (P=.04) were more frequent in group B. No significant differences were observed in neurophysiologic variables or in the respiratory disturbance index, although group A presented higher oxygen saturation levels (97 [1.7] vs 95 [2]; P< .007), lower oxygen desaturation index scores (7 [7] vs 15 [10]; P=.007), and a lower cumulative percentage of time with oxygen saturation lower than 90% (2.2 [4] vs 16.4 [4]; P=.01). Twenty-three patients (88.5%) in group A underwent tonsillectomies compared to 7 (44%) patients in group B (P=.003). Seven patients (44%) in group B were treated with continuous positive airway pressure (CPAP) and 2 patients were treated with bi-level positive airway pressure (BiPAP), compared to 1 patient (3.8%) treated with CPAP in group A (P=.003). Three children in group B underwent maxillary surgery. The evolution of clinical and polygraphic variables was more favorable in group A (P=.04). CONCLUSIONS: Children with SAHS suffer from repeated infections, delayed weight gain, hyperactivity, and neuropsychiatric manifestations. Obesity (associated with concomitant disease) and sleepiness are uncommon. Although most patients require surgery, as many as a third require treatment with CPAP or BiPAP. Furthermore, children with SAHS and concomitant disease show no specific clinical characteristics, although they tend to be more obese, have more craniofacial abnormalities, and greater nocturnal hypoventilation.

Association between Obstructive Sleep Apnea and Community-Acquired Pneumonia.

BACKGROUND: We hypothesized that obstructive sleep apnea (OSA) can predispose individuals to lower airway infections and community-acquired pneumonia (CAP) due to upper airway microaspiration. This study evaluated the association between OSA and CAP. METHODS: We performed a case-control study that included 82 patients with CAP and 41 patients with other infections (control group). The controls were matched according to age, sex and body mass index (BMI). A respiratory polygraph (RP) was performed upon admission for patients in both groups. The severity of pneumonia was assessed according to the Pneumonia Severity Index (PSI). The associations between CAP and the Epworth Sleepiness Scale (ESS), OSA, OSA severity and other sleep-related variables were evaluated using logistic regression models. The associations between OSA, OSA severity with CAP severity were evaluated with linear regression models and non-parametric tests. FINDINGS: No significant differences were found between CAP and control patients regarding anthropometric variables, toxic habits and risk factors for CAP. Patients with OSA, defined as individuals with an Apnea-Hypopnea Index (AHI) ≥10, showed an increased risk of CAP (OR = 2·86, 95%CI 1·29-6·44, p = 0·01). Patients with severe OSA (AHI≥30) also had a higher risk of CAP (OR = 3·18, 95%CI 1·11-11·56, p = 0·047). In addition, OSA severity, defined according to the AHI quartile, was also significantly associated with CAP (p = 0·007). Furthermore, OSA was significantly associated with CAP severity (p = 0·0002), and OSA severity was also associated with CAP severity (p = 0·0006). CONCLUSIONS: OSA and OSA severity are associated with CAP when compared to patients admitted to the hospital for non-respiratory infections. In addition, OSA and OSA severity are associated with CAP severity. These results support the potential role of OSA in the pathogenesis of CAP and could have clinical implications. This link between OSA and infection risk should be explored to investigate the relationships among gastroesophageal reflux, silent aspiration, laryngeal sensory dysfunction and CAP. TRIAL REGISTRATION: ClinicalTrials.gov NCT01071421.

Ventilación mecánica no invasiva en la Comunidad Valenciana: de la teoría a la práctica / Noninvasive Mechanical Ventilation in Valencia, Spain: From Theory to Practice

Objetivo: obtener datos representativos acerca del abordaje, la prevalencia y los recursos disponibles para la práctica de la ventilación mecánica no invasiva (VMNI), tanto en pacientes agudos como en domicilio.Métodomediante un cuestionario específico por vía electrónica reforzado con encuesta telefónica se recabó información de todos los hospitales de la Comunidad Valenciana(AU)

Resultados: se obtuvieron datos del 70% de los centros encuestados. Durante los episodios agudos la VMNI se realizaba en la unidad de cuidados intensivos en el 100% de los casos y en el servicio de neumología en el 88%; las enfermedades más frecuentes (media±desviación estándar) fueron las siguientes: enfermedad pulmonar obstructiva crónica (EPOC; 60±20%), síndrome de obesidad-hipoventilación (22±12%), enfermedades neuromusculares (6,5±8%), cifoescoliosis (6,5±7%) y otras (4±11%). La VMNI se realizaba en urgencias en el 69% de los casos, en medicina interna en el 37%, en la unidad de hospitalización domiciliaria en el 19% y en otros servicios en el 12%. Ninguno de los hospitales encuestados dispone de Unidad de Cuidados Intermedios y existió gran disparidad entre los sistemas de VMNI empleados. La VMNI en domicilio se efectuaba en el 88% de los hospitales y se aplicaba a pacientes con EPOC (31±18%), síndrome de obesidad-hipoventilación (30±18%), enfermedades neuromusculares (16±23%), cifoescoliosis (12±10%) y otras enfermedades (11±17%), con amplia variabilidad en el número de pacientes por hospital. El tipo de interfaz domiciliaria fue nasal en el 65±32% de los casos, oronasal en el 33±33%, traqueostomía en el 2±3% y bucal en el 1±3%. Sólo disponía de consulta monográfica el 31,3% de los hospitales. El control domiciliario lo realizaban principalmente empresas suministradoras. La prevalencia calculada de VMNI domiciliaria fue 29/100.000. Sólo el 50% de los centros disponía en neumología de protocolos de VMNI para pacientes hospitalizados un 44% para domicilio, un 19% para urgencias y un 12% para medicina interna(AU)

Conclusiones: se observan importantes carencias en recursos humanos y técnicos, disparidad en el material empleado y escasez en sistemas de apoyo. Aunque en la mayoría de los hospitales la VMNI se realiza en pacientes agudos, el número y el tipo de pacientes que reciben VMNI en su domicilio son más variables, pero la VMNI en domicilio presenta alta prevalencia. Además, se objetiva falta de protocolos escritos tanto para pacientes agudos como crónicos

Objective: To obtain representative data on the frequency of use and availability of resources for noninvasive mechanical ventilation (NIV) in hospitals (acute respiratory failure) and at home (chronic respiratory failure).MethodWe sent a purpose-designed questionnaire to all the hospitals in the Autonomous Community of Valencia, Spain and followed up with a telephone interview(AU)

Results: Seventy percent of the hospitals responded to the survey. NIV was used to treat patients with acute respiratory episodes in 100% of the intensive care units and in 88% of the respiratory medicine departments. The most common diseases were chronic obstructive pulmonary disease (COPD) (mean [SD] 60% [20%]), obesity hypoventilation syndrome (22% [12%]), neuromuscular diseases (6.5% [8%]), and kyphoscoliosis (6.5% [7%]). Other diseases accounted for 4% [11%] of cases. Emergency departments used NIV in 69% of patients, internal medicine departments in 37%, hospital-based home care units in 19%, and other departments in 12%. None of the hospitals that responded to the survey had an intermediate care unit and considerable differences were found in terms of NIV systems used. Home NIV was provided by 88% of hospitals. Patients using home NIV had COPD (31% [18%]), obesity hypoventilation syndrome (30% [18%]), neuromuscular diseases (16% [23%]), kyphoscoliosis (12% [10%]), and other diseases (11% [17%]). Patient numbers varied greatly from one hospital to the next. Home NIV was delivered using a nasal interface in 65% (32%) of cases, an oral-nasal interface in 33% (33%), a tracheostomy tube in 2% (3%), and a mouthpiece in 1% (32%). Only 31.3% of hospitals has a specialized home NIV unit. Home monitoring was performed mainly by service providers. We calculated that home NIV was used in 29 individuals per 100 000 population. Only 50% of the respiratory medicine departments surveyed had written hospitalization protocols; the corresponding percentages for other departments were 44% for home care units, 19% for emergency departments, and 12% for internal medicine departments.

Conclusions: We observed differences in the type of requirement used, and considerable deficiencies in the availability of human and material resources and support systems. Although NIV is mostly used in hospitals to treat patients with acute respiratory failure, home NIV is also very common and is characterized by greater variability in terms of the number and type of patients. We also observed deficiencies in terms of written protocols for patients with acute and chronic disease.

Síndrome de apneas-hipopneas durante el sueño en población infantil: diferencias en su expresión entre niños con hipertrofia amigdalar y con enfermedad concomitante / Sleep apnea-hypopnea syndrome in a pediatric population: differences between children with tonsillar hypertrophy and those with concomitant disease

Objetivo: Comparar la expresión clínica y polisomnográfica del síndrome de apneas-hipopneas durante el sueño (SAHS) en niños con hipertrofia amigdalar y enfermedad concomitante. Pacientes y métodos: Se estudió a 42 niños con SAHS ­con una edad media (± desviación estándar) de 8 ± 4 años, índice de masa corporal (IMC) de 19,6 ± 5,2 kg/m2, cuello de 29 ± 4 cm y percentil de IMC de 67 ± 36­, 26 sanos (grupo A) y 16 con enfermedad concomitante (grupo B). Resultados: Al comparar los grupos A y B no se observaron diferencias en la edad (7,7 ± 3,9 frente a 8,4 ± 3,9 años; p = no significativa [NS]), el sexo, el IMC (17,6 ± 4 frente a 20,4 ± 6 kg/m2; p = NS), el perímetro del cuello (29,3 ± 4,7 frente a 30,7 ± 3,5 cm; p = NS) ni el percentil de IMC (61 ± 37 frente a 76 ± 34; p = NS). En el grupo A fue más frecuente la hipertrofia amigdalar (p = 0,02), y en B, las alteraciones del macizo facial (p = 0,008), macroglosia (p = 0,04) y dolicocefalia (p = 0,04). No se observaron diferencias en las variables neurofisiológicas ni en el índice de alteración respiratoria, aunque el grupo A presentó mayor saturación de oxígeno basal (97 ± 1,7 frente a 95 ± 2%; p < 0,007), menor índice de desaturaciones/h (7 ± 7 frente a 15 ± 10; p = 0,007) y menor porcentaje de tiempo de sueño con saturación de oxihemoglobina inferior al 90% (2,2 ± 4 frente a 16,4 ± 4; p = 0,01). Fueron tratados con amigdalectomía 23 pacientes del grupo A (88,5%) frente a 7 (44%) del B (p = 0,003). En el grupo B, 7 pacientes recibieron tratamiento con presión positiva continua de la vía aérea (44%) y 2 con BiPAP®, frente a uno (3,8%) en el grupo A (p = 0,003). Se realizó cirugía maxilar a 3 niños del grupo B. La evolución clínica y poligráfica fue más favorable en el grupo A (p = 0,04). Conclusiones: Los niños con SAHS cursan con infecciones de repetición, retraso ponderal, hiperactividad y manifestaciones neuropsíquicas, mientras que son poco frecuentes la somnolencia y la obesidad, la cual se asocia a enfermedad concomitante. Aunque la mayoría necesitará cirugía, hasta un tercio precisará tratamiento con presión positiva continua de la vía aérea/BiPAP®. Además, los niños con SAHS y enfermedad concomitante no muestran características especiales en su expresión clínica, aunque tienden a ser más obesos, con mayores alteraciones del macizo facial y mayor hipoventilación nocturna

Objective: Our aim was to compare clinical and polysomnographic variables in pediatric patients with sleep apnea­hypopnea syndrome (SAHS) secondary to tonsillar hypertrophy with those in patients with concomitant disease. Patients and methods: We studied 42 children with SAHS (mean [SD] age, 8 [4] years; body mass index [BMI], 19.6 [5.2] kg/m2; neck circumference, 29 [4] cm; and BMI percentile, 67 [36]), 26 of whom were otherwise healthy (group A) and 16 of whom had concomitant disease (group B). Results: A comparison of groups A and B showed no significant differences in age (7.7 [3.9] years vs 8.4 [3.9] years; P=not significant [NS]); sex, BMI (17.6 [4] kg/m2 vs 20.4 [6] kg/m2; P=NS), neck circumference (29.3 [4.7] cm vs 30.7 [3.5] cm; P=NS), or BMI percentile (61 [37] vs 76 [34]; P=NS). Tonsillar hypertrophy was more frequent in group A (P=.02) and craniofacial abnormalities (P=.008), macroglossia (P=.04), and dolichocephalia (P=.04) were more frequent in group B. No significant differences were observed in neurophysiologic variables or in the respiratory disturbance index, although group A presented higher oxygen saturation levels (97 [1.7] vs 95 [2]; P<.007), lower oxygen desaturation index scores (7 [7] vs 15 [10]; P=.007), and a lower cumulative percentage of time with oxygen saturation lower than 90% (2.2 [4] vs 16.4 [4]; P=.01). Twenty-three patients (88.5%) in group A underwent tonsillectomies compared to 7 (44%) patients in group B (P=.003). Seven patients (44%) in group B were treated with continuous positive airway pressure (CPAP) and 2 patients were treated with bilevel positive airway pressure (BiPAP), compared to 1 patient (3.8%) treated with CPAP in group A (P=.003). Three children in group B underwent maxillary surgery. The evolution of clinical and polygraphic variables was more favorable in group A (P=.04). Conclusions: Children with SAHS suffer from repeated infections, delayed weight gain, hyperactivity, and neuropsychiatric manifestations. Obesity (associated with concomitant disease) and sleepiness are uncommon. Although most patients require surgery, as many as a third require treatment with CPAP or BiPAP. Furthermore, children with SAHS and concomitant disease show no specific clinical characteristics, although they tend to be more obese, have more craniofacial abnormalities, and greater nocturnal hypoventilation

Síndrome de apnea central de origen multifactorial tratado mediante soporte ventilatorio domiciliario / Treatment of central sleep apnea syndrome of multifactorial origin by home ventilatory support

Se describe el caso de una paciente afectada de insuficiencia renal crónica e hiperparatiroidismo primario, que presentó síndrome de apnea central (SAC) no hipercápnico, de origen multifactorial, que se atribuyó a factores metabólicos. Fue tratada inicialmente con soporte ventilatorio bipresión tras comprobar, mediante diversos estudios poligráficos, la respuesta inadecuada a oxigenoterapia y presión positiva continua de la vía aérea (CPAP). Tres meses más tarde, tras paratiroidectomía e inicio de hemodiálisis, se observaron la desaparición de la somnolencia, mejoría parcial del SAC en la polisomnografía y normalización del patrón ventilatorio al aplicar CPAP nasal a 7 cmH2O. Se discute la patogenia del SAC asociado a insuficiencia renal crónica, así como las opciones de tratamiento, que en cualquier caso debe ser individualizado, debido a su respuesta imprevisible

We report the case of a patient with chronic renal failure and primary hyperparathyroidism who developed nonhypercapnic central sleep apnea syndrome (CSAS), which was multifactorial in origin and attributed to metabolic factors. Given an inadequate response to oxygen therapy and continuous positive airway pressure (CPAP) revealed by several polygraph studies, the patient was treated with bilevel positive airway pressure ventilatory support. Three months after treatment commenced, a parathyroidectomy was performed and hemodialysis was initiated. At this point it was observed that the patient no longer experienced somnolence; moreover, polysomnography revealed partial improvement in the CSAS and normalization of ventilatory patterns on application of nasal CPAP at 7 cm H2O. We discuss the pathogenesis of CSAS associated with chronic kidney failure along with the treatment options and conclude that treatment should be customized due to the lack of predictability of patient response

Mycobacterium fortuitum: una rara causa de infección de marcapasos / Mycobacterium fortuitum: a rare cause of pacemaker infection

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